I am running teaching on Lean for first line health and social care managers. The groups include Charge Nurses, Team Leaders, Senior Staff Nurses, Care Home Managers, dental team leaders and people with similar responsibilities. With a few exceptions, they are people who have been promoted from posts in which all their time was spent caring for people, to jobs in which they also have a management responsbility.
This is a very important group of staff. They spend a substantial proportion of their time in areas where care is delivered – the ‘gemba‘, in Lean. They see what is happening in a service, and are the first point of contact for staff. Their response to problems, and their use of problem solving and quality improvement methods sets the tone for their staff and the patients and clients they work with. If these first level managers feel confident in identifying problems, applying root cause analysis, quantifying causes, prioritising and leading PDSA cycles, then this will make a big contribution to how their staff think about problems.
The course attenders are positive about most of the methods. Affinity diagrams, cause and effect, and driver diagrams are commonplace in health and social care, even if their source is not always recognised. Pareto charts make sense as soon as you see them, and prioritisation matrices take less time to teach than they take to say. PDSA cycles have often been covered in people’s undergraduate training, so don’t come as a surprise. Error proofing, visual controls, and 5S all make sense to people who want to deliver a good service every time, and who need the supplies and materials to do it.
The part that often causes a sudden pause is when I use the term ‘Standard Work’. It doesn’t worry everyone, but there are usually at least a few worried faces. When I explore this, the comments usually include,
‘It could take away professional judgement.’
‘It might treat staff like robots.’
‘It would be handed down to a team.’
‘It conflicts with person-centred care.’
This puzzled me at first. Health care is full of standard work. Clinical guidelines, treatment protocols, patient safety bundles, admission pro formas, discharge forms, medicines safety, medicines dispensing – there are few areas that don’t have some kind of view on how to do things. These usually pass unremarked.
In Lean, Standard Work is the current best way of doing something, decided by the people who provide the service, with input from service users on what adds value for them. This Standard Work may well incorporate decisions on how to deliver a national guideline, or to follow a particular protocol, It usually includes who does what, and with what equipment or supplies. This helps wards or teams to work out what supplies they need, what standard they are applying, and should make it easier to take new staff through the process, and to avoid errors. The Standard Work applies until the team work out a better way of doing things that enhances the value to the service user.
Person-Centred care has varying definitions, but the core is reasonably consistent. The Health Foundation definition includes:
- Affording people dignity, compassion and respect.
- Offering coordinated care, support or treatment.
- Offering personalised care, support or treatment.
- Supporting people to recognise and develop their own strengths and abilities to enable them to live an independent and fulfilling life.
Undertaking tasks consistently well does not conflict with ‘dignity, compasson and respect‘ and Lean should actively enhance ‘coordinated care, support or treatment‘. It’s difficult to see what in Standard Work would stop teams from supporting people to ‘recognise and develop their own strengths and activities‘. Concerns seem to come down to worries about the third point – personalised care, treatment or support.
This is not just a local worry. A Nursing Times article in 2013 commented, ‘the focus on standardisation makes it difficult to meet patients’ individual needs and denies health professionals the opportunity to exercise their skills and professional judgement‘.
This isn’t how I understand Standard Work. The reason health care services employ trained staff is because they need to apply ‘skills and professional judgement‘. While many people using care services will have common issues, professionals are valued precisely because they can make a judgement on when they need to vary from the usual procedures or approaches.
The focus in Lean is on value to the service user. It is possible that some services have improved services at the expense of patient experience, and called it Lean, or have used staff for tasks that do not use their talents and abilities appropriately. This is what Mark Graban calls LAME – Lean as Mistakenly Executed.
The third item on the Health Foundation list above is ‘personalised care‘. A Google search on personalised care brings up 1.6 million hits. Eight of the first ten hits on Google UK refer to personalised care plans , and to standard ways of producing them (search conducted March 2017).
Examples from this first page include personalised care plans for people with long term conditions, Department of Health guidance, an IT system, and details of Personal Care and Support Planning (PCSP). PCSP is ‘a systematic process‘ and the authors comment, ‘it is the personalised care and support planning process as well as conversation which is at the heart of this new relationship and way of working‘. This is, in effect, Standard Work for personalised care. The details of the care will vary by person, but the point of the processes is to ensure that the planning happens to a consistent standard. Standard Work seems to be a core part of how national bodies see personalised care being delivered, rather than an opposing idea.
It’s never good to hypothesise in the absence of information, but I suspect the reasons behind concerns about Standard Work are worry that professional judgement will not be respected; concerns about reduced clinical autonomy; worries about capacity, and a fear that service improvements will focus on productivity rather than quality. All of these are possible, but the way to avoid them is by focusing on value to service users, making sure staff take the lead on the development of their own Standard Work, and making it easier for staff to undertake these value added activities by making other processes easier to perform.
Respect for people is a principle of Lean. Understanding concerns is important, and is part of the respect due to colleagues. We need to be clear on the core values of quality improvement, and be sure that the use of Standard Work is in line with Lean principles. If we do this, we reduce time spent on waste, re-work, miscommunication and error, and increase the time available for value added personalised discussions of care needs.