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9 Creating a New Culture of Care In July 2000, Mr. Q., a 50-year-old man, was admitted to a local hospital for surgery on his right ankle to correct hemophilia-related arthritis. Arriving at the surgical check-in center at 6:00 AM, Mr. and Mrs. Q. found the waiting room filled with more than 100 other patients and family members, all attempting to reach the one staff member handling the check-in process. After checking in, they found that the hematology nurse had not arrived; instead, Mr. and Mrs. Q. were responsible for ensuring that Mr. Q. received the requisite blood clotting factor before undergoing anesthesia. At 7:20 AM, Mr. Q. was wheeled to his operating room, while Mrs. Q. proceeded to the waiting room. Mr. Q’s surgery was finished at 9:30 AM, but it took until 3:30 PM for him to be assigned a room in the hospital. Because of unanticipated bed demands, he was not assigned to the orthopedics ward, but to another ward that had space. Yet, when Mrs. Q. proceeded to the designated room, she found it empty and had to search the ward to find her husband’s room. Mr. Q. required regular medication to control his pain, and although he requested additional medication to control his pain on his first night, he was forced to wait until the next morning for a resident to fill his request. When Mr. Q. was ready to be discharged, Mrs. Q had to take the initiative to ensure that her husband had the right prescriptions and could retain a wheel- chair. While Mr. and Mrs. Q. both felt the doctors who provided Mr. Q.’s care were excellent, they agreed that the only efficiency 255

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256 BEST CARE AT LOWER COST they experienced throughout this ordeal was receipt of Mr. Q.’s bill (Cleary, 2003). As with many other aspects of the health care enterprise, there is great diversity in the organizations that deliver care, from small group practices, to independent practice associations, to individual hospitals, to large inte- grated delivery systems. Each brings different strengths and weaknesses, and each plays a significant and important role in delivering high-quality, high-value care. Because of their size and care capacities, however, health care organizations can set an example for improvement in the health care system by using new practice methods, setting standards, and sharing re- sources and information with smaller practices. The role of health care organizations is especially important in a learn- ing health care system, because organizational factors have been shown to have an impact on care quality and patient outcomes. One study found that high-performing organizations in heart attack care, as measured by improved mortality rates, generally had features such as good communi- cation and coordination, shared values and culture, and experience with problem solving and learning (Curry et al., 2011). Similarly, another study found that staff engagement and hospital leadership influenced the success of a program designed to prevent hospital-acquired infections (Sinkowitz- Cochran et al., 2011). And numerous studies have shown that engagement of hospital boards and other leaders in quality improvement has a signifi- cant effect on quality and outcomes (IHI, 2007; Jiang et al., 2008, 2009; Vaughn et al., 2006). Given the importance of health care organizations to the broader learn- ing enterprise and the impact of organizational factors on care, it is critical that health care organizations increase their learning capacity. A learning health care organization harnesses its internal wisdom—staff expertise, patient feedback, financial data, and other knowledge—to improve its operations. It engages in a continuous feedback loop of monitoring in- ternal practices, assessing what can be improved, testing and adjusting in response to data, and implementing its findings both locally and across the organization. Although the particular policy elements that will encour- age well-led, continuously learning organizations while discouraging those that are poorly run are unknown, it is evident that organizations engaged in continuous improvement efforts are more nimble and better suited to weathering changes in the market and in the practice of medicine. Simply put, an organization that promotes continuous learning and improvement is one that “make[s] the right thing easy to do” (Halvorson, 2009). Its environment reduces stress on front-line staff, improves job satisfaction, and prevents staff burnout (Boan and Funderburk, 2003). Its

