5
Building Organizational Supports for Change

Between front-line clinical care teams and the health care environment lies an array of health care organizations, including hospitals, managed care organizations, medical groups, multispeciality clinics, integrated delivery systems, and others. Leaders of today’s health care organizations face a daunting challenge in redesigning the organization and delivery of care to meet the aims set forth in this report. They face pressures from employees and medical staff, as well as from the local community, including residents, business and service organizations, regulators, and other agencies. It is difficult enough to balance the needs of those many constituencies under ordinary circumstances. It is especially difficult when one is trying to change routine processes and procedures to alter how people conduct their everyday work, individually and collectively.

This chapter describes a general process of organizational development and then offers a set of tools and techniques, drawing heavily from engineering concepts, as a starting point for identifying how organizations might redesign care. Chapter 3 offered a set of rules that would redesign the nature of interactions between a clinician and a patient to improve the quality of care. This chapter describes how organizations can redesign care to systematically improve the quality of care for patients. This is not an exhaustive list of possible approaches, but a sampling of techniques used in other fields that might have applicability in health care. The broad areas discussed in this chapter apply to all health care organizations; the specific tools and techniques used would need to be adapted to an organization’s local environment and patients.



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Crossing the Quality Chasm: A New Health System for the 21st Century 5 Building Organizational Supports for Change Between front-line clinical care teams and the health care environment lies an array of health care organizations, including hospitals, managed care organizations, medical groups, multispeciality clinics, integrated delivery systems, and others. Leaders of today’s health care organizations face a daunting challenge in redesigning the organization and delivery of care to meet the aims set forth in this report. They face pressures from employees and medical staff, as well as from the local community, including residents, business and service organizations, regulators, and other agencies. It is difficult enough to balance the needs of those many constituencies under ordinary circumstances. It is especially difficult when one is trying to change routine processes and procedures to alter how people conduct their everyday work, individually and collectively. This chapter describes a general process of organizational development and then offers a set of tools and techniques, drawing heavily from engineering concepts, as a starting point for identifying how organizations might redesign care. Chapter 3 offered a set of rules that would redesign the nature of interactions between a clinician and a patient to improve the quality of care. This chapter describes how organizations can redesign care to systematically improve the quality of care for patients. This is not an exhaustive list of possible approaches, but a sampling of techniques used in other fields that might have applicability in health care. The broad areas discussed in this chapter apply to all health care organizations; the specific tools and techniques used would need to be adapted to an organization’s local environment and patients.

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Crossing the Quality Chasm: A New Health System for the 21st Century Recommendation 7: The Agency for Healthcare Research and Quality and private foundations should convene a series of workshops involving representatives from health care and other industries and the research community to identify, adapt, and implement state-of-the-art approaches to addressing the following challenges: Redesign of care processes based on best practices Use of information technologies to improve access to clinical information and support clinical decision making Knowledge and skills management Development of effective teams Coordination of care across patient conditions, services, and settings over time Incorporation of performance and outcome measurements for improvement and accountability To achieve the six aims identified in Chapter 2, board members, chief executive officers, chief information officers, chief financial officers, and clinical managers of all types of health care organizations will need to take steps to redesign care processes. The recommended series of workshops is intended to serve multiple purposes: (1) to help communicate the recommendations and findings of this report and engage leaders and managers of health care organizations in the pursuit of the aims, (2) to provide knowledge and tools that will be helpful to these individuals, and (3) to encourage the development of formal and informal networks of individuals involved in innovation and improvement. STAGES OF ORGANIZATIONAL DEVELOPMENT The design of health care organizations can be conceptualized as progressing through three stages of development to a final stage that embodies the committee’s vision for the 21st-century health care system, as represented by the six aims set forth in Chapter 2 (see Table 5–1). Although settings and practices vary, the committee believes much of the health sector has been working at Stages 2 and 3 over the last decade or more. As knowledge and technologies continue to advance and the complexity of care delivery grows, the evolution to Stage 4 will require that Stage 3 organizations accelerate efforts to redesign their approaches to interacting with patients, organizing services, providing training, and utilizing the health care workforce. Stage 1 Stage 1 is characterized by a highly fragmented delivery system, with physicians, hospitals, and other health care organizations functioning autonomously.

