When every surgeon uses his or her own preferred operating technique, there is a higher chance of misunderstandings and errors. In a ‘high reliability’ organization, on the other hand, measurement, roles and culture are all aligned with standard pathways and operating procedures, which can reduce complexity and variation, improves cooperation and communication, and enhances quality.
“Guidelines are typically forgotten half of the time, so we made these automated pathways the default way of doing things.” - Dr. Brent James, Chief Quality Officer, Intermountain Healthcare, US
With a higher level of scrutiny and double-checks, processes can become far more resilient. Front-line professionals are responsible for confirming that guidelines are being followed, and have the capability and will to intervene should they fear that this is not happening.
Standard operating procedures should be embedded in the workflow, which is an approach that has produced tremendous results for Intermountain Healthcare.
Based in Utah, US, Intermountain has pioneered the integration of standard processes and measurement of outcomes, as Dr. Brent James, Chief Quality Officer explains: “We blended the guidelines into the flow of clinical work at the bedside, and added it to the checklists, order sets and clinical flow sheets that the clinicians already routinely used to deliver care. Guidelines are typically forgotten half of the time, so we made these automated pathways the default way of doing things around here.”
In the UK, University Hospitals Birmingham’s IT system has similar, constant checks on whether crucial process steps are made, guidelines are followed, and medications are given. In some cases, innovations can be very simple, as proven by Helios Clinics’ ‘Stroke Box,’ which put all the material needed for acute stroke treatment (syringe, anti-thrombolytic drug, checklist) in one container, automating the process and increasing compliance to guidelines.
“You have to build in mechanisms for people to find and follow those guidelines,” argues Mary Jo Haddad, President and CEO of Toronto’s SickKids Hospital. “Translating requires a clear message and a clear understanding of the target, and crystal clear roles and responsibilities.” This is where the different building blocks come together. The compliance with and outcomes of the care paths are measured, with results fed back to the ‘owners,’ who monitor and constantly improve the value delivered by the care path. “Once you have the process in place, and you measure the outcomes and close the feedback loop, you improve the guidelines as well.”
Opponents of clinical care pathways argue that they stifle individual judgment, losing the ‘art’ of medicine. Yet, in the same way that improvisational jazz is based upon standard chords and melodies (actually called ‘standards’), it is by mastering the ‘standards’ that one learns to improvise. Subtly deviating from the standard at the right time, in the right way, turns the standard into art. True professional excellence is achieved through standards; not in spite of them.
The Mayo Clinic’s Mike Harper also emphasizes the importance of evidence-based, user friendly processes, infused with the newest insights from the ongoing measurement and improvement cycles. “We call this our ‘knowledge-to-delivery engine.’ By using all of Mayo’s expertise to filter internal and external information and knowledge, we arrive at optimal processes, which are made actionable in dynamic care pathways that are constantly updated with new knowledge. This is the upgraded Mayo philosophy that is fit for our larger scale and technology-supported, as if you have the power of all of Mayo behind you.”
As Ralf Kuhlen of Helios notes, there is a history of deep resistance towards ‘standardization’ in healthcare: “In Germany, the medical specialist is still very much his or her own boss. We are told that every patient is unique and that standards do not work for doctors.”
Despite some regional differences, such observations were recognized by everyone we interviewed for this report. However, leading doctors do recognize that standardization can go hand-in-hand with clinical expertise and judgment, an observation made many times by the surgeon and writer Atul Gawande.1 To achieve true excellence, an organization first needs a standard as a basis for continual improvement. This standard operating procedure remains the default, liberating practitioners to focus on the truly unique aspects of any given case.
By introducing standard workflow guidelines, and measuring outcomes, Intermountain Healthcare has made dramatic and continuous improvements. For patients who were most seriously ill with acute respiratory distress syndrome, the rate of guideline variances dropped from 59 percent to 6 percent within just 4 months. Patient survival increased from 9.5 percent to 44 percent, physicians’ time commitments fell by about half, and the total cost of care decreased by 25 percent.2 This approach has since been extended to cover 104 clinical processes that account for the vast majority of the care within Intermountain’s care delivery system, with a similar degree of success. The group is now widely regarded as one of the top, high-value providers in the US, achieving excellent outcomes at low costs.
1 James, B.C. and L.A. Savitz, “How Intermountain trimmed health care costs through robust quality improvement efforts.” Health Affairs, 2011. 30(6):1185-91.
2 For example: The Checklist, Big Med. Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care? Atul Gawande, The New Yorker, 2012.