Standardized Best Practices and Individual Craft-Based Medicine: A Conversation About Quality

Lara Goitein; Brent James

doi:10.1001/jamainternmed.2016.1641

Special Communication

June 2016

Standardized Best Practices and Individual Craft-Based Medicine: A Conversation About Quality

Lara Goitein, MD¹; Brent James, MD, MStat²

Author Affiliations Article Information

¹Departments of Clinician-Directed Performance Improvement and Pulmonary and Critical Care Medicine, Christus St Vincent Regional Medical Center, Santa Fe, New Mexico
²Intermountain Healthcare, Salt Lake City, Utah

JAMA Intern Med. 2016;176(6):835-838. doi:10.1001/jamainternmed.2016.1641

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Abstract

Standardization of medical care through protocols, order sets, and other tools is increasingly a part of efforts to improve quality. The authors, a physician beginning a new position as director of a community hospital quality program and the chief quality officer of a health care system and director of a course in health care delivery improvement, discuss the benefits and risks of standardization in health care. Recommendations for responsible standardization are presented.

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June 17, 2016

Quality Questions in Medicine : A Patient Perspective

Esha Ray Chaudhuri PhD | N/A

Thank you for the interesting Special Communication on “Standardized Best Practices and Individual Craft-Based Medicine” in JAMA Internal Medicine ,June, 2016 (1)

From a stakeholder’s perspective, “A Conversation about Quality”, between two ardent physicians debating competing benefits of standard protocols and critical inquiry, offers hope for a truly 21st century transformative medicine (2), one that integrates the rigour of evidence based empirical science with creative interpretations of critical inquiry, bridging the ‘chasm’ between the two paradigms of scientific inquiry into reinventing and redesigning health care.

Epistemologically, the two paradigms are not perceived as alternatives but as complementary. Their distinct approaches offer unique perspectives on complex matters of learning and research, knowledge and action (3). The industrial models of technical protocols such as “Lean Production “ or “Mass Customization “ would be evidently effective for improving efficiency of systems, as illustrated by Intermountain’s success in integrated delivery of care , engaging organizational, regulatory and ethical issues (4). The impact of the Standardization expands even to patient outcomes, as evidenced in Intermountain’s deployment of a shared baseline protocol, the Antibiotic Assistant , where its use led to a substantial drop in infection mortality. Still, standardization can not be perceived “as a worthy end in and of itself because it reduces errors and inefficiency” or since its processes lend themselves to more rigorous evaluation that can generate the needed evidence. Recent studies, undertaken to test the influences of technical care quality and patient centered care on outcomes among patients with acute myocardial infarction , report that there is a significant positive relationship between the degree of personalized care experienced by patients during hospitalization , on both patient recovery and their post -discharge cardiac symptoms(5) The critical inquiry approach is clearly superior to standardization in detection and relational analysis of the outlier variables of quality and care, such as subjective interpretation of socio-cultural contexts, not captured in conventional algorithms of empirical inquiry.

Yet if Medicine wishes to remain true to its heritage, of being both an art and a science, there would be a need for many more physicians like Lara Goitein and James Brent , perceptive practitioners and sensitive healthcare professionals, who have comprehensive competencies to recognize that a holistic approach to illness care require equally the safety of uniform protocols as well as individual craft- based sensitivity to core principles and practice of medicine.

REFERENCES

1 Goitein, L. James, B. Standardized Best Practices and Individual Craft-Based Medicine. A Conversation About Quality. Special Communication. JAMA Intern Med. 2016;176(6):835-838

2 Committee on Quality of Health Care in America; Institute of Medicine. Crossing the Quality Chasm : A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001.

3. Kuhn,T.S. The Structure of Scientific Revolutions. Chicago: The University of Chicago Press, 1970

4. James, BC. Quality Improvement Policy at Intermountain Healthcare. Bruce Jennings et al (ed.) Health Care Quality Improvement : Ethical and Regulatory Issues .NY :Hastings Center, 2007

5. Meterko M ,Wright S et al. Mortality among patients with acute myocardial infarction: the influences of of patient-centered care and evidence-based medicine .Health Serv Res.2010;Oct;45(5 Pt 1):1188-204

CONFLICT OF INTEREST: None Reported

Standardized Best Practices and Individual Craft-Based Medicine: A Conversation About Quality

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