Standardized Work Should Not be Robotic – Especially in Healthcare

Why ‘Quality' Care Is Dangerous – WSJ.com

Yesterday's WSJ opinion piece by Dr. Jerome Goopman (author of How Doctors Think) and Pamela Hartzband caught my eye.

Thanks to the four or five of you who also emailed me the link — please do that in the future if you see something I might have missed (and it helps me gauge interest in a subject).

Goopman and Hartzband write:

“…an analysis of this drive for better health care reveals a fundamental flaw in how quality is defined and metrics applied. In too many cases, the quality measures have been hastily adopted, only to be proven wrong and even potentially dangerous to patients.”

ThedaCare's Dr. John Toussaint has already blogged about this and writes:

“…incentives should be developed to help medical staffs focus on improving care not dictating how to practice medicine.”

Toussaint emphasizes that measures should not be used for punishment (as Goopman argued in his piece) and wrote the following about ThedaCare's quality improvement results:

These results have not been acheived by the government dictating how we practice but by the use of a consistent improvement process derived from the Toyota Production System and applied to healthcare. The authors point out how shockingly sloppy processes like hand washing are in the hospital.There are many other shocking events that occur every day in hospitals and clinincs.Without a consistent continuous improvement method and culture we can't improve them.

I agree with what Toussaint wrote, speaking as a process person and lean thinker, not a clinician We need more than targets and goals, we need process. Oh, and probably some leadership, not more regulation.

Guidelines, and even checklists, in medicine are a form of Standardized Work, as we would say in the Lean approach. In any setting, Standardized Work (in the Toyota model) shouldn't be inflexible. We don't want physicians checking their brains at the door any more than we would want factory workers to do so. Yes, following a standard protocol should probably be done most of the time, but what about cases where judgment is required?

As I quoted in my book, Lean Hospitals, Bill Marriott (of the hotel chain) once wrote:

“Mindless conformity and the thoughtful setting of standards should never be confused. What solid Standard Operating Procedures do is nip common problems in the bud, so that staff can focus instead on solving uncommon problems.”

This weekend, I will quote Toyota's view on Standardized Work from the book Toyota Talent, as it's exactly the same as Marriott's.

So why don't more people in healthcare understand this view that we can't have one-size-fits-all guidelines for most any process? We have some cases, like the cardiac surgeons at Geisinger Health System who realize that standardized work is often appropriately just a guideline and that judgment may require you to deviate.

Goopman and Hartzband add:

“The hospital was seen as a large factory where systems needed to be standardized to prevent avoidable errors. A shocking degree of sloppiness existed with respect to hand washing, for example, and this largely has been remedied with implementation of standardized protocols. Similarly, the risk of infection when inserting an intravenous catheter has fallen sharply since doctors and nurses now abide by guidelines. Buoyed by these successes, governmental and private insurance regulators now have overreached. They've turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect.”

Healthcare, apparently, has this simplistic and possibly condescending view that factories are simple places full of simple jobs and simple people. Of course, systems need to be standard-ized (with the emphasis on the -IZED). Standardized represents a spectrum from fully chaotic (nobody does it the same way) to robotically identical (everyone always does it the same way).

I'll take issue with G & H with their characterization that the handwashing sloppiness has been “remedied.” Hogwash. Where's the data on that? It might be fixed “somewhere” but not everywhere. I've seen many types of measures in different hospitals and they still don't have above average hand washing compiance. What we need is a focus on process and management that will go to the “Gemba” and see, first hand, if people are really washing their hands and following other “we should do this” procedures (such as properly gowning up before entering an isolation patient's room).

Abiding by guidelines is great. That means a process and standardized work is being followed. But having “iron-clad rules” doesn't sit well with me and I'll believe the doctors like Goopman and Toussaint who say, medically speaking, that we have to be careful about that and not take a good thing too far.

The G&H also has an Orwellian twist by telling a tale of a doctor who was sent to “re-education sessions” to be browbeaten over not following the protocols. This would also not be the Toyota way. How about treating the doctor with respect and having a discussion with him — why did you think it was important to NOT follow the ICU blood sugar protocol for that particular patient? That discussion would show real leadership instead of hiding behind rules and bureaucratic sameness.

As Dr. Deming would have predicted, having harsh inflexible rules with the threat of punishment involved will cause people to “game the system.” Case in point:

And research by the Brigham and Women's Hospital published last month in the Journal of the American College of Cardiology indicates that report cards may be pushing Massachusetts cardiologists to deny lifesaving procedures on very sick heart patients out of fear of receiving a low grade if the outcome is poor.

So doctors are afraid to help the sickest and most vulnerable of patients? We could ask for bravery on the doctors' part, but can we ask for career suicide? Probably not.

As with the financial crisis and its aftermath, we should be asking: who's regulating the regulators???

I'm all in favor of EVERY hospital using ICU central line infection checklists, for example. They are proven to save lives and save money. But, the only sustainable route to making this happen is to SELL hospitals and clinicians on the idea. If we try to mandate it or force it through regulation or law, that probably won't work or we'll have severe dysfunctions. I'm much more comfortable with the government playing the role of educator and facilitator than I am having them policing doctors.

If the regulation and brute force method were so effective, let's just “ban” medical mistakes and throw anybody who commits one in jail. Sounds silly, right? That's not too far off from what's being tried, by some, to improve quality today.

Related Links:

• Healthcare Efficiency Blog: Quality as a False God
• Quality Care and other Metrics can yield Unhealthy Behaviors

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