I attended a gathering of healthcare providers recently to participate in a site review and listen to some nice TPS success stories. During a Q&A session at the conclusion of the review this question came from one of the participants:
“How can we get the docs to accept standardization?”
I smiled at the question, not only because doctors as a group are notorious individualists, but also because they are not so different from any other occupation in their view of standards. The word “standard” makes people cringe because to many it implies loss of personal choice:
Several years ago a program manager at a local defense contractor offered this view of standardization: “I never liked the idea of sameness. I want my engineers to be creative.” I snapped back at her with some frustration, “When you’re driving home tonight on the right side of the road, would you consider that “sameness?”
On factory floors, where work has been measured (although too infrequently) for a long time, standards have a bad name as well. A shopfloor employee related to me, “They (the industrial engineer) ‘made up’ a standard when the product was released and it’s been wrong from the start. Then last year to meet a cost reduction target, they just arbitrarily reduced the labor figure.”
My friend Gifford Brown, a former site manager at Ford relates the outcome of a set-up reduction exercise at his plant conducted by Shigeo Shingo (a story for another post) back in the mid-80’s. In just half a day, working with Dr. Shingo, Ford operators, tool makers and set-up folks changed over a 300 ton press in just 10 minutes, down from a previous standard of four hours. When Gifford saw this, he ran up to congratulate the Ford team:
“Did you imagine this time-savings was possible?,’ he asked one operator.
“Actually, much of what Dr. Shingo showed us we already had discussed,” the operator replied.
“Then why didn’t you make these changes before now?” Gifford queried.
“We don’t set the standards, boss. You do.”
So there are more than a few reasons for skepticism surrounding standards. American industry’s track record of time-setting without careful observation and without significant involvement of workers (be they doctors, engineers or machine operators) has created an almost universal cynicism. The road to standardization has many obstacles, but the start of the journey is often the hardest because of a legacy system that suggests standards will be forced upon us and will stifle originality.
On the other hand, coming from a musical family long before I got into industry, I understood “standards” to be the great songs that every musician should learn. They define a level of excellence to which we should all aspire. I have never heard a blues player complain about sameness because only three or four chords are a standard for blues. In fact, those standards define the genre and are the basis for creativity. We establish boundaries within a norm and sometimes stretch that norm to create new standards. Just as in TPS, the standards for musicians are the baseline for creativity. Standardization means “reading from the same sheet of music.”
So I responded to the question posed to me at the hospital gathering:
“Doctors worry that forced conformity will impact their ability to care for their patients. Docs don’t want to be the objects of change. So, make them the change agents by first finding a few small things on which they already agree. Dr. Shingo referred to this as “Socrates Secret.” Then pick some small differences and normalize those. Every doc will have some preferred practice on which he or she is intractable – don’t go there, leave those objections alone for now. The first objective is to create a more positive view of standardization itself. “