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The Decision Making for Managers (Deming Collaboration Library Book 5) eBook: Jordi Cabré Caballería, Dan Strongin, Rafael Aguayo, Alan Pippenger.
Table of contents

Edwards Deming Institute.? The Institute views these columns as opportunities to enhance, extend, and illustrate Dr. The authors have knowledge of Dr. Deming, W. Out of the Crisis. Center for Advanced Engineering Study. Walton, Mary. The Deming Management Method, Perigree books. Copyright Murray B. August 26 - 29, San Diego. Reach Process Excellence professionals through cost-effective marketing opportunities to deliver your message, position yourself as a thought leader, and introduce new products, techniques and strategies to the market. Join Process Excellence Network today and interact with a vibrant network of professionals, keeping up to date with the industry by accessing our wealth of articles, videos, live conferences and more.

Use of this site constitutes acceptance of our User Agreement and Privacy Policy. For further information on how we process and monitor your personal data click here. You can unsubscribe at anytime. Conferences Online Events Webinars Awards. Tags: competitive tendering bidding procurement Government Murray B. Stanley Deming Files W. Edwards Deming. Murray B. The Advantages of Competitive Tendering Competitive tendering is often considered to promote competition, provide transparency and give all suppliers the opportunity to win business.

The Disadvantages of Competitive Tendering Disadvantage 1: Leading suppliers may not tender In Australia, for example, government procurement guidelines only allow suppliers who actually tender to be considered for a procurement decision. Disadvantage 2: Barriers to communication between supplier and customers When making significant purchases, frank and open communication between potential supplier and customer is crucial. Disadvantage 3: The cost-plus phenomenon Dr. Disadvantage 5: Safety shortcuts Another area where suppliers may be tempted to lower costs is safety standards.

Disadvantage 6: Competitive tendering can be extremely slow When government agencies, and indeed, private companies use competitive tendering it can take several years to choose a successful bidder. Disadvantage 7: Insufficient profit margin to allow for investment in research and development, new technology or equipment Competitive tendering can force a supplier to accept a very slim profit margin. A better procurement model The type of solution to competitive tendering may vary depending on the type of industry, the complexity of the product, the price of the purchase, whether the purchase is a one-off or a long-term supply relationship.

Open communication with current or potential suppliers. Purchasing decisions based on a strong relationship of trust. Developing a long-term and healthy relationship with a reputable supplier or suppliers. Paying the supplier a fair profit margin.

Review of Selected Literature

Potential barriers to implementation of the improved procurement model In government organizations, procurement methods are influenced by politicians. References Deming, W. Latest Webinars How to take the fast lane to process improvement AM - PM EST How can a major infrastructure project, conducted across a huge geographical area with hundreds of r Our webinar explores how Process Mining vs Process Modelling 25 - 27 March, Building the future from the ground up.

A Lean look at International Women's Day The collaboration factor. It takes two: dialogue. Key components of TQM are employee involvement and training, problem solving teams, statistical methods, long-term goals and thinking, and recognition that the system, not people, produces inefficiencies.

A library should be focusing on providing the best services possible, and be willing to change to serve its customers. How can I look at the efficiency of my library? How do we serve the current users that exist today? First learn about the customer, then solve the problems. An American, W. The concept of TQM is applicable to academics. According to this principle, an organization must focus, first and foremost, on its suppliers and customers. In other words, teamwork and collaboration are essential. Traditionally, education has been prone to individual and departmental isolation.

The second pillar of TQM applied to education is the total dedication to continuous improvement, personally and collectively. Within a Total Quality library setting, administrators work collaboratively with their users. The foundations for this system were fear, intimidation, and an adversarial approach to problem-solving. According to Deming, no human being should ever evaluate another human being.

The Collaborative Challenge: Making Quality Decisions Together in the Age of Complexity

Therefore, TQM emphasizes self-evaluation as part of a continuous improvement process. The third pillar of TQM as applied in academics is the recognition of the organization as a system and the work done within the organization is an ongoing process. Quality speaks to working on the system, which will identify and eliminate the flawed processes.

Since systems have made up of processes, the improvements made in the quality of those processes largely determine the quality of the resulting product. The librarians must establish the context in which users can have benefit by providing best services through the continuous efforts and improvement in the services. According to the practical evidences, the TQM principles help the library in following clauses:.

In order to achieve the above as opportunities to the academic scenario, in addition to patience, participatory management among well-trained and educated partners is crucial to the success of TQM in libraries, everyone involved must understand and believe in principles. Some personnel who are committed to the principles can facilitate success with TQM. Their vision and skills in leadership, management, interpersonal communication, problem solving and creative cooperation are important qualities for successful implementation of TQM.

