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National Academy of design (US) and also Institute of medicine (US) Committee top top Engineering and the Health care System; Reid PP, Compton WD, Grossman JH, et al., editors. Structure a far better Delivery System: A new Engineering/Health care Partnership. Washington (DC): nationwide Academies push (US); 2005.


National Academy of engineering (US) and Institute of medication (US)Committee on Engineering and also the Health treatment System; Reid PP, Compton WD, Grossman JH, et al., editors.

To consider how information/communications technologies and also systems-engineering tools can be provided to help realize the IOM vision that a patient-centered health care system, we must first understand the difficulties facing the U.S. Health care system (IOM, 2001). The committee has adjusted a four-level model by Ferlie and also Shortell (2001) come clarify the structure and dynamics of the health care system, the rough departments of labor and also interdependencies among major elements that the system, and also the levers because that change. A brief description of the version follows. The remainder the this chapter offers a “systems view” of health care and also a quick description of the potential role of information/ communications systems.


In this model, adjusted from Ferlie and also Shortell (2001), the health care system is separated into four “nested” levels: (1) the separation, personal, instance patient; (2) the care team, which contains professional care providers (e.g., clinicians, pharmacists, and also others), the patient, and family members; (3) the company (e.g., hospital, clinic, education home, etc.) that supports the development and occupational of treatment teams by offering infrastructure and complementary resources; and (4) the political and economic environment (e.g., regulatory, financial, payment regimes, and markets), the conditions under i m sorry organizations, treatment teams, individual patients, and also individual treatment providers operate (see number 2-1).



Conceptual drawing of a four-level health care system.

The separation, personal, instance Patient

We begin as necessary with the individual patient, who needs and preferences need to be the specifying factors in a patient-centered health care system. Recent transforms in health treatment policy reflect an emphasis on “consumer-driven” health and wellness care. The availability of information, the facility of private health care spending accounts, and other measures reflect an enhancing expectation the patients will certainly drive changes in the mechanism for improved quality, efficiency, and effectiveness. Overall, the role of the patience has adjusted from a passive recipient of treatment to a much more active participant in treatment delivery.

At the exact same time, the fragmented shipment system, linked with the growing burden of chronic disease and the require for continuous care, have actually all but forced plenty of patients to assume an active duty in the design, coordination, “production,” and also implementation of their care, whether they want to or not. Unfortunately, most world do no have accessibility to the information, tools, and other sources they have to play this brand-new role effectively. Considering the roles, needs, and also objectives the first-level actors—individual patients—and their interdependencies v actors at various other levels the the system, methods abound for making use of information/ communications technologies and systems-engineering tools to improve the in its entirety performance of the health care system.

A beginning point for increasing the “patient-centeredness” of health care delivery is an altering the perspective of clinicians to take into consideration patients and their families as “partners” and to incorporate their values and wishes into treatment processes. The level of obligation patients and also their families assume differs from patient to patient. Some choose to delegate some, if not most, that the decision making come a trusted clinician/counselor in the treatment system; others desire to be full partners in decision making. In one of two people case, however, patients need a totally free exchange the information and communication through physician(s) and also other members of the treatment team, and also with the establishments that administer the supporting framework for the care teams.

For patients to communicate “informed” needs and also preferences, participate properly in decision making, and also coordinate, or at least monitor the coordination, of their care, they have to have access to the same info streams—in “patient-accessible” form—as their physician(s) and care team. Info that support evidence-based, effective, efficient treatment encompasses the patient"s medical record, including real-time physiological data; the most up-to-date medical proof base; and also orders in process concerning the patient"s care. The patience and/or his or her clinician/counselor or household member must likewise have accessibility to educational, decision-support, information-management, and communication tools that can aid them integrate an essential information from different sources.

From the patient"s perspective, improving the timeliness, convenience, effectiveness, and also efficiency of treatment will need that the patient be interconnected come the health treatment system. Synchronous communication in between patient and physician could improve the high quality of treatment in a number of ways. Because that example, continuous, real-time interaction of a patient"s physiological data to treatment providers can accelerate the pace of diagnosis and also treatment, in order to reducing complications and injuries the might an outcome from delays. Remote (e.g., in-the-home, on-the-go) monitoring, diagnosis, and also treatment would certainly make treatment much more convenient because that patients, save them time, and conceivably improve compliance with care regimes (see record by Budinger in this volume). Interaction technologies also have the potential to readjust the nature that the relationship between patient and provider, make it easier for patients to develop and maintain trusting relationships with their clinicians.

