Monday, June 22, 2009

Pig -- Part 1

One of the lessons of Lean is that if you standardize work, you not only reduce variation, but you improve the quality of the product or service. This is known to be true in the delivery of medical care, but it is often not practiced in hospitals. Instead, hospitals remain cottage industries, with each craftsperson (doctor) plying his or her craft (clinical care) on the basis of experience, intellect, and creativity rather than on the basis of scientific evidence. This leads, nationwide, to extension variation in practice patterns (and cost). More locally, it leads to greater potential for harm. What we need, instead, is a greater reliance on standardized practices in those portions of medical care than can and should be standardized -- still leaving to doctors their ability, creativity, and craftsmanship for those circumstances that truly demand those attributes.

This pig game demonstrates the value of standard work flows. It's fun and illustrative of the concept. Find some friends on whom you can experiment. We'll start with this posting in round one, and then rounds two and three follow below. First, prepare standard size pieces of paper with the grid shown above -- one per participant. (If you click on the picture of the grid, you will get an enlarged version you can print out on paper.)

Now, read the following instructions to your friends: You'll probably have to repeat the instructions.

1) Draw the side profile of a pig, centered on the page.
2) Make sure the pig's head is facing left.
3) The pig should be drawn large enough so that a piece of it is in every box EXCEPT the top right.
4) You have 2 minutes to draw your pig.

Now, have everyone show their pig drawing to everyone else. OK, go to round two, below.


Marcus Cazier ( said...


What a great tool to teach standards. May I use it with my staff? Do I need to give credit to anyone besides you?

Thanks for sharing!

Anonymous said...

Go for it! That's why I shared it. I'm not sure who developed it. If I find out, I'll add that, and you can give due credit.

Anonymous said...

Where's the part where you put the lipstick on it? (:

Seriously - interesting exercise.


SGJ RN MSN said...

I agree that there needs to be science, but when providers of health care are no longer allowed to practice their art, to trust their guts, then we have lost something very important.

And patients will die and wrong decisions will be made.

I do not see yet how you can find the proper balance between science and art, between EBP and gut, in health care.


Anonymous said...

No one is suggesting that people shouldn't practice their art but I am suggesting that there are many routine aspects of medicine that can be standardized. Just look at the examples I have included. The physicians involved do not feel that their rightful prerogatives have been taken away.

I don't see why you find it hard to believe that the balance can't be drawn. Our protocols are designed by our doctors.

Anonymous said...

To SGJ RN MSN, I think the exact opposite is true: more patients are being unnecessarily hurt because there is a lack of system design and intentional process standards design. We are simply lucky more people aren't hurt. Spend a couple of hours quietly observing workflow at an inpatient unit in ANY hospital - maybe a unit other than your own, as most people are too close to their own space - and watch the challenges people run into each moment. Does everything go perfectly each time? (Is everything where it should be - information, equipment, immediate access to any other caregivers with whom you need to consult?). Does everyone know all of the details of every single policy, and follow it to the letter everytime? I would think not.

I find it frightening, frankly, to rely on "trust the gut" instincts of a highly stressed, sleep deprived resident (or any provider), without standards and systems in place to support him/her. Providers are human, and need to be supported by systems that make sense. This is true of virtually every high stress environment.

Anonymous said...

Now, add to the 'craft' problem - where variation remains well-defended but essentially untested - the silo problem. Each department applies its own standards and oversight subject to the intelligence and influence of its chief. Now ask each chief to play by the same playbook, pick up the pen and take this test together. I'd venture to say that the best academic hospital would have a misshapen pig. Eliminating harmful variation and playing this game requires power as well as cooperation.

Unknown said...

I love this exercise and have used it many times. I don't know, either, where it originated...

Anonymous said...

I agree with the 2 last anon's that more standardization is needed, for sure. I think, however, that what SGJ RN MSN is trying to say is that sometimes an experienced practitioner gets a "sixth sense" sort of feeling about a patient that something is not quite right about their clinical condition, even if all the protocols are being followed and all the numbers look right.
The practitioner must retain the ability to take action on this basis, rather than being constrained to ONLY follow the protocols. This is an integral part of the "art" of medicine, and, as I mentioned, is highly experience-based. We used to use the phrase "the patients don't read the books" - in other words, the disease may not manifest itself in a typical way that is described in the literature. One must always allow for this, otherwise anyone could practice by just blindly following the protocols.

nonlocal MD