TL;DR: Standardized work, influenced by Toyota and Dr. Atul Gawande, is crucial for improving safety, quality, and efficiency in healthcare. It should be created by those who do the work, be flexible, and serve as a basis for continuous improvement. Standardization isn't the goal but a tool for better outcomes.
I've written about many of these ideas and themes in various blog posts before, but I wanted to consolidate my thoughts on the Lean concept of “standardized work” in a single place. This is partly for my own personal reference (and future linking) but can also prompt some discussion amongst my friends, the Lean Blog readers.
What I'm documenting here is consistent with how I've taught and coached people in healthcare since 2005. The concepts described here are directly influenced by Toyota (especially the book Toyota Talent: Developing Your People the Toyota Way) and, I believe, is very consistent with what's expressed in Dt. Atul Gawande's The Checklist Manifesto: How to Get Things Right). These points are also expressed in the chapter on Standardized Work in my book, Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement.
This is a looooong post, so here are the quick bullets:
- Standard-IZED
- Don't standardize for the sake of standardizing
- It's created by the people who do the work
- It's not always a detailed procedure
- It's not restrictive or limiting
- It's not permanent
- You don't beat people up for not following it
Hear Mark read this post (subscribe to the podcast of blog post audio):
Standard-IZED
In the past, I used the term “standard work.” In fact, the tag I use here on the blog (look at the bottom of this post) is “Standard Work,” not “Standardized Work.” I'd also accept “Standardised Work” for those who speak the Queen's English.
I think that one syllable makes a huge difference. “Standard” implies fixed and inflexible. “Standardized” reflects, to me, a spectrum. David Meier, through his books and personal conversations, confirmed the idea that it's important to understand WHAT you standardize and to what DEGREE you standardize it.
See this later post on the “spectrum” of standardization:
Is more standardization always better? Probably not always. You can take things too far, to an extreme that's not beneficial. If somebody in a hospital laboratory walks from one station to another, does it matter which foot they take their first step with? Of course not, there's no need to standardize that, there's no benefit.
Are there any benefits to making call center staff read a script like robots, not letting them deviate or do what's necessary to serve customer needs? Probably not. Then again, working with one hospital, the radiology scheduling team created standardized work for how and when and what they communicated to parents of patients who were coming in for sedation and an MRI. By communicating in a more standardized way (not 100% scripted, but having key points), they significantly reduced process defects where parents came to the wrong location or the children had mistakenly eaten that morning, meaning they couldn't have their procedures.
I've found, that in many cases, healthcare (and patients) benefit from more standardization. Experience and published evidence confirm that. In many healthcare settings, highly skilled people are working hard in what some describe as a “process-free zone.” There is a lot of evidence (see Gawande's books, including Better: A Surgeon's Notes on Performance) that standardized work leads to better patient safety and better quality outcomes. See ThedaCare's work in improving “door to balloon” time for “Code STEMI” patients and how they receive faster care (therefore, better outcomes) through standardization of work processes and care decisions.
Don't standardize for the sake of standardizing
I've always taught that standardizing is NOT the goal. The goals are to have better safety, quality, access (waiting time), cost, and staff morale — these are the usual goals of a Lean organization. Since we're very concerned about staff morale (especially since staff satisfaction correlates very well to patient satisfaction in healthcare), we have to think about how people would feel if they're FORCED to follow an arbitrary procedure – is this good for morale? Probably not, especially among highly-skilled professionals.
There must be a clear “why?” statement for standardizing in a certain way. High-level example: Why is doing it consistently good for quality? Again, consistently doesn't mean robotically identical.
Update 8/15/14 — See my article about this at LEI's “The Lean Post” site:
Standardization is a Countermeasure, Never the Goal
Back to the laboratory example above, I can think of one example from my past where it DOES matter greatly — a marching band. Fellow band geeks will know you always take your first step with your LEFT foot. Beats “1” and “3” in a song are always your left foot. Why is this important? Visually, for the marching band performance, it looks better when people are stepping in unison. When you march in a line, you stay better aligned.
Does it matter in almost any other setting NO? You always have to understand the purpose and the context of what's being done and why.
It's created by the people who do the work
“Work standards” are the old-school approach – inflexible, detailed procedures pushed on people by managers, engineers or experts. This is the old Taylorist approach that separates thinking from doing. This is not the Lean approach, as I've learned it.
