Nick Downham – 2015
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A few years back I was captivated by surgeon Atul Gawande’s superb Reith lecture on the role of systems and standards in healthcare (Reith Lecture No 2). It got me thinking.
Lots of organisations struggle with variation, with standards (sometimes called standard operating procedures, protocols or specifications) and with the practical application of improvement methods. I thought it would be useful to share some of my insights about how standards and managing variation are vital disciplines for any organisation; and how they have to be used appropriately, carefully and with a systems perspective.
Standards are a means to an end
Firstly, standards are there to control or reduce variation. Lots of people trying to improve services, departments or teams lose sight of this. They try to standardise work for the sake of it. This is generally because they have seen the tools applied elsewhere or they are in the school of thought where ‘I say, you do’ prevails.
The use of standards is all about limiting variation in certain parts of an organisation, process or activity. They are generally about consolidating an exercise, task or procedure to reduce variation.
Appropriate reduction of variation is a good thing
This is the biggie and the key here is the term appropriate. In health care, and many social care settings, controlling all variation is neither appropriate nor desirable. That said, reducing variation in the right areas can be amazingly helpful for patients, organisations and clinicians. We just want to avoid restricting those in a position to help people by wrapping them up in unneccary standards that in fact have the unintended consiquence of actually reducing our ability to help people.
Reducing variation can help make processes more predictable – making planning easier and helping waiting lists go down. It can help in the application of known best practice, raising confidence levels and outcomes. It can help with governance and it can improve the experience for patients.
Watch out for the toolheads
There are many examples of standard operating procedures implemented in a clumsy manner by improvement specialists who lose sight of the core principles. When done in a clumsy way, it can end up in the national press. Check out this piece of press coverage about a rather avoidable and unnecessary approach. In this case the application of visual standards in the National Insurance Contributions (NIC) main offices in Newcastle.
How this happened we can only speculate. There are many transactional, high volume repeat processes in NIC which suit the use of traditional standards, and so why the consultants ended up looking at tidying desks in a manner that got such a reaction is slightly mystifying.
You need to understand the variation in the first place
The first step is to understand the levels of variation in a process or activity. Using techniques such as run charts and SPC charts, you can understand the nature of the variation and differentiate between natural and special cause variation. It is key to understanding whether the process or activity in question actually needs some form of activity to reduce variation in the first place.
Standards are one way of doing that
Creating standards often makes an important contribution to the aim of controlling or reducing variation. Reiterating an earlier point, the end point is the reduction in variation. One of the means to that end is the creation of standards. Of course, there are many other factors to consider. Such as staff engagement, understanding the current levels of variation and, finally, identifying the most appropriate point for an intervention. What you want to avoid is putting in a standard to try an limit variation in work, that is infact caused by a poor system. In this case the system would need to be redesigned, rather than a sticking plaster standard applied.
It depends on what you are working on
There are lots of ways of creating and applying standards to help reduce variation. It generally depends whether you are looking at process or clinical variation. Of course, it is never that black and white as you can never tease the two fully apart – but it is useful to try to make the distinction.
Another consideration is the root cause of the variation. Lots of demands on services are in fact caused by failures in another process or activity upstream (before). You don’t want to be standardising processes and activities resulting from failure demand. For example information not being passed on, sub optimum interventions or certain information not being collected. This often means extra consultations, clinic visits, bed days or diagnostics are required. These extra demands are called failure demand (a term coined by John Seddon). You don’t want to be standardising processes and activities resulting from failure demand – you want to be removing the failure demand in the first place.
Professionals hate the term standard
The words ‘standard’ and ‘standard operating procedure’ don’t have a great reception in healthcare. After all, healthcare is hugely complex and inherently has huge variation in much of what is demanded of it. I tend to talk about increasing consistency of approach; something most clinicians have no problem connecting with.
Lots of things are standards – they take many forms
Limiting variation is not all about paper standard operating procedures. Visual management techniques are, in many cases, visual techniques that are intended to reduce variation around a specification. Take the most recognisable visual management standard of them all – the double yellow line. The humble double yellow line is a visual standard that is designed to standardise (reduce variation) around car parking behavior. Helping parking attendants make quick decisions around parking violations and, more importantly, help car drivers understand where they can and cannot park. Imagine what life would be like if you had to consult a book or a map to find out where you could park….
Standards are no good if they are not upheld….
A fairly obvious point but one that is often under considered. The key to ensuring standards are upheld is to make sure they are created by the people doing the work; by those who are closest to the activity and by those who have the most knowledge of the practical detail. This ideal links back to the earlier point around the move from craft to professional group-based accountability. In recent work with newly integrated local authority teams who are tasked with supporting and protecting vulnerable children, we have been having some fantastic discussions around the role of professional accountability in upholding standards. With the teams we reflect on how it is not just about a team leader, or a manager being responsible for a given standard. But rather we need to work towards the whole professional group, across disciplines, supporting and holding each other to account.
John Bicheno from Buckingham University’s Lean Enterprise Unit has created a useful matrix for deciding on the best form of standard – featured below. It links to all the points above, especially the point about being very selective in the use of standards.
The most common form of standard in healthcare continues to be, and should be the checklist. It is not something clinicians should fear or take as a challenge to their expertise. It is simply an aid for clinicians in busy, complex and stressful situations. Situations that clinicians increasingly find themselves in.