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Building a Better Delivery System: A New Engineering/Health Care Partnership
BUILDING A BETTER DELIVERY SYSTEM
A New Engineering/Health Care Partnership
Proctor P. Reid, W. Dale Compton, Jerome H. Grossman, and Gary Fanjiang, Editors
NATIONAL ACADEMY OF ENGINEERING AND INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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Building a Better Delivery System: A New Engineering/Health Care Partnership
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Science, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
Support for this project was provided by the National Science Foundation (Award No. DMI-0222041), the Robert Wood Johnson Foundation (Grant No. 044640), and the National Institutes of Health (Contract No. N01-OD-4-2139, Task Order No. 111). Any opinions, findings, and conclusions or recommendations expressed in this report are those of the National Academy of Engineering/Institute of Medicine Committee on Engineering and the Health Care System and do not necessarily reflect the views of the funding organizations, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government.
International Standard Book Number 0-309-09643-X
Copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (888) 624-8373 or (202) 334-3313 (in the Washington metropolitan area); online at http://www.nap.edu.
Copyright 2005 by the National Academies. All rights reserved.
Printed in the United States of America
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Building a Better Delivery System: A New Engineering/Health Care Partnership
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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Building a Better Delivery System: A New Engineering/Health Care Partnership
COMMITTEE ON ENGINEERING AND THE HEALTH CARE SYSTEM
W. DALE COMPTON (NAE), co-chair,
Purdue University, West Lafayette, Indiana
JEROME H. GROSSMAN (IOM), co-chair,
John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts
REBECCA M. BERGMAN,
Medtronic Inc., Minneapolis, Minnesota
JOHN R. BIRGE,
University of Chicago, Chicago, Illinois
DENIS CORTESE,
Mayo Clinic, Rochester, Minnesota
ROBERT S. DITTUS,
Vanderbilt University and Veterans Administration Tennessee Valley Healthcare System, Nashville, Tennessee
G. SCOTT GAZELLE,
MGH Institute for Technology Assessment, Boston, Massachusetts
CAROL HARADEN,
Institute for Healthcare Improvement, Cambridge, Massachusetts
RICHARD MIGLIORI,
United Resource Networks, Golden Valley, Minnesota
WOODROW MYERS (IOM),
WellPoint, Thousand Oaks, California
WILLIAM P. PIERSKALLA,
Anderson Graduate School of Management, University of California, Los Angeles
STEPHEN M. SHORTELL (IOM),
School of Public Health and Haas School of Business, University of California, Berkeley
KENSALL D. WISE (NAE),
University of Michigan, Ann Arbor
DAVID D. WOODS,
Ohio State University, Columbus
Project Staff
PROCTOR P. REID, Study Director and Director, Program Office,
National Academy of Engineering
JANET M. CORRIGAN, Senior Board Director for Health Services,
Institute of Medicine
CAROL R. ARENBERG, Editor,
National Academy of Engineering
PHILIP ASPDEN, Senior Program Officer, Board on Health Services,
Institute of Medicine
GARY FANJIANG, Fellow,
National Academy of Engineering
PENELOPE J. GIBBS, Program Associate, Program Office,
National Academy of Engineering
JAMES PHIMISTER, J. Herbert Hollomon Fellow,
National Academy of Engineering
AMANDA SARATA,
Intern, National Academy of Engineering
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Building a Better Delivery System: A New Engineering/Health Care Partnership
Preface
In 2000 and 2001, the Institute of Medicine (IOM) issued two reports, To Err Is Human and Crossing the Quality Chasm, documenting a glaring divergence between the rush of progress in medical science and the deterioration of health care delivery. The first report included an estimate that systems failures in health care delivery (i.e., poorly designed or “broken” care processes) were responsible for at least 98,000 deaths each year. The second report revealed a wide “chasm” between the quality of care the health system should be capable of delivering today, given the astounding advances in medical science and technology in the past half-century, and the quality of care most Americans receive. Documenting deep crises related to the safety, efficacy, efficiency, and patient-centeredness of health care in America, Crossing the Quality Chasm set forth a vision for a transformed health care system and challenged system stakeholders to take bold actions to bring about that transformation.
