Leading Innovation and Change in the Health Service: A book of readings

Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services. In general, however, there has been a decrease in the number of local governmental public health agencies involved in direct service provision. In a recent survey of public health agencies, primary care or direct medical care services were the least common services provided NACCHO, Despite this, 28 percent of local public health departments report that they are the sole safety-net providers in their communities Keane et al.

During the s, Medicaid shifted from a fee-for-service program to a managed care model. This change has been a challenge to the multiple roles of public health departments as community-based primary health care providers, safety-net providers, and providers of population-based or traditional public health services. The challenge has been both financial and organizational. First, managed care plans reimburse safety-net providers less generously than fee-for-service Medicaid providers do under Medicaid, federally qualified health centers benefited from a federal requirement for full-cost reimbursement , and they impose administrative and service restrictions that result in reduced overall rates of compensation IOM, a.

In many states and localities, these changes have decreased the revenue available to public health departments and public clinics and hospitals. In many cases, funds were no longer available for population-based essential public health services or had to be diverted to the more visibly urgent need of keeping clinics and hospitals open CDC, The result of this interplay is that many governmental public health agencies have found themselves in a strained relationship with managed care organizations: Second, the shift of Medicaid services to a managed care environment led some public health departments to scale down or dismantle their infrastructure for the delivery of direct medical care.

The recent trend of the exit of managed care from the Medicaid market has left some people without a medical home and, in cases of changes in eligibility, has left some people uninsured. This problem may be most acute in rural areas, where public health departments are often the sole safety-net providers Johnson and Morris, One strategy to help lessen the negative impacts of changes in health care financing undertaken by some public health departments has been the development of formal relationships e.

Such arrangements have made possible some level of integration of health care and public health services, enhanced information exchange and continuity of care, and allowed public health departments to be reimbursed for the provision of some of the services that are covered by the benefits packages of managed care plans Martinez and Closter, At this time, governmental public health agencies are still called on to play a role in assurance broader than that which may be compatible with their other responsibilities to population health. However, closer integration between these governmental public health agencies and the health care delivery system can help address the needs of the uninsured and underinsured.

Denver Health, in Colorado, provides an intriguing example of a hybrid, integrated public—private health system Mays et al. Denver Health is the local county and city public health authority, as well as a managed care organization and hospital service. Although changes in the Medicaid program continue to challenge Denver Health, it continues to balance its broad responsibilities to the public's health with its role and capacity as a large health care provider. Disease surveillance and reporting provide a classic exemplar of essential collaboration between the health care system and the governmental public health agencies.

The latter rely on health care providers and laboratories to supply the data that are the basis for disease surveillance. For instance, in the fall of , reports from physicians who diagnosed the first cases of anthrax were essential in recognizing and responding to the bioterrorism attack. States mandate the reporting of various infectious diseases e. Governmental public health agencies also depend on astute clinicians to inform them of sentinel cases of recognized diseases that represent a special threat to the public's health and of unusual cases, sometimes without a confirmed diagnosis, that may represent a newly emerging infection, such as Legionnaires' disease or West Nile virus in North America.

Other types of public health surveillance activities, such as registries for cancer cases and for childhood immunizations, also depend on reporting from the health care system. Effective surveillance requires timely, accurate, and complete reports from health care providers. In the case of infectious diseases, if all systems work effectively, the necessary information regarding the diagnosis for a patient with a reportable disease is transmitted to the state or local public health department by a physician or laboratory.

For unusual or particularly serious conditions, public health officials offer guidance on treatment options and control measures and monitor the community for any additional reports of similar illness. For diseases like tuberculosis and sexually transmitted diseases, public health agencies facilitate active tracking and prophylactic treatment of persons exposed to an infected individual. Disease reporting requirements vary from state to state, although most states include diseases identified by the Centers for Disease Control and Prevention CDC as part of the National Notifiable Disease Reporting System.

Disease reporting is not complete, however. For diseases under national surveillance, from 6 to 90 percent of cases are reported, depending on the disease Teutsch and Churchill, ; Thacker and Stroup, Incomplete reporting may reflect a lack of understanding by some health care providers of the role of the governmental public health agencies in infectious disease monitoring and control.

In some instances, physicians and laboratories may be unaware of the requirement to report the occurrence of a notifiable disease or may underestimate the importance of such a requirement. The difficulty of reporting in a busy practice is also a barrier. Notifiable disease reporting systems within public health departments with strong liaisons with the health care community are important in the detection and recognition of bioterrorism events.

However, this valuable tool has not been well supported and, as noted earlier, suffers from issues of lack of timeliness and incomplete reporting, as well as complex or unclear reporting procedures and limited feedback from governmental public health agencies on how data are used Baxter et al.

Health care delivery systems may fear that the data will be used to measure performance, and concerns about patient confidentiality can also contribute to a reluctance to report some diagnoses. New federal regulations regarding the confidentiality of medical records, required by the Health Insurance Portability and Accountability Act P.

Health care providers may also reduce their use of laboratory tests to confirm a diagnosis. This may be because of cost concerns or insurance plan restrictions or simply professional judgment that the test is unnecessary for appropriate clinical care. However, when fewer diagnostic tests are performed for self-limiting illnesses like diarrhea, there may be delays in recognizing a disease outbreak.

Reduced use of laboratory testing prevents the analyses of pathogenic isolates needed for disease tracking, testing of new pathogens, and determining the levels of susceptibility to antimicrobial agents. Other changes in the health care delivery system also raise concerns about the infectious disease surveillance system. As patterns of health care delivery change, old reporting systems are undermined, but the opportunities offered by new types of care systems and technologies have not been realized.

For example, traditional patterns of reporting may be lost as health care delivery shifts from inpatient to outpatient settings. Hospital-based epidemiological reporting systems no longer capture many diagnoses now made and treated on an outpatient basis. This would not be a problem if health care systems used currently available information technologies, including electronic medical records and internal disease surveillance systems. Better information systems that allow the rapid and continuous exchange of clinical information among health care providers and with public health agencies have the potential to improve disease surveillance as well as aid in clinical decision making while avoiding the use of unnecessary diagnostic tests.

With such a system, a physician seeing an influx of patients with severe sore throats could use information on the current community prevalence of confirmed streptococcal pharyngitis and the antibiotic sensitivities of the cultured organisms to choose appropriate medications. From a public health perspective, such a system would permit continuous analysis of data from a number of clinical sites, enabling rapid recognition and response to new disease patterns in the community see Chapter 3 for a discussion of syndrome surveillance.

