The heart of fundamental care delivery innovation lies in the standardisation of care into ‘care programs’ (see Figure 8.1). Currently, the archetypal mode of organising healthcare delivery is the ad hoc step-by-step approach. Since every patient trajectory is unpredictable, the care professional requires the freedom to ‘pick’ what this unique patient requires next from the palette of their professional knowledge base. Every patient follows his own trajectory and in these trajectories each next step is decided upon the step before (de Vries & Hiddema 2001, Strauss et al 1985).

One-hundred years ago, before the times of medical specialisation, physicians could handle most of what any patient could bring to their attention, and few diagnostic and therapeutic options were available (Howell 1989). At that time, the step-by-step mode of care delivery was both patient centred and efficient. In our times, however, the theory and practice of medicine have become highly complex. Healthcare institutions are populated by many different professions and specialists, handling patients that often require the attention of several of these. Yet most of our care delivery is still organised according to this archetypal form. Every next step (e.g. a surgical operation) is only conceived and planned at the completion of the previous step (e.g. obtaining diagnostic test results), resulting in frequent waits and, more often than not, very ad hoc and variably shaped patient trajectories. The result is a care process that is fragmented (not patient centred), unsafe and inefficient (see Claridge & Cook, Chapter 4).

Yet is patient care not in principle organised this way because individual patients have individual histories and needs (Strauss et al 1985, Timmermans & Berg 2003)? The individual trajectory of a patient suffering from heart failure, for example, is indeed unpredictable. A patient’s personal and medical history will shape his and his physician’s preferences in unique ways, and symptoms and reactions to therapeutic interventions never quite behave according to textbook definitions. Yet at an aggregated level, much of this individual variation disappears. For the category of heart failure patients, the steps that are mostly taken, or that should be taken, can be predicted.

For the major categories of patients that an organisation deals with care programs can be developed. As stated, care programs are work routines based upon multidisciplinary protocols that encompass tasks, decision criteria and work procedures for the care professionals involved in the care of such a patient category (see Box 8.1). Care programs can be limited to a hospital or a department, but they should ideally include all providers having a role in the care of a category of patients. The different professionals jointly develop these protocols, drawing upon evidence-based guidelines wherever possible.

Most of the benefits of care programs are well known: care delivery becomes more evidence based, and colleagues, patients and payers know what care to expect. Time after time, it has been shown that following smart guidelines meticulously yet non-dogmatically saves lives (Berenholtz et al 2004, Luthi et al 2003, Schiele et al 2005). Also, care programs afford safer care. Every safety expert knows that there is nothing more lethal than unwarranted variation in critical processes. Uncontrolled variation obstructs flow, unnecessarily burdens the cognitive processes of those involved in the process check and prohibits learning (because the process outcomes cannot be compared to each other) (Carroll & Rudolph 2006, McManus et al 2003, Rozich et al 2004).

Care programs also afford a reduction of coordination work. Working step-by-step requires each next step to be organised and planned anew, including all the ad hoc phone calls and form filling that comes with that. In organisations that work under pressures of time and resources (and most healthcare organisations do), this implies stress and loss of professionals’ and patients’ time. With care programs, the sequence of activities to pursue and professionals to see is already established. Rather than establishing this anew every time a patient comes in with ‘heart failure’, this care program is made beforehand by the professionals involved. Since everyone knows what to expect in the next, and previous, steps, coordination work is reduced (Mintzberg 1979, Timmermans & Berg 2003).

Finally, well-designed care programs are patient friendly. Those who mistake this call for standardisation for a call to quench the ‘art’ of medicine cannot be more mistaken. There is nothing ‘patient friendly’ in unnecessary waiting times and unnecessary safety risks. There is, on the other hand, nothing more patient friendly than a well-organised, smooth trajectory, in which everyone involved knows what is expected of them, is optimally informed, and can give their full attention to the patient (Millenson 1997).

For this to work, it is crucial that care programs are not just written guidelines. They should be concretely ‘anchored’ in the organisation through working arrangements between professionals and departments, special outpatient and inpatient facilities, the information technologies and forms used, material affordances and constraints, and so forth. For example, charts may be prestructured to indicate the steps to take next, or an outpatient clinic designed for optimal breast cancer care may be put in place. Likewise, the sterilised instrument baskets used in operating rooms can be standardised to ensure that the right tools for the job will be at hand, and checklists can be put in place that must be followed before a high-risk procedure is started (Committee on Quality of Healthcare in America 2000, Norman 1988, Parker 1997). (See Box 8.3 for the importance of ‘flexible standardisation’ in making care programs work.)

When developing care programs, the individual tasks, decision moments and work procedures should be critically reconsidered as to their organisational safety, patient centredness and efficiency. Can blood tests not be performed on the same day as the next visit? Can the variety in surgical techniques used by different surgeons be limited (Bell et al 2006, Committee on Quality of Healthcare in America 2000, Dy et al 2003)? This redesign starts by considering the four different components that constitute every care program: triage, intake, the core activities of the care program, and follow-up. Not all care programs will require these steps to be separated, but any care program requires:

Triage and intake are often necessarily entwined. In emergency situations the intake and the core activities are often inseparable. In chronic care the ‘core’ of the care program can extend for years. In acute care situations it may last only briefly. In general, however, disentangling these components helps in designing subtasks that can be delegated, or executed in a more effective, patient-friendly and efficient way. In current practices, every individual patient encounter seems unique because every patient comes to that encounter through a different route, with different diagnostic and therapeutic activities being done. In current healthcare practices, every single patient encounter is unique partially because there is no conscious attempt to streamline these encounters. By separating ‘triage’ and ‘intake’, and by organising the care delivery process accordingly, patient flows become more predictable. Patients remain unique, but not in the sense of varyingly incomplete diagnostic histories, or large differences in therapeutic steps already taken.

Often, (specialised) nurses can do (part of the) intake, so that the physician is freed from tasks that do not require their expertise. Ensuring a complete work-up before the consultation with a medical specialist, for example, can save many unnecessary outpatient visits. Given shortages in qualified personnel, such a redistribution of tasks is essential to managing the increasing demand for care. Retinopathy screening for diabetes patients, medication optimisation in heart failure patients (see Box 8.2) and glaucoma treatment are some of the examples where a redistribution of tasks between doctors, nurses and/or paramedics can provide optimal care for more patients (Johnson et al 2003).

Care programs and restructuring and delegating tasks are mutually dependent (see the arrows in Figure 8.1). On the one hand, restructuring and delegating tasks makes standardisation feasible: without this, one could not achieve as much quality gain with care programs. Again, multiple dimensions can now be optimised simultaneously: efficiency (optimal use of expensive capacity), timeliness (reduced throughput times), effectiveness (appropriate combinations of expertise at the right time and place) and patient centredness (a care program organises the care delivery resources around the patient rather than vice versa).

On the other hand, care programs are a necessary element of redesign and task delegation. Care programs can ensure both (a) the quality of the work delivered by the different care professionals involved and (b) the coordination of their work tasks. Both require standardisation of decision criteria (which patients may be handled by the nurse; what to do in case of doubt), data (what to register, terminology to use) and work procedures (what actions that should be done by whom). In the example of heart failure care (see Box 8.2), the nurse practitioner is supported by simple computer-based decision support systems that have been made by the physicians who hold final responsibility. In addition, the chance of errors is minimised: whenever uncertainty arises, the patient drops out of the ‘standard’ category, and is seen by a cardiologist immediately.