Based on his work with Japanese managers and others, Deming ; Walton, outlined 14 steps that managers in any type of organization can take to implement a total quality management program. Cease dependence on mass inspection. Inspect products and services. End the practice of awarding business on price tag alone. The lowest priced goods. Improve constantly and forever the system of product and service. It decreases complications and is more cost-effective. If the Respiratory Therapist notes an abnormal lab value, he or she is comfortable not just taking a blood sample and reporting it, but managing it.

The technicians are caregivers. Expectations have changed. They [adjust] therapy to within physiological parameters. They are cross-trained so that they can take on nursing tasks, for example, starting IVs when needed. When fully trained and confident, they may tell an admitting doc that a patient is not ready to have a ventilator tube removed. A key challenge for organizations, requiring a range of competencies, is translating the evidence base into practice.

The competencies involved include tracking and disseminating new information, managing the clinical change that helps incorporate new information into practice, and ensuring that health care professionals have the skills they need to make use of new knowledge.

All such competencies are interrelated. New information and technologies may require new skills. And new technologies, such as simulation, may enhance skills, such as those involved in performing surgical procedures or managing crises. As described in greater detail in Chapter 6 , the flood of new information that is relevant to practice can no longer be managed adequately by individual clinicians trying to keep up with the literature and attending conferences or lectures Davis et al. One new approach to timely management of information involves including clinical librarians as a part of clinical care teams, for example, on morning rounds or on call, to note questions and search the literature for the best and most relevant information Davidoff and Florance, Another response is to create easily accessible systematic reviews of the literature, using well-understood criteria for determining the strength of evidence and the generalizability of findings.

Such systematic reviews, though important, are only the first stage, however, in disseminating the flow of new knowledge and translating it for use with individual patients. First, clinicians need evidence-based guidelines that make clear which steps are well founded and which are based on expert consensus Institute of Medicine, These efforts may occur within practices or larger institutions, or may be developed by external entities such as specialty groups, independent organizations established for the purpose, or governmental groups.

Whatever the source of such guidelines, any group that uses them needs to understand their validity and ensure that they are kept up to date. Ensuring that new knowledge is incorporated into practice also requires a thorough understanding of how change is managed most effectively in health care, including the barriers to and facilitators of change. Knowledge about why guidelines are or are not used is accumulating, and experts now better understand the circumstances in which such strategies as education, administrative changes, incentives, penalties, feedback, and social marketing are likely to be effective Greco and Eisenberg, ; Grol, ; Oxman et al.

One strategy for successfully managing change is to design guidelines and implementation processes so that it is easier to apply the best evidence than not to do so. This strategy begins with a systematic review of the evidence, but attends to the creation of clinical guidelines or protocols that match the logic and flow of care. Implementing this strategy also requires agreement on the part of clinicians that they will use the new guidelines and protocols, as well as the resources needed to redesign care processes despite such resources often being scarce so that the guidelines and protocols will become an integral and efficiently designed element of the care process.

Health care requires complex, sophisticated judgments and psychomotor skills, perhaps at a level unmatched in any other field. Other industries test judgment and psychomotor skills. In aviation, for example, simulations are used to assess competence and to help pilots improve their judgment and skills. Medicine has traditionally relied on cognitive testing of knowledge, not of judgment or skills. The field also relies on privileges granted by hospitals using various levels of rigor to assess professionals' skills, but such mechanisms do not include testing to ensure that those skills are current and have not deteriorated.

Making use of new knowledge may require that health professionals develop new skills or that their roles change. New skills might include basic technical proficiency, for example, in executing a procedure, using equipment, and interpreting data from new tests and devices. Managing new knowledge may also require the use of new psychosocial skills to elicit behavior change in patients and colleagues.

Other new skills might include designing data collection efforts and managing and interpreting quality-of-care information. Finally, incorporating new knowledge requires skilled leadership to engage the participation of health professionals in collaborative teams. Leaders need to devote explicit attention to ensuring that the most appropriate individuals are trained in, maintain competence in, and are supported in their new tasks.

Why Deming, Why Now? - Deming Collaboration

There has been a radical change since we introduced teams. You can see it even where they hang out. Before the docs were together, the nurses together, etc. But now the team hangs out with the team. At the morning meetings, you may see the medical assistants providing the leadership. They work under pressure and stress and try to find a way to control it.

