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4
Case Studies in Transformation
Through Systems Engineering
INTRODUCTION
Creative approaches are necessary to meet the Roundtable’s goal that
“by the year 2020, 90 percent of clinical decisions will be supported by ac-
curate, timely, and up-to-date clinical information and will reflect the best
available evidence.” In this section of the workshop, guidance was solicited
from organizations both within and outside health care that have achieved
successful elements of transformation. Presenters provided accounts of their
achievements and offered insights into their organization’s transformation
through approaches to systems engineering. The aim was to stimulate the
sense of what might be possible in health care through the lenses of three
industries in particular: airlines, manufacturing, and health care.
For practitioners seeking to reform various aspects of health care,
good models of the applications of principles, tools, and practices from
systems engineering can be found in both business settings and healthcare
systems. Four veterans of such work described their experiences to the
workshop audience, discussing how complex enterprises have successfully
developed systems-oriented procedures and integrated a systems orientation
into practice. The session investigated how systems engineering has been
successfully applied in the three industries and sought to understand which
lessons might be applied to the transformation of the sociologically and
technologically complex healthcare sector. Implicit in the discussions was
the importance of bold leadership in driving reform, the imperative of hav-
ing clarity of mission, the merits of developing strong metrics and sharing
results widely, and the value of investing in people.
11
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12 ENGINEERING A LEARNING HEALTHCARE SYSTEM
John J. Nance, founding member of the National Patient Safety Foun-
dation, reported on a rich set of systems reforms that has been achieved
by the aviation industry. Nance highlighted strategies that go beyond well-
honed aviation practices, such as checklists and methodologies in crew
resource management (CRM), which could be of benefit to healthcare
systems. He described how systems engineering has been applied in so-
phisticated feedback systems for reporting and learning from mechanical
problems, the development of robust computerized processes for many as-
pects of daily operations, and standardization that has been applied widely
across airline operations. He also described systems that have been built
around the assumption that human beings can never be perfect, and thus
they are designed to be capable of absorbing anticipated levels of human
failure. The discussion also touched on the importance of applying systems
thinking to training, on the value of improved communication among staff
at all levels, on the usefulness of minimization of variables, and on how
systems interact.
To demonstrate how systems thinking can help effect deep-set, mean-
ingful, and lasting organizational change, Earnest J. Edwards, formerly
of Alcoa, Inc., focused on improvements in a specific business practice,
the financial close process. Detailing how a similar change effort was ap-
plied successfully in a leading corporation, a federal government agency,
and a community hospital, Edwards demonstrated how systems thinking
can help organizations lower costs, improve quality, and leverage systems
to yield better information for use in decision making. Moreover, he sug-
gested, undertaking the process of change can itself help staff learn how to
become solution-oriented change agents with a focus on the future—and
thus become more vital partners in the enterprise, with an expanded role
in strategic decisions.
Kenneth W. Kizer, chair of Medsphere Systems Corporation, began by
describing the condition of the veterans healthcare system in the early 1990s.
Managed by the Veterans Health Administration (VHA) in the U.S. Depart-
ment of Veterans Affairs (VA), it was considered inefficient and indifferent
to patient needs. Kizer described how, through a concerted reengineering
effort, the VA healthcare system was transformed into a model healthcare
provider. Kizer described how the VA overhauled its accountable manage-
ment structure and control system, integrated and coordinated patient ser-
vices across the continuum of care, improved and standardized the quality of
care, improved information management, and aligned the system’s finances
with desired outcomes. Kizer suggested that similar interventions could help
other healthcare enterprises achieve new levels of success.
In the final presentation described in this chapter, David B. Pryor, chief
medical officer of Ascension Health, discussed the clinical transformation of
Ascension, which is the largest not-for-profit delivery system in the United
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States and the third largest system overall after the VA and the Hospital
Corporation of America. Pryor described Ascension Health’s “Call to Ac-
tion,” a program designed to reduce preventable injuries or deaths as well
as to achieve certain other measurable goals. Pryor outlined a systems pro-
cess for defining challenges, strategizing opportunities, focusing on goals,
implementing action plans, and testing and measuring results that allowed
Ascension Health to reach its goals. Pryor said that through this process
Ascension Health was able to simultaneously realize outstanding clinical
outcomes, achieve promising trends in financial outcomes, and develop new
metrics that influence quality across its entire system.
AIRLINE SAFETY
John J. Nance, J.D., National Patient Safety
Foundation, American Medical Association
Although it would be hyperbole to say that the solution to much of
what troubles American health care can be found in engineering disciplines,
I truly believe that engineering and the engineering community can provide
unprecedented expertise and contribute substantially, if not pivotally, to the
national task of creating order out of the chaos that characterizes American
health care today. This is not to demean health care. I am merely being
frank about the reality that a cottage industry based on individual physi-
cian autonomy has grown to unmanageable proportions on a thoroughly
inadequate organizational base. A century ago, hospitals were few and far
between, and the remarkable advances in medicine and equipment achieved
since that time have essentially been forced to fit the archaic mold that was
established in that period. And the system clearly is not working in terms
of either the reliable and safe delivery of the best care or the best value.
Engineering philosophies, approaches, and discipline are not a cure-all, but
where medicine has been unable to formulate a structural approach to the
problem through traditional methodologies, new thinking from external
disciplines may be of great benefit.
American health care needs to find a balance between two extremes.
At one end of the spectrum is the clearly inadequate 19th century model
of the individual doctor and the hospital as a sort of market that provides
beds, nurses, and lights. At the other end is a rigid, mechanized approach
to health care whereby autonomy is limited to small differences in the tech-
niques physicians may use within the context of inflexible procedures and
full employment directly by healthcare providers. Obviously, neither ex-
treme can take advantage of both the remarkable advances in science-based
medicine and the dexterity, intellect, and analytical abilities of individual
physicians (as well as the human caring−based attention of nurses as the
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1 ENGINEERING A LEARNING HEALTHCARE SYSTEM
bedside eyes and ears of the physician). One extreme needs no engineering,
while the other would overuse both systems engineering and the lessons
from such fields as airline safety. A careful balance is needed that preserves
the humanity and individual expertise of healthcare practitioners while
providing an efficient and workable structure that serves the primary goal
of doing the best possible job for patients and having physicians enjoy their
profession.
These introductory points are important in any discussion that looks
beyond medicine for answers, and this is especially true with respect to
the applicable lessons from airline and aviation safety. The application of
those lessons, as well as a brief look at how U.S. airlines have achieved a
nearly perfect safety record, requires a basic understanding of the strategy
employed and not just the tactical details of individual training programs
and methods.
My professional background melds aviation and medicine and includes
18 years of experience in translating to health care the surprising human
lessons we were forced to learn in the aviation industry (along with lessons
from other fields such as nuclear power generation). In summary, by the
late 1970s, aviation had reached the limits of its ability to improve safety
significantly through merely mechanical and procedural means, and it was
only by applying lessons from the human factors and performance disci-
plines that the airline industry was able to take the final step toward zero
accidents and incidents.
In many ways this nearly unnoticed transition can be characterized as
moving from a reliance on the principles of mechanical and aeronautical
engineering to an acceptance of the principles and benefits of human sys-
tems engineering. The sometimes difficult transformation from a myopic
focus on mechanical reliability to a focus on overall systemic reliability
was guided at every step by the discipline engineering brought to bear in
helping the airlines accept the realities of the potential for human failure
and the resulting ability of airline safety leaders to impose better order and
function. In other words, we finally had to stop believing that the only
bulwark against accidents was the fine-tuning of our machines and black
boxes and admit that, when even the finest airplanes could be flown into a
mountain by a well-trained but confused and distracted aircrew, the failure
modes of the human being would have to be addressed. The important
point for the present discussion is that the same elements of transition are
needed in American health care—and even more dramatically so because
the procedural/mechanical side and the human systems engineering side of
health care are equally undeveloped and undisciplined. To help explain why
this is the case, let me focus on the experience of aviation.
For perhaps 10 years now, there has been a growing realization that
aviation’s experience in transitioning from a high-risk industry to a low-
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risk, high-reliability industry has some applicability to American health
care. The problem has been oversimplification in translating that message.
People in both aviation and medicine have believed that the best lessons
the aviation industry can offer to health care are simply a few specific
programs and methods, such as CRM courses and checklist procedures.1
The assumption was that such tactical solutions could be transferred
intact to the medical arena and yield the same dramatic improvement
they achieved in aviation. In reality, while the principles of each of those
tactical measures can benefit medicine if properly translated and adjusted
for the realities and complexities of medical practice and application,
a far richer body of lessons and benefits can be derived from aviation’s
experience.