Asynchronous communication additionally has the potential to substantially improve quality of care. The easy accessibility of the Internet and the World wide Web should enable all but consistent inquiries and feedback in between patients and the rest of the health treatment system (IOM, 2001). The World broad Web has already adjusted patients" capability to connect with the system and to self-manage elements of your care. One of the fastest cultivation uses that the these communication technologies is together a resource of medical information from third parties, which has actually made the customer (i.e., the patient) both more informed, and, unfortunately, sometimes misinformed.

Some of the improvements just explained are accessible today, some are under study, and also some space as much as a te away native realization. Thus, research study is still critical component in transforming the present system.

The treatment Team

The treatment team, the second level of the health treatment system, consists of the individual physician and a group of care providers, including wellness professionals, patients" family members members, and others, whose collective efforts an outcome in the distribution of care to a patience or population of patients. The treatment team is the straightforward building block the a “clinical microsystem,” defined as “the the smallest replicable unit in ~ an organization the is replicable in the sense that it includes within chin the important human, financial, and technological resources to perform its work” (Quinn, 1992).

In addition to the treatment team, a clinical microsystem consists of a identified patient population; an information atmosphere that supports the work-related of professional and family caregivers and patients; and also support staff, equipment, and also facilities (Nelson et al., 1998). Ideally, the duty of the microsystem is come “standardize care where possible, based on best present evidence; come stratify patients based on medical need and provide the best evidence-based treatment within every stratum; and also to customize treatment to accomplish individual demands for patient with facility health problems” (Ferlie and also Shortell, 2001). Most health and medical solutions today, however, room not ceded by teams or teams.

The duty and demands of individual physicians have undergone changes parallel come those of separation, personal, instance patients. The exponential boost in medical knowledge, the proliferation of medical specialties, and the climbing burden of giving chronic care have radically undercut the autonomy of separation, personal, instance physicians and required that they learn to job-related as component of treatment teams, one of two people in a solitary institution/organization or throughout institutional settings. The slow adaptation of separation, personal, instance clinicians to team-based health care has been influenced by numerous factors, consisting of a absence of formal training in cooperation techniques, a persistent society of skilled autonomy in medicine, and the lack of tools, infrastructure, and also incentives come facilitate the change.

To get involved in, permit alone lead and orchestrate, the work of a care team and maintain the to trust of the patient, the medical professional must have on-demand accessibility to crucial clinical and also administrative information, and information-management, communication, decision-support, and also educational devices to synthesize, analyze, and make the ideal use of the information. Moreover, to provide patient-centered care (i.e., care based on the patient"s needs and also preferences), the physician have to be equipped and also educated to serve as trusted advisor, educator, and counselor, and also medical expert, and also must know exactly how to encourage the patient"s authorized in the design and delivery the care.

At the existing time, precious few care groups or clinical microsystems are the main agents that patient-centered clinical care. Unwarranted sports in medical practice are common, also for conditions and patient populations for i m sorry there are standard, evidence-based, patient-stratified “best practice” protocols (McGlynn et al., 2003; Wennberg et al., 1989). Also though plenty of clinicians currently accept the worth of “evidence-based medicine” and recognize the they cannot provide evidence-based care on their own, they are many barriers to their changing accordingly: the guild structure of the health treatment professions; the absence of maintain in teamwork; the solid focus on the requirements of individual patients together opposed to the demands of patient populations; and the lack of supporting info tools and infrastructure. Every one of these can, and also do, avoid systems reasoning by clinicians, the diffusion of evidence-based medicine, and also the clinical microsystems approach to care delivery. Thus, tailoring evidence-based treatment to satisfy the needs and also preferences the individual patient with facility health troubles remains one elusive goal.

For care teams to end up being truly patient-centered, the rule of engagement between care teams and also patients must be changed. Like individual care providers, the care team have to become much more responsive come the needs and preferences the patients and involve them and also their households (to the level they desire) in the design and implementation the care. Treatment teams must carry out patients v continuous, convenient, timely accessibility to high quality care. One member of the treatment team have to be responsible for ensuring effective communication and also coordination between the patient and also other members of the care team.

