Crossing the Quality Chasm A New Health System for the 21st Century (2001) / Chapter Skim
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3 Formulating New Rules to Redesign and Improve Care
3 Formulating New Rules to Redesign and Improve Care
Pages 61-88
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From page 61... ...
Recommendation 4: Private and public purchasers, health care organizations, clinicians, and patients should work together to redesign health care processes in accordance with the following rules: 1. Care based on continuous healing relationships.
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From page 62... ...
To create a new health care system that more closely matches the purpose and aims described in Chapter 2, it will be necessary, first, to examine old assumptions to understand why they have led to our current ineffective health care systems, and second, to consciously craft new operating assumptions embodied in the rules set forth above. As a guide in formulating its agenda for change, the committee used as a framework recent work in understanding complex adaptive systems (Kauffman, 1995; Stacey, 1996; Waldrop, 1992; Weick, 1995; Zimmerman et al., 1998)
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From page 63... ...
FORMULATING NEW RULES TO REDESIGN AND IMPROVE CARE 63 Following a brief review of this work, we describe in greater detail the ten rules outlined above. HEALTH CARE ORGANIZATIONS AS COMPLEX ADAPTIVE SYSTEMS A health care system can be defined as a set of connected or interdependent parts or agents including caregivers and patients bound by a common purpose and acting on their knowledge.
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From page 64... ...
Many irrational variations in practice cannot be justified as better meeting patients' needs, and they represent lost opportunities for benefit. A surprising finding from research on complex adaptive systems is that relatively simple rules can lead to complex, innovative system behavior.
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From page 65... ...
The statement of purpose and aims set forth in Chapter 2 lay out a common purpose for the health system. Second, a new set of simple rules is needed to guide behavior in the 21stcentury health care system.
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TEN SIMPLE RULES FOR THE 21ST-CENTURY HEALTH CARE SYSTEM Table 3-1 summarizes ten simple rules for the 21st-century health care system. In the following subsections, each rule is described and contrasted with the corresponding current approach.
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From page 67... ...
The Internet is likely to be a major platform for such communication. Face-to-face visits will likely continue to be an important form of clinician and patient interaction; for many people, some direct human contact is critical to establish and maintain a strong healing relationship.
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A focus on the healing relationship emphasizes that this transfer of trustworthy information is the core product of health care, not something tacked onto a health care visit. In the 21st-century health care system, interaction should be understood in a fundamentally different way.
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From page 69... ...
Variations in approaches today often reflect different local and individual styles of practice and training that may or may not be consistent with the current evidence base. The new rule states that variations in treatment should be based primarily on differing patient needs and preferences.
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Rule 3: The Patient as the Source of Control In the current system, control over decisions, access, and information is typically in the hands of caregivers and is ceded to patients only when caregivers choose to do so. For example, patients are often required to obtain permission to see their own medical records, to have visitors, or to participate in treatment decisions.
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(1989) found that patients who had been coached to ask questions during office visits reported fewer functional limitations and had better control of blood sugar and blood pressure than did patients in the control group.
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A group of Australian investigators used a similar approach with cancer patients and concluded that a question prompt sheet is a simple, inexpensive, and effective means of promoting the asking of questions by cancer patients (Brown et al., 1999~. As noted earlier, patients are increasingly able to use the Internet and other interactive technologies to help them make informed decisions about their medical treatment.
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From page 73... ...
Ensuring that health information is accurate and complete is critical to its use for patient care, research and quality improvement, and legal and financial accountability. Beyond the generally acknowledged right of a patient to know his or her diagnosis and treatment, patients are sometimes given a summary of their care to help them in their self-care.
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From page 74... ...
In one study, chronically ill patients who had access to their records reported understanding about half or more of the information they contained (Gittens, 1986~. In a study of stroke patients, those having access to their complete medical record reported understanding more about their condition than did control patients who had been given only relevant descriptive medical information (Banes and Felchlia, 1997~.
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One exception to the above findings is a recent randomized control trial of 650 cancer patients. In that study, no differences in outcomes (i.e., global health status, emotional functioning, cognitive functioning, or satisfaction)
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From page 76... ...
The rule does not require that all decisions be based on the results of randomized controlled trials because such results are not always available and because other forms of knowledge exist, such as that derived from epidemiological and population-based data. Neither does the new rule discount clinician experience or the integration of information about a patient's special circumstances.
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From page 77... ...
A growing body of evidence demonstrates that the use of clinical practice guidelines with other supportive tools, such as reminder systems, can improve patient care (Cabana et al., 1999; East et al., 1999; Morris, 1993; Thomsen et al., 1994; Wells et al., 2000~. Despite the best of intentions, clinicians cannot be expected to process unaided all the details, strengths, and limitations of scientific evidence under normal conditions of practice in which the number of variables to be considered is great, but resources, including time, are severely limited (Weed, 1999)
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From page 78... ...
The assumption underlying the new rule is quite different. This rule might be stated as: Threats to patient safety are the end result of complex causes such as faulty equipment; system design; and the interplay of human factors, including fatigue, limitations on memory, and distraction.
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recommends that health care organizations and the professionals affiliated with them make continually improved patient safety a declared and serious aim by establishing patient safety programs with a defined executive responsibility. That report further recommends that patient safety programs: (1)
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A health care system that operates under a rule of transparency will be more patient-centered and safer because patients will be able to recognize outdated and wrong information and to share in information that affects their care, such as the results of laboratory tests, medications being taken, and the correct doses. Rule 8: Anticipation of Needs Under the current approach, health care resources are marshaled when they are needed.
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From page 81... ...
Other countries, including the United Kingdom and Finland, have also focused on such linkages designed to anticipate patient needs (The Ministry of Social Affairs and Health and The Association of Finnish Local and Regional Authorities, 1999~. Rule 9: Waste Continuously Decreased The current system tries to conserve resources through restrictions and budget limits, withholding services and creating queues to drive costs down.
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From page 82... ...
The new rule states that increased value will not be derived by stressing the current system, that is, by asking people to work harder, faster, and longer, and while doing so, not to make (or admit to) any errors.
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Patient Reactions to a Program Designed to Facilitate Patient Participation in Treatment Decisions for Benign Prostatic Hyperplasia. Medical Care 33(8)
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Ann Int Med 130:829-34, 1999. Chambers, Jo.
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Ann Int Med 102:520-8, 1985. Greenfield, Sheldon, Sherrie H
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Patients' Preferences for Risk Disclosure and Role in Decision Making for Invasive Medical Procedures. J Gen Intern Med 12:114-7, 1997.
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Ann Int Med 131:43844, 1999. Rich, Michael L
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From page 88... ...
Ann Int Med 131(12)
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