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