Value by Design

The Editors Eugene C. Nelson, DSC, MPH, is director of Population Health and Measurement for the Dartmouth-Hitchcock Medical Center and professor of Community and Family Medicine at Dartmouth Medical School and the Dartmouth Institute for Health Policy and Clinical Practice. He is the recipient of the Joint Commission on Accreditation of Healthcare Organizations' Ernest A. Codman award for his work on outcomes measurement in health care. Paul B. Batalden, MD, is professor of Pediatrics and of Community and Family Medicine at Dartmouth Medical School. He is the associate director of the Dartmouth-Hitchcock Leadership Preventive Medicine Residency, and teaches at the Dartmouth Institute for Health Policy and Clinical Practice, the Institute for Healthcare Improvement and in the Jönköping Academy for the Improvement of Health and Welfare in Sweden. Marjorie M. Godfrey, MS, RN, is codirector of the Microsystem Academy, instructor for the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, and a recognized national and international leader in health care improvement with interdisciplinary professionals. Joel S. Lazar, MD, MPH, is assistant professor of Community and Family Medicine at the Dartmouth Institute for Health Policy and Clinical Practice and section chief and medical director of Family Medicine at Dartmouth-Hitchcock Medical Center, where he also serves as director of quality improvement. Companion Web site: www.josseybass.com/go/nelson

• Figures and Tables xiForeword Elliott S. Fisher xviiPreface: Improvement at the Front Line of Care xxiAcknowledgments xxixThe Editors xxxiiiThe Contributors xxxv1 Introducing Clinical Microsystems 1Learning Objectives 1Microsystems in Health Care 1A Broader View of Systems and Microsystems 6Research on Microsystems in Health Care 11Three Conceptual Imperatives in the Work of Value Improvement 20Conclusion 24Summary 25Key Terms 25Review Questions 26Discussion Questions 26References 26Chapter One Action Guide 29Introduction to the 5PS 29The Clinical Microsystem Process and Structure of the 5Ps Model 29External Mapping Tool 35Microsystem Assessment Tool (MAT) 402 Partnering with Patients to Design and Improve Care 47Learning Objectives 47The Aim of Health Care and the Need to Partner with Patients 48Conceptual Frameworks for Partnering with Patients 51Tactics for Partnering with Patients 61Patients as Informants and Advisors 65Conclusion 67Summary 67Key Terms 67Review Questions 68Discussion Questions 68References 68Chapter Two Action Guide 71Gaining Customer Knowledge 71Institute for Patient and Family-Centered Care Matrix 82Value Stream Mapping 83Definitions of Selected Value Stream Mapping Terms 843 Improving Safety and Anticipating Hazards in Clinical Microsystems 87Learning Objectives 87Case Study of Organizational Factors to Promote a Culture of Safety 88Discussion 92Definitions 93Identification of Medical Errors and Adverse Events 94Frequency of Adverse Events and Medical Errors 95Conclusion 107Summary 107Key Terms 108Review Questions 108Discussion Questions 109References 109Chapter Three Action Guide 1135S Method 113Checklists 116Failure Mode and Effects Analysis 118Rehearsals or Simulations 120Designing Patient Safety into the Microsystem 122The Link Between Safety, the Microsystem, and Mindfulness 123Conclusion 129References 1304 Using Measurement to Improve Health Care Value 131Learning Objectives 131Measuring What Matters at All Levels of the System 132Tips and Principles to Foster a Rich Information Environment 138Designing Information Flow to Support High-Value Care 140Conclusion 150Summary 151Key Terms 152Review Questions 152Discussion Questions 152References 153Chapter Four Action Guide 155Patient Value Compass 155Balanced Scorecard 156Measure What Matters Worksheet 157Examples of Data Walls 159References 1605 Starting the Patient’s Care in Clinical Microsystems 161Learning Objectives 161The Entry Functions of Clinical Microsystems 162Conclusion 182Summary 183Key Terms 183Review Questions 183Discussion Questions 184References 184Chapter Five Action Guide 187Process Mapping with Flowcharts 187Access Measures and Tools 190CARE Vital Signs 192Reference 1956 Designing Preventive Care to Improve Health 197Learning Objectives 197The Work of Preventive Health Care 198An Action-Based Taxonomy of Preventive Health Services 202Conclusion 213Summary 213Key Terms 213Review Questions 214Discussion Questions 214References 214Chapter Six Action Guide 217Radiology Microsystem Preventive Activity of Mammography and VAP Bundles in Critical Care 2177 Planning for Responsive and Reliable Acute Care 221Learning Objectives 221Anticipating the Needs of Acutely Ill Patients 222Defining Acute Care Needs of Patients and Families 222An Overview of Design Requirements for Acute Care 225Advanced Access and Effective Care Transitions 233Conclusion 235Summary 236Key Terms 236Review Questions 236Discussion Questions 237References 237Chapter Seven Action Guide 239Microsystem Transitions and Handoffs 2408 Engaging Complexity in Chronic Illness Care 241Learning Objectives 241An Invitation to Complexity 242The Experience of Chronic Illness 244The Burden of Chronic Illness 245The Goals of Chronic Illness Care 248Clinical Complexity in Chronic Illness Care 250Designing for Complexity Through Alignment of Problems and Practice Solutions 252The Nature of Complex Adaptive Systems 254The Chronic Care Model 255Care Coordinaton and Transitions 260Patient Self-Management 262Conclusion 265Summary 266Key Terms 266Review Questions 267Discussion Questions 267References 267Chapter Eight Action Guide 271STAR Generative Relationships 271Reference 2739 Supporting Patients and Families Through Palliative Care 277Learning Objectives 277The Need for Palliative Care in Modern America 278End-of-Life Experience Yesterday and Today 279Principles of Palliative Care 281Reducing Variation in End-of-Life Care 283Core Processes in Palliative Care 285Care Coordination Near the End of Life 287Formal Palliative Care and Hospice Programs 289Planning for Both Life and Death with Advance Directives 291Conclusion 293Summary 295Key Terms 295Review Questions 295Discussion Questions 296References 296Chapter Nine Action Guide 297Mental Models 297Using the Ladder of Inference to Explore Mental Models 297Reference 30110 Designing Health Systems to Improve Value 303Learning Objectives 303From Parts to Whole 304New Vision of Integrated Systems to Produce High Value 305The Execution Triangle 313Leading Change at All Levels 315Changing Local Culture 318The Path Forward for Making High-Value Health Systems 323Summary 326Key Terms 326Review Questions 326Discussion Questions 327References 327Chapter Ten Action Guide 331Micro-, Meso-, and Macrosystem Matrix 331Index 335

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