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10/17/2011 04:41 PM
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Hello, I am a lean facilitator in a city hospital ED and would appreciate hearing how others may have integrated the use of Standard Work into daily operations. (Thanks to those who responded to my previous thread about problem solving tips-very helpful!)
In my mind, I conceptualize "standard work" as a physical document, a "play-book" that staff and leaders can refer to in order to ensure they are operating beneath a consistent and agreed upon mental model--one that is of course the "best known, least-waste way" today.
Each kaizen event conducted over their past 2.5 years of value stream activity in the ED yielded Standard Work, or documents that illustrate future state workflows and process. The Standard Work experienced varying degrees of spread and sustainment during their tumultuous lean journey and leadership has come to the realization that user-friendly (and of course accurate/current) documentation of their work processes could assist them with maintaining consistency in otherwise variable operations. I'm grateful for the current opportunity to coach department leadership through a period of raising their standard work from the dead!
There is widespread frustration that their standard work has been collecting dust. Far too many documents saw their demise when they no longer stuck to the wall (or remained visible, but are not seen!), became buried after unsuccessful spread/sustainment or were swept to the side in light of the chaotic work environment. (I do acknowledge that there is a leadership component here, in terms of holding staff accountable to the standards).
The first step, the RESURRECTION of the standard work documents, has begun. The second step will of course be to re-spread and sustain by ensuring that all staff are aware of the standards (for clinical, administrative, patient flow processes) and reinforcing regularly. However, how does one physically install (or instill?) standard work into the gemba so that the document becomes not only a reference point, but a working, "living" entity?
Thank you!
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10/17/2011 05:46 PM
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The key to keeping it going to have an active process that CHECKS actual activity against the standard, and responds immediately when the worker needs to depart from the standard to get something done.
Those checks should be structured around the work content, sequence, timing, outcome.
You can start with broad things - for example, if the standard work to prepare a hospital room for a new patient SHOULD be performed without the worker needing to leave the room once the work is begun, then escalate as "a problem" anything causing the worker to leave the room.
You can also use timing - how long should it take, how long did it take.
The key is that without active, continuous monitoring and response to problems, the actual work WILL depart from your intended standard, and at some point the standard becomes irrelevant.
There are always small issues that are forcing people off your planned work. The key purpose to having a standard is to be able to see those issues as soon as they occur - a point of comparison.
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10/18/2011 07:24 AM
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Amy,
Sounds like you've hit the same wall many other people have with Standard Work (SW), so don't feel like you're all alone. Let me offer some personal experience with the topic if I can.
There are several reasons I believe SW doesn't stick. The very first one is that it just flat out wasn't followable (new word) in the first place. Many, many times when Kaizen teams are working to improve a process, they try to put SW in place to maintain the gains. After all, it makes sense. But many teams I've seen also miss a few important points in all of the pressure that comes with a Kaizen. The biggest reasons I've seen for SW developed in a Kaizen not being followable are:
- Sample size too small: Observing an operation once or twice rarely shows all of the things that regularly happen and / or real and repeatable times for the things that do happen. Yet many teams write SW based on just a few observations.
- The process is not repeatable: Related to the previous bullet, teams sometimes fail to notice that what they just arranged to observe and document rarely (if ever) happens in the real world. Remember, repetitive assembly work is very different from say, hospital emergency room visits too. The difference is in what level one can standardize to.
- No 5S: If a person who is supposed to be following SW has to search for anything, their SW is not followable because searching takes a highly variable amount of time. As many have said before, you need to do 5S before SW.
- Hawthorne Effect: This well documented effect is where people who know they're being observed perform differently - and generally work harder and faster. Energized Kaizen teams are fully capable of showing (proving?) that they can perform a given process in record time. It's just not real. As a colleague of mine always says, "Would you want your mom doing it for 8 hours?"
