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Standardization Customization Conception of health care Transactional Relational Conception of clinicians Clinicians will perform better with clear standards and regulations. Clinicians are the interpreters between the guideline and the individual circumstance and can be trusted to use good judgment in working for patient’s best interests. Organizational approach The approach is one of management: to regulate systems and direct individuals. The approach is one of leadership: to optimize systems and to guide individuals. Change management strategy The strategy is command/control; design and deploy. The strategy is to empower and encourage. Management approach Management makes top-down decisions, ideally with local input. Management encourages local engagement; promotes agency for the teams. Resultant culture Culture may have elements of security as clinicians don’t have to exert judgment over standard processes, yet culture also has elements of learned helplessness, along with fear or moral distress when the standard processes don’t match the needs of the patients. Culture is possibility-based; clinicians are empowered to embrace responsibility and creativity, and yet this requires additional cognitive work and accountability for outcomes beyond that of simply following a process. At its worst Oppressive; flawed standards and metrics may harm people and cause burn-out. Chaotic, unreliable, poor quality, difficult to measure. At its best Improves the chance that routine and required tasks will be performed, freeing clinicians for deep thinking and relationship building. Allows modification of care processes for people’s individual needs. Builds trust. Encourages innovation. Example of care at its best System-wide initiative to reduce cardiovascular events by promoting medication adherence at every opportunity (office consult, flu shot, pharmacy visit, etc). Primary care team at satellite clinic develops a workflow that includes co-location of reception staff with nurses and MAs, allowing greater sharing of care under the supervision of the local site leadership.
Contrary to hospital rules, a husband was allowed in bed with his dying wife and to bring extended family members into the ICU.10ICU = intensive care unit; MA = medical assistant.
Organization Standard Organizational Goals Actual Outcome Better Strategy All nurse practitioners and physician assistants must work the same patient care hours, 8:00am to 4:30pm. Provide dependable access to care.
Treat all NPs and PAs the same.Personal circumstances (eg, childcare) may prevent some individuals from working specified hours resulting in lower morale, difficulty with recruitment and retention, and worse access to care. Clinical sites allowed to work out coverage for specified hours and held accountable for access, resulting in greater individual flexibility, better team cohesion and morale. On entering the exam room, the first task for physicians and staff must always be to log in to the computer. Provide time stamp of staff activities. Disrupts the “golden minute” at the start of the interaction, with less eye contact and lower patient and staff satisfaction. Promote routine of “patient first, computer second.”
If needed, track staff activities in other ways (eg, radiofrequency fob).All emergency (“crash”) carts must have the same equipment and medication; no more or less. Better manage inventory. Prevent improper use. A woman at a rural site died after precipitous birth with uncontrolled uterine bleeding due to atonic uterus that did not respond to fundal massage. Transport time was at least 60 minutes to a hospital and there was no oxytocin or other tonic agents stocked in cart. Identify required items for all carts, and then allow additional items based on site needs.
Assure adequate training in the proper use of crash cart items (eg, ACLS, ALSO).Medical assistants are not allowed to perform orthostatic blood pressures. Assure quality of care. Protect the clinical domain of one role type. Orthostatic blood pressures are not done as frequently as clinically useful; patients have reduced access to the unique skill set of their physicians (who are spending time doing orthostatic blood pressures on other patients). Uptrain the staff; allow the supervising clinical staff to determine medical assistant competency to perform orthostatic blood pressure. All incoming patient calls are sent to a centralized call center. Efficiency
Reduce call volume for staff at clinic sites.Continuity is disrupted and care is less personalized when patient speaks with a nurse with whom they have no relationship; patients may be routed to someone other than their personal physician even when that physician would have seen them for their need. Allow individual units to determine how best to handle calls for their unit—locally or via a back-up central call center. ACLS = advanced cardiovascular life support; ALSO = advanced life support in obstetrics; NP = nurse practitioner; PA = physician assistant.
Domain Question Sub-Questions Problem clarification What problem are we trying to solve with our standard? How important is it to address this issue?
What are the root causes of this problem?
Are the problems localized or generalized?
What is the evidence that the proposed standard is effective?Collaboration Have we included front-line clinicians in the development of the standard? Has there been sufficient input from each clinical unit that will be impacted by the standard?
How are the various units working to improve this issue—what innovative ideas do they have?
What do individual sites or teams see as potentially beneficial improvements?
Has the standard been pilot tested with input from those impacted?
Is there agreement that a system-wide set of standards is needed?
How will we encourage local customization and evaluate its impact?Consequences Have we considered unintended consequences? What are the potential harms to patients, teams and the organization from implementing the standards? Resources Do we have sufficient resources to design, implement, and evaluate the impact of the standard? How difficult will it be to gather the evidence to design the standard?
Does the organization have the capacity to implement it?
Do we have valid metrics for subjective as well as objective outcomes?
Does the organization have the capacity to evaluate the full range of benefits and harms of implementing the standard?
