Standardization vs. Physician Autonomy – Are They Mutually Exclusive?

“Has all of the work you’ve done, using Lean to standardize processes, had a negative impact on your physicians’ sense of professional autonomy” 

An emphatic “No” – that was the response of Louis Kwong, M.D. and Chairman of Harbor UCLA’s Department of Orthopaedics, to the following question. His response was immediate.  From the short time we spent with his team, it was clear that the physicians, nurses, and staff all agreed.

We asked this question because we had started the week withanother organization that was struggling to get physician buy-in forstandardization work.  Some physiciansare complaining that “We aren’t making widgets!” or “You are taking all of thejoy out of my practice by dictating how I interact with my patients!”

Some physicians are complaining that “We aren’t making widgets!” or “You are taking all of the joy out of my practice by dictating how I interact with my patients!”

Standardization at Harbor-UCLA Orthopaedics

Dr. Kwong would argue, and the data would support, that the EXACT opposite is true.  Standardization, when approached the right way, can reduce wasted time, improve patient safety and the patient experience. Most importantly, it can allow physicians and nurses to focus their time and energy on what’s important to them – connecting with and treating patients.

Harbor-UCLA is one of the busiest orthopaedic programs in the country, meeting the needs of an underserved, challenging population. 

We joined his team’s early morning meeting to start the day and observed a few things:

Louis Kwong M.D.

Chairman, Harbor-UCLA Orthopaedics

• A complete sense of team – nurses, staff and physicians. (See our blog about building effective teams.)

• An incredibly efficient approach to managing their day. In just minutes they resolved a few complicated patient flow issues that in most organizations would have led to a string of emails and calls (and a fair share of physician frustration and time).

• They used the  workflow tools on the wall to manage everyone’s day and to talk about the metrics that they’ve decided are most important to them.

• Everyone started their day completely on the same page and excited to focus on PATIENT CARE.

Physicians feel like they are valued for their expertise and ability connect with patients and provide outstanding care.  There is open and honest dialogue and a consistent focus on identifying ways to improve every aspect of patient care – a focus shared by the most experienced surgeon and the unit secretary.

Standardization, when approached the right way, can reduce wasted time, improve patient safety and the patient experience and, most importantly, allow physicians and nurses to focus their time and energy on what’s important to them – connecting with and treating patients.

People Don't Like Change

People don’t like change.  It’s tougher for some people than others.  Most physicians are only familiar with whatever approach to patient care, patient and workflow management that they learned in their training. 

They know these processes work for them, but not whetherthese are the BEST processes or what it takes to keep those processes running –the amount of staff effort and work-arounds. Everyone does it differently which creates confusion for staff, anddrains energy, time, and resources that could otherwise be deployed to improveworkflow and the patient experience AND free up physicians to work moreefficiently. 

Dr. Kwong noted, “Once physicians realize that we aren’tforcing standardization on them because it’s better for the organization,or because we want to be a manufacturing facility – but because we know it’sbetter for patients, staff and the physicians themselves.  Once they can see the impact, they geton-board.”

 “We also insist that all faculty and residents are trained on Lean and no-one is allowed to deviatefrom our commitment to this approach.”

He laughed at the idea that any of his physicians would wantto go back to what some of them thought was the better way to do it – the way where they had full “professionalautonomy” to use processes that felt efficient because they understood them, butwere anything but.

Innovation, Adaptability and Psychological Safety

From our point of view, the journey of Dr. Kwong’s team brings up a few interesting individual and group behavioral points:

• Leadership – In the face of early resistance, Dr. Kwong needed to be an effective communicator and influencer.  He also brings a sense of positivity and optimism that sets the tone for his team. (See our blog about creating your physician leadership program.)

• Adaptability – To work on his team, you’d better be able to understand that change is constant, and understand how to respond to it – because constant improvement is a core principle of lean.

• Change Management – Few physician leaders have ever had practical, effective training on change management. Yet, every day, we are asking physicians to lead teams through almost constant change.

• Hard-Wiring Culture – Too many healthcare organizations look at lean and similar approaches as a distinct project or initiative.  Harbor UCLA Orthopaedics has created a new culture – and that takes consistent hard work and focus. 

• Innovation and Psychological Safety.  Psychological safety is a new concept in healthcare, but Dr. Kwong’s approach doesn’t work if people aren’t empowered to suggest ideas, to be appropriately critical, to give and receive feedback, and to ask for help.  The beauty of this approach is that physicians, residents, nurses and frontline staff take joy in constantly looking for an implementing new ideas.  Last year, they implemented SEVENTY (70) different improvement initiatives identified by members of the team!

Last year, they implemented SEVENTY (70) different improvement initiatives identified by members of the team!

I would argue that any physician who believes that standardization infringes upon their sense  of control and autonomy, should visit Harbor-UCLA.  They’d  see what it looks like to practice in an environment where you can be confident that workflow, communication, and teamwork are maximized – so physicians can INCREASE their sense of joy in their practice.  (Of course, this assumes there are effective leaders driving the initiative…)

 (A disclaimer – None of this work eliminates the frustration that many clinicians are experiencing as they adopt EHR systems.  Even in this space, though, Dr. Kwong’s team is working to streamline their processes).