Table 4 A description of simple, complicated and complex realities in the treatment of a patient hospitalised with community-acquired pneumonia (CAP)
Simple scenarios “all or none”Complicated scenarios “if/then”Complex scenarios “relational/may be”
Care process with respect to CAPObtaining vital signs and assessment of oxygenation status Assessing vaccination and smoking history Delivering vaccinations and smoking cessation counselling to eligible patientsSelection of appropriate empirical antibiotics based on risk factors, medical history and allergies Decision to admit for treatment Location of hospitalisation (ie, intensive care unit vs floor)Adaptation of guidelines to a patient with multiple comorbidities or conditions with conflicting treatments (That is, a critically ill 65-year-old patient with lung cancer who is having a myocardial infarction and has pneumonia. The patient also has a “do not resuscitate” order and does not want “aggressive” care)
Implementation of recommended care process and patient autonomy/input into care planEvery patient should or should not receive care process Typically, benefits outweigh risks so specific patient decision making/input is lowConditions of preferred use are known/discoverable but need to be adapted to specific patient input/valuesPatient and family input/values and influence of comorbidities appreciably determine treatment plan
Expected outcomeKnown—predictable based on outcome results from studies and previous experiencesKnowable—largely predictable based on previous experiences with similar patientsPartly known—essentially unpredictable due to the unique combination of patient characteristics and clinical uncertainty about treatments
Scientific evidenceBroad scientific agreement that the treatments/processes improve outcome measuresPatients who receive appropriate antibiotics for their specific clinical conditions have improved outcomesTreatment guidelines and evidence may not be applicable to a specific patient due to patient preferences and characteristics
Literature about treatment optionsClinical condition and past medical history/patient characteristics affect mortality rates which can guide treatment location (outpatient, floor, intensive care unit)Treatment guidelines may conflict
Ideal level of provider autonomy Improvement interventionsLow Admission checklist Standard admission template for doctors and nurses Discharge checklist for smoking and vaccinations Standing vaccination orders for nursingVariable Standard CAP admission orders Admission algorithm to guide treatment location/decision for hospitalisation Treatment guidelines for empirical antibiotic selectionHigh Provide space and time to encourage development of relationships between providers and patients/families
Oversight/monitoringPublic reporting of quality measuresFeedback to providers Public reporting of quality measuresLook for patterns of interventions and outcomes Examine disease burden of patient and families
Improvement aimIncreased reliabilityIncreased reliabilityIncreased resiliency