The health care system in the United States has been the subject of much debate as experts try to determine the best way to deliver high-quality care. The research and resources on system design of the Agency for Healthcare Research and Quality (AHRQ) complement and build on many other AHRQ programs. Below are examples of research, resources, and tools on system design developed with support from AHRQ.
Contents
Introduction
Research
Efficiency and Value
Organizational Transformation and Quality Improvement
Organization and Delivery of Care
Health Care Work Force and Environment
Resources and Tools
Efficiency Measures
Systemwide Transformation
Innovation and Performance Improvement
Process Redesign
Enhancing Minority Health, Cultural Competency, and Health Literacy
Implementing Information Technology and Other Health Technologies
Additional Resources: AHRQ 2009 Annual Conference
For More Information
References
Introduction
The health care system in the United States has been the subject of much debate as experts attempt to determine the best way to deliver high-quality care. In Crossing the Quality Chasm,1 the Institute of Medicine (IOM) called for the redesign of health care delivery systems and their external environments to promote care that is safe, effective, patient-centered, timely, efficient, and equitable. AHRQ conducts and supports research to inform providers, insurers (including the Centers for Medicare & Medicaid Services), policymakers, and other stakeholders about system designs that promote the IOM's aims. AHRQ also provides information about implementation processes that facilitate and sustain design initiatives.
Health care delivery systems are complex sociotechnical systems, characterized by dynamic interchanges with their environments (e.g., markets, payers, regulators, and consumers) and interactions among internal system components. These components include people, physical settings, technologies, care processes, and organization (e.g., rules, structure, information systems, communication, rewards, work flow, culture).2 Systems design research examines interactions among system components and their possible impact on quality and cost. Systems design resources and tools provide guides to changes in system design (also known as redesign) that can enhance value.
Value may be enhanced by improving quality while reducing or maintaining cost. Value is also increased when systems reduce waste and inefficiency while maintaining or improving quality. To foster sustainable value improvements, design initiatives often bundle changes in several mutually reinforcing system components (e.g., information technology, process redesign, and training programs).3
AHRQ's research and resources on system design complement and build on many other AHRQ programs. Below are examples of research, resources, and tools on system design developed with support from AHRQ. Many of the items listed were funded under AHRQ's Patient Safety and Health Information Technology (IT) portfolios.
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Research
Efficiency and Value
Fraser I, Encinosa W, Glied S. Improving efficiency and value in health care. Health Serv Res 2008 Oct;43(5 Pt 2):1781-6.
This theme issue of Health Services Research includes an introduction and 7 state-of-the-art research studies on improving efficiency and value in health care. The studies include examinations of 21 quality improvement (QI) programs in Minnesota hospitals; impact of the Group Health Cooperative's Access Initiative on physician productivity; frontline staff perspectives on opportunities for improving safety and efficiency in hospital work systems; effects of a tiered hospital network on hospital admissions; efficiency of specialty hospitals in the United States; efficient use of physician assistants across the country; and efficiency of 1,377 U.S. hospitals. Brief summaries appear at http://www.ahrq.gov/research/dec08/1208RA7.htm.
James B, Bayley KB. Cost of poor quality or waste in integrated delivery system settings. Final report. Rockville, MD: Agency for Healthcare Research and Quality; September 2008. AHRQ Publication No. 08-0096-EF. Available at: http://www.ahrq.gov/research/costpqids.
An estimated 30 percent of health care costs are attributable to waste. The average cost of poor quality is $1,500 per patient per year. Examples of poor quality and/or waste in health care are diverse and include: clinician interruptions, duplicated or repeat testing/procedures, delays in care, inefficient use of clinician time, improper documentation/record keeping, iatrogenesis, and patient injuries. The authors examine existing approaches for capturing the costs of waste/poor quality and present specific examples of these estimates. Drawing on available constructs from the literature, the authors then identify a model for estimating waste at the population, episode, and patient levels.
Wallace C, Savitz L. Estimating waste in frontline health care worker activities. J Eval Clin Pract 2008;14(1):178-80.
This publication reports on part of the study of waste mentioned in the previous listing. The authors found that hospital workers encounter substantial waste as they perform their duties. The paper describes their methods for identifying and quantifying the extent of waste.
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Organizational Transformation and Quality Improvement
Alexander JA, Hearld LR, Jiang HJ, et al. Increasing the relevance of research to health care managers: hospital CEO imperatives for improving quality and lowering costs. Health Care Manage Rev 2007 Apr-Jun;32(2):150-9.
This qualitative study identifies how hospital leaders view key determinants of quality and costs and how they think about solutions to these issues. The hospital leaders tend to think systemically and consider process-related factors as important cost and quality drivers.
Brokel J, Harrison M. Redesigning care processes using an electronic health record: a system's experience. Jt Comm J Qual Patient Saf 2009;35 (Feb.):82-92.
The paper describes how Trinity Health, a major integrated delivery system, successfully leveraged implementation of a systemwide electronic health record to promote process redesign and continuous quality improvement.
Frankel A. WalkRounds improve patient safety. Gaining feedback to provide exceptional patient care. Healthc Exec 2008 Mar-Apr;23(2):22-24, 26, 28.
Weekly rounds involving hospital executives and frontline medical staff encouraged caregivers to report operational concerns and discuss and learn from errors. However, only two of the seven participating hospitals successfully sustained the WalkRounds program.
Harrison M, Kimani J. Building capacity for a transformation initiative: system redesign at Denver Health. Health Care Manage Rev 2009 Jan-Mar;34(1):42-53.
This paper presents a case study of the first 2 years of a system design initiative at Denver Health and an analysis of developments during the preceding decade. These developments created positive antecedents for the transformation initiative. Practice and research implications are discussed.
Kritchevsky SB, Braun BI, Bush AJ, et. Al. The effect of a quality improvement collaborative to improve antimicrobial prophylaxis in surgical patients. A randomized trial. Ann Intern Med 2008 Oct;149(7):472-80.
This study reports that there was no demonstrated benefit to hospitals participating in a quality improvement collaborative in improving infection prevention in surgical patients compared to nonparticipating control hospitals. (Both groups did receive performance feedback). Since participation in both the experimental and the control group was voluntary, new reporting requirements may have motivated hospitals in both groups to give more attention to infection prevention.
