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March 23, 2023

How looking differently at standardization is turning these care providers into winners

Last week I was reading The Toyota Way by Jeffrey Liker and it forever changed the way I think about standardization in healthcare.

As we probably all have experienced making sure clinicians follow standardized protocols is a pain in the ass. A common argument used by clinicians to oppose standardization is that they are creative, thinking individuals, not robots. And because clinicians still bear the final responsibility and risk if something goes wrong it’s their call on how they want to provide care, meaning standardized care protocols are often not adopted.

This stubbornness of clinicians is costing society time, money and lives. Several studies have shown that a lack of standardization leads to unwanted variation in outcomes, decreased clinical efficiency and waste

Now, I’m not here to blame clinicians for their stubbornness. And it’s unfortunate that the perception of standardization as something limiting is wrong. As Henry Ford described it: What I propose is that we reframe standardization to, what Toyota calls, flexible standardization

Here’s Henry Ford describing standardization: 

“You need to look at standardization as the necessary foundation on which tomorrow’s improvement will be based. Standardization is the best you know today, but which is to be improved tomorrow. If you think of standards as confining, then progress stops.”

Now, perception is unfortunately reality so let’s see how we can do standardization better. 

First, let’s dive deeper into how standardization should not be done. 

Most care organizations I’ve talked to tackle standardization in two ways:

  1. They don’t tackle standardization at all. They have zero standardized clinical protocols written down and their care team provides care based on experience and know-how.
  2. They tackle standardization top down. It’s their Chief Medical Officer that creates clinical protocols in Lucidchart based on years of experience, scientific research, interviews with experts, etc. Protocols are then shared with the care team with the hope they will be adopted. Once shared they are rarely or never revisited. 

Both ways are wrong. While the first one will lead to clinical errors the second way treats care team members as machines instead of humans that have years of experience.

So, how should standardization be done? 

As Henry Ford described above, standardized clinical protocols should be used as a foundation for continuous improvement. A standardized protocol that is finished is a bad protocol. And rather than enforcing rigid standards that can make jobs feel routine and degrading, standardized work should be the basis for empowering care teams, sharing ideas for improvements and driving innovation for the care organization. 

In her book Steady Work Karen Gaudet shared the same finding from her personal experience at Starbucks:

“Humans just are not hardwired for repetition. And in service industries, quality human contact is central to the work. Human contact and standardization can seem like oil and water. But here is the truly important discovery from our observations: when task standardization is adopted and steady work cadences are achieved, people are freer to do the satisfying work of making human connections. When work tasks are both repeatable and rote, managers, executives and frontline baristas all have more space in their lives to chat a little, to ask questions, and listen to others.”

There are 2 distinct situations to empower your care team through standardization but where most care providers fail and actually leave their teams powerless.

The first is finding the right balance between imposing rigid protocols and giving your care team the flexibility to deviate from them during care delivery. Crucial here is closing the feedback loop: if deviated from standard protocol, why and based on what information? 

This input can then be used for the second distinct moment to empower your care team. Designing a bunch of static clinical protocols in Lucidchart or Miro is not that difficult. The hard part is to seek feedback and insights from the work floor and clearly show your care team that their insights as well as those from the outcomes, cost and experience data are being used for continuous improvement. 

Most organizations fail in both these moments: on the one hand imposing no protocols at all or too rigid protocols that can’t be deviated from in clinical practice and on the other hand failing to incorporate real world data and feedback for continuous improvement.

A key factor playing here is  the old nemesis of how healthcare guidelines are traditionally operationalized:

  • Literature on same subjects is often published in wide time intervals because of research study development and duration
  • This literature evidence is used to build into a consensus guideline 
  • Compiling of an official guideline version to be published follows a rigid, long winded editing and approval process
  • The end result is a +70 pages document that is too hard to find, interpret and implement in clinical practice
  • If implemented at all, it’s often partial and top-down

Because of this nemesis, it takes 17 years for new biomedical innovation to translate “from bench to bedside”, negatively impacting patient outcomes and killing innovation.

So yes, in a perfect world, we only make changes if there’s scientific-based evidence. But the reality is that life is not perfect, and though it’s critical that new ways of care delivery ensure patient safety and effectiveness, care organizations should dare to be agile and experiment. 

Luckily for me, I’m not the only one with this opinion, successful care providers are already embracing this mindset. Some examples: 

Dr. Ali Khan, Chief Medical Officer at Oak Street Health:

“When the COVID-19 pandemic was in full swing, guidelines changed every week. So we were continuously thinking “How do we build the infrastructure to get high agility that will give us the iterative stance that we need?”. Because besides these guidelines that change all the time, our local teams would also have a ton of learnings that we needed to incorporate. We were successful because of this reflective practice and the infrastructure devoted to it. Individuals were able to come together, reflect, and then act because of our mindset and infrastructure. 

