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.
Part 2 in a Two-Part Series
Outpatient anticoagulation therapy is wholly lacking in standardization, and is one of the most common areas of serious adverse medication outpatient events. The multiple method approach makes it nearly impossible to train health care workers and to track defects in the process. Standardization would reduce errors, and make it easier to recognize them when they occur.
Standardization also improves the reliability of processes and operations, as demonstrated in nuclear power, on flight decks, in cockpits, and closer to home, in anesthesia. In fact, standardized order sets and standardized processes are two important tools in the reliability toolbox. (Am J Med Qual 2007;22:50.) Since the 1980s, anesthesia has moved toward universal standards of care and has become one of the most reliable specialties in medicine. The Anesthesia Patient Safety Foundation has tracked and disseminated data for safe anesthesia administration for more than 20 years, which led to standards of care for the specialty.
Staff training is easier when a single treatment approach is adopted. Increasingly we are appreciating that a team approach to medical care is the safest and most efficient. In the most critical medical situations (cardiac arrest, trauma resuscitation), protocol utilization and a med teams approach were accepted long ago. Most Level I trauma centers run a code like a military operation with assigned positions and responsibilities, and it is easier to train personnel using these standardizations than to run each resuscitation in a random fashion.
One important step on the pathway to increased reliability, safety, and efficiency is the recognition of defects in a process. By recognizing where mistakes might occur, systems can be adapted to compensate for them. When there is no standard process as a baseline, the recognition of these defects is slower at best and utilizes more resources. Many processes in the emergency department have no clearly articulated procedures.
Urine collection is one that occurs randomly in most departments, and it is notoriously unreliable (“Where is the urine on bed 10?”), and defects are repeated daily. When processes become standardized, it is easier to recognize and remedy the defects. Using an abbreviated version of the root cause analysis methodology called the Learn-from-Defects tool, one of the first questions asked is, “Was there a protocol in place?” (Joint Comm J Qual Patient Safety 2006;32:102.)
Because there is not enough evidence-based knowledge about ED operations, most standardization will need to be developed locally; this is a good thing. When standardization is developed by front-line workers who know the processes and constraints of the institution best, as opposed to being imported by an outside regulatory body, the likelihood of successful implementation is increased and ownership of the process occurs.
Currently in the Institute for Healthcare Improvement's Emergency Department Innovation Community (the ED Collaborative), a dozen EDs are part of the Protocols and Process Improvement Workgroup. These teams are testing protocols for various ED processes such as urine collection and CAP treatment. They are encouraged to take a protocol “off the shelf” from the IHI web site and to customize it for their department and institution. Already these teams are showing improved performance with the implementation of standardization, and success is building upon success.
The financial case for standardization is easy to make, and I will devote an upcoming column to this subject. In short, standardized processes save money for many reasons. By reducing defects, money is saved, and by increasing efficiency, the number of bed turns is increased, which increases revenue. While fixed costs remain the same, the increased number of patients processed through the system means increased profit margins. As many ED managers can attest, when a physician group commits to a single treatment plan, supplies and medications can be ordered in bulk and cost savings occur there as well. When waits and delays occur due to operational inefficiency, what is the cost of a complaint? It is easy to make the fiscal case for standardization.
The case for standardization in medicine has been made again and again, and nowhere is this paradigm shift more needed than in the trenches of the hospital, the emergency department. For those physicians who would cynically ask, “What do you need the doctor for then?” the answer is, “For every important decision!” So much of the work that we do in the trenches involves high-level processing of information. Patients who present with many medical conditions and numerous medications require our full concentration and highest levels of cognitive functioning to make their diagnoses and treatment decisions.
Such complex cases need the physician's uninterrupted focus on this high level of problem-solving. If treatment protocols can prevent the physician from being distracted by mundane treatment decisions (shall we give Zofran or phenerghan as an anti-emetic), then isn't that another bonus? Some of the most critical decisions a physician must make on the front lines will never be made by protocol. Your elderly patient with CHF is in some respiratory distress. Do you need to intubate him now, or can you buy time with CPAP and avoid an intubation as you treat him? Protocols will free physicians to focus on the difficult diagnostic and therapeutic dilemmas in our practices. Why not embrace the new paradigm and be off?