The health care system in the United States has been the subject of
much debate as experts try to determine the best way to deliver high-quality
care. The research and resources on system design of the Agency for Healthcare
Research and Quality (AHRQ) complement and build on many other AHRQ programs.
Below are examples of research, resources, and tools on system design developed
with support from AHRQ.
Contents
Introduction
Research
Organization of Care
Health Care Work
Environment
Resources and Tools
For More Information
References
Introduction
The health care system in the United States has been the subject of much debate as experts attempt to determine the best
way to deliver high-quality care. In Crossing the Quality Chasm,1 the Institute of Medicine (IOM) called for the redesign of health care delivery
systems and their external environments to promote care that is safe,
effective, patient-centered, timely, efficient, and equitable. AHRQ conducts
and supports research to inform providers, insurers (including the Centers for
Medicare & Medicaid Services), policymakers, and other stakeholders about
system designs that promote the IOM's aims. AHRQ also provides information
about implementation processes that facilitate and sustain design initiatives.
Health care delivery systems are complex sociotechnical
systems, characterized by dynamic interchanges with their environments (e.g.,
markets, payers, regulators, and consumers) and interactions among internal
system components. These components include people, physical settings,
technologies, care processes, and organization (e.g., rules, structure,
information systems, communication, rewards, work flow, culture).2 Systems design research examines interactions among system components and their
possible impact on quality and cost. Systems design resources and tools provide
guides to changes in system design (also known as redesign) that can enhance
value.
Value may be enhanced by improving quality while reducing or
maintaining cost. Value is also increased when systems reduce waste and
inefficiency while maintaining or improving quality. To foster sustainable
value improvements, design initiatives often bundle changes in several mutually
reinforcing system components (e.g., information technology, process redesign,
and training programs).3
AHRQ's research and resources on system design
complement and build on many other AHRQ programs. Below are examples of
research, resources, and tools on system design developed with support from
AHRQ. Many of the items listed were funded under AHRQ's Patient Safety and
Health Information Technology (IT) portfolios.
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Research
Organization of Care
Wears RL, ed. Organizations and safety in health care. Qual
Saf Health Care 2004 Dec;13 (Suppl).
This
AHRQ-sponsored journal supplement examines the influence of higher level organizational
factors on safety and introduces theoretical and empirical work on safety to
those who may not be familiar with this literature. The papers explore
organizational learning, organizational conditions affecting safety, and
leadership.
Jiang J, Friedman
B, Begun J. Factors associated with quality/low-cost hospital performance. J
Health Care Finance 2006 Spring;32:39-52.
Jiang J, Friedman B, Begun J.
Sustaining and improving hospital performance: the effects of organizational
and market factors. Health Care Manage Rev 2006;31(3):188-96.
These two studies explore organizational and
market characteristics associated with superior hospital performance with
regard to both quality and cost of care. The research uses AHRQ's Healthcare Cost and Utilization Project (HCUP)
State Inpatient Databases for 10 States.
Tucker A, Singer S, Hayes J, et al. Frontline perspectives on
opportunities for improving the safety and efficiency of hospital work systems.
Harvard Business School Working Paper 08-015. 2007. Available from atucker@hbs.edu.
This paper explores systemic gaps in efforts
to improve patient safety and efficiency, based on observations of senior
managers and frontline staff in 20 U.S. hospitals. It recommends giving
priority to improvements in work systems in general, rather than targeting
specific clinical conditions. This is the first paper to result from a study supported by an AHRQ grant, Improving Safety Culture and Outcomes in
Healthcare, and by
the Fishman-Davidson Center for Service and Operations Management at the Wharton School.
Begun J, Jiang J. Changing organizations for their likely
mass-casualties future. Adv Health Care Manage 2004;4:163-80.
Drawing on complexity science, the authors
provide recommendations for transforming health care organizations into more
resilient learning organizations capable of managing unexpected events.
Behara R, Wears RL, Perry S.J., et al. A conceptual framework for studying
the safety of transitions in emergency care. In: Henriksen K, Battles J, Marks
E, et al., eds. Advances in patient safety: from research to implementation.
