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“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