In response to this challenge, the National Academy of Engineering (NAE) and IOM, with support from the National Science Foundation, Robert Wood Johnson Foundation, National Institutes of Health, and the NAE Fund, initiated a project in 2002 to (1) identify engineering applications that could contribute significantly to improvements in health care delivery in the short, medium, and long terms; (2) assess factors that would facilitate or impede the deployment of these applications; and (3) identify areas of research in engineering and other fields that could contribute to rapid improvements in performance. This report, Building a Better Delivery System, is the culmination of the joint NAE/IOM study.
The report builds on a growing realization within the health care community of the critical role information/ communications technologies, systems engineering tools, and related organizational innovations must play in addressing the interrelated quality and productivity crises facing the health care system. The report provides a framework for change and an action plan for a systems approach to health care delivery based on a partnership between engineers, health care professionals, and health care managers. The goal of the plan is to transform the U.S. health care sector from an underperforming conglomerate of independent entities (individual practitioners, small group practices, clinics, hospitals, pharmacies, community health centers, etc.) into a high-performance “system” in which participating units recognize their interdependence and the implications and repercussions of their actions on the system as a whole. The report describes opportunities and challenges to using systems engineering, information technologies, and other tools to advance a twenty-first century system capable of delivering safe, effective, timely, patient-centered, efficient, equitable health care—a system that embodies the six “quality aims” envisioned in Crossing the Quality Chasm.
The committee co-chairs are grateful to the members of the committee, not only for their knowledge, expertise, and commitment to change, but also for their participation in wide-ranging discussions on various aspects of this complex topic. Their collegiality and openness to ideas from many directions enabled the committee as a whole to overcome some of the very communications and cultural barriers described in the report and reach consensus on key recommendations. We also thank the outside experts who contributed their time and efforts to the success of this project, and the NAE and IOM staff for their research, editorial, and administrative support.
W. Dale Compton, co-chair
Committee on Engineering and the Health Care System
Jerome H. Grossman, co-chair
Committee on Engineering and the Health Care System
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Building a Better Delivery System: A New Engineering/Health Care Partnership
Acknowledgment of Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for reviewing this report:
David E. Daniel, University of Texas
Paul Griner, Emeritus, University of Rochester School of Medicine and Dentistry
John D. Halamka, CareGroup Health System
Angela Barron McBride, Indiana University School of Nursing
James C. McGroddy, IBM Corporation (ret.)
John M. Mulvey, Princeton University
Robert M. Nerem, Georgia Institute of Technology
Don M. Nielsen, American Hospital Association
Vinod K. Sahney, Henry Ford Health System
Edward J. Sondik, National Center for Health Statistics
Paul C. Tang, Palo Alto Medical Foundation
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Don E. Detmer, American Medical Informatics Association, and Charles E. Phelps, University of Rochester, appointed by the National Research Council Report Review Committee, who was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Building a Better Delivery System: A New Engineering/Health Care Partnership
Contents
EXECUTIVE SUMMARY
1
PART I: CONSENSUS REPORT
1
A NEW PARTNERSHIP BETWEEN SYSTEMS ENGINEERING AND HEALTH CARE
11
The Paradox of American Health Care,
11
Interconnected Crises in U.S. Health Care,
11
Proximate Causes of Health Care Crises,
12
The Role of Engineering in the Transformation of Health Care,
14
The Engineering/Health Care Partnership,
15
Structure of the Report,
16
References,
16
2
A FRAMEWORK FOR A SYSTEMS APPROACH TO HEALTH CARE DELIVERY
19
A Four-Level Model of the Health Care System,
19
A Systems View of Health Care,
22
The Role of Information and Communications Technology,
24
References,
24
3
THE TOOLS OF SYSTEMS ENGINEERING
27
The Need for Good Data,