Vol. 2, Concepts and methodology. Rockville, MD: Agency for Healthcare Research
and Quality; 2005. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.2879.
This paper reports on
observations of transitions of care in five hospital emergency departments and
develops a conceptual framework for characterizing handover events. The
framework contributes to future research and to selecting interventions that
better fit the context of clinical work.
Reinertsen J, Clancy C. Keeping our promises: research, practice, and
policy issues in health care reliability. Health Serv Res 2006 August;41(4,
part II):1535-38 (available as AHRQ Publication No. 06-RO74).
This AHRQ-sponsored supplement
contains articles on the factors that contribute to high reliability in health
care delivery systems and explores lessons about reliability from other
industries.
McDonald KM, Sundaram V, Bravata, DM, et al. Closing the Quality Gap: A
Critical Analysis of Quality Improvement Strategies: Vol. 7, Care Coordination.
Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville, MD: Agency for Healthcare
Research and Quality, June 2007. AHRQ Publication No. 04(07)-0051-7. http://www.ahrq.gov/clinic/tp/caregaptp.htm.
This report develops a working
definition of care coordination and provides a systematic research review. It
also identifies theoretical frameworks that might predict or explain how care
coordination mechanisms are influenced by factors in the health care setting
and how they relate to patient outcomes and health care costs.
Savitz L. Cost of waste/poor quality. PowerPoint® presentation. AHRQ 2007 Annual Conference:
Improving Healthcare, Improving Lives; 2007 Sept 26-28; Bethesda, MD. http://www.blsmeetings.net/2007AHRQANNUAL/agenda_thur.cfm.
This presentation provides an overview of a study of the
extent of waste in hospitals. It reports that nearly half of the resource use
in hospitals involves potentially recoverable forms of waste. The presentation
indicates how the authors assessed waste and reports that waste is primarily
due to inefficient systems, high variability in work processes, and a
workaround culture.
Wallace C, Savitz L. Estimating waste in frontline health care worker
activities. J Eval Clin Pract 2008;14(1):178-80.
This publication reports on part of the study of waste
mentioned in the previous listing. The authors found that hospital workers
encounter substantial waste as they perform their duties. The paper describes
their methods for identifying and quantifying the extent of waste.
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Health Care Work Environment
Kane R, Shamliyan T, Mueller C, et al. Nurse Staffing and Quality of
Patient Care. Evidence Report/Technology Assessment Number 151 (Prepared by the
Minnesota Evidence-based Practice Center under Contract No. 290-02-0009). Rockville, MD: Agency for Healthcare Research and Quality, March 2007. AHRQ Publication No.
07-E005. http://www.ahrq.gov/clinic/tp/nursesttp.htm.
This evidence report documents the effects of nurse staffing
on quality.
Harrison M, ed. Improving the health care work environment to promote
quality and safety. Jt Comm J Qual Patient Saf 2007 November;33 (Suppl).
Available as AHRQ Publication OM 08-0007.
This AHRQ-sponsored journal supplement reviews evidence on
the effects of working conditions on the quality of health care. The papers
examine persistent threats to patient safety in hospital work environments and
present options for improvement. The supplement contains six papers, five of
them written by AHRQ-funded researchers or staff members, along with an
introduction and afterword.
Stone P, Harrison MI, Feldman P, et al. Organizational climate of staff
working conditions and safety—an integrative model. In: Henriksen K, Battles J,
Marks E, et al., eds. Advances in patient safety: from research to
implementation. Vol. 2, Concepts and methodology. Rockville, MD: Agency for
Healthcare Research and Quality; 2005. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.3614.
This paper compares measures of organizational climate in
ongoing patient safety studies and develops a model of climate domains that are
hypothesized to affect outcomes across settings. It also tests aspects of the
model with data from six separate AHRQ-funded studies.
