Standardization: Pro and Con Neerav Goyal, MD, MPH, and Ellen S Deutsch, MD, MS PAO-HNS Patient Safety Committee Patient care is complex and often involves managing conflicting goals, such as balancing potential risks vs benefits of a treatment or providing the best care for an individual patient vs conserving resources for society. The PAO-HNS Patient Safety Committee has decided to tackle specific patient safety principles with the same appreciation for nuanced understanding that you face in making clinical recommendations. We present a “point-counterpoint” discussion about a patient safety / healthcare quality principle, and conclude with areas of agreement, which we hope will provide the foundation for the optimal application of safety and quality principles.
PRO: STANDARDIZATION IS GOOD
Standardization has its roots in eliminating variation with a goal of simplifying processes and making them more efficient and safer. The concept is employed in industries that require high reliability such as manufacturing, aviation, and healthcare.
We rely on many standardized processes, some of which are so embedded in our culture that we may not even recognize their power. Standardization informs our expectations;1 when information about a patient is presented to us, we know that first we’ll hear a high-level summary (e.g., this is a 5 year old boy who underwent tonsillectomy 7 days ago) and then relevant details in a predictable sequence that allows us to understand the patient’s condition.
However, it is also important to understand that standardized algorithms in healthcare often come from administrators and managers and not clinicians,2 and represent “work as imagined” rather than “work as done.”3 This disconnect can lead to well-intended processes contributing to worse patient outcomes. For example, to reduce the rate of catheter associated urinary tract infections (CAUTI), many hospitals have implemented algorithms for earlier catheter removal as a triggered nursing task. The result is an increased number of catheter removals on post-operative day 0 or 1. Interestingly, in select populations the policy has been associated with increases in urinary retention and re-catheterization without decreasing the rate of CAUTIs.4,5
Similarly, the documentation of patient care starts with history, proceeds through examination, incorporates an assessment, and concludes with a plan. While the details may vary, the familiar structure helps us find the information we seek. Standardized processes underpin handoffs, often based on an SBAR format (situation, background, assessment, recommendation), operative reports and other informational resources. Standardization allows us to generate evaluation and treatment processes that ensure completeness and consistency; indeed, creating an informed algorithm requires review and integration of current knowledge. These processes provide stable guidance to improve the care of individual patients by providing direction for technical processes such as surgical procedures as well as non-technical processes such as obtaining a complete patient history.
Standardization can oversimplify complex processes, especially when applied to a heterogenous population. In contrast to industries like manufacturing or aviation, healthcare must accommodate the significant variations introduced by different comorbidities, diagnoses, necessary management, and preferences of each individual patient. In chasing efficiency and standardization, we can lose sight of the individual and collective expertise that clinicians can bring, and instead suggest that all members of a discipline have equivalent skills. For example, considering all floor level beds to be equivalent can lead to an increased availability of beds for admitted patients and improve hospital efficiency and available capacity. However, it negates the unique expertise specialized hospital units could bring when taking care of patients with tracheotomies, nasogastric tubes, or free flap reconstructions. Having less experienced teams care for complex patients can lead to more patient safety events. For otolaryngologists this can be especially concerning for patients such as laryngectomees, who have undergone relatively low volume procedures that result in complex, critical airway needs and require allied clinicians with specific expertise.
Standardization also supports our efforts to move beyond analysis based on anecdotal information to evidence-based medicine. Some knowledge may only be revealed through analyzing collective experiences over many patient encounters. Effective treatment algorithms should be based on meaningful data; to accomplish this, data must be aggregated in a standardized manner. This knowledge is then disseminated in a standardized format: healthcare publications use an “IMRAD” (introduction, methods, results, analysis, discussion) structure, again to make it easier for readers to find the information we seek. Standardization helps us in the direct provision of care. Standardized roles help us distribute responsibilities during routine patient care and enhance our responses during crises; we know what capabilities to expect from the different personnel in our healthcare teams.
Standardization can lead to diffusion of responsibility, and complacency; we have all witnessed recitations of pre-operative site verifications that are conducted in a perfunctory thoughtless manner.
Standardization allows predictability, which decreases anxiety, and anticipation, which improves planning and responses. When managing a patient in the operating room, shared expectations of responsibilities and understanding of each healthcare provider’s skill set allow us to respond effectively to, for example, an airway crisis.
As we have seen with responses to COVID-19, variations such as resource limitations, technologic advances and disease evolution require flexibility and adaptability. Standardization, even when based on proven principles and processes, is inherently fixed in the past; rigid adherence can create a brittle system that prevents innovation.
Studies of standardization have demonstrated decreased costs, increased compliance with guidance, decreased hospital length of stay, and improved timeliness of healthcare delivery, among other benefits.2 In summary, standardization contributes to efficient, thorough care processes.
CON: STANDARDIZATION IS BAD
In summary, standardization can be detrimental to patients with unique needs and limit a system’s ability to adapt. Continued on page 10
SOUNDINGS | Fall 2020
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