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CREATING A NEW CULTURE OF CARE 257 environment simplifies procedures and workflows so that providers can operate at peak performance to care for patients, and embraces cognitive supports such as checklists and reminders that make providers’ jobs easier. In this environment, internal processes and procedures align with the orga- nization’s aim or mission and with leaders’ vision and actions. Many institutions still struggle to implement sustainable, transfor- mational system changes (Leape and Berwick, 2005; Lukas et al., 2007; Wachter, 2010). They face both external obstacles, such as financial in- centives that emphasize quantity of services over quality, and internal challenges to achieving improvement. To overcome these obstacles and challenges and become entities that continuously learn and improve, health care organizations must adopt systematic problem-solving techniques, build operational models that encourage and reward sustained quality, become transparent on cost and outcomes, and foster leadership and a culture that support improvement efforts. Finally, the lessons learned by pioneer organi- zations must be diffused more broadly so the whole system can benefit. This chapter examines the common elements necessary to build organizations that continuously learn and improve, including organizational leadership for care transformation; teaming, partnership, and continuity; consistency, reliability, and transparency of results; and alignment of incentives within and across organizations. The chapter ends with recommendations for achieving the vision of a new culture of care. ORGANIZATIONAL LEADERSHIP FOR CARE TRANSFORMATION An organization’s leadership sets the tone for the entire system. Lead- ers’ visibility makes them uniquely positioned to define the organization’s quality goals, communicate these goals and gain acceptance from staff, make learning a priority, and marshal the resources necessary for the vision to become reality. Furthermore, leadership has the ability to align activities to ensure that individuals have the necessary resources, time, and energy to accomplish the organization’s goals. By defining and visibly emphasizing a vision that encourages and rewards learning and improvement, leadership at all levels of the organization prompt its disparate elements to work to- gether toward a common end. Leadership at All Levels If the aim is to build an organization that maximizes effectiveness and efficiency through continuous learning, an effective leader is one that defines continuous learning and improvement as central to the organiza- tion’s overall mission (Boan and Funderburk, 2003; Denison and Mishrah, 1995; Fisher and Alford, 2000; Garvin et al., 2008). Leaders at all levels

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258 BEST CARE AT LOWER COST of the organization, from the chief executive officer (CEO) and the board to middle managers and front-line staff, have a role to play in translating the organization’s learning aim to practice. Beyond orienting the organiza- tion’s staff toward a common goal, a leader’s definition and communication of this mission can have a positive impact on the quality of care delivered (IOM, 2001; Weiner et al., 1996, 1997). A survey of hospital leaders found that those hospitals whose leader was heavily engaged in quality improve- ment efforts tended to provide higher-quality care (Vaughn et al., 2006). Another study showed that hospitals with better outcomes from their heart attack care tended to have senior management involvement (Curry et al., 2011). At the helm of the organization, effective CEOs disseminate their vi- sion so that all employees can see their role in the overall mission (Ford and Angermeier, 2008; IOM, 2001). Executive leadership can align inter- nal policies with this mission and marshal the resources necessary to drive continuous improvement efforts. Other strategies employed by successful CEOs include establishing compacts that outline what clinicians and the organization can expect of one another, embodying a sense of realistic optimism that encourages the organization to pursue its aim at the highest level while acknowledging the likely challenges, harnessing “creative ten- sion” to highlight the difference between their vision and the current state of the organization, directing the organization away from the status quo, and directing the organization toward learning by making the benefits of a learning system attractive (IHI, 2006; Menkes, 2011; Senge, 1990; Silversin and Kornacki, 2000). As highly visible members of the organization’s leadership team, CEOs and other executives are uniquely positioned to serve as role models who embody the organization’s aim. Executives’ high visibility has even led to the development of formal methods of “rounding to influence,” where lead- ers are seen engaging with staff and asking specific questions to monitor and evaluate the implementation of specific patient safety initiatives (Reinertsen and Johnson, 2010). Executives also can mentor internal networks of the front-line leaders who are the key changemakers in the organization and provide the resources, support, and incentives these leaders need to drive change. In this way, senior leaders can acknowledge that their role is to set the stage for continuous learning and step back while other organizational leaders—clinical leaders and other front-line providers—work in teams to accomplish the organization’s goals (Carroll and Edmondson, 2002; Gov- ernment Accountability Office, 2011). Thus while senior leadership is responsible for setting and advancing the aim of the organization, a continuously learning organization also re- quires leadership on the part of the managers and front-line workers who translate that aim into practice. Middle managers play a crucial role in

