Standardization: Autonomy versus Consensus
On March 1, 2007, I had the privilege to be an invited speaker at the Wellspan Health System Quality Forum. I talked about standardization of medical care. As mentioned by Timmermans and Berg in their book, The Gold Standard: The Challenge of Evidence-based Medicine and Standardization in Health Care, there are four types of standards: standard designs, standard terminology, standards for performance, and standard procedures.1 Standardized procedures produce reproducible outcomes. Standardizing procedures around best known practice produces optimal outcomes.
Having a single way of providing care for a single patient situation makes any deviation or variation from usual practice conspicuous and more likely to lead to correction of the error or, if warranted, refinement of the system. For most problems, the theoretical single best practice is not the same in the minds of every provider. Some consensus must be achieved, usually around the evidence in the literature and the opinions of the experts.
The resulting “best practice” may not be the very best in the minds of all. Physicians, in particular, value the autonomy to treat each patient situation individually. But their question should be “How should I go about providing treatment for 100 patients with the same clinical situation?,” not “How should I go about providing treatment for patients with the same clinical situation 100 times?” The difference is subtle, but important. A protocol that is designed to do something 100 times the same way should be more robust than a protocol that assumes you will do the same thing 100 times.
Physicians should not think about how they would provide treatment for a patient with a particular clinical situation, but about how they would set up a system to provide treatment for every patient with that same clinical situation. When they think this way, they see that their care will involve other healthcare providers in the system. They will need to worry about more than their own behavior. They will need to involve themselves in how the system works to provide consistent care to their patients. They will need to work with the others who are trying to achieve the same objectives of consistently good care. To achieve that objective, they will need consensus, not autonomy.
Timmermans S, Berg M. The gold standard: the challenge of evidence-based medicine and standardization. Philadelphia: Temple University Press; 2003.