“The goal is to make sure we are reliably providing the best- possible care at the right time for every disease process.” 28 U MAGAZINE STANDARDIZATION ALSO DOESN’T NECESSARILY MEAN one set of rules for all patients. “A patient with a brain tumor can be a 16-year-old girl who is otherwise perfectly healthy, or it could be a 78-year-old man with cardiac and pulmonary disease and diabetes. Obviously, those two very different patients, with the same diagnosis, will require different patterns of treatment,” says Neil Martin, MD, chair of neurosurgery at the David Geffen School of Medicine at UCLA. “The goal is to make sure we are reliably providing the best-possible care at the right time for every disease process. We don’t want to rigidly standardize, but we want to eliminate variation that is non-scientific and based on individual physician preference.” Dr. Martin’s department is in the process of systematically evaluating every step of treatment for patients with particular conditions to define the best approaches and ensure that they are applied in all cases. The effort involves weighing the existing scientific evidence and collecting input from all personnel involved in the care of patients before, during and after the surgery, along with surveying the patients themselves. Standardized protocols have been developed to enhance recovery after surgery in a way that emphasizes safety and value to the patient. For example, benchmarks have been set for when and how to begin mobilizing postoperative patients, including specific criteria they need to pass to advance to the next level. This has led to a substantial increase in the percentage of patients who are able to ambulate under their own power — an important achievement that stimulates the patient’s motivation to recover — the first morning after elective surgery, from 20 percent to 60 percent. Promptly getting a patient up and moving dramatically reduces the risk of dangerous postsurgical complications, such as pneumonia and deep-vein thrombosis, and increases the likelihood of a shorter hospital stay. “Standardization allows us to be sure we are meeting specific goals for the care items most important to our patient population,” says Nancy McLaughlin, MD (FEL ’12), assistant clinical professor of neurosurgery and leader of the department’s care-redesign effort, which also has focused on pain management, patient education and communication and transition of care among care providers. “Standardization drives care delivery so that we are not reinventing the process every time a care provider comes into contact with a patient.” She notes that the standardization of processes shouldn’t be undertaken blindly; rather, it should be done in conjunction with a value-redesign initiative that will ensure improved outcomes and reduced costs, with room for customization of elements, where appropriate. “Ninety percent of the patient problems we see can be managed with some type of algorithm,” says Michael Yeh, MD, section chief of the UCLA Endocrine Surgery Program. “And I would argue that you could bring it to 99 percent by making a thinking algorithm that adapts.” Dr. Yeh’s group has developed and studied two clinical pathways for endocrine-surgery patients. One assigns patients to the most-appropriate surgical setting based on the clinical complexity of their case. It has resulted in substantially lower costs by shifting appropriate patients to community inpatient or ambulatory-care facilities. A second standardizes the initial management of patients with thyroid cancer by assigning them to care pathways based on their parathyroid-hormone levels. The new protocol resulted in a 70-percent reduction of laboratory tests, while decreasing the likelihood of patients presenting with critically low calcium levels by 30 percent. “We have reduced costs and improved quality by eliminating wasteful services,” Dr. Yeh says. He argues that improved quality will often go hand-in- hand with reduced cost because “the most-expensive thing you can have in surgery is a complication that requires additional care.” In cardiac surgery, the complexity of the cases and the multidisciplinary-team approach to care demand that it be highly protocol-driven — from the preoperative evaluation of patients to the surgery itself and through the postoperative treatment and post-discharge care. But there are inevitably variations in the care that is provided, and those become an opportunity to formally discuss and improve on the standards, says Richard Shemin, MD, chief of cardiothoracic surgery at UCLA. Dr. Shemin heads a consortium of the five University of California chiefs of cardiac surgery that is examining aspects of the operations that lead to costly complications. The group is seeking to develop best-practices by sharing clinical and