Kralewski J. Organizational factors influencing patient safety/quality in
medical group practices. PowerPoint presentation. AHRQ 2007 Annual Conference:
Improving Healthcare, Improving Lives; 2007 Sept 26-28; Bethesda, MD. http://www.blsmeetings.net/2007AHRQANNUAL/agenda_wed.cfm
This presentation summarizes findings from four studies of
the effects of organizational and payment factors on measures of patient safety
and quality in ambulatory settings.
Nelson C, West T, Goodman C. The Hospital Built Environment: What Role
Might Funders of Health Services Research Play? (Prepared by The Lewin Group
under Contract No. 290-04-0011). Rockville, MD: Agency for Healthcare Research
and Quality, August 2005. AHRQ Publication No. 06-0106-EF. http://www.ahrq.gov/qual/hospbuilt/.
This report summarizes evidence
to date about relationships between the built environment in hospitals (i.e.,
its physical features) and patient outcomes, safety, and satisfaction, as well
as hospital staff safety and satisfaction. The report discusses research needs
and implications for current practice.
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Resources and Tools
Efficiency Measures
McGlynn E. Identifying, categorizing, and evaluating healthcare efficiency
measures. PowerPoint presentation. AHRQ 2007 Annual Conference: Improving
Healthcare, Improving Lives; 2007 Sept 26-28; Bethesda, MD. http://www.blsmeetings.net/2007AHRQANNUAL/agenda_fri.cfm.
This presentation summarizes an AHRQ-commissioned report
titled "Identifying, Categorizing, and Evaluating Health Care Efficiency
Measures." The report identifies and describes existing measures of health care
efficiency, organizes them into a typology, and evaluates them according to
broad criteria.
Systemwide Transformation
Arnold SB, editor. Transforming Health Systems Through Leadership, Design,
and Incentives. Invitational Meeting Sponsored by Agency for Healthcare
Research and Quality, Centers for Medicare and Medicaid Services, National
Cancer Institute, and Health Affairs. 2004 Oct 18-19; Rockville. Rockville, MD: Centers for Medicare & Medicaid Services; 2005. http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/MMA646_Conference_Proceedings_p.pdf [PDF Help].
These are proceedings from an expert meeting at which
participants reviewed prospects for better aligning payment and system design,
along with opportunities for redesign within the context of current payment
systems.
Wang M, Hyun J, Shortell M, et al. Redesigning health systems for quality:
lessons from emerging practices. Jt Comm J Qual Patient Saf 2006
November;32:599-611.
This article
reports on an AHRQ-funded scan of redesign practices among leading health
systems. The authors develop an integrated systems approach to redesign, which
reflects the success factors observed in the scan. Recommendations are included
for payers, providers, and policymakers.
Gabow P, Eisert S, Karkhanis A, et al. A Toolkit for Redesign in Health
Care. (Prepared by Denver Health under Contract No. 290-00-0014-7). Rockville, MD: Agency for Healthcare Research and Quality, September 2005. AHRQ Publication
No. 05-0108-EF. http://www.ahrq.gov/qual/toolkit/.
Managing and
Evaluating Rapid-Cycle Process Improvements as Vehicles for Hospital System
Redesign. (Prepared by Denver Health under Contract No.
290-00-0014). Rockville, MD: Agency for Healthcare Research and Quality,
September 2007. AHRQ Publication No. 07-0074-EF. http://www.ahrq.gov/qual/rapidcycle/.
Denver
Health initiated a systemwide change initiative that sought to transform its
physical environment, culture, reward system, staffing, and processes. To drive
process redesign, it applied Toyota Production Systems/Lean methods throughout
its delivery system. This effort is documented in the report and the toolkit cited above. Both publications contain lessons learned and recommendations for providers.
Getting Lean: health care's challenge. A "Lean" training and health care
system redesign conference. 2005 Oct 19-21; Denver. Denver: Denver Health;
2005. http://www.denverhealth.org/gettingLean.
These are proceedings from a
conference on applying Toyota Production Systems/Lean to health care. The
conference was organized and hosted by Denver Health with support from AHRQ.
Members of several health systems presented their experiences in applying Lean
to improve quality and efficiency.
