THE LEARNING HEALTH SYSTEM SERIES
ROUNDTABLE ON VALUE & SCIENCE-DRIVEN HEALTH CARE
ENGINEERING A LEARNING
HEALTHCARE SYSTEM
A Look at the Future
Workshop Summary
Claudia Grossmann, W. Alexander Goolsby, LeighAnne Olsen,
and J. Michael McGinnis
INSTITUTE OF MEDICINE AND
NATIONAL ACADEMY OF ENGINEERING
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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 Sciences, the National Academy of Engineering, and the Institute of Medicine.
This project was supported by the Agency for Healthcare Research and Quality, America’s Health Insurance Plans, AstraZeneca, Blue Shield of California Foundation, Burroughs Wellcome Fund, California Health Care Foundation, Centers for Medicare & Medicaid Services, Charina Endowment Fund, Department of Veterans Affairs, Food and Drug Administration, Johnson & Johnson, Gordon and Betty Moore Foundation, National Institutes of Health, the Peter G. Peterson Foundation, sanofi-aventis, and Stryker. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
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Copyright 2011 by the National Academy of Sciences. All rights reserved.
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Suggested citation: IOM (Institute of Medicine). 2011. Engineering a learning healthcare system: A look at the future: Workshop summary. Washington, DC: The National Academies Press.
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. Charles M. Vest 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. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
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This workshop summary is dedicated to Jerome H. Grossman, M.D., a long-time member, friend, and leader in the work of the National Academies. Bridging by nature and by profession, Jerry Grossman served as the liaison between the Institute of Medicine and the National Academy of Engineering and was a key motivator and intellectual compass for this workshop and its focus on bringing the insights of engineering principles to the benefit of the complex and vital activities of health care. He passed away suddenly on April 1, 2008.
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ROUNDTABLE ON VALUE & SCIENCE-DRIVEN HEALTH CARE*
Denis A. Cortese (Chair), Emeritus President and Chief Executive Officer, Mayo Clinic; Foundation Professor, ASU
Donald Berwick, Administrator, Centers for Medicare & Medicaid Services (ex officio)
David Blumenthal, National Coordinator, Office of the National Coordinator for Health IT (ex officio)
Bruce G. Bodaken, Chairman, President, and Chief Executive Officer, Blue Shield of California
David R. Brennan, Chief Executive Officer, AstraZeneca PLC
Paul Chew, Chief Science Officer and CMO, sanofi-aventis U.S., Inc.
Carolyn M. Clancy, Director, Agency for Healthcare Research and Quality (ex officio)
Michael J. Critelli, Former Executive Chairman, Pitney Bowes, Inc.
Helen Darling, President, National Business Group on Health
Thomas R. Frieden, Director, Centers for Disease Control and Prevention (designee: Chesley Richards) (ex officio)
Gary L. Gottlieb, President and CEO, Partners HealthCare System
James A. Guest, President, Consumers Union
George C. Halvorson, Chairman and Chief Executive Officer, Kaiser Permanente
Margaret A. Hamburg, Commissioner, Food and Drug Administration (ex officio)
Carmen Hooker Odom, President, Milbank Memorial Fund Board
Ardis Hoven, Board Chair, American Medical Association
Brent James, Chief Quality Officer and Executive Director, Institute for Health Care Delivery Research, Intermountain Healthcare
Michael M. E. Johns, Chancellor, Emory University
Craig Jones, Director, Vermont Blueprint for Health
Cato T. Laurencin, Vice President for Health Affairs, Dean of the School of Medicine, University of Connecticut
Stephen P. MacMillan, President and Chief Executive Officer, Stryker
Mark B. McClellan, Director, Engelberg Center for Healthcare Reform, The Brookings Institution
Sheri S. McCoy, Worldwide Chairman, Johnson & Johnson Pharmaceuticals Group
Elizabeth G. Nabel, President, Brigham and Women’s Hospital
*Formerly the Roundtable on Evidence-Based Medicine, Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.
Mary D. Naylor, Professor and Director of Center for Transitions in Health, University of Pennsylvania
Peter Neupert, Corporate Vice President, Health Solutions Group, Microsoft Corporation
William D. Novelli, Former CEO, AARP; Professor, Georgetown University
Jonathan B. Perlin, Chief Medical Officer and President, Clinical Services, HCA, Inc.
