Best Care at Lower Cost The Path to Continuously Learning Health Care in America (2013) / Chapter Skim
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9 Creating a New Culture of Care
9 Creating a New Culture of Care
Pages 255-280
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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.
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From page 256... ...
The role of health care organizations is especially important in a learning 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 communication and coordination, shared values and culture, and experience with problem solving and learning (Curry et al., 2011)
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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 organizations must be diffused more broadly so the whole system can benefit.
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. A survey of hospital leaders found that those hospitals whose leader was heavily engaged in quality improvement efforts tended to provide higher-quality care (Vaughn et al., 2006)
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Accomplishing these goals often requires understanding continuous improvement methods, the design of learning cycles, and improvement metrics 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)
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For instance, when boards spend time examining health care quality issues, set a quality agenda, formally monitor quality performance 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)
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. 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)
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. 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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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 delivery (IOM, 2001)
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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 observedto-expected hospital mortality rate in the University Healthsystem Consortium, a consortium of academic medical centers and affiliated hospitals (Cosgrove et al., 2012)
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. Additionally, in response to variations 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)
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Improved patient flow also led to greater work satisfaction among staff and reduced wait times for patients (IOM, 2010; Joint Commission, 2009)
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Finally, some organizations may adopt a new innovation enthusiastically only to find that their staff reject it because the organization lacks the business model, leadership, or cultural elements that make adoption sustainable. One means of supporting organizations that continually learn from others may be through the accreditation, certification, and licensure processes for health care organizations provided by the Joint Commission and state agencies.
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. The approach calls for in-depth analysis of the processes and workflows that improve quality in learning organizations that face risks similar to those faced by the potential adopting organization.
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In the case study in Box 9-5, for example, a grant BOX 9-5 Positive Deviance Approach to Improvement at Cincinnati Children's Hospital Medical Center's Cystic Fibrosis Center As part of a Robert Wood Johnson Foundation/Institute for Healthcare Im provement (IHI) Pursuing Perfection grant, Cincinnati Children's Hospital Medical Center undertook a project to improve the performance of its Cystic Fibrosis Center.
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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.
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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)
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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.
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• 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 continuously learns and improves.
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Recommendation 10 outlines the commitments that leaders and governing boards of health care delivery organizations, as well as others, need to make to promote continuous learning and improvement. Recommendation 10: Broad Leadership xpand commitment to the goals of a continuously learning health care E system.
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Joint Commission Journal on Quality and Patient Safety Joint Commission Resources 33(10)
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Joint Commission Journal on Quality and Patient Safety 33(7)
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Joint Commission Journal on Quality and Patient Safety 31(6)
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Joint Commission Journal on Quality and Patient Safety 31(6)
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Joint Commission Journal on Quality and Patient Safety 37(11)
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