McDonald KM, Sundaram V, Bravata, DM, et al. Closing the quality gap: a critical analysis of quality improvement strategies: Vol. 7, Care coordination. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville, MD: Agency for Healthcare Research and Quality; June 2007. AHRQ Publication No. 04(07)-0051-7. http://www.ahrq.gov/clinic/tp/caregaptp.htm.
This report develops a working definition of care coordination and provides a systematic research review. It also identifies theoretical frameworks that might predict or explain how care coordination mechanisms are influenced by factors in the health care setting and how they relate to patient outcomes and health care costs.
Raab S. Implementation of Lean in laboratory medical services, PowerPoint® presentation. AHRQ 2007 Annual Conference: Improving Healthcare, Improving Lives. Bethesda, MD, September 26-28, 2007. http://www.blsmeetings.net/2007AHRQANNUAL/agenda_thur.cfm. 
Raab SS, Andrew-Jaja C, Grzybicki DM, et al. Dissemination of Lean methods to improve Pap testing quality and patient safety. J Low Genit Tract Dis 2008 Apr;12(2):103-10.
The AHRQ presentation describes applications to laboratory services of Lean methods as developed within Perfecting Patient Care™ by Pittsburgh Regional Healthcare. It provides data on the resulting quality and cost improvements. The subsequent paper documents how Lean-based process redesign among a group of clinicians improved Pap test quality and accuracy.
Savitz, L, ed. AHRQ's Partnerships for Quality Program: advancing quality together. Jt Comm J Qual Patient Saf 2007 Dec;33(12, Supplement).
This supplement contains papers examining the operations of a major AHRQ initiative in organization-based participatory research. The papers examine the theoretical underpinnings of this initiative, implementation lessons, processes of dissemination of quality improvements among program participants, and the program's impact on clinical quality.
Stratton TP, Worley MM, Schmidt M, et al. Implementing after-hours pharmacy coverage for critical access hospitals in northeast Minnesota. Am J Health Syst Pharm 2008 Sep 15;65(18):1727-34.
A round-the-clock hub pharmacy serving a network of rural hospitals enhanced the timeliness, availability, and safety of pharmacy services.
Wang M, Hyun J, Shortell M, et al. Redesigning health systems for quality: lessons from emerging practices. Jt Comm J Qual Patient Saf 2006 Nov;32:599-611.
This article reports on an AHRQ-funded scan of redesign practices among leading health systems. The authors develop an integrated systems approach to redesign, which reflects the success factors observed in the scan. Recommendations are included for payers, providers, and policymakers.
Weiner BJ, Alexander JA, Shortell SM, et al. Quality improvement implementation and hospital performance on quality indicators. Health Serv Res 2006 Apr;41(2):307-34.
Alexander JA, Weiner BJ, Shortell SM, et al. Does quality improvement implementation affect hospital quality of care? Hosp Top 2007 Spring;85(2):3-12
The first of these two articles summarizes results from a study of 1,784 community hospitals in which involvement by multiple hospital units in quality improvement (QI) efforts is associated with worse values on hospital-level quality indicators. Percentage of hospital staff and percentage of senior managers participating in formally organized QI teams are associated with better values on quality indicators. Percentage of physicians participating in QI teams is not associated with better values on the hospital-level quality indicators studied.
The second article expands on the above analysis by Weiner, et al., and examines how the association between QI implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. Forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators, specifically, data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.
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Organization and Delivery of Care
Begun J, Jiang J. Changing organizations for their likely mass-casualties future. Adv Health Care Manage 2004;4:163-80.
Drawing on complexity science, the authors provide recommendations for transforming health care organizations into more resilient learning organizations capable of managing unexpected events.
Butler M, Kane RL, McAlpine D, et al. Integration of mental health/substance abuse and primary care (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-0009). Rockville, MD: Agency for Healthcare Research and Quality; October 2008. AHRQ Publication No. 09-E003. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=B151103.
In general, integrated care achieved positive outcomes. The evidence is particularly strong for depression. However, it is not possible to distinguish the effects of specific strategies; correlation is lacking between measures of processes of integration of care and outcomes.
Coleman K, Austin B, Brach C, et al. Evidence on the chronic care model in the new millennium. Health Affairs 2009;28(1):75-85.
Accumulated evidence since 2000 appears to support the Chronic Care Model (CCM) as an integrated framework to guide practice redesign. These studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes. Work remains to be done in areas such as cost-effectiveness.
Jiang J, Friedman B, Begun J. Factors associated with quality/low-cost hospital performance. J Health Care Finance 2006 Spring; 32:39-52.
Jiang J, Friedman B, Begun J. Sustaining and improving hospital performance: the effects of organizational and market factors. Health Care Manage Rev 2006;31(3):188-96.
These two studies explore organizational and market characteristics associated with superior hospital performance with regard to both quality and cost of care. The research uses AHRQ's Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases for 10 States.
Jiang H. et al. Board oversight of quality: any differences in process of care and mortality? Journal of Healthcare Management, 54 (1) 15-30.
This study found that board commitment to quality, involvement in setting a quality agenda, and exercising oversight of quality performance are associated with higher quality, as measured by performance in care processes and risk-adjusted mortality.
Khare RK, Powell ES, Reinhardt G, et al. Adding more beds to the emergency department or reducing admitted patient boarding times: which has a more significant influence on emergency department congestion? Ann Emerg Med 2009 May;53(5):575-85.
A computer simulation using institutional data and augmented by expert estimates and assumptions shows that improving the rate at which admitted patients depart the ED produces an improvement in overall ED length of stay, whereas increasing the number of ED beds does not.
Kralewski J. Organizational factors influencing patient safety/quality in medical group practices. PowerPoint® presentation. AHRQ 2007 Annual Conference: Improving Healthcare, Improving Lives. Bethesda, MD, September 26-28, 2007.
This presentation summarizes findings from four studies of the effects of organizational and payment factors on measures of patient safety and quality in ambulatory settings.
Reinertsen J, Clancy C. Keeping our promises: research, practice, and policy issues in health care reliability. Health Serv Res 2006 August;41 (4, part II):1535-38 (available as AHRQ Publication No. 06-RO74).
This AHRQ-sponsored supplement contains articles on the factors that contribute to high reliability in health care delivery systems and explores lessons about reliability from other industries.
