Some years ago I found myself working in Omaha, Nebraska, facilitating a group of physicians in the design of disease and condition specific hospital admitting “order sets” (i.e. diagnostic tests) and related tools. My remit was helping to develop and deliver transformation through the implementation of electronic health records (EHRs). At the time, doctors were quite suspicious of what they saw as “cookbook” medicine and were concerned about moving away from applying the years of tailored practice for individual patients to more standardized systems and processes. One particular surgeon raised a curious question: “Aren’t you really placing us in the Procrustean dilemma?”
As some of you with a knowledge of Greek mythology may recall, Procrustes was a rogue “smith and bandit” from Attica who accosted people by stretching them to force them to fit his standard-sized bed. In general, when something is Procrustean, different lengths, sizes, or properties are fitted to an arbitrary standard. The surgeon questioned therefore whether we were presiding over the medical version of the Procrustean dilemma.
My response to the surgeon’s question was to explain a common misunderstanding of the role of standardization in EHRs. Standardization doesn’t mean to follow a set approach without question. However, efficiency and safety can be improved through standardization by embedding guidelines and reminders of selected evidence-based processes and procedures. While standardization provides clinicians with a “checklist” of sorts, doctors need to know that they can and should continue to use their knowledge and experience to tailor and enhance the care of individual patients.
The “sweet spot” of developing standard content for EHRs is in the ability to strike a balance between presenting evidence-based and experience-based options for care with the ability to tailor orders or tests for the individual patient. These serve to reduce the likelihood that clinicians, with an array of tests to order, might forget a necessary test. Most clinicians find that this frees them up to think more about how to best tailor treatment for individual patients.
After my previous experience working in a single acute hospital setting getting doctors and other clinicians to agree on a set of standard processes and content, I was able to take this experience to a much larger project with a health care provider responsible for 14 hospitals across five states. The leadership team was determined to standardize order sets and interdisciplinary plans of care across the multi-entity system and wanted to use the implementation of a single EHR system as a lever to move the organization from a holding company to an operating company. In this case, our goal was to move from an alignment of acute trusts to a care system that shared standard policies, processes, and content. While this challenge seemed somewhat daunting, we started from the assumption that certain characteristics would need to be in place to achieve success. These included:
- Initial face-to-face team meetings (five to six teams by specialty) for 1-1.5 days (to accommodate the different locations of the 14 hospitals)
- A large group session orienting all to the overall project including technology, content goals, and shared tools
- An opportunity to openly express concerns about the tool, standardization concerns, the proposed design process, etc.
- Teams predominantly consisting of doctors but were supported by nurses, pharmacists, and other health professionals as required
- Advanced preparation of an initial starting set to jump start the content design process
- Use of an automated tool to present and document decisions in real time
- Strong facilitation, wherever possible by a clinician experienced with the design process, with each team setting their own agenda and priorities and agreeing on what time of day and which day of the week to conduct “virtual” follow up sessions
This process worked very well and the organization created 75 common order sets and more than 30 interdisciplinary plans of care over a 10 month period. This approach was initially conducted for the clinical content, and then used for other aspects of clinical design such as the creation of fact-based processes for specific diseases and conditions. While many discussions still need to be conducted face-to-face, our general experience is that clinicians will agree on most things if:
- Advance preparation delivers drafts for review and action
- The process is strongly facilitated and group decision-focused
- Issues are addressed one at a time with supporting pros and cons and a recommendation for a preferred approach
- Items that are not agreed upon are followed up with additional research or escalated to someone higher in the accountability chain
- Clear guiding principles for decision making (safety, quality, effectiveness, efficiency)
- There is a sense of accomplishment and having contributed, by the end of each session
In general we found that the different medical specialties responded to the challenges in different ways, with clear leaders and some laggards. Indeed, one surgical specialty – neurosurgery – was unwilling to leave the design session without completing all of their allotted tasks. Interestingly this occurred in this same specialty in the three different systems, suggesting that the Procrustean dilemma can be overcome and the journey can actually be professionally rewarding and even fun!
By standardizing clinical workflows; developing and adhering to explicit guidelines; and developing IT systems that cement these practices into day-to-day practices, hospitals can improve workforce productivity. Once this and the necessary implementation of EHRs is achieved, health professionals should find any Procrustean elements become their servant rather than their master.
A version of this post originally appeared on the Deloitte UK Centre for Health Solutions blog.