Process Redesign
Anthony D, Chetty VK, Kartha A, et al. Reengineering the hospital
discharge: an example of a multifaceted process evaluation. In: Henriksen K,
Battles J, Marks E, et al., eds. Advances in patient safety: from research to
implementation. Vol. 2, Concepts and methodology. Rockville, MD: Agency for
Healthcare Research and Quality; 2005. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.3224
To better understand the current
hospital discharge process, the researchers applied a battery of epidemiologic
and quality control methods taken from industry. In this paper they describe
each of these methods and discuss their experience with them, displaying
concrete tools that have arisen from their application.
Greenwald J, Denham C, Jack B. The hospital discharge: a review of a high
risk care transition with highlights of a reengineered discharge process. J
Patient Saf 2007 June;3(2):97-106.
This article reviews the modifiable components of the
hospital discharge process that may increase or reduce the risk of adverse
events and rehospitalizations. These components include characteristics of the
hospital, patient, and clinician. Using multimethod analysis, the investigators
describe the principles thought to be important to the discharge process. They
also delineate 11 discrete and mutually reinforcing components that are
believed to contribute to safe discharge. See below for a toolkit derived from
this study.
Jack B. Project RED toolkit. Downloadable files from Project RED
(Re-Engineered Discharge). http://www.bu.edu/fammed/projectred/.
Accessed May 20, 2008.
This toolkit provides resources for redesigning the process
of discharging patients to reduce postdischarge adverse events and subsequent
rehospitalizations. The toolkit includes discharge training and instructional
manuals and software, patient education materials, instructions for telephone
reinforcement of the discharge plan, and guidelines for medication
reconciliation.
This toolkit includes
implementation tools for redesigning the flow of patients in the emergency room
in order to reduce waiting time and enhance capacity. The intervention consists
of a patient-flow process change that splits patients into less sick and sicker
patient subgroups. Less sick patients receive a quick look, rather than full
triage. The toolkit explains how to analyze patient flow and facilitate change
among clinical staff.
Raab S. Implementation of Lean in laboratory medical services, PowerPoint
presentation. AHRQ 2007 Annual Conference: Improving Healthcare, Improving
Lives; 2007 Sept 26-28; Bethesda, MD. http://www.blsmeetings.net/2007AHRQANNUAL/agenda_thur.cfm.
This presentation describes applications to laboratory
services of Lean methods as developed within Perfecting Patient Care™ by
Pittsburgh Regional Healthcare. The presentation provides data on the resulting
quality and cost improvements.
Redesign for Quality and Safety
Hines S, Luna K, Lofthus J, et al. Becoming a High Reliability
Organization: Operational Advice for Hospital Leaders. (Prepared by The Lewin
Group under Contract No. 290-04-0011.) Rockville, MD: Agency for Healthcare
Research and Quality, February 2008. AHRQ Publication No. 08-0022. http://www.ahrq.gov/qual/hroadvice/.
This publication discusses five key characteristics of high reliability organizations (HROs) and their application to hospitals:
- Sensitivity to operations.
- Reluctance to simplify.
- Preoccupation with failure.
- Deference to expertise.
- Resilience.
The document reflects the experiences and insights of leaders from 19 health
care systems who participated in an AHRQ Learning Network on HRO. For over a
year, leaders from these systems met to discuss their successes and challenges
in operationalizing HRO concepts in their organizations. In particular, the
document shares insights gathered from five site visits to learning network
member hospitals.
Transforming Hospitals: Designing for
Safety and Quality, DVD. AHRQ Publication No.
07-0076-DVD. http://www.ahrq.gov/qual/transform.htm#order (order form).
This DVD, available free from the Agency for Healthcare Research and
Quality reviews the case for evidence-based hospital design. The DVD discusses
how evidence-based design increases patient and staff satisfaction and safety,
quality of care, and employee retention and results in a positive return on
investment. Also see "The Hospital Built Environment: What Role Might Funders
of Health Services Research Play?"
Fairbanks RJ, Hays A, Webster D, et al. Clinical pharmacy services in an
emergency department. Am J Health-Syst Pharm 2004;61:934-7.