For example, toxic or infectious exposures could be tracked more easily if the characteristics of every patient encounter were integrated into one system and if everyone had unimpeded access to systems of care that could generate such data. A CDC-funded project of the Massachusetts Department of Public Health and the Harvard Vanguard Medical Associates a large multi-specialty group offers a glimpse of the benefits to be gained through collaboration between health care delivery systems and governmental public health agencies and specifically through the effective use of medical information systems Lazarus et al.

The Harvard Vanguard electronic medical system is queried each night for specific diagnoses assigned during the preceding day in the course of routine care. Diagnoses of interest are grouped into syndromes, and rates of new episodes are computed for all of eastern Massachusetts and each census tract. Expected numbers of new episodes are obtained from a generalized linear mixed model that uses data from to These expected numbers allow estimates of the probability of observing specific numbers of cases, either overall or in specific census tracts, and the rapid identification of an unusual cluster of events.

The value of this type of real-time monitoring of unusual disease outbreaks is obvious for early identification of bioterrorism attacks as well as for improvements in clinical care and population health. Reports of sentinel events have proved useful for the monitoring of many diseases, but such reports may be serendipitous and generated because of close clustering, unusual morbidity and mortality, novel clinical features, or the chance availability of medical expertise. Sentinel networks that specifically link groups of participating health care providers or health care delivery systems to a central data-receiving and -processing center have been particularly helpful in monitoring specific infections or designated classes of infections.

More recently, CDC has implemented a strategy directed to the identification of emerging infectious diseases in collaboration with many public health partners. The Emerging Infections Program EIP is a collaboration among CDC, state public health departments, and other public health partners for the purpose of conducting population-based surveillance and research on infectious diseases. At present, nine states California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee act as a national resource for the surveillance, prevention, and control of emerging infectious diseases CDC, The EIP sites have performed investigations of meningococcal and streptococcal diseases and have established surveillance for unexplained deaths and severe illnesses as an attempt to identify diseases and infectious agents, known and unknown, that can lead to severe illness or death CDC, Academic health centers AHCs serve as a critical interface with governmental public health agencies in several ways.

First, as noted earlier, AHCs are an important part of the safety-net system in most urban areas. Second, they are the principal providers of specialized services and serve as regional referral centers for smaller towns or cities and rural areas.

Leading Innovation and Change in the Health Service - A Book of Readings (Paperback)

Both in normal periods and especially when confronted with either natural disasters or terrorist events, the specialized care units are an essential resource for public health. Moreover, they are also primary loci for research and training. AHCs also have a unique and special set of values that they bring to health care that transcend the discrete functions they perform.

The environment in which AHCs operate has changed substantially over the past decade. The advent of managed care plans that seek services from the lowest-cost appropriate provider and changes in federal Medicare reimbursement policies that reduced subsidies for costs associated with AHCs' missions in education, research, and patient care have created considerable pressure on academic institutions to increase efficiency and control costs.

At the same time, advances in information technology and the explosion of knowledge from biomedical research have enormous implications for the role of AHCs in the health care system and in population health. Scientific and technological advances will permit clinical care to intervene early in a disease process by identifying and modifying personal risk. The burgeoning knowledge base will require different educational approaches to use the continuously expanding evidence base, with an emphasis on continuing education and lifetime learning. These changes may result in a broader mission for AHCs that explicitly includes improving the public's health, generating and disseminating knowledge, advancing e-health approaches i.

The ability of academic medicine to evolve into a broader mission will depend on changes in payment systems that may be difficult to achieve and on internal changes within AHCs that may be equally difficult. Governmental public health agencies may also play an important role in preventive medicine and public health education. Health departments, for example, provide unique venues for the training of nurses, physicians, and other health care professionals in the basics of community-based health care and gain an understanding of population-level approaches to health improvement.

Furthermore, public health students and preventive medicine residents gain practical experience in health department rotations, where they participate in program planning and evaluation and learn about assessing a community's health care needs and implementing strategies that change the conditions for health. In addition to the linkages between the health care delivery system and governmental public health agencies, health care providers also interface with other actors in the public health system, such as communities, the media, and businesses and employers. Relationships between the health care sector—hospitals, community health centers, and other health care providers—and the community are not new and have gained increased recognition for the value they bring to health care operations, their potential for enhancing provider accountability VHA and HRET, , the knowledge and empowerment they help to create in communities, and their potential for promoting health.

Calleson and colleagues surveyed the executives and staff of eight AHCs around the country and found that community—campus partnerships can strengthen the traditional mission of AHCs. The involvement of AHCs in the communities is also likely to increase in the coming years. The AHCs surveyed listed several factors that facilitated the development of relationships with communities and community organizations, including the request of the communities themselves and the growing population health orientation of the health care sector.

Furthermore, non-academic community health centers also frequently have close ties to their communities, collaborating to assess local health needs, providing needed services, and supporting community efforts with research expertise and technical assistance in planning and evaluation. Many hospitals participate in broad community-based efforts to achieve some of the conditions necessary for health, for instance, collaborating with community development corporations to contribute financial, human, and technical resources U.

Department of Housing and Urban Development, Montefiore Medical Center in the Bronx, New York, for example, has partnered with a local nonprofit organization to develop low- and moderate-income housing and to establish a neighborhood kindergarten Seedco and N-PAC, Additionally, Montefiore Medical Center partners with local high schools to develop health care professions education programs intended to create new career options and improve the likelihood inner-city youth will stay in school Montefiore Medical Center, Hospitals are also employers, and in the case of two Lawndale, Illinois, hospitals, collaboration with the local development corporation and other neighborhood organizations in made affordable local housing available to employees, helping to facilitate community development University of Illinois, Many hospitals and health care systems have seen the value of going beyond the needs of the individuals who enter the health care system to engage in broader community health action, even within the constraints of the current environment.

