Monday, June 22, 2009

Pig -- Part 3


Turning from round 2, we go finally to round three of the pig game. Hand out this set of instructions, along with another grid. Now, compare the results of the participants.

I'm guessing you will see higher quality pictures and more uniformity. All right, I know this is not a clinical procedure, with all of its potential complications, but the lesson is nonetheless powerful. After our residents took their Lean training course, several of them said this was the most powerful lesson they learned. They now apply it in clinical settings, looking for "pigs" to standardize their work where appropriate.

Remember, we are not trying here to standardize those parts of patient care that should not be standardized; but we are trying to do so for those elements of care than can be and, most importantly, should be to reduce and eliminate harm. In our hospital, we have done so in the following arenas among others. This has saved lives and reduced other harm, plus making life better for staff and patients:

Clinical pathways -- obstructive sleep apnea; Whipples;
Central line infections;
Ventilator associated pneumonia;
Rapid response teams;
Surgical time-outs.

4 comments:

Marianne said...

Paul, you correctly point out that this standardization can help to reduce harm. It can also play a role in ensuring customer satisfaction. We know, for example, that folks have some fairly consistent things that they want to / need to know as they leave the hospital. Ensuring that all those standard questions are answered clearly helps them and you. (And is related to reducing harm...)

Mark Graban said...

This exercise applies in many hospital settings. It can be used to prompt discussion not just about how to write standardized work or protocols, but about how we train.

How often do we just verbally tell someone to do a job, without really defining a clear standardized method?

Or, how often do we throw a procedure printout and say "here, follow this"?

Even with the pig standardized work, you get variation if you don't follow a good basic training method:

1) Show the trainee the procedure document and let them review
2) Demonstrate the work to the trainee
3) Let the trainee do the work under supervision
4) Follow up and test that the trainee has learned.

I've watched a poor medical technology student frantically following an experienced med tech around the microbiology lab, taking notes as the technologist verbally talked her through how to do the job. She wasn't hearing everything and certainly wasn't getting it all down? Is that any way to train a person?

What other questions come to mind about how to train, from this exercise?

And the debate about standardization is a good one. Toyota says "standard-IZED" rather than "standard" because there is a spectrum ranging from full chaos to robotic precision.

Often, the most quality benefit comes at a point somewhere in between. I'm sure Paul and BIDMC aren't trying to turn anyone into an unthinking robot. That's not the point of standardized work at all in any setting, yet alone a hospital.

Anonymous said...

on a bigger scale, have you had any success incorporating lean techniques into the rest of the academic and/or private hospitals in boston?

if not, why do you think that is?
resistance at administrative level towards working together? resistance of physicians? lack of time to work towards these common goals? lack of agreement about what goals need to be addressed?

thanks

Paul Levy said...

Sorry, I don't understand the question. I don't have any authority with regard to the other hospitals.