A Strategy to Accelerate Change
Many of the problems besetting the health care system are widely recognized, and a growing consensus has emerged that new approaches must be tried to solve them. Health care is commonly described as a system but, as this report shows, it was not created as a system and is not managed as a system. For the most part, management of the highly fragmented health care enterprise does not take into account interdependencies among patients, care teams, organizations, and the political-economic environment. Instead, individual units focus primarily on improving their unit performance with little regard for the impact on others.
A primary purpose of this report is to show that a broad portfolio of systems-engineering tools, information/ communications technologies, and associated organizational and business processes are immediately available, or can be readily adapted, to improve health care delivery. Indeed, Chapters 3 and 4 have documented many examples at the patient, care-team, organizational, and environmental levels that demonstrate, albeit on a limited scale, the potential of these tools, technologies, and complementary knowledge to improve health care delivery dramatically. The successful use of many of these tools and technologies by the Veterans Health Administration (VHA), Kaiser-Permanente, Mayo Clinic, Institute for Healthcare Improvement (IHI) collaboratives, and other care providers demonstrates that both the productivity of the system and the quality of its processes can be improved simultaneously. In the committee’s view, this may be the only sustainable pathway toward safer, more effective, more patient-centered care.
EDUCATIONAL BARRIERS TO CHANGE
Beyond the islands of progress mentioned above is a vast sea that remains virtually untouched by the portfolio of systems tools, information/communications technologies, organizational/managerial innovations, and cultural changes that have helped transform the quality and productivity of many other industries (both manufacturing and services) in recent decades. As described at length in Chapters 3 and 4, the combined economic, policy-related, technical, cultural, and organizational barriers to the widespread diffusion and implementation of these complementary tools, technologies, and knowledge in health care are formidable. In addition, the health care system faces significant educational barriers.
Currently, very few health care professionals or administrators are equipped to think analytically about health care delivery as a system. As a result, very few of them appreciate the relevance, let alone the potential benefits, of systems-engineering tools. And of these, only a fraction are equipped to work with systems engineers to adapt and apply these tools to meet the challenges in health care delivery. In addition, although most care professionals and administrators now appreciate the relevance of information/communications technologies to improving the quality and efficiency of health care delivery, very few of them are equipped to use these technologies systematically.
There are many reasons for the “systems-education” challenge, some of them related to changes in the structure of medical education early in the twentieth century and the rapid growth of biomedical research in the latter half of the century. In the early twentieth century, medical education underwent a revolutionary change with the development of entrance requirements for medical students, the adoption of a four-year curriculum, and the inclusion of laboratory and clinical experience in medical training. Training sites included academic medical centers, community hospitals, and affiliated facilities.
In the mid-twentieth century, large increases in funding from federal and private sources stimulated basic and clinical research, resulting in advances in knowledge of the biological basis for disease, diagnosis, and treatment. The specialized nature of this knowledge led to the creation of specialties and subspecialties among physicians, and the majority of physicians became specialists in one area or
another of medicine (Ludmerer, 1999; Starr, 1992). Graduate medical education—internships, residencies, and fellowships—now supplement medical school education, providing practical training in clinical practice in medical specialties and subspecialties. Specialty boards were created to oversee this training, and eventually the control and regulation of training was transferred from academic medical centers to these specialty boards (Ludmerer, 1999).
Subsequently, new methods of disease prevention, diagnosis, and treatment were developed and tested through clinical research, thus bringing laboratory results to the bedside. Clinical epidemiology provided a scientifically rigorous evidentiary foundation for clinical practice, which has been widely adopted by medical specialties and has led to the notion of “evidence-based medicine.” Changes in medical education reflected and reinforced the specialization in fields of medical research and practice, and graduate education of health professionals is now characterized by deep knowledge in narrow fields; a focus on individual patient care, with the primary emphasis on diagnosis and treatment and a lesser emphasis on disease prevention; little appreciation for populations/or public health; and almost no emphasis on the structure and processes of health care delivery. No substantive perspective on the entire system of health care or training in the uses and implications of systems tools and information/ communications technologies for managing and improving the system is included in medical education.