Aviation, of course, is inherently no smarter about preventing disasters
than is health care. But the fact that our failures were both very public and
very frightening to our future customers and the fact that our death tolls
reached large numbers with each major accident meant we had to address
the last remaining unsolved cause of airline accidents—human mistakes—
decades before health care had to face that same issue. We simply did not
have the luxury of waiting for improvements to evolve. We had to figure
out why dedicated, intelligent, and well-meaning air crews continued to fly
mechanically perfect airliners into the ground or otherwise cause horrible
accidents—so-called “pilot error” accidents.
In truth, the safety challenges the airline industry faced through the
1970s were perplexing. We had enjoyed great progress in airline safety
from the dawn of commercial aviation in the late 1920s through the dawn
of the jet age in the 1960s and into the 1970s. In fact, the curve of major
accidents plotted against time had been declining at a remarkable rate as the
machines were greatly improved, instrument flying became sophisticated,
and the new jet engines introduced far greater reliability. That descending
curve also represented greatly decreasing passenger fatalities, and while
our metrics left something to be desired, we clearly improved by many
orders of magnitude over time as mechanical failures triggering accidents
became increasingly rare. Boeing, McDonnell Douglas, Convair, and later
Airbus all learned how to build significant redundancy into their products,
helping to pioneer the principle that no single or even dual failure of any
component should ever result in the loss of control of an airplane. In fact,
one of the earliest instances of human factors engineering was the decision,
based on an understanding of the human propensity for failure, to have at
1 CRM is a discipline that recognizes that no one leader, captain, or physician is capable
of perfection. Therefore, the best defense against disaster due to human error is to utilize the
professional talent and cognitive abilities of all participants through collegial communication
that can be codified, taught, and required.
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1 ENGINEERING A LEARNING HEALTHCARE SYSTEM
least two pilots in each commercial cockpit specifically to provide a human
backup system. For the most part, the positive safety trends—albeit mostly
mechanically based—continued into the 1980s and 1990s. With only a few
exceptions—a faulty cargo-door latching mechanism (United 811, 1989,
south of Honolulu); a destroyed engine and flight control system in a United
DC-10 flight ending in Sioux City, Iowa, in July of the same year; the loss
of the upper forward fuselage of a highly corroded Boeing 737 belonging
to Aloha Airlines south of Maui in 1986; and the loss of TWA 800 due to
a fuel tank explosion years later near Moriches, New York—by and large it
had become a rule that when an airliner was destroyed, with or without loss
of life, the primary contributing cause was human error. Indeed, records
show that this was true in more than 90 percent of cases. Even the term
“pilot error” (which implies a professional discretionary mistake such as
making a conscious decision to violate the rules, with catastrophic results)
was criticized as inadequate because being human inevitably implies being
able to make errors that sometimes cause accidents.
By the 1970s, the trend curve for major airline accidents, especially in
the United States, had flattened and was lying on average just a few points
above zero. But it refused to descend to zero. In other words, while airline
flying had become remarkably safe and reliable, especially with respect to
mechanical accidents, no amount of industry effort, Federal Aviation Ad-
ministration (FAA) pressure, or pilot training could completely eliminate
human-caused disasters, and no accelerated application of the traditional
engineering solutions appeared to improve the situation.
In the 1980s, however, a true revolution, quiet and unnoticed, began to
change the equation. As a direct result, 16 years later the airline accident
death rate for U.S. airlines finally hit bottom and remained at 0 for nearly
5 years—a stunning achievement. Although this 5-year 0-accident record
ended with a crash in 2006 in Lexington, Kentucky, the passenger death
rate in U.S. service has remained flat since then (Levin, 2009). This achieve-
ment was due to a recognition of the fact that aviation is a human system
and that humans will never be able to operate without making mistakes. In
other words, the path to perfect safety was through the process of building
a system that fully expected and was ready to absorb human mistakes. The
engineering-based disciplines that evolved in the airline business (and avia-
tion in general) from that pivotal recognition are loosely known as human
factors engineering, but they include systems engineering as well and bor-
row heavily from sociology, physiology, and behavioral science.
Before the industry realized in the early 1980s that it had never really
addressed human failure (except to ineffectually order humans not to fail),
there was a growing silence about the prospects of ever fully eliminating
passenger deaths and disasters. It was quietly acknowledged that a certain
number of accidents might be the cost of doing business, that accidents
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might be inevitable in a system that each day sent as many as 3,000 flights
around the country and carried many tens of millions of passengers each
year. Moreover, as the airlines came under tremendous cost pressure during
the early 1980s because of deregulation and cut-rate competition, estab-
lished airlines began looking desperately at ways of reducing costs. In that
environment, concern grew that massive new investments in maintenance,
training, and electronics would be needed to realize even an incremental
improvement in safety (given that there were already so few crashes). This
situation did little to generate enthusiasm for expanding safety measures
or investing in new disciplines such as CRM (which was in its infancy at
United at the time). The heavy price of small improvement, in other words,
furthered the idea that a small number of accidents might have to be ac-
cepted as the cost of having an airline system. Of course, this was not an
illogical argument at that time. In fact, one major airline executive rather
infamously replied to the question of why his airline did not spend millions
to establish a safety department by saying: “We don’t need one. That’s why
we have insurance.”
Before the emergence of human factors in the 1980s, the airlines had
successfully applied systems engineering principles in many ways (some-
times without labeling them correctly) to develop high levels of mechanical
and operational reliability. Across the industry, we had developed sophis-
ticated feedback systems for learning rapidly about mechanical problems,
systems that included the so-called Airworthiness Directives issued by the
FAA (the strongest type of legal directive the FAA can issue to effect me-
chanical changes), as well as less urgent service bulletins transmitted to the
entire commercial aviation industry within and outside the United States. In
addition, there was a broad range of methods by which the airlines could
communicate with each other, the FAA, and the National Transportation
Safety Board, including a number of task forces and special industry groups
working voluntarily with the government on problems of special concern
(e.g., the revelations in the late 1980s about the susceptibility of aircraft
structures to accelerated corrosion and fatigue in high-salt environments
following the Aloha accident of 1986). To a certain extent, those systems
have all now matured (along with individual reporting systems such as the
National Aeronautics and Space Administration’s Aviation Safety Reporting
System), to the point that any significant problem discovered in commercial
aviation can be fully discussed and communicated to every operator world-
wide within hours. Aviation, in other words, worked hard to learn serious
lessons about maintenance and training once the FAA pushed for airline
safety by working with, instead of against, the industry.
In the same period of the 1970s through the 1990s, under Part 25 of the
Federal Aviation Regulations (14 Code of Federal Regulations 25), the ma-
jor airline manufacturers developed a level of redundancy in their designs
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18 ENGINEERING A LEARNING HEALTHCARE SYSTEM
such that the anticipated failure rates of most of aircraft and components
had a long string of zeros to the right of the decimal point before a non-
zero digit appeared. Through backup systems and preventive maintenance
(pulling and replacing or overhauling components long before their first
anticipated failure range), the so-called “dispatch reliability” of airliners
exceeded the most optimistic expectations. In addition, airlines developed
processes for the computerized tracking of maintenance, parts, and all oper-
ational elements—including crew scheduling, reservations, ship scheduling,
dispatch, and coordination of all functions—optimizing the rapidly devel-
oping capabilities of computers. The airlines achieved computer-assisted
standardization of nearly everything done in the maintenance hangars,
in the cockpit, and even in operations. All of these elements were honed
continuously because they were the most cost-effective methods of doing
business. Airlines realized that in a heavily competitive environment, they
simply could not afford the type of public relations catastrophe that any
major accident would cause. The costs to an airline’s reputation would be
far beyond the direct costs of any such accident.
