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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.
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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.
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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
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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.
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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 ...