Robert A. Petzel, Under Secretary, Veterans Health Administration (ex officio)
Richard Platt, Professor and Chair, Harvard Medical School and Harvard Pilgrim Health Care
John C. Rother, Group Executive Officer, AARP
John W. Rowe, Professor, Mailman School of Public Health, Columbia University
Susan Shurin, Acting Director, National Heart, Lung, and Blood Institute (ex officio)
Mark D. Smith, President and CEO, California HealthCare Foundation
George P. Taylor, Assistant Secretary for Health Affairs (Acting), Department of Defense (designee: Michael Dinneen) (ex officio)
Reed D. Tuckson, Executive VP and Chief of Medical Affairs, UnitedHealth Group
Frances M. Visco, President, National Breast Cancer Coalition
Workshop Planning Committee
William B. Rouse (Chair), Georgia Institute of Technology
Jerome H. Grossman, Harvard University
Brent C. James, Intermountain Healthcare, Inc.
Helen S. Kim, Gordon and Betty Moore Foundation
Cato T. Laurencin, University of Virginia
The Honorable Paul H. O’Neill, Value Capture, LLC
Roundtable and National Academy of Engineering Staff
Christie Bell, Financial Associate
Katharine Bothner, Senior Program Assistant (through July 2008)
Patrick Burke, Financial Associate (through December 2009)
Andrea Cohen, Financial Associate (through December 2008)
W. Alexander Goolsby, Program Officer (through September 2008)
Claudia Grossmann, Program Officer
Kiran Gupta, Mirzayan Fellow (through May 2009)
J. Michael McGinnis, Senior Scholar and Executive Director
LeighAnne Olsen, Program Officer (through July 2010)
Daniel O’Neill, Research Associate (through January 2009)
Stephen Pelletier, Consultant
Laura Penny, Consultant
Brian Powers, Senior Program Assistant
Proctor Reid, Director, National Academy of Engineering Program Office
Valerie Rohrbach, Program Assistant
Julia Sanders, Program Assistant
Robert Saunders, Program Officer
Ruth Strommen, Intern (through August 2009)
Leigh Stuckhardt, Program Associate
Kate Vasconi, Senior Program Assistant (through January 2011)
Pierre L. Young, Program Officer (through May 2010)
Catherine Zweig, Senior Program Assistant (through June 2010)
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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’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its 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 their review of this report:
Arthur Garson, University of Virginia
C. David Naylor, University of Toronto
David Pryor, Ascension Health
Ronald Rardin, University of Arkansas
Harold W. Sorenson, University of California, San Diego
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Patricia F. Brennan, University of Wisconsin, Madison. Appointed by the Institute of Medicine, she 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.
Institute of Medicine
Roundtable on Value & Science-Driven Health Care
Charter and Vision Statement
The Institute of Medicine’s Roundtable on Value & Science-Driven Health Care has been convened to help transform the way evidence on clinical effectiveness is generated and used to improve health and health care. Participants have set a goal that, by the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence. Roundtable members will work with their colleagues to identify the issues not being adequately addressed, the nature of the barriers and possible solutions, and the priorities for action, and will marshal the resources of the sectors represented on the Roundtable to work for sustained public–private cooperation for change.
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The Institute of Medicine’s Roundtable on Value & Science-Driven Health Care has been convened to help transform the way evidence on clinical effectiveness is generated and used to improve health and health care. We seek the development of a learning health system that is designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care.
Vision: Our vision is for a healthcare system that draws on the best evidence to provide the care most appropriate to each patient, emphasizes prevention and health promotion, delivers the most value, adds to learning throughout the delivery of care, and leads to improvements in the nation’s health.
Goal: By the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence. We feel that this presents a tangible focus for progress toward our vision, that Americans ought to expect at least this level of performance, that it should be feasible with existing resources and emerging tools, and that measures can be developed to track and stimulate progress.
