The value of standard work

"The most important thing we can teach our residents and trainees is the value of standard work."

Imagine if that were the philosophy in every academic medical center. It is the philosophy at the Mayo Clinic, according to Dr. Stephen Swensen, Director for Quality. Dr. Swensen commented on these matters during last week's IHI Annual Forum. I was not able to attend his session, but a colleague did go and reported back to me.

For years, I have been hearing about the quality of care given at Mayo and was having trouble learning what distinguishes the place. I should have figured it out. The simple summary of process improvement is that you cannot design and implement improvement if there is too much variability in your process. Why? First, you cannot design an experiment for change unless you are confident that your change is being applied to a relatively uniform "prior." Second, you cannot measure improvement compared to a base case if there is not base case.

Dr. Swensen talks a lot about the "cottage industry" and "farmers' market" approaches to medicine, as opposed to the Mayo way of standard work, decision support, and forced protocolization. Mayo has a Clinic Clinical Practice Committee that has the authority to set practice standards and methods across the organization. When improvements are discovered, there is rapid diffusion of learning.

When it comes to residents, they must be bronze-certified through Mayo Quality Academy before treating patients. This includes training on simulators before being allowed to practice procedures (like central lines) on patients.

Dr. Swensen also discussed four conflicts in academic medical centers that prevent truly patient centered care:

• Physician Autonomy - As mentioned, a high variation environment is inherently unsafe.
• Financial conflicts - Some care receives higher payments; there are financial conflicts between the doctors and the hospital; and fee-for-service creates conflicts of interest.
  
• Research - The well-intentioned focus on the mission that "we're here to advance knowledge" can interfere with care.
• Education - The well-intentioned view that "we're here to provide training opportunities" lets trainees practice on patients and causes care to be organized around the training program, rather than vice versa.
  

As I heard this, I thought about our place. While we have instituted some standard practices, it is clear that we have not gone as far as we might. On the financial front, we have started to move away from fee-for-service, but there is not a uniform payment system across all of our payors. And his comments about research and teaching are often likely to be valid.

I will state immodestly that we are viewed as one of the leaders among academic medical centers with regard to quality, safety, and process improvement. If we still have so far to go, after several years of concerted effort, the academic medical sector as a whole has miles to travel.