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CREATING A NEW CULTURE OF CARE 259 on-the-ground, day-to-day management of a hospital’s departments and services—the units that, collectively, make up the organization. These man- agers form the critical bridge between senior leaders and front-line staff and bear primary responsibility for translating executives’ vision into action by aligning department goals with the strategic goals of the organization (Federico and Bonacum, 2010). Unit leaders therefore must challenge the prevailing mental models—deep-seated assumptions and ways of thinking about problems—and refocus attention on the barriers to learning and improvement (Senge, 1990). To this end, middle managers must be able to set priorities for improvement efforts, establish and implement continuous learning cycles, and generate enthusiasm for continuous learning among staff by fostering a culture of respect that empowers staff to undertake improvements. Accomplishing these goals often requires understanding continuous improvement methods, the design of learning cycles, and improvement met- rics and measurement. Leaders at all levels need to practice evidence-based management, which calls for demanding data from continuous learning cycles, logically interpreting these data to effect changes, and encouraging experimentation (Pfeffer and Sutton, 2006). Finally, leaders must be adept at coaching and empowering staff to take on continuous improvement proj- ects successfully (Federico and Bonacum, 2010; Pfeffer and Sutton, 2006). Furthermore, these changes require both technical and adaptive leadership styles to manage the different types of challenges facing health care organi- zations (Heifetz and Laurie, 2001). To ensure that clinical leaders have the tools needed to support large-scale improvement, additional opportunities are needed to educate health care workers about organizational manage- ment, systematic problem-solving techniques, and process improvement. Initiatives such as the Institute for Healthcare Improvement (IHI) Open School have been developed to address these needs, and the Accreditation Council for Graduate Medical Education (ACGME) recently announced a shift to an outcomes-based accreditation system encompassing core compe- tencies that include practice-based learning and improvement and systems- based practice (Nasca et al., 2012). However, additional efforts are needed to cultivate the leadership, process improvement, and problem-solving skills necessary for the transition to a continuously learning health care system. Box 9-1 presents an example of leadership commitment to creating a learn- ing organization. Governance Like CEOs and other executives, hospital boards play an important role in guiding the organization toward continuous learning and improvement. Under federal regulations and accreditation standards, hospital boards are

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260 BEST CARE AT LOWER COST BOX 9-1 An Example of Leadership Commitment to Creating a Learning Organization In 2004, ThedaCare, a community health system in Wisconsin, first began the process of incorporating lean engineering principles for continuous improve- ment across its entire system to increase productivity and improve outcomes. As a first step, a project team representing a range of ThedaCare operations managers was assembled to identify the core components and goals of an ideal management system. Most of the managers highlighted the need for a structured management reporting system and clear performance expectations if improvements were to be realized. The organization’s leadership thus became aware that the lack of a distinct management system was the direct cause of the hospital’s inability to sustain process improvements and productivity gains. S ­ imultaneously, leaders realized that they could not simply transplant a pre- defined system into their operations, and the focus thus shifted to developing standard strategies for identifying and solving problems, including such tasks as preparing daily stat sheets to keep track of ongoing safety and quality defects, managing daily huddles, teaching, coaching and mentoring, and collecting data for monthly performance review meetings. Two pilot sites—Appleton Medical Center and Theda Clark Medical Center— applied these lessons to their operations. By doing so, the Appleton Medical Center’s medical/surgical unit was able to increase its productivity by 11 percent between 2008 and 2009, and the radiation oncology unit achieved a productivity increase of 5 percent. In addition to productivity, patient safety improved—the Appleton inpatient oncology unit and the Theda Clark neuro/surgical unit were able to reduce falls by 70 percent and 35 percent, respectively. Similar successes were seen with other follow-up programs, which has encouraged further work to eliminate wasteful processes and process variations (Barnas, 2011). accountable for the quality of care provided by their organization (Belmont et al., 2011). They also are responsible not only for ensuring the organiza- tion’s financial health and reputation, but also for overseeing its executives and shaping the organization’s mission (Conway, 2008). Studies have demonstrated that greater board involvement in the orga- nization’s activities is associated with improved quality of care and patient health outcomes. For instance, when boards spend time examining health care quality issues, set a quality agenda, formally monitor quality perfor- mance metrics, and reward executive leadership on the basis of measured progress toward quality and safety goals, better outcomes tend to result (IHI, 2007; Jiang et al., 2009; Vaughn et al., 2006). One survey found that hospitals governed by boards with a committee dedicated to quality were