Context: As unprecedented developments in the diagnosis, treatment, and long-term management of disease bring Americans closer than ever to the promise of personalized health care, we are faced with similarly unprecedented challenges to identify and deliver the care most appropriate for individual needs and conditions. Care that is important is often not delivered. Care that is delivered is often not important. In part, this is due to our failure to apply the evidence we have about the medical care that is most effective—a failure related to shortfalls in provider knowledge and accountability, inadequate care coordination and support, lack of insurance, poorly aligned payment incen-
tives, and misplaced patient expectations. Increasingly, it is also a result of our limited capacity for timely generation of evidence on the relative effectiveness, efficiency, and safety of available and emerging interventions. Improving the value of the return on our healthcare investment is a vital imperative that will require much greater capacity to evaluate high-priority clinical interventions, stronger links between clinical research and practice, and reorientation of the incentives to apply new insights. We must quicken our efforts to position evidence development and application as natural outgrowths of clinical care—to foster health care that learns.
Approach: The IOM Roundtable on Value & Science-Driven Health Care serves as a forum to facilitate the collaborative assessment and action around issues central to achieving the vision and goal stated. The challenges are myriad and include issues that must be addressed to improve evidence development, evidence application, and the capacity to advance progress on both dimensions. To address these challenges, as leaders in their fields, Roundtable members will work with their colleagues to identify the issues not being adequately addressed, the nature of the barriers and possible solutions, and the priorities for action, and will marshal the resources of the sectors represented on the Roundtable to work for sustained public–private cooperation for change.
Activities include collaborative exploration of new and expedited approaches to assessing the effectiveness of diagnostic and treatment interventions, better use of the patient care experience to generate evidence on effectiveness, identification of assessment priorities, and communication strategies to enhance provider and patient understanding and support for interventions proven to work best and deliver value in health care.
Core concepts and principles: For the purpose of the Roundtable activities, we define evidence-based medicine broadly to mean that, to the greatest extent possible, the decisions that shape the health and health care of Americans—by patients, providers, payers, and policy makers alike—will be grounded on a reliable evidence base, will account appropriately for individual variation in patient needs, and will support the generation of new insights on clinical effectiveness. Evidence is generally considered to be information from clinical experience that has met some established test of validity, and the appropriate standard is determined according to the requirements of the intervention and clinical circumstance. Processes that involve the development and use of evidence should be accessible and transparent to all stakeholders.
A common commitment to certain principles and priorities guides the activities of the Roundtable and its members, including the commitment to the right health care for each person; putting the best evidence into practice; establishing the effectiveness, efficiency, and safety of medical care delivered; building constant measurement into our healthcare investments; the establishment building constant measurement into our healthcare investments; the establishment of healthcare data as a public good; shared responsibility distributed equitably across stakeholders, both public and private; collaborative stakeholder involvement in priority setting; transparency in the execution of activities and reporting of results; and subjugation of individual political or stakeholder perspectives in favor of the common good.
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Foreword
The nation turns to the National Academies for sound advice on issues related to science, technology, and health. Accordingly, the Institute of Medicine (IOM), as the healthcare arm of the National Academies, is the advisor to the nation on matters of health and medicine. Similarly, the National Academy of Engineering (NAE) serves as the nation’s preeminent advisor on matters of engineering and technology. Improving our nation’s healthcare system is a challenge which, because of its scale and complexity, requires a creative approach and input from many different fields of expertise.
This publication summarizes presentations and discussions at Engineering a Learning Healthcare System: A Look at the Future, a meeting sponsored by the IOM’s Roundtable on Value & Science-Driven Health Care (formerly the Roundtable on Evidence-Based Medicine) in cooperation with the NAE. The IOM Roundtable provides a neutral forum for engaging in key health issues through collaborative discussion, with a focus on improving evidence generation and its application in health care. The Roundtable membership has developed the concept of a learning health system with the stated goal that, by the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence.
Building on previous work done by the IOM and NAE in this area, including production of the report Building a Better Delivery System: A New Engineering/Health Care Partnership, the workshop convened leading engineering practitioners, health professionals, and scholars to explore how the field might learn from and apply systems engineering principles in the
design of a learning healthcare system, one that embeds real-time learning for continuous improvement in the quality, safety, and efficiency of care, while generating new knowledge and evidence about what works best.
The following pages summarize the workshop discussions during which participants explored barriers to care delivery, lessons in transformation from other organizations, and harnessing the technical talent of the engineering field to inform the development of necessary decision support, feedback mechanisms, and infrastructure. Throughout the workshop, participants emphasized that health care is substantially underperforming on many dimensions and that significant opportunity remains for the system to learn and to develop into one that yields the best results and the highest value. Among the most important of these opportunities are the realignment of incentives to compel continuous improvement, fostering a leadership culture that reinforces teamwork, enhancing opportunities for sustained learning and research from different perspectives, accounting for human error but requiring perfection in system performance, and, most importantly, centering the system’s processes on the major consideration—the patient experience. The engagement of diverse perspectives, including those of engineering and healthcare professionals, will be essential to designing such a system.
