Examples of Hazards of Standardized Operations
| 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.