Topic last updated Aug. 2006
system is defined as "a set of inter-
dependent elements interacting to achieve a common
Professional Training: Preparing Providers for Systems Change
Concepts for Health Care Providers
The following is a review of concepts that will help health care
professionals effectively contribute to the process of systems change.
systems improve when changes are made in the performance of the
system, rather than in the performance of individual physicians
or other professionals. A system is defined as "a set of interdependent
elements interacting to achieve a common aim." This definition
emphasizes the importance of interdependence and interaction. For
example, elements in the system that work to obtain a patient's
A1C value usually include:
People - doctors, nurses, laboratory technicians, phlebotomists,
Technology - automated analyzers, computerized reports, patient
elements alone do not constitute the system - rather the elements
plus their interactions constitute the system.
|Improvement is leveraged by changing interactions among the elements of the system and in redesigning the overall flow of work rather than trying to improve the individual elements.
patient safety arena has taught health care teams a great deal about looking for
root causes of problems in the system rather than blaming individual
professionals when things go wrong. Greater improvement is leveraged
by changing the patterns of interaction among the elements of the
system and in redesigning the overall flow of work rather than trying
to improve the individual elements.
example, using a registry and call-back system will increase health care professionals'
implementation of standards of care more than their participation
in continuing education about the importance of standards of care. The
registry provides information to manage a population of people with
diabetes in addition to critical information at the time of a patient's
|System change tools such as flowcharts, cause-and effect diagrams, and registry data are used to achieve clinical improvements.
Continuing education for health care professionals is traditionally a passive activity that provides updated
information on best practices. Unless these best practices are integrated
into the system of care, the process of care is rarely improved.
By understanding the systems involved in delivering care, health care professionals
can gain insight into existing opportunities for improvement.
System change tools such as flowcharts, cause-and effect diagrams,
and registry data are used to achieve clinical improvements.
efficacy is the desirable outcome that is associated with an
intervention under ideal circumstances such as in clinical trials.
For example, the Diabetes Control and Complications Trial demonstrated
intensive management compared with standard care resulted in significant
lowering of A1C.
control resulted in a 35 percent decrease in microvascular complications
for each one percent reduction in A1C.
|Clinical effectiveness associates desirable outcomes with an intervention in the real world.
effectiveness associates the desirable outcomes with an intervention
in the real world.
For example, Health Partners of Minnesota provides valid and reliable information for physician/provider groups to use in their efforts toward continuous improvement of patient care and outcomes. As a result, optimal diabetes care results (A1C <8.0 + LDL <130 + BP < 130/85 + No Tobacco + Daily Aspirin) tripled between 1999 and 2005. Between 1994 and 2005, eye complications decreased by 20 percent, amputations by 55 percent, and heart attacks by 29 percent. For further information visit www.healthpartners.com/files/28455.pdf.
The difference between the efficacy and effectiveness of an intervention
defines the performance "gap" described in the How section.
Implementation of systems of care can successfully
bridge the gap and result in improved clinical outcomes. These systems
are developed and implemented through multiple small-scale improvements
in the components of the health care delivery system.
Competency vs. System Capability
competency requires individual health care professionals to attain, demonstrate
and maintain competency within their discipline. For example, physicians
attend an accredited medical school, train in an accredited residency,
become board certified, and complete ongoing CME and recertification
requirements. The premise is that if the individuals competently
practice their discipline, then the standards of care will always
be met. This fails to occur, however, for three reasons.
complexity of clinical needs for numerous chronic diseases makes
it difficult for individual health care professionals to function effectively
without some form of technological assistance.
Even the most competent health care professionals will fail to perform their best
if they are not supported by appropriate systems.
Competency will preserve the core of practice but it is not able
to stimulate the progress and actions that are needed to continually
|System capability refers to coordination of the components of clinical care to ensure achieving the desired outcomes.
capability refers to coordination of the components of clinical
care to ensure achieving the desired outcomes, such as use of registries
and recall systems to remind patients of the need for annual influenza
vaccinations. System support of health care professionals results in improved process
and clinical outcomes. Continuous striving to improve the systems
of care stimulates progress to better care.
Research vs. Quality Improvement
research involves trials conducted to test if a single variable
(medication, procedure, counseling) in a stable setting will result
in a difference between the control and study groups. All other
variables are controlled in an attempt to minimize variation. When
applied in the clinical practice environment, however, control over
confounding variables is lost and the results may differ from those
demonstrated in the trial.
improvement involves changing multiple variables
in a clinical care process over time in order to
improve the performance of the system.
Improvement is used in systems that are not tightly controlled.
Multiple small changes are made and evaluated to determine how best
to achieve optimal outcomes. For more information, click here.
vs. Analytic Statistics
Enumerative statistics are used in clinical research to
evaluate the outcome of testing a hypothesis. The analysis assumes
a stable system - one in which all variables are held constant except
the one under study. The goal is to estimate whether the outcomes
between the control and study group are different. The statistics
ascribe a degree of confidence to the accuracy of the estimate.
|Analytic statistics are used to evaluate clinical improvement.
statistics are used to evaluate clinical improvement such as
Plan-Do-Study-Act (PDSA) cycles. The goal
of the analysis is to determine the stability
of the process producing
the data. For example, will the patient recall system that increased
the rate of eye exams from 36 percent to 70 percent consistently
result in the higher percentage of patients having annual exams?
In this example, the accuracy of the measure is not the issue - was
the improvement in the rate of eye exams 70 percent or 68 percent
or 72 percent? Rather, if the process is statistically stable, one
can assess its current performance and take action either to predict
future performance or to measure the effects of an improvement intervention.
For example, now that eye exam rates have improved to 70 percent,
how can we further improve the system to increase the rate to >90
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