Thursday, April 3, 2014

A key concept in Lean is that of standard work, but it goes beyond Lean.  A major cause of harm to patients worldwide is the large variation in how common medical procedures are carried out.  By definition, if there is a lack of standardization, not all approaches can be based on the best available clinical evidence.  We seek then, to adopt protocols that embody the best knowledge about how to do something right.

Brent James explained this a few years ago:

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

Part of adopting protocols is to enable people to learn them, and it is here that there's "many a slip 'twixt the cup and the lip," as the old proverb goes.  In many hospitals that have adopted protocols, the sequence of steps is presented in written form in a hospital manual or on its intranet site.  Perhpas a nurse or resident is taught the protocol on the floor, but the teaching is uneven--sometimes not reflecting the entire protocol--and many times it occurs once, and then the clinician is left to try to remember it. Variation sneaks in and standard work is eroded.  Patient safety problems emerge.

It is our nature to vary from the protocol we are taught, especially if the training occurs in just a few episodes and especially if the training material that remains is only in written form.

Annette Koning from the hygiene department at Jeroen Bosch Ziekenhuis in the Netherlands realized this was a problem with regard to the hospital's protocol for cleaning and maintaining central lines.  So, with a colleague, she prepared this short video as a teaching tool, but also as a reminder tool for the staff.  I think it is an elegant presentation, and I offer it to you as an excellent example of (1) a Lean appraoch, where every person feels empowered to engage in process improvement; (2) quality and safety instruction; and (3) pedagogical excellence.  I hope you enjoy it and will consider using it or a similar approach in your hospital.


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