Doctors have not learned yet how to enhance the team with other kinds of providers—health education, behavioral medicine, physical therapy, pharmacy. Organized work groups, or multidisciplinary teams, have become a common way to organize health care, and considerable attention has been focused on their value and functioning. Such teams are found in primary care practice, in the focused care of patients with chronic conditions, in critical acute care the intensive care unit, trauma units, operating rooms , and in geriatrics and care at the end of life.

In such settings, smooth team functioning is needed because of the increasing complexity of care, the demands of new technology, and the need to coordinate multiple patient needs Fried et al. Nonphysician team members may increase efficiency e. Such distributions of roles and tasks change dramatically over time. Many tasks, such as monitoring and adjusting equipment for an ill newborn after hospital discharge, have been taken over by family members and patients themselves Hart, ; Lorig et al. An IOM study of small work teams at the front lines of patient care Donaldson and Mohr, included asking practitioners and staff who worked together on a daily basis about that experience.

Respondents cited the importance of collaborative work both for clinical care and for improvement efforts. They emphasized the need to base quality improvement work within the team and to recognize the contributions that all members of the group could make, with various individuals taking leadership roles for specific improvement activities. They also described new or expanded roles and the need for coaching and training new members of the team in their work relationships. Effective working teams must be created and maintained.

Yet members of teams are typically trained in separate disciplines and educational programs, leaving them unprepared to enter practice in complex collaborative settings. They may not appreciate each other's strengths or recognize weaknesses except in crises, and they may not have been trained together to use established or new technologies Institute of Medicine, An enormous amount of knowledge has been accumulated about team creation and management, including effective communication among team members Fried et al.

In commercial aviation, for example, emphasis is placed on crew resource management because of its importance to airline safety, and communication among flight personnel has become a special focus of proficiency checks by certified examiners e. Considerable research has gone into identifying the characteristics of effective teams Fried et al. These characteristics include 1 team makeup, such as having the appropriate size and composition and the ability to reduce negative effects of status differences between, for example, physicians and nurses; 2 team processes, such as communication structures, conflict management, and leadership that emphasizes excellence and conveys clear goals and expectations; 3 the nature of the team's tasks, such as matching roles and training to the level of complexity and promoting cohesiveness when work is highly interdependent; and 4 the environmental context, such as obtaining needed resources and establishing appropriate rewards.

Effective teams have a culture that fosters openness, collaboration, teamwork, and learning from mistakes. Shortell et al. Such interaction includes the dimensions of culture, leadership, communication, coordination, problem solving, and conflict management. Research on team interactions has also demonstrated that teams often fall short of the expectations of their clinical leaders, members, and administrative managers Pearson and Jones, One reason is that medical education emphasizes hierarchy and the importance of assuming individual responsibility for decision making.

An emphasis on personal accountability comes at the price of losing the contribution of others who may bring added insight and relevant information, whatever their formal credentials. Acculturation to medical roles makes it difficult for members of a team to point out or admit to safety problems and thereby prevent harm. Indeed, challenges to those in positions of power and authority by nurses, physicians in training, and others is notoriously difficult and discouraged Helmreich, ; Institute of Medicine, Avoiding overt hostility over a slip or lapse and acknowledging shared knowledge and proficiency when recovering from unexpected patient events Helmreich, are examples of how strong collaborative working relationships can improve patient safety.

In health care environments characterized by uncertainty, instability, and variability such as operating rooms and intensive care units , high levels of stress are common Mark and Hagenmueller, ; Perrow, Other environments do not have the level of instability and uncertainty associated with critical care units and operating suites, yet the complexity of patients' needs still necessitates highly effective coordination of resources across a spectrum of settings, disciplines, and the community. An example is the care of frail elderly patients, in which the ability to coordinate care and assemble effectively functioning health care teams is paramount, and flexibility in role functioning may be key.

In Chapter 3 , new rule 10 emphasizes the importance of collaboration for effective team functioning. What is sometimes thought to be collaboration, however, may in fact be uncoordinated or sequential action rather than collaborative work. That is, the work of each individual may be efficient from the perspective of his or her own tasks, but overall the efforts are suboptimal and do not serve the needs of patients.

An example of suboptimization may occur when an elderly woman breaks her hip and comes to the emergency department. She may spend several hours receiving x-rays and being stabilized and will certainly need to be admitted. At the end of this time, someone may call to notify the nursing staff that the patient is being admitted, and several hours more may elapse while admission orders are written and the patient's room is made available.

When emergency department and floor staff collaborate, notification is given immediately after the patient arrives in the emergency department so that the admission process can begin, and the patient can go from the emergency department directly to her hospital room, where she will be much more comfortable. In such cases and in many others, running parallel processes reduces delays and improves outcomes Nugent et al.

