Skip to main content

Currently Skimming:

5 Building Organizational Supports for Change
Pages 111-144

The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.


From page 111...
... Chapter 3 offered a set of rules that would redesign the nature of interactions between a clinician and a patient to improve the quality of care. This chapter describes how organizations can redesign care to systematically improve the quality of care for patients.
From page 112...
... to encourage the development of formal and informal networks of individuals involved in innovation and improvement. STAGES OF ORGANIZATIONAL DEVELOPMENT The design of health care organizations can be conceptualized as progressing through three stages of development to a final stage that embodies the committee's vision for the 21st-century health care system, as represented by the six aims set forth in Chapter 2 (see Table 5-1~.
From page 113...
... Stage 2 Stage 2 is characterized by the formation of well-defined referral networks, greater use of informal mechanisms to increase patient involvement in clinical decision making, and the formation of loosely structured multidisciplinary teams. For the most part, health care is organized around areas of physician specialization and institutional settings.
From page 114...
... 114 Cq o .s .5 by o an o ·_4 Cq an o o g o Cq an VO ˘ EM sit Cal v V, o C)
From page 116...
... Whatever the organizational arrangement, it should promote innovation and quality improvement. Every organization should be held accountable to its patients, the populations it serves, and the public for its clinical and financial performance.
From page 117...
... reueslgmng care processes; time; and · incorporating performance and outcome measurements for improvement and accountability. making effective use of information technologies; managing clinical knowledge and skills; developing effective teams; coordinating care across patient conditions, services, and settings over The following discussion of these six challenges includes excerpts from interviews with clinical leaders conducted as a part of an IOM study aimed at identifying exemplary practices (Donaldson and Mohr, 2000~.
From page 118...
... Effective and reliable care processes whether registering patients who come to the emergency room, ensuring complete immunizations for children, managing medication administration, ensuring that accurate laboratory tests are completed and returned to the requesting clinician, or ensuring that discharge from hospital to home after a disabling injury is safe and well coordinated can be created only by using well-understood engineering principles. Not only must care processes be reliable, but they must also be focused on creating a relationship with a caregiver that meets the expectations of both the patient and the family.
From page 119...
... Although these organizations have recognized the need for leadership to provide the necessary commitment to and investment in change, they have also recognized that change needs to come from the bottom up as front-line health care teams recognize opportunities for redesigning care processes and acquire the skill to implement those new approaches successfully (National Committee for Quality Health Care, 1999; Washington Business Group on Health, 1998~. Many other organizations have taken steps toward redesigning processes, but have found replication and deployment difficult or short-lived (Blumenthal and Kilo, 1998; Shortell et al., 1998~.
From page 120...
... Engineering principles have been widely applied by other industries and in some health care organizations to design processes that improve quality and safety (Collins and Porras, 1997; Donaldson and Mohr, 2000; Hodgetts, 1998; Kegan, 1994; Peters and Waterman, 1982~. The following subsections describe five such principles and their use by health care professionals to improve patients' experiences and safety, the flow of care processes, and coordination and communication among health professionals and with patients (Langley et al., 1996~.
From page 121...
... The more predictable the work, the more it makes sense to standardize care so that it can be performed by a variety of workers in a consistent fashion. When needs are predictable, standardization encompasses the key dimensions of work that should be performed the same way each time using a defined process and is a key element of the principle of mass customization discussed later in this section.
From page 122...
... As described in detail in the committee's earlier report, To Err Is Human (Institute of Medicine, 2000) , designing health care processes for safety involves a three-part strategy: (1)
From page 123...
... Mass Customization Mass customization involves combining the uniqueness of customized products and services with the efficiencies of mass production. In manufacturing, this strategy has been developed as a way to give customers exactly what they want in a way that is feasible from a business standpoint that is, quickly, at an acceptable cost, and without added complexity (Pine et al., 1995~.
From page 124...
... Emergency department Each morning we make rounds on all 34 intensive care patients. The discussion includes pointed, patient-oriented reports, social as well as medical needs.
From page 125...
... Emergency department 125 Continuous flow, sometimes referred to as "a batch size of one," is an important design concept in which the system is designed to match demand so there is no aggregation of persons or units during processing. It represents the theoretical optimum for any production or service delivery system.
From page 126...