The Organization

The 3rd level the the health treatment system is the organization (e.g., hospital, clinic, education home) that provides infrastructure and also other complementary resources to assistance the occupational and development of care teams and also microsystems. The organization is a vital lever of readjust in the health care system because it can “provide an in its entirety climate and society for change through its various decision-making systems, operating systems, and also human resource practices” (Ferlie and also Shortell, 2001). The organization includes the decision-making systems, details systems, operation systems, and also processes (financial, administrative, human-resource, and clinical) to coordinate the tasks of multiple treatment teams and also supporting units and also manage the allocation and also flow the human, material, and also financial resources and information in support of treatment teams. The company is the organization level, the level in ~ which most investments room made in details systems and also infrastructure, process-management systems, and systems tools.

Health care organizations challenge many challenges. In response to the escalating expense of wellness care, government and also industry—the third-party payers for most people—have change a cultivation share that the cost burden back to care providers and also patients in recent years. Together a result, hospitals and ambulatory care facilities space under an excellent pressure to accomplish an ext work with fewer civilization to keep earnings ahead of rising costs.

In specific respects, monitoring of health treatment organizations is not well positioned to respond to mounting cost and quality crises. Contrasted to other industries, health treatment has developed with tiny shaping through the visible hands of management. Historically, most leaders the health treatment organizations were originally trained in medicine or public health. Moreover, except in the relatively couple of integrated, that company provider organizations (e.g., Kaiser-Permanente, mayo Clinic, et al.), the monitoring of most hospitals encounters the an obstacle of “managing” clinicians, the majority of whom role as “independent agents.”

Less 보다 40 percent of every hospital-based physicians are employed as full time staff by the hospitals whereby they practice, a enjoy of the deep ingrained society of skilled autonomy in medicine and the deeply held id of care professionals the their ultimate duty is to separation, personal, instance patients. These circumstances have posed significant challenges come the government of health treatment management in many organizations, often producing discord and mistrust in between health treatment professionals and health care management. Other challenges to management encompass the hierarchical nature the the wellness professions and inherent resistance to team-based care, significant regulatory and also administrative requirements (e.g., regulated substances, biohazardous garbage disposal, patience privacy, safety, etc.), and also health treatment payment/reimbursement power that carry out little, if any, incentives because that health care organizations come invest in non-revenue-generating assets, such together information/ communications technologies and also process-management tools.

To assistance patient-centered care delivery by well functioning clinical care teams or microsystems, health organizations must uncover ways to leg the health treatment professional/ shipment system monitoring divide and invest in information/ communications technologies, systems-engineering tools, and also associated knowledge. Integrated, patient-centered, team-based care requires material, managerial, logistical, and also technical support that can cross organizational/institutional boundaries—support that is very an overwhelming to provide in a very fragmented, distributed-care distribution system.

Financial investments in information/communications technologies and also systems-engineering tools alone will not it is in enough, however. This investments have to be accompanied by an organizational society that urges the breakthrough of treatment teams working through semiautonomous agents/ physicians (see document by Bohmer in this volume). “Developing a society that emphasizes learning, teamwork, and also customer focus may it is in a ‘core property" that health care organizations …will need to take on if far-reaching progress in quality innovation is to it is in made” (Ferlie and also Shortell, 2001). Finally, health treatment institutions must end up being “learning organizations” that are “skilled in ~ creating, acquiring, and also transferring knowledge, and also at editing habits to reflect new knowledge and also insights” (Garvin, 1993).

The Political and also Economic Environment

The fourth and also final level the the health care system is the political, financial (or market) environment, which consists of regulatory, financial, and also payment regimes and entities that influence the structure and performance the health treatment organizations straight and, v them, all other levels that the system. Many actors affect the political and also economic atmosphere for wellness care. The federal federal government influences care through the reimbursement methods of Medicare/ Medicaid, through regulation of private-payer and also provider organizations, and also through its assistance for the advance and usage of selected diagnostic and also therapeutic interventions (e.g., drugs, devices, equipment, and procedures). State governments, which play a major role in the administration of Medicaid, likewise influence care systems. Private-sector purchasers of health care, particularly big corporations that contract straight with health care provider organizations and third-party payers (e.g., health plans and also insurance companies), are likewise important environment-level actors, in some instances reimbursing companies for services not covered by the commonwealth government.