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CREATING A NEW CULTURE OF CARE 261 associated with more than 25 percent lower risk-adjusted mortality rates for three common medical conditions (Jiang et al., 2008). Interventions that boards can undertake to improve quality and safety include setting goals for improving performance, gathering qualitative and quantitative data to shed light on current practices, establishing and moni- toring system measures, focusing on the hospital’s culture, learning from other high-performing boards, and establishing accountability measures for the board and hospital executives (Conway, 2008; Conway et al., 2011). If implemented, these system-based practices can provide boards with the capability not only to meet regulatory standards in terms of care quality and public reporting, but also to accomplish the broader aim of steering their organization toward continuous learning and improvement. TEAMING, PARTNERSHIP, AND CONTINUITY If leadership provides the top-down mission of an organization, the organization’s culture represents the social scaffolding that empowers sys- tem transformation. Simply defined, organizational culture is the pattern of prevailing attitudes, beliefs, and assumptions among leaders and staff (Parmelli et al., 2011; Schein, 2004). Organizational culture can foster strong communication and coordination among providers, provide the kind of psychological safety that encourages the reporting of errors, and support innovation and creativity. An organization’s underlying culture therefore is fundamental to the implementation and sustainability of its learning and improvement initiatives (Garvin et al., 2008; Klein and Sorra, 1996). Several examples demonstrate the way in which an organization’s cul- ture affects care quality and patient outcomes. A study of hospitals ranked in the top 5 percent for heart attack outcomes found that those hospitals had cultures that shared a commitment to organizational learning, in- novation, creativity, and trial and error and had nonpunitive approaches to problem solving (see Box 9-2) (Curry et al., 2011). Other studies have found that cultural factors, such as empowering all members of the team to speak up when they see problems and placing priority on patient safety, are critical to reducing catheter-related blood stream infections in intensive care units (Pronovost et al., 2006a,b; Vigorito et al., 2011). Still other stud- ies have linked an organization’s patient safety culture with lower rates of in-hospital complications and adverse events (Mardon et al., 2010). A first step toward improving an organization’s culture is to measure it. A variety of instruments exist with which to measure different aspects of culture, including the Veterans Health Administration Patient Safety Culture Questionnaire and the Agency for Healthcare Research and Qual- ity’s (AHRQ’s) surveys on patient safety. The appropriate instrument for a given set of circumstances depends on the goals of the organization and the

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262 BEST CARE AT LOWER COST BOX 9-2 Nonpunitive Reporting as a Tool for Culture Change In 1995, two incidences of chemotherapy overdose occurred at Dana-Farber Cancer Institute, spurring a period of self-assessment characterized by a culture of blame. The errors led to low morale among the staff, a loss of trust among patients and their families, the loss of deemed status from Medicare, and the designation of conditional accreditation by the Joint Commission. After these incidents, Dana-Farber endeavored to investigate how the errors occurred. Leaders engaged the staff to gain an understanding of the organiza- tion’s approach to reporting and responding to errors, finding that the Institute had a culture in which the response to errors was disciplining staff. At the same time, system analyses were not conducted to investigate the root cause of those errors. As a result of these findings, leaders gathered to develop a set of principles that would define a fair and just culture. The principles centered on the belief that staff should feel safe in talking about mistakes and noted the core values of respect, impact, excellence, and discovery. They also acknowledged the difference be- tween individual accountability and system failures and highlighted Dana-Farber’s responsibility to ensure the competency of its staff. As a result of these efforts, managers now use a systems approach to investigate errors before disciplining staff, and staff surveys indicate improved perceptions of respect among clinical and nonclinical staff members. SOURCE: Connor et al., 2007. elements of culture it wishes to modify (AHRQ, 2010; Colla et al., 2005; Scott et al., 2003). Following measurement, a variety of interventions— many of which were developed outside of the health care enterprise—can be undertaken to change the organization’s culture to support high perfor- mance, although questions remain about which intervention is most effec- tive for a given health care organization (Parmelli et al., 2011). A culture of teamwork is fundamental to building a learning organi- zation and ensuring the continuity of care that yields better outcomes for patients. Initiatives that promote teamwork have been found to correlate positively with quality of care. In a large, multifacility integrated health care system, an intervention that focused on teamwork training, coaching, and communication skills saw an 18 percent reduction in annual mortality among participating facilities, with adverse events continuing to decrease, versus only a 7 percent reduction among nonparticipating facilities (Neily et al., 2010, 2011). In another initiative, implementing collaborative care protocols with a care team resulted in a 34 percent increase in patient satisfaction, 32 percent lower average costs per case compared with units