The National Community Care Network Demonstration Program, sponsored by the Hospital Research and Education Trust HRET , reports on hospitals across the country that are supporting activities beyond the delivery of medical care to improve health status and quality of life in local communities. Some of the motivation comes from the increasing pressure on nonprofit hospitals to justify their tax-exempt status through the provision of services that benefit the community, largely the provision of charity care; yet, many are seeing that investments in community health improvement are greater in value than the provision of medical care for preventable diseases Barnett and Torres, For example, in , Parkland Health and Hospital System in Dallas noted that injury rates in the community were three times the national average and that trauma admissions had jumped 38 percent in one year 53 percent of that care is uncompensated.

As a result, the organization decided to convene the county's leading trauma care providers, police, and civic groups to investigate and solve the problem. Coalition members decided to tackle, in order, injuries caused by car accidents, violence, falls, and burns, through 11 initiatives involving more than 80 community organizations and agencies. Over a 2-week period, there was a 13 percent reduction in trauma admissions from car crashes due to a public awareness campaign and police initiative AHA, A finalist for the Foster G. In a further example, the Crozer-Keystone Health System that serves Chester, Pennsylvania, was declared a distressed municipality by the state in Immunization rates have improved from 36 to 99 percent, and teen pregnancy is down to 31 per 1, from 44 per 1, Fifteen of 20 winners participated in a study, which included a self-assessment of changes since the time of the award and in-depth interviews with chief executive officers, trustees, and those leading the initiative.

Although this survey serves only as an illustration of what may be possible, several elements appeared supportive of a sustained commitment to efforts at community health improvement. Boufford has suggested a Community Health Improvement Strategy that identifies a number of steps that provider organizations can take in such community-based efforts see Box 5—9. However, payment systems are critical to encourage and sustain these network initiatives, and current reimbursement policies in public and private insurance are not designed to support population-focused care in a noncapitated system.

Community Health Improvement Strategy. The health care sector can also develop linkages with the media to help ensure the accuracy of health information, communicate risk, and facilitate the public understanding of health care. For example, health care organizations may use the media to disseminate health care information to their market areas, as demonstrated by the Minneapolis Allina Health System in its collaboration with a local television station and a health care news provider Rees, Additionally, the media may be a powerful tool for familiarizing the public with health and health care issues and a conduit for raising important questions, stimulating public interest, or even influencing the public's health behaviors.

For example, the popular prime time television show ER frequently serves as a platform for health information, with episodes exploring topics such as childhood immunizations, contraception, and violence Brodie et al. Businesses and employers most commonly interface with the health care sector in purchasing and designing employee health benefits, with goals such as the inclusion of comprehensive preventive health care services.

However, there are examples of wide-reaching business—health care linkages, such as the efforts to ensure quality of care and enhanced consumer choice undertaken by the Pacific Business Group on Health see Chapter 6. Chapter 4 provides additional examples of fruitful community partnerships involving the health care sector. After a period of stability in the mids, health care costs are again rising because of several factors Heffler et al.

Prescription drug spending, in particular, has increased sharply, and increased by This increase comes from the growth of the older population and the proportion of the overall population with chronic conditions, along with the introduction of new and more expensive drugs, many of which are used to treat chronic conditions. In addition, spending for hospital services increased by 5. However, the increase in health spending also reflects the success of federal and state efforts to enroll more low-income children in Medicaid and the State Children's Health Insurance Program, increased enrollment in Medicare as the population ages, and some erosion of unpopular cost-control features imposed by managed care plans.

With the economic downturn in , the growth in health care spending creates added financial burdens for everyone, including individuals seeking care or insurance coverage, employers offering health insurance benefits, and governments at the federal, state, and local levels managing publicly funded insurance programs Fronstin, ; Trude et al. Substantial increases in health insurance premiums are a clear indication of these economic stresses. For example, the California Public Employees' Retirement System, which is the nation's second largest public purchaser of employee health benefits, recently announced that health insurance premiums would increase by 25 percent Connoly, States are experiencing serious pressures from growth in Medicaid spending, which increased by about 13 percent from to , following a With revenues increasing by only about 5 percent in the same period, Medicaid now accounts for more than 20 percent of total state spending NASBO, b.

The growing cost of health care has obvious implications for the nation's readiness to address the problems discussed in this chapter. Providing coverage to the uninsured, improving coverage for certain types of care, strengthening the emergency response and surge capacity in the hospital sector, and investing in information systems that can improve the quality of individual care and population-based disease surveillance will all require significant new resources from the public and private sectors.

Although these steps can be expected to improve the nation's health and may even reduce costs over time, the initial investment will be substantial. The committee is concerned that with the escalation of expenditures, going in large measure toward maintaining current services, it will be difficult to identify the necessary public- and private-sector resources that will be needed for new activities.

The committee recommends that bold, large-scale demonstrations be funded by the federal government and other major investors in health care to test radical new approaches to increase the efficiency and effectiveness of health care financing and delivery systems. The experiments should effectively link delivery systems with other components of the public health system and focus on improving population health while eliminating disparities.

The demonstrations should be supported by adequate resources to enable innovative ideas to be fairly tested. This chapter has outlined the main areas in which the health care delivery system and the governmental public health agencies interface. These areas include the regulatory and quality monitoring functions performed by governmental agencies, disease surveillance and reporting by health care providers, and the provision of safety-net services.

Although assurance is a core function of public health, governmental public health agencies often do more than assure that people can access health care services; public health departments may become providers of last resort in areas where no other services are available for low-income, uninsured populations and when managed care services to Medicaid and uninsured populations are discontinued. These circumstances force public health departments to provide personal health care services instead of using their resources and population-level approaches to guide and support community efforts to change the conditions for health.

Closer collaboration and integration between governmental public health agencies and the health care delivery system may enhance the capacities of both to improve population health and may support the efforts of other public health system actors. Defined-contribution health care benefits are a new way for employers to provide health care coverage to their employees, while no longer acting as brokers between employees and insurance companies contracted to provide benefits.

An employer may choose from several different ways to put money into a health benefits account for each employee and offer the employee a menu of coverage options, with different funding levels and employee financial responsibility for each. McGaw Prize for Excellence in Community Service is awarded by the American Hospital Association to recognize hospitals that have distinguished themselves through efforts to improve the health and well-being of everyone in their communities.

Turn recording back on. National Center for Biotechnology Information , U. The Uninsured and the Underinsured The persistently large proportion of the American population that is uninsured—about one in five working-age adults and one in seven children— is the most visible and troubling sign of the nation's failure to assure access to health care. Safety-Net Providers Absent the availability of health insurance, the role of the safety-net provider is critically important.

