Crossing the Global Quality Chasm Improving Health Care Worldwide (2018) / Chapter Skim
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2 The Path to a High-Quality Future: The Need for a Systems Approach and a Person-Centered System
2 The Path to a High-Quality Future: The Need for a Systems Approach and a Person-Centered System
Pages 53-78
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From page 53... ...
• Trusted and accurate communication between health care staff and patients (and their family members) is a central clinical function and a key component of quality health care delivery.
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From page 54... ...
As demonstrated in Chapter 1, many challenges to achieving high levels of quality care still exist worldwide, leading to fragmented and undesirable patient journeys. Improvng the patient journey requires an integrated system of care i and productive interactions among many system levels -- both public and private.
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. To integrate care, optimize the patient journey through the health care system, and thereby improve health care quality, all countries will need to apply a systems-thinking perspective.
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In accordance with a systems-thinking perspective, the adapted IOM quality dimensions are characterized in the figure as cross-cutting, suited for use in measuring the structure, process, and outcomes of health care quality. The committee encourages nations and leaders seeking to improve the patient journey to adopt the systems thinking approach, viewing health care as a sociotechnical system and accounting for the emerging field of human factors and ergonomics (HFE)
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FIGURE 2-1 Integration of conceptual frameworks guiding health systems and quality of care. FIGURE 2-1 NOTE: IOM = Institute of Medicine; WHO = World Health Organization.
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It is important to note, moreover, that while understanding and applying sociotechnical system theory as an approach to quality improvement in health care includes identifying what interfaces are weak or when and where processes break down and errors occur, this is only part of the picture. Recently, health care quality experts have been providing additional support for understanding what makes care delivery go well in so many of these complex systems -- the majority of the time.
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A health care system should be designed and structured in a way that makes it easy for patients to access quality health care and easy for providers to deliver such care. Such an approach draws on the field of HFE, which is defined: the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance.
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Despite multiple patient deaths throughout the 1990s, the response initially was limited to providing additional nurse training, thus overlooking the design of the PCA as the source of error. This is reflective of a broader trend in relation to how faulty medical devices were evaluated.
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This issue, coupled with poor product design, likely contributed to the rising numbers of PCA pump–related patient deaths. In response, the PCA pump manufacturer injected human factors expertise into management levels and product design processes -- a strategy that can be used to improve health care quality in other settings.
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highlights the importance of processes for health care outcomes, it does not allow for in-depth analysis of the interactions that occur within a system, nor does it account for the experiences of patients and providers. In response to this gap, the literature on sociotechnical systems has proposed an expanded SPO model -- the Systems Engineering Initiative for Patient Safety (SEIPS)
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What in the organization promotes or hinders patient safety and other quality domains? Following a root-cause analysis of unexpected deaths in the Hamad Medical Corporation (HMC)
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. The crucial roles of sociotechnical systems, human factors, and the interactions within the work system make it clear that to improve the patient journey and health care quality, health care leaders need to build a truly person-centered health system.
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NOTE: This framework integrates Berwick's (2002) system levels and the adapted quality dimensions of Crossing the Quality Chasm (IOM, 2001)
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Health care delivery does not always seek to achieve all six of the quality dimensions identified in Crossing the Quality Chasm (IOM, 2001) , often delivering on only a few of them.
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Care is integrated and coordinated across the patient journey. As discussed in Chapter 1, health care currently is fragmented and siloed, often involving multiple providers at multiple facilities who may even be in different networks and often do not share information with one another.
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Thus, by attempting to identify the upstream causes of poor outcomes, a health care system can achieve better health outcomes. The capacity for such analysis has been realized in vari ous existing learning health care systems and has benefited from innovative team-based health care models that include ancillary health care workers, such as those in social work and community health workers.
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While ambitious, such a model has already been launched at Hospital Italiano in Buenos Aires.2 2 Hospital Italiano in Buenos Aires, Argentina, has a portfolio of health informatics, housed in a stand-alone department that was established in 1999 within the health care network. Department personnel are from backgrounds such as sociology, anthropology, research, technology development, and engineering and include medical students to inform how digital health technologies are being used and how they can improve.
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First, by specifying a systems-thinking approach for the transformation of care delivery and calling for consideration of the needs of patients and health care staff, the design principles envision care that acknowledges a person's self-determination and personal preferences and reflects respect for choices while also supporting health workers and providing employment conditions that are safe and promote their well-being. An indicator of whether these characteristics are being achieved is increased health literacy and effective communication among all parties.
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For those without sick days or paid time off, missing work to travel to a health care facility can impose an enormous opportunity cost, making patients less likely to access care. Finally, the committee wishes to emphasize that, although ambitious, its design principles are within reach of many health care systems in LMIC settings, and are often already being used.
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PurpleSource aggregates such facilities and deploys financial management, SafeCare quality certification, and technology solutions to inte grate care across facilities. It also works with patients to understand what matters to them, using a deep customer development focus to build services around their priori ties.
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Hospital In response to economic pressure and decreasing levels of health care quality, the government of Ecuador initiated reforms in 2012 with the goals of consolidating the public health network, improving the quality of care, and expanding health coverage. As a result of prolonged government neglect, AGP Hospital experienced frequent instances of contracted services, being overcrowded with patients, and other forms of reduced capacity to provide quality health care.
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Health systems need to embrace a vision of the patient journey that is anticipatory, not reactive, and wholly centered on continually improving the experience of patients, families, and communities. Recommendation 2-1: Fundamentally Redesign Health Care Using Systems Thinking Health care leaders should dramatically transform the design of health care systems.
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2002. A user's manual for the IOM's "quality chasm" report.
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2016a. Applying human factors and usability en gineering to medical devices: Guidance for industry and Food and Drug Administration staff.
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2002. Health care quality improvement in Mexico: Challenges, opportunities, and progress.
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2003. Using usability heu ristics to evaluate patient safety of medical devices.
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