Dr. Welch is the quality improvement director in the emergency department at LDS Hospital in Salt Lake City, a clinical faculty member at the University of Utah School of Medicine, faculty at the Institute for Healthcare Improvement and the Urgent Matters Project for the Robert Woods Johnson Foundation, a quality improvement consultant to Utah Emergency Physicians, and a member of the Emergency Department Benchmarking Alliance.
The case for standardization in emergency medicine has been made, and yet we still hear physicians decrying what they call “cookbook medicine.” Imagine hearing this from the pilot on your next commercial airline flight:
“Folks, the FAA has some checklists and protocols they want me to follow for landing this aircraft. Let me tell you this: I am a good pilot with 20 years of experience, and I hate cookbook piloting! I am going to put this baby down MY WAY!!”
You'd be appalled! You'd be frightened! You'd think he was an egotistical maniac! And you'd look for a parachute. Yet this type of dialogue ensues every time physicians are asked to standardize care for patients. Ironically, it has been noted that physician pilots who have no trouble accepting standardization and protocols in the cockpit rail against them in the clinic or emergency department. Why is that? Part of it is cultural.
According to Brent James, MD, of the Institute for Healthcare Delivery and the Institute for Healthcare Improvement, physicians enter medicine with the expectation that they will practice with autonomy and develop customized treatments for each individual patient. The understanding was that if the physician cared, studied, and tried hard, quality health care would be the expected result. Dr. James calls this model the “craft of medicine.”
Unfortunately, as health care has become increasingly complex and data driven, the old model does not deliver. In fact, the more we learn about human cognition, the limits of human performance, and the functioning of complex systems, the more we appreciate how error prone the old paradigm really is.
As patients become increasingly complex, their emergency department visits will involve longer stays with more diagnostic and therapeutic interventions, more information to be managed and more opportunities for individual errors to accrue. Errors of commission (doing something incorrectly such as misreading a label) occur three times out of 1000. (Leadership Guide to Patient Safety, Institute for Healthcare Improvement White Paper, www.ihi.org, accessed Feb. 21, 2007.) Errors of omission (not doing something such as failing to follow-up on abnormal lab tests) occur one time in 100.
Best Tonic for Failure
Consider the compounding effects of these human errors in health care processes which involve multiple steps. For instance, filling a physician's medication order for a patient has been estimated to have between 40 and 60 steps. If a 50-step process has a one in 100 chance of error, then the chance that the process will be completed successfully and error free for all 50 steps is 0.61, or only 61 percent of the time! System changes can increase the base success for each step and for the overall process.
One of the best tonics for operational and process failures is standardization. In fact, some of the most innovative, progressive, and operationally efficient emergency departments have standardized order sets (sometimes called advanced triage protocols) for the top five to 10 chief complaints. These physicians also are standardizing the processes for things like urine collection and radiology operations, common sources of bottlenecking and delays in the emergency department.
While this type of standardization of emergency department operations is still rare, aviation world standardization has been embraced and systematized to compensate for human error. Commercial aviation is one of the most highly reliable industries. Mistakes are expected, the limits of human performance are recognized, and the system includes processes and mechanisms to compensate for error. And it all starts with standardization. There is less than one fatality per million take-offs (flying is one of the safest things you do) while health care is reliable only eight out of 10 tries. (Improving the Reliability of Healthcare, Institute for Healthcare Improvement White Paper, www.ihi.org, accessed Feb. 21, 2007.)
While advances in medical research have given us evidence-based treatments (what to do), the delivery of this health care (how to do it) is problematic and fraught with error. Delivery, which is the operational side of medicine, has not kept pace with clinical advances. On the other hand, we can expect some of the most exciting advances in our specialty in the coming decade to occur in operations. It will have to start with standardization, and as many familiar with health policy realize, if we do not develop standardization on the front lines and within our own industry with a knowledgeable eye toward work flow, it will be imposed on us in the form of regulations.
These regulations are likely to come from large bureaucracies like the Joint Commission on Accreditation of Healthcare Organizations or the Centers for Medicare and Medicaid Services, and will be less palatable than standardization that is industry-driven by practitioners who understand the work of the emergency department.
Next month: Nowhere is the need for standardization greater than in the trenches of the emergency department. Believe it or not, this doesn't take away from physicians but allows them to focus on critical decisions.