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Better Care at Lower Cost: The Path to Continuously Learning Healthcare in America, Mark Smith, Robert Saunders, Leigh Stuckhardt, J. Michael McGinnis, editors. Committee on the Learning Health Care System in America, Institute of Medicine, 2012, Washington, DC, The National Academies Press, Hardcover, Soft Cover, and free PDF download 587 page available for purchase $79 or $89. Can be ordered from The National Academies Press at http://www.nap.edu (This review is based on the pdf version, which is noted as uncorrected proofs).
This report is probably the most complex and comprehensive review of our health care system. The committee of 18 represented multiple sectors and disciplines, including Mary D. Naylor, University of Pennsylvania School of Nursing. The committee was supported by 9 IOM (Institute of Medicine) staff, 2 consultants, and 16 reviewers, including Angela Barron McBride, Indiana School of Nursing.
The title of the report demonstrates the intent of the committee. They wanted their work to be more than a discussion around the perils of our current health system but in fact outcome driven. They used purposeful phrasing such as: Better Care at Lower Cost; Continuously Learning Healthcare; Evidence Based. All of their work is supported in research with an extensive bibliography.
Highlights of the report:
* A clear, well-defined vision
* "The committee believes that achieving a learning health care system-one in which science and informatics, patient-clinician partnerships, incentives, and culture are aligned to promote and enable continuous and real-time improvement in both the effectiveness and efficiency of care-is both necessary and possible for the nation." This vision is supported with a table defining the characteristics of a Continuously Learning Health Care System (S 11)
* Seventeen (17) Conclusions
* Example particularly meaningful to nursing is Conclusion 3: Care delivery has become increasingly fragmented, leading to coordination and communication challenges for patients and clinicians. (S6). Two statistics stand out: it would take 21 hours a day for individual primary care physicians to provide all of the care recommended to meet their patients' acute, preventive, and chronic disease management (Yarnall et al, 2009). Hospital nurses spend only about 30 percent of their time in direct patient care (Hendrickson et al, 2008). Another study found that in a single year, a typical primary care physician coordinated with an average of 229 other physicians in 117 different practices just for Medicare patients (Pham et al, 2009).
* Ten recommendations supported by 40 strategies for achieving these recommendations:
* Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge
* Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.
* Accelerate integration of the best clinical knowledge into care decisions
* Involve patients and families in decisions regarding, health and health care, tailored to fit their preferences
* Promote community-clinical partnerships and services aimed at managing ad improving health at the community level
* Improve coordination and communication within and across organizations
* Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.
* Structure payment to reward continuous learning and improvement in the provision of best care at lower cost
* Increase transparency on health care system performance
* Expand commitment to the goals of a continuously learning health care system
* (reviewer note: most of if not all of the above recommendations require nursing participation and/or leadership)
* Data support, in measures, table, charts, throughout the report with 4 Appendices at the end
The report is written in 3 parts:
1. Part I: The Imperatives (the needs driving this work)
2. Part II: The Vision (where we need to be)
3. Part III: The Path (How to get there)
Serious students and teachers of health care reform will benefit greatly from this report. It is not an easy read. Most service sectors of nursing leadership may take a glance and think who has time to pour through this report. Minimally, nurse leaders will want this book on their bookshelf for reference. Many will look to their nurse researchers and quality steering committees for comments. This report is meant to be taken seriously. It will be discussed and integrated at the highest levels. The committee tackled one of our nation's most complex challenges, the health of our nation. They avoided the political pitfalls of tweaking the system but instead chose to go for not only a paradigm shift but one that is achievable and sustained only through continuous learning. Peter Senge of MIT would applaud their thinking (The Fifth Discipline: The Art & Practice of The Learning Organization, 1990, Currency Press). Both Demining (Edward Deming, Out of the Crisis, 1986, MIT Press) and Juran (Juran's Quality Control Handbook, 4th edition, 1951, McGraw Hill) would herald the continuation of their work on Quality. It will be interesting to see how current scholars Michael E. Porter of Harvard and Elizabeth Olmsted Teisberg of the University of Virginia view the committee's work (Porter and Teisberg, Redefining Healthcare, 2006, Harvard University Press). As nursing works on its future, using work from another IOM committee on the future of nursing, it will be best served to also incorporate the Better Care Lower Cost Report to assure nursing's alignment within the system. There is little doubt that any of these can be achieved without nursing's leadership and continued contribution to our patients and community.
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