Lean standardized work is created by those who do the work. It was the case at Geisinger in Pennsylvania, where a cardiology group created standardized work for better cardiac bypass surgery care.
Standardized work was created Dr. John Tebbetts, a Dallas cosmetic surgeon, and he specifically credits Lean and Toyota in his peer-reviewed medical journal articles. Be warned if you go downloading his journal articles, they have some “NSFW” before and after photos. That point aside, HE created standardized work for how he performs surgery and his patients get better results. He owns the standardized work since he created it and it has clear benefits.
It's not just doctors. I've worked with folks in many different hospital departments that created their own new standardized work.
It's not always true that everyone gets to have their way on everything, it's more complicated than that. In the marching band, the standardized work (left foot first) was dictated to me. In the case of safety glasses in a factory or gloves in a medical laboratory, this is not optional – it's standardized work that you must follow for your own safety. We don't let the staff vote or decide on their own.
But very generally, people don't like to be told what to do. They don't like to be forced into an inflexible way of doing things, regardless of their education level. But if you do have to “dictate” the standardized work (and this had better be done rarely and judiciously), give them a good reason why. Treat them like adults, don't just bark orders. You can't depend on just blind compliance.
It's not always a detailed procedure
Standardized work doesn't always mean a long, detailed document. Organizations, especially hospitals, usually have no shortage of procedures. But they're pretty useless – they weren't written by the people who do the work, they're often out of date, and they're often just a bunch of binders on the shelf. In a Lean approach, you might update those documents and make sure they reflect reality.
The “Checklists” approach (from aviation and now in medicine) emphasizes simple single-page documents that have just the “key points” (to use a word from the Training Within Industry approach) – the important things that shouldn't be forgotten, due to the impact on the patients.
Instead of huge documents, you might also create guidelines — rules of thumb, even — that might be documented in a simple way. I think standardized work is about four questions:
- Who does what?
- When do you do it?
- How do you do it?
- Why do you do it that way?
The old procedures approach usually focuses very heavily on the detail of #3. The other things are important too — asking the staff to re-evaluate and determine who does what. Should nurses be dragging bags of dirty linens down the hallway? No, they decide that should be done by a tech — and management and the team also make sure that the tech hasn't been overloaded with a 120% job. It's not about just dumping work on others, it's about making the best of use talent (often, it's scarce talent).
When should you do things? Why do the first shift laboratory technologists shut the testing machine down for maintenance at 7 am – a busy time of day when test results are delayed?? Because it's the start of their shift. Habit. If it needs to be done once daily, the team can decide to do it at 10 am, when it' s a very slow period
In all of these cases, people should understand why. Why does it matter who does what? Why does it matter when you do it? Why does it matter how you do it?
It's not restrictive or limiting
I love the quote from Bill Marriott that says, at the hotel chain, procedures (they don't call it standardized work) don't lead to “mindless conformity” from employees. Standardized work doesn't eliminate the need for judgment, it doesn't mean shut your brain off at the door. From a review of the book The Spirit to Serve:
Emerson once disparaged “foolish consistency” as the “hobgoblin of little minds.” But Bill Marriott has not confused mindless conformity with thoughtful standard-setting. Consistent systems and procedures are main engines for the company's success – and at the heart of “Marriott's way”:
“At the most basic level, systems help bring order to the natural messiness of human enterprise. Give 100 people the same task – without providing ground rules – and you'll end up with at least a dozen, if not 100, different results. Try that same experiment with a few thousand people, and you end up with chaos. Efficient systems and clear rules help everyone to deliver a consistent product and service.”
It helps. Procedure manuals don't create good service. Thinking people do. At Marriott, and Toyota, the idea is to standardize what you can so you can have the mental energy left to focus on UNUSUAL situations and problem solving. Do their manuals cover EVERY situation that could possibly occur? Not possible. As a pilot friend of mine says, “checklists don't fly the airplane.”
In the Geisinger case, the cardiac surgeons are allowed, of course, to deviate from the standardized method. But they have to be able to articulate and defend a clear medical need. It's not just a matter of you woke up on the wrong side of the world and didn't feel like giving an antibiotic before surgery.
