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a joint-replacement operation vary
dramatically, even when the unit
prices and patient-acuity levels
are the same,” Dr. Rosenthal notes.
“That tells us that if we were able
to reduce that variance, we would
have a more-efficient health system,
with more resources available for
other things.”
At the individual patient level,
Dr. Yeh argues, the issue is value,
not cost. “People aren’t looking
for the cheapest care possible,
Standardization of care “isn’t one-size-fits all. The
because that would be no care at
goal of standardization is to make sure the right
all,” he says. “We need to be able
patient is getting the right care in the right place at
the right time for the right cost,” says Dr. Michael Yeh.
to provide the highest-quality care
Photo: Ann Johansson
for the lowest-possible cost.”
Dr. Yeh found in his study that moving simple
operations out of the hospital to the outpatient-
surgery center cut costs in half. “Those patients
are getting the same quality, if not higher quality,
because we can streamline the operation so that
many of them go home the same day,” he says.
“By holding the quality constant and dropping the
cost by half, we double the value.”
Standardization also makes it easier for health
Beyond affording
systems to measure their performance. “If 100
accountability, people have a gall-bladder operation, and each
time you improvise — using slightly different
standardization medications, different lab tests, different vital
promotes advances
signs — you don’t have a controlled experiment
in care through
that you can look back at in a year,” Dr. Yeh says.
“That makes systematic improvement impossible.”
testing the effects of
Beyond affording accountability, standardization
incremental changes
promotes advances in care through testing the
effects of incremental changes against a backdrop
against a backdrop
in which all other aspects of care remain constant.
in which all other
“Standardization doesn’t mean care pathways are
aspects of care
static,” Dr. Yeh says. “They evolve through a process
of continuous improvement.”
remain constant.
The potential for standardization to improve
the quality and efficiency of care at UCLA is
bolstered by the health system’s electronic health-
record (EHR) program. Instituted in 2013, the EHR
enables the records of UCLA Health patients to
be immediately accessible, regardless of where the
patients are seen, and facilitates standardization
across the enterprise in the way medical information
30 U MAGAZINE
is stored and accessed. Beyond that, UCLA’s EHR
provides clinical-decision support to make it easier
for providers to follow evidence-based approaches.
More than 1,000 standardized order sets, designed
by UCLA clinicians, are used in both the hospital
and ambulatory settings.
“As you see patients with specific medical
problems, you can call up one of these evidence-
based order sets, and it will guide you through
the care of the patient,” explains Michael Pfeffer,
MD (RES ’07), assistant clinical professor of
medicine and chief medical informatics officer,
who was the lead physician in implementing
UCLA Health’s EHR. Active clinical-decision
support is also provided in the form of alerts.
Providers are notified of everything from
potentially dangerous drug-drug and drug-
allergy interactions to notifications specific to
the patient’s disease state or health-maintenance
needs, such as reminders of when an inf luenza
vaccine or cancer screening is due.
The EHR also makes it possible to conduct
the types of systematic analyses that can inform
quality-related efforts. “We’re able to look at gaps
in processes based on evidence,” Dr. Pfeffer
explains. “It helps us identify opportunities for
improvement across our enterprise in a much-
faster, more data-driven way.”
IDEALLY, STANDARDIZATION OF CARE
PROMOTES ADHERENCE to evidence-based
medicine, making decisions about patient care
supported by the best-available research findings.
But there are many aspects of patient care that have
been studied inadequately, if they’ve been studied
at all. “It’s easy to say that we’re going to only
practice evidence-based medicine,” Dr. Skootsky
says. “The problem is that there isn’t strong
evidence for every situation.”
In such cases, clinical teams will often get
together in an effort to agree on what is the
best practice so that decisions don’t come down
to individual preferences. Another approach,
increasingly applied at UCLA and other major
institutions, involves bringing clinicians together,
agreeing on a protocol, applying it systematically,
tracking the data and then learning from the
results. Where applicable, input is collected from