Students of engineering and management are much more likely than their counterparts in health fields to be trained in systems thinking and the uses and implications of systems-engineering tools and information/communications systems for the management and optimization of production and delivery systems. Nevertheless, students at most U.S. engineering and business schools are not likely to find courses that address the operational challenges to the quality and productivity of health care delivery.
One major contributing factor to the absence of health care delivery challenges in engineering curricula has been the long-standing lack of demand for engineers in the health care delivery sector. In contrast to engineering careers in device and pharmaceutical companies and other for-profit industries, engineering careers in medical care institutions are nearly nonexistent. In addition, there is a pervasive under-appreciation by engineering faculty, researchers, and practitioners of the magnitude, complexity, and importance of the operational challenges and opportunities facing the nation’s health care system combined with a reluctance to meddle in the “art” of highly respected health care professionals.
A PLATFORM FOR INTERDISCIPLINARY RESEARCH, EDUCATION, AND OUTREACH
In the preceding chapters, the committee has recommended a number of actions by industry, government, academia, and the health and engineering professions to begin to break down barriers to the use of systems-engineering tools, information/communications technologies, and business and managerial knowledge. Recommendations have included calls for public- and private-sector investments in research and development, demonstration projects, new approaches to reimbursement, expanded outreach and dissemination efforts by public- and private-sector health care quality improvement organizations, actions to advance the development of health care data, software, and network standards and other components of a National Health Information Infrastructure, and steps to harness the power of wireless integrated microsystems. The committee believes that action on these recommendations will accelerate the development, adaptation, implementation, and diffusion of systems-engineering tools and information/communications technologies in health care delivery. However, breaking down barriers and improving the overall health care system will also require bold, intentional, far-reaching changes in the education of researchers, educators, and practitioners in health care, engineering, and management through interdisciplinary research.
First, the academic research and educational engineering enterprise must be more closely linked to “real-world” needs in the public and private sectors to help bridge disciplinary research-to-application gaps in health care delivery. Some steps have already been taken in this direction. The NSF-sponsored Engineering Research Centers (ERCs) Program—which started in the 1980s and currently supports 22 centers—brings together industrial and academic researchers and graduate students on university campuses to conduct cross-disciplinary research focused on a single topical area and, in the process, encourages multidisciplinary interactions among faculty and students (NAE, 1983) (see Box 5-1).1 In addition, guidelines for the ERCs explicitly call for strengthening connections between research and the creation of new curricular material (NAE, 1983). ERCs have had a significant impact on both research and academic programs in the institutions where they are located.
NSF and other agencies have also established other university-based interdisciplinary research centers involving engineering (e.g., NSF science and technology centers and materials research science and engineering centers; U.S.
In December 1983, NAE was asked by the National Science Foundation (NSF) to provide advice on developing engineering research centers (ERCs), which the NSF described as “on-campus centers that would house cross-disciplinary experimental research activities.” In addition to conducting research, the principal purposes of the ERCs are: (1) to provide a means of bringing together people in academia and industry1 to improve the education of engineers; and (2) to expose a significant number of engineering students to the nature and problems of cross-disciplinary research on engineering systems.
In its report to NSF, Guidelines for Engineering Research Centers, NAE emphasized four themes: “(1) the relationship with industry must be real and must be perceived by both sides, the faculty and students of the Centers and the engineers and management of the participating companies, as mutually beneficial and as dealing with problems which are industrially important and intellectually demanding; (2) the Centers are experimental, will take time to grow, and will inevitably require altering protocols and programs; (3) to have an impact, the program must be a significant one, meaning that it is better to have fewer Centers with sufficient funding rather than many with inadequate funding; and (4) the Centers must complement and not supplant, either in size or numbers, the [National Science] Foundation’s grants to individual investigators.”
Source: NAE, 1983.
Department of Energy materials research centers; U.S. Department of Transportation [DOT] university transportation centers; and university-based nanotechnology research centers sponsored by NSF, National Aeronautics and Space Administration, and DOD) (DOE, 2004; DOT, 2004; NNI, 2004; NSF, 2004a). As the results of interdisciplinary research are translated into classroom materials (e.g., new textbooks and courses) by participating faculty, these centers are directly affecting the way scientists and engineers are educated.
