Standardization Versus Innovation
I have argued institutional rigidity is a major barrier to improving patient care, so it was interesting to read two papers approaching this issue from different perspectives. The first, by Tiffany Diamond, represents an approach from the payer’s perspective.
“Pursuits of value-based reimbursement arrangements have been rolled out with requirements that have led to unintended consequences. Volume and variability spring from every health plan program, and it can sometimes overwhelm providers with variety and complexity. This growing demand can steal time away from patient encounters and challenge provider organizations with a seemingly infinite number of requests to accommodate. And the patient lives at the tail end of this confusion—coping with illness, uncertainty, and perhaps a challenging care plan.
The problem of administrative burden is not going away. In fact, as we’ll explain in this article, it’s getting worse. Removing administrative burden requires answering three questions:
She goes on to propose a bureaucratic solution—a new “chief outcomes officer” whose job is to focus solely on the metrics and coordinating the different requirements. She assumes the health plan should be directing the care and that its data needs are paramount. Unanswered is the question as to what, if anything, these efforts contribute to patient outcomes.
“As health plans strive to differentiate, they may develop a variety of programs that they believe will help them achieve their business goals, improve the health outcomes of their members, and set them apart in the market…But to gain consistency, health plans will need to put down the desire to be unique.”
This gets back to the original question—what interventions/services actually improve outcomes. There are only a few interventions with a decent amount of and these are largely standardized. The rest is advertising. But note the assumption that standardization is the goal and variation, in this case of health plan requirements, is bad. The second article by Begun and Jiang argues healthcare management during the pandemic can learn much from complexity science.
“Complexity science views health care delivery organizations as complex adaptive systems that operate in highly complex and unpredictable environments. The perspective assumes that much of organizational life is unknowable, uncertain, or unpredictable and thus cannot be standardized and controlled…
The view of organizations as complex adaptive systems is fundamentally different from the traditional view of organizations as machines with the purpose of producing outputs through tightly controlled and standardized processes. Complex systems are built for adaptation, flexibility, and learning.
Simple rules such as underlying values and cultural norms help to ensure that agents and units react to change in a timely and coordinated manner.”
They identified a number of specific challenges posed by the pandemic, including increasing capacity rapidly, changing care models, and coping with financial losses. The authors summarize various principles proposed by students of the subject to guide decision-making and examine six case-studies.
“To manage capacity, financial loss, and care redesign, health care organizations have made the critical decision to release or reduce workforce or to shift many employees to remote work, including clinicians with telehealth technologies. Rightsizing and retraining workers is difficult in normal times and is even more difficult when changes need to be implemented expeditiously…
Extensive communication, collaboration, and innovation need to happen quickly in response to major surprises. Underlying conditions necessary for a quick response include pre-existing structures and cultures that encourage widespread and diverse participation on the frontlines of care.”
So, here we have two different perspectives on improving outcomes. The first paper assumes more standardization is a key to a solution, while the second argues a flexible, non-standardized responses is key. Proponents of the first argument would say the pandemic is an “exceptional” time as is said in television advertisements. But I would argue it is just more extreme than the usual time in health care. We have had a surge of influenza cases every winter, but we never know exactly when or how severe until it is over. The main difference with coronavirus, for now, seems to be that lulls follow behavioral changes by the public, not improving weather and the numbers are higher.
I have been assuming a “complexity” view of the enterprise, even though I had not specifically studied the subject. Hence my calls for reasonable variability, front-line clinical microsystems, and breaking down clinical and administrative silos and recognizing both uncertainty and the “quality paradox.” Since the first paper represents the perspective of a private insurer, (United Healthcare,) and I suspect the golden rule—he who has the gold rules—still pertains. But in health care wouldn’t the original Golden Rule be a better principle? More importantly, which mental model is more realistic?
26 October 2020
 Diamond T. Help Wanted: A Chief Outcomes Officer—A New Role Leads a Human-Centered Approach to Improve Outcomes. NEJM Catalyst 19 August 2020. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0469. She is a Senior Vice-President of Optum, a care management branch of United Healthcare.
 Begun JW, Jiang HJ. Health Care Management During Covid-19: Insights from Complexity Science. NEJM Catalyst 9 October 2020. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0541.
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