Call for anecdotes that support the use of standard processes

October 18, 2013 10:16 AM

I do systems redesign work with clinicans/health care workers who have no experience in formal operations theory and I'm having difficulty convincing them of the importance of developing standard processes. In solving systems problems, they have little practice in abstraction and modeling, so appealing to them on the basis of first principles is usually not effective.

They respond well to stories, anecdotes, narrative. I have a couple, difficult-to-translate stories from my time as an IE manufacturing arcane check/payment processing machines (yawn), but they just don't connect with my audience.

Does anybody have any stories that support the use of standard processes, ie, what happened when they weren't used, when they were inconsistently used, when they were adopted?

posted by klarck to Work & Money (16 answers total)

Surely physicians, nurses and other allied healthcare folks have tons of SOPs, and a lot of them probably know why. You're not going to reach them by talking about formal operations theory. Try talking to them about why they have procedures, checklists, and the like. Come at this from their point of view.
posted by Emperor SnooKloze at 10:23 AM on October 18, 2013 [3 favorites]

I think the standard on this, although I don't have the source, is the decrease in the incidence of infection (and subsequent death) from standardized checklists for PICC line insertion. I would actually search PubMed.
posted by OmieWise at 10:24 AM on October 18, 2013 [1 favorite]

You may be able to get something out of this article on what hospitals can learn from The Cheesecake Factory.
posted by ubiquity at 10:25 AM on October 18, 2013 [2 favorites]

Can you explain a little more about developing standard processes for what, exactly? Because all of the health care workers I know use and value standard processes in their practice (given some allowance for flexibility, of course, since their patients are people).

On preview: What Emperor said.
posted by rtha at 10:25 AM on October 18, 2013

Atul Gawande's essays/books are full of relevant anecdotes. See "The Checklist," other articles, The Checklist Manifesto, and (on preview) ubiquity's link.
posted by Monsieur Caution at 10:27 AM on October 18, 2013 [5 favorites]

There is an article from the New Yorker about the industrialization of childbirth that has an interesting story about the Apgar score (read the whole thing or start at the paragraph "There are a hundred and thirty million births around the world each year, more than four million of them in the United States.")

The score was published in 1953, and it transformed child delivery. It turned an intangible and impressionistic clinical concept—the condition of a newly born baby—into a number that people could collect and compare. Using it required observation and documentation of the true condition of every baby. Moreover, even if only because doctors are competitive, it drove them to want to produce better scores—and therefore better outcomes—for the newborns they delivered.

That seems like a good, tangible narrative about the power of processes (but, um, ignore the parts of the article that argue against medical standardization, I guess).
posted by muddgirl at 10:36 AM on October 18, 2013

You are fighting the wrong battle. You don't have to convince them, you only have to convince their manager.

Then, bring in the manager to tell them to listen to you.

As long as you play their game, they will feign not understanding or not being convinced as a stalling tactic to avoid change.

"You can lead a worker to water, but only their manager can make them drink."

G
posted by gnossos at 10:38 AM on October 18, 2013

I'm a speech therapist. I have a whole set of mental or formal checklists, templates and assessments I use during my everyday work. However, my patients are people and I abandon them as often as I use them (always with good reason). I would be extremely suspicious of a manager who is not a speech therapist trying to impose a checklist or standard procedure on to me unless there was a problem I understood that needed to be solved.

So for me, you'd need to start with stating the problem and talking as a team/professional group about what was needed to solve the problem, then reviewing the evidence base to find out what would be best practice and then (sadly) modifying that to what we feel we could achieve with the local resources. Then I would stick to it when I felt it would solve the problem and not when it didn't. . .

We do have some useful flow charts about what to do in different situations where the decisions we make involve difficult decisions about vulnerable people, to help us practice as safely and legally as possible. But most of the work I do is too complex and varies for standard operations.