All of the mechanical and computerized systems were largely in place
by the end of the 1970s, but, as previously noted, crashes still happened,
usually because of human failure. In 1982 an Air Florida Boeing 737
crashed on takeoff in a snowstorm in Washington, DC, killing all but five
of those aboard, who were rescued from the icy Potomac River. There was
nothing wrong with the airplane. In 1985, an Arrow Air flight chartered
to bring U.S. troops from the Middle East to Kentucky crashed in Gander,
Newfoundland, killing all 256 people aboard. Although there is still con-
troversy about that crash, it was attributed to the crew’s departing with ice
on the wings—again, there was nothing mechanically wrong with the air-
plane. A Northwest Airlines plane crashed in Romulus, Michigan, in 1987
because of the pilot’s failure to extend the flaps, and all but one died. A year
later, a Delta flight at Dallas–Fort Worth Airport also tried to take off with
the flaps up and crashed, killing 17 people. The flight crew survived, and
they were astounded at the National Transportation Safety Board’s finding
that all three of them had missed clear signs that the flaps had not been
extended. Three highly trained, highly qualified human beings had caused
a major accident, and all three had “seen”—and were willing to swear they
had seen—instrument indications that the flaps were in the correct position
(15-degree extension). The flaps were not in the correct position.
Given events such as these, the airline industry realized by the early
1980s that such tragedies would continue unless it adopted radically dif-
ferent practices and, for the first time, addressed not just advertent human
failure but wholly inadvertent mistakes. To that end, the industry had to do
more than adopt major changes; it had to change its philosophy and, most
important, to change the entire culture of airline piloting.
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Many who look at the aviation industry’s excellent safety record today
erroneously think it is simply the result of engineering successes based on
the mechanics of the operation, on systems, and on getting people under
control and completing more and more checklists. In fact, even some mem-
bers of the industry are unaware of the cultural revolution that transformed
our ability to prevent accidents due to human mistakes. More to the point
for this workshop, the changes I refer to as a renaissance in thinking during
the 1980s and 1990s have helped us create a new paradigm that can, as
many have realized, be transferred to health care. In fact, I and many oth-
ers have been doing exactly that with solid success for a number of years,
primarily by focusing on training healthcare professionals in the discipline
of how humans fail and what can be done to create a human system that
can prevent those failures from hurting patients. That training is completely
counter to the traditional, autonomous approach to health care, especially
in relation to physicians, in holding as a fundamental tenet that although
individual humans—including surgeons—are incapable of achieving perfec-
tion, interactive and collegial teams of humans can do so. Indeed, this is the
primary legacy of the CRM revolution in airline cockpits, where we have
saved countless lives and aircraft in the past 20 or more years by requiring
more than 1 human mind to weigh in when something appears amiss and
using a teamwork approach based on the common goal of flight safety to
approach self-correction and safe operational decisions. Eliminated in such
an atmosphere is the angry autonomous leader who disciplines a subordi-
nate by berating, belittling, and ignoring that individual just for speaking
up. Gone as well is the situation in which a subordinate has the key to save
everyone but cannot pass it to the leader.
Health care today and the airline industry of yesterday are remarkably
parallel in that every physician, nurse, and other healthcare professional is
trained, essentially, to be perfect and never to make mistakes. Worse, the
system is built the same way aviation was—on the expectation of human
perfection, with few if any buffers to allow for major human mistakes. In
the airline industry, thousands of work-years of engineering had been de-
voted (with great success) to providing backup systems for even the most
arcane failure modes, but when it came to engineering for human failure,
the approach taken was simply to order the human not to fail. Equally
appalling in light of what we now know was the lack of emphasis on
human-to-human relationships as the platform for true communication, co-
ordination, and self-correction. Similarly in medicine, there is traditionally
no expectation of human error in good doctors, nurses, and pharmacists, so
there appears to be no valid reason for having backup and buffer systems
to absorb mistakes.
The lesson from the airline industry, then, is that buffers against nor-
mal human error are a prime safety component in any human system. Of
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180 ENGINEERING A LEARNING HEALTHCARE SYSTEM
equal importance is the reality that the healthcare culture, as previously
was the case with the airline culture, includes an expectation of hierarchical
autonomy that is challenged by any subordinate speaking up to report a
mistake or concern. In the airline industry, subordinates’ sensitivity to the
feelings of a senior created a culture-based reluctance to point out concerns,
problems, or even impending disasters lest the leader become angry at the
suggestion that he or she was in error. Leaders, after all, are trained never to
make mistakes. But that left only one mind operating in an airplane (or an
operating room), while the other qualified professionals sat in silence, even
(in the airlines) if the captain was a gentle individual who wanted to hear
from his or her crew. This situation kept us from improving safety levels
and preventing that last tier of human mistake−driven accidents.
Perhaps the most important experience the airline industry can share
with health care is its realization that no human can be perfect and that no
team can function as a team without collegiality and mutual respect. We
proceeded to build a system around those assumption, constructing buf-
fers and backups for all reasonably anticipatable human failures that might
otherwise lead to an incident or accident. And history shows that we have
succeeded.
We learned that a safety system has three distinct tiers. Tier 1 encom-
passes all the training and indoctrination and agreed-upon or imposed
professional methods, such as checklist compliance and “time-outs,” that
are designed to prevent human error. Understanding that some human er-
ror will occur despite our best efforts at standardization and training, we
then must construct Tier 2, comprising those buffers and backups that will
catch and cancel out the effects of human error and latent system failures.
Finally, Tier 3 reflects the realization that even after accomplishing highly
effective work in preventing and then screening out the effects of mistakes,
we will still occasionally experience catastrophic failure unless we enter
every operational sequence expecting a 50 percent chance of failure. With
this expectation and through collegial teams whose members have no
hesitation in communicating with each other for the good of the mission,
we construct a systemic approach that ensures our leaders are ready and
willing to consider even the most tenuous concern as potentially valid and
“stop the line,” or hold off on the operation, or abort the takeoff until the
team and the leader are sure that safety is not threatened. Thus, either a
junior flight engineer or a new circulating nurse would get an instant and
serious audience by saying, “I’m not sure, but I think something’s wrong,”
rather than having to overcome a group presumption of normalcy. That
one change—the Tier 3 approach—can be the final key to constructing a
system that protects against catastrophic patient injury or death from pre-
ventable medical human mistakes. But to institutionalize such procedures
requires a systemic approach that is foreign to the American healthcare
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experience, which is why looking to the engineering community for help
is so important.
Human beings fail in three basic ways—by making mistakes in per-
ception, assumption, and communication. Perception failures include, for
example, a flight crew’s failure to recognize that the aircraft’s wing flaps
are not properly extended for takeoff. One mistaken assumption caused an
accident in 1977, when two pilots assumed their Boeing 747 was cleared for
takeoff when in fact it was not. Another 747 had missed a turn and was sit-
ting sideways on the runway ahead, unseen in the fog. The decision to start
the takeoff was a human mistake nurtured by a poor cockpit culture. That
day it resulted in the loss of 583 lives. The third human failure is mistakes
in communication, a human propensity shared by health care and aviation.
Approximately 12.5 percent of the time in human verbal communication,
people who otherwise understand each other fail to do so in that instance.
The old phrase “I know you think you understood what you thought I said,
but I am not sure you realize that what you heard wasn’t what I meant”
points to the universality of misunderstanding. We have learned, however,
that reading back a clearance or a medical order can reduce the potential
for mistakes to below half a percent.
Aviation had to learn these basic failure modes instead of fighting to
deny them or ordering them to not occur. We had to learn to inculcate
the expectation of such failures in everything we did. So, too, must health
care. But to accept these realities operationally and culturally and integrate
them into health care (with its largely autonomous tradition), we need a
structured, engineered framework within which such approaches as the
minimization of variables, collegial team communication, and the three
tiers discussed above can be deployed as standard operating methodology.
Equally important—and not just to avoid the charge of creeping cookbook
medicine—is that the resulting structure must nurture physicians in using
their cognitive, analog, diagnostic, and surgical skills to do what checklists,
machines, and procedures alone can never accomplish. By finding the proper
balance, one can create a system that enables humans—through technol-
ogy and enlightened methodologies—to practice what they do best—apply
judgment, skill, and reason.
We cannot incorporate an expectation of perfection in a human system
without creating and nurturing disasters. We cannot fail to accommodate
human attitudes, feelings, or physiological limitations without perpetuating
a societally unacceptable level of patient injuries and service quality. What
health care needs from the applied and unique expertise engineering can
provide is a structure that legitimizes and inculcates known best practices,
eliminates the need or latitude to reinvent each procedure, and provides the
best possible operational buffers against inevitable human fallibility, while
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Berriel-Cass, D., F. W. Adkins, P. Jones, and M. G. Fakih. 2006. Eliminating nosocomial
infections at Ascension Health. Joint Commission Journal of Quality and Patient Safety
32(11):612–620.
