The same challenge in Sao Paulo, Dallas and Phoenix: how to reduce unwarranted clinical variability?

David Font

Triple Aim, Right Care, Less is More, Nothing with Me without Me, Lean are concepts, principles and methodological approaches that are increasingly present in healthcare institutions and which we frequently discuss in the posts on Advances in Clinical Management. All of them aim to make better use of resources and allocate them to what adds value to the patient, thereby advancing sustainability, quality and safety. While it is clear that this is the way, the real challenge is how to put it into practice in each of our institutions. And so it is essential to read and travel to learn from other institutions.

Advisory Board is an international organisation whose objective is to identify the best practices that exist in the world to help the leaders of the institutions to take action and solve their challenges. It has more than 4,000 organisations from different countries registered in one of its programs that work in strategy, quality and operations, people, clinical units and information technologies. Thanks to a working session organised by the Advisory Board in Madrid, I travelled, albeit with the virtual help of PowerPoint, to Montefiore, in New York, to Gesundes Kinzigtal, in southern Germany, to Manchester Strategic Health and Social Care and Clalit Health Services, in Tel Aviv, to review models of accountable care organisations, and Banner Health, in Phoenix, Texas Health Resources, Dallas, and the Albert Einstein Hospital in Sao Paulo as success stories on how to address the reduction of unwarranted variability. In this post, I want to share my learning about this second theme.

John Weenberg defines unwarranted variation as the variation that cannot be explained because it is not based on disease, evidence, or patient preferences. Reducing it, therefore, makes it possible to do things well based on the evidence and what the patient wants and to allocate resources to what provides value for the patient. Moreover, to reduce it, the three centres mentioned face it in a very similar way:

• It is a strategic priority led by medical management.
• Medical-led consensus teams with a comprehensive multidisciplinary representation are established.
• The progressive development of protocols with criteria such as the VCR (VCR = volume, cost and risk) is prioritised, in the case of the Albert Einstein Hospital, in which it is a priority to work in the processes that involve a greater volume of patients, higher cost and increased possibility of adverse events.
• Support teams are created for healthcare professionals with profiles such as process engineers, clinical IT staff, and program and project administrators. They give methodological support to design and implement, organise the consensus team, provide relevant documentation, integrate protocols created in the workflow, offer information system aids, outline the implementation plan, and monitor, identify, and correct barriers to adoption.
• There is a secure investment IT time and resources, the key to the success of the application and the evaluation of results.

The Advisory Board experts highlight that protocols are designed in all centres, but that the differential elements of these institutions are aspects such as the real integration in workflows and the correction of adoption barriers, thanks to the support teams and the information systems. Thus, significant and coincident results are observed in quality improvement, increased efficiency and improved financial results. It should always be noted that quality improvement and cost reduction often, although sometimes thought otherwise, go hand in hand.

In conclusion, I would like to highlight the intelligence of the three institutions by strategically prioritising the reduction of low variability, taking care of the method and investing in information systems and engineers, resources in which many institutions still hardly invest anything.

And let us not forget to travel, albeit virtually, to read and copy, adapting to each reality and different environments.