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
Improving Efficiency and Value
Organizational Improvement and Transformation
Organization of Care
Health Care Work Environment
Resources and Tools
Efficiency Measures
Systemwide Transformation
Performance Improvement
Process Redesign
Redesign for Quality and Safety
Enhancing Minority Health, Cultural Competency, and Health Literacy
Implementing Information Technology and Other Health Technologies
Delivering Care During Emergencies
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
Improving Efficiency and Value
Fraser I, Encinosa W, Glied S. Improving efficiency and value in health care. Health Serv Res 2008 Oct;43(5 Pt 2):1781-6.
This theme issue of Health Services Research includes an introduction and 7 state-of-the-art research studies on improving efficiency and value in health care. The studies include examinations of 21 quality improvement (QI) programs in Minnesota hospitals; impact of the Group Health Cooperative's Access Initiative on physician productivity; frontline staff perspectives on opportunities for improving safety and efficiency in hospital work systems; effects of a tiered hospital network on hospital admissions; efficiency of specialty hospitals in the United States; efficient use of physician assistants across the country; and efficiency of 1,377 U.S. hospitals. Brief summaries appear at http://www.ahrq.gov/research/dec08/1208RA7.htm.
James B, Bayley KB. Cost of poor quality or waste in integrated delivery system settings. Final report. Rockville, MD: Agency for Healthcare Research and Quality; September 2008. AHRQ Publication No. 08-0096-EF. Available at: http://www.ahrq.gov/research/costpqids.
An estimated 30 percent of health care costs are attributable to waste. The average cost of poor quality is $1,500 per patient per year. Examples of poor quality and/or waste in health care are diverse and include: clinician interruptions, duplicated or repeat testing/procedures, delays in care, inefficient use of clinician time, improper documentation/record keeping, iatrogenesis, and patient injuries. The authors examine existing approaches for capturing the costs of waste/poor quality and present specific examples of these estimates. Drawing on available constructs from the literature, the authors then identify a model for estimating waste at the population, episode, and patient levels.
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.
Zinn JS, Spector WD, Weimer DL, et al. Strategic orientation and nursing home response to public reporting of quality measures: an application of the Miles and Snow typology. Health Serv Res April 2008;43(2):598-615.
This article reports on the response of nursing home administrators to the first publication of the Nursing Home Compare Report in 2004. Administrators were also asked to select the strategic orientation that best characterized their facility, based on the typology developed by Miles and Snow. The researchers noted an association between whether/how a facility responded to the Nursing Home Compare Report and its strategic orientation.
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Organizational Improvement and Transformation
Brokel J, Harrison M. redesigning care processes using an electronic health record: a system's experience. Jt Comm J Qual Patient Saf 2009;35 (Feb.):82-92.
The paper describes how Trinity Health, a major integrated delivery system, successfully leveraged implementation of a systemwide electronic health record to promote process redesign and continuous quality improvement.
Harrison M, Kimani J. Building capacity for a transformation initiative: system redesign at Denver Health. Health Care Manage Rev 2009 Jan-Mar;34(1):42-53.
This paper presents a case study of the first 2 years of a system design initiative at Denver Health and an analysis of developments during the preceding decade. These developments created positive antecedents for the transformation initiative. Practice and research implications are discussed.
Alexander JA, Hearld LR, Jiang HJ, et al. Increasing the relevance of research to health care managers: hospital CEO imperatives for improving quality and lowering costs. Health Care Manage Rev 2007 Apr-Jun;32(2):150-9.
This qualitative study identifies how hospital leaders view key determinants of quality and costs and how they think about solutions to these issues. The hospital leaders tend to think systemically and consider process-related factors as important cost and quality drivers.
Wang M, Hyun J, Shortell M, et al. Redesigning health systems for quality: lessons from emerging practices. Jt Comm J Qual Patient Saf 2006 Nov;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.