Best, W. R., S. F. Khuri, M. Phelan, K. Hur, W. G. Henderson, J. G. Demakis, and J. Daley.
2002. Identifying patient preoperative risk factors and postoperative adverse events in
administrative databases: Results from the Department of Veterans Affairs National
Surgical Quality Improvement Program. Journal of the American College of Surgeons
194(3):257–266.
Bhatia, S. C., and P. P. Fernandes. 2008. Quality outcomes management: Veterans Affairs case
study. Psychiatric Clinics of North America 31(1):57–72.
Block, S. D. 2002. Medical education in end-of-life care: The status of reform. Journal of
Palliatie Medicine 5:243–250.
Booth, B. M., R. L. Ludke, D. S. Wakefield, D. C. Kern, L. F. Burmeister, E. M. Fisher, and
T. W. Ford. 1991. Nonacute days of care within Department of Veterans Affairs medical
centers. Medical Care 29(8 Suppl.).
Bozzette, S. A., B. Phillips, S. Asch, A. L. Gifford, L. Lenert, T. Menke, E. Ortiz, D. Owens,
and L. Deyton. 2000. Quality enhancement research initiative for human immunodefi-
ciency virus/acquired immunodeficiency syndrome: Framework and plan. HIV-QUERI
Executive Committee. Medical Care 38(6 Suppl. 1):I60–I69.
Brennan, T. A., L. L. Leape, N. M. Laird, L. Hebert, A. R. Localio, A. G. Lawthers, J. P.
Newhouse, P. C. Weiler, and H. H. Hiatt. 1991. Incidence of adverse events and neg-
ligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New
England Journal of Medicine 324(6):370–376.
Brown, D. 2007. VA takes the lead in paperless care: Computerized medical records promise
lower costs and better treatment. The Washington Post, April 10. http://www.wash-
ingtonpost.com/wp-dyn/content/article/2007/04/06/AR2007040601911.html (accessed
September 20, 2010).
Brown, S. H., M. J. Lincoln, P. J. Groen, and R. M. Kolodner. 2003. VistA—U.S. Depart-
ment of Veterans Affairs national-scale HIS. International Journal of Medical Informatics
69(2–3):135–156.
Butler, K., P. Mollo, J. L. Gale, and D. A. Rapp. 2007. Eliminating adverse drug events at Ascen-
sion Health. Joint Commission Journal of Quality and Patient Safety 33(9):527–536.
Carver, P. 2002. The Veterans Health Administration and the Institute for Healthcare Im-
proement’s adanced clinic access initiatie 2001–2002. Boston, MA: Institute for
Healthcare Improvement.
CBS Evening News. 2006 (December 8). VA: High-quality health care at low cost. http://www.
cbsnews.com/stories/2006/12/08/eveningnews/main2243606.shtml (accessed September
20, 2010).
CDC (Centers for Disease Control and Prevention). 2007. National ital statistics reports, ol.
, no. 19. Washington, DC: U.S. Government Printing Office.
Chapko, M. K., and C. Van Deusen Lukas. 2001. VA community-based outpatient clinics
improve access to care and increase patient satisfaction. Forum June:4–5.
Charles, R. 2000. The challenge of disseminating innovations to direct care providers in health
care organizations. Nursing Clinics of North America 35(2):461–470.
Chen, S., T. H. Wagner, and P. G. Barnett. 2001. The effect of reforms on spending for veter-
ans’ substance abuse treatment, 1993–1999. Health Affairs (Millwood) 20(4):169–175.
Chen, S., M. W. Smith, T. H. Wagner, and P. G. Barnett. 2003. Spending for specialized mental
health treatment in the VA: 1995–2001. Health Affairs (Millwood) 22(6):256–263.
Childs, C. 1970 (May 22). From Vietnam to a VA hospital: Assignment to neglect. Life
68(19):24–33.
OCR for page 227
22
TRANSFORMATION THROUGH SYSTEMS ENGINEERING
Cleeland, C. S., C. C. Reyes-Gibby, M. Schall, K. Nolan, J. Paice, J. M. Rosenberg, J. H.
Tollett, and R. D. Kerns. 2003. Rapid improvement in pain management: The Veterans
Health Administration and the Institute for Healthcare Improvement collaborative. Clini-
cal Journal of Pain 19(5):298–305.
Conn, J. 2004. A veteran IT system. Modern Healthcare 34(47):30–31.
Cope, D. W., S. Sherman, and A. S. Robbins. 1996. Restructuring VA ambulatory care and med-
ical education: The Pace model of primary care. Academic Medicine 71(7):761–771.
Daley, J., S. F. Khuri, W. Henderson, K. Hur, J. O. Gibbs, G. Barbour, J. Demakis, G. Irvin,
III, J. F. Stremple, F. Grover, G. McDonald, E. Passaro, Jr., P. J. Fabri, J. Spencer, K.
Hammermeister, J. B. Aust, and C. Oprian. 1997. Risk adjustment of the postoperative
morbidity rate for the comparative assessment of the quality of surgical care: Results
of the national Veterans Affairs surgical risk study. Journal of the American College of
Surgeons 185(4):328–340.
Davis, R. 1998. Veterans facilities air medical errors and take action. USA Today, October
18, 4D.
DeLuca, M. A. 2000. Trans-Atlantic experiences in health reform: the United Kingdom’s Na-
tional Health Serice and the United States Veterans Health Administration. Washington,
DC: The PricewaterhouseCoopers Endowment for The Business of Government.
Demakis, J. G., L. McQueen, K. W. Kizer, and J. R. Feussner. 2000. Quality Enhancement
Research Initiative (QUERI): A collaboration between research and clinical practice.
Medical Care 38(6 Suppl. 1):I17–I25.
Edmondson, A. C., B. R. Golden, and G. J. Young. 2006. Turnaround at the Veterans Health
Administration. Boston, MA: Harvard Business School Publishing.
Edwards, J. R., K. D. Peterson, M. L. Andrus, J. S. Tolson, J. S. Goulding, M. A. Dudeck, et
al. (2007). National healthcare safety network (NHSN) report, data summary for 2006,
issued June 2007. American Journal of Infection Control 35(5):290–301.
Employee Education System. 1999. Care management in VA—Coordinating care across all
settings. Washington, DC: Department of Veterans Affairs.
Every, N. R., S. D. Fihn, A. E. Sales, A. Keane, and J. R. Ritchie. 2000. Quality enhancement
research initiative in ischemic heart disease: A quality initiative from the Department
of Veterans Affairs. QUERI IHD Executive Committee. Medical Care 38(6 Suppl. 1):
I49–I59.
Ewing, H., G. Bruder, P. Baroco, M. Hill, and L. P. Sparkman. 2007. Eliminating perioperative
adverse events at Ascension Health. Joint Commission Journal of Quality and Patient
Safety 33(5):256–266.
Feussner, J. R., K. W. Kizer, and J. G. Demakis. 2000. The quality enhancement research initia-
tive (QUERI): From evidence to action. Medical Care 38(6 Suppl. 1):I1–I6.
Fihn, S. D., M. Vaughan-Sarrazin, E. Lowy, I. Popescu, C. Maynard, G. E. Rosenthal, A. E.
Sales, J. Rumsfeld, S. Piñeros, M. B. McDonell, C. D. Helfrich, R. Rusch, R. Jesse, P.
Almenoff, B. Fleming, and M. Kussman. 2009. Declining mortality following acute
myocardial infarction in the Department of Veterans Affairs Health Care System. BMC
Cardioascular Disorders 9:44.
Fink, A. S., D. A. Campbell, Jr., R. M. Mentzer, Jr., W. G. Henderson, J. Daley, J. Bannister,
K. Hur, and S. F. Khuri. 2002. The National Surgical Quality Improvement Program in
non-Veterans Administration hospitals: Initial demonstration of feasibility. Annals of
Surgery 236(3):344–353; discussion, 353–354.
Finney, J. W., M. L. Willenbring, and R. H. Moos. 2000. Improving the quality of VA care
for patients with substance-use disorders: The quality enhancement research initiative
(QUERI) substance abuse module. Medical Care 38(6 Suppl. 1):I105–I113.
OCR for page 228
228 ENGINEERING A LEARNING HEALTHCARE SYSTEM
Fischer, E. P., S. R. Marder, G. R. Smith, R. R. Owen, L. Rubenstein, S. C. Hedrick, and G. M.