Two important lessons have been learned from these multidisciplinary engineering activities. First, they have contributed both to solving important research problems and to broadening the education of students. Each center, focused on a multidisciplinary area (e.g., tissue engineering, earth-quake engineering, or surgical technology), necessarily addresses systems problems. Second, these centers have identified research topics that might not have been undertaken by researchers in a single discipline, which has led to the development of new curricular offerings and materials (NSF, 2004b).
Another instructive, large-scale, multidisciplinary research effort is the NIH-sponsored human genome project. In 1990, NIH embarked on a 13-year, multicenter project to map the human genome. The completion of the map laid the foundation for a wave of multidisciplinary systems research exploring the applications of this new knowledge base to medical practice. The translation of genome research into useful products and services has required a significant expansion of multidisciplinary research, including the establishment of multidisciplinary research centers where physicists, chemists, bioengineers, and mathematicians join forces to undertake the step-by-step progression from gene sequencing to the determination of protein function and the development of applications in screening, diagnostics, and treatment (Collins et al., 2003). These interdisciplinary centers have also demonstrated that multidisciplinary research and education can break down disciplinary barriers between the life sciences and their complements in the physical sciences and engineering (Harvard University, 2004a; MIT, 2004).
These new opportunities for multidisciplinary systems research in engineering and the biological sciences have demonstrated the potential for the development of analogous capabilities to address the challenges of health care delivery based on engineering sciences. The committee believes that a similar approach could build sustainable interdisciplinary bridges between the fields of engineering, health care, and management and begin to address the major challenges facing the health care delivery system. An environment in which professionals from all three fields engage in basic and applied research and translate the results of their research and advances both into the practice arena and the classroom, where students from the three disciplines interact, could be a powerful catalyst for cultural change.
The following recommendations are based on the logic, lessons, and momentum of these recent large-scale, multidisciplinary, research/education/technology-transfer initiatives focused on systems challenges in engineering and biomedical sciences.
Recommendation 5-1a. The federal government, in partnership with the private sector, universities, federal laboratories, and state governments, should establish
multidisciplinary centers at institutions of higher learning throughout the country capable of bringing together researchers, practitioners, educators, and students from appropriate fields of engineering, health sciences, management, social and behavioral sciences, and other disciplines to address the quality and productivity challenges facing the nation’s health care delivery system. To ensure that the centers have a nationwide impact, they should be geographically distributed. The committee estimates that 30 to 50 centers would be necessary to achieve these goals.
Recommendation 5-1b. These multidisciplinary research centers should have a three-fold mission: (1) to conduct basic and applied research on the systems challenges to health care delivery and on the development and use of systems-engineering tools, information/communications technologies, and complementary knowledge from other fields to address them; (2) to demonstrate and diffuse the use of these tools, technologies, and knowledge throughout the health care delivery system (technology transfer); and (3) to educate and train a large cadre of current and future health care, engineering, and management professionals and researchers in the science, practices, and challenges of systems engineering for health care delivery.
Interdisciplinary research centers could be configured in any number of ways. For example, schools of engineering, health science, and business administration at a single university might be allied with an academic medical center or other health care facility, or a combination of units from two or more academic institutions might work in collaboration with one or more health care facilities, or units from one or more academic institutions and health care facility might join with units from one or more federal laboratories. Whatever their configuration, it is essential that health care facilities (e.g., academic medical centers, regional health centers) be intimately involved, because they will provide a locus where innovations in systems design and operation can be tested, evaluated, and/or implemented.
Multidisciplinary centers would not only blend research and practice, they would also provide a means of demonstrating the value and promoting the use of existing systems tools to the larger community of practicing health care providers. Because each center will choose its focus area based on its inherent strengths, it will be important for the combination of centers to include the full spectrum of health care service providers, patient-advocate organizations, federal and state governments, health care provider organizations, private-sector insurers, technology vendors, medical service companies, university-based researchers and educators, federal laboratories, professional associations, and others. Only through close interactions of researchers, tools, technology developers, end users, and ultimate beneficiaries will the barriers to their widespread use be overcome.