This report describes the pilot
testing of an emergency department-based clinical pharmacist program. It
discusses costs of the program and strategies used to overcome barriers to
implementation.
This toolkit is designed to
facilitate the implementation of an emergency department pharmacist program to
improve medication safety. The toolkit includes a description of the formal,
optimized role of the emergency department pharmacist; discussion of challenges
and accompanying solutions to implementing emergency department pharmacist
programs; and evidence to support the efficacy of such programs, including
documentation of the cost savings that can be obtained by reducing adverse
events and avoiding inappropriate use of expensive medications.
Page, A, ed. Keeping patients safe: transforming
the work environment of nurses. Institute of Medicine. Washington, DC: National Academies Press; 2004. http://www.iom.edu/CMS/3809/4671/16173.aspx.
This report calls for substantial
changes in nurses' work environment, including staffing levels and work hours,
to protect patients from health care errors.
Sharkey S. On-time quality improvement for long term care: redesigning work
flow. PowerPoint® presentation. AHRQ 2007 Annual Conference: Improving
Healthcare, Improving Lives; 2007 Sept 26-28; Bethesda, MD. http://www.blsmeetings.net/2007AHRQANNUAL/agenda_thur.cfm
This presentation describes how documentation and
communication processes in long-term care facilities were redesigned and
Certified Nursing Assistants' time was used more efficiently with the help of
an inexpensive health IT device. The redesign substantially reduced pressure
ulcers while saving costs for the nursing home.
Daugherty K. Improving patient safety through
enhanced provider communication. http://www.safecoms.org.
This toolkit provides clinicians and other health care professionals
with the tools to implement teamwork and communication strategies in their
practice settings to improve patient safety. The toolkit contains a
framework for specific communication strategies, educational materials, and
evaluation and analysis tools. The toolkit was used
to implement safe team communication practices at Denver Health Medical Center. Improving communication is one of the five main components of Denver
Health's system design transformation (Go to Managing
and Evaluating Rapid-Cycle Process Improvements as Vehicles for Hospital System
Redesign, described above.)
Enhancing Minority Health,
Cultural Competency, and Health Literacy
Beach M, Cooper L, Robinson K, et al. Strategies
for Improving Minority Healthcare Quality. (Summary Evidence
Report/Technology Assessment: Number 90.) Rockville, MD: Agency for Healthcare
Research and Quality, January 2004. AHRQ Publication No. 04-E008-1. http://www.ahrq.gov/clinic/tp/minqualtp.htm.
This report synthesizes research on strategies that can help health care providers or organizations enhance cultural competency and
improve minority health care quality.
Andrulis D, Brach C. Integrating literacy, culture, and language to improve
health care quality for diverse populations. Am
J Health Behav 2007;31(Suppl 1):S122-S133. Reprinted as AHRQ
Publication No. 07-R079.
To improve care for diverse patients with limited health
literacy, health care organizations must make changes in their delivery
systems. Leadership and senior management must be willing to invest in
training, staffing, and physical plants. The authors present a vision for an
integrated approach to health literacy and cultural and linguistic competence
that illustrates the important roles that both clinicians and health care
organizations play.
Brach C, Paez K, Fraser I. Cultural Competence California Style. Rockville, MD: Agency for Healthcare Research and Quality Working Paper No. 06001, February
2006. http://www.gold.ahrq.gov/pdf/70.pdf [PDF Help].
California health plans have led the country in implementing innovative
practices to improve health care for diverse populations. This article reports
on eight leading California plans' cultural competence activities and how they
were influenced by California's promulgation of cultural and linguistic
competence standards for public insurance programs.
Implementing Information
Technology and Other Health Technologies
Langley J, Beasley C. Health information technology for improving quality
of care in primary care settings. (Prepared by the Institute for Healthcare
Improvement for the National Opinion Research Center under contract No. 290-04-0016.)
