Pediatric Informatics: Computer Applications in Child Health (Health ...

120 A. Matlow and J.M.A. Bohnen
A standard of care is not a “guideline or list of options; instead it is a duty
determined by a given set of circumstances that present in a particular patient with
a specific condition at a definite time and place;… a measure of the duty practitioners
owe patients to make medical decisions in accordance with any other prudent
practitioner’s treatment of the same condition in a similar patient.” 5 In a legal sense,
“the standard of care” includes but may surpass the lowest stratum of clinical care
that provides patient safety and effective care; it is the primary yardstick used in
medical malpractice litigation. Key elements within this definition include individualized
patient care, physician assessment and judgment, and care comparable
to that practiced by others in the profession.
In contrast, standardization of care refers to reducing variations in care processes.
From a clinical care perspective, the ultimate goals of standardization are
to reduce harm and improve the quality of care. From a hospital or payer point of
view, standardization should facilitate financial accounting to help rein in overspending.
Examples of methods used to standardize care include clinical practice
guidelines (CPGs), bundles, and checklists. More recently, methodologies rooted
in the business industry, such as Six Sigma and reliability science are being applied
to the health care sector to improve quality and patient safety. We will discuss the
successes and limitations of each.
9.3 Clinical Practice Guidelines (CPGs)
CPGs (also covered in Chapter 11) are “systematically developed statements to
assist practitioners’ and patients’ decisions about appropriate health care for specific
clinical circumstances.” 6 They were first introduced in the USA in the 1980s
as a cost containment strategy, at a time when Medicaid and Medicare programs
were under pressure and variability in care was evident at many levels: institutional,
departmental, practitioner, and individual patient. The impact of this variability on
the quality of care, in addition to fiscal considerations, resulted in the establishment
of the federally legislated Agency for Health Care Policy and Research (now
known as the Agency for Healthcare Research and Quality), “to enhance the quality,
appropriateness, and effectiveness of health care services and access to these
services.” 7 Development of CPGs was a specific mandate of this newly formed
Agency. With the profile of CPGs elevated, many organizations developed CPGs as
a tool to improve the quality of care. 8 Given endorsement by the American Medical
Association, attention from the IOM, involvement of hospitals, insurers, and others,
a new paradigm in medicine was clearly evident. 9
CPGs generally are based on literature review by subject matter and domain
experts who apply the tenets of evidence-based care. In its policy statement on
classifying recommendations for CPGs, the American Academy of Pediatrics
describes three steps in evidence – based CPG development: “1. determination
of evidence quality in support of a proposed recommendation, 2. evaluation of