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It is widely recognized that the US health care system does not provide every American with the quality of care they deserve. Broad gaps in quality were documented in a recent report from the Institute of Medicine1 and in studies showing that children receive less than half of recommended acute, preventive, and chronic care.2 The Institute of Medicine 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.


Pediatricians want to provide the best care they can for their patients, but 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. The challenge of providing the best care is heightened by ongoing change in the nature of morbidity, the development of new knowledge, and the evolution of technology. For example, the increasing importance of psychosocial morbidities, the growing prevalence of children with chronic illness, the complexity of immunization schedules, and the advent of electronic medical record systems imply a need to adopt new approaches and tools and linkages to accomplish many of the things that cannot be done in the office (see Chapter 1). 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.


Multiple studies have documented the long interval between health care innovation and use in practice.3-6 Traditional methods of translating research findings into practice, such as peer-reviewed publications and continuing medical education, are passive and slow,7,8 and the passive provision of information is rarely effective in helping busy clinicians adapt new knowledge to practice.9


All practices 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 Institute of Medicine’s six dimensions of quality. 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) and cites evidence-based resources that can support efforts to adapt these systems to all types of practice settings to optimize patients’ health outcomes.


A system is a “set of interrelated processes carried out by multiple individuals to achieve a purpose.”10 A primary practice, a specialty clinic, or a unit in a hospital can be thought of as a small, organized group of clinicians and staff working together with a shared clinical purpose to provide care for a defined set of patients. Many practices are part of a larger organization and are embedded in a legal, financial, social, and regulatory environment.11 Note ...

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