High-performing Health Care Research Articles

Process improvement in cardiac surgery: Development and implementation of a reoperation for bleeding checklist

High-performing health care organizations differentiate themselves by focusing on continuous process improvement initiatives aimed at enhancing patient outcomes. Reoperation for bleeding is an event associated with considerable morbidity risk. Hence, our primary objective was to develop and implement a formal operative checklist to reduce technical reasons for postoperative bleeding. From January 1, 2011, through June 30, 2012, 5812 cardiac surgical procedures were performed at Cleveland Clinic (Cleveland, OH). A multidisciplinary team developed a simple, easy-to-perform hemostasis checklist based on the most common sites of bleeding. An extensive educational in-service was performed before limited, then universal, checklist implementation. Geometric charts were used to track the number of cases between consecutive reoperations for bleeding. We compared these before (phase 0) and after the first limited implementation phase (phase 1) and the universal implementation phase (phase 2) of the checklist. The average number of cases between consecutive reoperations for bleeding increased from 32 in phase 0 to 53 in both phase 1 (P=.002) and phase 2 (P=.01). A substantial reduction in reoperation for bleeding cases followed implementation of a formalized hemostasis checklist. Our findings underscore the important influence of memory aids that focus attention on surgical techniques to improve patient outcomes in a complex, operative work environment.

Personnel reform in Chinese hospitals: policy interdependence and the challenge of coherent incrementalism

Health care in China is plagued with problems, including barriers to access, maldistribution of resources, inefficiencies and uneven quality. The management of human resources in the health care system has a significant effect on what happens in the clinic and the ward. The management of staff appointments and the remuneration system are two critical areas that remain problematic although they have received government attention. We argue that new approaches to policy development and implementation are needed to achieve a high-performance health care system. In particular, we suggest a new focus on the challenges of policy interdependence across sectors and among levels of administration. We highlight the need for a clear vision for health care, which would provide direction for the entire reform process, and also for a restructuring of the system of accountability.

Innovation more than an artefact? Conceptualizing the effects of drawing medicine into management

Innovation is increasingly viewed as a key behaviour for high-performing healthcare organizations of the future. The growing significance of chronic diseases including multi-morbidity, the emerging health workforce crisis, the persistent quality and safety problems as well as the accelerating costs of hospital care underline the urgency of finding better ways to deliver health services. Against this background, policy makers assume that involving doctors in management roles will not only enhance financial control and effective governance but also serve the innovation agenda. However, this relationship is not well understood as there is not sufficient research on the subject. In this positioning paper, we draw on a review of the existing literature on innovation and professions in general. Our objective is to explore the impact of medical participation in management on innovation, and provide a framework that conceptualises this relationship.

The Challenge of Advancing Quality in Canadian Primary Healthcare

Understanding the issues in advancing quality in Canadian primary healthcare requires some comprehension of systems theory as it applies to healthcare, as well as an understanding of the context of Canadian primary healthcare, particularly the roles of family physicians. With that background, one is then prepared to appreciate the current challenge in advancing the quality agenda, where provider learning of the content and skills of quality improvement and leading change, models of community or regional governance, and infrastructure such as information technology and its necessary supports for interoperability with other healthcare systems, are all primitive. For primary care providers, driven in large part by their desire to improve the health of the individuals and populations they serve, "Framework for Advancing Improvement in Primary Care" is a welcome guide for direction in how to begin their quality journey. The framework provides the map with the destination (the Institute for Healthcare Improvement's Triple Aim) and roads to get there (six characteristics of high-performing primary healthcare systems). Finally, our ability to improve the system builds from partnerships with our practice citizens - we need to move beyond the patient care construct.

Health care reform and the primary care workforce bottleneck.

To establish and sustain the high-performing health care system envisioned in the Affordable Care Act (ACA), current provisions in the law to strengthen the primary care workforce must be funded, implemented, and tested. However, the United States is heading towards a severe primary care workforce bottleneck due to ballooning demand and vanishing supply. Demand will be fueled by the "silver tsunami" of 80 million Americans retiring over the next 20years and the expanded insurance coverage for 32 million Americans in the ACA. The primary care workforce is declining because of decreased production and accelerated attrition. To mitigate the looming primary care bottleneck, even bolder policies will be needed to attract, train, and sustain a sufficient number of primary care professionals. General internists must continue their vital leadership in this effort.