Alexander JA, Weiner BJ, Shortell SM, et al. Does quality improvement implementation affect hospital quality of care? Hosp Top 2007 Spring;85(2):3-12
Expanding on the analysis by Weiner, et al., below, the authors examined how the association between quality improvement (QI) implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. Forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators, specifically, data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.
Weiner BJ, Alexander JA, Baker LC, et al. Quality improvement implementation and hospital performance on patient safety indicators. Med Care Res Rev 2006 Feb;63(1):29-57.
This study examines the association between scope of quality improvement (QI) implementation in hospitals and hospital performance on patient safety indicators. In a sample of 1,784 community hospitals, involvement by multiple hospital units in the QI effort was associated with worse values on all four patient safety indicators. Percentages of hospital staff and of senior managers participating in QI teams exhibited no statistically significant association with any patient safety indicator. Percentage of physicians participating in QI teams was associated with better values on two patient safety indicators.
Weiner BJ, Alexander JA, Shortell SM, et al. Quality improvement implementation and hospital performance on quality indicators. Health Serv Res 2006 Apr;41(2):307-34.
Analysis of the same data set shows that Involvement by multiple hospital units in QI efforts is associated with worse values on hospital-level quality indicators. Percentage of hospital staff and percentage of senior managers participating in formally organized QI teams are associated with better values on quality indicators. Percentage of physicians participating in QI teams is not associated with better values on the hospital-level quality indicators studied.
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Organization of Care
Coleman K, Austin B, Brach C, et al. Evidence on the chronic care model in the new millennium. Health Affairs 2009;28(1):75-85.
Accumulated evidence since 2000 appears to support the Chronic Care Model (CCM) as an integrated framework to guide practice redesign. These studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes. Work remains to be done in areas such as cost-effectiveness.
Jiang, H. et al. Board oversight of quality: any differences in process of care and mortality? Journal of Healthcare Management, 54 (1) 15-30.
This study found that board commitment to quality, involvement in setting a quality agenda, and exercising oversight of quality performance are associated with higher quality, as measured by performance in care processes and risk-adjusted mortality.
Thomas JC, Carter C, Torrone E, et al. Pulling together: interagency coordination and HIV/STD prevention. J Public Health Manag Pract 2008 Jan-Feb;14(1):E1-E6.
This study analyzed 170 HIV prevention agencies in 10 counties in North Carolina and found a relationship between interagency coordination and prevention of HIV and STDs.
Rodriguez HP, Marsden PV, Landon BE, et al. The effect of care team composition on the quality of HIV care. Med Care Res Rev 2008 Feb;65(1):88-113.
This study uses data from the HIV Cost and Services Utilization Study to assess the effect of care team composition on the quality of HIV care. The study examines advantages of having multiple clinicians with condition-specific expertise and complementary knowledge, skills, and roles, as well as disadvantages arising from problems in care coordination and decreased continuity of care.
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.
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. Cambridge, MA: Harvard University, 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.
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.
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.
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.
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.
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.
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Health Care Work Environment
Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, National Research Council. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Washington, DC: National Academies Press; 2008. Available at: http://www.iom.edu/CMS/3809/48553/60449.aspx 
This IOM committee report recommends: protected sleep periods, limits on work hours for residents, redesigned schedules, increased resident training on better communication during handovers, and more involvement of residents in patient safety activities and adverse event reporting.
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.
Hoff T. How work context shapes physician approach to safety and error. Qual Manag Health Care 2007 Apr-Jun;17(2):140-53.
This article examines how the work environment (e.g., workload, relationships among physicians) affects patient safety behaviors in the surgery, medical intensive care unit (ICU), and emergency departments of an academic medical center. The author found that the medical ICU had the highest potential capacity for dealing with patient safety and quality of care. The article also discusses interventions most likely to improve patient safety in each setting.
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.
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.ahrq.gov/about/annualmtg07/0926slides/kralewski/Kralewski-contents.html
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.