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Crossing the Quality Chasm: A New Health System for the 21st Century The scope of practice for many physicians is very broad. Patients rely on physician training, experience, and good intentions for guidance. Individual clinicians do their best to stay abreast of the literature and rely on their own practice experience to make the best decisions for their patients. Journals, conferences, and informal consultation with peers are the usual means of staying current. Information technology tools are almost entirely absent. Norman (1988) has characterized this approach to work as based on “knowledge in the head,” with heavy dependence on learning and memory. The patient’s role tends to be passive, with care being organized for the benefit of the professional and/or institution. Stage 2 Stage 2 is characterized by the formation of well-defined referral networks, greater use of informal mechanisms to increase patient involvement in clinical decision making, and the formation of loosely structured multidisciplinary teams. For the most part, health care is organized around areas of physician specialization and institutional settings. Patients have more access to health information through print, video, and Internet-based materials than in Stage 1, and more formal mechanisms exist for patient input. However, these tend to be generic mechanisms, such as consent forms and satisfaction surveys. Patients have informal mechanisms for input on their care. Most health data are paper based. Little patient information is shared among settings or practices; the result is often gaps, redundancy of data gathering, and a lack of relevant information. In this stage, institutions and specialty groups, for example, try to help practitioners apply science to practice by developing tools for knowledge management, such as practice guidelines. Stage 3 In Stage 3, care is still organized in a way that is oriented to the interests of professionals and institutions, but there is some movement toward a patient-centered system and recognition that individual patients differ in their preferences and needs. Team practice is common, but changes in roles are often slowed or stymied by institutional, labor, and financial structures, as well as by law and custom. Some training for team practice occurs, but that training is typically fragmented and isolated by health discipline, such as medicine, nursing, or physical therapy. Clinicians and managers recognize the increasing complexity of health care and the opportunities presented by information technology. Some real-time decision support tools are available, but information technology capability is modest, and stand-alone applications are the rule. Computer-based applications for laboratory data, ordering of medications, and records of patient encounters typically

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Crossing the Quality Chasm: A New Health System for the 21st Century TABLE 5–1 Stages of Evolution of the Design of Health Organizations Stage The Patient Experience Knowledge and Skills Management Care Delivery 1 • The physician determines what is in the best interest of the patient and controls care. The patient’s role tends to be passive, with care being organized for the benefit of the professional and/or institution. • There is heavy reliance on human memory and knowledge without significant real-time aids and tools. Information technology is almost entirely absent. • Individual physicians craft solutions for individual patients. 2 • Members of the professional team informally share control among themselves, but physician autonomy predominates. Care is organized for the benefit of the professional and/or institution. • Patients have informal mechanisms for input on their care. • Clinicians have some protocols and knowledge assistance available, but still rely on memory and basic knowledge management tools (journals, conferences, consultation with peers, general Internet information sites). Very little information technology is in use. technology is in use. • Patients receive some information from clinicians (generally stock print material and verbal information). • Recognition of the variability in treatment may lead to interest in protocols and guidelines. • Traditional professional roles define working relationships.

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Crossing the Quality Chasm: A New Health System for the 21st Century 3 • Formal mechanisms for patient input exist. • Care is organized for the benefit of the professional and/or institution, but there is some movement toward a patient-centered system. • Clinicians and patients have ready access to clinical knowledge. There is significant reliance on best practices, guidelines, and disease management pathways for clinicians and patients. Some real-time decisionsupport tools are available, but information technology capability is modest. • Some training for team practice occurs. • The professional team formally shares roles and responsibilities among its members. The physician as responsible leader emerges. Practices recognize the need for changing professional roles, but change is slowed or stymied by institutional and financial structures, law, and custom. • A small number of practices apply system design principles and incorporate information systems in their daily work. • Many conditions are managed through special care management programs. 4 • Care processes and transactions are based on the new rules set forth in Chapter 3. Care is patient-centered, with patient and family being part of the health care team. Patients have access to as much information as they wish to have and opportunities to exercise as much control over their care as they desire. • The environment is rich in clinical information for patients and clinicians. • Automated decision support systems incorporating patient-specific data are used at the point of patient care. • Skill development, training, and leadership support the multidisciplinary character of clinical practice. • The delivery of services is coordinated across practices, settings, and patient conditions over time. Information technology is used as the basic building block for making systems work, tracking performance, and increasing learning. Practices use measures and information about outcomes and information technology to continually refine advanced engineering principles and to improve their care processes. The health workforce is used efficiently and flexibly to implement change.