Promoting cancer screening within the patient centered medical home

While consensus has grown that primary care is the essential access point in a high-performing health care system, the current model of primary care underperforms in both chronic disease management and prevention. The Patient Centered Medical Home model (PCMH) is at the center of efforts to reinvent primary care practice, and is regarded as the most promising approach to addressing the burden of chronic disease, improving health outcomes, and reducing health spending. However, the potential for the medical home to improve the delivery of cancer screening (and preventive services in general) has received limited attention in both conceptualization and practice. Medical home demonstrations to date have included few evidence-based preventive services in their outcome measures, and few have evaluated the effect of different payment models. Decreasing use of hospitals and emergency rooms and an emphasis on improving chronic care represent improvements in effective delivery of healthcare, but leave opportunities for reducing the burden of cancer untouched. Data confirm that what does or does not happen in the primary care setting has a substantial impact on cancer outcomes. Insofar as cancer is the leading cause of death before age 80, the PCMH model must prioritize adherence to cancer screening according to recommended guidelines, and systems, financial incentives, and reimbursements must be aligned to achieve that goal. This article explores capacities that are needed in the medical home model to facilitate the integration of cancer screening and other preventive services. These capacities include improved patient access and communication, health risk assessments, periodic preventive health exams, use of registries that store cancer risk information and screening history, ability to track and follow up on tests and referrals, feedback on performance, and payment models that reward cancer screening.

Pay-for-performance model of medication therapy management in pharmacy practice

ObjectiveTo use an existing pharmacist-run medication therapy management (MTM)/lifestyle medicine program to propose a new model of reimbursement for pharmacists that is based on pay for performance (P4P) rather than product-based dispensing or fee for service. Data sourcesSpecific patient outcomes were collected during a 1-year period from an existing pharmacist-run MTM/lifestyle medicine program as the basis to propose this new model of reimbursement. Data synthesisThe proposed model outlines a P4P model of reimbursement for pharmacists that includes both traditional MTM services and patient-centered lifestyle medicine programming. The model uses an all-or-none bundled approach for reimbursement in which the pharmacist is reimbursed at a higher rate if patients achieve all six proposed outcome criteria at 1 year. Pharmacists could earn as much a 43% more income with this model compared with traditional MTM services. This model is an incentive for payers because it is based on patient outcomes and preestablished return on investment models. ConclusionPharmacist should begin to explore ways they can participate in a high-performance health care system by moving to a P4P model of reimbursement rather than fee-for-service or product-based dispensing reimbursement models. P4P models of reimbursement could be beneficial to the patient, the payer, and the pharmacist.

How The Affordable Care Act Can Help Move States Toward A High-Performing System Of Long-Term Services And Supports

The United States may advance toward a high-performing health care system that offers long-term services and supports for people with disabilities and chronic conditions, or it may retreat from gains achieved in recent years. Since the 1980s, policy makers and advocates for the disabled have sought to move from a system that emphasizes nursing homes and institutional care to one that includes a broader range of care options. The Affordable Care Act of 2010 gives this movement a considerable boost by offering states timely new options and enhanced federal funding to create a care system that meets the diverse needs and preferences of people with disabilities and that also recognizes the role of family caregivers. In this paper we outline the five key characteristics of a high-performing system of long-term services and supports. We describe an emerging "scorecard" that could help measure states' progress toward this goal. And we itemize aspects of the Affordable Care Act intended to support the creation of such a high-performing system for the disabled and those with chronic conditions.

Small Steps … Improving Quality One Team at a Time in Saskatchewan

Saskatchewan's Health Quality Council (HQC) was launched in 2003 with a mandate to not only measure and report on healthcare but also work with a range of partners to improve the province's health system. In late 2007, HQC's board decided it was time for Saskatchewan to reinvent its healthcare system, using the highest-performing systems in the world as its model. And in 2008, HQC launched Accelerating Excellence, a multi-level program to rethink, redesign and renew healthcare. To help maintain momentum and show other provinces whether high-performing healthcare can be achieved in Canada, HQC is documenting its journey. This fifth article in this series discusses the incremental steps needed to effect and sustain change.

Education in High-Performing Hospitals: Using the Baldrige Framework to Demonstrate Positive Outcomes

Hospital education departments can better align with the strategic direction of the organization, effectively prioritize work processes, and focus on what matters most to the organization when the organization adopts an assessment process known as the Baldrige Health Care Criteria for Performance Excellence. This article describes the Baldrige assessment process, a framework of seven criteria based on a set of core values and concepts that encourage organizations to use an integrated systematic approach to improve organizational performance practices and achieve better outcomes. Examples of high-performing health care organizations that have earned a national Baldrige Award are cited, with examples of how the education departments of these high-performing organizations realigned their education plans to become more proactive and outcome-focused.