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.
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.ahrq.gov/about/annualmtg07/0928slides/mcglynn/McGlynn-contents.html.
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.
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Systemwide Transformation
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 HROs. For more than 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.
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/.
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/.
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.
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.
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.
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Performance Improvement
Rundall TG, Martelli PF, Arroyo L, et al. The informed decisions toolbox: tools for knowledge transfer and performance improvement. J Healthc Manag 2007 Sep-Oct 2007;52(5):325-41; discussion 341-2.
Decisionmakers do not always use research evidence when making decisions about the organization and financing of health care. The Informed Decisions Toolbox describes six steps to assist health care decisionmakers in acquiring the best available evidence when making management decisions; assessing whether evidence is useful, defined as accurate, applicable, actionable, and accessible; and improving the process by which evidence is used in decisionmaking.
Brach C, Lenfestey N, Roussel A, et al. Will it work here? a decisionmaker's guide to adopting innovations. Rockville, MD: Agency for Healthcare Research and Quality; September 2008. AHRQ Publication No. 08-0051 http://www.innovations.ahrq.gov/resources/guideTOC.aspx
This new guide provides guidance about the full range of considerations for selecting appropriate health care delivery innovations and planning for their adoption. Individual sections address tasks such as assessing the suitability of innovations and an organization's readiness, and planning and executing implementation.
The Health Care Innovations Exchange (HCIE) is a searchable Web site designed to support health care professionals in sharing and adopting innovations that improve the delivery of care to patients. The Web site contains descriptions of a wide range of innovations, their impact, and how the innovations were developed and implemented. Among the many strategies and quality-related tools reported on the HCIE Web site are redesign innovations for enhancing access to care, reducing hospitalizations, and reducing costs through improved information technology-supported workflow, including:
- Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients
http://www.innovations.ahrq.gov/content.aspx?id=1746
This new care program improves reported health and saves $600-$1,000 per month in reduced rehospitalization expenditures. [AHRQ-supported project].
- Onsite Nurses Work With Primary Care Physicians To Manage Care Across Settings, Resulting in Improved Patient Satisfaction and Lower Utilization and Costs for Chronically Ill Seniors
http://www.innovations.ahrq.gov/content.aspx?id=1752
This initiative improves care for chronically ill seniors; specially trained nurses work with primary care physicians to coordinate care, facilitate care transitions, and act as patient advocates. Results include improvements in reported health and savings of 23 percent on readmission costs. [AHRQ-supported project].
- Unit-Based Safety Program Improves Safety Culture, Reduces Medication Errors and Length of Stay
http://www.innovations.ahrq.gov/content.aspx?id=1769
This initiative improves safety culture through a structured process in which a unit-based, multidisciplinary team identifies and prevents safety hazards. [AHRQ-supported project] .
- Adopting "Flow Management" Improves Efficiency, Throughput, and Quality of Care in Hospital Surgery Units
http://innovations.ahrq.gov/content.aspx?id=1714
This initiative implements principles of "flow management," borrowed from other industries, to redesign the flow of operations in one large hospital medical-surgical department.
- "Hospital at Home" Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients
http://innovations.ahrq.gov/content.aspx?id=1787
This initiative provides hospital-level care (including daily physician and nurse visits, diagnostic testing, treatment, and other support) in a patient's home as a full substitute for acute hospital care for selected conditions.
- Electronic Medical Record–Facilitated Care Process Redesign Enhances Access to Care, Reduces Hospitalizations and Costs for Patients With Chronic Illnesses
http://innovations.ahrq.gov/content.aspx?id=1725
This initiative redesigns patient care and workflow processes for chronically ill patients to take advantage of the organization's full-function EMR and wireless tablet personal computer technologies.
- Daily Intensive Care Unit Team Communication Enhances Provider Understanding of Care Goals, Reduces Length of Stay
http://innovations.ahrq.gov/content.aspx?id=260
This initiative redesigns ICU team communications.