We would like to offer our thanks to the Roundtable members for the leadership that they bring to these important issues; to the members of the workshop planning committee, especially its chair, NAE member William B. Rouse, for the invaluable insight and guidance provided; to the Roundtable and NAE staff for their skill and dedication in coordinating and facilitating the activities; and, importantly, to the sponsors who make this work possible: Agency for Healthcare Research and Quality, America’s Health Insurance Plans, AstraZeneca, Blue Shield of California Foundation, Burroughs Wellcome Fund, California Health Care Foundation, Centers for Medicare & Medicaid Services, Charina Endowment Fund, Department of Veterans Affairs, Food and Drug Administration, Johnson & Johnson, Gordon and Betty Moore Foundation, National Institutes of Health, the Peter G. Peterson Foundation, sanofi-aventis, and Stryker.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
Charles M. Vest, Ph.D.
President, National Academy of Engineering
Preface
Engineering a Learning Healthcare System: A Look at the Future focuses on current major healthcare system challenges and what the field of engineering has to offer in the redesign of the system toward one of continuous improvement—a learning healthcare system. The Institute of Medicine’s (IOM’s) Roundtable on Value & Science-Driven Health Care (formerly the Roundtable on Evidence-Based Medicine) envisions that such a system will be the product of collaboration across major healthcare stakeholders and could draw significant benefits from insights from the field of engineering. Thus this workshop is a product of a collaboration between the IOM and the National Academy of Engineering (NAE) and investigates the interfaces and synergies between the engineering and medical sciences. The workshop convened experts to identify and discuss issues related to healthcare system improvement and how lessons learned from engineering might inform current thinking about the different components of healthcare delivery, from research and knowledge generation to clinical care at the bedside.
The Roundtable has outlined important crosscutting issues in healthcare system transformation through the Learning Health System set of workshops. These provide a framework for working toward the Roundtable’s goal that by the year 2020, 90 percent of clinical decisions will reflect and be supported by accurate, timely, and up-to-date evidence. A reworking of the current healthcare delivery system to one that ensures that the right patient receives the right care at the right time is essential to this transformation, and insights from the systems engineering field, such as those discussed during these 2 days, will be crucial in making progress toward that goal.
Workshop presentations and discussions surveyed the potential for greater interaction between the disciplines of medicine and engineering. Presentations covered various opportunities for learning on the part of health care as well as teaching opportunities for engineering fields. Participants heard accounts of how engineering engages complex systems, such as health care; case studies of how systems engineering has transformed other industries and sectors; and ways in which the application of engineering principles can foster changes toward continuous learning in health care. Presentations and discussions also identified current healthcare system complexities, impediments, and failures; identified opportunities for capturing more value in health care; and considered ideas about how to initiate the necessary systems changes and align policies and leadership opportunities with them.
Numerous themes emerged over the course of the 2-day workshop, and they centered on the issue of how to transform the current healthcare system into one that learns throughout the continuum of care. These themes included the need to center the system’s processes on the right target—the patient experience, the notion that system excellence is created by the reliable delivery of established best practices, the idea that complexity compels reasoned allowance for tailored adjustments, the need to emphasize interdependence of different components and to address the interfaces of the different components, the importance of communication through teamwork, the need for cross-checking, transparency and feedback as engines for system improvement, the acknowledgment and management of human error, the alignment of rewards to foster continuous improvement, the enhancement of opportunities for sustained learning and research from different perspectives, and the need to foster a leadership culture that reinforces teamwork and results.
In addition to these themes, a number of cross-sector follow-up actions were identified that may be pursued by the Roundtable. These actions may include further collaboration between the IOM Roundtable and the NAE to clarify terminology in order to prompt healthcare professionals to draw more naturally upon relevant and helpful engineering principles for system improvement. Actions may also include greater focus on identifying and disseminating best practices in order to improve patient outcomes; exploring the possibility of changing the education of health professionals to advance skills in knowledge navigation, teamwork, patient–provider partnerships, and process awareness; advancing the notion of paying for value; and exploring the elements of inefficiency in health care and developing a science of waste assessment and how to mobilize resources to eliminate it.