Engaging Physicians to Improve Quality

Saskatchewan’s Health Quality Council (HQC) was launched in 2003 with a mandate to not only measure and report on healthcare but also work with a range of partners to improve the province’s health system. In late 2007, HQC’s board decided it was time for Saskatchewan to reinvent its healthcare system, using the highestperforming systems in the world as its model. And in 2008, HQC launched Accelerating Excellence, a multi-level program to rethink, redesign and renew healthcare. To help maintain momentum and show other provinces whether high-performing healthcare can be achieved in Canada, HQC is documenting its journey toward high-performing healthcare. This third article in this series discusses the challenge of physician engagement. T he doctor, when he gets to sit down, perches on a bar-height chair in the corner, his laptop with the electronic records sharing space on a narrow counter with a jar of lollipops. Across the room, the big desk Dr. Mark Brown used to occupy has been given over to his medical office assistant. This unconventional arrangement saves Dr. Brown running to the back of the building every time he wants a word with his assistant, and keeps both of them just steps from the waiting and treatment rooms. It’s part of Dr. Brown’s “continuous quality improvement” efforts to run his family practice more efficiently and effectively. “My involvement in improving quality came about through my own interest in my own practice,” he says in an interview in the small, crowded office in Moose Jaw. “It wasn’t, ‘Let’s change the world.’ It was more a question of things being too busy and too chaotic … I had to use my time better and learn to work smarter.” A dawning realization that there must be better ways to practise medicine is a typical experience for the relatively few physicians already involved in Saskatchewan’s efforts to transform the quality of healthcare in the province. The program, called Accelerating Excellence, is run by the Health Quality Council (HQC). It’s a multi-level effort to rethink and renew healthcare through system-wide change, and includes Quality as a Business Strategy, a rigorous program for administrators and board members, and Releasing Time to Care TM , a new approach to hospital care that’s spreading ward by ward around the province.

Analysis & commentaryUnleashing Nurse Practitioners’ Potential To Deliver Primary Care And Lead Teams

Highly skilled primary care is a hallmark of high-performing health care systems. We examine nurse practitioners' role in delivering primary care and the effects of current restrictions on their ability to practice. By resolving differences between states' individual scope-of-practice regulations, we can fully benefit from the skills of advanced-practice nurses in all fifty states. We recommend substantive changes in the way health care professionals in all disciplines are trained, and in their roles, so that patients can receive appropriate and cost-effective care from skilled and fully functional health care teams.

Efficiency, effectiveness and efficacy: towards a framework for high-performance in healthcare commissioning

This article reports on research to identify the key characteristics of highperforming healthcare commissioning organizations of the future. Previous assessments have focused on efficiency and effectiveness, but have paid no attention to the role of efficacy which this research suggests is crucial. In order for healthcare organizations to become high-performing they must be able to re-construct the criteria of performance for the healthcare system deployed by the government and other key stakeholders. Although this study focuses on English healthcare organizations, this article suggests that the importance of efficacy similarly applies in other sectors and other geographical locations given the dominance of notions of performance worldwide.

Releasing Time to Care

Saskatchewan's Health Quality Council (HQC) was launched in 2003 with a mandate to not only measure and report on healthcare but also work with a range of partners to improve the province's health system. In late 2007, HQC's board decided it was time for Saskatchewan to reinvent its healthcare system, using the highest-performing systems in the world as its model. And in 2008, HQC launched Accelerating Excellence, a multi-level program to rethink, redesign and renew healthcare. To help maintain momentum and show other provinces whether high-performing healthcare can be achieved in Canada, HQC is documenting its journey toward high-performing healthcare. This second article in this series discusses the Releasing Time to Care program.

Family Medicine: Preparing for a High-Performance Health Care System

As policy leaders seek to lower costs, increase access, and improve quality in the American health care system, strengthening primary care has become a key strategy for achieving high performance. Health reform proposals under consideration in Congress include provisions that increase Medicare and Medicaid payment rates for prevention and primary care services, spread the patientcentered medical home (PCMH) model in the Medicare program, and create a payment innovation center to test and share savings with innovative primary care practices. 1 There is wide consensus that primary care is at the center of a high-performing health care system. The health professional community is leading change. The Future of Family Medicine report in 2004 set forth a new model of family medicine that is the foundation of a high-performance health system. 2 In 2007, 4 primary care professional associations endorsed joint principles for the PCMH. 3 Policy leaders have responded to the argument for the benefits to patients and the nation from a new model of care, and they are increasingly willing to commit resources to primary care with the expectation that such investment will yield returns not only in better care for patients, but also in greater value for the resources dedicated to health care. Primary care will need to undergo fundamental change in the design and delivery of care to meet these high expectations. The National Demonstration Project, launched by the American Academy of Family Physicians in 2006, is already gaining valuable experience with transforming care delivery and yielding important lessons. 4 Despite the leadership of the health professional community, change is difficult and resistance can be expected. Perhaps the greatest barrier to change is a belief that physicians are already delivering patient-centered care. A review of the performance of the health system along key dimensions is, therefore, instructive in identifying gaps in performance that can be addressed by a new model of care. In 2005, my colleagues and I 5 set forth a “2020 Vision of Patient-Centered Primary Care,” with 7 attributes of patient-centered primary care that are likely to yield cost and quality outcomes valued by patients and sought by policy leaders. These include:

