Emma logsdon· 4· 5 the six challenges for resigning health c

Emma Logsdon
· 4
· 5
The six challenges for resigning health care organizations are
each very crucial for the success of healthcare delivery. In my
opinion, I believe that the six challenges rank by importance as
follows: (1) redesigned care processes, (2) incorporating
performance and outcome measurements for improvement and
accountability, (3) managing clinical knowledge and skills, (4)
making effective use of information technologies, (5)
coordinating care across patient conditions, services, and
settings over time, and (6) developing effective teams.
Redesigning healthcare processes is the most important, in my
opinion, because all the other challenges intertwine or rely on
this in some way. This challenge focuses on simplifying,
standardizing, reducing waste, and implementing continuous
flow methods, which has a positive impact on every other
challenge. This challenge also focuses on redesigning the
process to meet the needs of evolving healthcare needs, which is
significantly essential to ensure organizations care up-to-date
and well equipped to meet the population's needs. Incorporating
performance and outcome measurements is next, in my opinion,
because it shows the leadership what works or does not work for
an organization. This step assists in developing the basis of
every other challenge. Managing clinical knowledge and skills
follows this because healthcare professionals must be
knowledgeable of current healthcare practices. As well, this
step incorporates change within an organization, which falls
onto the remaining challenges. Making effective use of
information technologies is equally as important in my opinion
as to the previous challenges. By implementing better use of IT,
communication is done more efficiently, errors and the harm
from mistakes can be reduced, and data can be narrowed down
for more accessible use. Coordinating care across patient

conditions is next on my list since many of the previous steps
include work to implement this step. This challenge focuses on
making sure different teams working on the same patient are all
on the same page to increase efficiency. This step is done more
easily with the implementation of IT. The last on my ranking is
developing effective teams. Even though this step is significant,
I believe that if all other challenges are met, this step will reap
the benefits, and success will be found here. Many members of
different backgrounds are required to fulfill team needs. If all
these challenges are met, the success of a healthcare
organization is endless. I believe that these qualities are
necessary for a productive and effective healthcare
organization.
Bottom of Form
Lydia Terry
· 4
· 5
After reading “Building Organizational Supports for Change”,
and after much careful thought, I had a difficult time ranking
these challenges in order of importance. There is no doubt that
each challenge is vital in terms of redesigning our health care
system. However, drawing upon my personal experience and
observations, I have ranked the challenges in the order that I
believe most pertinently affect patients in our health care
system.
1. Redesigning care processes based on best practices – I ranked
this challenge as most important because it has the most time-
sensitive impact on quality of care for patients, which is our
number one priority as healthcare providers. We must evaluate
the best way to treat our patients and immediately put these

processes into practice. I truly believe that ranking any other
challenge above this does a disservice to our communities and
the patients that need us in the here and now.
2. Coordinating care across patient conditions, services and
settings over time, AND
3. Developing effective teams – I have coordination of care and
developing effective teams tied for #2/#3 because I feel that
they go hand in hand. As a pharmacist, I have had the
opportunity to work closely with healthcare professionals from
other areas, such as MDs, nurses, social workers and physical
therapists to make sure that patients receive well-rounded,
totally encompassing healthcare solutions. As we discussed in
the last module, chronic conditions is one of the biggest
healthcare problems in the US, and most people that have one
chronic condition also have more than one. Knowing this, we
must use an interdisciplinary approach to treat these patients.
This may mean different healthcare professionals in different
settings such as inpatient, outpatient, home health, therapy, and
follow up visits.
4. Making effective use of information technologies to improve
access to clinical information and support clinical decision-
making – As we all know, information technology is more
important than ever in 2021. If we can implement better use of
IT, we can reduce communication errors and access information
that is significant to patient care in a more timely and organized
manner.
5. Incorporating performance and outcome measurements for
improvement and accountability – Evaluation of staff and
processes and accountability for failures and shortcomings is an
important part of redesigning our healthcare system. Having a
streamlined system for improvement based upon inadequacies is
vital for providing the best care for patients and running a
successful healthcare institution.
6. Managing clinical knowledge and skills – I have ranked this
last not because it isn’t important, but because I truly believe in
the clinical knowledge and skills that are already possessed by