Federal regulations influence the structure, level, and nature of competition amongst providers and also insurers. They can also influence the transparency the the health care system by setup requirements pertained to patient safety and other elements of the top quality of care. By exercising its obligation to monitor, protect, and improve publicly health, the federal government shapes the market setting for health care. Federal agencies, the major sources of funding for biomedical research, influence the research study and technological trajectories of health and wellness care, and, through them, the education of health care professionals and also professionals in other areas invested in the health treatment enterprise.

At present, numerous factors and forces in ~ the environmental level, consisting of reimbursement schemes because that health care services and some regulatory policies, execute not support the goals and also objectives that patient-centered, high-performance health care organizations or the health treatment delivery device as a whole. Although the commonwealth government, the single largest purchaser that health care services, primary regulator, and major research patron, is, in plenty of ways, best positioned to drive transforms in the health treatment delivery system, some private-sector payer organizations and also state federal governments are much better positioned come experiment with brand-new mechanisms and also incentives for enhancing the high quality of care and also making health care an ext affordable (see records by De Parle and also Milstein in this volume).

A equipment VIEW OF health CARE

In thing 1, the health treatment delivery mechanism was defined as a “cottage industry.” The key characteristic of a cottage sector is that it comprises plenty of units operation independently, each focused on its own performance. Every unit has substantial freedom to set standards that performance and measure itself against metrics of its very own choosing. In addition, cottage markets do not normally attempt to standardize or name: coordinates the processes or performance of Unit A v those of devices B, C, and also so on.

Indeed, this is an apt characterization of the present health care delivery system. Even in numerous hospitals, individual departments operate much more or much less autonomously, developing so-called “silos.” plenty of physicians practice individually or in tiny groups, and also ambulatory clinics, pharmacies, laboratories, rehabilitation clinics, and also other organizations—although component of the shipment system—often act together independent entities. We often call this setup a “health care system,” also though it was not produced as a system and also has never performed together a system.

Moving from the current conglomeration of live independence entities towards a “system” will need that every participating unit recognize its dependence and also influence top top all various other units. Every unit should not only accomplish high performance yet must also recognize the imperative of joining with other units to optimize the performance of the device as a whole. Moreover, every individual care provider have to recognize his or she dependence and influence on other care team members (e.g., experts in different fields, pharmacists, nurses, society workers, psychologists, physical therapists, etc.) (IOM, 2003). These are the underlying attitudes that assistance a systems approach to addressing problems.

Changing perspectives to embrace teamwork and systems “thinking” have the right to be extremely an overwhelming and may encounter resistance. Nevertheless, a concerted, visible commitment by monitoring will be necessary to accomplish this new way of reasoning as a large step toward the improvements established in crossing the top quality Chasm (IOM, 2001).


It is basic to display mathematically that the optimization the individual systems rarely, and also only under highly improbable circumstances, results in optimization that the whole. Optimization is determined by a range of metrics, consisting of the performance of a unit, the quality of service, the use of physical resources, or a combination of all of these. Optimization of the totality requires a clear knowledge of the score of the in its entirety system, as well of interactions among the subsystems. The whole must be well-known as being higher than the sum of its parts (Box 2-1).


BOX 2-1

Optimizing system Performance. Optimization that the power of a large system is frequently attempted through the optimization of every sub-element the the system. In industry, this is commonly achieved by developing independent “profit/loss” (more...)

A handful of health care organizations have taken on the equipment view (e.g., the Veterans management and Kaiser-Permanente health Care). These far-reaching exceptions to the general rule demonstrate that the equipment view is applicable to wellness care and also could it is in a model for various other health care organizations. The score of this report is to recognize existing tools that can be offered to resolve problems and also to suggest locations for more exploration.

In any huge system that has countless subsystems, achieving high operating performance for each subsystem if taking right into account the mutual influence of subsystems on each other and on the device as a totality can it is in a complicated task. A basic pictorial summary of interacting facets in a system may be valuable for understanding exactly how the device works. However, a deeper understanding invariably involves developing a mathematical summary of subsystems, their performance, and also their interactions. This, in turn, calls for a model, the is, an abstract depiction of how the device operates (a mathematical kind that deserve to be provided to analyze the system) that includes parameters that determine the performance of every sub-element the the system, and also descriptions of interactions. The model is a device for simulating the performance of the actual system.

