In our recent report Vital Signs: How to deliver better healthcare across Europe, one of the vital signs was hospital productivity which highlighted the importance of standardised systems and processes, technology and new ways of working. This week's blog discusses how one hospital group in the United States (US) standardised its clinical processes across multiple sites to improve efficiency and productivity. This is the second in a series of contributions from Dr Bob, a partner in our health consulting business on secondment from the US who has spent 20 years as a practicing physician in the US, followed by 20 years as a healthcare consultant working with numerous health systems.
Some years ago I found myself working in Omaha, Nebraska, facilitating a group of physicians in the design of disease and condition specific hospital admitting 'order sets' (i.e. diagnostic tests) and related tools. My remit was helping to develop and deliver transformation through the implementation of electronic patient records (EPRs) [also known as electronic health records (EHRs) or electronic medical records (EMRs)]. At the time, doctors were quite suspicious of what they saw as 'cookbook' medicine and were concerned at the risks involved in moving away from applying the years of tailored practice for individual patients, to more standardised systems and processes. One particular surgeon raised a curious question: 'Aren't you really placing us in the Procrustean dilemma?'
As some of you with a knowledge of Greek mythology may recall, Procrustes was a rogue 'smith and bandit' from Attica who accosted people by stretching them or cutting off their legs, so as to force them to fit the size of his standard sized bed. In general, when something is Procrustean, different lengths or sizes or properties are fitted to an arbitrary standard. The surgeon questioned therefore whether we were presiding over the medical version of the Procrustean dilemma.
My response to the surgeon's question was to explain a common misunderstanding of the role of standardisation in EPRs, which is that it does not mean a requirement to follow a set approach without question, but that by embedding guidelines and reminders for clinicians of selected evidence-based processes and procedures, efficiency and safety can be improved. For example having a reminder to administer a prophylaxis to avoid a venous thromboembolism. And importantly, that doctors need to know that they can and should continue to use their knowledge and experience to tailor and enhance the care of individual patients.
The 'sweet spot' of developing standard content for EPRs is in the ability to strike a balance between presenting evidence-based options for care and experience-based options for care with the ability to tailor orders or tests for the individual patient. These serve to reduce the likelihood that clinicians, with an array of tests to order, might forget a necessary test (order set). Most clinicians find that this frees them up to think more about how to best tailor treatment for individual patients.1
Having previously worked with doctors and other clinicians in a single acute hospital setting to agree a set of standard processes and content, I was able to take this experience to a much larger project with a healthcare provider responsible for 14 hospitals spread across 5 states. The leadership team was determined to standardise order sets and interdisciplinary plans of care across the multi-entity system and wanted to use the implementation of a single EPR system as a lever to move the organisation from a holding company to an operating company (in this case moving from an alignment of acute trusts to a care system sharing standard policies, processes and content). While this challenge seemed somewhat daunting, we started from the assumption that certain characteristics would need to be in place to achieve success. These included:
- initial face to face team meetings (5-6 teams by specialty) for 1-1.5 days (to accommodate the different locations of the 14 hospitals )
- a large group session orienting all to the overall project including technology, content goals and shared tools
- an opportunity to openly express concerns about the tool, standardisation (the 's' word) concerns, the proposed design process, etc.
- teams were predominantly doctors but were supported by nurses, pharmacists and other health professionals as required
- advanced preparation of an initial starting set to jump start the content design process
- use of an automated tool to present and document decisions in real time
- strong facilitation, wherever possible by a clinician experienced with the design process, with each team setting their own agenda and priorities and agreeing on what time of day and which day of the week to conduct 'virtual' follow up sessions.
This process worked very well and the organisation created 75 common order sets and 30+ interdisciplinary plans of care over a 10 month period – job done! This approach was initially done for the clinical content, and then used for other aspects of clinical design such as the creation of fact-based processes for specific diseases and conditions. While many discussions still need to be conducted face to face, our general experience is that clinicians will agree on most things if:
- advance preparation delivers drafts for review and action
- the process is strongly facilitated and group decision-focused
- issues are addressed one at a time with supporting pros and cons and a recommendation for a preferred approach
- items that are not agreed upon are followed up with additional research or it is escalated to someone higher up the accountability chain
- there are clear guiding principles for decision-making (safety, quality, effectiveness, efficiency)
- there is a sense of accomplishment and having contributed, by the end of each session.
In general we found that the different medical specialties responded to the challenges in different ways, with clear leaders and some laggards. Indeed, one surgical specialty - neurosurgery - was unwilling to leave the design session without completing all of their allotted tasks! Interestingly this occurred in this same specialty in the three different systems, suggesting that the Procrustean dilemma can be overcome and the journey can actually be professionally rewarding and even fun!
As the UK and other healthcare systems seek to widen the application of EPRs, the learnings discussed here may offer a faster and more effective route into achieving clinical consensus on what the EPR needs to cover. Once this and the necessary implementation of EPRs is achieved, health professionals should find any Procrustean elements become their servant rather than their master.
Footnotes
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