The Hidden Cost of Variability

To the Editor When Fischer created the first preoperative evaluation clinic, he created a standardized system that coordinated multiple aspects of a patient's care to identify necessary tests or treatments.1 Around the world, anesthesiologists have subsequently modified the process with preadmission questionnaires, telephone prescreening by nurses, and Internet-based computer programs designed to alert surgeons to complex patients requiring an evaluation by an anesthesiologist.2–5 Although the ideal preoperative evaluation clinical model is not known, Katz et al. pointed out that there is still a high degree of variability in the ordering practices of surgeons and anesthesiologists.6 With increased variation in practice comes the increased potential for error and the associated increase in cost. Lean Six Sigma (LSS) and the use of disruptive innovation have allowed other industries to control cost and increase quality, but have been slow to gain acceptance in the healthcare industry.7 Six Sigma was first developed by the Motorola Corporation for the purpose of standardizing manufacturing processes and reducing errors to <3.4 per million. This technique often is labeled as cookbook medicine, but many proponents, such as Hayes et al., have shown that standardizing procedures in a checklist can have dramatic impacts on quality of care.8 LSS, made famous by the Toyota Corporation, involves streamlining a process to eliminate waste. It has at its core the ability to address the legacy issues of “we have always done it this way” and instead align the procedures on the basis of value to the end user and customer. This eliminates waste in terms of time, value, and cost. For the past 20 years, it is obvious that the improvements in the preoperative evaluation process have been sustaining, minor improvements. The next rendition of the preoperative assessment clinic needs to take lessons learned from LSS as a guide for disruptive innovation. It should place the anesthesiologist in charge of the surgical patient's nonsurgical issues; directly involve patients in their care; improve the clinical workflow of the perioperative process; expand the utility of the electronic health record; and provide a continuous, validated quality assurance process. What factors are needed for this endeavor? Recently, Moonesinghe stated that change in the health care environment must involve changes in structure, process, and outcome measures.9 Thus, changes in the preoperative evaluation process must move beyond the local practice patterns of any institution and start to examine the broader regional testing patterns. These measures must be communicated to all levels of the health care team, including nurses, surgeons, anesthesiologists, and primary care physicians. Future preoperative evaluation should involve processes learned from LSS, demonstrate test–test reliability, and address the issues of cost efficiency and timeliness. Without a doubt there will be multiple hurdles, but anesthesiologists should be leading this change together and be searching for the next disruptive innovation that will minimize the variability that is inherent in the health care delivery systems in this country. Mitchell Tsai, MD, MMM University of Vermont College of Medicine Fletcher Allen Health Care Burlington, VT [email protected] James D. Polk, DO, MS, MMM, CPE, FACOEP Space Medicine Division NASA Johnson Space Center Houston, Texas