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CREATING A NEW CULTURE OF CARE 263 not participating in the collaborative care process, and a 30 percentage point improvement in adherence to guidelines on door-to-balloon times (Toussaint, 2009). Alternatively, failure to provide this type of team envi- ronment can have real negative consequences for patients, because adverse events often occur when health care professionals are afraid to speak up. In one study, 58 percent of nurses surveyed said a safety tool warned them of a problem, but they felt unsafe in speaking up or were unable to get the attention of their clinical colleagues (Maxfield et al., 2005). One challenge to promoting partnership across disciplines is that it re- quires providers to shed elements of their traditional roles in favor of new roles as members of a care team. Unfortunately, the increased specialization of health care professionals has led to a situation in which practitioners receive little training in coordinating across specialties to manage care de- livery (IOM, 2001). Clear lines of communication may help break down barriers between units, as well as between front-line staff and managers. One tool for building improved communication is promoting a common language and terminology within the organization. Other important fac- tors for successful teams include an environment of psychological safety that allows all team members to speak up and participate, effective conflict management processes, and leadership that effectively frames the quality challenges the team will address (Edmondson et al., 2001; IOM, 2001). CONSISTENCY, RELIABILITY, AND TRANSPARENCY OF RESULTS Although supportive leadership and culture are necessary elements for an organization to undertake continuous learning, these elements alone are not sufficient to create sustainable, transformational change. Continu- ous learning cannot proceed without concrete learning processes—that is, mechanisms that help the organization continuously capture knowledge and implement improvements (Pisano et al., 2001). These mechanisms can take many forms and may even be borrowed from leaders in other industries, but they share some essential elements: conducting systematic problem solving and experimentation, transferring knowledge throughout the organization, learning from past experience and from others, and using internal transparency as a tool to motivate further improvements (Garvin, 1993; Garvin et al., 2008; Young et al., 2004). Engineering of Reliable Performance As noted above, to learn and improve continuously, organizations must undertake problem solving in a systematic way. Too often, ambiguity exists with respect to who has responsibility for certain tasks or how work should be done, leading to errors, inefficiencies, and wide variations in how tasks

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264 BEST CARE AT LOWER COST are carried out. These ambiguities are compounded by the natural tendency to work around problems rather than engage in problem solving to ad- dress the underlying causes (Senge, 1990; Spear and Schmidhofer, 2005). Systematic problem solving, grounded in the scientific method, requires that staff work in teams to identify a problem, discover the underlying factors behind the problem, create a plan to address those factors, implement the solution thus generated, and measure whether the solution is achieving the desired results (Furman and Caplan, 2007; Spear, 2005; Young et al., 2004). Sometimes a team’s first approximation of a solution to an identified problem will fail, but this, too, presents a learning opportunity. Through multiple iterations, these closed-loop learning cycles have the potential to yield answers as to how the unit, the department, and ultimately the whole institution can standardize complex processes for optimal effectiveness and efficiency and the highest quality of care (Garvin, 1993; Lukas et al., 2007; Spear, 2006; Toussaint, 2009). They represent a tool organizations can use to learn from errors and inefficiencies to drive improvement. The benefits can be substantial. For example, Denver Health introduced Lean process improvement across the organization in 2006 and by 2012 had realized $151 million in financial benefits, as well as the lowest observed- to-expected hospital mortality rate in the University Healthsystem Con- sortium, a consortium of academic medical centers and affiliated hospitals (Cosgrove et al., 2012). This sort of systems-based problem solving requires that employees be willing to experiment, seek out new knowledge, and anticipate problems instead of addressing only problems immediately at hand. It requires an organizational culture that incentivizes experimentation among staff—one that recognizes failure as key to the learning process and does not penal- ize employees if their experiments are unsuccessful. Further, because these projects are undertaken by employees, they require that employees possess skills that include experiment design, workflow analysis, storyboarding, and statistical analysis (Garvin, 1993). This kind of employee engagement has been found to be effective in sustaining quality improvement efforts in leading organizations. In a study of four high-value hospitals, the most efficient organizations translated the tools of systems-based problem solving beyond their quality improve- ment departments, training their clinical and nonclinical staff in process improvement methods (Edwards et al., 2011). Such training yields a staff that is more engaged in problem solving and that, in solving problems, gains a sense of accomplishment and enthusiasm and generates forward momentum for further efforts (Edwards et al., 2011; Lukas et al., 2007). To encourage a spirit of continuous learning and improvement among health care employees, systems tools such as organizational management, human factors engineering, and process improvement could be incorporated into

