Can Standardization Cut Costs & Improve Quality?

A couple of articles in today's USA Today identify a growing - and seemingly controversial - trend at US hospitals: standardizing approaches to clinical care delivery in order to reduce costs.

Medical cost-cutting also can improve care

Hospitals try to find savings, cut unnecessary care

There is nothing really new here to drive the controversy as numerous healthcare organizations around the country are implementing Lean, Toyota Production System, or other methodologies in order to reduce waste. Some of that waste comes in the form of avoidable costs - which it would be good to remove from the system. 

The controversy lies in the insinuation that this cost reduction comes at the expense of patient care or improvements in quality. In reality, numerous organizations have demonstrated that standardization of clinical processes leads to both improvement in quality as well as reduction of costs.

• Virginia Mason Production System
• Intermountain Health - Brent James 
• Institute for Healthcare Improvement - Breakthrough Collaboratives

Doctors worry because they feel that their decision-making authority will be taken away from them in the process of "standardization"; but if you study the improvement efforts closely you realize that the common thread is that doctors and frontline staff are integrally involved in the standardization efforts, without whom the efforts would surely fail. Once the team has determined, with a lot of careful input and thought process, that "one particular approach" makes sense for their organization in order to improve quality AND reduce waste, individual physicians and staff would certainly be encouraged to implement that approach. 

As clinicians will readily point out, the "one size fits all" approach doesn't work in medicine. That's when professional judgement is truly needed - knowing when to deviate from the standard approach, and personalizing the protocol or treatment to the individual patient and the particular scenario. However, the fact that we need to deviate from a standard should not be an argument against the development of standards, merely the recognition of the limits of standardization. 

The real message of the critics of standardization should be that organizations pursuing standardization need to be vigilant in also building in appropriate mechanisms for deviation from the standard.

"No one wants to be an Outlier" - Spine Surgeons at BIDMC Use Performance Improvement Tactics to Reduce Waste

This initiative at BIDMC to reduce waste in spine surgery is a great example of a "performance improvement system" (in this case they used Lean) to improve outcomes (in this case clinical utilization). A similar "performance improvement" approach can work in improving quality, mitigating risk, and improving patient safety.

The article identifies the following "performance improvement tactics" that should be integral components of all improvement projects:

• Examined how much they used and spent (review and monitor data)
• Questioned why each device was being being used (ask why five times)
• Studied reasons for wastage (undertake root cause analysis)
• Asked surgeons, operating room personnel, industry representatives, and nurses to help them identify waste (seek multi-disciplinary input)
• Compiled lists of who had been wasting more instruments than others (create profiles)
• Shared lists [of waste generators] with each other (create report cards)
• Awareness campaign (educate)
• Physician leadership prompted change (get support from leadership)

The key behavioral drivers that project leader, Dr. Kevin McGuire, Chief of Orthopedic Surgery, identified are "physicians are competitive in nature" and "no one wants to be an outlier". Understanding these drivers is key to understanding some of the performance improvement tools and how to deploy them effectively.