One would expect the research and demonstrations conducted at these centers to inform, complement, and build on ongoing public- and private-sector efforts to promote the use and diffusion of systems engineering and information/ communications technologies, such as IHI multiprovider innovation and diffusion collaboratives; the National Health Information Network initiative of the Office of the National Coordinator for Health Information Technology, the Joint Commission on the Accreditation of Healthcare Organizations and the VHA promotion of the use of failure/risk analysis tools; the VHA eHealth Initiative; the Centers for Disease Control (CDC) Centers of Excellence in Public Health Informatics; and the Leapfrog Group’s campaign to promote the use of EHRs and CPOE systems (CDC, 2005; IHI, 2005; JCAHO, 2002; McDonough et al., 2004; Milstein in this volume; Thompson and Brailer, 2004; VHA, 2005).
A number of university-based multidisciplinary research centers explored the intersection of engineering and health care delivery during the 1970s and 1980s, but, according to some observers, their impact was significantly muted by the gap between their research results and the capacity of health care providers and organizations to implement them (see Box 5-2). The integration of research and education will be essential for sustained progress. Therefore, as in the NSF ERCs, faculty participating in these centers should be strongly encouraged to develop new curricular materials based on their research (NSF, 2004b). Research faculty could also provide materials for continuing education for health professionals, engineers, and managers involved or interested in becoming involved in the operational management and improvement of health care delivery systems.
The committee estimates that 30 to 50 geographically dispersed centers may be needed to involve and affect a significant number of current and emerging professionals in health care, engineering, and management. This estimate was arrived at in committee discussions on (1) the magnitude of effort at individual institutions of higher learning necessary to attract the attention/interest of faculty and students in relevant fields; (2) the number and geographic reach of the centers necessary to engage a critical mass of individuals and institutional players, including state governments, in the effort; and (3) the relative size of other initiatives (e.g., NSF’s Engineering Research Centers Program; NIH’s General Clinical Research Centers Network). The centers may vary in size, depending on their area(s) of focus, but core support of roughly $3.25 million annually for an average center would fund the work of eight faculty researchers, 24 graduate students, six support staff, and one senior administrator/ center director and provide roughly $500,000 of working capital. An annual core funding level of $100 to $160 million would be anticipated for 30 to 50 centers.
Multiple government agencies (e.g., NIH, NSF, Agency for Healthcare Research and Quality, CDC, VA, and the Defense Advanced Research Projects Agency) would have a stake in the research, technology transfer, and educational missions of the proposed research centers, and these agencies
From 1970 to 1985, a number of interdisciplinary research centers were established at several academic centers (e.g., Georgia Institute of Technology, University of Missouri-Columbia, University of Pittsburgh, and University of Wisconsin, Madison) to explore the intersection of engineering and health care delivery. Faculty from business schools, engineering schools, medical schools, and nursing schools participated in research in industrial engineering, operations research, quality control, ergonomics, and statistics. At one time, there were more than a half dozen health care multidisciplinary research centers, but by the end of 1985, most of them had been closed down due to a lack of grant money and support from the health care industry. The centers at Georgia Institute of Technology and the University of Wisconsin still exist but are now associated with industrial engineering and have connections with medical schools at Emory University and the University of Wisconsin, respectively (Georgia Institute of Technology, 2005; University of Wisconsin-Madison, 2005).
The scope of research in the network of multidisciplinary centers proposed in this report would go far beyond the modest projects at these forerunner centers. The new centers would be configured not only to carry on research, but also to maintain a parallel focus on demonstration and diffusion of engineering techniques. Application, education, and diffusion would be advanced in living laboratories where engineering, health care, and management professionals and other researchers would work together to identify ways to overcome barriers to the application of currently available tools and to develop new tools.
should provide their core financial support. The continuity of funding will be critical for the centers to achieve their full potential. Experience has shown that periodic competitive reviews (for example, every five years) can provide evidence of progress and opportunities for renewing funding. In addition to core funding, center-based researchers and research teams would be expected to compete for additional public- and private-sector funding from health care provider organizations, private foundations, companies, and state governments for research, development, and/or demonstration projects of particular interest to them. An annual meeting of key researchers would ensure that important engineering/ health care delivery issues were not overlooked.
Recommendation 5-2. Because funding for the multidisciplinary centers will come from a variety of federal agencies, a lead agency should be identified to bring together representatives of public- and private-sector stakeholders to ensure that funding for the centers is stable and adequate and to develop a strategy for overcoming regulatory, reimbursement-related, and other barriers to the widespread application of systems engineering and information/ communications technologies in health care delivery.