Rodriguez HP, Marsden PV, Landon BE, et al. The effect of care team composition on the quality of HIV care. Med Care Res Rev 2008 Feb;65(1):88-113.
This study uses data from the HIV Cost and Services Utilization Study to assess the effect of care team composition on the quality of HIV care. The study examines advantages of having multiple clinicians with condition-specific expertise and complementary knowledge, skills, and roles, as well as disadvantages arising from problems in care coordination and decreased continuity of care.
Singer SJ, Gaba DM, Falwell A, et al. Patient safety climate in 92 US hospitals: differences by work area and discipline. Med Care 2009 Jan;47(1):23-31.
Singer SJ. Falwell A, Gaba DM. et al. Patient safety climate in U.S. hospitals: variation by management level and clinical disciplines. Med Care 2008 Nov 2008 46(11):1149-56.
Many studies of culture and climate in hospitals overlook divergence among ranks, work areas, and occupational disciplines. The differences in patient safety climate within and between organizations documented in these papers point to the need for better communication between senior management and frontline workers. Moreover, safety and quality interventions need to be tailored for rank, work areas, and disciplines.
Thomas JC, Carter C, Torrone E, et al. Pulling together: interagency coordination and HIV/STD prevention. J Public Health Manag Pract 2008 Jan-Feb;14(1):E1-E6.
This study analyzed 170 HIV prevention agencies in 10 counties in North Carolina and found a relationship between interagency coordination and prevention of HIV and STDs.
Tucker A, Singer S, Hayes J, et al. Frontline perspectives on opportunities for improving the safety and efficiency of hospital work systems. Harvard Business School Working Paper 08-015. Cambridge, MA: Harvard University, 2007. Available from atucker@hbs.edu.
This paper explores systemic gaps in efforts to improve patient safety and efficiency, based on observations of senior managers and frontline staff in 20 U.S. hospitals. It recommends giving priority to improvements in work systems in general, rather than targeting specific clinical conditions. This is the first paper to result from a study supported by an AHRQ grant, Improving Safety Culture and Outcomes in Healthcare, and by the Fishman-Davidson Center for Service and Operations Management at the Wharton School.
Wears RL, ed. Organizations and safety in health care. Qual Saf Health Care 2004 Dec;13 (Suppl).
This AHRQ-sponsored journal supplement examines the influence of higher level organizational factors on safety and introduces theoretical and empirical work on safety to those who may not be familiar with this literature. The papers explore organizational learning, organizational conditions affecting safety, and leadership.
Zinn JS, Spector WD, Weimer DL, et al. Strategic orientation and nursing home response to public reporting of quality measures: an application of the Miles and Snow typology. Health Serv Res 2008 Apr;43(2):598-615.
This article reports on the response of nursing home administrators to the first publication of the Nursing Home Compare Report in 2004. Administrators were also asked to select the strategic orientation that best characterized their facility, based on the typology developed by Miles and Snow. The researchers noted an association between whether/how a facility responded to the Nursing Home Compare Report and its strategic orientation.
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Health Care Work Force and Environment
Castle NG, Engberg J. Further examination of the influence of caregiver staffing levels on nursing home quality. Gerontologist 2008 Aug;48(4):464-76.
Alexander GL. An analysis of nursing home quality measures and staffing. Qual Manag Health Care 2008 Jul-Sep;17(3):242-51.
These two papers show that staffing mix (e.g., % temporary, ratio of RNs to other caregivers) and turnover affect nursing home quality, whereas overall staffing levels have only weak associations with quality measures.
Harrison M, ed. Improving the health care work environment to promote quality and safety. Jt Comm J Qual Patient Saf 2007 November;33 (Suppl). Available as AHRQ Publication OM 08-0007.
This AHRQ-sponsored journal supplement reviews evidence on the effects of working conditions on the quality of health care. The papers examine persistent threats to patient safety in hospital work environments and present options for improvement. The supplement contains six papers, five of them written by AHRQ-funded researchers or staff members, along with an introduction and afterword.
Hoff T. How work context shapes physician approach to safety and error. Qual Manag Health Care 2007 Apr-Jun;17(2):140-53.
This article examines how the work environment (e.g., workload, relationships among physicians) affects patient safety behaviors in the surgery, medical intensive care unit (ICU), and emergency departments of an academic medical center. The author found that the medical ICU had the highest potential capacity for dealing with patient safety and quality of care. The article also discusses interventions most likely to improve patient safety in each setting.
Hutt E, Radcliff TA, Liebrecht D, et al. Associations among nurse and certified nursing assistant hours per resident per day and adherence to guidelines for treating nursing home-acquired pneumonia. J Gerontol 2008 Oct;63A(10):1105-11.
Staffing and turnover rates were the best predictor of whether a patient received recommended care for preventing and treating pneumonia.
Kane R, Shamliyan T, Mueller C, et al. Nurse Staffing and Quality of Patient Care. Evidence Report/Technology Assessment Number 151 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-0009). Rockville, MD: Agency for Healthcare Research and Quality, March 2007. AHRQ Publication No. 07-E005. http://www.ahrq.gov/clinic/tp/nursesttp.htm.
This evidence report documents the effects of nurse staffing on quality.
Mukamel DB, Spector WD, Limcangco R, et al. The costs of turnover in nursing homes. Med Care 2009 Oct;47(10):1039-45.
Nursing homes in California with higher turnover experience lower costs. This finding helps explain the persistence of staffing practices that encourage high turnover and points to the need for policy initiatives to reduce the financial incentives for turnover.
Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? (Prepared by The Lewin Group under Contract No. 290-04-0011). Rockville, MD: Agency for Healthcare Research and Quality, August 2005. AHRQ Publication No. 06-0106-EF. http://www.ahrq.gov/qual/hospbuilt/.
This report summarizes evidence to date about relationships between the built environment in hospitals (i.e., its physical features) and patient outcomes, safety, and satisfaction, as well as hospital staff safety and satisfaction. The report discusses research needs and implications for current practice.
Rutledge T, Stucky E, Dollarhide A, et al. A real-time assessment of work stress in physicians and nurses. Health Psychol 2009;28(2):194-200.
This study shows that doctors and nurses in teaching hospitals report widespread sleep deprivation and job stress, despite growing awareness of the consequences of these conditions and attempts to mandate shorter hours for residents.
