Clinical Standardization

Seamless integration of clinical systems to provide collaborative patient-centered care

What are clinical standards?

Clinical standards are benchmarks, measures or quality statements. They are created based on evidence-informed best practice guidelines to provide safe, high quality care.

Clinical standardization is the process through which standards and protocols for health care practitioners and learners are identified, adopted and put into practice.

Clinical standardization:

  • Supports patient safety and provides consistency in care
  • Delivers patient and family-centered care
  • Increases efficiency and optimizes health care resources
  • Improves health outcomes, as well as practitioner and learner accountability

Why are clinical standards important?

Clinical standards are used every day to deliver health care. Evidence supports the use of clinical standards in health care delivery in terms of patient safety and health outcomes. Standardized hand hygiene measures for health care workers is a great example. A recent systematic review showed that both the World Health Organization technique and the Center for Disease Control technique reduced bacterial load on health care worker hands (Price, et al. 2018).

Another good example is medication reconciliation during patient transfer. A 2018 systematic review on the subject found that electronic medication reconciliation reduced discrepancies and improved safety (Wang, et al.)

By using established standards to organize and enter patient information electronically, such as date of specimen collection and elements of acuity assessment of patients presenting in the emergency department, we enable seamless integration of services in terms of the flow of patient information. With a new clinical information system on the horizon (One Person One Record) standardization of data elements will optimize integration now and into the future.

The Vision of One Person One Record

Right Information, Right Person, Right Time and Place

The One Person One Record (OPOR) program is a joint provincial initiative. The IWK and Nova Scotia Health are working towards achieving a seamless integration of clinical information systems to provide collaborative patient-centered care.

The work towards clinical standardization can be understood through four key domains:

How are clinical standards established?

Clinical standards are established by:

  • Engaging clinicians and physicians to drive high levels of clinical adoption
  • Consulting existing best practices and evidence for guidance
  • Leveraging existing standardized clinical content
  • Gathering local input to make sure standards fit unique contexts
  • Optimizing time of staff and physicians involved in steering committees and working groups
  • Establishing clear standards of documentation and approval processes

(Healthtech, 2019)

What elements are standardized in a clinical information system (CIS)?

Patient Data

  • Demographics
  • Patient Headers
  • Allergies
  • Medications
  • Health and Social History

Diagnostic Tests and Results

  • Lab
  • Diagnostics

Assessment and Exam Findings (Nursing and Allied Health)

  • Core Documentation Tools
  • Progress Notes
  • Standardized Assessments
  • Specialty Documentation Tools

Physician Documentation

  • Admission
  • Discharge Summary
  • Consultation Report
  • Progress Notes
  • Procedure Notes


  • Order Catalogue
  • Order Sets

Care Planning

  • Consults/Referrals
  • Discharge Plans
  • Patient and Family Education
  • Problem Lists
  • Kardex

(Healthtech, 2019)

Healthtech (2019). Clinical documentation methodology [presentation]. Presented to IWK and NSHA February 5, 2019.

Price, L., Melone, L., McLarnon, N., Bunyan, D., Kilpatrick, C., Flowers, P., & Reilly, J. (2018). A systematic review to evaluate the evidence base for the World Health Organization's adopted hand hygiene technique for reducing the microbial load on the hands of healthcare workers. American journal of infection control, 46(7), 814-823.

Wang, H., Meng, L., Song, J., Yang, J., Li, J., & Qiu, F. (2018). Electronic medication reconciliation in hospitals: a systematic review and meta-analysis. European Journal of Hospital Pharmacy, 25(5), 245-250.