the healthcare professionals in the US. The most common
source of medical errors in the United States is not from lack of
knowledge, but from lack of communication. If we can resolve
this issue through other improvements as mentioned above, we
can reduce medical errors and provide better care to our
patients.
Bottom of Form
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SUGGESTED CITATION
http://nap.edu/10027
Crossing the Quality Chasm: A New Health System for the 21st
Century (2001)
360 pages | 6 x 9 | HARDBACK
ISBN 978-0-309-07280-9 | DOI 10.17226/10027
Committee on Quality of Health Care in America; Institute of
Medicine
Institute of Medicine 2001. Crossing the Quality Chasm: A New
Health System for
the 21st Century. Washington, DC: The National Academies
Press.
https://doi.org/10.17226/10027.
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Century
Copyright National Academy of Sciences. All rights reserved.
111
5
Building Organizational
Supports for Change
Between front-line clinical care teams and the health care
environment lies
an array of health care organizations, including hospitals,
managed care organi-
zations, medical groups, multispeciality clinics, integrated
delivery systems, and
others. Leaders of today’s health care organizations face a
daunting challenge in
redesigning the organization and delivery of care to meet the

aims set forth in this
report. They face pressures from employees and medical staff,
as well as from
the local community, including residents, business and service
organizations,
regulators, and other agencies. It is difficult enough to balance
the needs of those
many constituencies under ordinary circumstances. It is
especially difficult when
one is trying to change routine processes and procedures to alter
how people
conduct their everyday work, individually and collectively.
This chapter describes a general process of organizational
development and
then offers a set of tools and techniques, drawing heavily from
engineering con-
cepts, as a starting point for identifying how organizations
might redesign care.
Chapter 3 offered a set of rules that would redesign the nature
of interactions
between a clinician and a patient to improve the quality of care.
This chapter
describes how organizations can redesign care to systematically
improve the
quality of care for patients. This is not an exhaustive list of
possible approaches,
but a sampling of techniques used in other fields that might
have applicability in
health care. The broad areas discussed in this chapter apply to
all health care
organizations; the specific tools and techniques used would
need to be adapted to
an organization’s local environment and patients.
http://www.nap.edu/10027

Century
112 CROSSING THE QUALITY CHASM
Recommendation 7: The Agency for Healthcare Research and
Qual-
ity and private foundations should convene a series of
workshops
involving representatives from health care and other industries
and
the research community to identify, adapt, and implement state-
of-
the-art approaches to addressing the following challenges:
• Redesign of care processes based on best practices
• Use of information technologies to improve access to clinical
information and support clinical decision making
• Knowledge and skills management
• Development of effective teams
• Coordination of care across patient conditions, services, and
settings over time
• Incorporation of performance and outcome measurements for
improvement and accountability
To achieve the six aims identified in Chapter 2, board members,
chief execu-
tive officers, chief information officers, chief financial officers,
and clinical man-

agers of all types of health care organizations will need to take
steps to redesign
care processes. The recommended series of workshops is
intended to serve
multiple purposes: (1) to help communicate the
recommendations and findings
of this report and engage leaders and managers of health care
organizations in the
pursuit of the aims, (2) to provide knowledge and tools that will
be helpful to
these individuals, and (3) to encourage the development of
formal and informal
networks of individuals involved in innovation and
improvement.
STAGES OF ORGANIZATIONAL DEVELOPMENT
The design of health care organizations can be conceptualized
as progressing
through three stages of development to a final stage that
embodies the committee’s
vision for the 21st-century health care system, as represented by
the six aims set
forth in Chapter 2 (see Table 5-1). Although settings and
practices vary, the
committee believes much of the health sector has been working
at Stages 2 and 3
over the last decade or more. As knowledge and technologies
continue to ad-
vance and the complexity of care delivery grows, the evolution
to Stage 4 will
require that Stage 3 organizations accelerate efforts to redesign
their approaches
to interacting with patients, organizing services, providing
training, and utilizing
the health care workforce.