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CREATING A NEW CULTURE OF CARE 265 professional education and continuing education curricula (IOM and NAE, 2005; Spear, 2006). Numerous examples of effective uses of systems-based problem solving show how engineering principles can be applied to embed quality, safety, and patient-centeredness into care delivery. A variety of such methods are available for achieving improvement in health care, including Total Qual- ity Management, Six Sigma, Lean, Plan-Do-Study-Act cycles, and hybrid approaches, their success depending on various contextual factors (Chassin and Loeb, 2011; Kaplan et al., 2010). One application of systems engineer- ing principles is for standardizing care protocols. Through multiple itera- tions of problem-solving cycles, learning organizations have been able to elucidate standard protocols and guidelines for a variety of clinical condi- tions and processes. In so doing, they have streamlined patient care while allowing for the variation in practice required to tailor treatment to each patient’s unique circumstances. For example, a team at Intermountain’s LDS Hospital created a clinical practice guideline for managing ventilator settings in the treatment of acute respiratory distress syndrome. The guideline underwent multiple iterations, with 125 changes being made within the first 4 months of use, now down to 1-2 changes per month. Implementing this guideline has increased pa- tient survival from 9.5 to 44 percent while saving physicians time and the hospital money (James and Savitz, 2011). Standard protocols for clinical processes also can improve safety. In 2009, Kaiser Permanente’s Sepsis Care Performance Initiative established protocols for early intervention and treatment for sepsis; the result was a more than 50 percent decrease in sepsis mortality (Cosgrove et al., 2012). Additionally, in response to varia- tions in practice and failures to follow evidence-based protocols, checklists have been developed to improve care for ventilated patients, for central venous catheterized intensive care unit patients, for surgical patients, and for patients with catheter-related blood stream infections (Berenholtz et al., 2004a,b; Hales and Pronovost, 2006; Haynes et al., 2009; Pronovost et al., 2006a). Such interventions are prime examples of system redesign to pre- vent human error in complex systems—errors that can cause downstream effects such as patient harm, poorer outcomes, and potential malpractice claims (Gawande, 2007; Hales and Pronovost, 2006; IOM, 2001; Kohn et al., 2000; Winters et al., 2011). Systems-based problem solving also has been applied off the front lines, as illustrated in Box 9-3. Systems engineering methods have been used as well to reduce vari- ability in hospital admissions. In response to mismatches between available resources and patient demand that result in long wait times for patients and empty beds for hospitals, learning organizations have implemented methods for decreasing the variability in patient admissions from emergency depart- ments and elective procedures. Not only does the smoothing of peaks and

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270 BEST CARE AT LOWER COST from the Robert Wood Johnson Foundation was integral to the redesign of the treatment protocols of Cincinnati Children’s Hospital Medical Center’s Cystic Fibrosis Center. Transparency as a Transformational Tool One critical tool for promoting improvement is broad transparency. By linking provider performance to patient outcomes and measuring providers’ utilization rates and performance against internal and external benchmarks, organizations can improve the quality and value of care provided and be- come better stewards of limited resources. Because most clinicians and or- ganizations lack important data on their own performance and how it relates to that of their peers, such transparency empowers them to improve their performance and helps them improve care processes, reduce variations in practice, and reduce waste. Highly efficient organizations have been able to sustain transformational change by using internal performance informa- tion beyond administrative data to drive improvement efforts (Edwards et al., 2011; James and Savitz, 2011); an example is presented in Box 9-6. External transparency may also help organizations improve performance. BOX 9-6 Transparency on Primary Care Performance Yields Improvements at Denver Health To improve performance and reduce variation in practice among primary care providers in 2006 Denver Health began developing preventive health and chronic disease patient registries for the 100,000 users of its community health center network. By using a single patient identifier to link care from multiple sites to each patient and focusing on high-impact, high-opportunity areas such as dia- betes care, hypertension care, and cancer screening, Denver Health developed a system for monitoring provider performance, tracking service utilization, and supporting clinicians in managing patients between visits. To help clinicians un- derstand their own performance, Denver Health created performance report cards with information aggregated across patients and time and populated by nearly real-time data. The report cards included transparent, unblinded data on clinicians’ performance by site and by provider, and reduced variation and improved overall performance. Since their inception, Denver Health’s report cards have led to a nearly twofold increase in colorectal cancer screening rates, a 20 percent increase in breast cancer screening rates, and an increase in hypertension control rates from 60 to 72 percent. SOURCE: Cosgrove et al., 2012.