Curran. 2000. Quality enhancement research initiative in mental health. Medical Care
38(6 Suppl. 1):I70–I81.
Fong, T. 2003. An army of patients. Modern Healthcare (March 19) 33(20):48–50, 62.
Frayne, S. M., V. A. Parker, C. L. Christiansen, S. Loveland, M. R. Seaver, L. E. Kazis, and
K. M. Skinner. 2006. Health status among 28,000 women veterans. The VA Women’s
Health Program Evaluation Project. Journal of General Internal Medicine 21(Suppl. 3):
S40–S46.
Freedberg, S. J. 2006. Veterans’ care praised, finally. National Journal 38(6):65–66.
GAO (General Accounting Office). 1987. VA health care: VA’s patient injury control program
not effectie. Washington, DC: General Accounting Office.
———. 1989. Better patient management practices could reduce length of stay in VA hospitals.
Washington, DC: General Accounting Office.
———. 1993. VA health care: Restructuring ambulatory care system would improe serices
to eterans. Washington, DC: General Accounting Office.
———. 1994a. Veterans health care: Veterans’ perceptions of VA serices and VA’s role in
health care reform. Washington, DC: General Accounting Office.
———. 1994b. Veterans health care: Use of VA serices by Medicare-eligible eterans. Wash-
ington, DC: General Accounting Office.
———. 1995. VA health care, physician peer reiew identifies quality of care problems but
actions to address them are limited. Washington, DC: General Accounting Office.
———. 1998. VA health care status of efforts to improe efficiency and access. Washington,
DC: General Accounting Office.
———. 1999. Veterans affairs: Progress and challenges in transforming health care. Washing-
ton, DC: General Accounting Office.
Gaul, G. M. 2005. Revamped veterans’ health care now a model. The Washington Post, August
22. www.washingtonpost.com/wp-dyn/content/article/2005/08/21/AR2005082101073.
html (accessed May 30, 2010).
Gearon, C. J. 2005. Military might: Today’s VA hospitals are models of top-notch care. U.S.
News and World Report, July 18:100–106. http://health.usnews.com/usnews/health/
articles/050718/18va.htm (accessed May 30, 2010).
Gebhart, F. 1999. VA facility slashes drug errors via barcoding. Drug Topics 143:44.
Gibbons, W., H. T. Shanks, P. Kleinhelter, and P. Jones. 2006. Eliminating facility-acquired
pressure ulcers at Ascension Health. Joint Commission Journal of Quality and Patient
Safety 32(9):488–496.
Gibson, R. 1998. The Robert Wood Johnson Foundation grant-making strategies to improve
care at the end of life. Journal of Palliatie Medicine 1(4):415–417.
Glendinning, D. 2007. VA health care quality: The road to recovery. American Medical
News 50(46). www.ama-assn.org/amednews/2007/12/10/gvsa1210.htm (accessed May
30, 2010).
Greenberg, G. A., R. A. Rosenheck, and M. P. Charns. 2003. From profession-based leader-
ship to service line management in the Veterans Health Administration: Impact on mental
health care. Medical Care 41(9):1013–1023.
Greenfield, S., and S. H. Kaplan. 2004. Creating a culture of quality: The remarkable trans-
formation of the Department of Veterans Affairs health care system. Annals of Internal
Medicine 141(4):316–318.
Groen, P. J. 2005. A history of health information technology (IT) in the VA: 19–200.
Washington, DC: P.J. Groen.
Harada, N. D., V. M. Villa, and R. Andersen. 2002. Satisfaction with VA and non-VA outpa-
tient care among veterans. American Journal of Medical Quality 17(4):155–164.
OCR for page 229
229
TRANSFORMATION THROUGH SYSTEMS ENGINEERING
Haugh, R. 2003. Reinventing the VA: Civilian providers find valuable lessons in the once-
maligned health care system. Hospitals & Health Networks (77):50–52, 55.
Hendrich, A., A. R. Tersigni, S. Jeffcoat, C. J. Barnett, L. P. Brideau, and D. Pryor. 2007. The
Ascension Health journey to zero: Lessons learned and leadership. Joint Commission
Journal of Quality and Patient Safety 33(12):739–749.
Hitcho, E. B., M. J. Krauss, S. Birge, D. W. Claiborne, I. Fischer, S. Johnson, P. A. Nast, E.
Costantinou, and V. J. Fraser. 2004. Characteristics and circumstances of falls in a hos-
pital setting. Journal of General Internal Medicine 19:732–739.
Holohan, T. V., T. Mitchell, and K. W. Kizer. 1999. At war with hepatitis C, part 2: Evaluation,
screening and diagnosis in the VHA. Federal Practitioner 16:12–15.
Humphreys, K., and D. Horst. 2002. Datapoints: Moving from inpatient to residential sub-
stance abuse treatment in the VA. Psychiatric Serices 53(8):927.
Humphreys, K., P. D. Huebsch, R. H. Moos, and R. T. Suchinsky. 1999. Alcohol and drug
abuse: The transformation of the Veterans Affairs substance abuse treatment system.
Psychiatric Serices 50(11):1399–1401.
Huskamp, H. A., A. M. Epstein, and D. Blumenthal. 2003. The impact of a national prescrip-
tion drug formulary on prices, market share, and spending: Lessons for Medicare? Health
Affairs (Millwood) 22(3):149–158.
Hynes, D. M., R. A. Perrin, S. Rappaport, J. M. Stevens, and J. G. Demakis. 2004. Informatics
resources to support health care quality improvement in the Veterans Health Administra -
tion. Journal of the American Medical Informatics Association 11(5):344–350.
Institute for Healthcare Improvement. 2006. 100k lies campaign. http://www.ihi.org/IHI/
Programs/Campaign/100kCampaignOverviewArchive.htm (accessed June 21, 2010).
IOM (Institute of Medicine). 2000a. Description and analysis of the VA National Formulary.
Washington, DC: National Academy Press.
———. 2000b. To err is human: Building a safer health system. Washington, DC: National
Academy Press.
Jackson, G. L., E. M. Yano, D. Edelman, S. L. Krein, M. A. Ibrahim, T. S. Carey, S. Y. Lee,
K. E. Hartmann, T. K. Dudley, and M. Weinberger. 2005. Veterans Affairs primary care
organizational characteristics associated with better diabetes control. American Journal
of Managed Care 11(4):225–237.
Jha, A. K., J. B. Perlin, K. W. Kizer, and R. A. Dudley. 2003. Effect of the transformation of
the Veterans Affairs health care system on the quality of care. New England Journal of
Medicine 34:2218–2227.
Jha, A. K., S. M. Wright, and J. B. Perlin. 2007. Performance measures, vaccinations, and
pneumonia rates among high-risk patients in Veterans Administration health care. Ameri-
can Journal of Public Health 97(12):2167–2172.
Johnson, C. L., R. A. Carlson, C. L. Tucker, and C. Willette. 2002. Using BCMA software to
improve patient safety in Veterans Administration medical centers. Journal of Healthcare
Information Management 16(1):46–51.
Kazis, L. E., X. S. Ren, A. Lee, K. Skinner, W. Rogers, J. Clark, and D. R. Miller. 1999. Health
status in VA patients: Results from the Veterans Health Study. American Journal of Medi-
cal Quality 14(1):28–38.
Kee, J. E., and K. E. Newcomer. 2007. Leading change, managing risk: The leadership role in
priate sector transformation. Washington, DC: George Washington University School
of Public Policy and Public Administration.
Kerr, E. A., R. B. Gerzoff, S. L. Krein, J. V. Selby, J. D. Piette, J. D. Curb, W. H. Herman, D. G.
Marrero, K. M. Narayan, M. M. Safford, T. Thompson, and C. M. Mangione. 2004.
Diabetes care quality in the Veterans Affairs health care system and commercial managed
care: The Triad Study. Annals of Internal Medicine 141(4):272–281.
OCR for page 230
20 ENGINEERING A LEARNING HEALTHCARE SYSTEM
Khuri, S. F. 2006. Safety, quality, and the National Surgical Quality Improvement Program.
American Surgeon 72(11):994–998; discussion 1021–1030, 1133–1148.
Khuri, S. F., J. Daley, W. Henderson, K. Hur, J. O. Gibbs, G. Barbour, J. Demakis, G. Irvin, J. F.