Stage 1
Stage 1 is characterized by a highly fragmented delivery
system, with physi-
cians, hospitals, and other health care organizations functioning
autonomously.
Century
BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE
113
The scope of practice for many physicians is very broad.
Patients rely on physi-
cian training, experience, and good intentions for guidance.
Individual clinicians
do their best to stay abreast of the literature and rely on their
own practice
experience to make the best decisions for their patients.
Journals, conferences,
and informal consultation with peers are the usual means of
staying current.
Information technology tools are almost entirely absent.
Norman (1988) has
characterized this approach to work as based on “knowledge in
the head,” with
heavy dependence on learning and memory. The patient’s role
tends to be pas-
sive, with care being organized for the benefit of the

professional and/or institu-
tion.
Stage 2
Stage 2 is characterized by the formation of well-defined
referral networks,
greater use of informal mechanisms to increase patient
involvement in clinical
decision making, and the formation of loosely structured
multidisciplinary teams.
For the most part, health care is organized around areas of
physician specializa-
tion and institutional settings. Patients have more access to
health information
through print, video, and Internet-based materials than in Stage
1, and more
formal mechanisms exist for patient input. However, these tend
to be generic
mechanisms, such as consent forms and satisfaction surveys.
Patients have infor-
mal mechanisms for input on their care.
Most health data are paper based. Little patient information is
shared among
settings or practices; the result is often gaps, redundancy of
data gathering, and a
lack of relevant information. In this stage, institutions and
specialty groups, for
example, try to help practitioners apply science to practice by
developing tools
for knowledge management, such as practice guidelines.
Stage 3
In Stage 3, care is still organized in a way that is oriented to the

interests of
professionals and institutions, but there is some movement
toward a patient-
centered system and recognition that individual patients differ
in their prefer-
ences and needs. Team practice is common, but changes in
roles are often slowed
or stymied by institutional, labor, and financial structures, as
well as by law and
custom. Some training for team practice occurs, but that
training is typically
fragmented and isolated by health discipline, such as medicine,
nursing, or physi-
cal therapy.
Clinicians and managers recognize the increasing complexity of
health care
and the opportunities presented by information technology.
Some real-time deci-
sion support tools are available, but information technology
capability is modest,
and stand-alone applications are the rule. Computer-based
applications for labo-
ratory data, ordering of medications, and records of patient
encounters typically
Century
114

T
A
B
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5
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Century

115
3
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Century
cannot exchange data at all or are not based on common
definitions. Practice
groups—particularly those that are community based—typically
lack informa-
tion systems to make such decision support tools available at
the point of patient
care, or to integrate guidelines with information about specific
patients. Clinical
leaders recognize the need for what has been called “knowledge
in the world”
(Norman, 1988)—information that is retrievable when needed,
replaces the need
for detailed memory recall, and is continuously updated on the
basis of new
information. More organized groups rely on best practices,
guidelines, and dis-
ease management pathways for clinicians and patients, but these
are not inte-
grated with workflow.
Stage 4
Stage 4 is the health care system of the 21st century envisioned
by the
committee. This system supports continued improvement in the
six aims of
safety, effectiveness, patient-centeredness, timeliness,
efficiency, and equity.
Health care organizations in this stage have the characteristics
of other high-

performing organizations. They draw on the experiences of
other sectors and
adapt tools to the unique characteristics of the health care field.
Patients have the opportunity to exercise as much or as little
control over
treatment decisions as they choose (as long as their preferences
fall within the
boundaries of evidence-based practice). Services are
coordinated across prac-
tices, settings, and patient conditions over time using
increasingly sophisticated
information systems.
Whatever their form, health care organizations can be
characterized as “learn-
ing organizations” (Senge, 1990) that explicitly measure their
performance along
a variety of dimensions, including outcomes of care, and use
that information to
change or redesign and continually improve their work using
advanced engineer-
ing principles. They make efficient and flexible use of the
health workforce to
implement change, matching and enhancing skill levels to
enable less expensive
professionals and patients to do progressively more
sophisticated tasks (Christen-
sen et al., 2000).
The committee does not advocate any particular organizational
forms for the
21st-century health care system. The forms that emerge might
comprise corpo-
rate management and ownership structures, strategic alliances,
and other contrac-

