Dealing with Variance in Health Care

Our guest blogger this week is Dr Andrew S. Gallan, PhD Assistant Professor, Department of Marketing, Driehaus College of Business, DePaul University, Chicago, IL, and faculty research fellow at the Center for Services Leadership at Arizona State University.

Many efforts in health care today have been to standardize care – that is, to provide the same care to patients with various conditions in an effort to comply with standards of care. These efforts are commendable, certainly, given the increased understanding we have of best practices for treating disease. For instance, if a patient presents to an Emergency Department with signs of a myocardial infarction, physicians should immediately follow guidelines for treatment (which may include nitroglycerin, aspirin, CPR, ECG, etc. as per ACC/AHA Guidelines: http://circ.ahajournals.org/content/110/5/588.full). While these and other disease-related guidelines provide decision-trees that allow care to be provided according to a patient’s condition, there are specific actions that no patient should be denied (e.g., smoking cessation counseling, blood pressure control, aspirin and other medical therapies should be provided when appropriate). The development and application of evidence-based guidelines have vastly improved the quality of delivered health care as well as patient health outcomes (e.g., Nieuwlaat et al. AMJ 2007).

As a result, health systems have developed and adopted processes and systems to drive variance out of health care. An example of this is the application of six-sigma approaches to medical care (i.e., Loay Sehwail, Camille DeYong, (2003) “Six Sigma in health care”, Leadership in Health Services, Vol. 16 Iss: 4, pp.1 – 5). Many of these efforts have reduced waste in the delivery of care, as well as at times increased patient satisfaction (for more, see http://asq.org/healthcaresixsigma/lean-six-sigma.html).

There are aspects of care, however, that present formidable challenges to any health system, which includes dealing with variance among patients. Sources of variance may include health conditions, comorbidities, demographics, as well as intellectual, emotional, and psychological capabilities, and differences in social support. These are often sources of frustration to systems and providers: Why can’t the patients just understand what we need to do? Why can’t patients’ families get out of our way, so we can help them? Why do I have to explain what the patient needs to do repeatedly? (For some interesting perspectives, see Lin et al. J of Gen Int Med 1991; Krebs et al. BMC Health Serv Res 2006; and, ABC news: http://abcnews.go.com/Health/WellnessNews/story?id=7884555&page=1). Improper management of patient variance can negatively affect productivity, utilization, financial returns, and employee morale.

But the essence of health care is that one never knows who and what will walk through the door on any given day. This is particularly evident in the ED, but is also true for primary care physicians (see the literature on patient waiting time!). So, how can we reconcile the need for standardization with the demand for customization? This is a difficult paradox to handle, and is especially relevant for health care managers and providers. No patient should be denied care that meets generally accepted and empirically validated standards – a violation of the Hippocratic Oath, which inflicts harm on patients. Physicians are generally very good at appreciating this aspect of care, despite often low guideline adherence rates (Cabana et al. JAMA 1999). However, with the advent of patient-perception and –satisfaction measures and a patient-experience movement, rewards for managing and appreciating patient variance are increasing. Providers often feel pulled in different directions – being asked to accommodate differences among patients while endeavoring to meet and exceed standards of care.

Insights may be found in understanding aspects of service delivery that demand standardization, and differentiating them from aspects of service that benefit from customization (for a fantastic perspective, see Larsson & Bowen AMR 1989). Organizations should design health care service delivery to standardize essential clinical operations, in order to ensure safety, deliver appropriate care, and optimize patient health outcomes. At the same time, processes should be designed to accommodate differences in patient tolerance for risk, understanding and compliance, and to garner and enact suitable levels of support from family and social resources. Organizational service design should be thought of as having a “platform” for delivering excellent clinical care, while also hiring, training, empowering, and rewarding employees who empathize with individual patient conditions and limitations.

Patients need to feel that the health care organization is providing care that provides them the best odds of recovery. Patients do not like to feel that they are being treated at a facility that is out-of-touch with the latest, cutting-edge treatments. At the same time, patients are increasingly searching for treatments that are “for me.” The internet has enabled patients to connect with others with similar conditions, which has allowed them to explore similarities as well as differences (e.g., www.patientslikeme.com). Moreover, patients want providers to connect with them as sovereign human beings capable of discerning individualized care. Conversations between patients and providers should be free of interruptions and allow for questions and concerns to be aired. Finally, patients need to feel supported and have to be empowered to go forward to improve their health.

I urge health care professionals to view variance differently. Not all variance should be, or can be, eliminated from the provision of health care. Patients are different in important ways, and some of the differences are important to recognize and retain throughout the entire experience.

I hope this helps. I’d love to hear your thoughts and comments.



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2 replies

  1. please can you tell me more sources of variance in health care as I do not understand them

    • “Thank you for your question. I’m glad I have the opportunity to clarify some issues.

      Sources of variance that are unacceptable in health care include process measures and outcomes. For instance, if a nurse is charged with administering IV antibiotics to a patient every four hours, and instead the interval between doses is six hours, this is variance from process measures that is unacceptable and should be managed out of the system. Another example would be if a patient presented at the ED with symptoms of a MI, the physician has guidelines for a proper workup and treatment. The guidelines are based on scientific studies of what can be done to optimize the probability of patient survival. As a result, any deviance from adherence to the plan creates an unacceptable variance that poses a risk to the patient. Outcome variance would include things like how well and how soon patients return to daily activities after knee replacement. If one hospital is significantly behind the outcomes of its peer institutions, the impact on patients’ lives is negative. Thus, efforts should be undertaken to reduce the variance in outcomes.

      As the topic of variance applies to measures of patient experience, including survey items, certain dimensions of the patient experience may have more variance (larger standard errors) than others, indicating a wider range of responses. Many have called for efforts to focus on these items, to standardize the behaviors and processes surrounding a particular dimension (e.g., nurse communication or noise at night). While this is admirable and not altogether unwarranted, my point in the blog is that variance in scores cannot be reduced by reducing variance in process; in fact, the variance walking in the door won’t allow it. A “one size fits all” approach may in fact produce greater variance in scores due to the lack of accommodation of a variety of patient preferences. In order to reduce variance in scores and measures, the system must be designed to recognize, treat, and appreciate variance on the patient side.

      I hope this helps. If I can be of any further assistance, do not hesitate to post additional questions. Thank you.”

      Regards,

      Andrew S. Gallan, PhD
      Assistant Professor of Marketing
      Kellstadt Graduate College of Business
      DePaul University
      Chicago, IL

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