NEGLECTED CARE The committee is concerned that the specific types of care that are important for population health—clinical preventive services, mental health care, treatment for substance abuse, and oral health care—are less available because of the current organization and financing of health care services. Clinical Preventive Services The evidence that insurance makes a difference in health outcomes is well documented for preventive, screening, and chronic disease care IOM, b.

Medicare Coverage of Preventive Services Preventive services are important for older adults, for whom they can reduce premature morbidity and mortality, help preserve function, and enhance quality of life. Medicaid Coverage of Preventive Services Medicaid benefits vary by state in terms of both the individuals who are eligible for coverage and the actual services for which coverage is provided. Mental Health Care The Surgeon General's report on mental illness DHHS, estimates that more than one in five adults are affected by mental disorders in any given year see Box 5—6 and 5.

Oral Health Care Like mental illness and addiction disorders, oral health has been neglected in the health care delivery system. Care for Chronic Conditions Americans now live longer. Wagner and colleagues identified five elements required to improve outcomes for chronically ill patients: Ready access to necessary clinical expertise. Shortages of Health Care Professionals The committee took special note of certain shortages of health care professionals, because these shortages are having a significant adverse effect on the quality of health care.

Underrepresentation of Racial and Ethnic Minorities In , 9 percent of physicians and Hospital Nursing Shortage RNs work in a variety of settings, ranging from governmental public health agency clinics to hospitals and nursing homes. Hospitals and the Capacity for Emergency Response Hospitals contribute in various ways to assuring the health of the public, particularly by providing acute care services, educating health professionals, serving as a site for research, organizing community health promotion and disease prevention activities, and acting as safety-net providers.

Access to Primary Care The adequacy of hospital capacity cannot be assessed without considering the system inefficiencies that characterize current insurance and care delivery arrangements. The Unfulfilled Potential of Managed Care Although Billings and colleagues focused on the preventable demands for hospital care among low-income and uninsured populations, Closing the Quality Chasm IOM, b makes clear that the misuse of services also characterizes disease management among insured chronically ill patients.

Information Technology The development of enhanced information technology and its use in hospitals, individual provider practices, and other segments of the health care delivery system are essential for improving the quality of care. The Emergence of Separate Systems Within the public health system in the United States, collaboration between the health care sector and governmental public health agencies is generally weak. The Role of Governmental Public Health Agencies as Health Care Providers Public health departments have always differed greatly in regard to the delivery of health care services, based on the availability of such services in the community and other reasons Moos and Miller, Disease Surveillance and Reporting Disease surveillance and reporting provide a classic exemplar of essential collaboration between the health care system and the governmental public health agencies.

Sentinel Surveillance Reports of sentinel events have proved useful for the monitoring of many diseases, but such reports may be serendipitous and generated because of close clustering, unusual morbidity and mortality, novel clinical features, or the chance availability of medical expertise. Preparing Health Care Professionals Academic health centers AHCs serve as a critical interface with governmental public health agencies in several ways.

These included Committing leadership at multiple levels through the top leadership to sustain changes;. Protecting funding and leadership of community health initiatives while integrating community health values into the culture of the parent organization;. Building an evidence base through evaluation and ongoing measurement of community health indicators; and. Association of American Medical Colleges. Emergency departments—an essential access point to care.

AHA TrendWatch 3 1. The health care workforce shortage and its implication for America's hospitals. Accessed April 9, Nova Award Winners — Available online at www. Accessed October 7, Depression in Primary Care: Treatment of Major Depression. Department of Health and Human Services. Nurses' report on hospital care in five countries.

Health Affairs 20 3: Lower Medicare mortality among a set of hospitals known for good nursing care. Dental insurance is essential, but not enough. In Closing the Gap, a newsletter.

1. Planning and Studying Improvement in Patient Care: The Use of Theoretical Perspectives.
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Emergency departments and crowding in United States teaching hospitals. Annals of Emergency Medicine 20 9: Unmet health needs of uninsured adults in the United States. Journal of the American Medical Association Warning signs in the mouth. Health insurance and access to care for symptomatic conditions. Archives of Internal Medicine 9: Barnett K, Torres G. Beyond the Medical Model: Hospitals Improve Community Building. Reducing the frequency of errors in medicine using information technology.

Journal of the American Medical Informatics Association 8 4: PMC ] [ PubMed: Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Baxter R, Mechanic RE. The status of local health care safety-nets. Health Affairs 16 4: The Lewin Group, Inc. Berk ML, Schur C. Impact of socioeconomic status on hospital use in New York City. Health Affairs 12 1: Recent findings on preventable hospitalizations. Health Affairs 15 3: Preventable hospitalizations and access to health care. Health Affairs 20 6: Race and discretion in American medicine.

Available online at http: Accessed October 6, Journal of Health Administration Education 17 4: Progress in cancer screening over a decade: Journal of the National Cancer Institute Center for Studying Health System Change. Communicating health information through the entertainment media: For instance, a wide range of positive outcomes, such as reductions in hospital stay and patient mortality, have been reported as a result of good teamwork and multidisciplinary collaboration in patient care.

An examination of the relationship of organizational culture, quality improvement, and selected outcomes in hospitals showed that a flexible, risk-taking culture was associated with more quality-improvement activities and that this was related to better perceived patient outcomes Shortell et al. Our overview of theories is not comprehensive but is a challenge to apply theories from different disciplines to the health care setting. Overall, the lack of scientific work underpinning even some of the most popular models for change in health care is striking.

One of our conclusions must therefore be that future studies on change interventions need to focus more on applying specific theories of change to health care. This conclusion agrees with that of Greenhalgh and colleagues , who strongly emphasized the need for more research on mechanisms that determine whether a specific innovation will be successful in a particular health care setting. This will help us discover which theories are helpful for planning change in health care and which are not and which theoretical assumptions are particularly helpful for which purposes.

The results of such research should gradually provide a better understanding of the black box of change in health care. Making explicit the theoretical assumptions behind the choice of interventions should be important to both researchers and change agents, for a number of reasons. First, the use of theory can offer a generalizable framework for considering effectiveness across different clinical conditions and settings Eccles et al. Second, basing interventions or a change program on different theoretical assumptions should prevent overlooking important factors ICEBeRG Group Third, a variety of factors at different levels of health care professional, social context, organizational or economic usually are important to improving patient care Ferlie and Shortell ; Grol , so hypotheses regarding effective change that are derived from different theories should be useful.

