Standardizing Perfusion Protocols Across a Multi-Site Health System

As health systems have consolidated, a growing number of institutions find themselves operating two, three, or more cardiac surgery programs under a single administrative umbrella — often with entirely different perfusion protocols, supply formularies, equipment platforms, and staffing structures at each site. The clinical and economic consequences of this fragmentation are significant, and the path to standardization is rarely straightforward.

Why Variability Persists

Protocol variability across sites is almost never the result of deliberate design. It is the accumulated product of acquisitions, each site bringing its pre-existing practices into the system, combined with the legitimate clinical autonomy that surgeons and perfusionists have historically exercised. Add to that different vendor relationships at each site, different equipment inventories, and different training backgrounds among the perfusion teams, and you have a system where standardization feels both necessary and politically impossible.

The resistance to standardization is often framed in clinical terms — "our patient population is different" or "our surgeons have specific preferences." These concerns are sometimes valid and should be taken seriously. But in our experience, the majority of protocol variation across sites does not reflect meaningfully different clinical requirements. It reflects history, habit, and vendor influence.

A Framework for Standardization

Effective multi-site standardization requires distinguishing between elements that should be uniform system-wide, elements that should be standardized within defined parameters, and elements that should remain at site discretion. Trying to standardize everything produces resistance. Failing to standardize anything leaves the system's scale advantages unrealized.

• Uniform system-wide: credentialing standards, documentation requirements, quality metrics and reporting, incident reporting protocols, and equipment safety check procedures. These should not vary by site — they are the foundation of system-wide accountability.
• Standardized within parameters: anticoagulation protocols (same target ranges, site flexibility on monitoring frequency), prime composition (approved formulary with defined substitution criteria), temperature management targets (range defined, approach flexible).
• Site discretion: cannulation strategy preferences, surgeon-specific circuit configurations within approved equipment list, scheduling and call structure.

The Supply Formulary Question

Supply standardization is where multi-site systems realize the most immediate financial benefit — and where the political dynamics are most complex. A system purchasing oxygenators from three different vendors across four sites has essentially no leverage with any of them. Consolidating to a single preferred supplier — or at most two — across all sites creates purchasing volume that can drive meaningful price reductions, typically in the range of 15–25% on disposables.

The process requires a clinical evaluation of candidate products against defined criteria (not just price), a structured trial period at participating sites, and a transparent decision-making process that includes the perfusion teams. Formulary decisions made without clinical input tend to generate ongoing resistance; decisions made with it tend to stick.

Governance Structure

Multi-site standardization requires a governance structure that does not currently exist in most health systems. A system-level perfusion committee — with representation from each site's clinical perfusion leadership, cardiac surgery physician leadership, and health system administration — provides the forum for developing standards, adjudicating site-specific exception requests, and tracking system-wide quality metrics.

Without this structure, standardization efforts tend to stall in committee, get blocked by a single influential surgeon, or succeed initially only to drift back toward site-specific variation over time. The governance structure is not optional infrastructure — it is the mechanism by which standardization becomes durable.

Measuring the Outcome

The results of a well-executed standardization initiative should be measurable within 12–18 months of implementation. Key metrics to track include per-case supply cost across sites (target: <10% variance), protocol adherence rates, quality outcomes by site, and staff cross-coverage capability (standardized protocols enable staff to work across sites, which is a meaningful operational benefit). Systems that have completed this process typically find that the financial return exceeds the initial estimate — because supply savings compound, and the operational benefits of a mobile, interchangeable perfusion workforce are substantial.