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  • Nury Moreira, Healthcare Lead, Strategic and Partnerships, The Institute of Engineering and Technology

What is the challenge your project is going to address and how does it connect to your chosen theme?

The NICE clinical processes are only a fraction of the processes undertaken in an NHS Trust. Their UK business equivalent are referred to, by business, as product or service realisation processes. Other processes, often referred to as business processes, still need to be process managed. As they are non added value processes they are therefore costly to the organization if miss managed. There is often a fine line between what should be classed as a service realisation process and what should be classed as a business process but what is important is that they are managed. For example how should ward round or clinical handover be classified?

The Challenge is: To test the hypothesis that ‘documented standard work, process visualization and process management are fundamental quality tools in achieving the NHS Long Term Plan and will enhance the great QI activity that is already being undertaken in the NHS’.

These are all key elements of a ‘Lean’ methodology.

What does your project aim to achieve?

Business processes that are poorly defined and miss managed make a large contribution to poor outcomes particularly in terms of flow, throughput and cost. Like the service realization processes these business processes can be defined and documented by good practice and presented in a similar format to the NICE guidance.


1. Work with a number of NHS Trust to document some ‘standard work’. For a description of standard work see:

2. Seek out support for process management in the NHS to gain a higher profile with stakeholders.

3. Document a draft strategy for implementing standard work, process visualization and process management.

4. Document a draft methodology implementing standard work, process visualization and process management.

5. Test development ideas generated via the project.

6. Clearly show how QI activity can be made more sustainable and scalable as a result of being part of a Process Management System (PMS).

How will the project be delivered?

The term standardized work has been used in the manufacturing industries since the old days of piece work. A more up-to-date term is process management. Our day-to-day work is divided into a number of processes e.g. Ward Round and Handover.

NICE Guidance for clinical processes, is maybe an example of how standardized work, or the first stage of process management, could be presented for non-clinical processes in the NHS. The NHS guidance is presented via the internet, under multiple headings, in a flow chart format with links from the illustration to more detailed procedures and guidance. Trusts have no obligation to follow this guidance but, assuming it is an example of good practice, then why wouldn’t they?

The project delivery process will be to create some examples of standard work by collaborating with up to six Trusts. Process illustrations will be created from the standard work. Process management techniques will be used to improve the processes. All examples will be published.

What and how is your project going to share learning throughout?

In the book ‘Transforming Health Care – Virginia Mason Medical Centre’s Pursuit of the Perfect Patient Experience’, Charles Kenney talks about the difficulties the Virginia Mason Medical Centre has had with the implementation of standardized work.

The term standardized work is perhaps not the best terminology for an equivalent activity in today’s NHS. Work is the many tasks we each carry out every day whilst at work. Work in the NHS in increasingly defined by outcomes but the defined outcome gives only a brief indication of how that outcome should be achieved. Standardized work is critical to the implementation of Lean and VMPS.

This idea will document a draft strategy and methodology that will clarify the situation, outlined above, in the NHS around ‘standard work’ and ‘process management’. Learning will be shared by the publication of a series of newsletters published as Q blogs, articles in relevant journals and a final report published on the Q Community portal as the timeline shows.

How you can contribute

  • Join me and be part of this project. All are welcome to play an active part in this idea.
  • Comment on my idea. All comments are welcome and will be responded to.
  • Name some of your key processes and help to define them.
  • Work with me to document some 'standardized work' in your workplace.
  • Would you like to design some examples of standard work in your Trust?
  • If 'yes' please post a comment to this idea and we will be in touch.
  • Let me know, via comments, if you do not understand any aspects of this idea.
  • Please read the document
  • This document explains what 'standard work' is in the NHS.
  • Please comment on the above document.
  • See first ‘comment’ for an explanation of acronyms used.

