Table 2

Examples of Hazards of Standardized Operations

Organization StandardOrganizational GoalsActual OutcomeBetter 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.