The committee believes strongly that the establishment of a national network of multidisciplinary centers focused on improving the quality and productivity of U.S. health care delivery will be critical to achieving and sustaining the critical mass of research, education, and outreach that will be necessary to realize IOM’s vision of a transformed twenty-first century health care system. At the same time, the committee believes that support for these new multidisciplinary centers should not crowd out public- and private-sector funding for research by individual investigators on systems-engineering tools and information/communications technologies for health care. A mix of funding for interdisciplinary centers and individual researchers will ensure that a wide range of individuals from many parts of the research community are engaged in a common effort to improve health care delivery.
Accelerating Cultural Change through Formal and Continuing Education
Making systems-engineering tools, information technologies, and complementary social-science, cognitive-science, and business/management knowledge available and training individuals to use them will require commitment and cooperation among professionals in engineering and health care and changes in the cultures of health professionals and engineering professionals. The committee believes that these long-term cultural changes must begin in the formative years of professional education. Individuals in both professions must have opportunities to participate in learning and research environments in which they can contribute to a new approach to health care delivery.
The recommended interdisciplinary centers are not intended to produce health care professionals who can individually apply systems-engineering tools or engineers who can practice health care delivery. They are intended to provide an environment in which engineers and health professionals can work together and share experiences, thus breaking down disciplinary and linguistic barriers and building mutual trust and a shared understanding of the problems
facing health care and the systems-engineering tools and information/communications technologies that can contribute to improving operations.
Recognizing and exploiting the potential contributions of systems engineering to health care delivery will be an enormous challenge for educators of health professionals. The current view of professional excellence accepted by health care providers will have to be expanded to encompass population health and the structure, processes, and systems of health care delivery. Physicians, nurses, and other health professionals will need new skills to work effectively with engineering and management professionals to change the design, implementation, and understanding of structures and processes of health care to ensure that care is safe, effective, timely, efficient, patient-centered, and equitable.
Thus, the training of health professionals will have to be changed. The curriculum will have to include systems-engineering concepts and skills, both directly in specifically focused courses and indirectly as part of other courses and units of study and practice. This will require that faculty with expertise in health care delivery be identified or recruited and educational and research links be established between clinical professions and schools of engineering and management.
This paradigm shift will require new strategies. The health professions have already taken some steps in this direction with the establishment of core competencies, including systems-based practice and practice-based learning and improvement, which have already attracted the attention of every training program and every trainee (Brennan et al., 2004; IOM, 2003; Leach, 2002). If these competencies are extended to requirements for relicensing, they will certainly be incorporated into clinical practice over time (Brennan et al., 2004; IOM, 2003; Leach, 2002; Lynch et al., 2004). Another encouraging sign is the VHA’s adoption of formal courses in quality improvement and systems theory (VA, 2004).
New training strategies for interdisciplinary education should include health professional trainees in many aspects of health care working together and learning about each other’s disciplines, perspectives, traditions, goals, objectives, tools, and techniques. This would give each clinician an opportunity to see the health care system in a broader context, to work as part of a team, to identify potential problems, and to be better prepared to contribute to system improvements.
Clearly, adding requirements to already crowded health professional curricula poses serious challenges. In medicine, the expansion of core competencies and a new emphasis on the clinician-patient relationship in teaching and testing have already led to a reexamination of the medical school curriculum (Brennan et al., 2004; IOM, 2003; Leach, 2002; Lewin et al., 2001). Core competencies in information technologies have also been identified in nursing at four levels of practice (Staggers et al., 2001).
Dramatic improvements in the efficiency and quality of health care delivery will only be possible with skilled engineers and health care management teams that understand and can implement the types of methods, tools, and technologies described in this report. To ensure that enough engineering and management professionals with these skills are available, curricula in schools of engineering, management, and public health will have to be expanded to encompass problems, concepts, and topics in health care delivery. These changes will have to be incorporated into formal classroom education, applied training, and continuing education for both professions. Thus, new models of education and training will have to be designed, implemented, and evaluated.
In addition to the development of supporting curricula and other resource materials, engineering educators face the challenge of cultivating demand for health care delivery-trained engineering graduates in an industry that has traditionally hired very few engineers and currently has no clearly defined career tracks for engineers. The lack of awareness of career opportunities in the health care industry for managers trained in the quantitative disciplines and tools described in this report may be the most significant reason so few MBAs enter the health care industry.2 To attract more MBAs and other graduates to health care and to ensure a supply of leaders in health care improvement will require a significant effort to increase the visibility of the health care industry in MBA-related curricula.