The Primary Care Medical Home: Whose Home is It? Reaction to the Paper by Karen Davis, PhD, and Kristof Stremikis, MPP

In their article titled “Family Medicine: Preparing for a High-Performance Health Care System,” Karen Davis and Kristof Stremikis[1][1] present an exciting and affirming vision for the future of primary care in this country. Thanks to the wide acceptance of the concept of the medical home among

Effective transitions for youth from pediatric to adult systems of care: the role of care coordination in integration

Background: Care coordination (CC) involves a critical, cross-cutting set of activities. In the United States (US), consensus about core functions and competencies is lacking; ambiguity exists regarding disciplines, outcomes, measures, and financing. Effectively transitioning care from pediatric to adult systems of care remains a significant challenge. Objective: Present a newly developed, multidisciplinary framework for CC, including definition, characteristics, competencies, levels, outcomes, as well as recommendations for future policy, research and education. Look at challenges currently facing youth with special health care needs attempting to transition to adult systems of care. Results: Developing a family-centered system of health care requires full engagement of patients, youth, and families in the planning and implementation process. The CC framework offers strategies including clarification of definition of CC, role descriptions, characteristics, core competencies, levels of service, and culturally-effective approaches. The framework also details anticipated outcomes resulting from the experience of receiving and providing highly effective coordination of care. The family-centered ‘medical home’ is highlighted as a hub for community-based CC. Functional relationships and communications are assumed at points of engagement along the health care continuum and across community partner organizations. The CC framework provides a structured approach to empower youth with chronic conditions and their families/caregivers to address and overcome some of the challenges of transitioning care from pediatrics to adult health systems. Conclusions: To achieve a high performance health care system, it is essential to create, sustain, and measure the performance of an integrated, consistent CC infrastructure. This is systematically lacking at the present time in the US. Driving this transformation will be the creation and implementation of multiple elements and promoting factors within the healthcare system and across multiple sectors of the broader community. These factors will enable effective transitions from pediatric to adult health care systems. Acknowledgements: Grateful acknowledgement is made to The Commonwealth Fund and to the US Maternal and Child Health Bureau for partial support of this work. The presenter wants to acknowledge the contributions of Jeanne McAllister, BSN, MS, MHA, Jill Popp, MA and to colleagues at the US Healthy and Ready to Work National Resource Center.

High-Performance Healthcare: Access and Quality

High-Performance Healthcare: Access and Quality

How to Achieve a High-Performance Health Care System in the United States

Letters6 May 2008How to Achieve a High-Performance Health Care System in the United StatesHarvey S. Zarren, MDHarvey S. Zarren, MDFrom Integrative Medicine Alliance, Arlington, MA 02474.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-148-9-200805060-00020 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:The single biggest issue in the quality of health care is the failure to provide adequate time for caregivers to spend with patients (and even with colleagues). Time for quality history assessment, thorough examinations, and careful formulation of diagnosis and treatment plans is not being reimbursed adequately.Single-payer health insurance makes great sense, and there must also be a shift in reimbursement away from testing and procedures toward adequate time for physicians and nurses to form the relationships with patients that are the essence of health care that heals. In 1994, the Pew-Fetzer Task Force report (1) ...Reference1. Pew-Fetzer Task Force on Advancing Psychosocial Health Education. Health Professions Education and Relationship-Centered Care. San Francisco: Pew Health Professions Commission; 1994. Google Scholar Author, Article, and Disclosure InformationAuthors: Harvey S. Zarren, MDAffiliations: From Integrative Medicine Alliance, Arlington, MA 02474.Disclosures: None disclosed. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAchieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other CountriesHow to Achieve a High-Performance Health Care System in the United States Jack A. Ginsburg , Robert B. Doherty , and J. Fred Ralston Jr. How to Achieve a High-Performance Health Care System in the United States S. Ward Casscells and MG Elder Granger How to Achieve a High-Performance Health Care System in the United States Arvind R. Cavale How to Achieve a High-Performance Health Care System in the United States Richard S. Leff How to Achieve a High-Performance Health Care System in the United States Richard L. Cruess and Sylvia R. Cruess How to Achieve a High-Performance Health Care System in the United States Thomas James III Metrics 6 May 2008Volume 148, Issue 9Page: 711-712KeywordsCaregiversConflicts of interestHealth careHealth care qualityHealth insurance ePublished: 6 May 2008 Issue Published: 6 May 2008 Copyright & PermissionsCopyright © 2008 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

How to Achieve a High-Performance Health Care System in the United States

How to Achieve a High-Performance Health Care System in the United States