Stone P, Harrison MI, Feldman P, et al. Organizational climate of staff working conditions and safety—an integrative model. In: Henriksen K, Battles J, Marks E, et al., eds. Advances in patient safety: from research to implementation. Vol. 2, Concepts and methodology. Rockville, MD: Agency for Healthcare Research and Quality; 2005. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.3614.
This paper compares measures of organizational climate in ongoing patient safety studies and develops a model of climate domains that are hypothesized to affect outcomes across settings. It also tests aspects of the model with data from six separate AHRQ-funded studies.
Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, National Research Council. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Washington, DC: National Academies Press; 2008. Available at: http://www.iom.edu/Reports/2008/Resident-Duty-Hours-Enhancing-Sleep-Supervision-and-Safety.aspx
This IOM committee report recommends: protected sleep periods, limits on work hours for residents, redesigned schedules, increased resident training on better communication during handovers, and more involvement of residents in patient safety activities and adverse event reporting.
Vasilevskis EE, Meltzer DM, Schnipper J, et al. Quality of care for decompensated heart failure: comparable performance between academic hospitalists and nonhospitalists. J Gen Intern Med 2008 Sep;23(9):1399-1406.
Hospitalists and general internists provide similar quality of care for patients with congestive heart failure, However, hospitalists' patients were nearly twice as likely to have a 30-day posthospitalization followup.
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Resources and Tools
Efficiency Measures
McGlynn E. Identifying, categorizing, and evaluating healthcare efficiency measures. PowerPoint presentation. AHRQ 2007 Annual Conference: Improving Healthcare, Improving Lives; 2007 Sept 26-28; Bethesda, MD.
This presentation summarizes an AHRQ-commissioned report titled "Identifying, Categorizing, and Evaluating Health Care Efficiency Measures." The report identifies and describes existing measures of health care efficiency, organizes them into a typology, and evaluates them according to broad criteria.
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Systemwide Transformation
Arnold SB, editor. Transforming Health Systems Through Leadership, Design, and Incentives. Invitational Meeting Sponsored by Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid Services, National Cancer Institute, and Health Affairs. 2004 Oct 18-19; Rockville. Rockville, MD: Centers for Medicare & Medicaid Services; 2005.
These are proceedings from an expert meeting at which participants reviewed prospects for better aligning payment and system design, along with opportunities for redesign within the context of current payment systems.
Gabow P, Eisert S, Karkhanis A, et al. A Toolkit for Redesign in Health Care. (Prepared by Denver Health under Contract No. 290-00-0014-7). Rockville, MD: Agency for Healthcare Research and Quality, September 2005. AHRQ Publication No. 05-0108-EF. http://www.ahrq.gov/qual/toolkit/.
Melinkovitch P. Adoption of rapid cycle improvement process from Toyota increases efficiency and productivity at community health clinics. http://www.innovations.ahrq.gov/content.aspx?id=1807, updated May 25, 2009.
Denver Health initiated a systemwide change initiative that sought to transform its physical environment, culture, reward system, staffing, and processes. To drive process redesign, it applied Toyota Production Systems/Lean methods throughout its delivery system. This effort is documented in the report and the toolkit and in the Innovations Clearinghouse entry, which reports on extensions of Denver's work in its ambulatory clinics. These three items contain detailed descriptions of improvements in efficiency, access, and quality and lessons learned and recommendations for providers.
Getting Lean: health care's challenge. A "Lean" training and health care system redesign conference. 2005 Oct 19-21; Denver. Denver: Denver Health; 2005. http://www.denverhealth.org/2005LEANCONFERENCE/Default.aspx.
These are proceedings from a conference on applying Toyota Production Systems/Lean to health care. The conference was organized and hosted by Denver Health with support from AHRQ. Members of several health systems presented their experiences in applying Lean to improve quality and efficiency.
Hines S, Luna K, Lofthus J, et al. Becoming a high reliability organization: operational advice for hospital leaders. (Prepared by The Lewin Group under Contract No. 290-04-0011.) Rockville, MD: Agency for Healthcare Research and Quality; February 2008. AHRQ Publication No. 08-0022. http://www.ahrq.gov/qual/hroadvice/.
This publication discusses five key characteristics of high reliability organizations (HROs) and their application to hospitals:
- Sensitivity to operations.
- Reluctance to simplify.
- Preoccupation with failure.
- Deference to expertise.
- Resilience.
The document reflects the experiences and insights of leaders from 19 health care systems who participated in an AHRQ Learning Network on HROs. For more than a year, leaders from these systems met to discuss their successes and challenges in operationalizing HRO concepts in their organizations. In particular, the document shares insights gathered from five site visits to learning network member hospitals.
Integrating chronic care and business strategies in the safety net: a toolkit for primary care practices and clinics. Rockville, MD: Agency for Healthcare Research and Quality; August 2008. AHRQ Publication No. 08-0104-EF. http://www.ahrq.gov/populations/businessstrategies/.
This toolkit is designed to help safety net organizations implement the Chronic Care Model (CCM) effectively and sustainably. The toolkit provides a step-by-step approach to redesigning safety net systems of care while attending to financial realities. Included are links to more than 60 commonly used quality improvement tools and examples from practices that have made quality improvement pay.
Managing and Evaluating Rapid-Cycle Process Improvements as Vehicles for Hospital System Redesign. (Prepared by Denver Health under Contract No. 290-00-0014). Rockville, MD: Agency for Healthcare Research and Quality, September 2007. AHRQ Publication No. 07-0074-EF. http://www.ahrq.gov/qual/rapidcycle/.
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Innovation and Performance Improvement
Brach C, Lenfestey N, Roussel A, et al. Will it work here? a decisionmaker's guide to adopting innovations. Rockville, MD: Agency for Healthcare Research and Quality; September 2008. AHRQ Publication No. 08-0051 http://www.innovations.ahrq.gov/resources/guideTOC.aspx
This new guide provides guidance about the full range of considerations for selecting appropriate health care delivery innovations and planning for their adoption. Individual sections address tasks such as assessing the suitability of innovations and an organization's readiness, and planning and executing implementation.
Dougherty D, Conway PH. The "3T's" road map to transform US health care: the "how" of high-quality care. JAMA 2008;299(19):2319-21 (doi:10.1001/jama.299.19.2319).
The authors present a model characterizing the conditions for accelerating spread and implementation of evidence-based clinical innovations.