Plan timeline

31 Jul 2019 Launch of Community of Practice
31 Aug 2019 Publish 'Back to Basics' pamphlet re 2018 Q Exchange idea
30 Sep 2019 Design example standard work Trust 1
31 Oct 2019 Design example standard work Trust 2
30 Nov 2019 Design example standard work Trust 3
23 Dec 2019 Design example standard work Trust 4
31 Jan 2020 Design example standard work Trust 5
29 Feb 2020 Design example standard work Trust 6
31 Mar 2020 Test ideas and define key NHS processes
30 Apr 2020 Publish draft strategy - standard work and process manage
31 May 2020 Publish draft methodology - standard work
30 Jun 2020 Publish example 'standard work' documentation
31 Jul 2020 Publish draft methodology - process management
31 Aug 2020 Publish final report via Q Community


  1. Thank you to all the people that supported this idea. Although the idea was not selected I'm still working on it. The CoP mentioned above is now on line and I'm seeking comments on its structure prior to inviting membership. If you would be prepared to comment please let me know and I'll send a link. Regards Tom

  2. The document has been updated and should be read in conjunction with this Q Exchange idea.

  3. I've been researching how standard work, if designed and managed correctly, can help the transition to a participative work environment and participative management. Findings so far are very positive but limited. Do you have any thoughts on this subject please?

  4. Hi Tom, do you have a particular healthcare discipline in mind to work with and use it as a testing ground? Radiotherapy has been using QMS since two major UK incidents in the 80s and we have a very mature culture of incident reporting and use of QMS is mandatory in our service specification. We have lots of good practice to share and I think process management approach would work really well hand in hand with the the soft approach which is gaining traction in healthcare, see idea 'Psychology 4 improvement' on Q exchange

    1. Isabel I'd like to work with your particular healthcare discipline if you'd like to have a look at standard work in your organization. I've had another look at psychology-4-improvement and have added a comment suggesting a collaboration between projects. Thanks for the tip.

  5. Guest

    Rollo Moore 1 year, 9 months ago

    Dear Tom

    Thanks for pointing me to the Idea Q exhange, much appreciated.
    I agree that these ideas are key and of central importance to rationalised quality improvement and process control and system modelling are a core component. The work we've been doing at RMH Physics have strong resonance. We are constrained by several pragmatic aspects - workload and resource balancing the risk mitigation that the quality initiative would bring.

    I do strongly support this initiative and would be keen to participate in a practical sense to the development. I'd like to share some of the investigations and practical forays into this area, and state outset that these are relatively modest, but we as a small team in a larger department would be able to participate on a prearranged meeting or teleconference series.

    1. Thanks Rollo. I look forward to some collaborative work. As much as anything else, this project is about spreading understanding of these methodologies and how, if used correctly, they can facilitate and accelerate innovation and ownership of what we do at work. Particularly our impact on Patient Safety. It's all about empowerment.

  6. I've added a link to a document that discusses 'standard work' in the NHS. Here it is again:


  7. Would it be possible to involve/engage patients in the design and/or implementation phases of this work?

    1. Eric, Thanks for your comment. Certainly as each organization develops their processes they can undertake what ever level of co-production they think is appropriate for each process. This project is looking at developing a process management methodology for the NHS and at this stage I'm hoping that patient and other members of the public will join the Community of Practice and will be free to comment as they see fit. Regards Tom

  8. Tom, You may find the work undertaken in Scotland interesting. Here is a link

    Regards Tom

    1. Tom It's

    2. Guest

      Tom rollinson 1 year, 10 months ago

      Great, Yes it would be great to chat about this. Do you have an email address I could contact you on to discuss further?



  9. Guest

    Tom rollinson 1 year, 10 months ago

    Hi Thomas, 

    I work for a transformation team currently working to embed an adapted Lean approach across the trust supported by NHS I. Standard work (SW) is a key component on this approach and it would be useful to discuss your idea further as SW is often a sticking point especially when working with clinical staff. I am also completing an evaluation of this approach as well to support our own continuous improvement. Happy to discuss our findings so far if that would be helpful.