I used to work somewhere where there were lots of infuriating paper exercises, like a monthly casenote audit (good!) with endless meetings about why we had to make sure we wrote 'mr' 'mrs 'dr' 'ms' etc on the notes, and why that had caused us to fail the audit.
posted by kadia_a at 11:19 AM on October 18, 2013

The power of checklists in medicine.
posted by Doohickie at 11:26 AM on October 18, 2013

Response by poster: (given some allowance for flexibility, of course, since their patients are people)

This is a dangerous, ubiquitous proviso common among clinicians because they've had such broad autonomy for literally thousands of years. It's exactly what I'm trying to refute because it's often misused to dismiss the concept of standard processes altogether.

For example, if one is reprocessing/cleaning an endoscope, it doesn't matter what kind of patient it was removed from or what kind of patient it's going into next. While any deviation from the proven sterilization process may pose a threat to patient safety, the clinical culture doesn't necessarily view the deviation as a big deal - whatevs, so long as it gets clean. They're just not used to thinking about dangers of deviation and variance because they're trained more as craftsmen, not automatons.

Try talking to them about why they have procedures, checklists, and the like.

Clinicians often see these tools as external impositions. I've seen a lot of eye-rolling from clinicians wrt to checklists and sops. I'm not the only one.

I think I'm looking for relatable examples that are outside of the healthcare industry. (P.S. I'm also an 2nd career RN.)
posted by klarck at 11:39 AM on October 18, 2013

This is a dangerous, ubiquitous proviso common among clinicians because they've had such broad autonomy for literally thousands of years.

Huh. I was thinking more along the lines of "use XYZ size [thing] for [procedure]" and clinicians should be able to look at the patient and know that XYZ size is too large/small for that patient (I'm thinking particularly about this because of a recent story someone - a patient - related).

I got no examples at the moment, but I will try to think of some.
posted by rtha at 12:05 PM on October 18, 2013

The mining industry is a (heh) goldmine for stuff like this.

Here's a recent story:

The Department of Mines and Petroleum has analysed the 52 mining deaths between 2000 to 2012, when the industry workforce increased by 60,000.

"Forty nine per cent of these deaths involved workers who were in the first year at their mine sites or fulfilling new roles," safety director Simon Ridge said this week.

He said the findings reinforced the importance of inductions, training and familiarisation with new environments. The study found 62 per cent of the cases involved onsite procedures not being followed.

"This drives the point home that we must always apply known precautions to known hazards and, where new tasks, machines or processes are being introduced, detailed hazard analysis and risk assessment should be carried out," he said.

The research also showed 44 per cent of deaths involved supervisors in their first year on the job, highlighting the need for supervisors to be fully aware of the hazards and risks, so workers are monitored.

Check for case studies on the North Sea drilling disasters - the lack of procedures there has resulted in many unnecessary deaths, and subsequently had a huge impact on operations.
posted by smoke at 2:15 PM on October 18, 2013

This set of resources and articles from AHRQ has many examples. I don't have handy the handouts from a lecture on process improvement that I had to go to, but process-improvement techniques are a pretty standard topic that searches well on AHRQ.

All the MDs and RNs are familiar with the importance of having systematic approaches (to a chest x-ray, trauma assessments, ACLS, how to do procedures, etc). That formal process improvement rather than having a process will save them time and improve patient outcomes is probably what you're having trouble with.
posted by a robot made out of meat at 5:00 PM on October 18, 2013

Hey dude, I don't know if you saw in the follow up: "I think I'm looking for relatable examples that are outside of the healthcare industry."
posted by smoke at 5:06 PM on October 18, 2013

Point out that procedures can be used to support us or back us up in the face of resistance. For example, a technician saw something on the assembly line that wasn't supposed to be happening. He reported it to the engineer, who didn't want to take the time to stop and fix it. The technician was able to refer to the procedure, which showed he was in the right. The engineer gave in and the technician was able to make the change that was needed.

I don't have an example for this next one, but some people may respond to it. Procedures hold everyone to the same standard. This can make performance evaluations more objective and more transparent.
posted by balacat at 5:49 PM on October 18, 2013

Bemjamin Whorf has some examples, such as at a tannery where a worker tossed a match onto the "pond" and the pond ignited.
posted by at at 6:15 AM on October 20, 2013