More theory-driven research on effective change should ultimately help us decide on the best approaches. QLRT for their support. National Center for Biotechnology Information , U. Journal List Milbank Q v. Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract A consistent finding in articles on quality improvement in health care is that change is difficult to achieve.

Theories, quality improvement, health care. The Complexity of Changing Practices In their excellent attempt to develop a unifying model of the diffusion of innovations in health care, Greenhalgh and colleagues found that the available theoretical literature on this issue is large, diverse, and complex. The Use of Theories in Planning and Evaluating Change Interventions The perspective taken in this article is that for most changes in health care, a range of factors interact at different levels patients, professionals, interactions among professionals in teams, the organizational context, and the economic and political context to determine whether and to what extent change is achieved.

Methods We included those theories that seemed relevant or referred directly or indirectly to quality improvement and the implementation of change in health care. Hand Hygiene and Diabetes Management Hand Hygiene In many countries, one of the priorities for health care is reducing the number of hospital-acquired infections. Diabetes Management International consensus on optimal diabetes management emphasizes the continuous monitoring of diabetes patients to detect complications particularly in arteries, eyes, feet, and kidneys.

Open in a separate window. Although the scientific basis for these principles is still sketchy, they provide the following model for creating an implementation plan for health care Grol and Wensing b: Changing practice routines should take into account the complexity of the practice, as many factors may stimulate or hamper change. Effective implementation requires a systematic, well-planned approach that considers all relevant factors.

For the implementation to be successful, the entire target group must be committed to it. As far as possible, the target group should be involved in both the development of the innovation for change and the implementation plan. Attention should be given to the specific innovation to be implemented, for example, its scientific basis, the group or organization that developed it, and the ultimate form in which it is to be presented.

Particular characteristics of innovations proposed changes, new technologies, clinical guidelines may promote or hamper their actual adoption e. Table 2 is an overview of such characteristics Grol and Wensing a. Although there has been little research on the impact of these characteristics on change in health care, recommendations that could easily be tried and stopped if they did not work were found to be associated with higher compliance rates Grilli and Lomas A series of observational studies in primary care Burgers et al.

Characteristic Description Relative advantage or utility Better than existing or alternative working methods. Compatibility Consistent with existing norms and values. Complexity Easy to explain, understand, and use. Costs Balance between cost and benefits, necessary level of investment. Risks Degree of uncertainty about result or consequences.

Leading Innovation & Change in the NHS

Involvement Degree to which target group is involved in development. Divisibility Degree to which parts can be tried out separately and implemented separately. Trialability, reversibility Degree to which an innovation can without risk be tried out, stopped, or reversed if it does not work. Visibility, observability Degree to which other people can see and observe the results. Centrality Degree to which the innovation affects central or peripheral activities in the daily working routine. Pervasiveness, scope, impact How much of the total work is influenced by the innovation, how many persons are influenced, how much time it takes, and what the influence on social relationships is.

Magnitude, disruptiveness, radicalness How many organizational, structural, financial, and personal measures the innovation requires. Duration The time period within which the change must take place. Form, physical properties What sort of innovation or change it is material or social, technical or administrative, etc. Collective action Degree to which decisions about the innovation must be made by individuals, groups, or a whole institution.

Presentation Nature of presentation, length, clarity, attractiveness. Successful implementation often requires a sequential approach, with different problems resolved at each step. Individuals or subgroups within the implementation's target group may be in different phases of a process of change see the next section. Because different subgroups may demand different approaches, the target group and the context for change must be well known. Therefore the implementation process requires a diagnostic or problem analysis to find out the reasons for departures from the desired performance, characteristics of the target group and setting, influential involved parties, and factors that could hamper or stimulate change.

The choice of measures and strategies for changes should be linked as closely as possible to the results of the problem analysis. On this basis, a cost-effective mix of measures, such as education, feedback, rewards, or organizational changes, can be devised. Attempts to change clinical practice should be accompanied by a plan to monitor progress and to determine whether the intended changes are being achieved. On the basis of such an evaluation, the targets or the plan can be adjusted.

The implementation of change should be a cycle in which the implementers learn from earlier steps in the process and continually improve their approach. The implementation plan must be incorporated into established structures for professional development and quality management in the target setting. Awareness of innovation Not familiar, does not read literature, no contact with colleagues Distribute brief messages via all types of channels; approach key figures and networks 2.

Interest, involvement No sense of urgency, does not see it as relevant Attention-catching brochure; personal approach and explanation; confrontation regarding performance Insight 1. Understanding No knowledge, information too complex or too extensive Good instruction materials, concise messages; information based on problems in practice; regular repetition of message 2. Insight into own routines No insight, overestimation of own performance Simple methods of audit and feedback on performance; comparisons of data with peers Acceptance 1.

Positive attitude Sees disadvantages, doubt about value or developers, not attracted to change Adapt innovation to wishes of target group, with local discussion and consensus; discuss resistance; provide good scientific arguments; involve key individuals and opinion leaders 2. Decision to change Doubt about feasibility, success, and own efficacy Have peers demonstrate feasibility; detect bottlenecks, seek solutions, and propose feasible objectives for change Change 1.

Actual adoption, tryout Not starting, no time, lack of skills, does not fit into fixed routines Extra resources, support, training in skills, redevelopment of care processes, temporary support or consultants, information materials for patients 2. Confirmation of value Insufficient success, negative reactions of others Devise plan with feasible objectives for change, inventory of bottlenecks, and finding solutions Maintenance 1.

New practice integrated into routines Relapse, forgetting Monitoring, feedback, and reminder systems; integration in routine care plans and local protocols 2. New practice embedded in organization No support, no budget Provide resources, support from top management, organizational measures, rewards, payment for certain tasks. Impact Theories Impact theories describe the hypotheses and assumptions regarding how a specific intervention will facilitate a desired change; that is, they describe the causes and effects and the factors determining success or the lack thereof in improving care.

Theory Hypotheses Derived from Theory on Changing Practice Possible Interventions Applied to Hand Hygiene and Diabetes Examples Individual professionals Cognitive theories Implementation of change needs to take into account professionals' decision processes, and they need good information and methods to support their decisions in practice. Provide convincing and timely information to professionals on desired care, and support their decision making on hand hygiene routines or diabetes management.

