With policy makers and consumers increasingly demanding proof of high–quality, safe, and cost-effective care, it is incumbent on hospitals to find a way to improve clinical performance. Today, we’re going to explore how all healthcare managers should think about clinical standardization when it comes to improving organization predictability and efficiency.
Imagine a scenario in which each physician supports his decision-making exclusively on his previous knowledge and experiences. That is to say that, within a care unit, patients with similar conditions will follow different care journeys, depending on the person they are being followed by. How difficult it would be to manage your unit, ranging from stocks to hospital technical resources? Additionally, and knowing that a patient requires an interconnected and multidisciplinary care flow, how inefficient it would be to adjust every step of the way to every patient in a random fashion?
Now, imagine that, in the previous scenario, for some reason, a particular patient hasn’t reached the expected outcomes. How difficult it would be to find out which set of actions led to the final result?
From theory to practice:
- In the last decade and a half, only 50-60% of care has been delivered in line with level 1 evidence or consensus-based guidelines. 
- Around a third of medicine was a waste, with no measurable effects or justification for the considerable expenditure. 
- Between 20-25% of all healthcare costs are attributable to unwarranted variations. 
And what does it have to do with standardization? Everything.
Improving quality, reducing unwanted variations
The process of standardization is common in several industries and has been taken by the healthcare sector based on the premise that when procedures are uniform and based on scientific criteria care settings correspond to the actual needs of the people who receive it.
Evidence-based standards not only improve cost efficiency, but can also help doctors make better decisions, avoid medical errors and omissions, explain therapeutic decisions to patients, and can support high-quality care. (find a close-up on practical examples here and here). However, physicians often feel standardization represents a loss of autonomy and less personalized care.
That’s why organizational leaders must develop and communicate a clear, compelling vision that ties standardization to key objectives. Leaders must ensure that they have the right team, the right partners, the right data, and the right platform to deliver timely feedback and a well-coordinated management process that works.
All in all, we are talking about helping providers uniformly make important care decisions, saving time and money, while still accounting for variety among patients.
Let’s talk about waste.
Previously, we’ve highlighted that, in the last decade, around a third of medicine was waste. But what does it exactly mean?
The Institute for Healthcare Improvement defines it as resources expended in services, money, time, and/or personnel that do not add value for the patient, family, or community. And adds: “waste in the US health care system is real, of monumental and quantifiable magnitude”.
In 2012, Berwick and Hackbarth delineated six categories of waste in healthcare: failures of care delivery, failures of care coordination, overtreatment, administrative complexity, pricing failures, and fraud and abuse. Let’s have a closer look at the first three:
- Failures of care delivery: this group includes the waste that comes with poor execution or lack of widespread adoption of known best care processes that are effective.
- Failures of care coordination: in this case, that’s all about the waste that comes when patients fall through the slats in fragmented care, resulting in complications, hospital readmissions, declines in functional status, etc.
- Overtreatment: the waste that comes from subjecting patients to care that cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science.
According to the author’s analysis, together, these three waste categories were responsible for between $285 billion to $285 billion in the US wasteful spending in healthcare in 2011.  And guess what: it could be preventable by standardized evidence-based clinical processes.
An overview of what standardized best practices mean to cost reduction (by The Institute for Healthcare Improvement)
- Infections: between 50% and 70% of these infections were preventable with current evidence-based practices, which would save approximately $6.2 billion in direct acute care medical costs to American hospitals over one year.
- Overdiagnosis: C. difficile infection, breast cancer screening, hypertension, pre-diabetes, and asthma were all highlighted by the BMJ as conditions or tests that are commonly overused or overdiagnosed. Reducing the rates of diagnosis/usage of all six conditions/tests by 25% percent would yield total estimated savings of $33.7 billion over a one year.
- Hospital-acquired conditions: a meta-analysis of the additional costs attributable to two of the main hospital-acquired conditions found an estimated cost per case of $14,506 to $18,537 for pressure ulcers and $8,723 to $17,367 for venous thromboembolism that could be saved with an increase of best practices compliance:
- A “Stop the Pressure” campaign implemented by NHS Midland and East in the United Kingdom saw a 50% reduction in the rate of pressure ulcers during the campaign’s first year.
- Evidence-based strategies and risk assessments for venous thromboembolism (VTE) prevention by various collaboratives has demonstrated a nearly 40% reduction in VTE rates.
- Antimicrobial Stewardship: between 20% and 50% of prescribed antimicrobials in the US are unnecessary or inappropriate, contributing to antibiotic-resistant bacteria that infect 2 million people and cause more than 20,000 deaths per year. Assuming a 30% reduction nationally, we can estimate savings to the health system between approximately $917 million and $1.1 billion in 2018 US dollars over one year.
- Blood use: the overuse of blood transfusions was found as one of the most common medical errors in the US. Considering that there is evidence that around 60% of blood transfusions are unnecessary, the US health system could save between $3.6 billion and $5.9 billion over one year.
Despite the complexity, diversity, and exigence that characterizes the healthcare sector, the core of patient care are processes that should be uniformly implemented to better inform clinicians as to how best to treat their patients.
Besides the widely reported advantages in care quality and patient safety, standardization also impacts the organizational efficiency of healthcare units, reducing costs and improving key performance indicators both for individuals and the system as a whole.
Standardization promotes organizational predictability, providing specialists in medical processes the ability to respond to frequently posed questions about what will happen if the same circumstances remain. In short: outcomes and costs are a consequence of clinical and non-clinical processes. So standardizing processes you’ll be able to increase your healthcare unit predictability.
 Braithwaite Jeffrey. Changing how we think about healthcare improvement BMJ 2018; 361 :k2014
 Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019;322(15):1501–1509. doi:10.1001/jama.2019.13978
 Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513–1516. doi:10.1001/jama.2012.362
 Bueno B, Leo JD, Macfie H. IHI Leadership Alliance. “Trillion Dollar Checkbook”: Reduce Waste and Cost in the US Health Care System. Boston: Institute for Healthcare Improvement; 2019. (Available at www.ihi.org)