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Crossing the Quality Chasm: A New Health System for the 21st Century cannot exchange data at all or are not based on common definitions. Practice groups—particularly those that are community based—typically lack information systems to make such decision support tools available at the point of patient care, or to integrate guidelines with information about specific patients. Clinical leaders recognize the need for what has been called “knowledge in the world” (Norman, 1988)—information that is retrievable when needed, replaces the need for detailed memory recall, and is continuously updated on the basis of new information. More organized groups rely on best practices, guidelines, and disease management pathways for clinicians and patients, but these are not integrated with workflow. Stage 4 Stage 4 is the health care system of the 21st century envisioned by the committee. This system supports continued improvement in the six aims of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Health care organizations in this stage have the characteristics of other high-performing organizations. They draw on the experiences of other sectors and adapt tools to the unique characteristics of the health care field. Patients have the opportunity to exercise as much or as little control over treatment decisions as they choose (as long as their preferences fall within the boundaries of evidence-based practice). Services are coordinated across practices, settings, and patient conditions over time using increasingly sophisticated information systems. Whatever their form, health care organizations can be characterized as “learning organizations” (Senge, 1990) that explicitly measure their performance along a variety of dimensions, including outcomes of care, and use that information to change or redesign and continually improve their work using advanced engineering principles. They make efficient and flexible use of the health workforce to implement change, matching and enhancing skill levels to enable less expensive professionals and patients to do progressively more sophisticated tasks (Christensen et al., 2000). The committee does not advocate any particular organizational forms for the 21st-century health care system. The forms that emerge might comprise corporate management and ownership structures, strategic alliances, and other contractual arrangements (“virtual” organizations) (COR Healthcare Resources, 2000; Robinson and Casalino, 1996; Shortell et al., 2000a). New information and delivery structures might be located in a particular city or region or might be the basis for collaborative networks or consortia (COR Health LLC, 2000). Whatever the organizational arrangement, it should promote innovation and quality improvement. Every organization should be held accountable to its patients, the populations it serves, and the public for its clinical and financial performance.

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Crossing the Quality Chasm: A New Health System for the 21st Century In some respects, such as economies of scale, workforce training and deployment, and access to capital, larger organizations will have a comparative advantage. In other cases, small systems will evolve to take on functions now performed by larger organizations. The use of intranet- or Internet-based applications and information systems may enable the development of an infrastructure to accomplish certain functions. New forms might include, for example, Web-based knowledge servers or broker-mediated, consumer-directed health care purchasing programs. KEY CHALLENGES FOR THE REDESIGN OF HEALTH CARE ORGANIZATIONS Health care services need to be organized and financed in ways that make sense to patients and clinicians and that foster coordination of care and collaborative work. They should be based on sound design principles and make use of information technologies that can integrate data for multiple uses (Kibbe and Bard, 1997a; Rosenstein, 1997). Whatever their form, organizations will need to meet six challenges, see Figure 5–1, that cut across different health conditions, types of care (such as preventive, acute, or chronic), and care settings: redesigning care processes; making effective use of information technologies; managing clinical knowledge and skills; developing effective teams; coordinating care across patient conditions, services, and settings over time; and incorporating performance and outcome measurements for improvement and accountability. The following discussion of these six challenges includes excerpts from interviews with clinical leaders conducted as a part of an IOM study aimed at identifying exemplary practices (Donaldson and Mohr, 2000). Redesigning Care Processes I try to help people understand that we can “work smarter.” You can feel rotten about how you are practicing. I tell them, “You are right—and it’s going to get worse.” But change is possible. We don’t need a billion-dollar solution. We need a billion $1 solutions. You have to create the will to change. There’s the will to change, then execution.—Hospital-based endoscopy unit Like any complex system, health care organizations require sophisticated tools and building blocks that allow them to function with purpose, direction, and high

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Crossing the Quality Chasm: A New Health System for the 21st Century FIGURE 5–1 Making change possible. reliability. Effective and reliable care processes—whether registering patients who come to the emergency room, ensuring complete immunizations for children, managing medication administration, ensuring that accurate laboratory tests are completed and returned to the requesting clinician, or ensuring that discharge from hospital to home after a disabling injury is safe and well coordinated—can be created only by using well-understood engineering principles. Not only must care processes be reliable, but they must also be focused on creating a relationship with a caregiver that meets the expectations of both the patient and the family. Redesign can transform the use of capital and human resources to achieve these ends. Redesign may well challenge existing practices, data structures, roles, and management practices, and it results in continuing change. It involves conceptu-