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CREATING A NEW CULTURE OF CARE 271 A study of the responses of 17 large, multispecialty physician groups to public reporting on the quality of the diabetes care they provided found that the reporting prompted increased implementation of diabetes improvement interventions (Smith et al., 2012). ALIGNMENT OF INCENTIVES WITHIN AND ACROSS ORGANIZATIONS While each of the factors discussed above is important, it is the or- ganization’s operational model—the way it aligns goals, resources, and incentives—that makes learning actionable. An organization’s operational model can incentivize continuous learning, help eliminate variability and waste that do not contribute to quality care, enable savings that can be invested in improving care processes and patient health, and make improve- ment sustainable. The concept of using an organization’s operational model to drive sustainable improvement has gained traction in manufacturing and high- reliability industries. With the exception of a few standout institutions, however, continuous learning rarely is built into the operational model of health care organizations. Yet, doing so is critical as leaders need a plan to direct the allocation of resources to support continuous improvement, as well as strategies for what to measure, incentivize, and reward to actively embed a culture of improvement (Bagian, 2005; Schein, 2004). Several strategies have been developed for aligning an organization’s operational model with continuous learning. New methods, such as value stream and cost mapping, that can be used to examine the benefits and waste at each step in the delivery of health care services have allowed organizations to learn from their own processes and eliminate waste and harmful variability. The cost savings achieved through these processes can then be allocated to investments that add value, such as information technology and analytic capabilities and staff time devoted to quality improvement projects (IOM, 2008; James and Savitz, 2011; Kaplan and Porter, 2011). In addition to quality improvement gains, health care institutions’ align- ment of business practices with continuous learning may provide a com- petitive advantage. A learning organizational culture has been shown to be predictive of successful financial performance, and studies have found that financially successful organizations score highly on organizational health metrics, including training and development, communication, flexibility and openness to change, job satisfaction, managers facilitating and recog- nizing staff performance, and customer satisfaction (Barney, 1986; Boan and Funderburk, 2003; Fisher and Alford, 2000; Gordon and Ditomaso, 1992; Keller and Price, 2011; Rotemborg and Saloner, 1993; Senge, 1990). In addition, several health care organizations have found that embracing

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272 BEST CARE AT LOWER COST business practices that promote continuous learning and improvement en- hances quality and reduces costs (Cosgrove et al., 2012). However, the health care reimbursement system traditionally has not rewarded learning, making it difficult for organizations to establish operational models that are advantageous from both a financial and a continuous improvement perspective. Current reimbursement systems may even penalize health care organizations that implement best practices by failing to pay for crucial steps in those evidence-based workflows (Toussaint, 2009). New payment models, several of which are outlined in the Patient Protection and Afford- able Care Act, are emerging that may change the value proposition in favor of organizations with operational models that promote continuous learning and improvement. Chapter 8 explores the value proposition for creating a learning health care system in greater depth. Conclusion 9-1: Realizing the potential of a continuously learning health care system will require a sustained commitment to improve- ment, optimized operations, concomitant culture change, aligned incentives, and strong leadership within and across organizations. Related findings: • Systematic designs, processes, and problem solving improve pro- ductivity and outcomes. Denver Health introduced Lean process improvement across the organization in 2006, and by 2012 had realized $151 million in financial benefits, as well as the lowest expected-to-observed hospital mortality rate in a consortium of academic medical centers and affiliated hospitals. • Organizational culture influences quality and outcomes over time. One intervention that focused on teamwork training, coaching, and communication skills saw an 18 percent reduction in annual mor- tality, with adverse events continuing to decrease, versus only a 7 percent reduction in facilities not participating in the intervention. • Leadership matters in health care improvement. One study found that hospitals that ranked in the top 5 percent for heart attack outcomes had strong leadership and a governance commitment to improvement, good communication and coordination, shared val- ues and culture, and experience with problem solving and learning. • Board engagement guides quality improvement. One survey found that hospitals governed by boards with a committee dedicated to quality were associated with more than 25 percent lower risk- adjusted mortality rates for three common medical conditions.