Educational theories Implementation of change should be linked to professionals' needs and motivation; intrinsic motivation is crucial; people change on basis of experienced problems in practice. Motivational theories Implementation of change needs to focus on attitudes, perceived social norms, and experienced control related to desired performance. Convince professionals of importance of better hand hygiene or diabetes care; show that they can do it and that others find it important that they do it.

Social context Theories of communication Importance of the source of innovation credibility , the framing and rehearsal of messages, and the characteristics of the messages' recipient. Develop very convincing message, have credible persons present it, and adapt message to receiver's competence and motivation. Social learning theory Changing performance takes place through demonstration and modeling and through reinforcement by others. Social network and influence theories Change demands local adaptation of innovations and use of local networks and opinion leaders in dissemination, including identifying innovators and key persons in the social network.

Study the interaction in the team; determine the opinion leaders; and use these to improve infection control or diabetes management. Theories related to teamwork More effective teams are better able to make necessary changes to improve care because they share goals and are able to share knowledge. Create teams in which roles are defined and people encourage one another to work on the common goal of fewer infections or complications in diabetes patients.

Use professional pride and define professional standards for the desired performance. Theories of leadership Involvement and commitment of leaders and top management in change process are important. Have top management or informal leaders initiate activities and provide continuous support aimed at changing routines in diabetes care or hand hygiene. Organizational context Theory of innovative organizations Implementation should take into account the type of organization; decentralized decision making teams about innovation is important.

Create broad coalitions of clinicians from different wards to change the systems for infection control or diabetes care; increase responsibilities for the wards. Theory of quality management Improvement is a continuous cyclic process, with plans for change continually adapted on the basis of previous experience; organization-wide measures are aimed at improving culture, collaboration, customer focus, and processes.

Reorganize work processes around diabetes care or infection control; develop primary care or hospital-wide system for optimal diabetes care or for prevention of infections; monitor progress and continually adapt plans for change on the basis of data. Theories of integrated care Change multidisciplinary care processes and collaboration instead of individual decision making. Analyze and redesign the work processes related to diabetes care or hand hygiene, and make these more effective and efficient. Complexity theory Focus on system as a whole, find patterns in behavior attractors and link change plan to these, and test and improve the plan.

Organizational learning theory The creation or availability of conditions in the organization for continuous learning at all levels can lead to successful changes. Offer continuous learning and exchange of information about diabetes management and better hygiene at all levels of the organization. Theories of organizational culture Changes in the culture can stimulate changes in performance, particularly a culture of teamwork, flexibility, and external orientation.

Work on improving the general culture in the hospital or at the wards, in which infection control and integrated care for diabetes patients are seen as priorities. Political and economic context Reimbursement theories Attractive rewards and financial incentives can influence the volume of specific activities. Theory of contracting Contractual arrangements can guide professional and organizational performance. Provide contractual arrangements of purchasers and care providers related to diabetes control or meeting of infection targets.

Theories Focused on Individuals Theories of factors related to changes by individual professionals in health care focus on the way that they physicians, nurses, managers, etc. Cognitive Theories Rational Decision Making Cognitive theories of change management focus on the rational processes of thinking and acting by individual professionals.

Consistency Other theories describe cognitive mechanisms that may prevent rational decision making. Educational Theories Problem-Based Learning Most educational theories focus less on cognitions and more on the motivation to learn and change. Learning Style Another factor seen as important to change is professionals' personal learning style.

Theories Related to Social Interaction Most of the theories related to social interaction discuss determinants of change in the interaction between an individual professional and others, such as the influence of key individuals and opinion leaders, participation in social networks and teams, and the role of leadership see Table 5. Theories about Communication Several theories focus on effective communication aimed at changing individual attitudes and behaviors.

Social Network and Influence Theories Theories of the diffusion of innovations state that the adoption of new ideas and technologies is largely influenced by the structure of social networks and by specific individuals in or at the margins of these networks Rogers Opinion Leaders Local opinion leaders are particularly important to social network and social influence theories, as they are considered to be respected persons with great influence in their field or setting. Theories Related to Team Effectiveness Although the importance of teamwork to achieving organizations' aims was established at least seventy years ago, it is only in the past twenty years that large organizations have taken up this idea widely.

Theories of Professional Development Health professionals have knowledge that is not easily accessible to nonprofessionals and that is highly valued by society because of its practical relevance to people. Theories of Leadership Both formal and informal leaders can be very influential in changing clinical practice or implementing new procedures or processes. Theories Related to the Organizational Context Several theories see the opportunity for change in patient care in terms of structural or organizational conditions and reforms, such as the better organization of care processes, a different division of tasks and roles, and change in the culture in the work setting or the collaboration among professionals see Table 5.

Theories of Innovative Organizations Theories of innovative organizations focus on those characteristics of organizations that determine whether and to what extent they are able to implement innovations Wolfe Theories of Integrated Care Change of Processes of Care In line with the TQM approach, theories of integrated care stress the radical or gradual redesign of the steps in providing care.

Multidisciplinary Collaboration Wagner found that effective chronic care generally relied on multidisciplinary teams.

Complexity Theory Complexity theory refers to systems behavior and systems change, starting from the assumption that because the world of health care has become increasingly complex, it is important to observe and improve systems as a whole instead of dividing them into parts or components. Theories about Organizational Culture The interest in theories regarding organizational culture is based on the assumption that it is related to performance and that an organization's culture can be altered to change performance Scott et al.

Theories Related to the Political and Economic Context Theories that focus on the wider environment can encompass determinants of organizational change related to regulation, insurance systems, markets, and other factors outside the organization. Reimbursement Theories Economic theories are based on the premise that individuals and organizations make decisions in order to optimize their goals and to reduce risks.

Conclusions and Discussion Because the introduction of innovation and change in health care is difficult and many current programs for improving care are, at best, only partly successful, we argue that a better use of theoretical assumptions to develop and test plans and interventions to improve patient care may improve our understanding of this very complex and to date largely empirical field.

The Need for Theory-Informed Research Overall, the lack of scientific work underpinning even some of the most popular models for change in health care is striking. Attitudes, Personality and Behaviour. Open University Press; The Theory of Planned Behaviour. Organizational Behavior and Human Decision Processes.