- Acuity-Adaptable Inpatient Rooms Eliminate Most Patient Transfers, Leading to Enhanced Safety, Satisfaction, and Efficiency
http://innovations.ahrq.gov/content.aspx?id=1701
This initiative uses "acuity-adaptable" inpatient rooms as a means of keeping patients in the same room from admission until discharge, regardless of the patient's acuity level.
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Process Redesign
Harrison M and Moss D. Reducing waste and inefficiency in health care through Lean process redesign.
Our Nation's health service delivery systems face growing challenges to enhance quality while reducing costs. Lean/Toyota Production Systems (TPS) is a process redesign strategy developed in manufacturing that promises to help health care delivery systems meet these twin challenges. Lean/TPS is a method for eliminating "waste"—defined as any activity that consumes resources without enhancing value to those being served by the process. This literature review explores possible adaptation of Lean/TPS to health care settings.
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.)
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.
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.
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.ahrq.gov/about/annualmtg07/0927slides/raab/Raab-contents.html.
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.
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.ahrq.gov/about/annualmtg07/0927slides/sharkey/Sharkey-contents.html
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.
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.
Hagg HW, Workman-Germann J, Flanagan M, et. al. Implementation of systems redesign: approaches to spread and adoption. Advances in patient safety: from research to implementation. Vol. 2, Concepts and methodology. Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ Publication No. 05-0021-2. http://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Hagg_80.pdf [PDF Help]
The authors describe how they are applying Lean and systems engineering methods in 21 hospitals in an initiative to reduce methicillin-resistant Staphylococcus aureus (MRSA). The article discusses implementation strategy, business case analysis, assessment methods and provides examples of Lean and systems engineering tool applications.
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Redesign for Quality and Safety
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?"
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.
Battles JB, ed. Safety by design. Qual Saf Health Care 2006;15 (Suppl 1):i1-i3; doi:10.1136/qshc.2006.020347
Is it possible to actually "design-in" quality and "design-out" failure? This journal supplement approaches quality and safety as challenges for design, rather than quality improvement. The 15 papers discuss methods and approaches for design of health care facilities, organizations, clinical microsystems, clinical work processes, and information technology systems. Go to www.qshc.bmj.com/content/vol15/suppl_1/ for a detailed table of contents and abstracts.
Carayon P, Schoofs Hundt A, Karsh B-T, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006;15 (Suppl 1):i50-i58.
This article describes the Systems Engineering Initiative for Patient Safety (SEIPS) model (http://cqpi.engr.wisc.edu/seips_home/ ). The model describes the system components that can contribute to causes and control of medical errors and explores how design of the components and interactions between them can result in acceptable or unacceptable processes.
Adams-Pizarro I, Walker Z, Robinson J, et al. Using the AHRQ Hospital Survey on Patient Safety Culture as an intervention tool for regional clinical improvement collaboratives. Advances in patient safety: new directions and alternative approaches. Vol. 2, Culture and redesign. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-2.
http://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Adams-Pizarro_109.pdf [PDF Help]
Since its release in November 2004, the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) has been used by more than 400 hospitals across the country as a tool for assessing and measuring patient safety culture. HSOPS can be found at http://www.ahrq.gov/qual/hospculture/. This article describes the findings on use of the HSOPS to couple a safety culture approach with clinically relevant interventions in three hospital microsystems. The study examined effects of this combined approach on identifying, measuring, and redesigning processes of care to improve patient safety.
Dingley C, Daugherty K, Derieg MK, et. al. Improving patient safety through provider communication strategy enhancements. Advances in Patient safety: new directions and alternative approaches. Vol. 3, Performance and tools. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-3.
http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Dingley_14.pdf [PDF Help]
This article reports on implementation of interventions and strategies designed to improve patient safety through improved communications during rounds at an integrated urban safety net medical center. A toolkit was developed on teamwork and communications strategies.