Stremple, F. Grover, G. McDonald, E. Passaro, P. J. Fabri, J. Spencer, K. Hammermeister,
and J. B. Aust. 1997. Risk adjustment of the postoperative mortality rate for the compar-
ative assessment of the quality of surgical care: Results of the National Veterans Affairs
Surgical Risk Study. Journal of the American College of Surgery 185(4):315–327.
Khuri, S. F., J. Daley, W. Henderson, K. Hur, J. Demakis, J. B. Aust, V. Chong, P. J. Fabri,
J. O. Gibbs, F. Grover, K. Hammermeister, G. Irvin, III, G. McDonald, E. Passaro, Jr.,
L. Phillips, F. Scamman, J. Spencer, and J. F. Stremple. 1998. The Department of Vet-
erans Affairs’ NSQIP: The first national, validated, outcome-based, risk-adjusted, and
peer-controlled program for the measurement and enhancement of the quality of sur-
gical care. National VA Surgical Quality Improvement Program. Annals of Surgery
228(4):491–507.
Khuri, S. F., W. G. Henderson, J. Daley, O. Jonasson, R. S. Jones, D. A. Campbell, Jr., A. S.
Fink, R. M. Mentzer, Jr., L. Neumayer, K. Hammermeister, C. Mosca, and N. Healey.
2008. Successful implementation of the Department of Veterans Affairs’ National Surgi-
cal Quality Improvement Program in the private sector: The Patient Safety in Surgery
study. Annals of Surgery 248(2):329–336.
Kizer, K. W. 1996. Prescription for change: The strategic principles and objecties for
transforming the Veterans Health Administration. Washington, DC: Veterans Health
Administration.
———. 1998. Clinical practice guidelines. Federal Practitioner 15:52–58.
———. 1999. The “New VA”: A national laboratory for health care quality management.
American Journal of Medical Quality 14(1):3–20.
———. 2000. Promoting innovative nursing practice during radical health system change.
Nursing Clinics of North America 35(2):429–441.
———. 2001. Reengineering the veterans healthcare system. In P. Ramsaroop, M. J. Ball, D.
Beaulieu, and J. V. Douglas (eds.), Adancing federal sector healthcare (pp. 79–96). New
York: Springer-Verlag.
Kizer, K. W., and T. L. Garthwaite. 1997. Vision for change: An integrated service network.
In Computerizing large integrated health networks: The VA success (pp. 3–13). New
York: Springer-Verlag.
Kizer, K. W., and G. A. Pane. 1997. The “New VA”: Delivering health care value through
integrated service networks. Annals of Emergency Medicine 30(6):804–807.
Kizer, K. W., J. E. Ogden, and J. E. Ray. 1997. Establishing a PBM: Pharmacy benefits manage-
ment in the Veterans Health Care System. Drug Benefit Trends August:24–27, 47.
Kizer, K. W., T. S. Cushing, and R. Y. Nishimi. 2000a. The Department of Veterans Affairs’
role in federal emergency management. Annals of Emergency Medicine 36(3):255–261.
Kizer, K. W., J. G. Demakis, and J. R. Feussner. 2000b. Reinventing VA health care: Sys-
tematizing quality improvement and quality innovation. Medical Care 38(6 Suppl. 1):
I7–I16.
Klein, R. 1981. Wounded men, broken promises. New York: McMillan.
Knopman, D., S. Resetar, P. Norling, R. Rettig, and I. Brahmakulam. 2003. Innoation and
change management in public and priate organizations: Case studies and options for
EPA. Washington, DC: RAND Corporation.
Korthuis, P. T., H. D. Anaya, and S. A. Bozzette. 2004. Quality of HIV care within Veterans
Affairs health system: A comparison using outcomes from the HIV cost and services
utilization study. Journal of Clinical Outcomes Management 11:766–774.
OCR for page 231
21
TRANSFORMATION THROUGH SYSTEMS ENGINEERING
Krein, S. L., R. A. Hayward, L. Pogach, and B. J. Boots-Miller. 2000. Department of Veterans
Affairs’ Quality Enhancement Research Initiative for diabetes mellitus. Medical Care
38(6 Suppl. 1):I38–I48.
Krugman, P. 2008. Health care confidential. The New York Times, January 27. http://select.
nytimes.com/2006/01/27/opinion/27krugman.html?_r=1 (accessed February 23, 2010).
Kupersmith, J., J. Francis, E. Kerr, S. Krein, L. Pogach, R. M. Kolodner, and J. B. Perlin.
2007. Advancing evidence-based care for diabetes: Lessons from the Veterans Health
Administration. Health Affairs (Millwood) 26(2):w156–w168.
Lancaster, A. D., A. Ayers, B. Belbot, V. Goldner, L. Kress, D. Stanton, P. Jones, and L.
Sparkman. 2007. Preventing falls and eliminating injury at Ascension Health. Joint Com-
mission Journal of Quality and Patient Safety 33(7):367–375.
Landrum, M. B., E. Guadagnoli, R. Zummo, D. Chin, and B. J. McNeil. 2004. Care following
acute myocardial infarction in the Veterans Administration medical centers: A compari-
son with Medicare. Health Serices Research 39(6 Pt. 1):1773–1792.
Leape, L. L., D. D. Woods, M. J. Hatlie, K. W. Kizer, S. A. Schroeder, and G. D. Lundberg. 1998.
Promoting patient safety by preventing medical error. JAMA 280(16):1444–1447.
Levin, A. 2009. Airlines go two years with no fatalities. USA Today. January 11. www.usatoday.
com/travel/flights/2009-01-11-airlinesafety_N.htm (accessed February 23, 2010).
The Lewin Group and PricewaterhouseCoopers. 1998. Veterans equitable resource allocation
assessment. Final Report Task Order 2. Washington, DC.
Light, P. C. 1992. Forging legislation. New York: W. W. Norton & Co.
Long, J. A., D. Polsky, and J. P. Metlay. 2005. Changes in veterans’ use of outpatient care from
1992 to 2000. American Journal of Public Health 95(12):2246–2251.
Longman, P. 2007. Best care anywhere. Why VA health care is better than yours. Sausalito,
CA: PoliPointPress.
Luciano, L. 2000. A government health system leads the way. Accelerating Change Today
February:9–11.
Management Decision and Research Center. 1995. Primary care in VA primer. Washington,
DC: Veterans Health Administration.
———. 1998. Clinical practice guidelines primer. Washington, DC: Veterans Health
Administration.
Mather, J. H., and R. W. Abel. 1986. Medical care of veterans—a brief history. Journal of the
American Geriatrics Society 34(10):757–760.
Mazza, F., J. Kitchens, S. Kerr, A. Markovich, M. Best, and L. P. Sparkman. 2007. Eliminat-
ing birth trauma at Ascension Health. Joint Commission Journal of Quality and Patient
Safety 33(1):15–24.
Mills, P. D., and W. B. Weeks. 2004. Characteristics of successful quality improvement teams:
Lessons from five collaborative projects in the VHA. Joint Commission Journal of Qual-
ity and Patient Safety 30(3):152–162.
Mills, P. D., W. B. Weeks, and B. C. Surott-Kimberly. 2003. A multihospital safety improve-
ment effort and the dissemination of new knowledge. Joint Commission Journal on
Quality and Patient Safety 29(3):124–133.
Mitchell, T., T. V. Holohan, L. W. Wright, and K. W. Kizer. 1999. At war with hepatitis C:
Part 1: The VA’s strategic initiative. Federal Practitioner 16(11):12–15.
Mitkowski, A., and J. Feinstein. 2007. Veterans Health Administration: Dr. Kizer consid-
ers radical surgery on an ailing system. New Haven, CT: Yale University School of
Management.
Morgan, M. W. 2005. The VA advantage: The gold standard in clinical informatics. Healthcare
Papers 5(4):26–29.
OCR for page 232
22 ENGINEERING A LEARNING HEALTHCARE SYSTEM
National Quality Research Center, Federal Consulting Group. 1999. Veterans Health Admin-
istration—Inpatients, Veterans Affairs customer satisfaction study: Final report 1999.
Ann Arbor, MI.
National Quality Research Center, Federal Consulting Group, CFI Group. 2007a. Veterans
Health Administration—Inpatients, Veterans Affairs customer satisfaction study: Final
report 200. Ann Arbor, MI.
———. 2007b. Veterans Health Administration—Outpatients, Veterans Affairs customer
satisfaction study: Final report 200. Ann Arbor, MI.
NBC Nightly News. 2006 (March 15). A healthcare system seen as model for reform.
