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discussing the report's basic themes. Understanding these themes will help us grasp the deployment challenge.

Antecedent Processes and the Outputs of Health Care

The overarching theme of this report is a bit hidden. Although the point is not brought together in one place, the report strongly emphasize that the outputs of health care are the combined results of several important antecedent processes. Thus, outputs for a population of patients, or for an episode of care, are dictated not just by clinical care but by a much more complex interplay of practitioner, patient, and organizational factors and by a variety of forces external to the organization.

Figure 15.1 depicts this reality. In the quality improvement world, this is called a "cause and effect" or "fish-bone" diagram. It is used to understand the many causes of a measured effect. Using any measure of output one wishes to explore—a patient outcome, a change in functional status or psychological status, mortality rates, morbidity rates, a measure of value (cost and quality)—at the head of the fish-bone diagram, one can easily identify the many potential determinants of these outcomes.

As the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) and health care organizations have worked with this tool it has become clear (as noted in Figure 15.1) that the activities of practitioners, governing boards, and managerial and support staff all have a potentially powerful influence on patient outcomes.

At the interface between these internal influences and the external world is the manner in which the results of clinical research are synthesized and disseminated to health care practitioners and then used to influence day-to-day practice. Here we are talking about the work of the research community in conducting and reporting clinical and health services research; the professional associations in their work efforts to develop and disseminate useful practice guidelines; and the educational community in its use of continuing education mechanisms. All have a critical, though often unmeasured, impact on quality. "Health policy" (Figure 15.1) is broadly construed to include such matters as the availability of insurance coverage and the structure of insurance plans, the imposition of nonproductive standards by accreditors and by government, the level of resources made available to health care organizations, the use of price-based selective contracting, the stimulation of aggressive competition within local markets, and professional liability law and practice. All have a potentially powerful effect on the outputs of the system. So government, accrediting organizations, unions, insurers, and purchasers of care all influence outcomes.

Before leaving my discussion of this overall theme, let me return to the health care organization. Most believe, or at least most act as though, the

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