AHRQ Publication No. 07-0079-EF. Rockville, MD: Agency for Healthcare Research
and Quality; July 2007. http://healthit.ahrq.gov/portal/server.pt/gateway/ PTARGS_0_1248_661809_0_0_18/AHRQ_HIT_Primary_Care_July07.pdf. [PDF Help]
The authors identify effective change ideas for implementing
and spreading health IT to large numbers of primary care practices. The guide
shows how to use IT to support system improvements, as well as to improve
efficiency.
Karsh B. Embracing technology is dumb. Embracing
Well-designed technology is smart. PowerPoint® presentation. AHRQ 2007
Annual Conference: Improving Healthcare, Improving Lives; 2007 Sept 26-28; Bethesda, MD. http://www.blsmeetings.net/2007AHRQANNUAL/agenda_wed.cfm.
This presentation explains and illustrates the human factors
engineering perspective on the importance of integrating health technologies
with the needs of the individual users and the work system in which the
technology will operate.
Sociotechnical features (such as workflow, organizational
culture, and staff attitudes) must be incorporated into the design and
implementation of health IT systems if they are to succeed. At this Web
conference, AHRQ grantees discuss strategies for the successful incorporation
of health IT in health care practices. This Webcast will be useful both to
those designing Health IT systems and to those working to implement them.
PowerPoints of the presentations and a bibliography of sociotechnical resources
are also available at the above URL.
Harrison M, Koppel R, Bar Lev S. Reducing unintended
consequences of health information technology through interactive
sociotechnical analysis. J Am Med Inform Assoc 2007 September;14:542-9.
When health care information technologies (Health IT) are
implemented to promote system improvement, they often produce unintended
consequences. These Health IT side effects flow from interactions between
Health IT and the health care organization's sociotechnical system. This
paper develops and illustrates a model of common types of sociotechnical
interaction that produce such unintended consequences.
Delivering Care During
Emergencies
Phillips SJ, Knebel A, eds. Mass Medical Care With Scarce Resources: A
Community Planning Guide. (Prepared by Health Systems Research, Inc., an
Altarum company, under Contract No. 290-04-0010.) AHRQ Publication No. 07-0001.
Rockville, MD: Agency for Healthcare Research and Quality; 2007. http://www.ahrq.gov/research/mce/.
Mass casualties resulting from a
catastrophic public health- or terrorism-related event (e.g., an influenza
pandemic or the detonation of an improvised nuclear device) will likely
overwhelm the resources of a community's health care system. This guide
provides planners at the facility/community, State, and Federal levels with
valuable approaches and strategies for planning and responding to a mass
casualty event.
Return to Contents
For More Information
For more
information, contact:
Michael I. Harrison, Ph.D.
Senior Research Scientist—Organizations and Systems
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
540 Gaither Rd.
Rockville, MD 20850
Phone: (301) 427-1434
Michael.Harrison@ahrq.hhs.gov
Printed copies of reports with an AHRQ
publication number are available free of charge from the AHRQ Publications
Clearinghouse via phone at
800-358-9295 or E-mail at AHRQPubs@ahrq.hhs.gov.
Mention the publication number when ordering.
For more information on system design for
quality and safety, go to: http://www.psnet.ahrq.gov.
For more information on use of health
information technology in system design, go to: http://healthit.ahrq.gov/portal/server.pt.
For further information on system design
innovations, go to: http://www.innovations.ahrq.gov/.
Return to Contents
References
1. Institute of Medicine. Crossing
the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.
2. Harrison K, Henriksen R, Hughes RG. Improving the health care
work environment: a sociotechnical systems approach. Jt Comm J Qual Patient Saf
2007 Nov;33(11 Suppl):3-6.
3. Wang
M, Hyun J, Harrison M, et al. redesigning health systems for quality: lessons
from emerging practices. Jt Comm J Qual Patient Saf 2006 Nov;32(11):599-611.
Return to Contents
Publication
No: AHRQ 08-M050-EF
Current
as of June 2008
Internet Citation:
AHRQ Resources on Systems Design. June 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/systemdesign.htm
540 Gaither Road Rockville, MD 20850