Performance Improvement Tip of the Day: Hierarchy of Clinical Decision Support

As we construct checklists, order sets, and various other tools to help guide clinical activity, there is a hierarchy of decision support that patient safety and quality improvement experts need to be aware of.

HIERARCHY OF CLINICAL DECISION SUPPORT
Level	Description
1	No decision support provided
2	Education provided re. clinical decision,  but no decision support at point-of-care
3	Decision support provided at point-of-care, but not integrated into workflow
4	Decision support integrated into clinical workflow, but optional
5	Decision support mandatory to complete,  but "opt in" required to activate
6	Decision support is the default option,  with "opt out" required to de-activate
7	Decision support automatic, e.g., initiated by protocol, with parameters built in for safety

In general, as you implement higher levels of decision support, the likelihood of the "right" action being undertaken increases as the dependence on the clinician making an "active effort to choose the right action" decreases. However, at the same time, clinical autonomy in decision-making is also reduced, which is often perceived as  "administrative" or "heavy-handed" by physicians. As such, it is wise to embark upon the "hierarchical" journey with caution, full support of the medical leadership, and a clear sense of what the "medical culture" and "institutional culture" will be able to support.


Over the course of future blogs, I will provide some examples of these decision support levels in practice.