Standardization: a quality driver in healthcare

The health sector is complex, but the core of patient care are processes, and those should be uniformly implemented.

Standardization: a quality driver in healthcare

All healthcare providers follow a common goal - to promote the best medical care at the lowest cost, assuring their competitiveness and future viability. However, ensuring the best medical care represents a huge challenge. Bigger than it can seem at first glance:

  1. On the last decade and a half, only 50-60% of care has been delivered in line with level 1 evidence or consensus-based guidelines; [1]
  2. Around a third of medicine was waste, with no measurable effects or justification for the considerable expenditure; [1]
  3. The rate of adverse events across healthcare has remained at about 1 in 10 patients for the last 25 years. [1]

The challenge is going to persist in the next decades with some major details exacerbating the problem: antimicrobial resistance is increasing and has a significant impact on long hospital stays and mortality; [2] the world’s population aged 60 years and older is expected to total 2 billion in 2050 (up from 900 million in 2015), [3] representing an additional risk factor for multiple chronic diseases; the number of patients with multiple diseases will increase and demand 40 million additional health workers globally by 2030. [4]

Achieving consistency in the middle of unstoppable scientific evidence production

We live in exciting times concerning biomedical and health research, recognized drivers for health innovation, but it’s humanly impossible to be permanently updated and follow all the novel findings while working in a hospital - to take just the current context, more than 23.500 unique articles [5] have been indexed on Web of Science and Scopus between January and June 2020.

The gap between knowledge production and its implications is, indeed, the main reason for the different performances between healthcare professionals, teams, hospitals, and even systems. And with that said, eliminate this gap should be a global priority focusing on standardization as a key part of the process.

Why bringing standardization to the health sector?

The process of standardization is a common practice in several industries, ranging from aviation to food handling. Throughout the ages, we’ve seen these industries responding to major safety crises by standardizing processes to reduce variation and ensure consistency among the workforce. This has resulted in a uniformity level that has allowed them to perform their job functions with fewer incidents and more predictable overall results.

There is no question that the health sector is extremely complex. Every patient is different, and each person has his or her own personal story. However, at the core of patient care, processes that are agreed upon by the physician community and supported by relevant evidence can and should be uniformly implemented to better inform clinicians on how to treat their patients. This is all about Clinical Pathways.

From clinical practice guidelines to clinical pathways: a journey to improve quality in healthcare
Variability leads to suboptimal care and resources waste. Nevertheless, it is possible to mitigate it by providing detailed, updated, multidimensional, and reliable information, related to the best approach to the disease concerned.

While we currently may see similarities in health care delivery across several organizations and practice areas, standardization is not a reality yet not even inside a single hospital. One undisputed barrier is the physicians’ lack of keeping up with guidelines updates underlined in several reports. [6]

For healthcare leaders looking for a competitive advantage, standardization represents efficiency gains. It helps decrease variation among medical procedures, increases quality, and safety while reducing costs and increasing predictability All in all, from a healthcare manager’s perspective, standardization helps foster an environment of quality patient care.

Quality: the one million dollar goal

The World Health Organization defines quality in healthcare as “the extent to which health care services provided to individuals and patient populations improve desired health outcomes” and adds that to achieve it, healthcare must be safe, effective, timely, efficient, equitable, and people-centered. [7] In other words, improving quality implies delivering healthcare that minimizes risks and harm to service users, avoiding preventable injuries, and reducing medical errors; means providing services based on scientific knowledge and evidence-based guidelines while reducing delays, maximize resources use and avoids waste.

Standardization has proven its worth in all the previous axes. A 2017 report published by The Economist Intelligence Unit points it out: “(…) standardization efforts resulted in widespread improvements in outcomes that would be of interest to both healthcare providers and patients. In all instances, direct costs were reduced, and in just over half of the studies covered the length of hospital stay was reduced. Patients typically received appropriate care more quickly and reduced their use of healthcare services, suggesting that appropriate, timely care meant they spent less time in hospital”.

