Standardization vs. customization: Understanding physicians' and hospitals' perspectives

The resistance to “cookbook medicine” is not new, but The Centers for Medicare & Medicaid Services and The Joint Commission created the impetus for practitioners to use protocols and order sets when they required hospitals to publicly report core measures for heart failure, acute myocardial infarction, pneumonia, and surgical care. Although most physicians have embraced protocols and order sets for these diagnoses, it has been an uphill battle for them to apply similar protocols to more routine surgeries.  

I recently approached the surgery department about standardizing preoperative doses of cefazolin, vancomycin, and clindamycin, and the surgeons responded with, “Why can’t we have our own customized orders?” My answer was that the surgical departments had agreed to a set of post-operative orders more than four years ago, and the universal use of those orders drove reliability and excellence in the core measures. Despite hard evidence in favor of using protocols, I was met with resistance when trying to standardize pre-operative antibiotic dosages and penicillin alternatives.

Nurses who wanted to reduce the customized options for surgeons requested that the surgery department create a standardized order set for pre-operative antibiotic dosages and penicillin alternatives. By creating a standardized order set, the nurses hoped to end the confusion caused by physician’s preferences, which had already generated errors. For example, a typical order set might look something like this:

For patients who are allergic to penicillin:

• Dr. A’s patients get clindamycin
• Dr. B’s patients get vancomycin
• Dr. C’s patients get vancomycin dosed by pharmacy  

When I suggested standardized order sets at a department meeting, I expected pushback, and that is just what I got. However, after further reflection, I understood that the unique care each physician provides to inpatients is reflected in order sets, and the content of those orders is the result of hard-won experience. Clinicians see patients as individuals, not populations, and they attempt to meet the needs of those individuals through order sets. However, the hospital sits on the opposite side of the divide; it sees patients as populations and attempts to standardize the care provided to those populations to produce desirable outcomes. 
  
As the healthcare industry continues to adopt computerized physician order entry, and regulators continue to demand expanded quality reporting, hospitals may be able to offer physicians some variation when making minor decisions about care, but the need for continued standardization around the larger therapeutic decisions will drive protocols and order sets. Younger physicians and emerging hospitalist specialists will appreciate that patient-centered care involves not only making the right decisions about treatment and diagnosis, but also the efficient and timely implementation of those decisions. 

Two steps forward and one step backward, perhaps, but I’m happy that physicians are so heavily invested in the care they deliver patients that they challenge the system. In the end, everyone has the best interest of the patient in mind, and this push and pull between standardization and customization probably generates improved quality and patient satisfaction.   

Carlotta Rinke, MD, FACP, MBA
Assistant vice president of quality and patient safety
Alexian Brothers Medical Center