Henriksen K, Joseph A, Zayas-Caban T. Human factors of home health care: a conceptual model for examining safety and quality concerns. J Patient Saf 2009;5:229-36.
This paper uses a sociotechnical systems model to examine potential threats to safety and quality in home health care and possible responses to them.
Hughes R, ed. Patient safety and quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043. http://www.ahrq.gov/qual/nurseshdbk.
This comprehensive handbook provides research, techniques, and interventions that nurses can use to enhance patient and organizational outcomes.
King H. TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety. Advances in patient safety: new directions and alternative approaches. Vol. 3, Performance and tools. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-3.
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=aps2v3&part=advances-king_1.
This article describes the research foundation, development, and implementation of TeamSTEPPS™, a multiyear research and development project jointly undertaken by the Department of Defense and AHRQ. TeamSTEPPS™ is composed of tools and strategies to improve team performance in health care. For more information, go also to: Webster J, King HB, Toomey LM, et al. Understanding quality and safety problems in the ambulatory environment: seeking improvement with promising teamwork tools and strategies. Advances in Patient Safety: New Directions and Alternative Approaches. Volume 3. Performance and tools. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-3. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=aps2v3&part=advances-webster_76. Tools are available at: http://www.innovations.ahrq.gov/content.aspx?id=2212
This article discusses types of safety problems and errors that can occur in ambulatory care settings and describes six evidence-based tools and strategies for addressing them. These strategies were developed under the TeamSTEPPS™ initiative and are designed to improve the quality and safety of patient care by improving teamwork and communication.
Rundall TG, Martelli PF, Arroyo L, et al. The informed decisions toolbox: tools for knowledge transfer and performance improvement. J Healthc Manag 2007 Sep-Oct 2007;52(5):325-41; discussion 341-2.
Decisionmakers do not always use research evidence when making decisions about the organization and financing of health care. The Informed Decisions Toolbox describes six steps to assist health care decisionmakers in acquiring the best available evidence when making management decisions; assessing whether evidence is useful, defined as accurate, applicable, actionable, and accessible; and improving the process by which evidence is used in decisionmaking.
The Health Care Innovations Exchange (HCIE) is a searchable Web site designed to support health care professionals in sharing and adopting innovations that improve the delivery of care to patients. The Web site contains descriptions of a wide range of innovations, their impact, and how the innovations were developed and implemented. Among the many strategies and quality-related tools reported on the HCIE Web site are redesign innovations for enhancing access to care, reducing hospitalizations, and reducing costs through improved information technology-supported workflow, including:
- Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients
http://www.innovations.ahrq.gov/content.aspx?id=1746
This new care program improves reported health and saves $600-$1,000 per month in reduced rehospitalization expenditures. [AHRQ-supported project].
- Onsite Nurses Work With Primary Care Physicians To Manage Care Across Settings, Resulting in Improved Patient Satisfaction and Lower Utilization and Costs for Chronically Ill Seniors
http://www.innovations.ahrq.gov/content.aspx?id=1752
This initiative improves care for chronically ill seniors; specially trained nurses work with primary care physicians to coordinate care, facilitate care transitions, and act as patient advocates. Results include improvements in reported health and savings of 23 percent on readmission costs. [AHRQ-supported project].
- Community Referral Liaisons Help Patients Reduce Risky Health Behaviors, Leading to Improvements in Health Status
Community Health Educator Referral Liaisons (CHERLs) helped patients reduce drinking, smoking, and physical inactivity by linking them with community resources, offering counseling and encouragement over the telephone, and providing feedback to referring physicians [AHRQ-supported project]. http://www.innovations.ahrq.gov/content.aspx?id=2244
- Unit-Based Safety Program Improves Safety Culture, Reduces Medication Errors and Length of Stay
http://www.innovations.ahrq.gov/content.aspx?id=1769
This initiative improves safety culture through a structured process in which a unit-based, multidisciplinary team identifies and prevents safety hazards. [AHRQ-supported project] .
- Adopting "Flow Management" Improves Efficiency, Throughput, and Quality of Care in Hospital Surgery Units
http://innovations.ahrq.gov/content.aspx?id=1714
This initiative implements principles of "flow management," borrowed from other industries, to redesign the flow of operations in one large hospital medical-surgical department.
- "Hospital at Home" Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients
http://innovations.ahrq.gov/content.aspx?id=1787
This initiative provides hospital-level care (including daily physician and nurse visits, diagnostic testing, treatment, and other support) in a patient's home as a full substitute for acute hospital care for selected conditions.
- Electronic Medical Record-Facilitated Care Process Redesign Enhances Access to Care, Reduces Hospitalizations and Costs for Patients With Chronic Illnesses
http://innovations.ahrq.gov/content.aspx?id=1725
This initiative redesigns patient care and workflow processes for chronically ill patients to take advantage of the organization's full-function EMR and wireless tablet personal computer technologies.
- Daily Intensive Care Unit Team Communication Enhances Provider Understanding of Care Goals, Reduces Length of Stay
http://innovations.ahrq.gov/content.aspx?id=260
This initiative redesigns ICU team communications.
- Chronic Care and Disease Management Improves Health, Reduces Costs for Patients With Multiple Chronic Conditions in an Integrated Health System
http://www.innovations.ahrq.gov/content.aspx?id=1696
Combining chronic care and disease management for patients with multiple conditions reduced hospitalizations and visits to specialists and the ED. Capitation payments allowed for shared savings among the payer and providers.
- Primary Care Managers Supported by Information Technology Systems Improve Outcomes, Reduce Costs For Patients With Complex Conditions
http://www.innovations.ahrq.gov/content.aspx?id=264
The Care Management Plus program at Intermountain Healthcare combines care manager services in primary care clinics plus electronic tracking and reminder systems to ensure comprehensive, coordinated care for seniors with multiple chronic illnesses. The program improved outcomes and reduced costs.
- Solo Physician's Use of Virtual and Phone Visits, Same-Day Appointments, and Extended In-Person Visits Leads to High Patient Satisfaction and Improved Chronic Disease Outcomes
http://www.innovations.ahrq.gov/content.aspx?id=2196
A solo family practitioner reports how she designed her practice along the lines of the Ideal Medical Practice (L.G. Moore and J.H. Wasson). Without foundation or research support, she introduced year-round, 24-hour-a-day, 7-day-a-week access to care for her patients through liberal use of "virtual" or E-mail visits, telephone calls, same-day appointments, and extended office visits. The initiative is gratifying to the provider and has fostered patient satisfaction, low patient turnover, improved outcomes for patients with chronic disease, and lower costs.
