implemented a variant of the “single ingredient” approach by initially adopting three tangible operating practices, including computer physician order entry (CPOE), which improvement experts predicted would lead to big leaps in the safety of American hospital care.

However, rewarding single or multiple structural ingredients carries the risk of not fitting all providers equally well, and they are subject to implementation flaws. Accordingly, they may not lead to better performance. We may best use them as a stopgap until robust provider performance measurements are routinely available, if our prioritization of the structural ingredients that we encourage is evidence-based and strategic. One of the attractive features of tangible improvements like CPOE is that a purchaser or insurer can easily determine if a provider has implemented it. It is much harder to assess implementation of broad engineering principles, such as continuous flow production. For this reason, purchasers understandably favor narrow, less flexible, tangible engineering advances over the implementation of broad engineering principles.

Besides purchaser-mediated rewards, purchasers can apply engineering principles to their own purchasing processes. In the world of health care purchasing, there is no clear consensus on intermediate outcomes or the best way to pursue them. We operate in what systems engineers call a “zone of complexity,” so we must focus on simple rules, good-enough vision, and room for innovation. The Leapfrog Group’s approach of focusing on tangible operating practices aligns well with this heuristic from complex, adaptive systems thinking. The Leapfrog Group advocates a few simple, good-enough purchasing rules:

1. Hold purchasers responsible for rating their highest volume providers directly or via their plans.

2. Offer purchasers multiple methods for rewarding higher provider performance and creating a “business case” for quality and quality improvement.

3. Test each purchaser member’s aggregate improvement incentives by applying Leapfrog’s criterion that every year the percentage of the patient population receiving care from a provider that adopts the three Leapfrog safe practices must increase at a statistically significant rate. If not, the Leapfrog purchaser must notch up its provider rewards until this rule is met or drop out of the group.

4. Encourage consumers to take an interest in differences in quality of care ratings for providers.

5. Make the “back bencher purchasers” visible. We want Leapfrog purchasers to be clearly distinguished from other purchasers. It has been easy for purchasers to talk about quality, but to do very little about it.

Obviously, the application of complex, adaptive systems thinking to the purchase of health care is still in an embryonic stage. Leapfrog purchasing principles illustrate an intuitive, initial application. The concept of engineered purchasing warrants further development.

Let me close by briefly addressing a pivotal engineering challenge for all institutional stakeholders—the need for consumers and physicians to recognize the magnitude of current quality failure in health care in their own work. Research in social science by Kahneman, Tversky, and others is available on which to base new approaches, but applications have been few. As long as we continue to permit poor quality to remain invisible, purchasers and consumers will have trouble becoming robust advocates for quality care, and providers will only slowly incorporate engineering knowledge into their work. Today, quality defects are largely invisible to most stakeholders. Until we find a better way of addressing the invisibility problem, it is going to be hard to motivate any of the key stakeholders to apply the rich resources of engineering knowledge to improving health care.

Front Matter (R1-R14)

Executive Summary (1-8)

Part I: Consensus Report. 1. A New Partnership Between Systems Engineering and Medicine (9-18)

2 A Framework for a Systems Approach to Health Care Delivery (19-26)

3 The Tools of Systems Engineering (27-62)

4 Information and Communications Systems: The Backbone of the Health Care Delivery System (63-82)

5 A Strategy to Accelerate Change (83-90)

Part II: Workshop Presentations--Framing the Health Care Challenge (91-114)

Equipping the Patient and the Care Team (115-138)

Engineering Tools and Procedures for Meeting the Challenges (139-188)

Information Technology for Clinical Applications and Microsystems (189-224)

Barriers and Incentives to Change (225-240)

Appendix A: Agenda, NAE Workshop on Engineering and Health Care Delivery System, May 21 22, 2001 (241-244)

Appendix B: Participants, Workshop on Engineering and the Health Care System, May 21 22, 2001 (245-248)

Appendix C: Agenda, NAE Workshop on Engineering and Health Care Delivery System, February 6-7, 2003 (249-250)

Appendix D: Participants, Workshop on Engineering and the Health Care System, February 6-7, 2003 (251-252)

Appendix E: Agenda, NAE Workshop on Engineering and Health Care Delivery System, March 10-11, 2003 (253-254)

Appendix F: Participants, NAE Workshop on Engineering and Health Care Delivery System, March 10-11, 2003 (255-258)

Appendix G: Biographical Information (259-262)