There's a guy who criticizes my advocacy for standardized work because (I think) he assumes that I am advocating “mindless conformity.” That's never been the case and if he read my book or really read my blog, he'd have a chance of seeing that. Then again, he makes blanket statements like standardized work is always bad for services or lean doesn't work. We agree that the wrong-headed application of the concept is harmful, but he takes it to an extreme that it's always bad because it's sometimes misapplied…
It's not permanent
In any Lean setting (and this is true in the checklists approach), standardized work is NEVER permanent. It's just the best way we know how to do the work today. Even Henry Ford said almost 100 years ago that every process is experimental. Today's standardized work is the basis for tomorrow's kaizen (or continuous improvement). This is clearly taught by Toyota and it's being taught in healthcare.
As Toyota teaches – every employee has two jobs:
- Do the work
- Improve the work
With Lean, we follow a scientific method for improvement – the “Plan Do Check Act” cycle.
You don't beat people up for not following it
One final point – what happens when a manager sees somebody not following standardized work?
You don't yell. You don't make a thoughtless remark that pressures them into conforming. You don't make a face that says “what's wrong with you?”
The best thing you can do — ask WHY? Maybe there's a good reason (and that's OK). Maybe the employee doesn't understand the standardized work and they need more coaching – be a coach, not a cop. Maybe the person is experimenting with a new, better way.
If you force conformity, you'll kill kaizen. Your organization starts to die. Back in my days at GM, the UAW guys had a term — “malicious obedience.” Managers yelled at them and told them to follow orders, to not think. The workers said, “OK” and did things that were often bad for the product quality because the bosses told them to. And you wonder why GM had such problems? We don't want hospitals, or other organizations going down the Lean path to have such problems.
Thanks for reading – thoughts on any of the points? This post will evolve over time as I better document some of the references, particularly to the Toyota source material that I don't have right in front of me.
If you agree with these points, which ones do you see violated most often? What can we do about it?
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Mark, get John Bichenos new book called the New Lean Tool Box and look at his section on standardised work. Andrew
Thanks, Andrew – is his take wildly different or consistent with what I’m saying?
After asking that, I found that page on standardized work on google books:
http://www.amazon.com/Lean-Toolbox-4th-John-Bicheno/dp/0954124456/ref=cm_cr_dp_orig_subj
He calls it “standard work,” I see. It seems pretty consistent with what I’m saying. I like how he says that forcing standard work (work standards) on people leads to absenteeism and industrial sabotage.
He shares that Toyota places emphasis on workers creating their own standards. Good!
Thanks for sharing the link and reference. How nice that you can read that online!
I’m pretty sure Bob was never a Wiremold employee, but he did write about them.
Hi Mark, Great post that brings it all nicely together. I often quote Julian Richer from Richer Sounds – a UK hi-fi retailer that consistently holds the record for highest turnover per square foot. Julian says that “at any one time there is one best way of doing something”. His people are all different but they all manage to provide excellent, knowledgable service.
I guess the biggest challenge I find with management is getting them to get the balance right between creating the discipline to follow the procedure and encouraging the improvement ideas. Staff can equally find this tricky but not quite as often as the managers :-)
Is ‘scientific method’ the same as ‘scientific management’?
.-= Jefferson Martin/synfluent ´s last blog ..Factory Floor Revisited =-.
Jefferson – no, I think “scientific management” (the approach from Taylor — your avatar) is altogether different than the scientific method.
http://en.wikipedia.org/wiki/Scientific_management
If you believe wikipedia, the 3 main criticisms of Taylorism are:
That’s not the Lean approach, although we owe Mr. Taylor gratitude for his advances of the Industrial Engineering field… I think the mindset was mostly wrong.
http://en.wikipedia.org/wiki/Scientific_method
I think scientific method is much more self-directed. Healthcare people, especially, relate well to this as they’re trained this way as doctors, nurses, etc.
Dr. Jack Billi, from the University of Michigan Health System, has a great comparison chart showing the lean improvement / PDCA cycle and how it perfectly parallels medicine.
Mark;
Thanks for the comments.
I like the personal responsibility which comes with PDCA; something which was absent in Fred Taylor’s time and age.
.-= Jefferson Martin/synfluent ´s last blog ..Factory Floor Revisited =-.
