Reducing Costs Through the Appropriate Use of Specialty Services

SpecialtySvcsWPCover.jpgHow to cite this paper:

Baker N, Whittington JW, Resar RK, Griffin FA, Nolan KM. Reducing Costs Through the Appropriate Use of Specialty Services. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2010. (Available on

This IHI white paper describes efforts by the Institute for Healthcare Improvement (IHI) to find ways to reduce overuse, with a focus on specialty services, by identifying the most promising change ideas from case examples and the literature, and by incorporating improvement methodology to implement these changes. The resulting framework is a theory of the elements needed to reduce costs through the appropriate use of specialty services, focused primarily on changing professional practice culture by engaging physicians in developing and implementing practice standards that will work best in local circumstances.
Given the plethora of specialties and procedures, the object of IHI’s work in this area has been to identify approaches that could be applied across many specialties, procedures, and types of organizations.
The IHI Framework for Appropriate Use of Specialty Services has six steps:
  • Step 1. Opportunity Search and Engagement of Physicians, Patients, and Key Stakeholders
  • Step 2. Define a Standard (Consensus Criteria)
  • Step 3. Discernment
  • Step 4. Evaluation of Discernment
  • Step 5. Additional Interventions
  • Step 6. Execution (Implement Standards)
These steps constitute a theory of what will work to reduce certain patterns of overuse in specialty services. The framework requires proactive and intentional testing. It does not explicitly define a design and sequence of changes to address all the dimensions of overuse such as patient expectations, patient engagement in decision making, payment incentives, medical-legal issues, etc., that will be needed for broader, comprehensive change. This does not mean these additional issues are ignored; they must be taken into consideration and addressed appropriately. 
The goal of the framework is to achieve cultural change by carefully selecting improvements and standards that will work best in local circumstances. Selective, smaller-scale efforts to reduce overuse can still result in meaningful reductions in cost and improvement of the clinical value of care, and will prepare the local culture for broader changes in the future.
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