The translation of interdisciplinary research results into instructional materials by faculty participants in the multidisciplinary research centers would impact the graduate, undergraduate, and continuing education of students and practitioners in all participating disciplines. In the meantime, however, the committee recommends the accelerated, intense training and development of select health care, engineering, and management professionals who understand the systems challenges facing health care delivery and the value of, and perhaps the application of, the tools and technologies to address them.
Recommendation 5-3. Health care providers and educators should ensure that current and future health care professionals have a basic understanding of how systems-engineering tools and information/communications technologies work and their potential benefits. Educators of health professionals should develop curricular materials and programs to train graduate students and practicing professionals in systems approaches to health care delivery and the use of systems tools and information/communications technologies. Accrediting
organizations, such as the Liaison Committee on Medical Education and Accreditation Council for Graduate Medical Education, could also require that medical schools and teaching hospitals provide training in the use of systems tools and information/communications technologies. Specialty boards could include training as a requirement for recertification.
Recommendation 5-4. Introducing health care issues into the engineering curriculum will require the cooperation of a broad spectrum of engineering educators. Deans of engineering schools and professional societies should take steps to ensure that the relevance of, and opportunities for, engineering to improve health care are integrated into engineering education at the undergraduate, graduate, and continuing education levels. Engineering educators should involve representatives of the health care delivery sector in the development of cases studies and other instructional materials and career tracks for engineers in the health care sector.
Recommendation 5-5. The typical MBA curriculum requires that students have fundamental skills in the principal functions of an organization—accounting, finance, economics, marketing, operations, information systems, organizational behavior, and strategy. Examples from health care should be used to illustrate fundamentals in each of these areas. Researchers in operations are encouraged to explore applications of systems tools for health care delivery. Quantitative techniques, such as financial engineering, data mining, and game theory, could significantly improve the financial, marketing, and strategic functions of health care organizations, and incorporating examples from health care into the core MBA curriculum would increase the visibility of health care as a career opportunity. Business and related schools should also be encouraged to develop elective courses and executive education courses focused on various aspects of health care delivery. Finally, students should be provided with information about careers in the health care industry.
Recommendation 5-6. Federal mission agencies and private-sector foundations should support the establishment of fellowship programs to educate and train present and future leaders and scholars in health care, engineering, and management in health systems engineering and management. New fellowship programs should build on existing programs, such as the Veterans Administration National Quality Scholars Program (which supports the development of physician/scholars in health care quality improvement), and the Robert Wood Johnson Foundation Health Policy Research and Clinical Scholars Programs (which targets newly minted M.D.s and social science Ph.D.s to ensure their involvement in health policy research). The new programs should include all relevant fields of engineering and the full spectrum of health professionals.
The goal of these recommendations is to make available and encourage the use of engineering tools and information/ communications technologies in the health care community and to move toward meeting the six goals of the vision stated by IOM. Meeting the combined objectives of increasing research, demonstrating feasibilities, and diffusing successful demonstrations will require the commitment of many organizations.
CALL TO ACTION
As important as good analytical tools and information/ communications systems are, they will not ultimately transform the system unless all members of the health care provider community actively participate and support their introduction and use. Communicating the overall system and subsystem goals to individuals and groups at all levels will be a crucial task for the management of health care organizations. Empowering individuals who do the day-to-day work in health care to make changes will require that everyone understand the overall goals and objectives of the system and subsystem in which they work. Participants must be energized and empowered to make continuous improvements in all processes, and encouraging and recognizing individuals for their contributions to the “continuous improvement” of operations must be a principal operating goal for management.
The committee recognizes the immensity of the task ahead and offers a word of encouragement to all members of the engineering and health care provider communities. Over-hauling the health care delivery system will not come quickly, and achieving the long-term goal of improving the health care system will require the ingenuity and commitment of leaders in the health care community, as well as practitioners in all clinical areas. But if we take up the call now to change the system, we can perhaps avoid crises, reduce costs, reduce the number of uninsured, and make affordable, high-quality care available to all Americans.
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