A Theory of Action Perspective. Archives of Internal Medicine. Behavioural Change in Professional Practice. Supporting the Development of Effective Implementation Strategies. Centre for Health Services Research; Social Foundation of Thought and Action: A Social Cognitive Theory. The Anatomy of Stages of Change. American Journal of Health Promotion. Incentives and Provider Payment Methods. International Journal of Health Planning and Management. Continuous Improvement as an Ideal in Health Care.

New England Journal of Medicine. Physicians as Leaders in Improving Health Care. Annals of Internal Medicine. Healthcare Quality Improvement and Organisational Culture. Botti M, Reeve R. Nursing and Health Sciences. Quality and Safety in Health Care. British Journal of General Practice. Persuasion as Argument Processing.

Contemporary Problems in Group Decision Making. Journal of the American Medical Association. Effects of Financial Incentives on Medical Practice: International Journal for Quality in Health Care. The Foundation of Improvement. Information Technology Implementation Research: A Technological Diffusion Approach.

Counte MA, Meurer S. Academy of Management Journal. Translating Guidelines into Practice: Canadian Medical Association Journal. Journal of Applied Psychology. Implications for Continuing Medical Education. Understanding Organizational Learning Capability. Journal of Management Studies. Netherlands Journal of Medicine. Eagly AH, Chaiken S. The Psychology of Attitudes. Harcourt Brace Jovanovich; Changing the Behaviour of Healthcare Professionals: Journal of Clinical Epidemiology. A Framework for Change. A Theory of Cognitive Dissonance.

ACCESS TO HEALTH CARE

Stanford University Press; Quality in Health Care. Belief, Attitude, Intention and Behavior. Journal of Business Research. Improving Team Structure and Communication. Managing Knowledge Transfer by Knowledge Technologies. Organisational Context for Quality: Building a Learning Organization. An Educational and Environmental Approach. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. The State of the Art versus the State of the Science. Implementing Guidelines in General Practice Care.

Beliefs and Evidence in Changing Clinical Practice. From Best Evidence to Best Practice: Effective Implementation of Change in Patients' Care. Medical Journal of Australia. Characteristics of Successful Innovations. Grol R, Wensing M. Grumbach MD, Bodenheimer T. Health Care Management Review. Improving the Performance of Health Services: The Role of Clinical Leadership. A Modern Measure with Big Effects.

Fellows work on Capitol Hill with elected officials and congressional staff. The goal is for fellows to use their academic and practice experience to inform the policy process and to improve. Investigators are funded to complete innovative studies of topics relevant to current and future health policy. Participants in both programs receive intensive training to improve the content and delivery of messages intended to improve health policy and practice.

This training is critical, as investigators are often called upon to testify to Congress about the issues they have explored. The health policy fellows bring their more detailed understanding of how policies are formed back to their home organizations. In this way, they are more effective leaders as they strive to bring about policy changes that lead to improvements in patient care.

Although not an individual leadership program, the American Nurses Credentialing Center ANCC Magnet Recognition Program 11 recognizes health care organizations that advance nursing excellence and leadership. In this regard, achieving Magnet status indicates that the nursing workforce within the institution has attained a number of high standards relating to quality and standards of nursing practice. Some of these Forces include quality of nursing leadership, management style, quality of care, autonomous nursing care, nurses as teachers, interprofessional relationships, and professional development.

Leadership is also fostered through effective mentorship opportunities with leaders in nursing, other health professions, policy, and business. All nurses have a responsibility to mentor those who come after them, whether by helping a new nurse become oriented or by taking on more formal responsibilities as a teacher of nursing students or a preceptor.

Nursing organizations membership associations also have a responsibility to provide mentoring and leadership guidance, as well as opportunities to share expertise and best practices, for those who join. Fortunately, a number of nursing associations have organized networks to support their membership and facilitate such opportunities:. The American Association of Colleges of Nursing AACN conducts an expertise survey that is used to identify subject matter experts across topic areas within its membership; it also maintains a list of nursing education experts.

Names of these experts are shared with members on request. These resources also are used to identify experts to serve on boards, respond to media requests, and serve in other capacities. In addition, AACN offers an annual executive leadership development program and a new deans mentoring program to further promote and foster leadership.

While AONE does not have a formal mentoring program, it has developed online learning communities where members are encouraged to interact, post questions, and learn from each other. These online communities facilitate collaboration; encourage the sharing of knowledge, best practices, and resources; and help members discover solutions to day-to-day challenges in their work. Edge Runner names and contact information are prominently displayed so that learning and mentoring can take place freely.

The American Nurses Association just passed a resolution at its House of Delegates to develop a mentoring program for novice nurses. The program has yet to be developed. It serves as a model worth emulating throughout the nursing profession. The Edge Runner designation recognizes nurses who have developed innovative, successful models of care and interventions to address problems in the health care delivery system or unmet health needs in a population. Nurses may articulate what they want to happen in health care to make it more truly patient centered and to improve quality, access, and value.

They may even have the evidence to support their conclusions. As with any worthy cause, however, they must engage in the policy-making process to ensure that the changes they believe in are realized. To this end, they must be able to envision themselves as leaders in that process and seek out new partners who share their goals.

The challenge now is to motivate all nurses to pursue leadership roles in the policy-making process. Political engagement is one avenue they can take to that end. For example, engaging school board candidates about the fundamental role of school nurses in the management of chronic conditions among students can make a difference at budget time.

And if the goal is broader, perhaps to locate more community health clinics within schools, achieving buy-in from the local school board is absolutely vital. Political engagement can be a natural outgrowth of nursing experience. In February , Ms. Tavenner was named deputy administrator for the federal Centers for Medicare and Medicaid Services.

Like many nurses, she had never envisioned working in government. But she realized that she wanted to have an impact on health care and health care reform. She wanted to help the uninsured find resources and access to care. For her, that meant building on relationships and finding opportunities to work in government. Other notable nurses who have answered the call to serve in government include Sheila Burke, who served as chief of staff to former Senate Majority Leader Robert Dole, has been a member of the Medicare Payment Advisory Commission,.

This paragraph draws on personal communication with Marilyn Tavenner, principal deputy administrator and chief operating officer, Centers for Medicare and Medicaid Services, May 11, The fellowship rotates among three branches of service Army, Navy, and Air Force annually. Shirley Chater led the reorganization of the Social Security Administration in the s. Carolyne Davis served as head of the Health Care Finance Administration predecessor of the Centers for Medicare and Medicaid Services in the s during the implementation of a new coding system that classifies hospital cases into diagnosis-related groups.