    1. Tom It's

    2. Tom, Thank you for your comments. I would like to hear about your finding so far, what you are doing sound very interesting to me. The work (research) that I am currently undertaking is focused on process management in the NHS and my expertise lie in process management. My approach to this is based around SW but I do have a solution (methodology) that is more appropriate than that based upon manufacturing - the area covered by almost all of the available literature. This Q Exchange idea will elaborate on this methodology specifically designed for application in the NHS. If you would like to meet up to discuss this idea further please let me know. Regards Tom


  10. Darren, Thank you for your comment. Although 'every intervention is likely to be different' the process is not, but I do agree with your view on the value of the Toyota methodology for the process being implemented (progressing). The Toyota Production System, (TPS), is about a method of working and not just an improvement activity like QI. Continuous improvement of work processes is the ultimate aim but first you must understand your work processes. Understanding work processes an be a major task. Regards Tom

  11. Hi John,

    It’s a good idea, standardisation is the key to quality.

    FYI and perhaps an example to help others understand what you are trying to achieve. On Honda’s production lines there is a book in every section. Each book explains with pictures exactly how to build a car. Pictures show the order in which each and every component is fitted, and pictures show where quality is ’built-in’ by other staff checking the work of the person before as the car moves down the production line. Practically anyone could walk into Honda, pick up the book and build a car.

    Wherever Honda builds the same car in Japan, America, Australia, Thailand etc around the world there are identical books so regardless of where your car is built the processes and the quality is the same.

    The books are used to train new staff and keep the process standardised, this would be great in the NHS. Then I could walk into a hospital and perform a knee operation?

    1. I think there is certainly some benefit in exploring this. Especially in seeing how we can document processes outside of the value-added process business model. The Toyota model is only superficially applicable in a context where every intervention is likely to be different, but I think something in line with their six rules could be a really interesting approach to setting out how a process could progress.

      This would be interesting to explore.

    2. Thanks for your comment Dinesh. There is a lot of new learning required and I'm hoping that this Q Exchange idea will help with that. I will be publishing the work that I have done from one of my 2018 Q Exchange ideas, that did not get funded. It will, hopefully, put this new idea into context. Tom

    3. Agree Mark about Standardisation, given the complexities of the NHS, perhaps we may need even adopting-QMS. I'm with Thomas about taking the same approach from existing standardisation of clinical practices e.g. adopting NICE guidelines to other areas, every 'operation' of the NHS.

      • NHS-is the largest employer in UK & enjoys the lion's share of 'Public' expenditure..

      Perhaps it's time that we move on from local QI, CIP etc to whole system quality managing/QI-using Lean..

      I found this interesting read(dated, 2017), seem very topical though;

      Thomas, Best wishes going forward...

    4. Thanks Mark. I have worked for Jaguar Rover and they have the same lineside books. It is a similar thing that I have in mind when I talk about ’Process Visualization’. So much effort is wasted in the NHS by not linking improvement to relevant processes. Effort like QI, Audit, Inspection, Incident reporting, etc. Not sure about the knee operation!!

  12. You have my support! I will follow your progress and chip in where I can


    1. Thanks for your support John.

  13. Hello Thomas,

    I’m really interested in your ideas. I agree we need to think more creatively about how to embrace standard work. My experience of getting evidence into practice so far, has made me realise how hard this is to do. I found that it often takes a hybrid approach combing some standardised work and some local adaptations because no health system is identical. For example in my last role, we managed to introduce a standardised strategic approach and quality standard in relation to the use of magnesium sulphate to prevent cerebral palsy in pre term birth in 5 hospitals, but each clinical micro system needed to adapt how they operationalised this in practice as each hospital setting was different. I’d love to learn more about your ideas and if you have a particular NICE guidance in mind to try this with?

    Good luck!!!

    Best Wishes



    1. Anna, Thanks for your comments. I do agree that a hybrid approach combing some standardised work and some local adaptations is the answer. I'm suggesting a set 'good practice' processes that have been clearly documented using innovative visualization techniques from which local adaptations can be made. This will still permit continuous process improvement to be identified and shared across the NHS through the improved set of 'good practice' process examples.



  14. TPS - Toyota Production System, VMI - Virginia Mason Institute, VMPS - Virginia Mason Production System.

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