One of the most common problems in long-term care is around line staff not following correct work procedures. Long-term care communities have no shortage of policies and procedures, nor are they typically shy in disseminating them to staff over and over (usually after a disciplinary counseling or adverse event). Unfortunately, problems with compliance seem to reoccur, and significant time is spent fighting fires as a result.
So what can be done?
Lean uses a concept called standardized work to describe a more sustainable approach to process and work management. Standardized work is very different than a policy and procedure, and it creates a much different result, as well.
1) Standardized work is written by those who do it. I once worked with an Executive Director who hated writing policies and procedures. “Anything but that!” he would say. His biggest obstacle, however, was that he tried to sit in his office and write out what staff were supposed to do. This is a recipe for disaster. Standardized work is accomplished by having those who do the work write out the process. Managers need to be involved too, particularly making sure all regulatory requirements are addressed, but line staff should lead the exercise.
2) Standardized work is the best knowledge at the time and must be changed whenever improvements occur. Policies and procedures tend to last far longer than their usefulness, and it’s not uncommon for us to walk into a building and find P&Ps that haven’t been reviewed or updated for years. In addition, line staff view P&Ps as mandates from above that must be followed regardless of whether they make sense or describe the best way to accomplish work. Standardized work, on the other hand, is supposed to be improved upon. By tasking line staff with the primary responsibility to write the process, they are likely to be more empowered to change the work as they discover better ways to accomplish tasks.
3) Standardized work must be clearly displayed. Standardized work serves as both a guide for line staff and a tool for supervisors to ensure work processes are completed corrected. By communicating the information clearly, and placing the information in easily accessible places (NOT in a binder on the shelf that no one reads!), it’s much easier for employees to do what is expected of them.
4) Standardized work makes orientation much more effective and complete. How many times have you hired a new staff person only to find they are trained “the wrong way” by their trainer? With turnover between 30% and 75% in most communities, consistency of training is a huge concern. Standardized work helps ensure consistency because it represents the best way to accomplish a task. It also provides an easy to understand, easy to follow guide to the work expected of new staff.
5) When standardized work is not being followed, managers must ask why. In typical environments, managers respond to failure to follow work procedures by admonishing or disciplining an employee and requiring compliance. Lean requires a different approach. Instead, managers must ask the employee why the standardized work is not being followed. Employees rarely choose to do bad work for the sake of doing bad work. Instead, other problems (the root causes) such as not having adequate equipment or supplies, not having enough time, or an outdated practice are the reasons behind deviation. By asking why and finding the actual problems, we help to create better work environments for all staff, leading to better care and service to residents.
For more thoughts on standardized work, read Mark Graban’s post, where he summaries the main concepts from Lean Hospitals.