tual arrangements (“virtual” organizations) (COR Healthcare
Resources, 2000;
Robinson and Casalino, 1996; Shortell et al., 2000a). New
information and
delivery structures might be located in a particular city or
region or might be the
basis for collaborative networks or consortia (COR Health LLC,
2000). What-
ever the organizational arrangement, it should promote
innovation and quality
improvement. Every organization should be held accountable to
its patients, the
populations it serves, and the public for its clinical and
financial performance.
Century
117
In some respects, such as economies of scale, workforce
training and deploy-
ment, and access to capital, larger organizations will have a
comparative advan-
tage. In other cases, small systems will evolve to take on
functions now per-
formed by larger organizations. The use of intranet- or
Internet-based applications
and information systems may enable the development of an
infrastructure to

accomplish certain functions. New forms might include, for
example, Web-
based knowledge servers or broker-mediated, consumer-directed
health care pur-
chasing programs.
KEY CHALLENGES FOR THE REDESIGN OF
HEALTH CARE ORGANIZATIONS
Health care services need to be organized and financed in ways
that make
sense to patients and clinicians and that foster coordination of
care and collabora-
tive work. They should be based on sound design principles and
make use of
information technologies that can integrate data for multiple
uses (Kibbe and
Bard, 1997a; Rosenstein, 1997). Whatever their form,
organizations will need to
meet six challenges, see Figure 5-1, that cut across different
health conditions,
types of care (such as preventive, acute, or chronic), and care
settings:
• redesigning care processes;
• making effective use of information technologies;
• managing clinical knowledge and skills;
• developing effective teams;
• coordinating care across patient conditions, services, and
settings over
time; and
• incorporating performance and outcome measurements for
improvement
and accountability.

The following discussion of these six challenges includes
excerpts from
interviews with clinical leaders conducted as a part of an IOM
study aimed at
identifying exemplary practices (Donaldson and Mohr, 2000).
Redesigning Care Processes
I try to help people understand that we can “work smarter.”
You can feel
rotten about how you are practicing. I tell them, “You are
right—and it’s going
to get worse.” But change is possible. We don’t need a billion-
dollar solution.
We need a billion $1 solutions. You have to create the will to
change. There’s
the will to change, then execution.—Hospital-based endoscopy
unit
Like any complex system, health care organizations require
sophisticated tools
and building blocks that allow them to function with purpose,
direction, and high
Century

reliability. Effective and reliable care processes—whether
registering patients
who come to the emergency room, ensuring complete
immunizations for chil-
dren, managing medication administration, ensuring that
accurate laboratory tests
are completed and returned to the requesting clinician, or
ensuring that discharge
from hospital to home after a disabling injury is safe and well
coordinated—can
be created only by using well-understood engineering
principles. Not only must
care processes be reliable, but they must also be focused on
creating a relation-
ship with a caregiver that meets the expectations of both the
patient and the
family. Redesign can transform the use of capital and human
resources to achieve
these ends.
Redesign may well challenge existing practices, data structures,
roles, and
management practices, and it results in continuing change. It
involves conceptu-
FIGURE 5-1 Making change possible.
CARE SYSTEM
Supportive
payment and
regulatory
environment
Organizations
that facilitate

the work of
patient-
centered teams
High performing
patient-centered
teams
Outcomes
• Safe
• Effective
• Efficient
• Personalized
• Timely
• Equitable
REDESIGN IMPERATIVES: SIX
CHALLENGES
• Redesigned care processes
• Effective use of information technologies
• Knowledge and skills management
• Development of effective teams
• Coordination of care across patient conditions, services,
and settings over time
• Use of performance and outcome measurement for
continuous quality improvement and accountability
Century

