Balancing standardization and flexibility to address the needs of the moment

June 2, 2021 / By L. Gordon Moore, MD

There is good evidence that waste is abundant in health care. Inefficient care delivery is one source of waste, where inefficiency is defined as variability in the way we care for people who have the same condition.  Presuming there is an optimal way to care for a person’s condition, any deviation from that optimal path is waste.

This chain of logic leads to evidence-based-medicine in which clinicians follow guidelines and outcomes improve. The degree to which a clinician follows guidelines could then be used to judge that clinician’s willingness to adhere to low waste, higher quality care.

So far so good, but now we move from the theoretical to the real world.

First an acknowledgement that in the face of immense variability in care delivery, adherence to guidelines leads to improvements in health outcomes for people. Second, an acknowledgement that guidelines clearly state that they must be adapted to fit the context of the person and blind adherence to guidelines is recognized as inappropriate.

This latter statement is very helpful as it reminds us of the significant limitations of guidelines: They represent the best knowledge at a point in time, and they only ever address one aspect of the complex human organism. 

Point-in-time

Health care delivery and our understanding of disease is continually advancing. One of the challenges for guideline developers is that it takes time to develop and deliver a guideline, time for it to filter into practice, and by the time it is widely disseminated it is probably already out-of-date. This is not a bad thing, it’s just a lot of work.

Small-versus-big picture

This is a bigger challenge for guidelines: The source of information on best practices tends to come from randomized control trials that by their very nature tend to exclude people with more than the target condition. The resulting information is misaligned with the real world in which the bulk of people who have the condition will also have other conditions, sometimes several other conditions. Therefore, a guideline recommendation that may fit a person with (for instance) diabetes and no other condition, may not be appropriate for the majority of diabetics who have additional conditions.

Welcome to the real world of health care where clinicians must juggle the best evidence within the context of people with multiple conditions. These clinicians sometimes need to put aside the rules to do what’s right for a person, and sometimes invent new processes given the complexity of the human condition.

One day in his urgent care practice, Dr. Elvin Geng realized that he had an opportunity to adjust rules and practice to deal with a complicated issue for a patient.  He recognized this work as similar to what Dr. Michael Lipsky described as “The Street-Level Bureaucrat.” Come listen to them discuss this work and its implications in health care delivery on the 3M Inside Angle podcast.

Dr. Gordon Moore is Senior Medical Director, Clinical Strategy and Value-based Care for 3M Health Information Systems.