Tuesday, July 24, 2012

Drone on! Making standard work standard

A couple of months ago, a colleague told me that he had watched the video of my presentation at the BCPSQC Quality Forum.  In it, I had highlighted the detrimental effects of variation in clinical practice.

"Pretty good," he said, "but I'm not sure that everyone should do things the same way.  I mean, I didn't study for all those years just to be some kind of drone!"

It's interesting to hear this free-wheeling sentiment from surgeons.  I can't imagine any health professional more fussy about consistent practice than surgeons. (Why aren't all the scalpels pointing due north!?)  We develop a reliable method though training and experience, and we like to stick with it.  We know we're more prone to mistakes when we deviate from habit.

Coincidentally, my colleague had just completed 2 somewhat finicky procedures that day.  Actually, it was the same procedure performed on 2 different patients.  The operation required specialized equipment, nursing expertise and patient preparation.   Quite sensibly, he likes to do the procedure the same way every time.

I asked him how the cases went.  He saw where I was going.

"I do it the same way every time because that's what works for me.  I don't want to have to do it your way," he said.

He genuinely wants to give patients the best care he can, and uses his experience to best advantage.  From the viewpoint of his own practice, his personal "standard work" serves him fine.  He's convinced about the value of intra-practitioner consistency.

How to convince him that inter-practitioner consistency can further improve quality and safety?

As we discovered in our practice (see the video), demonstrating to practitioners that there is significant variation in clinical practice is illuminating.  (There's no shortage of variation to measure!) Approach the information with curiosity rather than judgment.  In most cases, physicians will have never seen this aspect of clinical work, that is comparisons between practitioners.  For us, it lead to sharing our individual "best practices".

Telling stories about the negative side of clinical variation has been powerful in our practice.  Our staff told us that they found having 8 different ways (8 urologists!) of doing the same task was confusing.  They worried that patients might receive the wrong information or be missed for followup. Solution: Consistency.

Finally, doctors need to have a role in developing standard work.  Last fall, I heard a great comment from Intermountain Health's Chris Wood.  "Yes, it's cookbook medicine.  And you get to write the cookbook!"



  1. Thanks Kishore. I'm really gaining a new appreciation for standardization. Standardizing the day-to-day work is what actually unleashes creativity. The gift of standardization is not for host, it's for the others you invite into the process. "Doing what works for me" is fine if I'm the only one doing the work or affected by the work. It gets dodgy when I need to involve others so we can reach a goal together. I might want them to "do what works for me," but if they're also hearing that same message from 10 other people, who do they listen to? Standardization provides the road map for others to help us collectively succeed. A star athlete can score goals by themselves, but it takes a team to win the game.

    1. Thanks, Lisa. Unleashing creativity - great thought. Freeing our minds from sweating over the mundane!

      A (different) surgeon once told me that he didn't agree with standardization because it squelched creativity and innovation. Au contraire. The very process of exploring clinical variation shows us different ways of approaching a clinical situation. We learn from our colleagues. Once a standardized process is in place, innovation can be deliberate, rather than serendipitous. I'm not sure what the T-shirt would be for that idea...

  2. This sounds like Atul Gawande's book "The Checklist Manifesto"!

    1. Yup. I'm just a few years behind the curve! Also, Jack Wennberg's "Tracking Medicine". I highly recommend both these books to anyone curious about the impact of variation in clinical practice.

  3. Kishore, you need to remind your readers (and other surgeons) that it is very difficult to reach agreement on the Best way to do something.

    In the example you present, I'm sure your colleague would quickly warm-up to standardization - provided everybody did it his way! I think it was you who mentioned that you might not get agreement on The Best, but you can get agreement on Pretty Darn Good - and if everyone does it this way then the inter-practice variation may be minimized.

  4. Thanks, Anon. I love the Pretty Darn Good concept, AKA Just Do It and Perfect Is The Enemy Of Good. Was it me who said that? If so, I stole it.

    Rather than the classic approach of having a committee develop a standardized process while working at a conference table, I prefer the Model for Improvement's PDSA/learning cycle approach. Start with something reasonable, try it in practice, get feedback/measurements, and make improvements. I suspect that even the first iteration of a standardized process would be better than the status quo!