Standard Work in the OR

In 2011 we will be celebrating, or at least acknowledging, the 100th anniversary of the Fredrick Winslow Taylor's process improvement classic Principles of Scientific Management. The book became a best-seller in the US, and also in Europe and Japan, and it was translated into over 10 languages within a year of its publication. Taylor proposed that we uncover and document the One Best Way to perform a work task, to train workers to do it that way, and then to continue to improve the method over time. This approach was applied to manufacturing work, and also to office and hospital processes. In the language of Lean, we call this Standard Work. As you can see, the concept of Standard Work is not new, and from our 21st century perspective the notion that standardization could be challenged seems quaint, but Taylor in fact did run into significant opposition in his time.

Let's recap the steps to follow in order to document work, from a Lean perspective. We first need to organize work into what we call "processes", groupings of similar work steps that take place in the same physical location and are done by the same type of resource. A grouping of processes to achieve a given outcome ("the value") is called a Value Stream, documented in a flow-chart format called a Value Stream Map. Each process on a Value Stream Map would need to be documented in detail, in what is called a Standard Work Definition or SWD. A Value Stream based on work done in the OR would follow a patient through from registration to discharge, and of course there are many different paths that the patient could take on that journey.

In creating a SWD we are interested primarily in three things: a description of the detailed work steps within the process, a reasonable estimate of the time required for each step, and a definition of the quality criteria for each step. This last requirement means this: if the work step can be done more than one way, but only one way is the right way, then it will be necessary to either redesign the process so that errors simply cannot occur ("error-proof") or double check the work before proceeding in the work sequence, and for that we must document the right way. In the case of critical or life-threatening steps, it will be necessary for two different people to confirm that the work step was done correctly. Just like taking off in an airplane, it is not sufficient for one person to do the work and check his/her work if the step is critical. Other data items that can be included on the SWD are machine vs. people time, changeover vs. work detail, a code for value-adding vs. non-value-adding steps, and supplies and equipment used.

In the Lean world, standardization has never been considered optional, but the complexity of modern Value Streams is making its use more and more essential. According to Atul Gawande, the author of The Checklist Manifesto, the era of the Master Builder in healthcare is drawing to a close. In construction the Master Builder would design the building, and also oversee all aspects of the construction and manage to project. Working in this way, a successful outcome, i.e. the building doesn't fall down, is dependent largely on the individual skill of the Master Builder, and not on a well-designed and defined process. The Master Builder method of construction was overwhelmed by modern complexity by the middle of the last century and is no longer used. The Master Building mentality still exists in healthcare, but it is also in the process of being overwhelmed. In its place is a multi-disciplinary approach with a foundation of Standard Work.

One way to gain perspective on the importance of Standard Work is through the lens of the Process Maturity Scale. By classifying a work process along a scale of five levels of maturity, we can determine the appropriate effort required to improve and sustain improvements in a process. The key point is this: changes made in a process that is not mature are at risk of not sustaining. Let's examine each of the levels, starting with Level 1.

At Level 1, the lowest level, the process has a name and an owner. Naming the process simply means that a grouping of work steps has been given a process name, like "case cart picking" or "OR suite changeover". Many individual work steps are required to change over the operating room, but it is still only one process. The owner of a process is the individual within the organization responsible for documenting the work, training staff to do the work that way, processing improvement ideas, maintaining metrics and auditing process performance. Getting to Level 1 is a positive step forward, but it is not nearly enough to ensure sustainability of process improvements.

At Level 2 we have documented the work in detail, using the Standard Work Definition form and method discussed earlier in this article. This step can be time consuming, especially if there are a lot of steps, and a lot a variants of the process. The work times that we document should be "reasonable and generous"; we're not trying to capture the time for the fastest person, but instead we are trying a document a reasonable average time. The work is best documented by observing or video-taping a number of difference experienced people. Note that in the OR we are primarily talking about operational work, and not procedure work, but opportunities abound there as well.

At Level 3 we have trained and certified the people doing the work in the documented process. It does little good to document the One Best Way to do something, if the workforce is not actually doing it. The training and certification process would normally be done under the guidance of a Master Trainer, and certification would be earned by performing the correct work steps while being observed by the Master Trainer. It will be additionally important to continue to audit Standard Work in a process, and this is normally the daily responsibility of managers and supervisors. An employee training status board is maintained in the OR, and kept current.

At Level 4 we are introducing "kaizen" or continuous improvement. Once a process has been stabilized through Level 3, there is no assumption  that we have arrived at perfection, and any process can be improved. We will want to have one or more key performance metrics that we track, and solicit ideas and input from the people working in the process. Every process should have a "Target Condition", a goal or next improvement that the team is working towards, under the leadership of the Process Owner. Once that goal has been reached, the next Target Condition will be defined. One of our Lean slogans is "What Gets Measured Gets Done". Every process on the OR Value Stream Map should always have a target condition that is being pursued.

At Level 5, we are able to sustain a trend a continuous improvement in the process. To declare that the process is at Level 5 it will be necessary to provide evidence of at least a 12-month track record of improvements in the key performance metrics that we established at Level 4. Achieving and sustaining Level 5 is especially important since if a process is not being actively improved, chances are excellent that it is actually degrading.

The value of a Process Maturity Scale and assessment is that if we are not at least at Level 3, it will be difficult or impossible to sustain process improvements, and kaizen efforts will be a waste of time. A strong foundation of Standard Work can therefore be considered a prerequisite for improvement. Concentrating improvement efforts on the OR will yield great benefits, since that is where a large percentage of the hospital revenue, material usage and process complexity reside.

Richard Rahn is a Senior Lean Consultant with Leonardo Group Americas, an international Lean consulting and training company based in Colorado. Richard can be reached at 303-494-4404, at rrahn@leonardo-group.com and at the website http://www.leonardogroupamericas.com.