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Crossing the Quality Chasm: A New Health System for the 21st Century alizing, mapping, testing, refining, and continuing to improve the many processes of health care. Redesign aimed at increasing an organization’s agility in responding to changing demand may be accomplished through a variety of approaches, such as simplifying, standardizing, reducing waste, and implementing methods of continuous flow (Bennis and Mische, 1995; Goldsmith, 1998). Students of organizational theory have learned a great deal through careful examination of the work of organizations that use very complex and often hazardous technologies. The committee’s earlier report, To Err Is Human, outlines the achievements of several manufacturing companies and the U.S. Navy’s aircraft carriers in using replicable strategies to achieve great consistency and reliability (Institute of Medicine, 2000). Other world-class businesses, notably those that have received the prestigious Malcolm Baldrige National Quality Award, have embraced many of the tenets of quality improvement described by Deming, Juran, and others (Anderson et al., 1994), which include the need to improve constantly the system of production and services. Yet few health care organizations have developed successful models of production that reliably deliver basic effective services, much less today’s increasingly advanced and complex technologies. Nor have most been able to continually assess and meet changing patient requirements and expectations. Some health care organizations have dedicated considerable energy and resources to changing the way they deliver care. Although these organizations have recognized the need for leadership to provide the necessary commitment to and investment in change, they have also recognized that change needs to come from the bottom up as front-line health care teams recognize opportunities for redesigning care processes and acquire the skill to implement those new approaches successfully (National Committee for Quality Health Care, 1999; Washington Business Group on Health, 1998). Many other organizations have taken steps toward redesigning processes, but have found replication and deployment difficult or short-lived (Blumenthal and Kilo, 1998; Shortell et al., 1998). The committee recognizes these efforts and the difficulties that stem from, among other things, restructuring and economic pressure, misaligned incentives, professional entrenchment, competing priorities, organizational inertia, and lack of adequate information systems (Shortell et al., 1998). A growing body of literature in health care indicates that well-designed care processes result in better quality (Desai et al., 1997; Griffin and Kinmouth, 1998). Some have argued that health care is not amenable to quality improvement approaches derived from other industries because inputs (patients) are so variable; outputs, such as health-related outcomes, so ill-defined; and the need for expert judgment and improvisation so demanding. Similar arguments have been made, but not substantiated, in other service industries and by those in the specialized departments (e.g., legal) of manufacturing industries that have subsequently experienced success in embracing principles of quality improvement (Galvin, 1998).

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Crossing the Quality Chasm: A New Health System for the 21st Century Fortunately, useful redesign principles that are now used widely in other industries can be (and in some cases have been) adapted to health care. Engineering principles have been widely applied by other industries and in some health care organizations to design processes that improve quality and safety (Collins and Porras, 1997; Donaldson and Mohr, 2000; Hodgetts, 1998; Kegan, 1994; Peters and Waterman, 1982). The following subsections describe five such principles and their use by health care professionals to improve patients’ experiences and safety, the flow of care processes, and coordination and communication among health professionals and with patients (Langley et al., 1996). System Design Using the 80/20 Principle The nurse assesses the patient demographics, risk factors, support available, medication, lifestyle, and barriers to making changes. The first visit is usually 45 minutes to an hour long. Preventive screening visits are done yearly—assess vital signs, behavior, willingness to make changes. We take retinal photos, which are sent directly to the ophthalmologist, instead of sending the patient there. We learned that we need to risk stratify and fit the level of services to the level of risk. Services are less or more intense based on risk. We use protocols to identify risk level: primary—those with diabetes, secondary—those with diabetes and any other risk factors, tertiary—those who have already had a stroke, myocardial infarction, or renal failure.—Diabetic management group This engineering principle can be restated: Design for the usual, but recognize and plan for the unusual. Process design should be explicit for the usual case—for 80 percent of the work. For the remaining 20 percent, contingency plans should be assembled as needed. This concept is useful both for designing systems of care and as an approach to acculturating new trainees. Also referred to as the Pareto Principle, the 80/20 principle is based on the recognition that a small number of causes (20 percent) is responsible for a large percentage (80 percent) of an effect (Juran, 1989; Transit Cooperative Research Program, 1995). In health care, for example, 20 percent of patients in a defined population may account for 80 percent of the work and incur 80 percent of costs. Similarly, 20 percent (or fewer) of common diagnoses may account for 80 percent of patients’ health problems. A fundamental approach in health care has been to build care systems to accommodate all possible occurrences. This approach is cumbersome and often the source of delays when, for example, laboratory tests are done in case a rare disease is present, or certain procedures must be followed in case an unusual event should happen. System design based on the 80/20 approach exploits the existence of routine work, often a large proportion of the total work load, that is involved in an assortment of patient problems. One determines what work is