NYT (New York Times). 1999. Progress on medical records (editorial). The New York
Times. December 29. www.nytimes.com/1999/12/28/opinion/progress-on-medical-errors.
html?pagewanted=1 (accessed February 23, 2010).
Nicholson, R. J. 2006. VA blazes path to preventing drug errors. USA Today, July 31. www.
usatoday.com/news/opinion/editorials/2006-07-31-letters-va_x.htm (accessed February
23, 2010).
Office of the Inspector General. 1997. The impact of downsizing inpatient substance abuse
rehabilitation programs on homeless eterans and other frequent users. Washington, DC:
Department of Veterans Affairs.
Office of the Inspector General and Department of Veterans Affairs. 1990. Audit of Veterans
Health Serices and Research Administration surgical complication reporting procedures.
Washington, DC: VA Office of the Inspector General.
———. 1991. Audit of VA’s control system for credentialing and priileging physicians. Wash-
ington, DC: VA Office of the Inspector General.
Oliver, A. 2007. The Veterans Health Administration: An American success story? The Mil-
bank Quarterly 85(1):5–35.
Oxford Analytica. 2007. VA could be model for health system. http://www.forbes.com/
2007/04/19/veterans-health-care-biz-cx_0420oxford.html (accessed April 20, 2007).
Page, L. 2005. Getting a handle on patient falls. www.matmanmag.com (accessed January
25, 2005).
Parrino, T. 2003. Information technology and primary care at the VA: Making a good thing
better. Forum October:1–2.
Pauly, M. V., D. J. Brailer, G. Kroch, O. Even-Shoshan, J. C. Hershey, and S. V. Williams.
1996. Measuring hospital outcomes from a buyer’s perspective. American Journal of
Medical Quality 11(3):112–122.
Penrod, J. D., T. Cortez, and C. A. Luhrs. 2007. Use of a report card to implement a network-
based palliative care program. Journal of Palliatie Medicine 10(4):858–860.
Perlin, J. B. 2006. Transformation of the U.S. Veterans Health Administration. Health Eco-
nomics, Policy and Law 1(2):99–105.
Perlin, J. B., R. M. Kolodner, and R. H. Roswell. 2004. The Veterans Health Administration:
Quality, value, accountability, and information as transforming strategies for patient-
centered care. American Journal of Managed Care 10(11 Pt. 2):828–836.
Petersen, L. A., S. L. Normand, J. Daley, and B. J. McNeil. 2000. Outcome of myocardial in-
farction in Veterans Health Administration patients as compared with Medicare patients.
New England Journal of Medicine 343(26):1934–1941.
Petersen, L. A., S. L. Normand, L. L. Leape, and B. J. McNeil. 2001. Comparison of use of
medications after acute myocardial infarction in the Veterans Health Administration and
Medicare. Circulation 104(24):2898–2904.
Petersen, L. A., S. L. Normand, L. L. Leape, and B. J. McNeil. 2003. Regionalization and the
underuse of angiography in the Veterans Affairs health care system as compared with a
fee-for-service system. New England Journal of Medicine 348(22):2209–2217.
OCR for page 233
2
TRANSFORMATION THROUGH SYSTEMS ENGINEERING
Piccard, A. 2005. U.S. veterans’ health care healed itself: So can our Medicare system. The
Globe and Mail, March 3.
Pizziferri, L., A. F. Kittler, L. A. Volk, M. M. Honour, S. Gupta, S. Wang, T. Wang, M.
Lippincott, Q. Li, and D. W. Bates. 2005. Primary care physician time utilization before
and after implementation of an electronic health record: A time-motion study. Journal
of Biomedical Informatics 38(3):176–188.
Popescu, I., M. S. Vaughan-Sarrazin, and G. E. Rosenthal. 2007. Declines in VHA mortality
in association with organizational efforts to improe care of patients with acute coro-
nary syndrome. Paper presented at Health Service Research and Development National
Meeting, Washington, DC.
Pryor, D. B., S. F. Tolchin, A. Hendrich, C. S. Thomas, and A. R. Tersigni. 2006. The clinical
transformation of Ascension Health: Eliminating all preventable injuries and deaths. Joint
Commission Journal of Quality and Patient Safety 32(6):299–308.
Quill, T. E. 2002. In-hospital end-of-life services: Is the cup 2/3 empty or 1/3 full? Medical
Care 40(1):4–6.
Rogers, W. H., L. E. Kazis, D. R. Miller, K. M. Skinner, J. A. Clark, A. Spiro, III, and R. G.
Fincke. 2004. Comparing the health status of VA and non-VA ambulatory patients: The
veterans’ health and medical outcomes studies. Journal of Ambulatory Care Management
27(3):249–262.
Rose, J. S., C. S. Thomas, A. Tersigni, J. B. Sexton, and D. Pryor. 2006. A leadership frame-
work for culture change in health care. Joint Commission Journal of Quality and Patient
Safety 32(8):433–442.
Roselle, G. A., L. H. Danko, S. M. Kralovic, L. A. Simbartl, and K. W. Kizer. 2002. National
Hepatitis C Surveillance Day in the Veterans Health Administration of the Department
of Veterans Affairs. Military Medicine 167(9):756–759.
Rosenheck, R. 2000. Primary care satellite clinics and improved access to general and mental
health services. Health Serices Research 35(4):777–790.
Rosenheck, R., and A. Fontana. 2001. Impact of efforts to reduce inpatient costs on clinical
effectiveness: Treatment of posttraumatic stress disorder in the Department of Veterans
Affairs. Medical Care 39(2):168–180.
Rosenheck, R., and K. W. Kizer. 1998. Hospitalizations and the homeless. New England
Journal of Medicine 339(16):1166; author reply, 1167.
Ross, J. S., S. Keyhani, P. S. Keenan, S. M. Bernheim, J. D. Penrod, K. S. Boockvar, A. D.
Federman, H. M. Krumholz, and A. L. Siu. 2008. Use of recommended ambulatory care
services: Is the Veterans Affairs quality gap narrowing? Archies of Internal Medicine
168(9):950–958.
Rubenstein, L. V., J. Lammers, E. M. Yano, M. Tabbarah, and A. S. Robbins. 1996a. Evalu- Evalu-
ation of the VA’s pilot program in institutional reorganization toward primary and
ambulatory care: Part II, A study of organizational stresses and dynamics. Academic
Medicine 71(7):784–792.
Rubenstein, L. V., E. M. Yano, A. Fink, A. B. Lanto, B. Simon, M. Graham, and A. S. Robbins.
1996b. Evaluation of the VA’s pilot program in institutional reorganization toward pri-
mary and ambulatory care: Part I, Changes in process and outcomes of care. Academic
Medicine 71(7):772–783.
Rundle, R. L. 2001. Oft-derided veterans health agency puts data online, saving time, lives.
Wall Street Journal, December 10.
Rutherford, G. W., T. R. Gerrity, K. W. Kizer, and J. R. Feussner. 1999. Research in the
Veterans Health Administration: The report of the Research Realignment Advisory Com-
mittee. Academic Medicine 74(7):773–781.
OCR for page 234
2 ENGINEERING A LEARNING HEALTHCARE SYSTEM
Sales, M. M., F. E. Cunningham, P. A. Glassman, M. A. Valentino, and C. B. Good. 2005.
Pharmacy benefits management in the Veterans Health Administration: 1995 to 2003.
American Journal of Managed Care 11(2):104–112.
Schall, M. W., T. Duffy, A. Krishnamurthy, O. Levesque, P. Mehta, M. Murray, R. Parlier,
R. Petzel, and J. Sanderson. 2004. Improving patient access to the Veterans Health
Administration’s primary care and specialty clinics. Joint Commission Journal on Quality
and Patient Safety 30(8):415–423.
Schuster, J. L. 1999. Addressing patients’ pain. Veterans Health Administration’s addition of
fifth vital sign may have far-reaching effects. The Washington Post, February 2:8.
Selim, A. J., L. E. Kazis, W. Rogers, S. Qian, J. A. Rothendler, A. Lee, X. S. Ren, S. C. Haffer,
R. Mardon, D. Miller, A. Spiro, III, B. J. Selim, and B. G. Fincke. 2006. Risk-adjusted
mortality as an indicator of outcomes: Comparison of the Medicare advantage program
with the Veterans’ Health Administration. Medical Care 44(4):359–365.
Shapiro, J. P. 1999. Doctoring a sickly system: Deadly medical mistakes are rampant. U.S.
