By February 9, 2010 10 Comments Read More →

Thinking and Adapting in the Context of Standardized Work

When I was in Sweden recently, we had a lot of good discussion about the Lean concept of “standardized work.”

There was a lot of agreement from different presenters at the Lean laboratories conference, and from the hospital people we visited, that standardized work isn’t a robotic form of cookbook medicine or cookbook processes. Standardized work isn’t “mindless conformity” as Bill Marriott writes about in regards to the hotel chain.

We found an interesting example of a situation where thinking is required.

Let’s say a process for phlebotomy (drawing blood from a patient) says that it’s preferable to draw blood from the patient’s left arm. Having a standardized process doesn’t mean we ALWAYS draw from the left arm.

Somebody asked, in an extreme situation, “what if the patient is an amputee and they don’t have a left arm?” Clearly, the phlebotomist should be empowered to make a decision — draw from the right arm! Even if the patient just expresses a preference to using the right arm (because they are left handed and don’t want that arm to hurt), the phlebotomist could be allowed to make a judgment call, even if the standardized work doesn’t spell out this choice.

As I’ve heard in other contexts: the role of an employee is:

  1. Follow the standardized work – unless there’s a good reason not to!
  2. Make contributions to improve the letter and the spirit of the standardized work (because the standardized work is defined by those doing the work, not the bosses)

To point #2, Dr. Göran Ornung, a cardiologist and emergency physician said, in their work:

“Standardized work is not what top management says, it’s what staff says.”

If people are afraid to use their judgment and make decisions, maybe the standardized work document (and more importantly, the training) should specify that you are not leaving your brain at the door!

Final thought – there’s a difference between not following the standardized work for a justifiable reason and not following it because you didn’t feel like it. See this article about cardiac surgeons defining standardized work and their guidelines about choosing to not follow it.

What do you do in your training or management to make sure standardized work doesn’t mean “mindless conformity”?

Many of these same ideas are expressed in Dr. Atul Gawande’s book The Checklist Manifesto: How to Get Things Right. More on that later in a full review of the outstanding book.


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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10 Comments on "Thinking and Adapting in the Context of Standardized Work"

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  1. Tim McMahon says:

    Mark, your last comment is an important distinction. There is big difference between adherence to standard work for cause and just doing whatever you want. We must encourage thinking and challenging status quo otherwise improvement is lost. Improvement does need be explained through current state, problem statement, countermeasure, and follow-up (PDCA). I think the important link to make this successful is an effective team leader. One that works with the team on structured improvements. Someone that can notice and support improvement or re-iterate the importance of adherence to the standard. Either extreme of this balanced equation of mindful improvement versus disciplined adherence is not good either. I suppose this is why it is so important to observe and seek understand before being understood.

  2. Simon Ellberger says:

    With regard to standard work, people need to understand “why?” and not just “what” and “how,” hence the importance of tools like proper job instruction training and job breakdown sheets. Without this understanding, making judgment calls can amount to guessing and/or lead to errors.

    So, if it is preferable to draw blood from the left arm, the phlebotomist needs to know why. Now suppose (and I am making this up) the reason for the preference is that some lab data are prone to being skewed if blood is taken from the right arm. Then if I draw from the right arm, I need to somehow notify the lab so that they can be aware of this. Or perhaps it’s simply that blood flows quicker down the left arm. Then I may be more apt to adjust according to patient preference; in fact, I would probably suggest adding a prior step to the standard in which the patient is asked for his/her preference, thus increasing the potential for patient satisfaction and comfort. Or perhaps the rest of the procedure (angle of insertion, how long the needle needs to remain in the arm, etc.) needs to be modified if the left arm is not used. If I don’t know this, I may have a bloody mess on my hands. Etc.

    By the way, I think standard work in the medical profession (perhaps in all work?) should include decision options. I.e., do step A unless conditions B or C exist, then instead do step D or step E respectively. Using standard process flow charts to show the standard work makes this easy; one uses the diamond symbol for such decision paths.

    • Mark Graban
      Twitter:
      says:

      Yes, that “know why” understanding is so critical. Making sure people know that allows them to be professionals, we are treating them like adults. Trying to use formal positional authority to force standardized work adherence is not the best approach in the long term. Better to have an environment where people want to follow standardized work because they created it or at least understand the why.

  3. All the points that have been brought up are very important. I think it’s also important to ensure that when the practitioner deviates from standard procedure, there is a method for communicating and sharing this knowledge. I see that this can help to both improve (as in evolve) the work as well as identify problem areas. If we see that multiple people are having to use a similar deviation, then we may have found a candidate for revision. It also provides an opportunity to learn from the good innovations that others have identified. If we don’t find a ways to have this be part of the conversation in the practitioner community, we risk losing some valuable inputs.