The next reason I see SW not sticking is that somebody (maybe nobody) sees any real value in doing things exactly the same way every time. Many folks are very creative about how they do their work. In fact in many cases, creativity is the only way they can overcome all of the obstacles that come between them and getting their job done every day. Better yet, some folks have even been pretty well rewarded for finding creative ways to get the job done in the past. All of this runs counter to doing things the same way every time and creates a huge cultural barrier.
Possibly the biggest reason for SW not sticking is a lack of confirmation checks by management. I've always said that if you tell me exactly how to do something, I might do it that way. If you tell me how and why, I'm much more likely to do it that way. If you tell me how, why and then check up on me to make sure I'm actually following the standard, you've got my undivided attention. Why is it that most of us only get as far as what and maybe why? Without regular confirmation checks and both positive and negative consequences, SW will fade into the sunset every time.
BTW, the other thing I've discovered is that posting SW in an area has less to do with the likelihood of folks following it than just about anything else. I can't tell you how many places I've been where SW was proudly and prominently displayed on a wall - and nobody paid any attention to it. And if you really look at a Toyota factory, you'll almost never see it posted.
Remember, SW is a tool that allows us to highlight the many forms of waste in a process. If management isn't interested in finding and eliminating all of this waste, you're wasting your time.
Tom
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10/18/2011 08:56 AM
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Ms. Silverstein,
Two sources that will give you ideas for sustaining standard work:
1. My book, Sustain Your Gains-The People Side of Lean-Six Sigma
http://aubreydaniels.com/sustain-your-gains-book
2. Lean Hospitals by Mark Graban.
Hope this helps. Feel free to correspond with me directly
if you wish. mikemccarthy@sustainleangains.com
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10/21/2011 09:38 AM
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As the others have stated well, if the problem statement is "standardized work isn't be used or followed," we should ask "why?" and understand the root cause of the situation, or multiple causes.
We can't just blame the workers (maybe the standardized work wasn't adequate or systems don't support it) and we can't simply blame the supervisors.
If the supervisors don't have time, we need to figure out how to create time. If they don't know how to oversee the standardized work and coach people on sustaining or improving, then they need to get that training.
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10/21/2011 02:37 PM
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Amy,
I would like to build on Mark's and Tom's points. The deterioration of workshop gains is very common, and I think it often comes from missing a fundamental concept. Documenting standard work is important; it allows for communication of the content to others, particularly those not familiar with the work. (either to coordinate different areas, or for training) It also makes it easier to discuss changes to it...not as good as being able to be live at the gemba, or at least within a physical representation / mockup, but better than trying to do it only verbally.
But, to really be standard work, your workers need to believe in it, so that they can internalize it. Nobody will be able to apply standard work (that is, move at speed and with expected quality) if they are constantly referring to an instruction. They will do what they know, so they need to know the standard work. The most direct way to do this is to involve them in the creation of standard work. This is why kaizen workshops can have problems--there then needs to be extensive communication / training of those who weren't involved. And they may have other ideas. However, when kaizen is a daily part of everyone's job, then standard work can evolve at any time, as people discover improvements. (of course, this needs to then be communicated) As Tom says, tell them what, then tell them why...and get them to agree.
I also agree there needs to be a check. But, I would say that if the workers believe in why the standard work is the way it is, then they can (to a great extent) check themselves. I have found the increased visibility of checklists to be applicable here. How do you step away from your task? How do you know what you are missing? A checklist allows someone trying to do the right thing (do standard work) ensure that they are. In addition, the right metrics at a workgroup level fill the gap. To use Mark's example, if the worker did not realize the deviation from standard by having to leave the room for some supplies, this should show up because they took longer than standard to do the prep. Their supervisor, reviewing their daily metrics, should ask why it took too long. In order to get participation, this can't be a matter of blame, but rather of problem solving: "Oh, you had to leave the room to get the supplies? Let's see if we can stock the supplies on your cart." "Or, we could have the admissions person who knows this is a special case bring the supplies to the room!" (engaging the person with the first knowledge of a special situation, rather than pushing burden downstream because of job boundaries)
This also points out why "concrete heads" are so damaging to a lean effort. To implement the type of work environment demanded by this style, everyone has to be open-minded. There is a vulnerability to raising your hand to say something is wrong; something you can't handle yourself. If you don't believe your whole team, including your supervisor, is working toward a common goal and "has your back," then you will keep your head down and hope for the best. Someone who argues for the sake of arguement, who is not interested in learning, who thinks they already do a "good enough" job, will torpedo an entire group. In such a touchy-feely work philosophy as lean, it is a hard point.
