Bundles in Health Care: Practice Field for Standardized Work and Daily Management

IHI faculty developed the concept of bundles 15 years ago and summarized the work in a 2012 IHI white paper available here (page numbers in this post refer to the white paper.)

Organizations that succeed with clinical bundles have a solid foundation to tackle standardized work and daily management comprehensively.

Bundle Basics

A bundle is “[a] small set of evidenced-based interventions for a defined patient segment/population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually.” (p. 2)

Discussing the development of the first two bundles--the Central Line Bundle and the Ventilator Bundle--the authors say:

“The bundles were not intended to be comprehensive care; rather, they were developed to test a theory—that is, when compliance is measured for a core set of accepted elements of care for a clinical process, the necessary teamwork and cooperation required will result in high levels of sustained performance [reliability] not observed when working to improve individual elements.” (p. 4, italics in the original)

Connection to Standardized Work and Daily Management

Standardized work in Lean aims to provide reliable outcomes through rigorous attention to the relevant processes—how people do the work and how they communicate with each other.  

Bundle theory shares features with standardized work:

1.      A multidisciplinary team defines the set of elements and allows the people who own and operate each instance of the clinical process to adapt to local circumstances, preserving “appropriate clinical judgment.”  

2.      The bundle applies to a specific place and patient population.  The IHI authors offer the example of managing sepsis—separate bundles are needed for the Emergency Department and the ICU.   From a Lean perspective, this makes immediate sense, as the treatment in the ED and ICU represent different processes so different standardized work applies.

3.       The process team tracks compliance with the bundle using “all-or-none” measurement; the team scores each opportunity to apply the bundle.  In Lean, daily huddles provide the time and place to review compliance scores.   In addition to the score, people running the process note circumstances in which the bundle is incomplete.   The notes of circumstances should drive the process team to develop and apply countermeasures.  The team then tests these countermeasures by Plan-Do-Study-Act.  

In Lean, sustained use of standardized work requires a management system, as outlined by David Mann (Creating a Lean Culture, 3rd edition, 2015) and Jim Lancaster (The Work of Management: A Daily Path to Sustainable Improvement, 2017).

Daily goal setting and tracking as part of visual management, audit of work by direct observation and daily reflection and improvement planning characterize an effective management system.

The IHI authors observed that management has a role in effective bundle use, too:

“Teams that have achieved high levels of bundle compliance and concomitant improved outcomes did so through working as a team in new ways. Contributors to bundle success include using specific daily goals developed by the team and patient, multidisciplinary rounds where the bundle elements are discussed and checked, and debriefs at the end of the day to reflect on compliance and to plan ongoing improvements.“ (italics added, p. 8).

So if your organization has experimented successfully with clinical bundles, you have a great basis to extend your bundle experience to a range of processes throughout your production system, testing the concepts and methods of standardized work and daily management.