We would like to acknowledge those individuals and organizations that donated their valuable time toward the development of this workshop summary. In particular, we acknowledge the contributors to this volume
for their presence at the workshop and their efforts to further develop their presentations into the manuscripts contained in this publication. We would also like to acknowledge those who provided counsel by serving on the planning committee for this workshop, including William B. Rouse (Chair) (Georgia Institute of Technology), the late Jerome H. Grossman (Harvard University), Brent C. James (Intermountain Health Care, Inc.), Helen S. Kim (Gordon and Betty Moore Foundation), Cato T. Laurencin (University of Virginia), and the Honorable Paul H. O’Neill (Value Capture, LLC).* Although not a formal member of the planning committee, Proctor Reid of the NAE contributed to the planning and execution of the workshop. Roundtable staff, including Katharine Bothner, Kiran Gupta, W. Alexander Goolsby, LeighAnne Olsen, Daniel O’Neill, Ruth Strommen, and Catherine Zweig, helped to translate the workshop proceedings and discussion into this workshop summary. Stephen Pelletier also contributed substantially to publication development. We would also like to thank Lara Andersen, Greta Gorman, Jackie Turner, Michele de la Menardiere, Vilija Teel, and Bronwyn Schrecker for helping to coordinate the various aspects of review, production, and publication. This book is dedicated to the memory of Jerry Grossman, who was a stellar planning committee member, with lifelong dedication to and leadership in the bridging of medicine and engineering.
Engineering a Learning Healthcare System: A Look at the Future offers important insights to the field of medicine from the field of engineering concerning the development of a learning healthcare system. It also provides an example of how collaboration across diverse disciplines can lead to vast improvements in healthcare delivery. The hope is that, by making major stakeholders more aware of the importance of the delivery system, it will prompt the development of strategies for applying the insights from this workshop to health system improvements and that these strategies will ultimately transform the current healthcare system into one that smoothly operates to both generate and apply evidence to improve the health of Americans.
Denis A. Cortese
Chair, Roundtable on Value & Science-Driven Health Care
J. Michael McGinnis
Executive Director, Roundtable on Value & Science-
Driven Health Care
* Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.
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Contents
1 ENGINEERING A LEARNING HEALTHCARE SYSTEM
Learning Opportunities for Health Care
Teaching Opportunities from Engineering: Learning by Example
Observations on Initiating Systems Change in Health Care: Challenges to Overcome
2 ENGAGING COMPLEX SYSTEMS THROUGH ENGINEERING CONCEPTS
Can We Afford Technological Innovation in Health Care?
Operations Research for the Operating Room and Much More!
On Designing an Integrated and Adaptive Healthcare System
James M. Tien and Pascal J. Goldschmidt
Engaging Complex Systems Through Engineering Concepts: A Methodology for Engineering Complex Systems
3 HEALTHCARE SYSTEM COMPLEXITIES, IMPEDIMENTS, AND FAILURES
Healthcare Culture in the United States
Diagnostic and Treatment Technologies
A Look at the Future of Clinical Data Systems and Clinical Decision Support
Transforming Hospitals Through Reform of the Care Process
A Perspective on Patient-Centric, Feed-Forward “Collaboratories,”
Eugene C. Nelson, Elliott S. Fisher, and James N. Weinstein
4 CASE STUDIES IN TRANSFORMATION THROUGH SYSTEMS ENGINEERING
Alcoa’s Reorientation: Streamlining the Financial Close Process
Veterans Health Affairs: Transforming the Veterans Health Administration
The Clinical Transformation of Ascension Health
5 FOSTERING SYSTEMS CHANGE TO DRIVE CONTINUOUS LEARNING IN HEALTH CARE
Chasing the Rabbit: What Healthcare Organizations Can Learn from the World’s Greatest Organizations
A Learning System for Implementation of Electronic Health Records
David C. Classen, Jane B. Metzger, and Emily Welebob
Breakout Session: Capturing More Value in Health Care
6 NEXT STEPS: ALIGNING POLICIES WITH LEADERSHIP OPPORTUNITIES
Process Standardization and Improvement
Leveraging People for Healthcare Improvement
Recurring Themes for Roundtable Attention
Areas for Innovation and Collaborative Action
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