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Al Fisk, chief medical officer of the physician-owned Everett Clinic
Fisk

Systems move to doc-led treatment standardization


By Andis Robeznieks
Posted: June 5, 2013 - 4:30 pm ET
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Advocates say standardization of healthcare protocols and procedures can save lives, time and money, but that doesn't mean establishing standards is easy.

“This is a very hot topic in the medical community,” said Dr. Al Fisk, chief medical officer of the physician-owned Everett (Wash.) Clinic. “For sure, there is always a fair amount of pushback—there was one physician who said he was happy to standardize, as long as everyone standardized the way he did.”

Fisk said Everett has decreased its MRI and CT scans by 30% to 40% by building standardized imaging protocols into its electronic health record. The EHR has boxes that physicians have to check to establish whether a patient meets the criteria to require a scan. If the criteria are not met, the EHR comes to a “hard stop” and the scan order is discontinued.

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“It was very effective,” he said. “What shocked me was that there was essentially no pushback.”

The key, Fisk explained, was that the physicians affected by standardization are involved in creating the standards. While some see overutilization of MRI and CT scans as a product of “defensive medicine,” Fisk disagreed, adding that physicians ordered the imaging tests because they thought it was the right thing to do based on their training.

“Physicians undergo 10 to 11 years of intense training and develop habits,” he said. “These habits may have been the right way to do things when they were trained five years ago or 20 years ago, but no longer.”

In addition to saving time and money, Fisk said the reduction in MRI and CT scans also reduces patients' unnecessary exposure to radiation, and this underscores how standardization leads to giving patients the best possible care.

In orthopedics, Fisk said standardization improves safety because the nurses and support staff learn a uniform way to operate with each doctor instead of having to adapt to the individual practices of every surgeon.

“There can't be a half-dozen 'best ways,' because—if the nursing staff does it one way instead of six or eight ways—they are less likely to make a mistake,” Fisk said. “None of this is easy, but it's the right thing to do for patients.”

Standardization is key to the successful integration of newly acquired practices or the merger of organizations into a system.

Englewood, Colo.-based Catholic Health Initiatives has about 480 physician practice sites in 17 states. Dr. T. Clifford Deveny, CHI senior vice president of physician practice management, said standardization of activities that don't involve patients—such as processing payroll—are the easiest. That is, except for standardization of food services, which he said triggers an emotional response in many people on staff.

Like Everett, CHI involves the physicians who will use the standards in developing them. Deveny said pushback has been lessened by the realization that both doctors and nurses need to be better stewards of the resources they use. He said a continued source of resistance, however, is where there are potential conflicts of interest when one physician may have a “special deal” with a vendor. Deveny said this too is going away as physicians realize such arrangements are not appropriate.

University of Colorado Health President Rulon Stacey said new procedural standards have been developed as have new protocols for where to send patients requiring emergency care. That system was created by joining together Aurora-based University of Colorado Hospital, Fort Collins-based Poudre Valley Health System and Colorado Springs-based Memorial Health System.

“The new stroke protocol has saved lives already,” he said.

Dr. Jason Stein, associate vice chair for quality at the Emory University School of Medicine's department of medicine in Atlanta, described the standardization at his organization as “getting people to work differently.”

“A hospital is an exquisitely chaotic place,” Stein said. “It's like countless 4-year-olds in a sandbox. From a distance, it looks like they're playing together, but they're not—and they may even be fighting over the same shovel.”

One way Emory has brought order to the chaos is by assigning hospitalists to one unit instead of to different patients in different units. What this allows is standardized workflow best illustrated by “structured interdisciplinary bedside rounds,” or SBIR, in which physicians and everyone in a patient's care team meets at the same time every day at the patient's bedside. Family members are also invited to be at the meeting.

“By having this shared time and space, we're actually able to chart a patient's response to treatment or lack of response to treatment,” Stein explained. “We're scheduling time to second-guess ourselves, share new information, adjust treatment to this new information or changing patient performance and have a common ground to address what we're doing for this human being.”

This simple approach has worked and “patients don't deteriorate in subtle ways under our noses anymore,” he said.

Stein and his colleagues are refining the data for a research paper they expect to submit in July, but he said there has been a “significant double-digit reduction” in mortality on the units where SIBR is practiced compared to the units where it isn't.

He added that SIBR “absolutely thrives” with hospitalist physicians, but it also works in areas without hospitalists, such as surgical units and in a hospital in Sydney, Australia, where they don't use the hospitalist model.

Stein said that Emory started on the standardization path in 2008. He quipped that “our brilliant solution was to talk to each other every day.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks


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