Hospitals and healthcare systems around the world are prioritizing the need to reduce clinical variation, as they recognize what quality gurus across many industries and settings have been preaching for decades: Uncontrolled variation is the enemy of quality.
For the purposes of this month’s Standard Practices column, let’s focus on just one variable: product selection. I recently read an article on LinkedIn by Li Ern Chen, MD, a surgeon and expert in healthcare quality and clinical safety. In the article, Dr. Chen advocated for the role of supply chain as a ‘traditionally underappreciated and overlooked business function” that can play a pivotal role in meeting all four goals of the Quadruple Aim: improving the health of populations, the individual patient and clinician experience, and the cost of care delivery. One of the sentences in her article that stood out for me was: “Repetitive tasks are commonplace in care delivery, yet we challenge our clinicians with a multitude of ever-changing products.” As an advocate for continual quality improvement, I wanted to explore the root causes of such variation in product choice and use, so I called Dr. Chen.
Divided we fall
The reality is, ask physicians or ask supply chain and they will often point the finger at the other. Supply chain will blame physicians whom they say want to be the sole decision makers, especially when it comes to expensive implants and other so-called “physician preference items.” Clinicians will blame supply chain for changing products and vendors every time they can get a lower price. The fact is, both examples, unfortunately, still exist in healthcare, but both statements are also grossly overstated. The good news is that clinicians, supply chain and other key players in healthcare delivery are focused more on what it takes to provide consistently high quality care at a more affordable cost. And this is why she calls on clinicians and supply chain to work together, from the very beginning on product selection.
Dr. Chen admits, physicians have been trained to work as autonomous practitioners and that they should have a choice in how they practice and what they use. But, she adds, that does not mean every individual physician should get to choose something different. Nor she says should supply chain make decisions without clinician engagement. Real value in healthcare comes when decisions are made using the expertise of both, and always with the patient in mind. She offered the example of urinary catheters and the use of those with silver coatings designed to reduce catheter-associated urinary tract infections (CAUTI), which according to study in the American Journal of Infection Control account for 36 percent of healthcare-associated infections (HAIs). That same study found that the use of the silver-coated catheters cut CAUTI rates in half, but at a significantly higher acquisition price.1
United we stand
Given the price difference, Dr. Chen says, you would not want to always use the more expensive device. Instead she says, consider those patients who have higher risks of infections, such as those in the burn unit, and stock the silver coated catheters there. She also cautions against making it harder for nurses and other clinicians by presenting them with too many choices. For that reason, she would not stock both the coated and non-coated catheters on a nursing ward with patients with a relatively low risk of infection. There she would recommend a more basic, and less expensive, catheter. In other words, physician and quality leaders should work with supply chain to make conscious decisions to vary which types of products are used based on the needs of different types of patient populations. Supply chain, she adds, should not simply ask clinicians which products they prefer, but rather to dig a little deeper, to get to the root cause of why and when they prefer one product over another. It could be that a particular product is viewed as truly better or worse for a particular indication. In other cases, it may just be that it is an ease-of-use issue that could be addressed with some training.
Ongoing training is also critical to effective supply selection and use and to both the patient and clinician experience, says Dr. Chen. Consider how uncomfortable a patient would be if he or she watched a doctor, nurse or medical assistant getting frustrated or appearing confused trying to figure out how to use a particular product. Often, training is included as part of a product purchase, but one-time training is not enough, especially with the increased use of temporary or visiting nurses.
Better yet, Dr. Chen advocates for sourcing supplies that are intuitive to use. She cites a specific example with central line dressing kits. When not intuitive, she has observed significant variation in how different clinicians changed the dressing, which can contribute to the high rate of central line associated bloodstream infections (CLABSI). Dr. Chen worked with a team of nurses, infection preventionists and infectious disease physicians to find just such a kit. The problem was, they did not bring in supply chain until they were ready to standardize on the product across the healthcare system, and when they did, supply chain wanted to investigate if it might be more cost-effective to manufacturer the product themselves. In the end, they collectively chose to go with the original manufacturer, but the lack of collective coordination and consultation from the very beginning delayed the introduction of the new product across the system. And when you consider that nearly 50 percent of ICU patients receive a central line and as many as 4,000 patient deaths each year are attributed to CLABSI, the delay of even a day can be a life or death decision.
1 Dikon A, Olah R. Silver Coated Foley Catheters – Initial Cost is Not the Only Thing to Consider. American Journal of Infection Control. June 2006; 34 (5): E39–E40.x R.
2 Why Do We Care about CLABSI? Johns Hopkins Medicine Website. https://www.hopkinsmedicine.org/heic/docs/CLABSI_prevention.pdf. Accessed February 8, 2019.