- E-Mail and Telephone Contact Replaces Most Patient Visits in Primary Care Practice, Leads to More Engaged Patients and Time Savings for Physicians
http://www.innovations.ahrq.gov/content.aspx?id=1785
Like the preceding entry, this case reports on a redesign using virtual visits. GreenField Health is an independent clinic that has a research and development arm.
- Revamped Scheduling Systems Promote Access, Reduce No-Shows, and Enhance Quality, Patient Satisfaction, and Revenues in Primary Care Practice
http://www.innovations.ahrq.gov/content.aspx?id=1856
Using the "advanced access model" (and without external funding), a primary care practice in Rhode Island revamped its appointment scheduling, tracking, and reminder processes to enhance access to same-day appointments and achieve the results listed above.
- Revised Processes Related to Daily Opening Reduce Wait Times and Enhance Patient Satisfaction at Two Urban Clinics
http://www.innovations.ahrq.gov/content.aspx?id=1904
Urban Health Plan, a federally qualified health center for underserved communities in the South Bronx, redesigned operational processes (e.g., checklists for start and end of day; staff assignment based on anticipated demand); the two clinics also standardized and streamlined layout. These changes improved care efficiency and improved patient-provider interactions.
- Plan-Funded Team Coordinates Enhanced Primary Care and Support Services to At-Risk Seniors, Reducing Hospitalizations and Emergency Department Visits
http://www.innovations.ahrq.gov/content.aspx?id=2243
Commonwealth Care Alliance of Massachusetts developed a health plan (Senior Care Options) that provides low-income, dual eligibles with a primary care team (physician, nurse practitioner, and geriatric specialist) in the enrollee's primary care clinic. The team ensures that these medically complex individuals receive needed medical care and social services at no additional cost to the enrollee. The program improved prevention, screening, and chronic disease management; reduced hospital stays, hospital admissions, and ED visits; and lowered costs and length of stay.
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Process Redesign
Adams-Pizarro I, Walker Z, Robinson J, et al. Using the AHRQ Hospital Survey on Patient Safety Culture as an intervention tool for regional clinical improvement collaboratives. Advances in patient safety: new directions and alternative approaches. Vol. 2, Culture and redesign. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-2.
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=aps2v2&part=advances-adams-pizarro_109.
Since its release in November 2004, the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) has been used by more than 400 hospitals across the country as a tool for assessing and measuring patient safety culture. HSOPS can be found at http://www.ahrq.gov/qual/patientsafetyculture/. This article describes the findings on use of the HSOPS to couple a safety culture approach with clinically relevant interventions in three hospital microsystems. The study examined effects of this combined approach on identifying, measuring, and redesigning processes of care to improve patient safety.
Battles JB, ed. Safety by design. Qual Saf Health Care 2006;15 (Suppl 1):i1-i3; doi:10.1136/qshc.2006.020347
Is it possible to actually "design-in" quality and "design-out" failure? This journal supplement approaches quality and safety as challenges for design, rather than quality improvement. The 15 papers discuss methods and approaches for design of health care facilities, organizations, clinical microsystems, clinical work processes, and information technology systems. Go to http://www.qshc.bmj.com/content/vol15/suppl_1/ for a detailed table of contents and abstracts.
Boyd CM, Reider L, Frey K, et al. The effects of guided care on the perceived quality of health care for multimorbid older persons: 18-month outcomes from a cluster-randomized controlled trial. J Gen Intern Med 2010 Mar;25(3):235-42. Epub 2009 Dec 22. Web site: http://www.guidedcare.org.
Guided Care is a major care redesign initiative funded in part by AHRQ. A Guided Care Nurse in a primary care office works with patients, families, and community agencies to improve quality of life and enhance efficiency of health service use. The article cited above shows that participants in the program rated their care higher than nonparticipants. Earlier results referenced in this publication and on the initiative's Web site showed that a pilot program enhanced care quality reported by patients and reduced insurance costs.
This toolkit includes implementation tools for redesigning the flow of patients in the emergency room in order to reduce waiting time and enhance capacity. The intervention consists of a patient-flow process change that splits patients into less sick and sicker patient subgroups. Less sick patients receive a quick look, rather than full triage. The toolkit explains how to analyze patient flow and facilitate change among clinical staff.
Carayon P, Schoofs Hundt A, Karsh B-T, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006;15 (Suppl 1):i50-i58.
This article describes the Systems Engineering Initiative for Patient Safety (SEIPS) model (http://cqpi.engr.wisc.edu/seips_home/ ). The model describes the system components that can contribute to causes and control of medical errors and explores how design of the components and interactions between them can result in acceptable or unacceptable processes.
Daugherty K. Improving patient safety through enhanced provider communication.
http://www.safecoms.org.
This toolkit provides clinicians and other health care professionals with the tools to implement teamwork and communication strategies in their practice settings to improve patient safety. The toolkit contains a framework for specific communication strategies, educational materials, and evaluation and analysis tools. The toolkit was used to implement safe team communication practices at Denver Health Medical Center. Improving communication is one of the five main components of Denver Health's system design transformation (Go to Managing and Evaluating Rapid-Cycle Process Improvements as Vehicles for Hospital System Redesign, described above.)
Dingley C, Daugherty K, Derieg MK, et. al. Improving patient safety through provider communication strategy enhancements. Advances in Patient safety: new directions and alternative approaches. Vol. 3, Performance and tools. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-3.
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=aps2v3&part=advances-dingley_14.
This article reports on implementation of interventions and strategies designed to improve patient safety through improved communications during rounds at an integrated urban safety net medical center. A toolkit was developed on teamwork and communications strategies.
Donaldson N, Rutledge D, Geiser K. Role of the external coach in advancing research translation in hospital-based performance improvement. Advances in patient safety: new directions and alternative approaches. Vol. 2, Culture and redesign. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-2.
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=aps2v2&part=advances-donaldson_87.
This article describes implementation of an innovative telephone-based coaching intervention aimed at reducing the incidence and severity of patient falls at 33 California acute care hospitals from the preengagement to the closure phases. The article discusses feedback and self-assessment results from participating hospitals, as well as the impact of the intervention on fall-related policies and clinician practices.
