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What the heck is a “preference card”?
We’ll get to answering that question, but let’s first take a quick detour and set the stage.
Volatility
Uncertainty
Complexity
Ambiguity
And the latter (my personal favorite):
Brittleness (Fragility)
Anxiety
Nonlinearity
Incomprehensibility
Coined in the 1980’s by the US Army War College, VUCA was intended to embody the zeitgeist of the post-Cold War world and has since been appropriated to describe any number of demanding environments. The latter, BANI, was created as an evolution of VUCA to more accurately capture a rapidly changing civilization beset by pandemics, climate change and a host of other previously almost unimaginable challenges.
Anyone who has spent time working in an operating room (OR) or adjacent procedural environment (think cardiac cath lab, interventional radiology suite, etc.) knows that both VUCA or BANI frequently apply to these environments. Other environments in which these concepts are relevant, such as aviation, utilize a series of organizational frameworks to mitigate the potentially catastrophic effects of any one of the rungs of the VUCA or BANI ladders. Flight plans. Check lists. The operating room is no different.
Surgeons have checklists, just ask Atul Gawande, MD. Operating rooms have flight plans. They are called “Doctor Preference Cards”, or just “preference cards”. Preference cards are blueprints that detail the nature and quantity of items that a surgical team will need to perform a particular procedure. Preference cards also describe utilization practices, including setup and positioning of the OR, manner of use for a variety of items intraoperatively and finally – like a well-conducted symphonic piece – the coda or closure.
Let’s take a look at one for arthroscopic rotator cuff repair, a procedure in which the surgeon repairs a torn tendon in a patient’s shoulder using only small incisions and a camera to guide their work.
Here we have two sections of the preference card document, the first (above) details specific items, quantities that should be opened and ready to go and those that should be “held”, or in the operating room in case they are needed. There are also a few prices listed, although the surgeon rarely has line-of-sight into these costs.
The second section (below) is a free-text comments section – notes often made by various members of the OR staff and rarely seen or reviewed by the surgeon.
By the way, the example above was pulled from a relatively “sophisticated” supply chain management system. Many preference cards, however, are actual 5 x 7 index cards – like the one below taken from a modern ambulatory surgery center (ASC) – word documents or simple spreadsheets, also for arthroscopic rotator cuff repair – no joke.
Furthermore, preference cards, by way of res ipsa loquitur, are subject to preference! Preference cards vary from surgeon to surgeon, from site to site, from system to system, from region to region. What I mean is that preference cards for a given procedure, say the rotator cuff repair example from above, can and will vary significantly from one surgeon to the next, from one hospital to the next, from one healthcare system to the next and from one region of the U.S. to the next!
How do they vary?
They can vary in almost every way. In whether one item is used versus another, in the quantity of a given item used, in how that item is used, and on and on.
By now it should be plain to see that most preference cards – even those contained within otherwise sophisticated EHR data architecture – are static documents, lacking real-time integration and plagued with inaccuracies.
In fact, one study reported that 80% of surgeons and 70% of perioperative nurses queried were dissatisfied with the accuracy of their preference cards.¹
Can you imagine boarding an airline in which 80% of the pilots were dissatisfied with their flight plan? Me either. But I work in an equally BANI environment on a daily basis in which that is the case. Head-scratcher, n’est-ce pas?
There are multiple arguments to make here revolving around preference card optimization. The preference card blueprint rests squarely upon an axis that connects patient safety, clinical outcomes, clinical variation, cost containment, and multiple other variables. All are extremely important. My particular focus is that of cost containment.
Now that you have an idea of what a preference card is, tune in to my next post to explore strategies for how we can pull this lever to contain costs!
Dr. McCarty is a practicing orthopedic surgeon in Minneapolis, MN, former team physician for the MN Twins Major League Baseball Team, healthcare leader and entrepreneur.
¹ Dawson A, Orsini MJ, Cooper MR, et al. Medication safety—reliability of preference cards. AORN J. 2005;82:399,401-404