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Crossing the Quality Chasm: A New Health System for the 21st Century routine and designs a simple, standard, and low-cost process for performing this work efficiently and reliably. This leaves the more complex work to be performed employing processes that appropriately use higher-skilled personnel or more advanced technologies. In accordance with this principle, approaches to planning care are designed to reflect the different sorts of clinical problems encountered in practice. Level 1 represents the most predictable needs. In a pediatric practice, well-child health supervision, immunization, and middle-ear infections represent a large portion of the work and very predictable needs. In an obstetrics-gynecology practice, prenatal care and contraceptive counseling are examples of Level 1. In adult primary care, examples include management of hypertension, acute sprains, low back pain, and sinusitis. For newly diagnosed patients with asthma, instruction in the use of an inhaler is an example of predictable work. The more predictable the work, the more it makes sense to standardize care so that it can be performed by a variety of workers in a consistent fashion. When needs are predictable, standardization encompasses the key dimensions of work that should be performed the same way each time using a defined process and is a key element of the principle of mass customization discussed later in this section. For example, variation in the care of patients with community-acquired pneumonia can be reduced by identifying and standardizing the key dimensions of care. Standardization may involve very complex or very simple technologies and processes. An example of the latter is a nursing assistant stamping on a patient’s chart, “Immunization up to date?” and circling “Yes” or “No” for a clinician to see as he or she enters the exam room. Focused standardization often entails simplifying processes. For example, instead of each clinician on staff having a different protocol, clinicians might agree to use a single chemotherapy protocol for most patients, or a single dose, route, or frequency for a commonly administered medication. Although it might be permissible to use other protocols, clinicians would have to agree to evaluate the outcomes for patients under both the standard and nonstandard protocols to determine which was best (Institute of Medicine, 2000). In another example, Duke University’s pediatric emergency department uses a color-coded tape to measure a child’s length and an approximate weight range. Color-coded supplies (e.g., IV tubing, airway masks, syringes) correspond to the four weight ranges. Standardizing equipment for each color zone ensures that dosages and equipment are appropriate and safe for children in that range (Glymph, 2000). Level 2 represents health care needs of medium predictability. At this level, it is important for practice settings to triage patients accurately to determine their needs. Examples are patients with chronic illnesses, such as asthma or diabetes, whose condition is not under control and who need special services to help them. Some patients might best be served by group visits with a diabetic counselor, others might need individual support, and others might need hospitalization. Appropriate triage based on needs could include working out a care plan with

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Crossing the Quality Chasm: A New Health System for the 21st Century vices) and other sites of care (such as hospice or home care) when and as appropriate. Coordination of care across clinicians and settings has been shown to result in greater efficiency and better clinical outcomes (Aiken et al., 1997; Gittell et al., 2000; Knaus et al., 1986; Shortell et al., 1994, 2000a, 2000b). Optimizing care for a patient with a complex chronic condition is challenging enough, but optimizing care for patients with several chronic conditions and acute episodes, as well as meeting health maintenance needs, represents an extraordinary challenge for today’s health care systems (MacLean et al., 2000; Shortell et al., 2000a). The challenges arise at many organizational levels and across the full range of tasks, including the design, dissemination, implementation, and modification of care processes and the payment for these tasks. What is important to patients and their families is that effective systems for transferring patient-related information be in place so that the information is accurate and available when needed. Patients and their families need to know who is responsible for decisions and can answer questions, and to be assured that gaps in responsibility will not occur. Some problems—such as substance abuse, AIDS, and domestic violence— are so interrelated that they appear to require a comprehensive rather than problem-by-problem approach (Shortell et al., 2000a). Other problems require assembling and making the best use of an array of resources, such as the numerous federal programs that might be involved in obtaining and paying for a wheelchair for a child with special needs. In any case, if care is to move beyond single solutions crafted by individual clinicians (as in the Stage 1 delivery of care described earlier in this chapter), it will require an accurate understanding of patient needs so that standard processes can be provided and individual solutions crafted as appropriate. Newly developed infrastructures, information technologies, and well-thought-out and -implemented modes of communication can reduce the need to craft laborious, case-by-case strategies for coordinating patient care. A variety of other mechanisms can improve coordination, such as involving a combination of individuals (e.g., clinicians, members of multidisciplinary teams, care managers), along with patients and their families. Some patients and their families become so expert in their condition that they choose to coordinate care for themselves or a family member. Those who do so are likely to need new skills in accessing information and new technologies for structuring and conveying information to others who are involved in their care. For example, patients can contribute to flow sheets, respond to questions about changes in health status, or upload data from micromonitoring devices worn on the body or from home monitoring devices. Not all patients or their families (or perhaps even most) will choose or be able to become central actors in coordinating their own care, however. In such cases, appropriate mechanisms within the delivery system must be available to meet this responsibility.