I just finished the Standardized Work chapter in your outstanding book. You may want to consider adding #4 to this post:
1.Who does what?
2.When do you do it?
3.How do you do it?
4.Why it is done that way?
You make a great case on pages 84-85 for the improtance of explaining why certain steps are necessary or why things shoulds be done a certain way.
Explaining why also is consistant with Spear’s first rule of use to include OUTCOME along with content, sequencing, and timing (questions 1-3 above).
.-= Brian Buck ´s last blog ..Advice For First Time A3 Authors =-.
Brian:
Good point about adding “Why”. In fact, in Job Instruction from Training Within Industry (also known as “Toyota 4 step training method” in my world – I’m sure they’re not perfectly equivalent!) the job breakdown includes: Major steps, key points, and reasons why. It makes a big difference in training. I tell people that if there isn’t a good “reason why” affecting safety, delivery, quality or cost, it probably isn’t a key point! (like which foot to step first with, in Mark’s example, above).
So, “why” gets emphasis in training, but it usually is dropped in descriptions of standard work which are more something to check against, audit and provide stability. And remember, it is the work itself that is standardized… the documentation is just that, documentation, and can take many forms. Pictures even. Or at least that’s how I see it!
Yes – you are right about explaining why. I assume that should be part of the approach and I didn’t articulate that clearly enough or well enough. You should explain “why?” and make sure people understand why even in the cases where you aren’t having to force standardized work (like gloves or safety glasses).
I’m making a few edits and clarifications based on your feedback. Thanks.
Mark,
Great post!
I work for as a Lean Six Sigma Black Belt in the public sector. Many years ago, we hired a consulting company that came in and tried to teach us the ‘ways of lean’. Generally speaking, they did a pretty decent job. In spite of that, and for many reasons, we have generally failed to implement any meaningful level of lean activities. Sure we’ve got a few isolated areas here and there that have done great things and continue to sustain and grow, but across the entire organization (~5,000 people) we’ve mostly fallen flat. Some might say I am being overly critical. If I am, it’s because now that I can see I recognize that we could do SO much more.
One of those variables that have impeded our progress is this simple little concept of “Standard Work”. I’ve heard it defined from: ‘doing it (the process) the same over and over [what I term process repeatability]’ to ‘your business unit is doing (insert any process here) and business unit X is doing the same work. You two need to do standard work. You know, do it the same as them’ [what I call stupidity].
This little concept turns out to be quite a bit more than what we think it is. In fact, after several years of using and teaching standard work, it still teaches me something nearly every day.
Keep up the good work.
Good post Mark and nice comment Todd. I found the post insightful and a very good description that seems lacking in many “Text” books. I find the comment just as insightful because it lends a lot of prudence to a statement a client of mine always makes. When people ask him which Lean tool is the most important, he always claims Std. Work without hesitation. He claims that of all his Lean Customers the ones that understand and have a procedure for Standard Work are the most successful.
Such a simple term with so much power. The more I understand Lean, the more I believe Standard Work may be at its center.
.-= Joseph T. Dager ´s last blog ..Interview with Author of the Lean Blog, Mark Graban =-.
Joe – thanks for your comment. Toyota always calls standardized work one of the three “foundations” of lean (as illustrated in the “lean house” diagrams”) — along with heijunka (level loading) and kaizen (continuous improvement).
Standardized work is very powerful… but I think the real intent is often misunderstood by those who view the world through a Taylorist lens. It’s not just the documents, but the way you manage and the philosophy around standardized work that’s important.
Some are hamstrung on the technical definition that Toyota standardized work has three elements: Takt-Time, Working Sequence, and Standard In-Process Stock. I think the Toyota definition is pretty narrow, although it suits their needs:
http://www.toyotageorgetown.com/terms.asp
They define working sequence as:
There’s a lot of talk about purpose there. And I don’t think they mean “do everything exactly the same” even on the assembly line. Certain things matter, certain details don’t.
Mark, I enjoyed this post and the comments. In my experience there are a number of myths about Standard work which you can discussed here. One you did not is that you can train anyone to do the task. Not true. Standard work doesn’t necessarily make the task easier. That is where mistake proofing, visual controls, and TWI comes in. There is also this belief by some that if you standard work people won’t deviate. Not true. Standard work makes it easier to notice but you still need trained observers. Again, I think this is where other techniques in combination with Standard work like the ones I listed above are more effective.