The principal objective that a simulation is to ask “what if” questions and assess the impact of alternate actions on the power of the device to identify which ones might improve overall system performance. For example, if a adjust is plan in the layout of a facility, a model can be offered to determine if it will boost the circulation of people and equipment with the facility. A model might help determine just how much inventory have to be maintained at station A to ensure that it deserve to respond come an emergency in much less than 5 minutes. A design might also reveal if a different communication system might reduce the compelled inventory or the best method to assign a education staff once 10 percent that the registered nurses are not available. As Alan Pritsker, the author of numerous treatises on large-scale system modeling and also simulation, writes, “The system technique is a methodology that looks for to for sure that changes in any component of the system will result in far-ranging improvements in full system performance” (Pritsker, 1990).

Because the health care system entails a myriad of interacting elements, the is difficult, or even impossible, for any individual to have actually a complete snapshot of the mechanism without utilizing special tools to do a solution analysis. A model of the health treatment system must include a description of “processes,” including a wide range of activities, from registered nurses administering medicine on the hospital floor come examinations by a medical professional to laboratory tests to the pour it until it is full of prescriptions by a pharmacist to follow-on access time by a nurse. The design must incorporate the role of each process in health care delivery and also its interaction with other processes in the system. However clinical aspects are no the only important aspects in an analysis. The interaction between administrative aspects (e.g., patient check-in and billing procedures) and other procedures can also significantly affect the as whole performance the the device from the patient and organization"s allude of view. All processes have to be quantitatively described to be had in the model.

Any effort to optimize the performance of a system must take right into account missions that are complicated to quantify and also that may, in fact, problem with every other. Quantifying the quality of care, for example, have the right to be difficult, largely since the definition of high quality varies relying on whether the patient, the health care professional, or the clinic or hospital is assessing it. Enhancements in productivity might mean boost in the number of patients that have the right to be accommodated or a decrease in wait time for the typical patient. IOM determined safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity as ideal quality goals for the health treatment delivery system. Solution analyses can be supplied to boost the as whole performance of equipment with multiple objectives since they include possible trade-offs and/or synergies amongst these objectives. In addition, perhaps conflicting goals—for example, price containment and patient-centeredness—can likewise be analyzed.


Many industries have attempted to usage information/ interactions systems in place of hands-on operations, such as document keeping. But information/communications systems deserve to be supplied for much much more than digital record keeping. With incredible advancements in computational speed and also capacity and parallel breakthroughs in computer software, clinical information and communications systems can administer immediate access to information, consisting of patient-based information (e.g., previous laboratory values and also current diagnoses and also medications), institution-based details (e.g., drug-resistance fads of assorted bacteria to various antibiotics), profession-based info (e.g., clinical-practice guidelines, including summaries the recommended best practices in assorted situations), real-time decision assistance (e.g., alerts around potential medicine interactions or dosing trends in a patient with a jeopardized drug-metabolism mechanism), practice-surveillance assistance (e.g., reminders around upcoming screening exam recommended for a patient), and populace health data (e.g., because that epidemiological research, an illness and biohazard surveillance, notice of post-introduction adverse medicine events).

Information/communications systems can also provide important info to the patient for self-treatment of illness and enable ongoing asynchronous communication between patients and care providers. In the future, v the introduction of remote monitoring devices and also wireless communication systems, information/communications systems have the potential to support continuous monitoring the a patient"s health status in ~ home, rapid diagnosis through clinicians, and also timely, reliable therapeutic interventions in the residence by the patient or a family member, through guidance by wellness professionals. Furthermore, by capturing procedure and mechanism performance data for solution analysis, control and design, information/communications technologies deserve to facilitate the use of systems-engineering devices by patient care teams, provider organizations, and environmental actors at all levels the the health care delivery system.

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Chapter 3 offers descriptions the a big portfolio the systems-engineering tools and concepts through the potential to significantly improve the quality and also cost performance of the health care system. These tools have actually been widely and also effectively provided to design, analyze, and also control facility processes and systems in many major manufacturing and services industries. In thing 4 opportunities are defined for increasing the breakthrough and prevalent diffusion the clinical information and communications solution for health care delivery that can support the use of solution tools and improve the connectivity, continuity of care, and also responsiveness that the health treatment system together a whole.

Quinn JB. New York: totally free Press; 1992. Clever Enterprise: A Knowledge and Service Based Paradigm for Industry.