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Crossing the Quality Chasm: A New Health System for the 21st Century One means of improving coordination is based on what are sometimes called clinical pathways. These blueprints for care set forth a set of services needed for patients with a given health problem and the sequence in which they should take place. For some conditions, a set of clearly identified processes should occur. In complex adaptive systems such as health care, however, few patient care processes are linear (such as the transition from hospital to nursing home). Rather, most organizational processes are reciprocal and interdependent (Thompson, 1967), and coordination requires the design of procedures that are responsive both to variations among individual patients and to unexpected occurrences. Incorporating Performance and Outcome Measurements for Improvement and Accountability We have a Clinical Roadmap team for breast cancer screening. The team has formulated four criteria for success that include process and outcome measures. They are (1) the proportion of women in our population who have received care in the last 2 years; (2) the number of women who came to the screening program when invited; (3) the number of women in the program who develop a late stage disease; and (4) survey responses during the time of enrollment in the program. These criteria give us specific as well as broad measures of success.—Breast care center We have a clinical “instrument panel.” We measure cycle time, patient satisfaction, phone calls (incoming and outgoing), proportion reaching treatment goals for hypertension, operating costs per visit, proportion of patients seeing their provider of choice, available appointments, team morale, practice size, and proportion of pap smears in eligible women.—Primary care practice The main outcome measure is risk adjusted mortality. We compare ourselves quarterly to similar institutions for observed versus predicted mortality on one axis and resource consumption on the other. Using 50 percent random sampling, we track mortality, admission and discharge rates, length of stay, number of patients readmitted to the ICU, and reintubation rates. This helps us know if changes that affect efficiency are affecting quality of care. Although our admissions are up, length of stay is down significantly, and our reintubation rate is very low.—Critical care unit Although we generally think of individuals as learning and enhancing their capabilities, it is also possible to think of an organization as learning—increasing its competence and responsiveness and improving its work (Davies and Nutley, 2000). The committee believes moving toward the health system of the 21st century will require that health care organizations successfully address the challenge of becoming learning organizations. A decade ago, Senge and others (Argyris and Schön, 1978; Senge, 1990) described such organizations as those that can learn quickly and accurately about their environment and translate this learning to the work they do. This idea has been incorporated in the work of

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Crossing the Quality Chasm: A New Health System for the 21st Century many companies, most outside of health care—such as 3M, Boeing, the Cadillac Division of General Motors, Fedex, Motorola, and Xerox—whose drive to reduce defects and improve quality and customer service has been recognized by the Malcolm Baldrige National Quality Award (National Institute of Standards and Technology, 2000b). In Senge’s terminology, “single-loop” learning results in incremental improvements in existing practice. In health care it might involve efforts to decrease waiting time for follow-up appointments for patients who have an abnormal laboratory test result. Another feature of learning organizations is their reexamination of mental models or assumptions on which they base their work, giving rise to “double-loop” learning. An example of double-loop learning is rethinking and reorganizing all ancillary and specialty medical services for women in a breast care center to eliminate any waiting between reporting of abnormal mammographic findings, definitive diagnosis, and therapy. A critical feature of learning organizations is the ability to be aware of their own “behavior.” In organizational terms, this means having data that allow the organization to track what has happened and what needs to happen—in other words, to assess its performance and use that information to improve. The committee is convinced that a major tool for accomplishing this critical function is the investment in and use of an effective information infrastructure to develop a balanced set of measures on, for example, clinical and financial performance, patient health outcomes, and satisfaction with care (Nelson et al., 1996). It is important that such measures be balanced—that they include a variety of measures so that when changes are made in processes, such as to increase efficiency, other outcomes, such as patient health, are not adversely affected. Clinical practices that participated in the IOM study of exemplary practices (Donaldson and Mohr, 2000) described how routine measurement has become part of their production process. Ideally, such measures can be aggregated for external reporting, whether to support contract discussions or to help patients make choices about where and from whom to seek care. Building measurement into the production process can counter the perception on the part of many health care leaders that reporting is a burden. Such a perception results when organizations must respond to numerous demands from external groups for quality measures, especially if those measures lack specificity or relevance to the clinical teams that must generate them. Measures need not involve expensive, large-scale, long-term evaluation projects to be useful. New methods that use sampling and small-scale rapid-cycle testing, modification, and retesting are proving useful in dynamic settings such as patient care units (Berwick, 1996; Langley et al., 1996). As other world-class businesses have learned, including American industry giants (Walton and Deming, 1986), attention to improving quality includes continuous monitoring, often based on small samples of events, that can provide organizations with timely data at the front lines to manage the processes of concern (James, 1989; Rainey et al.,