I also don’t buy in to the idea that “there is no improvement without standard work”. I believe “there is no improvement without improvement”. It is training in “learning to see” and the right attitude that leads to improvement.
To that point I have found from experience you can not implement standard work just because someone thinks that is the right thing to do. There are 3 prerequisites that are needed to be effective with Standard work which Liker points out: 1) Work tasks must be repeatable 2) line and equipment must be reliable with minimal downtime 3) quality issues must be minimal. I would recommend improving these first.
[…] My Thoughts on Standardized Work dal Lean Blog di Mark Graban: Un bellissimo post di Mark Graban che raccoglie la sua esperienza e idee riguardanti il lavoro standard (traduzione automatica) […]
Hi
I just read your blog for the first time and found your summary very helpful. I was wondering if you or any of the readers have ever tried to align ISO 9001 with Standardised Work? If so can you recomend an appraoch? Any lessons learned?
Thanks
Sue
Hi Sue – I’m not a huge fan of ISO 9000 because the certification seems to not correlate well to actual quality outcomes.
One thought on SW and ISO though – ISO can be very bureaucratic in the document control and change management process. Standardized work needs to be changeable over time (“kaizen”). Some organizations make their SW documents fall in the category of those that aren’t under ISO document control, so that they can be changed more easily by workers.
That workaround seems to illustrate one of the ways that ISO seems to work against quality (encouraging fixed work instructions that are hard to change)….
I’m glad to see this thread resurface – there’s important stuff here.
During training in the initial stages of bringing lean to one of our operations that was ISO 9000 certified, one manager’s eye’s openned wide, and she said “so, we’ve standardized and certified that we will be creating masses of waste every cycle”. It was brilliant insight, as far as I was concerned. I couldn’t have scripted it better!
It took a while, but they decided to drop the ISO 9000 program (there was no regulatory or customer requirement) and just focus on continuous improvement. Standardization as a platform for problem identification and improvement: What’s the target condition? Where are we deviating? How can we make these more visible? What action will we take to correct the deviation?
In the book JIT is flow, Erik Hager did an interview with a lot of these discussions about standardized work and standards. The key is to realize that standardized work documents are not just an operators tool but a managers tool. The training is based on the standardized document (that the operator helps to develop). Once the training is in place, the documents are used by the manager to observe the process and see if it is being followed and/or improved. If it is not being followed then the question why has to be used. Maybe the operator has found a better way, if so then the documents need to be updated and the learning needs to be applied to other areas (if applicable). Standardized work is not set in stone, it is the best way we’ve found so far to do the job.
[…] Mark. My Thoughts on Standardized Work. https://www.leanblog.org/2010/02/my-thoughts-on-standardized-work/ Like this:SukaBe the first to like this […]
[…] and quality are the goals. Standardizing is merely a tool to ensure that those real goals are met. Standardization for the sake of standardization is frivolous. All Lean tools should be implemented only if they will produce […]
Here is a new article I wrote for LEI:
“Standardization is a Countermeasure, Never the Goal“
Another post:
http://www.leanandtps.com/2011/10/why-your-standard-work-initiative-is.html
Mark,
I appreciate the sentiment expressed in the quote you posted but found that some of the rest of the post might hold people back from applying the principles of lean and standardized work to their circumstances:
This could encourage the commonplace thinking “we’re different, it won’t work here!” that we all run into as an objection to lean. Some of us don’t work in the world of those parameters, where those particular tools fit, but we still can find ways to create visual standards for work which, in turn, make deviations obvious and thus enable kaizen.
Cheers,
-ALB
Great point, Andrew. I encourage people to think through how standardized work concepts and different documents apply to their own settings.
I’ve seen some people get too prescriptive or rigid, trying to force fit a particularly form into healthcare. Standardized work doesn’t require “takt time,” even though that might seem shocking to some. Takt time can be very difficult to calculate in healthcare… I wouldn’t worry too much about “true standardized work” as much as “what works?”
Agree with having less rigid standard work in healthcare. I have seen many consultants and employees (new to healthcare) try to shoehorn takt time and combination sheets into healthcare jobs that do not meet the manufacturing requirements expressed above. It never works as well as a simple set describing the who, what, whens by the staff with their language. A set that gets reviewed as part of the PDSA cycle.