  4. I think the phlembotomy example emphasizes why the input of the people doing the work is so important in the development of standard work documents. Namely, is drawing blood from the right arm (specifically) an essential component of the task? Simon suggests incorporating tree-like decision points into standard work, e.g. right arm unavailable, use left arm. But this approach may lead to complex and unwieldy documents–that don’t get used as a result. Simon, I don’t think you were advocating girth over gist (flow charts can be highly effective), but balance is important and balance starts with clearly identifying the critical-to-performance factors in the process. We ought to standardize the drivers of performance, provide guidelines (less than a standard) for non-essential elements, and permit appropriate clinical judgment.

  5. Simon Ellberger says:

    Mr. Gonzalez: Excellent point.

    Mr. Hershfield: Agree with your insightful comment on employee input. Re your comment about complex and unwieldy documents that don’t get used as a result: Don’t get used by whom?

    The flow chart I suggest is not for the performer of the standard work — it’s to be visibly posted for leaders/supervisors/managers who observe the process to use so as to see if the standard is being followed, and to immediately detect deviations from it, so that appropriate action can be taken (which might be changing the standard, or doing a root cause analysis as to why it couldn’t be followed and implementing a countermeasure, etc.).

    As for the performers of the work, they should be thoroughly trained to do the standard work (as via the job instruction training method I referenced) before being allowed to do it independently. They should not be referencing documents to do standard work. This is I believe the approach Toyota uses.

    If the standard work is currently complex due to the existence of decision points, then this needs to be made visible (which the flow chart graphically does) so as to call attention to the need for improvement of the standard, as by the removal of waste/variation. If there is girth in the flow chart I am suggesting, it would be because there is girth in the process, and this must be made visible.

    Re the phlebotomy example: If there is a critical reason for using the left arm, this needs to be indicated in the job breakdown sheet used in the job instruction training. If there isn’t a critical reason, then “draw blood from left arm” should not be part of the standard (though, as you suggest, a preference for the left arm may be included in a guideline if there is a rational reason for the preference). There should be no reason for the obvious statement “right arm unavailable, use left arm” in a standard work flow chart or a job breakdown sheet.

  6. Mark Graban
    Twitter:
    says:

    My old boss, Mike, commented on Facebook:

    “I don’t know if deviating with good reason is a totally fair description of what’s really going here if you switch arms from one to another. Consider, if the standard exists to use the left arm to make the patient more comfortable as most people are right-handed, but you encounter a left-handed person and switch to the right, are you not then in actuality upholding the standard? Standards exist for many reasons so I may be overly simplistic here, but in the end it’s about optimal/maximal delivery of value added. Know “the why” so “the how” is obvious. Thus in this case perhaps deviation is an improper word. Our blood-drawing friend is really upholding/maintaining the value add. To follow the standard work, in this case, would be deviating, would it not? Embed this logic into the standard and avoid the debate altogether for future works to use! After all, i think we can all probably agree that standards should change when a better way is identified. To me, a standard without a mechanism for change is a shackle, so I hope they then change the standard work to capture the cause of the “deviation.”

  7. I think that Mike (quoted within Mark’s comment) supports the general line of reasoning that Simon and I advocate.

    Simon, I’m following the points you make in your most recent post. Here’s where I think we differ: you are more open to workplace documentation of longer lengths and in larger quantities than I am. I have been involved in too many situations where an abundance of documentation becomes too great for teams to sustain properly. The result is that it falls out of date and is not used by the appropriate process participants which then results in inconsistencies in the process–backsliding, if you will. I know that highly skilled and disciplined teams consistently maintain and improve their documentation. I do not often meet such teams in practice (despite my best attempts to inspire them!) and thus my focus, as suggested in my earlier post, is to strike a reasonable balance.

  8. Mark Graban
    Twitter:
    says:

    Gawande makes the case in his book (and this has been confirmed by my pilot friend) that the best checklists are as short as possible. They aren’t full process flow charts, they should fit into a single page and have just “key points.”

    A full process map with decision points may have value for other purposes.

    There’s a good reason by TWI job instruction documents are used for training, but they aren’t necessarily the only process documentation.

    So how any of this applies to lean and “standardized work” is up to us, I’d say. I think “reasonable balance” is key.

  9. Kayla Rogers says:

    I like the idea of being adaptable in different situations. Learning good principles but then being able to individualize things to different patients is a great idea. I think this should be explained to all physicians, not just phlebotomists.

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