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The Stigma--and Support--of Standard Work in Healthcare

By Tina Hallberg, RN, Senior Consultant, GE Healthcare Partners

In a world where personalized care and service is so pervasive, such as in healthcare, it’s common to hear hesitancy toward standardization through statements like, “I am not a robot” or “Every patient is unique and different.” Not every heart attack is the same, just as not every medication affects patients in the same manner. “Listen to the patient, provide a therapeutic milieu, treat them for the unique individual they are.” These words have been reiterated over and over by employers, educators, and even patients themselves. As a nurse, I get it. As healthcare providers, we have endured years of training and even pressure to be autonomous toward anyone before us in the exam room or hospital bed. It’s not surprising when I’m met with resistance to implementing standard work in the medical arena.

However, standards aren’t new to healthcare; they’re everywhere. Best practices exist for treating the heart attack, how to take the medication, even trauma care with the ABC approach of checking airway, breathing, and circulation. Patients are safer when we do adhere to best practices, when staff are consistently trained and follow clinical protocols. Medicine is part science and part art. The clinical algorithms, formulas, and research provide us with guidelines and standards to determine the overall health picture of each patient. That is the science. The art is how we mitigate and manage what the data tells us; how we select treatment plans by carefully incorporating the uniqueness of the individual patient into the numbers. Embedding evidence-based standards into the practice of medicine ensures we have consistent, high quality and safe treatment of patients.

So why do so many bristle at the sound of standard work? In its rudimentary definition, standard work is merely a prescribed sequence of repeatable steps. The objective is to minimize and control any inconsistency/variation whether it be in quality, inventory, cost, or outputs. It defines normal conditions and highlights instances when abnormal circumstances arise. The perception that standard work removes the art side of healthcare couldn’t be farther from the truth. It’s meant to make the care of patients simpler and create more time for the art of medicine; the personalized care and service. 

The Significance of Sequence

Consider standard rooming. When bringing a patient to the exam room, I carried a Visit Wizard, a simple checklist of the tasks I needed to perform in order to room the patient. Obtain chief complaint, review medications, take the pulse, temperature, respirations, and blood pressure. Anyone who has roomed a patient in an outpatient clinic may argue this Visit Wizard isn’t necessary, and I’ve heard the reasons. “I know how to take vital signs,” and “I do this already, it’s just extra paper.”

Two reasons why the Visit Wizard was helpful: first, it ensured I captured all components of the rooming process; second, and more importantly, it ensured I did the tasks in the right order. If I obtained the blood pressure first instead of at the end of the process, it would invariably be high due to the patient walking, taking off their coat, getting situated, etc., instead of at rest: the blood pressure we wanted. That higher reading could create a domino effect: the clinician is concerned about hypertension, possibly medicates the patient unnecessarily, and potentially puts the patient through a myriad of needless tests because of poorly timed data collection. In fact, when we instituted the Visit Wizard, they were able to declassify over 40% of the patients off the hypertension registry and off medication because they were falsely categorized.

Staff were trained on the Visit Wizard across all 30 clinics in our health system and, over time, the Visit Wizard became habitual. Any patient could go to any clinic and be roomed by any staff, but would receive the same rooming process, enabling consistent, high quality, and safe care. The Visit Wizard was even adapted by medical subspecialties who put their own twist on it. For example, the podiatry clinic used the same sequence, but added, “remove shoes and socks” at the end of the list.

The Aptitude of Autonomy

Another key takeaway is standard work frees up time for more personalized care and service (more time for the “art” of medicine). In the past, I may have finished rooming one patient and was on to the next when I realized I forgot to do something with the first patient. I would rush back, possibly interrupting the clinician visit, taking time away from the next patient or even missing the first patient altogether. These instances add time into the day, disrupt patient and provider flow, increase stress and chaos, and increase risk of inconsistent and/or missed opportunities of safe and quality care. With the Visit Wizard, my true task work was indeed shorter, and I had more free time to have that individual conversation with each patient without rushing.

Deliberate Design and the Spirit of Improvement

Standard work also means work is intentionally created. We don’t leave things to chance for individual team members to “figure out.”  Just as our healthcare products are carefully designed to keep customers safe, we must design the work to keep our team members safe. By using standard work to establish consistency it becomes the first line of detection for abnormalities. People are now in control of flow, quality, machines, material, and every other aspect of providing care. It certifies we don’t ask people to do the impossible. Training staff becomes easier and the identification of opportunities is clearly visible. Establishing a consistent baseline of how things are, standard work lets us easily see where we need to make improvements, and measure whether we accomplished what we set out to do.

Whenever employees develop new standard work, they become more confident and better skilled — mastering their jobs and growing in their understanding of new aspects of their work every day. After standard work is developed, deployed, and refined, staff are freed up to use creative thinking to investigate other systems and to devise new ways to improve them, because team members ask, “How can I make this work better for our patients?” While clinical studies and evidence of best practices guide our work, we’re still dependent on medical specialists and staff to use their best critical thinking, judgment, and knowledge gained through education and experience to deliver high-quality healthcare.

The challenge is that healthcare is complex and often chaotic, and people make mistakes. What’s more, variability in our processes leads to variation in patient care. In healthcare, we know that no mistake or variation should be acceptable if it leads to an increased risk of harming a patient or staff member. Standard work balances the science that can save a life with the art of personalized care and service we all deserve.

GE Healthcare Partners has helped dozens of organizations improve the quality and safety of their processes. I’m optimistic about the opportunities in front of us to keep moving these efforts forward.


HallbergTina Hallberg, RN, is a highly experienced registered nurse and senior consultant at GE Healthcare Partners. Her leadership and managerial skills are coupled with 20 years of nursing experience in acute hospital settings, including transplant and flight trauma, long-term care, and clinic settings including the roles of Chief Nursing Officer, Director of Nursing, Case Mix Manager, Staff Development Coordinator, and Operations Supervisor. Tina maintains sensei-level expertise in the application of Kaizen methodology to healthcare. She obtained her training under the tutelage of Taichii Ohno’s protégés through multiple missions to Japan. She may be reached at kristina.hallberg@ge.com.

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