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Clinical variation is the bane of many healthcare leaders, including quality leaders who realize it’s not acceptable to have better processes and outcomes in some areas but not in others. Standardizing clinical resources and processes can significantly improve quality while also reducing costs and resource use.
Some analysts have suggested that unnecessary clinical variation accounts for nearly half of all wasted healthcare expenditures in the country, but that variation often is tied to a relatively small number of physicians or individual hospital units. Pressure also comes from the Medicare Access and CHIP Reauthorization Act (MACRA), quality incentives and penalties, patient safety indicators, readmissions, and now Medicare Spending per Beneficiary. With this increased pressure to reduce costs while improving quality, hospitals are targeting clinical variation — the overuse, underuse, different use, and waste of healthcare practices and services with varying outcomes.
Acute care is still the leading frontier for cost expenditures and where reducing clinical variation is key, says Nancy Lakier, RN, BSN, MBA, CEO and managing principal of Novia Strategies, a consulting company based in Poway, CA. Hospitals and health systems are looking to the reduction of clinical variation to survive and thrive in their efforts to provide high-quality care while controlling costs. Lakier previously was a nursing executive and has seen what she says are meaningful improvements in the standardization of care.
“Historically, physicians were trained by different schools of medicine, and the different schools of medicine had their own philosophies and many things, both clinical and non-clinical,” Lakier says. “It was very much independent practice by physicians, so the patient’s care depended on their individual expertise and their particular way of doing things. One doctor might do something quite differently than another, but that was not seen as a problem necessarily.”
The healthcare community has made strides in integrating those silos of delivery, but there still can be substantial variation in how the same patient might be treated by different physicians or hospitals, Lakier says. Some healthcare groups, particularly nursing, have standardized much of their care processes but organizations have not sufficiently integrated those groups or departments for greater standardization, she says.
Clinical variation and redesign are important because unwarranted clinical variation may result in poor clinical outcomes, sub-standard care, wasted resources, excessive costs, and disappointing experiences for patients and families, says David A. Di Loreto, MD, FACS, MBA, senior vice president of GE Healthcare Camden Group in Chicago. Hospitals and healthcare providers increasingly are reimbursed through value-based contracts that factor clinical outcomes, patient experience, and healthcare costs into the rates that are paid, he notes.
“Delivering higher-quality care at a lower cost is proving to be a competitive differentiator for health systems that have successfully reduced unwarranted clinical variation,” Di Loreto says.
Reducing unwarranted clinical variation helps improve coordination and avoid redundancy, Di Loreto says. Standardization strategies also should detect gaps in care and seek previously unrecognized insights into performance. An overall goal should be to provide a framework for standardization by providing evidence-based protocols, care pathways, and clinical decision support tools, he says.
“One of the most important factors in successfully redesigning care is to design around the needs of patients and caregivers,” he says. “Automating administrative tasks, delegating more clinical responsibilities to nurses, medical assistants, and pharmacists, and reducing the clerical burden so that clinicians’ time with patients is increased builds trust and improves overall satisfaction.”
Lakier first addressed clinical variation when she was the nursing executive for Scripps Health when managed care hit California providers, which prompted her to lead a project to improve care while reducing costs. Scripps managed to save tens of millions of dollars by improving quality outcomes in all areas, she says.
“We did that by using risk-adjusted data and bring together groups of physicians to really discuss and look at the variation across physicians,” Lakier says. “That was something new because there had always been this acceptance of physicians doing what they thought best, in the way they wanted to do it. We said this isn’t necessarily right or wrong, but we should talk about it and see if there is something to change.”
Physicians began to learn from each other, and Scripps encouraged them to focus more on best practices. The effort yielded more clinical pathways, protocols, and practice guidelines, all intended to embed the changes in care to ensure that the patient was getting the best care process available, Lakier says. It was a switch for some physicians to look at their care decisions this way, she says.
After capitation and managed care fell by the wayside, the impetus for standardization of clinical practices also waned, Lakier says.
“Now, with the Affordable Care Act, we’re looking again at how to standardize care to best practice,” she says. “We have seen numerous times how it improves care for the patient and reduces costs. So many times, we are providing care ‘just because.’ The doctor has always ordered labs that way, or it’s just routine to do a task this way, whether it’s right or not.”
Clinical variation easily slips under the radar in healthcare systems, Lakier notes. Not everyone welcomes increased attention to the issue, she says, because people generally do not like their professional decisions and habits to be questioned. Younger physicians tend to be more receptive because they were trained with more attention to best practices, she says.
“Some hospitals have addressed this, but I would say the majority have not,” Lakier says. “If they have not addressed clinical variation, their patients are getting variable care based on the expertise of the individuals caring for their patients. Some people are more highly skilled than others, but more than that, we all have good days and bad days. Why not have protocols in place to support that care meeting optimal standards?” (See the story in this issue for examples of how clinical variation can be discovered and addressed.)
The interdisciplinary component is critical to clinical standardization, Lakier says. When working on case management projects, for example, she has found that not everyone knows the expected discharge date for the patient. Without that common knowledge, the teams from different disciplines cannot optimize care to meet that goal, and one individual’s non-standard care decision could throw off everyone else’s plans, she explains.
Embedding standardized clinical processes into an organization helps keep everyone on the same page, she says. If the whole team knows the patient should be discharged in four days, some decisions will stem from that as part of the standardized processes, Lakier says. Discharge education and planning may begin immediately, for instance.
“It’s not that people aren’t trying to do their best, but everyone gets busy. If the physician forgets to order physical therapy, now the patient waits a whole day for physical therapy and that might extend the patient’s stay,” she explains. “That increases their risk, because every day in the hospital puts them at risk of comorbidities, falling, or other complications. We want to make sure the care they need is delivered expeditiously, and that is achieved most effectively by having standardized care processes.”
Routine protocols take the burden off of physicians to remember every single detail of care, such as the physical therapy order that will delay discharge if overlooked, she says.
Addressing clinical variation starts with obtaining good risk-adjusted data, Lakier says. The data can include HAP scores, readmission rates, morbidity, mortality, and a range of other measures. The data should focus on quality improvement and outcomes, not just costs.
The data should be presented to medical leadership, identifying variation among physicians. It’s important to have risk-adjusted data and emphasize to the physicians what that means. This will eliminate the sometimes-valid retort that a physician with poor outcomes treats sicker patients than the others.
Rather than going to physicians with a predetermined solution and telling them, “this is how you’re going to practice medicine from now on,” the data can prompt internal discussions that will lead to better and more standardized practices, Lakier says.
“Pretty soon they’re talking to one another and saying, ‘Wait a minute, how come your costs are different from mine? What are you doing to get your patients a shorter length of stay than mine?’” Lakier says. “If this isn’t done in a collaborative and informative way, you’re going to have resistance. Our job in quality improvement is to present information to help them understand what the data says. Then if they choose to change their practices, our job is to embed that in the organization so you get sustainability.”
Author Greg Freeman, Editor Jill Drachenberg, Ebook Design Specialist Dana Spector, Nurse Reviewer Fameka Leonard, and Consulting Editor Patrice Spath, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.