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CREATING A NEW CULTURE OF CARE 273 FRAMEWORK FOR ACHIEVING THE VISION1 Transitioning to a health care system characterized by continuous learn- ing and improvement requires commitment on the part of the organizations that deliver care. One important goal of this transition is to optimize care delivery operations, continually improving the value achieved by care and streamlining processes to provide the best patient health outcomes. As de- scribed in Recommendation 7, organizations can use a variety of tools to meet this goal, and opportunities exist to share best practices in optimizing operations. Recommendation 7: Optimized Operations  ontinuously improve health care operations to reduce waste, stream- C line care delivery, and focus on activities that improve patient health. Care delivery organizations should apply systems engineering tools and process improvement methods to improve operations and care delivery processes. Strategies for progress toward this goal: • Health care delivery organizations should utilize systems engineer- ing tools and process improvement methods to eliminate inefficien- cies, remove unnecessary burdens on clinicians and staff, enhance patient experience, and improve patient health outcomes. • The Centers for Medicare & Medicaid Services, the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, quality improvement organizations, and process improvement leaders should develop a learning consortium aimed at accelerating training, technical assistance, and the collection and validation of lessons learned about ways to transform the ef- fectiveness and efficiency of care through continuous improvement programs and initiatives. A variety of factors, including an organization’s culture, teamwork and partnership among its staff, its ability to analyze and improve upon care delivery processes, and its alignment of rewards and incentives, are crucial in driving and sustaining the transition to a system that continu- ously learns and improves. In addition to leadership, the governing bodies of health care organizations play a key role in promoting and sustaining 1  ote N that in Chapters 6-9, the committee’s recommendations are numbered according to their sequence in the taxonomy in Chapter 10.

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274 BEST CARE AT LOWER COST continuous learning and improvement. As fiduciaries with responsibility for the organizations’ clinical and financial performance, governing bodies are accountable for the value of care delivered, and in turn can hold orga- nizational leaders accountable for achieving that aim. Recommendation 10 outlines the commitments that leaders and governing boards of health care delivery organizations, as well as others, need to make to promote continu- ous learning and improvement. Recommendation 10: Broad Leadership  xpand commitment to the goals of a continuously learning health care E system. Continuous learning and improvement should be a core and constant priority for all participants in health care—patients, families, clinicians, care leaders, and those involved in supporting their work. Strategies for progress toward this goal: • Health care delivery organizations should develop organizational cultures that support and encourage continuous improvement, the use of best practices, transparency, open communication, staff em- powerment, coordination, teamwork, and mutual respect and align rewards accordingly. • Leaders of these organizations should define, disseminate, support, and commit to a vision of continuous improvement; focus atten- tion, training, and resources on continuous learning; and build an operational model that incentivizes continuous improvement and ensures its sustainability. • Governing boards of health care delivery organizations should sup- port and actively participate in fostering a culture of continuous improvement, request continuous feedback on the progress being made toward the adoption of such a culture, and align leadership incentive structures accordingly. • Clinical professional specialty societies, health professional edu- cation programs, health professions specialty boards, licensing boards, and accreditation organizations should incorporate basic concepts and specialized applications of continuous learning and improvement into health professions education; continuing educa- tion; and licensing, certification, and accreditation requirements. As health care organizations continuously learn and improve, they can adapt to changes in the practice of medicine and developments in science and technology. Furthermore, increasing the learning capacity of health care organizations will improve the ability of the overall system to learn, as well

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