From the Society

Thinking about the basic science of quality improvement

Standardization in health care is difficult


Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.

I reviewed recent literature about my research topic, which is clinical pathways for hospitalized injection drug users due to injection-related infection sequelae and came up with my research proposal. As part of a scholarly pursuit, I believe having a theoretical background of quality improvement to be important. Before further diving into the research topic, I also generated a small reading list of the “basic science” of quality improvement, which covers topics of general operational science and those in health care applications.

Yun Li, an MD/MBA student at Geisel School of Medicine and Tuck School of Business at Dartmouth, Hanover, N.H..

Yun Li

Foundational operation concepts originate from applying physics and mathematics into factory production process. A well-known application is the Toyota Production System (TPS), featuring standardization and resulting in operation optimization. The system was first utilized in Toyota factories in Japan and later adopted and adapted in automobile and many other industries.

What makes standardization in health care difficult? In my operations class at Tuck School of Business, we watched a video showing former Soviet Union ophthalmologists performing “assembly line” cataract surgery. It includes multiple surgeons sitting around multiple rotating tables, each surgeon performing exactly one step of the cataract surgery. I recall all my classmates were amused by the video, because it appeared both impractical (as one surgeon was almost chasing the table) as well as slightly de-humanizing. In the health care setting, standardization can be difficult. The service is intrinsically complex, it is difficult to define processes and to measure outcomes, and standardization can create tension secondary to physician autonomy and organizational culture.

In service delivery, the person (the patient in health care organizations) is part of the production process. Patients by nature are not standard inputs. They assume different pre-existing conditions and have different preferences for clinical and non-clinical services/processes. The medical service itself, consisting of both clinical and operational processes, sometimes can be difficult to qualify and measure. A hospital can control patient flow by managing appointment and beds allocation. Clinical pathways can be defined for different diseases. However, patients can encounter undiscovered diseases or complications during the treatment, making the clinical service different and unpredictable.

Lastly standardization can encounter resistance from physicians and other health care providers. “Patients are not cars” is a phrase commonly used when discussing standardization. A health care organization needs to have not only tools, but also the cultural and managerial foundations to carry out changes. I am looking forward to using this project opportunity to further explore the local application of quality improvement.

Yun Li is an MD/MBA student attending Geisel School of Medicine and Tuck School of Business at Dartmouth. She obtained her Bachelor of Arts degree from Hanover College double-majoring in Economics and Biological Chemistry. Ms. Li participated in research in injury epidemiology and genetics, and has conducted studies on traditional Tibetan medicine, rural health, health NGOs, and digital health. Her career interest is practicing hospital medicine and geriatrics as a clinician/administrator, either in the US or China. Ms. Li is a student member of the Society of Hospital Medicine.

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