Of course, your people may vary. ;) Part of the art of a lean coordinator / facilitator / manager is to understand how much your people can swallow, in what order, and at what rate. Often times it will mean some hard compromises--putting aside things that you see as obvious needs. But if your organization isn't ready, pushing them too far, or at the wrong time, can set you back. It's the messy process of learning.
My own definition of standard work is "our shared understanding of the current best way to do our work." It's wordier than I would like, but it acknowledges a few important points: we own it together (anyone with a good idea can change it; we are all responsible) we all need to understand it (raise your hand if you have a question) and it is only good for right now. (it is not the be-all-end-all, and subject to change) Slightly more pithy is a different saying I have as advice for lean core team members: "Processes: use them as a tool, don't wield them like a weapon." No tool should take precedence over the end goal of the organization. Getting standard work right for it's own sake gains nothing. Variances from standard, like all defects, are valuable clues to point out parts of the work you don't yet understand well enough.
Matt
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10/21/2011 02:55 PM
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Yes -- even Toyota's Taiichi Ohno said that standardized work must be written by the people doing the work.
This is especially important in healthcare, with autonomy being valued and there being a lot of variety in the work.
It can't be written by a senior team member or a manager or an expert in isolation. It takes longer to build consensus in a team, but that's the only want to get standardized work to work.
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10/22/2011 04:23 PM
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I wrote a long blog post with my consolidated thoughts on standardized work:
http://www.leanblog.org/2010/0...-on-standardized-work/
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10/22/2011 06:28 PM
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I'd like to add to the great ideas shared in previous posts. Several posts have said that standard work is ' the best way that we know right now' or words to that effect. And I agree. But 'right now' implies that things may change. Perhaps one of the reasons standard work falls out of favour is that it ceases to be the 'best way'. Situations change, needs change and the work hasn't kept up. So one other thing required is a way of being able to migrate the current standard work to the new standard work.
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10/24/2011 04:29 PM
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Just a note: Michael Ballé also addresses this issue in his new column. the context is engineering, but I think it is generally in line with our discussion here.
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10/25/2011 11:13 PM
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Mike
If you support continuous improvement then standard work is a place to focus. Consider this as a stairway with each step getting better. As employees work and are supported they will continue to find a better way. The new standard would be reviewed and approved by people on all shifts if a multishift operation. team members and supervisors.
Ron Turkett
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10/28/2011 01:10 PM
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I believe that standards remain a vastly under-appreciated aspect of making life easier, and providing a firm foundation for improvement, so it's always refreshing to see the subject raised! Although there are lots of 'what' standards around us that barely get a second thought, it's the 'how' standards that can often be the most problematical. And, paradoxically, the semantics - because there's no standard nomenclature for all the associated topics.
All of this started to sink in with me when I realised that there was more to 'learning (and doing) a job' than 'standing next to Nellie' and hoping it would all gradually sink in, or that 'everyone finds their own best way' ( quite a common paradigm). I was tasked with defining methods etc. for certain production processes, and started with a clean sheet of paper.
In 1985 I joined Nissan and learned about The Standard Operation Sheet which defined the best practice method in every step it took to build a car - and ancillary routine tasks. This was (and remains) defined as 'The most efficient current method of safely meeting quality standards'. Quite a mouthful, but it says it all, I believe. The Std Op takes time and effort to prepare, but it serves a number of useful purposes, so it's a worthwhile investment.
