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SYSTEMS-BASED PRACTICE AND QUALITY OF CARE

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Better design and organization of healthcare service is a priority for healthcare systems because of ongoing gaps in the outcomes of care, changes in the nature of morbidity, rapid changes in technology and new payment models, and the explosive growth of new knowledge. Ongoing redesign of systems of care delivery will be required to keep pace with these changes. The Institute of Medicine (IOM) proposed a set of 6 expectations that high-performing health care should achieve—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—and described steps to promote more evidence-based practice. More recently, the IOM proposed a vision for Learning Health Systems in which patients and clinicians base decisions on evidence and discovery is a natural outgrowth of care.

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Pediatricians want to provide the best care they can for their patients. Extensive research indicates that much of the quality of care achieved is determined by the specific processes or systems of care delivery in place in the practice. For example, addressing psychosocial morbidities, managing the growing prevalence of children with chronic illness, the complexity of immunization schedules, and using electronic medical record systems effectively requires ongoing efforts to adopt new approaches, tools, and linkages to accomplish many of the things that cannot be done in the office. Thus, processes for care delivery cannot remain static. They must evolve over time as patients’ needs and patterns of illness change and new discoveries emerge.

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Multiple studies have documented the long interval between healthcare innovation and use in practice. Traditional methods of translating research findings into practice, such as peer-reviewed publications and continuing medical education, are passive and slow, and the passive provision of information is rarely effective in helping busy clinicians adapt new knowledge to practice. However, change is possible. Sinsky et al reported on the changes made by 23 primary care practices to become high-functioning teams with improved professional satisfaction.

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All healthcare domains have systems and processes to organize the work of caring for patients. Practice systems often develop on a somewhat ad hoc basis to address specific issues or problems. More contemporary approaches create practice-based systems that are linked directly to improving the IOM’s 6 dimensions of quality. A partnership between the IOM and the National Academy of Engineering highlighted underutilized methodologies from systems engineering that could be applied to optimizing delivery of health care. A practical approach for organizing care is to institute processes to manage the most common types of conditions encountered. This chapter highlights major practice systems for four key areas of care (prevention, acute care, chronic care, and access and efficiency). The evidence-based resources cited can be adapted to support efforts in all types of care delivery settings to optimize patients’ health outcomes.

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What Is a System?

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A system is a “set of interrelated processes carried out by multiple individuals to achieve a purpose.” A primary practice, a specialty ...

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