Much of operations is about standardization. There is much to be gained from building processes that are appropriately tailored to the task at hand and handling that task in the same “best” way every time. And then there is health care, where every patient is unique in some way and doing less is seen as an anathema. There is a very real possibility that not opting not to do some test or some procedure could lead to adverse outcomes for patients. However, not following best practices can lead to excessive cost.
The Wall Street Journal provides a nice example from a study at a small hospital system Christiana Care that made a conscious effort to get doctors to stick established best-practice guidelines (Hospitals Cut Costs by Getting Doctors to Stick to Guidelines, Sep 22). The procedure in question is cardiac telemetry, which is a monitoring technique, and how it should be used for patients that are not in an intensive care ward.
In cardiac telemetry, electrodes are used to monitor the heart for abnormal rhythms. To try to cut inappropriate use of the monitoring at Christiana Care, which operates two hospitals, a group of physicians redesigned the electronic system that doctors use to order tests and other care.
First, they removed the option to order telemetry for conditions not included in the [American Heart Association] guidelines. Doctors could get around this and order the monitoring, but they had to take an extra step to do so, according to Robert Dressler, who helped lead the study. “We didn’t want to get in the way of the bedside clinician who had a demonstrable concern” and wanted to use telemetry despite contradicting guidelines, he said.
Note that didn’t actually limit what a physician could do. Rather they just made it more complicated/time-consuming to order the test so this more of a judge than a push. The results, however, were fairly remarkable.
After the changes, the researchers found the hospital group’s mean daily number of non-ICU patients monitored with telemetry fell by 70%, from 357.5 to 109.1, while the mean daily cost for delivering non-ICU telemetry also fell by 70%, from $18,971 to $5,772. The changes had no negative effect on patient care; mortality rates at the hospitals remained stable, as did the number of “code blue” emergency calls to resuscitate patients.
I think this is a really nice story for two reasons. First, it does indeed show the power of standardizing at the right level. A large number of patients don’t need expensive monitoring and eliminating excessive use of the procedure can lead to substantial savings. Second, it really makes you wonder about how carefully the caregivers are actually thinking about how they carry out their work. Clearly, if a doctor has a deep held belief that this monitoring was necessary, she could still order it. But they are not ordering it. To my mind, that suggests that they find the American Heart Association’s recommendations sufficiently compelling that they will default to accepting them when doing so is easy. When ignoring the AHA guidelines is easy, they are happy to blow them off.