... Although the needs of patients and the work required to meet those needs will vary from day to day, all clinical practices have a natural rhythm defined by a period for example, a week after which the nature of the work repeats. One method of production planning involves the use of a repetitive master schedule to make the best use of resources in meeting patient needs.
From page 127...
... igning better production proThe reengineering principles described in this section system design using the 80/20 approach, design for safety, mass customization, continuous flow, and production planning are used by other industries, and, as indicated in the accompanying quotations, by teams across a range of health care settings that include ambulatory office practices, hospital units, emergency departments, and hospices. Such engineering principles illustrate what is meant by focusing at a system level.
From page 128...
... Such systems should be able to access all patient data wherever clinical decisions are made. They should be able to access the evidence base and decision supports, such as clinical practice guidelines.
From page 129...
... As described in greater detail in Chapter 6, the flood of new information that is relevant to practice can no longer be managed adequately by individual clinicians trying to keep up with the literature and attending conferences or lectures (Davis et al., 1999; Weed, 1999~. One new approach to timely management of information involves including clinical librarians as a part of clinical care teams, for example, on morning rounds or on call, to note questions and search the literature for the best and most relevant information (Davidoff and Florance, 2000~.
From page 130...
... Implementing this strategy also requires agreement on the part of clinicians that they will use the new guidelines and protocols, as well as the resources needed to redesign care processes (despite such resources often being scarce) so that the guidelines and protocols will become an integral and efficiently designed element of the care process.
From page 131...
... Such teams are found in primary care practice, in the focused care of patients with chronic conditions, in critical acute care (the intensive care unit, trauma units, operating rooms) , and in geriatrics and care at the end of life.
From page 132...
... Other environments do not have the level of instability and uncertainty associated with critical care units and operating suites, yet the complexity of patients' needs still necessitates highly effective coordination of resources across a spectrum of settings, disciplines, and the community. An example is the care of frail elderly patients, in which the ability to coordinate care and assemble effectively functioning health care teams is paramount, and flexibility in role functioning may be key.
From page 133...
... Hospice Another key challenge for organizations is coordination (or clinical integration) of work across services that are complementary, such as emergency response units, emergency departments, and operating suites, or across primary care practices, specialty practices, and laboratories to which patients are referred.
From page 134...
... . The challenges arise at many organizational levels and across the full range of tasks, including the design, dissemination, implementation, and modification of care processes and the payment for these tasks.
From page 135...
... For some conditions, a set of clearly identified processes should occur. In complex adaptive systems such as health care, however, few patient care processes are linear (such as the transition from hospital to nursing home)
From page 136...
... New methods that use sampling and small-scale rapid-cycle testing, modification, and retesting are proving useful in dynamic settings such as patient care units (Berwick, 1996; Langley et al., 1996~. As other world-class businesses have learned, including American industry giants (Walton and Deming, 1986)
From page 137...
... Learning organizations need leadership at many levels that can provide clear strategic and sustained direction and a coherent set of values and incentives to guide group and individual actions. The first criterion of performance excellence for health care organizations listed by the Baldrige National Quality Program is
From page 138...
... . Indeed, strong management leadership in hospitals is positively associated with greater clinical involvement in quality improvement (Weiner et al., 1996, 1997)
From page 139...
... Although the leadership roles described are not novel, the orientation toward facilitating the work of health care teams represents a fundamental shift in perspective. The new rules set forth in Chapter 3 and the engineering principles described in this chapter will require strong and visible leadership with corresponding reward structures.
From page 140...
... Kilo. A Report Card on Continuous Quality Improvement.
From page 141...
... Evidence-Based Implementation of Evidence-Based Medicine. Joint Commission Journal on Quality Improvement 25(10)
From page 142...
... A Roundtable Discussion: Have Computerized Patient Records Kept Their Promise of Improving Patient Care? Joint Commission Journal on Quality Improvement 23(12)
From page 143...
... Using Information Management to Implement a Clinical Resource Management Program. Joint Commission Journal on Quality Improvement 23(12)
From page 144...
... Shortell, and Jeffrey Alexander. Promoting Clinical Involvement in Hospital Quality Improvement Efforts: The Effects of Top Management, Board, and Physician Leadership.


This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More information on Chapter Skim is available.