We Must Follow Standardized Work, Right?


    The Informed Patient – WSJ.com

    Here's an article ($$) about hospitals working to prevent bedsores or “pressure ulcers” as they are called. I didn't get around to blogging about this more fully, but it was in the news recently that the federal government is going to stop paying hospitals for “reasonably preventable” errors, such as bed sores, items left inside patients after surgery and some others. On the one hand, this is good and “Lean” — it's a form of waste to pay for things twice, things that should have been done right the first time. There's plenty of argument over what's preventable and what's provable — did the patient have that condition before entering the hospital or not. I'll try to write more about that again in that delayed post on those issues.

    There are certain preventive measures that hospitals and their employees can follow to help reduce or eliminate bed sores. Those measures could be considered a form of “Standardized Work,” as we would call it in the Lean world. But are those measures followed?

    Owensboro Medical Health System in Kentucky began a program in 2000 that included putting pictures of clouds on the doors of at-risk patients to remind nurses to reposition them in their beds every two hours. But a study in 2003 found it hadn't made a dent in reducing pressure ulcers. Joni Sims, a nurse and director of medical/surgical services, says nurses weren't all adhering to the turn schedules, and some patients who were at risk didn't get the cloud symbols. The hospital switched to turn clocks in each patient's room with a clearly marked schedule for turning patients every two hours; it also provided nurses' assistants with pagers to remind them of turn times.

    Byron Morris, a nurse at Owensboro, says that the assistants help by repositioning patients if the nurse is busy. The paging system “can be unnerving, but it's all worth it in the end,” he adds. “A little prevention goes a long way.”

    So in the first attempt, 2000, the hospital basically relied on “be careful” reminders — reminders that weren't always put on the doors when needed (a different weakness in the standardized work). “Be careful” is a very weak form of error proofing, as we're human, we get busy, we get frazzled, we can't always “be careful.” The second attempt, in 2003, seemed a bit better, going with the clocks and the pagers, but what happened if the clocks or pagers are ignored? These technology solutions don't ENFORCE the standardized work. Who is overseeing the process to make sure the standardized work is followed properly? Nobody?

    Even with apparent flaws in the system, progress was made:

    Owensboro has reduced the incidence of skin breakdown at the hospital to 3% of patients from 24% in 2000, preventing an estimated 474 pressure ulcers from March 2003 to March 2007. That comes to a savings of as much as $1.9 million on treatment costs, and $97,457 in supply costs, “not to mention the harm to patients we've prevented,” says Ms. Sims.

    But there's still room for improvement!

    This isn't about terrorizing the employees — it's about making sure the patients are taken care of. It's about saving money for the hospital by preventing bedsores and the legal liability that can come along with it. I'm not blaming the individual employees. We have to look at the system. As administrators and leaders, there is an obligation to make sure that people CAN follow the standardized work. If it's important to do something every two hours, do you have the proper staffing levels required to ENSURE that can happen? People being too busy is NOT a good excuse. You have two options — reduce waste to free up time or add people. We all know what the preferred option would be.

    We could also challenge, as the hospital above did, why highly skilled nurses have to be repositioning patients. Why not have lower-paid assistants do that kind of more menial work? Seems like repositioning patients wouldn't be the best use of nurse time. That's a system design issue that management is responsible for — are the right people doing the right kind of work? Lean manufacturers solved this a long time ago — highly skilled machinists aren't responsible for chasing down their own parts, lower paid assistants bring the parts to them. Why don't we treat nurses and their time (and skill) with the same kind of respect?

    So, my final thought comes back to the enforcement of standardized work. We can't turn managers into police, running around making sure people are doing the right thing constantly. But, we have to recognize standardized work doesn't implement itself. It requires oversight — make sure people have the time required to follow the standardized work, make sure they know WHY the standardized work is important (to rely on intrinsic motivation), and make sure those who are not following the standard work aren't just blamed. Rather, they should be involved in the problem solving process to figure out how we can ensure the standardized work is really followed, every patient, every hour, every day. Too much is at stake to do otherwise, right?

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    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


    1. Mark, as usual a very good perspective but I see that you left out one (or two) of the most important elements that do dramatically factor into the reduction of bed sores (decubitus care) and that is the Beds, matresses and overlays. These have a dramatic effect and have many features that should be utilized as well as actually matching the higher risk patients to the available decubitus bed. Plus, the hospitals have to recognize through the use of value analysis and lean methods how to eleminate the wasteful features of patient beds and zero in on the functions and features that will elminate bed sores. Definitely a case for value chain mapping here starting with analyzing exact specifications but then realizing that not every bed is going to be created equal and that hospital staff needs to match those patients to the decubitus functionality bed. Sort of how they “HAVE TO” with Bariatric Patients, most bariatric beds incorporate decubitus care functionality into them because Bariatric Patients are more inclined to suffer beds sores. We also have to factor in the average length of stay for a patient which is around 4 days now. It is a tough world for hospitals thought with the new capital outlays that they did not anticipate with larger patients (bariatric) and more diabetic patients with more wound care/decubetus issues.

    2. Bob, that’s a great point. There *is* a role for equipment and technology here. There are fancy beds with air bladders that automatically adjust and reposition the patient at programmed intervals. That stuff is great and I wouldn’t discourage people from looking at fixes like that. But, oftentimes process and standardized work are a cheaper alternative to fixing problems, particularly in cash strapped organizations (like many hospitals).

      I’m glad you elaborated and raised that point though, thanks for the contribution!!


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