[Funny how this blog post from 2010 keeps being linked to from all kinds of places, today I found it in a LinkedIn group]
Thanks, Eduardo.
Yeah, we should often start with the basics of high-level standardized work — who does what and when do they do it before diving into details of timing everything. Most healthcare work is not a repetitive 60-second job cycle… so standardized work applies (conceptually) but it often has to be a little bit different for its environment and the type of work.
Takt time is partially set by the customer; how many “items” does the customer want in a certain time period. I would think that “turnaround” time is very meaningful to patients and as such should be calculated.
Yes, the takt time is customer demand divided by our working time. We often get to choose our working hours per day, but not always, in healthcare.
Turnaround time IS very important… it can be measured, but I’m not sure how you can “calculate” it.
Hi Mark,
This was a great article and I really enjoyed reading it. I fully agree on all of your opinions whenever implementing standardized work. My question for you is, do you think there is a correct time to standardize work? In other works, is a particular workstation only ready for standard work once is is free from major forms of waste? Many times if have been asked to standardize work that is filled with huge manufacturing issues. Such as 50% rework rates, old inconsistent machinery, and poor quality from supplied parts. How do you standardize such a process with so much wrong with it? I feel you must fix the quality/rework/machinery issues first prior to ever dreaming of any sort of standard way of doing something?
Hi Peter-
I think the right time is now. Standardized work is really just an understanding of how the work is done today, good bad or ugly.
There might be variation or variability in your current standardized work due to the problems you mention… remember, standardized doesn’t mean identical. As the environment gets more consistent, the process will probably be more consistent.
This all goes hand in hand… document your current process, work on improvement, and update your standardized work. It’s a cycle of continuous improvement, not a static document to create.
I’d also keep in mind WHY standardization is helpful. If you’re being asked to standardize, I’d ask “what problem do they want you to solve?” other than “lack of standardization.” Is it a quality problem? Efficiency? Both?
I hope that helps.
[…] is a blog post I wrote about “standardized work” a few years ago, which emphasizes, among other things, that Toyota has long emphasized that […]
Hi Mark – I’d like to frame a course on Standardized Work in the Shewhart cycle. Contemporary Problem Solvers explain the problem solving A3 as a CA-PDCA cycle. Mapping to Standardized Work, does this indicate we should teach the Check-Act tools of Standardized Work first? Say we only have time to teach a few concepts; would we benefit most from engaging the student in the reflective learning tools of Check/Act or better in the definitive planning tools like the Job Breakdown sheet and training matrix?
Thanks – in healthcare I am constantly affronted with the challenge to reduce classroom time. And to maximize value this question has come up.
As always, best regards to you!
Matt
[…] ‘New Staff Tax Auditor Manual’ is an excellent representation of standard work, helping to ensure new employees receive consistent training and are clear on what is expected of […]
[…] Checklists are also a very good form of mistake proofing (and an example of “standardized work“). […]
Great Article! The health organization that I work for often struggles with rolling out standard work and operating procedures. We will spend weeks bringing in team members who do the work and developing standardized work through best practices and when it becomes time to roll out the standardized work, there are 1 or 2 individuals who do not follow the processes or do not roll the processes out to their teams. Basically, they are not behind standardized work as they have been doing the process “the same way” for so long and it’s “working just fine”. How have you dealt with this in the past?
Hi Josh – Yes, I have been in that situation A LOT.
I’d want to dig in and ask why they’re not behind the standardized work. Does the variation matter? Does the variation cause a problem?
If they say, “I just like doing it the old way” or “That works for me” then you can try to bring the discussion back to what works best for the customer. What works best for safety? What works best for quality?
Maybe they are rightfully afraid that the new way will hurt their productivity in the short term. Is the organization being patient with them during that learning curve? Is the organization coaching them through the new way or just expecting them to flip a light switch and do it well right away?
Only as a last resort should leadership fall back on saying, “This is non-negotiable… you MUST do it this way.”
I like how you put an emphasis that standardizing for the sake of standardizing is not the goal of lean. While many people may think that standardization is the general goal of lean thinking, it is typically an outcome of pursuing the actual goals which are safety, quality, cost, etc.
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