News & World Report 127(23):60–61.
Singh, H., and J. Kalavar. 2004. Quality of care for hypertension and diabetes in federal-
versus commercial-managed care organizations. American Journal of Medical Quality
19(1):19–24.
Singh, J. A., S. J. Borowsky, S. Nugent, M. Murdoch, Y. Zhao, D. B. Nelson, R. Petzel, and
K. L. Nichol. 2005. Health-related quality of life, functional impairment, and healthcare
utilization by veterans: Veterans’ quality of life study. Journal of the American Geriatric
Society 53(1):108–113.
Skydell, B. 1998. Restructuring the VA health care system: Safety net, training, and other
considerations. Washington, DC: National Health Policy Forum.
Smith, C. B., R. L. Goldman, D. C. Martin, J. Williamson, C. Weir, C. Beauchamp, and M.
Ashcraft. 1996. Overutilization of acute-care beds in Veterans Affairs hospitals. Medical
Care 34(1):85–96.
Stalhandske, E., J. P. Bagian, and J. Gosbee. 2002. Department of Veterans Affairs patient
safety program. American Journal of Infection Control 30:296–302.
Stein, R. 2006. VA care is rated superior to that in private hospitals. The Washington
Post, January 20. www.washingtonpost.com/wp-dyn/content/artcle/2006/01/19/
AR2006011902936.html (accessed February 23, 2010).
Steiner, G. 1971. The state of welfare. Washington, DC: The Brookings Institution.
Stevens, D. P., K. W. Kizer, T. W. Elwood, and G. L. Warden. 1998. VA aligns health profes-
sions education with healthcare priorities. Journal of Allied Health 27(3):123–127.
Stevens, D. P., G. J. Holland, and K. W. Kizer. 2001. Results of a nationwide Veterans Affairs ini-
tiative to align graduate medical education and patient care. JAMA 286(9):1061–1066.
Stires, D. 2006 (May 15). How the VA healed itself. Fortune 153(9):130–136. http://money.
cnn.com/magazines/fortune/fortune_archive/2006/05/15/8376846/ (accessed February
23, 2010).
Thibodeau, N., J. H. Evans, N. J. Nagarajanh, and J. Whittle. 2007. Value creation in public
enterprises: An empirical analysis of coordinated organizational changes in the Veterans
Health Administration. The Accounting Reiew 82:483–520.
Thomas, E. J., D. M. Studdert, H. R. Burstin, E. J. Orav, T. Zeena, E. J. Williams, K. M.
Howard, P. C. Weiler, and T. A. Brennan. 2000. Incidence and types of adverse events
and negligent care in Utah and Colorado. Medical Care 38(3):261–271.
Tolchin, S., R. Brush, P. Lange, P. Bates, and J. J. Garbo. 2007. Eliminating preventable
death at Ascension Health. Joint Commission Journal of Quality and Patient Safety
33(3):145–154.
Trevelyan, E. W. 2002. The performance management system of the Veterans Health Admin-
istration. Cambridge, MA: Harvard School of Public Health.
OCR for page 235
2
TRANSFORMATION THROUGH SYSTEMS ENGINEERING
Tseng, C. L., J. D. Greenberg, D. Helmer, M. Rajan, A. Tiwari, D. Miller, S. Crystal, G.
Hawley, and L. Pogach. 2004. Dual-system utilization affects regional variation in
prevention quality indicators: The case of amputations among veterans with diabetes.
American Journal of Managed Care 10(11 Pt. 2):886–892.
U.S. Congress, House of Representatives, Committee on Government Operations. 1987.
Patients at risk: A study of deficiencies in the Veterans Administration quality assurance
program. Washington, DC: U.S. Government Printing Office.
U.S. Congress, House of Representatives, Committee on Veterans Affairs. 2001. Need to
consider VA’s role in strengthening federal preparedness. October 15. Washington, DC:
Government Accountability Office.
Versel, N. 2003. Wired and ready. Modern Physician August 1.
VHA (Veterans Health Administration). 1946 (January 30). Policy memorandum no. 2. Wash-
ington, DC: Department of Veterans Affairs.
———. 1967. Medical care of eterans. Washington, DC: Department of Veterans Affairs.
———. 1996a. VA innoations in ambulatory care. Washington, DC: Department of Veterans
Affairs.
———. 1996b (August 29). Directie 9-0. Roles and definitions for clinical practice guide-
lines and clinical pathways. Washington DC: Department of Veterans Affairs.
———. 1996c. VHA employee deelopment report: High performance deelopment model.
Washington, DC: Department of Veterans Affairs.
———. 1997a. Veterans equitable resource allocation system: Initial briefing booklet. Wash-
ington, DC: Department of Veterans Affairs.
———. 1997b. Veterans equitable resource allocation: Equity of funding and access to care
across networks. Washington, DC: Department of Veterans Affairs.
———. 1998. Veterans equitable resource allocation system. Washington, DC: Department
of Veterans Affairs.
Wahby, V. S., T. L. Garthwaite, and N. A. Thompson. 2000. The VA lessons learned project.
Focus on Patient Safety 3:1–2.
Waller, D. 2006 (September 4). How VA hospitals became the best. Time 168(10):36–37.
Ward, M. M., J. W. Yankey, T. E. Vaughn, B. J. Boots-Miller, S. D. Flach, K. F. Welke, J. F.
Pendergast, J. Perlin, and B. N. Doebbeling. 2004. Physician process and patient outcome
measures for diabetes care: Relationships to organizational characteristics. Medical Care
42(9):840–850.
Wasserman, J., J. Ringel, K. Ricci, J. Malkin, M. Schoenbaum, B. Wynn, J. Zwanziger, S.
Newberry, M. Suttorp, and A. Rastegar. 2001. An analysis of the Veterans Equitable
Resource Allocation (VERA) system. Santa Monica, CA: RAND Corporation.
———. 2003. An analysis of potential adjustments to the Veterans Equitable Resource Al-
location (VERA) system. Santa Monica, CA: RAND Corporation.
Weber, G. A., and L. F. Schmeckebiar. 1934. The Veterans’ Administration—Its history, actii-
ties and organization. Washington, DC: The Brookings Institution.
Whittington, K. T., and R. Briones. 2004. National prevalence and incidence study: 6-year
sequential acute care data. Adances in Skin and Wound Care 17:490–494.
Wilson, N. J., and K. W. Kizer. 1997. The VA health care system: An unrecognized national
safety net. Health Affairs (Millwood) 16(4):200–204.
———. 1998. Oncology management by the “New” Veterans Health Administration. Cancer
82(10 Suppl.):2003–2009.
Wooten, A. F. 2002. Access to mental health services at Veterans Affairs community-based
outpatient clinics. Military Medicine 167(5):424–426.
Wright, T., L. Jeffers, T. Mitchell, T. V. Holohan, and K. W. Kizer. 2000. At war with hepatitis
C, part 3: Managing chronic infection. Federal Practitioners (17):24–29.
OCR for page 236
2 ENGINEERING A LEARNING HEALTHCARE SYSTEM
Yaisawarng, S., and J. F. Burgess, Jr. 2006. Performance-based budgeting in the public sector:
An illustration from the VA health care system. Health Economics 15(3):295–310.
Yano, E. M., B. F. Simon, A. B. Lanto, and L. V. Rubenstein. 2007. The evolution of changes
in primary care delivery underlying the Veterans Health Administration’s quality trans-
formation. American Journal of Public Health 97(12):2151–2159.
Young, D. 2007. VA’s 10-year journey to one formulary concludes. American Journal of
Health-System Pharmacy 64(6):578, 580.
Young, G. J. 2000a. Managing organizational transformations: Lessons from the Veterans
Health Administration. California Management Reiew 43:66–82.
———. 2000b. Transforming goernment: The reitalization of the Veterans Health Admin-
istration. Arlington, VA: The PricewaterhouseCoopers Endowment for The Business of
Government.
Young, G. J., M. P. Charns, J. Daley, M. G. Forbes, W. Henderson, and S. F. Khuri. 1997. Best
practices for managing surgical services: The role of coordination. Health Care Manage-
ment Reiew 22(4):72–81.
Yu, W., A. Ravelo, T. H. Wagner, C. S. Phibbs, A. Bhandari, S. Chen, and P. G. Barnett. 2003.
Prevalence and costs of chronic conditions in the VA health care system. Medical Care
Research and Reiew 60(3 Suppl.):146S–167S.
