Foundations and Fundamentals

Thoughtful, forward-thinking program has:

  1. Meet or exceed performance targets
  2. Reduce unwarranted variability in care through standardization
  3. Trend positively
  4. Increasingly deliver value to key stakeholders

While all four are important for a robust delivery system, this paper focuses on the critical objective of championing standardization in patient care, thereby reducing variability. Achieving standardization is the objective that unifies and empowers the other three. Defining and achieving excellence in standardization requires the foundations of teamwork, data, systems, and partnerships, all of which are also required for the other three objectives.

The Opportunity

In recent years, there has been a dramatic increase in treatment and diagnostic options for patients. (The range of options for diagnostic workups and new pharmaceutical options are common examples.) This increase in clinical options, combined with evolving standards of care, means that standardization efforts now have a proportionately larger impact on overall cost, outcomes, and value. Studies show that appropriate clinical standardization allows clinicians to spend more time with their patients – which improves both patient and provider satisfaction, and powerful evidence shows that, as medical care has continued to advance, there is a need for more focus than ever on setting, communicating, and managing quality standards, especially in an environment of shrinking revenue and rising costs. Whatever role standardization played in our past, it will play a greater role in our future.

The Challenge

However, standardization programs are challenging to define and implement. Standardization of care is frequently misunderstood. Multiple perceptions and perspectives blur the meaning and diffuse focus. Implementation attempts are often shortsighted or limited in scope, resulting in unsustainable results, provider disengagement, administrative frustration, and over-reaching, reactionary policies from payors. In addition, initial standardization efforts are often under-resourced. The systems required for supplying actionable, point-of-care data can be elusive, incomplete, expensive, misaligned with other stakeholders, or too delayed to be meaningful. Even if some actionable data exists, the underlying systems may not be scalable. All of these issues limit the breadth and depth of attempts at standardization efforts. Initial efforts could wither on the vine and the promise that standardization of care presents never occurs.

New Framework for Success

As noted above, many health care executives believe that reduced variation in care is a critical performance imperative for their organization. Many systems have already addressed other “low-hanging fruit” including gaining efficiencies from supply chain management, staffing optimization, and economies of scale from overhead and G&A costs. The harder part is truly changing the variations in care delivered at the bedside, which can erode value for patients and for the health care delivery system. The continued evolution toward value-based care demands that health care leaders find a way to address the heavy lifting required to succeed. So, what now? Building a new framework for success requires that you consider three core concepts.

Create Value

According to the well-renowned economist Michael Porter3 , High-Value Care = Patient Health Outcomes ÷ Total Cost of Care

As we will discuss in our bullseye view, there are many ways in which we can increase value – by improving any number of patient outcomes; by reducing the cost of care; or an infinite combination of both. As the team defines the goals of standardization, specific outcomes should be defined, measured, targeted, and implemented by members of the team, leveraging their unique skills and contributions. In the end, success means that they must enhance value.

Leverage Five Key Stakeholders

While standardizing care is intuitively attractive, the perceptions of standardization are different for five key stakeholders: patients, providers, hospital executives, nurses, and payors. Each stakeholder sees a different meaning, focus, and set of implications for standardizing care. These differences must be well understood, and the positive attributes of each perspective must be respected and put to work, while the negative implications and drawbacks should be minimized.

For example, using one hospital administrator’s perspective on standardization (predictability) and imposing it on a provider without any filter or modification will result in inevitable conflict, disengagement, power struggles, and failure. The same is true if we used a typical practitioner’s primary focus (practice autonomy and personalization of care) and imposed it entirely upon a payor. This may result in wide variations in care and untenable cost, without acceptable benefit either individually or in aggregate. Moreover, a payor may think, “Standardization means low cost for the current instance of care” versus a provider’s perspective that, “If I deliver appropriate and personalized care now, I can reduce overall cost over time.”

Many failed attempts at standardization result from the failure to embrace, accommodate, and integrate the unique perspectives of these five key stakeholders. Those who have succeeded at sustainably standardizing care recognize it’s a team sport, and account for important perceptions and expectations from each audience. They unify them under a common vision and produce and manage practical, data-driven practices. Sustainable value is therefore created.

Balance Art and Science

From the time of Hippocrates until today, clinical practice has constantly involved some balance of the art and science inherent in medicine. The “art” involves recognizing unique patient presentations, individual characteristics, and all the elements that make each patient encounter distinctive. This requires well-founded clinical judgment and an appreciation for each patient’s experience of his or her care. Since no two people are identical, medical care cannot be entirely identical either. The “science” involves recognized, standard, or evidence-based approaches common to almost all patients with the same clinical conditions and presentations. Standards of care can be supported by diagnostic, treatment, utilization, and outcomes data. Over time and with enough patient encounters, the variability of care for similar conditions and presentations should become narrow. Wide variation patterns typically produce lower overall value. There are exceptions, but the general rule certainly applies.

The bottom line: with too much “art,” there is significant variation in care. With too much “science,” the unique needs of patients are not addressed, and worse outcomes happen. The work of standardization requires the right balance. Clarity, teamwork, and prompt access to actionable data is paramount.

