On a systems level, the issues of cost and value and the incentives for improvement and change were also of concern.

The workshop identified a number of research approaches used to address the problem. Rouse recognized the current cultural conflict in the field related to conducting quality improvement evaluations as medical research when much of the work is actually organizational research. These types of research are conducted differently and often have different goals, thereby creating a dilemma for researchers. Other research approaches that were discussed include interdisciplinary collaboration and the approaches required to properly address ethical questions surrounding quality improvement research. These approaches employed a variety of interventions at different levels, such as provider reminders and methods to manage risk. It was often mentioned that to study change, secular trends needed to be separated from trends actually caused by an intervention. To disseminate approaches and findings, the role of journals was discussed as critical.

Bringing the approaches, the tools, and the problems together are the people, who range from providers and purchasers to patients and researchers. The central question, Rouse said, is how to deal with professionals and their disciplines in terms of dealing with change. Effecting change requires people, but engaging people is itself a difficult task. Change requires encouragement of coordination, identification of attractors, understanding of patterns of behavior, and recognition of routines, rituals, and beliefs of all people involved. In other words, everyone is a participant in the process of addressing the problem, Rouse said.

The health care quality improvement ecosystem can thus be organized around the three themes—problem, approach, and people (Figure 8-1). The problem and approaches are connected by information gleaned from the problem and the interventions at all levels. In addressing the problem, people face the paradox of being agents of change as well as being the focus of change. People are connected to the approach because implementation of identified approaches