In 1992 I first worked with some ex-Toyota guys who flagged up Standard Work, which they showed me comprised a layout illustrating work sequence, Standard WIP, Safety Points and takt / TAKT (first time I'd seen tact spelt in German!). Not so much emphasis on the method - the 'how' - which was supposedly self-evident from the layout etc. I later worked with other ex-Toyota people and discovered that there were different understandings / perspectives depending on where they'd actually worked. I suspect when they'd worked there came in to it too, as these methodologies are dynamic and evolving.
I would echo most of what Mark Graban says on his blog, and offer the definitions:
Standard Work - what needs doing, and when. [e.g. Operator: attach wheel to every car; Technician: replace pump diaphragm after 100k cycles; Director: sign cheques every month end etc.]
Standard Operation: how, as mentioned
Standard Operating Procedure: a higher-level routine, perhaps better described in a flow chart than with words / pictures
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10/31/2011 10:20 AM
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A very interesting book written by a doctor is, "The Checklist Manifesto: How to Get Things Right", by Atul Gawande. I didn't think anyone could write an entire book on checklists, but this doctor did and it is very interesting reading. He makes the point that no matter how standardized work procedures are, it's still easy to make mistakes. Mistakes made in operating or emergency rooms are not something you like to read about obviously.
His recommendation is the use of check lists to assure standardized procedures are carried out competely and correctly. He cites a number of actual benefits that some hospitals had received from the use of checklists.
He also discusses the popular use of checklists by airplane pilots as one of the earliests applications of checklists.
Sam Tomas
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11/14/2011 10:16 AM
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Here's a thought from someone frequently on the ED gemba. Hope this pertains.
Sometimes we make the standards too defined and specific, aimed at task level activities, when the real need is for standards at a higher level to achieve the goals of safety, quality, delivery and cost appropriateness.
For instance, in emergency departments, the issues are often not around how to do specific procedural tasks in the current best way, as people have a variety of ways they have learned to do something and are very successful in achieving the goal of the task, ie, what needs to get done.
Often the issues really surround how to best prioritize the work at hand. When 6 people arrive at triage in the span of 5 minutes, what is the best way to make sure nobody is in the waiting area who should not be there (because their condition needs immediate attention). There is only one triage nurse usually. What is the best way to get 'eyes' on these patients? Who is possibly available, and how is it decided who of these is in the best current situation to go forward to provide this, since they will all be busy with their other current tasks? What is the standard way this ED identifies its overload and what is done to get caught up as quickly as possible to be optimally ready for the next emergency or influx? Once determined, the person probably has the skills to do the tasks needed already.
Another example: an ED nurse has 4 patients; one ready to be moved upstairs for admission; one needing pain meds; one needing antibiotics started; and a newly arrived patient. What is the standard for who they should take care of first in the context of individual patient need and over all department flow? Once determined, the nurse probably has the skills to do the tasks needed already.
Standards have to be relevant to what is really needed. Successfully achieved task level activities with variation in how they are completed are not going to be seen as relevant problems. There are so many situations, each with peculiar circumstances and conditions, well too many to create standard responses to each one. In both examples, the standard needed defines the parameters for a successful decision and presents the relevant options, but relies on the staff at that moment to assess the unique circumstances and implement the best plan. Reflecting later on whether or not the choices worked as expected provides learning and the evolution of the standard.
Standard ways to deal with problems relevant to those living the reality of the work and countermeasures to better address these problems rarely need any moment to moment check for compliance. And anyway, it isn't compliance we need to be successful. What we need in health care are people willing, able and valued to invest themselves in their work. The appropriate standard work applied to the problems that matter can certainly contribute to an environment of involvement and engagement.
Mark Jaben, MD
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06/07/2012 12:13 PM
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I agree with what you think standard work should be - a play book that staff and leaders use to guide them step by step in performing a task.
On your question on how to have this implemented and have it physically present into the gemba is by using "TWI" Training within the Industry that starts with simple but common task suh as; handwashing, gowning etc..
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