Agile product development tools will influence how operational changes happen in a care organization, but they will also drive those changes and create a culture of continuous improvement. For success, you must adopt a hypothesis-driven experimental mindset and accept failure as a part of the process.”

Dr. Ajay Haryani, Director of Clinical Systems at Galileo: 

“At the end of the day, everybody recognizes the limits of evidence-based medicine, and all clinicians have their own sense of clinical judgment. And when you open up the opportunity for them to be creative and say "What do you think is the most effective way to actually achieve this outcome?" I think most folks are surprised by how much clinicians are excited to engage with new ways of approaching patient care in that way.”

Joel Haugen, ex Chief Product Officer at Crossover Health:

“So, by nature, we allow flexibility and creativity within our care team. But there's a delicate balance here around how we drive that standard efficiency and how we make these decisions about failing fast and modifying. We've acknowledged that our care model is never done, we along with the industry need to constantly evolve our care model by looking at data. So is the data showing that people are engaged in closing care gaps differently if they go this way versus this way? What's the cost of that? Is that more effective for asynchronous care to solve that problem, or otherwise? And because we're focused on the destination rather than the path, it allows us more flexibility in collaboration with our care team to make changes, to fail and find the right path with them on getting to the best outcomes.”

So, in order to create a culture that embraces standardization instead of fighting it, we need to reframe standardization to, what Toyota calls, flexible standardization. This has two main principles:

  1. Specific, yet general: Standardized work must be specific enough to be a useful guide, yet general enough to allow for some flexibility. Repetitive manual work can be standardized, or even automated, to a high degree. However, a narrow interview guide that needs to be followed when telling a patient they have cancer would not make any sense.
  2. Focus on people doing the work (aka bottom up): The people doing the work are in the best position to improve the standardized work. There is simply not enough time in a workweek for a Chief Medical Officer to be everywhere writing and updating clinical protocols. Nor do people like following someone’s detailed rules and procedures when they are imposed on them. However, people happily focused on doing a good job appreciate getting tips and best practices, particularly if they have some flexibility in adding their own ideas.

What does all of this mean for your care operations? 

If you’re running clinical operations at a care organization: 

  1. Create a culture that empowers care team members to continuously improve clinical protocols. Clinicians often describe medicine as an art and a science, and flexible standardization is exactly this. To achieve this you need flexible standardization and trust in your care team so they can be creative in the way they deliver care. 
  2. Have the right infrastructure in place that can support flexible standardization. Your software should enable teams to continious question, reflect and iterate on their standardized care processes. I might be biased, but Awell fits perfectly here. 
  3. Invest significant time and resources in standardizing your care processes. This will  help you scale your care operations and reduce unwanted variation.

Or to say it in the words of Dr. Ali Khan (Chief Medical Officer, Oak Street Health):

“At Oak Street Health we think about standardization as a 70/30 split.  It is important that the largest aspects of what your care team does are standardized. (...) The bulk of the work that we do is to make sure not only that we set standards, but that we also disseminate standards, coach standards, review standards, and then update and iterate those based on the things we learned. Our standards are constantly evolving and improving.”

Some final thoughts from experienced operators in the space:

  • Dr. Matt Sakumoto & Dr. Raihan Faroqui: Protocols largely don’t get followed because they are not present at the point of care in the EMR. In order to make clinicians follow the protocol, you need to nudge the right information, to the right person, in the right intervention format, through the right channel at the right time in the workflow. This concept is what we call the 5 Rights of Clinical Decision Support.
  • Dr. Matt Sakumoto: Doctors are, unfortunately, primarily trained on multiple-choice tests. So standardization should still provide multiple choices to a clinician to give them a sense of autonomy. 
  • Dr. Morgan Stuart: Most well-thought protocols go to die when clinicians are faced with a rigid set of inputs that effectively disallow flexibility. We need technology that is built for flexible standardization
  • Dr. Arpan Parikh: A crucial reason standardization fails is a lack of aligned incentives and data sharing. Clinicians have the lens of one patient, and they see outcomes from that lens. They don’t get to see, on a regular basis, is the unwanted variation in outcomes, decreased efficiency or waste. Showing this data to clinicians and aligning incentives based on that would help with the adoption of standardization. This is also something John Klaus (NP) emphasized. 
  • Dr. Jared Dashevsky: In startups, it’s all about workflows and efficiency. But the reality is that clinicians are not taught this mindset. There are maybe five days in the medical education curriculum dedicated to learning about quality improvement, which 95% of medical students forget a few days after. If you want to succeed, you need to teach our clinicians this continuous improvement mindset, otherwise it’s a losing game.

I’d love to know what you think! Feel free to reply :-).

Rik Renard

Special thanks to Amy Story, Dr. Arpan Parikh, Dr. Jared Dashevsky, Jack Needham, John Klaus, Dr. Matt Sakumoto, Dr. Morgan Stuart, Dr. Puja Uppal, Dr. Raihan Faroqui & Richard Mockler for the feedback and input.

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