In the movie The Founder — about the creation of the McDonald’s fast-food chain — there is a wonderful scene in which Maurice and Richard McDonald lay out paper cutouts to depict how they might create a standardized work process for cooking and packaging hamburgers, fries, and drinks. One brother is standing on top of a step ladder while the other is moving the cutouts around a tennis court to find the optimum locations for the grill, the burger assembly line, the packaging area, and the drink station.
After numerous rearrangements, they arrive at what they believe is the ideal design for the speedy delivery of a customer’s order. In two-dimensional space, they developed their theory of how standard work could lead to greater efficiency. They then set up a prototype and began testing their design. After numerous failed PDSA cycles, they arrived at a design that could quickly and efficiently produce standardized products.
Regardless of what you may think about the food offered by McDonald’s, it is one of the first companies that people reference when I ask them to name a product or service that has a high level of standardization and consistency. Health care is certainly different from making hamburgers, but there are still lessons we can learn about standardization from a place like McDonald’s. After all, even within a service line or functional area, most internal and external observers of health care processes conclude that there is considerable variation and lack of standardization. This can lead to a less than satisfying experience for patients and families or even harm.
Imagine, for example, that you are a patient being treated for breast cancer in a health care system that has eight hospitals, two outpatient cancer treatment centers, and a group of 12 oncologists. You have had an initial lumpectomy and then a secondary procedure because the margins around the tumor were not clean. Next came chemo followed by radiation therapy.
When you make your next appointment, you are told that your oncologist will be on vacation but that one of her associates will see you. You show up on time for your appointment, but discover that the information from your primary oncologist’s records was not transferred to the new oncologist. You also learn, much to your dismay, that the appointment with the new doctor was not booked into his schedule. But you are told by the receptionist, “Don’t worry, we will squeeze you in.”
If the oncology group had standardized work that adjusted for changes in assigned doctor, revised schedules, and other contingencies, there would be no need to “squeeze you in” to the workflow process. In this case, there is not one process for scheduling and assignment but many. For a patient with a cancer diagnosis, this causes unnecessary stress and — because of the records not being transferred — a possible disruption in continuity of care.
Standardization is a fundamental starting point for improvement work. Figure 1 (below) is a flowchart that depicts the steps in the quality journey. The yellow boxes show the general steps, while the blue boxes highlight the steps focused on quality measurement. Look at the first row in the flowchart. The first question (in the yellow diamond) asks, “Is the process standardized?” In other words, have you reviewed the data and found consistent output and quality? If five people who use the process were asked to explain it, would each of them describe the same steps?
Figure 1. Flowchart of the Quality Journey
If the process is standardized to a degree that makes the owners of the process feel that work is done in a reasonably consistent and reliable manner, then the team would proceed to identify appropriate measures and continue its improvement journey. If not, then the next task is to standardize the process.
Processes that are standardized generally exhibit what is known as common cause variation. Common cause variation is built into the process, e.g., delays in a commute caused by stopping for red lights. In contrast, special cause variation is due to an attributable cause, e.g., a car accident during a commute.
A team should only attempt to improve processes that exhibit common cause variation.
Why? Because processes that reflect common cause variation are stable and, therefore, predictable.
Of course, just because a process is stable and predictable does not mean that the performance of the process is acceptable. The performance of a stable process can be predictably bad and far from your target, but this presents the opportunity for improvement. If, on the other hand, you have a process that is unstable and unpredictable, special causes are frequently at play because the work that produces the results is not standardized.
So, the next time you charter an improvement team to improve some aspect of service or care, think about the McDonald brothers. How would they assess your process? They’d probably remind you to standardize before you attempt to improve.
Bob Lloyd, PhD, is a Vice President at the Institute for Health Care Improvement.
You may also be interested in:
Video: Robert Lloyd whiteboard video on Flowcharts (Part 1)
Video: Robert Lloyd whiteboard video on Flowcharts (Part 2)
Navigating in the Turbulent Sea of Data: The Quality Measurement Journey
Statistical process control as a tool for research and healthcare improvement (JC Benneyan, RC Lloyd, and PE Plsek)