28
Systems-Design Tools,
28
Systems-Analysis Tools,
35
Systems-Control Tools,
45
Applying Systems Tools to Health Care Delivery,
52
Barriers to Implementation,
55
Findings,
56
Recommendations,
57
Conclusion,
57
References,
58
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Building a Better Delivery System: A New Engineering/Health Care Partnership
4
INFORMATION AND COMMUNICATIONS SYSTEMS: THE BACKBONE OF THE HEALTH CARE DELIVERY SYSTEM
63
The Centrality of Information to Health Care Delivery,
63
From Electronic Medical Records to a National Health Information Infrastructure,
64
Foundations of a National Health Information Infrastructure,
67
Communications Technologies,
72
Microelectronic Systems and Emerging Modes of Communication,
75
Conclusion,
78
References,
79
5
A STRATEGY TO ACCELERATE CHANGE
83
Educational Barriers to Change,
83
A Platform for Interdisciplinary Research, Education, and Outreach,
84
Call to Action,
89
References,
89
PART II: WORKSHOP PRESENTATIONS
FRAMING THE HEALTH CARE CHALLENGE
Crossing the Quality Chasm,
Janet Corrigan
95
Bridging the Quality Chasm,
David Lawrence
99
Envisioning the Future,
Jeff Goldsmith
103
Improving Health and Health Care,
Lewis G. Sandy
105
Engineering and the Health Care System,
Richard J. Coffey
107
Engineering and the Health Care Organization,
Vinod K. Sahney
113
EQUIPPING THE PATIENT AND THE CARE TEAM
Evidence-Based Medicine,
Brian Haynes
117
The Context of Care and the Patient Care Team: The Safety Attitudes Questionnaire,
J. Bryan Sexton, Eric J. Thomas, and Peter Pronovost
119
Engineering the Patient and Family into the Patient Care Team,
David Gustafson
125
Connecting Patients, Providers, and Payers,
John D. Halamka
129
New Paradigms for Working and Learning,
Richard Bohmer
133
Designing Caregiver- and Patient-Centered Health Care Systems,
H. Kent Bowen
135
ENGINEERING TOOLS AND PROCEDURES FOR MEETING THE CHALLENGES
Systems Engineering: Opportunities for Health Care,
Jennifer K. Ryan
141
Supply-Chain Management and Health Care Delivery: Pursuing a System-Level Understanding,
Reha Uzsoy
143
The Human Factor in Health Care Systems Design,
Kim J. Vicente
147
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Building a Better Delivery System: A New Engineering/Health Care Partnership
Changing Health Care Delivery Enterprises,
Seth Bonder
149
Transforming Current Hospital Design: Engineering Concepts Applied to the Patient Care Team and Hospital Design,
Ann Hendrich
153
Discrete-Event Simulation Modeling of the Content, Processes, and Structures of Health Care,
Robert S. Dittus
157
Measuring and Reporting on Health Care Quality,
Dana Gelb Safran
163
Archimedes: An Analytical Tool for Improving the Quality and Efficiency of Health Care,
David M. Eddy and Leonard Schlessinger
167
Applying Financial Engineering to the Health Services Industry,
John M. Mulvey
173
Engineering Tools and Methods in the Delivery of Cancer Care Services,
Molla S. Donaldson
177
Patient Trajectory Risk Management,
Charles Denham
183
Deploying Resources for an Idealized Office Practice: Access, Interactions, Reliability, and Vitality,
Thomas W. Nolan
187
INFORMATION TECHNOLOGY FOR CLINICAL APPLICATIONS AND MICROSYSTEMS
Engineering and the System Environment,
Paul C. Tang
191
Challenges in Informatics,
William W. Stead
193
A National Standard for Medication Use,
David Classen
195
Obstacles to the Implementation and Acceptance of Electronic Medical Record Systems,
Paul D. Clayton
199
Automation of the Clinical Practice: Cost-Effective and Efficient Health Care,
Prince K. Zachariah
205
The eICU® Solution: A Technology-Enabled Care Paradigm for ICU Performance,
Michael J. Breslow
209
Wireless Biomonitoring for Health Care,
Thomas F. Budinger
215
Rehabilitation Redefined,
Mindy L. Aisen
221
Evaluating the Potential of New Technologies,
Carolyn M. Clancy
223
BARRIERS AND INCENTIVES TO CHANGE
Political Barriers to Change,
Nancy-Ann DeParle
227
Lessons from Financial Services,
Ralph Kimball
231
Can Purchasers Leverage Engineering Principles to Improve Health Care?,
Arnold Milstein
233
Shibboleths in Modeling Public Policy,
Richard P. O’Neill
235
Matching and Allocation in Medicine and Health Care,
Alvin E. Roth
237
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Building a Better Delivery System: A New Engineering/Health Care Partnership
APPENDIXES
A
Agenda for First Workshop
243
B
Participants in First Workshop
245
C
Agenda for Second Workshop
249
D
Participants in Second Workshop
251
E
Agenda for Third Workshop
253
F
Participants in Third Workshop
255
G
Biographical Information
259