119
alizing, mapping, testing, refining, and continuing to improve
the many processes
of health care. Redesign aimed at increasing an organization’s
agility in respond-
ing to changing demand may be accomplished through a variety
of approaches,
such as simplifying, standardizing, reducing waste, and
implementing methods of
continuous flow (Bennis and Mische, 1995; Goldsmith, 1998).
Students of organizational theory have learned a great deal
through careful
examination of the work of organizations that use very complex
and often haz-
ardous technologies. The committee’s earlier report, To Err Is
Human, outlines
the achievements of several manufacturing companies and the
U.S. Navy’s air-
craft carriers in using replicable strategies to achieve great
consistency and reli-
ability (Institute of Medicine, 2000). Other world-class
businesses, notably those
that have received the prestigious Malcolm Baldrige National
Quality Award,
have embraced many of the tenets of quality improvement
described by Deming,
Juran, and others (Anderson et al., 1994), which include the
need to improve
constantly the system of production and services. Yet few
health care organiza-
tions have developed successful models of production that

reliably deliver basic
effective services, much less today’s increasingly advanced and
complex tech-
nologies. Nor have most been able to continually assess and
meet changing
patient requirements and expectations.
Some health care organizations have dedicated considerabl e
energy and re-
sources to changing the way they deliver care. Although these
organizations
have recognized the need for leadership to provide the
necessary commitment to
and investment in change, they have also recognized that change
needs to come
from the bottom up as front-line health care teams recognize
opportunities for
redesigning care processes and acquire the skill to implement
those new ap-
proaches successfully (National Committee for Quality Health
Care, 1999; Wash-
ington Business Group on Health, 1998). Many other
organizations have taken
steps toward redesigning processes, but have found replication
and deployment
difficult or short-lived (Blumenthal and Kilo, 1998; Shortell et
al., 1998). The
committee recognizes these efforts and the difficulties that stem
from, among
other things, restructuring and economic pressure, misaligned
incentives, profes-
sional entrenchment, competing priorities, organizational
inertia, and lack of
adequate information systems (Shortell et al., 1998).
A growing body of literature in health care indicates that well -

designed care
processes result in better quality (Desai et al., 1997; Griffin and
Kinmouth, 1998).
Some have argued that health care is not amenable to quality
improvement ap-
proaches derived from other industries because inputs (patients)
are so variable;
outputs, such as health-related outcomes, so ill-defined; and the
need for expert
judgment and improvisation so demanding. Similar arguments
have been made,
but not substantiated, in other service industries and by those in
the specialized
departments (e.g., legal) of manufacturing industries that have
subsequently ex-
perienced success in embracing principles of quality
improvement (Galvin, 1998).
Century
Fortunately, useful redesign principles that are now used widely
in other indus-
tries can be (and in some cases have been) adapted to health
care.
Engineering principles have been widely applied by other
industries and in
some health care organizations to design processes that improve

quality and
safety (Collins and Porras, 1997; Donaldson and Mohr, 2000;
Hodgetts, 1998;
Kegan, 1994; Peters and Waterman, 1982). The following
subsections describe
five such principles and their use by health care professionals to
improve pa-
tients’ experiences and safety, the flow of care processes, and
coordination and
communication among health professionals and with patients
(Langley et al.,
1996).
System Design Using the 80/20 Principle
The nurse assesses the patient demographics, risk factors,
support available,
medication, lifestyle, and barriers to making changes. The first
visit is usually
45 minutes to an hour long. Preventive screening visits are
done yearly—assess
vital signs, behavior, willingness to make changes. We take
retinal photos,
which are sent directly to the ophthalmologist, instead of
sending the patient
there. We learned that we need to risk stratify and fit the level
of services to the
level of risk. Services are less or more intense based on risk.
We use protocols
to identify risk level: primary—those with diabetes,
secondary—those with
diabetes and any other risk factors, tertiary—those who have
already had a
stroke, myocardial infarction, or renal failure.—Diabetic
management group

This engineering principle can be restated: Design for the
usual, but recog-
nize and plan for the unusual. Process design should be explicit
for the usual
case—for 80 percent of the work. For the remaining 20 percent,
contingency
plans should be assembled as needed. This concept is useful
both for designing
systems of care and as an approach to acculturating new
trainees. Also referred
to as the Pareto Principle, the 80/20 principle is based on the
recognition that a
small number of causes (20 percent) is responsible for a large
percentage (80
percent) of an effect (Juran, 1989; Transit Cooperative Research
Program, 1995).
In …

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