#64 1991 · Intermountain Healthcare / LDS Hospital (Brent James, Alan Morris) · Healthcare / clinical qualitylegibility
Doctors treating the same disease were quietly running different protocols, and the hospital fixed it without taking away their judgment
the problem
Expert practitioners doing the same job were producing wildly different, unmeasured variation, and neither rigid rules nor pure discretion had fixed it
background
In 1991, pulmonologist Alan Morris was running an NIH-funded trial at LDS Hospital in Salt Lake City testing a new artificial-lung treatment for acute respiratory distress syndrome (ARDS), and needed a stable standard-of-care control arm to compare it against. Instead he found that expert intensivists, all treating the same condition, were setting mechanical ventilators in substantially different, unstandardized ways from physician to physician — variation nobody had previously measured because no one had ever tracked it at that resolution.
The two obvious fixes both had real costs: mandating one rigid ventilator protocol for every patient would strip out clinically necessary judgment calls for genuinely atypical patients, while leaving the variation untouched meant patients' odds depended on which physician happened to be on shift rather than on the best available evidence.
the move
Working with quality officer Brent James, Intermountain built a documented default ventilator-management protocol embedded directly into clinical workflow as the automatic path, but let any physician override it whenever a specific patient's condition called for it — with every deviation recorded and fed back through a continuous improvement loop, so the aggregate pattern of exceptions became data the protocol itself could be refined against, rather than either a mandate or a suggestion.
the payoff
Under the standardized ARDS ventilator protocol, survival for patients meeting ECMO entry criteria rose from about 9.5% to about 44%, cost per case fell from roughly $160,000 to roughly $120,000, and physician time spent per case fell by about half — improved outcomes and lower cost arriving together rather than trading off against each other.
what came after
Brent James generalized the approach into Intermountain's broader 'shared baselines' methodology, applied across more than 100 standardized clinical processes system-wide, and it became a widely cited model in health-policy and quality-improvement circles for how to standardize expert practice without eliminating the clinical judgment that standardization is usually assumed to cost.
references
- [1]Not Running a Hospital: Shared baselines as a guide to protocolsNot Running a Hospital (Paul Levy), 2015runningahospital.blogspot.com
- [2]Brent James: Achieving transformational change: how to become a high-performing organisationSlideShare (Brent James presentation), 2014slideshare.net