Without a doubt, data is the ingredient that empowers each stakeholder to come to the table with results-driven approaches. Embedding clinically relevant data into a practitioner’s workflow is key, along with prompt feedback on clinical results using pertinent comparisons to peers and similar clinical cohorts. The most important factor that drives the data is the common vision that all parties share – delivering high-value patient care.

The Approach

Fortunately we've seen:

  • There are effective ways to succeed in standardizing care.
  • There are ways to respect the viewpoints of key stakeholders and capitalize on their contributions.
  • There are ways for each stakeholder to benefit (now and in the future).
  • There are ways to properly balance the art and science of care for individuals and populations.
  • There are ways to ensure high quality and cost efficiencies, and…
  • There are very effective ways to support standardization with well-designed systems, processes, and data.

The pathway to success starts with four simple pillars.

Respect

the perspectives of each stakeholder.

Reposition

the view of standardization within their roles, in terms that they relate to and value.

Ready

each stakeholder by empowering them with data, analyses, feedback, and tools that help them succeed within their workflow

Reward

success. Identify and celebrate accomplishments (and manage avoidable exceptions).

High-Value Patient Care can only result from unifying key stakeholders, supporting them well, and surrounding them with effective clinical partners.

Rethinking Standardization: Real-life Example

The Challenge
The Approach
The Results

Focused, team-based standardization methods drove dramatic increases in treatment compliance.

Key Success Factors:

  • The JOC platform has allowed open communication between the ED Providers, hospitalists, and nursing leaders. Presenting the challenging situations as case reviews that were constructive and considerate of the needs of all team members was especially helpful in refining processes.
  • A strong, experienced clinical partner at the table with deep capabilities in best practices, data, systems, and a mechanism for prompt provider feedback was critical in implementing and sustaining change.
  • Based on the decline in sepsis mortality rate, the JOC has established itself as the “go-to” forum for problem solving and standardization efforts at Hospital X.
  • Initial results were dramatic. But, more importantly, results continue. They are sustained because the hospital made the investment in data, feedback, systems, and clinical partnerships often required for long-term sustainability.
  • Hospital X intends to maximize the value of a team-based approach and a clinical partnership. The JOC at Hospital X provided an excellent test case for how emergency medicine and hospital medicine can work together to improve patient care – and use data to engage providers, resulting in life-saving measures for their patients.

The Winning Ticket: Strong Clinical Partnerships

A strong clinical partnership with your provider groups involves many key characteristics, including clinical leaders who:

  • Work with you to understand your goals, the needs of your patients, and your community;
  • Are personally aligned with these goals and have well-managed incentives to help you meet them;
  • Act as part of the fabric of your medical staff and your organizational culture;
  • Have teams, systems, and processes surrounding them to support and empower necessary transformation, capable of driving from within your organization.

Physician leaders don’t always possess an adequate range of skills and attributes to consistently succeed in a demanding clinical leadership role. Understandably, their priority is practicing medicine and taking care of patients. Therefore, the key is to identify, recruit, orient, and support physician leaders with certain critical attributes (empathy, emotional intelligence, business acumen, and interpersonal communications skills) and combine that with effective leadership training, team-based support, and performance feedback so they can succeed. Absent a clinical leader and a team that empowers them, many efforts will falter.

The essential role of effective, prompt, meaningful data cannot be understated. In order to hardwire excellent, standardized performance in day-to-day clinical practice, an engaged physician leader and team must be armed with up-to-date data and performance metrics aligned with your goals and supported by scalable systems. Strong clinical partnerships make this happen. When it does, an incredibly successful platform for today’s health care executives results.

Conclusion

To succeed in health care, problematic variations in patient care must be eliminated. To succeed with our patients, we must deliver personalized care that recognizes individuality and uniqueness. Extremes in either direction risk poor outcomes, the sustainability of the system itself, or both.

Standardization is increasingly fundamental for health care – and isn’t going away. Unacceptable variations in care create risk for patients and providers, increase costs, decrease value, and may risk your competitiveness or economic viability. Many articles, publications and seminars have advocated for standardization in recent years. However, hospitals and health systems still struggle to achieve and sustain successful standardization programs. Our approach must change.

Where prior solutions have failed, new solutions must be employed. Standardization won’t work without meaningful data flowing promptly to the right parties. It won’t work without the right teamwork and the right partners. It won’t last without scalable systems that engage providers. And, it won’t work without a balance of contributions from physicians, hospital executives, patients, nurses, and payors. Organizational leaders must develop and communicate a clear, compelling vision that ties standardization to key objectives. Leaders must ensure that they have the right team, the right partners, the right data, and the right platform to deliver timely feedback and a well-coordinated management process that works.

Fortunately, new advances and proven applications of technology, data, and analytics deliver provider-friendly opportunities, and can change the approach to standardization in ways that we haven’t been able to in the past. Pairing timely provider feedback and effective management with actionable data and incisive analytics gives hospitals a significant head start on both current and long-term performance. We must re-think standardization if we are to succeed. With the right team, the right vision, and the right partners, there is significant opportunity for cost-effective, standardized and personalized care.