This toolkit is designed to facilitate the implementation of an emergency department pharmacist program to improve medication safety. The toolkit includes a description of the formal, optimized role of the emergency department pharmacist; discussion of challenges and accompanying solutions to implementing emergency department pharmacist programs; and evidence to support the efficacy of such programs, including documentation of the cost savings that can be obtained by reducing adverse events and avoiding inappropriate use of expensive medications.
Greenwald J, Denham C, Jack B. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. J Patient Saf 2007 June;3(2):97-106.
This article reviews the modifiable components of the hospital discharge process that may increase or reduce the risk of adverse events and rehospitalizations. These components include characteristics of the hospital, patient, and clinician. Using multimethod analysis, the investigators describe the principles thought to be important to the discharge process. They also delineate 11 discrete and mutually reinforcing components that are believed to contribute to safe discharge. See below for a toolkit derived from this study.
Hagg HW, Workman-Germann J, Flanagan M, et. al. Implementation of systems redesign: approaches to spread and sustain adoption. Advances in patient safety: from research to implementation. Vol. 2, Concepts and methodology. Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ Publication No. 05-0021-2. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=aps2v2&part=advances-hagg_80.
The authors describe how they are applying Lean and systems engineering methods in 21 hospitals in an initiative to reduce methicillin-resistant Staphylococcus aureus (MRSA). The article discusses implementation strategy, business case analysis, assessment methods and provides examples of Lean and systems engineering tool applications.
Harrison M and Moss D. Reducing waste and inefficiency in health care through Lean process redesign.
Our Nation's health service delivery systems face growing challenges to enhance quality while reducing costs. Lean/Toyota Production Systems (TPS) is a process redesign strategy developed in manufacturing that promises to help health care delivery systems meet these twin challenges. Lean/TPS is a method for eliminating "waste"—defined as any activity that consumes resources without enhancing value to those being served by the process. This literature review explores possible adaptation of Lean/TPS to health care settings.
Jack B. Project RED toolkit. Downloadable files from Project RED (Re-Engineered Discharge).
http://www.bu.edu/fammed/projectred/. Accessed May 20, 2008.
This toolkit provides resources for redesigning the process of discharging patients to reduce postdischarge adverse events and subsequent rehospitalizations. The toolkit includes discharge training and instructional manuals and software, patient education materials, instructions for telephone reinforcement of the discharge plan, and guidelines for medication reconciliation.
Linking Clinical Practices and the Community for Prevention http://www.innovations.ahrq.gov/learn_network/resources-for-linking.aspx
This special page of the AHRQ Health Care Innovations Exchange focuses on integration of the delivery of clinical care, community-based prevention, and health promotion interventions. Among the innovations accessible from this page are several that were presented at the 2008 AHRQ Linking Clinical Practice and the Community for Health Promotion Summit.
Page, A, ed. Keeping patients safe: transforming the work environment of nurses. Institute of Medicine. Washington, DC: National Academies Press; 2004. http://www.iom.edu/CMS/3809/4671/16173.aspx.
This report calls for substantial changes in nurses' work environment, including staffing levels and work hours, to protect patients from health care errors.
Sharkey S. On-time quality improvement for long term care: redesigning work flow. PowerPoint® presentation. AHRQ 2007 Annual Conference: Improving Healthcare, Improving Lives; 2007 Sept 26-28; Bethesda, MD.
This presentation describes how documentation and communication processes in long-term care facilities were redesigned and Certified Nursing Assistants' time was used more efficiently with the help of an inexpensive health IT device. The redesign substantially reduced pressure ulcers while saving costs for the nursing home.
Transforming Hospitals: Designing for Safety and Quality, DVD. AHRQ Publication No. 07-0076-DVD. http://www.ahrq.gov/qual/transform.htm.
This DVD, available free from the Agency for Healthcare Research and Quality reviews the case for evidence-based hospital design. The DVD discusses how evidence-based design increases patient and staff satisfaction and safety, quality of care, and employee retention and results in a positive return on investment. Also see "The Hospital Built Environment: What Role Might Funders of Health Services Research Play?"
Triggers and Targeted Injury Detection Systems (TIDS). Expert Panel Meeting. Conference Summary Report. Rockville, MD: Agency for Healthcare Research and Quality; 2009. AHRQ Publication No. 09-0003. http://www.ahrq.gov/qual/triggers/
AHRQ has developed and supported the implementation of clinical triggers and targeted injury detection systems (TIDS) to identify patient safety risks and hazards. Clinical triggers are data flags identifying patients who may be at risk of harm or clinical situations that have the potential for harm. This meeting reviewed progress on trigger/TIDS development and explored options for future work. Topics discussed included alignment of trigger systems with other safety and performance monitoring practices and incorporation of triggers into health information technology.
Watson SR, George C, Martin M, et al. Preventing central line-associated bloodstream infections and improving safety culture: a statewide experience. Jt Comm J Qual Patient Saf 2009 Dec;35(12):593-97.
This article describes results and lessons learned from the statewide Keystone collaborative in 127 Michigan intensive care units. The main interventions involved a unit-based safety program, a daily goals sheet, a five-step program for preventing central-line associated bloodstream infections (CLABSI), and a program for preventing ventilator-associated pneumonia. Results included a 66 percent decrease in CLABSI and 18 months without an infection. Estimated savings for the 18-month period included 1,800 lives, 140,700 excess hospitalizations, and $271 million.
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Enhancing Minority Health, Cultural Competency, and Health Literacy
Andrulis D, Brach C. Integrating literacy, culture, and language to improve health care quality for diverse populations. Am J Health Behav 2007;31(Suppl 1):S122-S133. Reprinted as AHRQ Publication No. 07-R079.
To improve care for diverse patients with limited health literacy, health care organizations must make changes in their delivery systems. Leadership and senior management must be willing to invest in training, staffing, and physical plants. The authors present a vision for an integrated approach to health literacy and cultural and linguistic competence that illustrates the important roles that both clinicians and health care organizations play.
Brach C, Paez K, Fraser I. Cultural Competence California Style. Rockville, MD: Agency for Healthcare Research and Quality Working Paper No. 06001, February 2006. http://www.gold.ahrq.gov/pdf/70.pdf [PDF Help].
