Since the release of the Institutes of Medicine (IOM) report Crossing the Quality Chasm (Kohn et al., 2001), we have been clear about the importance of focusing on systems and measuring the quality of care. Something much more obvious has to be revisited more often to be appreciated. The high intensity of issues to be considered surrounding much of the diagnosis and treatment in medical care keeps on increasing. A relatively recent article in The New Yorker (Gawande, 2007) drew unusual attention and has since been discussed frequently in the medical literature, such as the Journal of the American Medical Association (Mathews & Pronovost, 2008). This discussion is all based on the simple notion of adhering to an accurate checklist when following procedures in intensive care as well as less complicated elements of the interaction between the healthcare team and the patient. The improvement in the quality of care and the reduction of medical errors in patient care is staggering (Hales & Pronovost, 2006). A pioneer in recognizing and disseminating this simple and redundant fact is Peter Pronovost (Pronovost & Holzmueller, 2004).
What is most surprising about the effectiveness of the checklist in medical care has been the long history of resistance from physicians in understanding the importance of its use as it might apply to their particular situation. Once they have seen the evidence, the physicians, physician groups, healthcare teams, and the organizations in which they serve completely understand and accept the relevance and importance of developing checklists. This has been particularly true with respect to critical care treatment and in the reduction of hospital infections. The point here is the need for redundance and simplicity in the practice of healthcare in general and the need for teamwork in the clinical practice setting.
Given the systems focus stimulated by the release of the IOM reports To Err Is Human and Crossing the Quality Chasm (Kohn et al., 1999, 2001), there is a shift away from individual performance in the health professions to the work of teams, which include the patient as a participant. Inherent in the study of systems is the exploration of roles as contrasted with personalities, and this simplifies the analysis and provides a much greater yield in the knowledge that results. There is less emphasis on the person, and the system is examined for the implications for change management processes deemed necessary for system improvement. We now look to systems to reduce unwanted variation.
This awareness of systems has become an essential part of the conceptual framework for anyone attempting to understand health services organization and delivery. The requirement of systems understanding makes perspective more important in the analysis of health organizations. What you see depends much more on where you stand such that clinical systems, organizationwide systems, and the systems at the organizational boundaries all need to be monitored.
Systems have inputs, throughputs, outputs, and outcomes. As compared with outputs, outcomes reflect environmental impact, which has significant implications for strategy and measurement including the sustainability of system outcomes. A basic tenet of systems is the fact that you can reach system outputs through differing initial conditions. The engagement of dependable role performance has the greatest potential for reducing variability of system performance. Efficiency and effectiveness of system production that can be replicated have become paramount in understanding system behavior.
If we accept system characteristics such as equifinality, that is, reaching the same end results by differing initial conditions, we need people in the system to function as pilots and navigators who do not lose sight of the intended goals of the system designers. In addition, there may be systems of activities that are in place but remain undetected and produce unwanted results. Pilots with navigational skills need to identify such systems and redesign them to get desired results.
Systems sharpen our focus of study in health services research, enable the development of evidence-based clinical guidelines, and facilitate the framing of health policy. The IOM reports taken together have sharpened our focus on how health organizations work. These organizations include community health centers (CHCs), quality improvement organizations, and the overall health system of the United States. So, in recent years, we have learned much about the identification of responsibility and the measurement of accountability for health system performance. We have developed our understanding of organizational role performance and the need for dependability and the inefficiencies of role ambiguity. From the Crossing the Quality Chasm (Kohn et al., 1999) findings, we know and generally agree across organizational and professional lines that healthcare for the 21st century era should be
* effective,
* efficient,
* equitable,
* safe,
* timely, and
* patient centered.
THE RECOVERY ACT AND THE AFFORDABLE HEALTHCARE FOR AMERICA ACT: AN UNPRECEDENTED NEED TO COORDINATE PROFESSIONAL AND ORGANIZATIONAL ROLES
In any system, massive infusions of energy, such as funding, new personnel, or information, create significant requirements for coordination and leadership. Lacking this attempt toward integration, the organization can become rudderless and lose sight of the intended goals. This will be a significant test for healthcare systems given the high likelihood of health reform. Any health reform scenario will result in millions of new users and players in the health system.
In February 2009, President Obama signed into law 10 major projects presented in the Stimulus Recovery Act of 2009, which is now updated continuously on the White House Web site. If we were to use CHCs as an example, CHCs alone will receive almost $3 billion in new funding. Estimates of general funding increases are in the area of 4 times that of prior levels. There will be $600 million alone for the upgrading of health information technology. All across the health industry, we should expect pressures for change management in cases of both budget reductions and, in other areas, contractions. So, there will be a forced integration of new professional and organizational roles for traditional organizational institutions, physicians, and healthcare teams.
PREFACE TO THE ARTICLE SERIES
In the article "A Conceptual Model for Transformational Clinical Leadership Within Primary Care Group Practice," Taylor and colleagues apply the concept and responsibility of a "care pilot" to the primary care setting organized as a patient-centered medical home. The need for the piloting and navigation concept is anchored on evidence from the literature that indicates that in order to become a patient-centered medical home, a group practice must completely redesign its behavior over a period of time. This requires a significant transformation in physician leadership focusing on a change in group behavior to that of a learning organization. Coordination is necessary for the group to meet the organizational requirements of a "home is where accountability and quality improvement are directed to specific measurable goals and objectives."
The Shalowitz article titled "Implementing Successful Quality Outcome Programs in Ambulatory Care: Key Questions and Recommendations" discusses the importance of choosing and monitoring standards to develop safe and effective quality outcome programs. The discussion includes the resistance and suggestions for making programmatic changes as well as the necessity to evaluate and reevaluate program activities to stay on course with quality improvement objectives that are measurable.
In the article "Improving Timeliness and Efficiency in the Referral Process for Safety Net Providers: Application of the Lean Six Sigma Methodology," Deckard and colleagues examined the specialty referral process of the Jackson Health System in Miami-Dade County. Two specialty clinics, the Genital Urinary and the Gynecology clinic services, participated in the application of the Lean and Six Sigma approaches by qualified process managers. The objective of the study was to restructure the referral system between the consulting and primary care physicians such that the turnaround time could be improved and a structured process could be developed that would sustain the improvement processes.
Alafaireet and a research team in the article titled "Toward Determining the Structure of Psychiatric Visit Nonadherence" examined 3 studies to develop a predictive model to improve the adherence of psychiatric patients in an ambulatory care setting. They focused on the actual visit rather than on patient demographics and found 8 determinants out of 22 measured that contributed to nonadherence.
Braxton and colleagues, in the article titled "Improving Antibiotic Stewardship: Order Set Implementation to Improve Prophylactic Antimicrobial Prescribing in the Outpatient Surgical Setting," studied the effectiveness of care by using a tailored antibiotic prophylaxis form to help standardize perioperative antimicrobial use. They found that by using evidence-based clinical guidelines, they were able to reduce the variability of antibiotic ordering practices, come into compliance with Surgical Care Improvement Project guidelines, and reduce pharmacy and other resource costs.
-Barry Greene, PhD
Professor and Head Department of Health Management & Policy College of Public Health University of Iowa, Iowa City, Iowa
REFERENCES