I recently coached a process improvement practitioner as he was working with a process improvement team in an ambulatory surgery practice. After one of the meetings, we were debriefing with the nursing manager and she said something that caught my attention: “You can’t counsel on a broken process.”
I thought, “What an insightful observation!” Her comment encircled a great truth and to put it in my own words, you cannot coach on a process without a standard. I have said it many times before and I will keep saying it: so many times, the root cause of the problem is that there is no standard. Pure and simple, many times it is just that. Or, perhaps, there is a standard, but nobody follows it. This is very prevalent in healthcare, but it happens in other industries as well.
So many times, the root cause of the problem is that there is no standard.
What Is the Best, Easiest, Safest Way?
According to Masaaki Imai, founder of the Kaizen Institute and author of the book Kaizen, a standard is “the best, easiest, safest way” and “there should only be one at a time.” So, if you have “more than one standard,” you really have none. Consequently, if there is no standard to follow in order to perform a certain task, how can you tell if someone is doing it right? How can you know if:
- Someone found a better way to do the job?
- Someone needs more training?
- Someone needs coaching?
Or furthermore, what are you going to coach them on?! If there is no documented standard, how can you support the notion of “the best, easiest, safest way?”How will you know when you have a problem?
Have you ever been driving down a particular road or highway wondering what the speed limit is? If the road does not have a speed limit sign for a long stretch, we are left to guess what the speed limit is. How do we know if we are over it or under it? In that same way, if you do not have a standard, which means a target or a goal, how will you know when you achieve it?
If you do not have a standard, which means a target or a goal, how will you know when you achieve it?
The idea of having a standard is NOT to discourage thinking. A lot of people, especially in healthcare, fear and resist the notion of having a standard. Most of the resistance I have experienced stems from the misconception that having and documenting a standard forces people to mindlessly follow it. Some people have used the term “cookbook medicine” and argued that “we are trying to turn them into robots” by standardizing. Others argue that we cannot have standardized work (the documented best, easiest, safest way) in healthcare because every patient is different and patients are not cars (alluding to the fact that the concepts developed on the shop floor do not work in the healthcare arena). Of course every patient is different! We know that. That does not mean there is not one best, easiest, safest way to carry out certain procedures, whether they are direct or related patient care. There are many examples of successful implementations of what we call standardized work in healthcare:
- Checklists
- Standard procedures
- Key points
- Guidelines
- Bundles
- Order Sets
One great example is Seattle Children’s Hospital Clinical Standard Work.
Standardizing Breeds Creativity
If there is no standard, people have to continually guess how they should do a certain task. Furthermore, they might always wonder if they are doing it right or if there is a better way. Having a documented standard frees people’s minds to look for further improvement opportunities. That’s right!
Instead of stifling thinking and creativity, standardized work fosters and encourages it! By not having to spend their efforts wondering or guessing, people can spend their energy in looking at the process and identifying and solving problems.
You’ve Probably Used Standardized Work Without Knowing It
To be clear, standardized work does not imply complicated, long documents. Quite the opposite! The more visual, simple and succinct you can make it the better! The idea is that it is easy to understand, easy to teach and easy to follow. One thing I have seen used well in healthcare is the use of standardized work with screenshots from the EMR (Electronic Medical Record) to show exactly the steps to be taken. If you are a healthcare provider and you have followed or created a process from screenshots, guess what? You have used standardized work! Was it so bad? Did it turn you into a robot? Or did it actually help you learn the best, easiest, safest way to accomplish your tasks?
The more visual, simple and succinct you can make it the better!
Going back to our nurse manager, we can take her observation to mean that we must first fix and standardize a process before we attempt to teach it and coach staff on it. How many times have I seen the cart in front of the horse on this one!
So, how do we get started? Once you have improved a process and have a new way of doing things:
- Start by bringing resistance walls down. They don’t like the word, “standard”? Use “Standardized” or call it “Checklist.” Use whatever term your organization decides that means that this is the document to be followed by everyone performing this task and it is, as of the latest review, the best, easiest, safest way to carry out this task.
- Ensure it is created by those who are going to use it. (i.e., those responsible for the process).
- Ensure it is visual and easy to follow.
- Train a small number of staff and observe if the standard is easy to understand and be followed.
- Review it, tweak it, and improve it after those observations.
- Deploy it. Train everybody on it, let them know the expectation and also encourage people to always look for opportunities for improvement.
- Review it often. This is the never-ending journey in pursuit of perfection.
If you respect your people, show it by guiding them in the creation, adherence and improvement of standards and standardized work.
In order for organizations to improve, they must become learning organizations. Without standard, there is no learning; there is no improvement. If you respect your people, show it by guiding them in the creation, adherence and improvement of standards and standardized work. This way you empower them to achieve higher levels of performance and your organization and your customers or patients will reap the benefits.