California health plans have led the country in implementing innovative practices to improve health care for diverse populations. This article reports on eight leading California plans' cultural competence activities and how they were influenced by California's promulgation of cultural and linguistic competence standards for public insurance programs.
Beach M, Cooper L, Robinson K, et al. Strategies for Improving Minority Healthcare Quality. (Summary Evidence Report/Technology Assessment: Number 90.) Rockville, MD: Agency for Healthcare Research and Quality, January 2004. AHRQ Publication No. 04-E008-1. http://www.ahrq.gov/clinic/tp/minqualtp.htm.
This report synthesizes research on strategies that can help health care providers or organizations enhance cultural competency and improve minority health care quality.
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Implementing Information Technology and Other Health Technologies
Harrison M, Koppel R, Bar Lev S. Reducing unintended consequences of health information technology through interactive sociotechnical analysis. J Am Med Inform Assoc 2007 September;14:542-9.
When health care information technologies (Health IT) are implemented to promote system improvement, they often produce unintended consequences. These Health IT side effects flow from interactions between Health IT and the health care organization's sociotechnical system. This paper develops and illustrates a model of common types of sociotechnical interaction that produce such unintended consequences.
Karsh B. Embracing technology is DUMB. Embracing well-designed technology is smart. PowerPoint® presentation. AHRQ 2007 Annual Conference: Improving Healthcare, Improving Lives; 2007 Sept 26-28; Bethesda, MD.
This presentation explains and illustrates the human factors engineering perspective on the importance of integrating health technologies with the needs of the individual users and the work system in which the technology will operate.
Karsh B. Beyond usability for patient safety: designing effective technology implementation systems. Qual Saf Health Care 2004;13(5):388-94.
This paper examines organizational, job, individual, and technological factors affecting adoption of technologies capable of promoting safety and quality. It derives a set of organizational design guidelines for implementing new technologies.
Koppel R, Wetterneck T, Telles JL, et al. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc 2008 Jul-Aug;15(4):408-23.
This study examined reasons for workarounds of bar-coded medication administration (BCMA) systems. The most common causes were organizational, in which workflow policies were incompatible with safety. Most workarounds resulted from poor process design, such as having to wake a patient to scan a wristband when providing IV medication.
Langley J, Beasley C. Health information technology for improving quality of care in primary care settings. (Prepared by the Institute for Healthcare Improvement for the National Opinion Research Center under contract No. 290-04-0016.) AHRQ Publication No. 07-0079-EF. Rockville, MD: Agency for Healthcare Research and Quality; July 2007. http://healthit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_1248_661809_0_0_18/AHRQ_HIT_Primary_Care_July07.pdf. [PDF Help]
The authors identify effective change ideas for implementing and spreading health IT to large numbers of primary care practices. The guide shows how to use IT to support system improvements, as well as to improve efficiency.
Sociotechnical features (such as workflow, organizational culture, and staff attitudes) must be incorporated into the design and implementation of health IT systems if they are to succeed. At this Web conference, AHRQ grantees discuss strategies for the successful incorporation of health IT in health care practices. This Webcast will be useful both to those designing Health IT systems and to those working to implement them. PowerPoints of the presentations and a bibliography of sociotechnical resources are also available at the above URL.
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Additional Resources: AHRQ 2009 Annual Conference
A number of sessions at AHRQ's annual conference addressed issues potentially related to system redesign. Presentation materials from all sessions are available at http://www.ahrq.gov/about/annualconf09.
The sessions of potential interest included:
- Health Reform and Health System Change: The View Ahead Addressing Health Disparities in Achieving High-Quality, Affordable Care (Plenary).
- Linking Clinical Practices and Community Resources to Improve Health Care: Innovative Approaches (session 25).
- Facilitating Chronic Disease Improvement in Primary Care (Session 33).
- Getting to Meaningful Use of Health IT: Experiences in Redesigning Workflow in the Ambulatory Setting (Session 106).
- Reforming Disease Prevention and Health Promotion (Session 26).
- Moving Beyond Institution-Based Service Delivery: Medical Homes and Health 2.0 (Session 107).
- Redesigning Hospital Care for Quality and Efficiency (Session 63).
- Enhancing Patient Safety and Quality With Evidence-Based Health Care Design (Session 136).
- Reducing Hospital-Associated Infections (HAIs) (Session 9).
- Using Collaboratives To Reduce Central Line-Associated Bloodstream Infections (CLABSI): A National Implementation Program (Session 21).
- Measuring Improvement in Hospital Teamwork (Session 14).
- Health Literacy in Action: Design, Development, and Measurement (Session 57).
- A Comprehensive Unit-Based Safety Program (CUSP) as an Intervention Strategy (Session 103).
- Progress of a Learning Network: Working To Reduce Disparities by Improving Access to Care (Session 75).
- Experiences in Patient-Centered Care: Improving Coordination and Communication Among Patients and Providers (Session 110).
- Project RED: Reengineering the Hospital Discharge Process (Session 12).
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For More Information
For more information, contact:
Michael I. Harrison, Ph.D.
Senior Research Scientist—Organizations and Systems
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
540 Gaither Rd.
Rockville, MD 20850
Phone: (301) 427-1434
Michael.Harrison@ahrq.hhs.gov
Printed copies of reports with an AHRQ publication number are available free of charge from the AHRQ Publications Clearinghouse via phone at 800-358-9295 or E-mail at AHRQPubs@ahrq.hhs.gov. Mention the publication number when ordering.
For more information on system design for quality and safety, go to: http://www.psnet.ahrq.gov.
For more information on use of health information technology in system design, go to: http://healthit.ahrq.gov/portal/server.pt.
For further information on system design innovations, go to: http://www.innovations.ahrq.gov/.
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References
1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.
2. Harrison K, Henriksen R, Hughes RG. Improving the health care work environment: a sociotechnical systems approach. Jt Comm J Qual Patient Saf 2007 Nov;33(11 Suppl):3-6.
3. Wang M, Hyun J, Harrison M, et al. redesigning health systems for quality: lessons from emerging practices. Jt Comm J Qual Patient Saf 2006 Nov;32(11):599-611.
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AHRQ Publication No. 10-0060-EF
Current as of March 2010
Internet Citation:
AHRQ Resources on Systems Design. AHRQ Publication No. 10-0060-EF, March 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/systemdesign.htm
540 Gaither Road Rockville, MD 20850 