From to , Rhetaugh Dumas was the first nurse, the first woman, and the first African American to serve as a deputy director of the National Institute of Mental Health Sullivan, Lois Capps organized and co-chairs the Congressional Nursing Caucus which also includes members who are not nurses. The group focuses on mobilizing congressional support for health-related issues. None of these nurses waited to be asked; they pursued their positions, both elected and appointed, because they knew they had the expertise and experience to make changes in health care. Very little in politics is accomplished without preparation or allies.

Health professionals point with pride to multiple aspects of the Prescription for Pennsylvania initiative, a state health care reform initiative that preceded the ACA and is also described in Box As is clear from a detailed review, success was not achieved overnight; smaller legislative and regulatory victories set the stage. Pennsylvanians were 11 percent more likely than all other Americans to use the emergency room ER. In January he announced a major new blueprint for that reform, Prescription for Pennsylvania known as Rx for PA, www.

This last strategy has had an impact on access to care, particularly for the uninsured and underinsured. Torregrossa said that of , visits to such clinics, about half would have been ER visits. Retail clinics have been shown to reduce costs and improve access to care Mehrotra et al. There are about nurse-managed health centers nationwide and 27 in Pennsylvania; many are affiliated with schools of nursing and provide care at a 10 percent lower cost than other models—including a 15 percent reduction in ER use and a 25 percent reduction in prescription drug costs according to unpublished data from the National Nursing Centers Consortium [NNCC].

The nurse-managed health centers in particular offer a preventive care model that improves access to care. Governor Edward Rendell speaks about the important role of nurses in improving access to health care in Pennsylvania. Even some apparent legislative failures built the foundation for future successes because they caused nurses to spend more time meeting face to face with physicians who had organized opposition to various measures. As a result, nursing leaders developed a better sense of where they could achieve compromises with their opponents. They also found a new ally in the Chamber of Commerce to counter opposition from some sections of organized medicine Hansen-Turton et al.

Hansen-Turton and colleagues draw three major lessons from this experience. First, nurses must build strong alliances within their own professional community, an important lesson alluded to earlier in this chapter. Second, nurses must build relationships with key policy makers. Third, nurses must find allies outside the nursing profession, particularly in business and other influential communities.

Perhaps the most important lesson to draw from the Pennsylvania experience lies in the way the campaign was framed. The focus of attention was on achieving quality care and cost reductions. A closer examination of the issues showed that achieving those goals required, among other things, expanding the roles and responsibilities of nurses. What drew the greatest amount of political support for the Prescription for Pennsylvania campaign was the shared goal of getting more value out of the health care system—quality care at a sustainable price.

The fact that the campaign also expanded nursing practice was secondary. Those expansions are likely to continue as long as the emphasis is on quality care and cost reduction. Similarly, the committee believes that the goal in any transformation of the health care system should be achieving innovative, patient-centered, highvalue care. If all stakeholders—from legislators, to regulators, to hospital executives, to insurance companies—act from a patient-centered point of reference, they will see that many of the solutions they are seeking require a transformation of the nursing profession.

Having enough nurses and having nurses with the right skills and competencies to care for the population is an important societal issue. More nurses need to reach out to new partners in arenas ranging from business, government, and philanthropy to state and national medical associations to consumer groups.

Additionally, nurses need to fortify alliances that are made through personal connections and relationships. Just as important, society needs to understand its stake in ensuring that nurses are effective full partners and leaders in the quest to deliver quality, high-value care that is accessible to diverse populations. The full potential of the nursing profession in care, leadership, and research must be tapped to deal with the wide range of health care challenges the nation will face in the coming years.

Eventually, to transform the way health care is delivered in the United States, nurses will have to move not just out of the hospital, but also out of health care organizations entirely. For example, nurses are underrepresented on the boards of private nonprofit and philanthropic organizations, which do not provide health care services but often have a large impact on health care decisions.

Managing Change, Creativity and Innovation: Reference Books @ www.newyorkethnicfood.com

The Commonwealth Fund and the Kaiser Family Foundation, for instance, have no nurses on their boards, although they do have physicians. Without nurses, vital ground-level perspectives on quality improvement, care coordination, and health promotion are likely missing.

1. Reluctant Revolution.
2. The Emeralds Flashed?
3. Advanced Dynamics and Model-Based Control of Structures and Machines.

On the other hand, AARP provides a positive example. At least two nurses at AARP have served in the top leadership and governance roles president and chair in the past 3 years. Nurses serve on the health and long-term services policy committee, and the senior vice president of the Public Policy Institute is also a nurse. Enactment of the ACA will provide unprecedented opportunities for change in the U. Strong leadership on the part of nurses, physicians, and others will be required to devise and implement the changes necessary to increase quality, access, and value and deliver patient-centered care.

If these efforts are to be successful, all nurses, from students, to bedside and community nurses, to CNOs and members of nursing organizations, to researchers, must develop leadership competencies and serve as full partners with physicians and other health professionals in efforts to improve the health care system and the delivery of care. Nurses must exercise these competencies in a collaborative environment in all settings, including hospitals, communities, schools, boards, and political and business arenas.

In doing so, they must not only mentor others along the way, but develop partnerships and gain allies both within and beyond the health care environment. The essentials of baccalaureate education for professional nursing practice. Enhancing diversity in the nursing workforce: Fact sheet updated March Why senior nursing officers matter: A national survey of nursing executives.

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Journal of Healthcare Management 53 2: Behaviors that undermine a culture of safety. Sentinel Event Alert Chief nursing officer retention and turnover: Results of a national survey. The wisdom of teams: Creating the high-performance organization. Harvard Business School Press. Channeling grief into action: Creating a culture of safety conference call, February 25, , Hosted by Institute for Healthcare Improvement.

Aligning resources to create and sustain partnerships. Journal of Professional Nursing 20 5: Championing quality and patient safety in the boardroom. Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses.

Annals of Internal Medicine 5: Creating a culture of regard: An antidote for workplace bullying. Creative Nursing 15 2: Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in healthcare. International Journal of Evidence-Based Healthcare 5: Which kind of collaboration is right for you? Harvard Business Review 86 Governance in high-performing community health systems: