Health Systems Action

Standardising or standardizing – the most important opportunity for improvement?

In a letter to colleagues this week, the Chief Medical Officer at a hospital in Cleveland with which I’m affiliated shared diabetes-related information resources and stated that the “most common opportunity for improvements” is standardizing care. Calls for standardisation in healthcare often lack specificity and have an almost magical, “wishful thinking” quality. Why is it needed? Why might it be a problem?

Diabetes is highly prevalent in the USA (14.7% of adults) but also in SA (15.3%) and globally, so it’s not surprising that this mailing would go to all the hospital’s doctors, or that it would include a pre-surgery checklist: the proportion of diabetes in surgical patients is even higher (17.8% in SA). Diabetes isn’t the reason why they’re in hospital, but they need their disease to be well managed to avoid its acute complications as well as to limit its impact on surgical outcomes – wound infection rates, for example.

 I would argue that the biggest opportunity overall might be in diabetes remission rather than diabetes control, and this could be initiated when patients are in the hospital. But that’s a topic for another day.

 Let’s discuss standardization – or standardisation.

 Standardised care, developed on the basis of “best evidence”, is recommended care and is therefore expected to lead to better health outcomes. But standardisation presumes that average results will be equally obtainable by everyone despite individual and contextual differences, which is hardly ever the case in healthcare settings.

Diabetes treatment goals (e.g. glycemic (blood sugar) targets may legitimately differ, context sometimes determines what treatment can be offered (e.g. newer insulins), so clinicians may have good reasons for alternative approaches, also based on evidence (not all evidence agrees) and informed by practical experience in their hospitals.

 Clinicians’ frequent resistance to standardisation might be due to the fear that it will restrict them in making appropriately individualised treatment decisions while patients, who are often “experts in their own care”, worry that they will not receive therapy that works for them.

 Hospital care involves specialists, nurses and allied health professionals, each with unique competencies and responsibilities, making it challenging to standardise across the entire workforce. For example, diabetes care of surgical patients often involves non-surgical team members, including anaesthesiologists and internal medicine specialists.

 The evolution of new technologies makes it hard to keep up with these changes and update competencies. The Cleveland letter contains tip sheets relating to insulin pumps and continuous glucose monitors because patients in well-resourced settings are offered these devices which promise to improve blood sugar control.

There are nevertheless strong arguments why standardisation should be pursued. For example:

 Standardising, if done in the right way, through a consensus process, brings clinicians to together to share their views and experiences; in a healthy, collaborative environment all learn, good ideas are shared, less successful ones are discarded, and improvement happens.

 The process helps establish clear roles and responsibilities for each member of the healthcare team. This can enhance communication and coordination.

 Patients can be brought into the development process. Their experiences, and their patient-reported outcomes, are what matter, and their insights can help.

 Nursing staff cannot easily provide reliable care when there are high levels of variability in what is offered. Mistakes and failure to provide the care outlined in the care plan and prescribed interventions are much more likely.

 Standardization does not mean a one-size-fits-all approach. Standard work can be in place for many aspects, without much debate or disagreement, and the rest tailored to patient characteristics. Care pathways can be customised to meet the unique needs of individual patients, so it is both evidence-based and patient-centered.

 Last, but perhaps most importantly, highly variable care makes improvement difficult. When care processes are standardised, it becomes easier to collect and analyze data to monitor and evaluate the effectiveness of care processes, and to identify and close gaps that cause inefficiency and create harm, and to continuously improve practice.

 When we understand both the benefits and potential drawbacks of standardisation we can move forward. Oh, and if standardizing could be spelled one way – with a “z” or an “s”, I don’t mind which – it would help too.

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