A close up on what success standardization looks like

  • A sliding scale insulin protocol | University Hospital in Pittsburgh:

An interdisciplinary committee created and implemented guidelines for the use of sliding scale insulin (SSI), frequently used for inpatient management of hyperglycemia and associated with a large number of medication errors and adverse events. One year after implementation, the physician order form was used for 91% of orders and, overall, 86% of SSI orders followed the guidelines. The number of prescribing errors found on chart review was reduced from 10.3 per 100 SSI patient-days to 1.2 and the number of hyperglycemia episodes decreased from 55.9 to 16.3 per 100 SSI patient-days.[8]

  • Antithrombotic therapy guidelines to treat patients with atrial fibrillation | REPOSI Study

The main goal was to evaluate if antithrombotic prophylaxis according to the 2012 European Society of Cardiology (ESC) guidelines is associated to a lower rate of adverse outcomes. The study was based on data from REPOSI - a prospective observational study enrolling inpatients aged ≥65 years with an Atrial Fibrillation (AF) diagnosis. The results show that guideline-adherent is associated with lower risk of all-cause and cardiovascular deaths. AF patients who were guideline adherent had a lower rate of both all-cause death (p = 0.007) and cardiovascular death (p = 0.024) compared to those non-adherent.[9]

  • The Financial and Clinical Impact of an EHR Integrated Pathway in Elective Colon Surgery

A retrospective cohort study of surgical patients age ≥ 18 years hospitalized from March 1, 2013 to August 31, 2016 evaluated an ERAS electronic pathway (E-Pathway) activity integrated with the EHR for patients undergoing elective colorectal surgery. Among the colon surgery cohort, there was a 1.28% decrease in costs of  per surgical encounter, per month, over the 18-month postintervention period, amounting to a total savings of $2,730 per patient at the 1-year postintervention period.[10]

Main takeaways:

  1. Standardization provides decision-makers and healthcare teams a means for comparing outcomes resulting from standardized process implementation within or across organizations.
  2. It allows teams to address problems pragmatically, basing decisions on what has worked, what has not worked, and why.
  3. Fundamentally, standardization touches the core challenge in reforming healthcare: achieving value without compromising patient outcomes.

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[1] Braithwaite Jeffrey. Changing how we think about healthcare improvement BMJ 2018; 361 :k2014

[2] World Health Organization | Urgent health challenges for the next decade | [internet] available at

[3] World Health Organization | Ageing and health | [internet] available at

[4] World Economic Forum | 5 ways to bridge the global health worker shortage | [internet] available at

[5] Nature Index | COVID-19 research update: How many pandemic papers have been published? | [internet] available at

[6] J Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65. doi: 10.1001/jama.282.15.1458. PMID: 10535437.

[7] World Health Organization | Maternal, Newborn, Child and Adolescent Health, and Ageing | [internet] available at

[8] Donihi AC, DiNardo MM, DeVita MA, Korytkowski MT. Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin. Qual Saf Health Care. 2006 Apr;15(2):89-91. doi: 10.1136/qshc.2005.014381. PMID: 16585106; PMCID: PMC2464821.

[9] Proietti M, Nobili A, Raparelli V, Napoleone L, Mannucci PM, Lip GY; REPOSI investigators. Adherence to antithrombotic therapy guidelines improves mortality among elderly patients with atrial fibrillation: insights from the REPOSI study. Clin Res Cardiol. 2016 Nov;105(11):912-920. doi: 10.1007/s00392-016-0999-4. Epub 2016 May 31. PMID: 27245329.

[10] Austrian JS, Volpicelli F, Jones S, Bernstein MA, Padikkala J, Bagheri A, Blecker S. The Financial and Clinical Impact of an Electronic Health Record Integrated Pathway in Elective Colon Surgery. Appl Clin Inform. 2020 Jan;11(1):95-103. doi: 10.1055/s-0039-1701004. Epub 2020 Feb 5. PMID: 32023638; PMCID: PMC7002169.