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Crossing the Quality Chasm: A New Health System for the 21st Century 1998; Scholtes, 1988). In the IOM study of exemplary practices, several health care teams described their use of such methods to manage their care processes (Donaldson and Mohr, 2000). It’s an incredible relief to try small changes on a small scale. It’s so simple it’s brilliant. We had been managing indigent diabetic patients for years and didn’t think we could do any better. The providers believed that these people are so hard. But the patients responded to the changes we made. You have to craft something that is doable. You have to look for the simplicity in complex things.—Diabetic management group for underserved minorities We have embraced the concept of “real-time tracking.” We have developed a “radar screen” that has 8 simultaneous processes continuously monitored. We get information on the census in the ER, the status of the patients, the x-ray cycle, etc. We know where in the process not only the patient is, but where the system is. Each process measured is summarized on the screen by graphs. All we have to do to obtain data is touch the screen. The graphs are equipped with goal lines that are based on customer satisfaction, for example waiting time.— Community based emergency department The key word to describe a micro-system is homeostasis. A micro-system is always changing and adapting, just like the human body. We have identified the “pathophysiology” of a micro-system. It is powerful, yet very predictable. Think about two downstream processes, x-ray cycle time and getting patients to the floor. If the downstream [processes] get out of control, there are predictable changes in the system. Occupancy in the ER goes up, the number of new patients seen in the ER goes down, the number of free beds in the ER goes down, and the cycle time between a patient’s arrival to a bed goes up. Eventually, every measurement goes up. When we obtain three consecutive 15-minute intervals going the wrong way, we realize that something needs to be done.— Community based Emergency Department. LEADERSHIP FOR MANAGING CHANGE The role of leaders is to define and communicate the purpose of the organization clearly and establish the work of practice teams as being of highest strategic importance. Leaders must be responsible for creating and articulating the organization’s vision and goals, listening to the needs and aspirations of those working on the front lines, providing direction, creating incentives for change, aligning and integrating improvement efforts, and creating a supportive environment and a culture of continuous improvement that encourage and enable success. Learning organizations need leadership at many levels that can provide clear strategic and sustained direction and a coherent set of values and incentives to guide group and individual actions. The first criterion of performance excellence for health care organizations listed by the Baldrige National Quality Program is

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Crossing the Quality Chasm: A New Health System for the 21st Century the provision of “a patient focus, clear and visible values, and high expectations” by the organization’s senior leaders (National Institute of Standards and Technology, 2000a). Indeed, strong management leadership in hospitals is positively associated with greater clinical involvement in quality improvement (Weiner et al., 1996, 1997). Leaders of health care organizations may need to provide an environment for innovation that allows for new and more flexible roles and responsibilities for health care workers; and supports the accomplishments of innovators despite regulatory, legal, financial, and sometimes interprofessional conflict (Donaldson and Mohr, 2000). Leaders need to provide such an environment because the learning, adaptation, and incorporation of best practices needed to effect engineering changes requires energy that is scarce in a demanding and rapidly changing environment. At the level of front-line teams, leaders should encourage the members of the team to engage in deliberate inquiry—using their own observations and ideas to improve safety and quality. The individual who serves as leader may not be constant over time or across innovative efforts, or be associated with a particular discipline, such as medicine. What is important is for the leader to understand how units relate to each other—a form of systems thinking—and to facilitate the transfer of learning across units and practices. Leaders of health care organizations must fill a number of specific roles. First, they must identify and prioritize community health needs and support the organization’s ability to meet these needs. Addressing community needs might involve collaboration with other community or health care organizations and the creation of new services. Examples include providing CPR training for a major employer and identifying and alerting the community to patterns of injury, such as the number of children with head injuries from bicycle accidents, or a newly appearing occupational illness. Other examples include addressing the more complex needs for coordinated local social and health services presented by low-income ill elderly individuals or the need for more accessible substance abuse treatment facilities. Leaders of organizations can support accountability to individual patients while also assuming responsibility for accountability to public bodies and the community at large for the populations they serve. Second, leaders can help obtain resources and respond to changes in the health care environment, which have been rapid and unrelenting. Leaders must ensure that their organization has the ability to change. Yet many leaders now view their role as shielding and protecting the organization from environmental pressures that may require them to change. Leadership should support innovation and provide a forum so that individuals can continuously learn from each other. Organizations must invest in innovation and redesign. Third, and perhaps the most difficult leadership role, is to optimize the performance of teams that provide various services in pursuit of a shared set of