Donaldson N, Rutledge D, Geiser K. Role of the external coach in advancing research translation in hospital-based performance improvement. Advances in patient safety: new directions and alternative approaches. Vol. 2, Culture and redesign. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-2.
http://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Donaldson_87.pdf [PDF Help]
This article describes implementation of an innovative telephone-based coaching intervention aimed at reducing the incidence and severity of patient falls at 33 California acute care hospitals from the preengagement to the closure phases. The article discusses feedback and self-assessment results from participating hospitals, as well as the impact of the intervention on fall-related policies and clinician practices.
Goeschel C, Pronovost P. Harnessing the potential of health care collaboratives: lessons from the Keystone ICU. Advances in patient safety: new directions and alternative approaches. Vol. 2, Culture and redesign. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-2.
http://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Goeschel_24.pdf [PDF Help]
This article describes results and lessons learned from a collaborative of 77 hospitals aimed at improving care by creating a culture of safety, reducing central line blood infections and ventilator-associated pneumonia, and improving compliance with evidence-based practices for ventilator care. See also: Daily Intensive Care Unit Team Communication Enhances Provider Understanding of Care Goals, Reduces Length of Stay.
Karsh B, Alper SJ. Work system analysis: the key to understanding health care systems. Advances in patient safety: from research to implementation. Vol. 2, Concepts and methodology. Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ Publication No. 05-0021-2.
http://www.ahrq.gov/downloads/pub/advances/vol2/Karsh.pdf
This paper shows how to use work systems analysis, which is based on industrial and human factors engineering tools, to analyze health care units or facilities and develop more robust patient safety interventions. Steps for executing a work system analysis are provided and illustrated for the medication administration system.
King H. TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety. Advances in patient safety: new directions and alternative approaches. Vol. 3, Performance and tools. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-3.
http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-King_1.pdf [PDF Help]
This article describes the research foundation, development, and implementation of TeamSTEPPS™, a multiyear research and development project jointly undertaken by the Department of Defense and AHRQ. TeamSTEPPS™ is composed of tools and strategies to improve team performance in health care. For more information, go also to: Webster J, King HB, Toomey LM, et al. Understanding quality and safety problems in the ambulatory environment: seeking improvement with promising teamwork tools and strategies. Advances in Patient Safety: New Directions and Alternative Approaches. Volume 3. Performance and tools. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034 3.
http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Webster_76.pdf. Tools are available at: http://www.innovations.ahrq.gov/content.aspx?id=2212
This article discusses types of safety problems and errors that can occur in ambulatory care settings and describes six evidence-based tools and strategies for addressing them. These strategies were developed under the TeamSTEPPS™ initiative and are designed to improve the quality and safety of patient care by improving teamwork and communication.
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.
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Enhancing Minority Health, Cultural Competency, and Health Literacy
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.
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.
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Implementing Information Technology and Other Health Technologies
Koppel R,. Wetterneck T, Telles JL, et al. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc 2008 Jul-Aug;15(4):408-23.
This study examined reasons for workarounds of bar-coded medication administration (BCMA) systems. The most common causes were organizational, in which workflow policies were incompatible with safety. Most workarounds resulted from poor process design, such as having to wake a patient to scan a wristband when providing IV medication.
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.
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.
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.ahrq.gov/about/annualmtg07/0926slides/karsh/Karsh-contents.html.
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.
Karsh B. Beyond usability for patient safety: designing effective technology implementation systems. Qual Saf Health Care 2004;13(5):388-94.
This paper examines organizational, job, individual, and technological factors affecting adoption of technologies capable of promoting safety and quality. It derives a set of organizational design guidelines for implementing new technologies.
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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.
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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/.
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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.
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Publication No: AHRQ 08-M050-EF
Current as of May 2009
Internet Citation:
AHRQ Resources on Systems Design. May 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/systemdesign.htm
540 Gaither Road Rockville, MD 20850