Tuesday, May 28, 2013

Following the Design and Doing Standard Work….It’s a Mindset Change

Getting every patient what he or she needs requires a large, complex system. In complex systems, the actions of one individual can have dramatic effects elsewhere in the system but since those effects are often not seen, the individual has no idea what they caused. As an example, when a nurse takes a medication from another patient’s bin because the medication is not in his patient’s bin and it is time for his patient to get that medicine, it seems like the appropriate thing to do. The move is well-intentioned. His patient needs the medication and the nurse is “doing whatever he needs to do to get whatever his patient needs.” What the nurse does not see is the effect, a few shifts later, when the second patient doesn't have the medicine in his bin and the pharmacy believes that he does. In unreliable systems, people begin gaming the system to get what they need, thereby making the system even worse.

In a hospital, the notion of moving toward a system of standard work and following a design is so important to making the work easier and ultimately the care of patients better.

It is time to change our mindset.

In our LEAN daily management rounds, we visit a number of units and departments to learn how those units did in the preceding 24 hours. These rounds show us just how hard all of our people are working to get the job done. Unfortunately, a lot of time is spent in working around broken systems. Through the LEAN rounds I have learned that on average, units are searching for a medication that should be there but isn't on the order about 15 to 18 times per day. This is not right. Our nurses should have the medicine they need every time. Rather than having them spend their time in the daily workarounds of broken systems, we need to get them energized about problem solving and redesigning those broken systems.

It is hard to get clinicians, especially doctors and nurses, to believe that following the design and doing work in a standard way will actually improve things. This is the reason why it is so difficult to change the mindset from “I do it whatever way feels right to me,” to “I do it according to the designed system.” They don’t trust that following the design will make it easier for them because the systems have not been reliable enough for them in the past. They believe that following the design will make their work harder. It’s a Catch 22 of sorts.

This is not about working even harder, it’s about working differently. 

We have some great examples of problem solving and change. This move toward standard work has already been successfully implemented on a number of our inpatient units and departments. One of those units is Unit 38. Clinical Partner Kim Vohrer and Administrative Director Justine Kellar have led their team to dramatic improvements in the availability of devices for patients at high risk of falls. These two leaders have really done well at helping their people become problem solvers and to redesign systems to make the work easier and get to better results. Kim and Justine also understand that the mindset change of standard work is hard and that managers need to check back to see that the design is actually being followed.  It’s not realistic to expect people to get into this high reliability mindset from the get-go. Kim and Justine have realized that the verification step is critical - so they now do spot checks of the standard work on their unit. And when they see that the design isn't working, they coach their team, or learn from others about how to improve the design.

Similarly, I’m incredibly impressed with Kathy Bull and her team on unit 35 for implementing the standard work of calling the Emergency Department within 15 minutes of the patient being ready to move to “pull” the patient to their Unit. This new design is having excellent results in reducing the time that an admitted patient waits in the ED.

I believe that if we work differently, we’ll realize that we’re not working harder, but more effectively. This is the power of a designed system where everyone does the standard work. It can be done. We’re seeing the positive effects on Units 35 and 38.

Think of moving from a bunch of smart people working very hard but each doing things their own way toward the new model of standard work as going up a very steep hill; right now, we’re half way up this hill, and if we can just get the courage to forge forward, we’ll make it to the top instead of sliding back down to where we began. Thanks to everyone for helping us on this journey towards higher reliability.


  1. It's not the nurses who need to fix the problems in the pharmacy. It's those who work in the pharmacy, and, more importantly, those at the top who supervise them. Many problems that need fixing are out of our direct control. We can report them all we want, but we really can't change what another department does. Our energy needs to be devoted to our patients, not to solving problems elsewhere.

  2. Thanks, Anonymous. I agree that nurses cannot fix the missing dose problem by themselves. Pharmacy must take the lead but in a large, complex, system like our medication system, it is not possible either for the Pharmacy to do it without nursing's help.

    I did not know how many times each day nurses were trying to give a medication to a patient and they did not have it to give. We cannot be accepting of unreliable systems. We need to get in the continuous improvement mindset and we all need to be problem solvers. I look forward to dramatic improvements to the missing medication problem precisely so that nurses can spend more time devoted to our patients.


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