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Crossing the Quality Chasm: A New Health System for the 21st Century aims. In any complex organization, there is danger in supporting some clinical services (perhaps those that are most profitable) to the detriment of the whole system. Leaders must strive to align the strategic priorities of their organization, its resources (financial and human), and support mechanisms (e.g., information systems). Balancing these elements can be extremely difficult and requires leaders to have a performance measurement capability that includes measures of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Fourth, leaders can support reward and recognition systems that are consistent with and supportive of the new rules set forth in Chapter 3 and that facilitate coordination of work across sets of services as necessary. Organizations should support an environment in which incentives to provide effective care are not distorted before they reach caregivers. An example of distortion is a payment system based solely on the numbers of home care visits made by a visiting nurse per day. This sort of productivity measure prevents nurses from focusing on patient needs. A system based on effectively caring for a given number of patients recognizes that a predictable mix of needs will occur over a period of time, and can encourage small teams to organize themselves to meet those needs. Such decision making can be very difficult, especially in the current economic environment and payment system (see Chapter 8). Fifth, leaders need to invest in their workforce to help them achieve their full potential, both individually and as a team, in serving their patients. The resulting interpersonal and technical competence can produce the synergies and improved outcomes that emerge from collaborative work. Although the leadership roles described are not novel, the orientation toward facilitating the work of health care teams represents a fundamental shift in perspective. The new rules set forth in Chapter 3 and the engineering principles described in this chapter will require strong and visible leadership with corresponding reward structures. All organizations must overcome their inherent resistance to change. It is role of leaders to surmount these barriers by visibly promoting the need for improvement, becoming role models for the required new behaviors, providing the necessary resources, and aligning recognition and reward systems in support of improvement goals. Leadership’s role in promoting innovation, gathering feedback, and recognizing progress is essential to successful and sustained improvement. Finally, leaders must recognize the interdependence of changes at all levels of the organization—individual, group or team, organizational, and interorganizational—in addressing the six challenges discussed in this chapter. For example, providing additional training in error correction or technical skill development to individuals without recognizing that they work as part of a team will have little impact. Similarly, working to develop more effective teams without recognizing that they are part of a complex organization with frequently misaligned incentives will have little effect on improving quality. Likewise, trying to redesign organizational structures and incentives and revise organizational cultures with-

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Crossing the Quality Chasm: A New Health System for the 21st Century out taking into account the specific needs of teams and individuals is likely to be an exercise in frustration. And attempting to make changes at any of these levels without recognizing the larger interorganizational networks that include other providers, payers, and legal and regulatory bodies (as discussed in subsequent chapters) is likely to result in the waste of well-intended plans and energy. REFERENCES Aiken, L.H., J.Sochalski, and E.T.Lake. Studying Outcomes of Organizational Change in Health Services. Medical Care 35(11 Suppl):NS6–18, 1997. Anderson, John C., Manus Rungtusanatham, and Roger G.Schroeder. A Theory of Quality Management Underlying the Deming Management Method. Academy of Management Review 19(3): 472–509, 1994. Argyris, Chris and Donald A.Schön. Organizational Learning. Reading, Mass.: Addison-Wesley Pub. Co., 1978. Bates, David W., Lucian L.Leape, David J.Cullen, et al. Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors. JAMA 280(15): 1311–6, 1998. Bennis, Warren and Michael Mische. The 21st Century Organization: Reinventing Through Reengineering. San Diego, CA: Pfeiffer & Company, 1995. Berner, Eta S., Richard S.Maisiak, C.Glenn Cobbs, and O.D.Taunton. Effects of a Decision Support System on Physicians’ Diagnostic Performance. J Am Med Inform Assoc 6(5):420–7, 1999. Berwick, Donald M. A Primer on Leading the Improvement of Systems. BMJ 312:619–22, 1996. Blumenthal, David. The Future of Quality Measurement and Management in a Transforming Health Care System. JAMA 278(19):1622–5, 1997. Blumenthal, David and Charles M.Kilo. A Report Card on Continuous Quality Improvement. Milbank Quarterly 76(4):625–48, 1998. Bowman, R.J.C., H.J.B.Bennet, C.A.Houston, et al. Waiting Times For and Attendance at Paediatric Ophthalmology Outpatient Appointments. BMJ 313:1244, 1996. Carey, J.C. Health Supervision and Anticipatory Guidance for Children with Genetic Disorders (including specific recommendations for trisomy 21, trisomy 18, and neurofibromatosis I). Pediatr Clin North Am 39(1):25–53, 1992. Christensen, Clayton M., Richard Bohmer, and John Kenagy. Will Disruptive Innovations Cure Health Care? Harvard Business Review September/October:102–12, 2000. Classen, David C. Clinical Decision Support Systems to Improve Clinical Practice and Quality of Care . JAMA 280(15):1360–1, 1998. Collins, James C. and Jerry I.Porras. Built to Last: Successful Habits of Visionary Companies. New York, NY: Harperbusiness, 1997. COR Health LLC. Collaboratives Are the Hot Ticket to Success with Performance Improvement Initiatives. COR Clinical Excellence 1:1–3, 2000. COR Healthcare Resources. It Takes a Network to Manage the Full Continuum of Stroke Care. Medical Management Network 8(3):1–7, 2000. Cushman, F.Reid and Don E.Detmer. 1998. “Information Policy for the U.S. Health Sector: Engineering, Political Economy, and Ethics.” Online. Available at http://www.milbank.org/art/intro.html [accessed Dec. 1, 2000]. Davidoff, Frank and Valerie Florance. The Informationist: A New Health Profession? Ann Int Med 132(12):996–8, 2000. Davies, Huw T.O. and Sandra M.Nutley. Developing Learning Organisations in the New NHS. BMJ 320:998–1001, 2000.

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