That is fundamental to what is important to me—that the focus be on the individual—a complex person—and you try to do the best you can for them. It seems odd to say, but that is what is fun. We did focus groups with families and learned key things that are important: 1 the organization and delivery of care, 2 shared medical decision making, 3 treating each person as an individual, and 4 attending to those who care for and love the dying person.

The building blocks to accomplish this are information and education of the patient and family, coordination, and continuity. Another key challenge for organizations is coordination or clinical integration of work across services that are complementary, such as emergency response units, emergency departments, and operating suites, or across primary care practices, specialty practices, and laboratories to which patients are referred. In particular, coordination encompasses a set of practitioner behaviors and information systems intended to bring together health services, patient needs, and streams of information to facilitate the aims of care set forth in Chapter 2.

For example, coordination may involve ensuring that treating physicians are informed about diagnostic results, therapies attempted during an earlier hospital admission, and the effectiveness of those efforts. Coordination may involve nurse case managers transmitting information to both primary and specialty care practitioners about a patient's unmet needs. Such coordination may be facilitated as well by procedures for engaging community resources such as social and public health services and other sites of care such as hospice or home care when and as appropriate. Coordination of care across clinicians and settings has been shown to result in greater efficiency and better clinical outcomes Aiken et al.

Optimizing care for a patient with a complex chronic condition is challenging enough, but optimizing care for patients with several chronic conditions and acute episodes, as well as meeting health maintenance needs, represents an extraordinary challenge for today's health care systems MacLean et al.

The challenges arise at many organizational levels and across the full range of tasks, including the design, dissemination, implementation, and modification of care processes and the payment for these tasks. What is important to patients and their families is that effective systems for transferring patient-related information be in place so that the information is accurate and available when needed. Patients and their families need to know who is responsible for decisions and can answer questions, and to be assured that gaps in responsibility will not occur.

Some problems—such as substance abuse, AIDS, and domestic violence— are so interrelated that they appear to require a comprehensive rather than problem-by-problem approach Shortell et al. Other problems require assembling and making the best use of an array of resources, such as the numerous federal programs that might be involved in obtaining and paying for a wheelchair for a child with special needs.

In any case, if care is to move beyond single solutions crafted by individual clinicians as in the Stage 1 delivery of care described earlier in this chapter , it will require an accurate understanding of patient needs so that standard processes can be provided and individual solutions crafted as appropriate. Newly developed infrastructures, information technologies, and well-thought-out and -implemented modes of communication can reduce the need to craft laborious, case-by-case strategies for coordinating patient care.

A variety of other mechanisms can improve coordination, such as involving a combination of individuals e. Some patients and their families become so expert in their condition that they choose to coordinate care for themselves or a family member. Those who do so are likely to need new skills in accessing information and new technologies for structuring and conveying information to others who are involved in their care.

For example, patients can contribute to flow sheets, respond to questions about changes in health status, or upload data from micromonitoring devices worn on the body or from home monitoring devices. Not all patients or their families or perhaps even most will choose or be able to become central actors in coordinating their own care, however. In such cases, appropriate mechanisms within the delivery system must be available to meet this responsibility.

One means of improving coordination is based on what are sometimes called clinical pathways. These blueprints for care set forth a set of services needed for patients with a given health problem and the sequence in which they should take place. For some conditions, a set of clearly identified processes should occur.

In complex adaptive systems such as health care, however, few patient care processes are linear such as the transition from hospital to nursing home. Rather, most organizational processes are reciprocal and interdependent Thompson, , and coordination requires the design of procedures that are responsive both to variations among individual patients and to unexpected occurrences. We have a Clinical Roadmap team for breast cancer screening. The team has formulated four criteria for success that include process and outcome measures.

They are 1 the proportion of women in our population who have received care in the last 2 years; 2 the number of women who came to the screening program when invited; 3 the number of women in the program who develop a late stage disease; and 4 survey responses during the time of enrollment in the program. These criteria give us specific as well as broad measures of success. The main outcome measure is risk adjusted mortality.

We compare ourselves quarterly to similar institutions for observed versus predicted mortality on one axis and resource consumption on the other. Using 50 percent random sampling, we track mortality, admission and discharge rates, length of stay, number of patients readmitted to the ICU, and reintubation rates. This helps us know if changes that affect efficiency are affecting quality of care.

Although our admissions are up, length of stay is down significantly, and our reintubation rate is very low. Although we generally think of individuals as learning and enhancing their capabilities, it is also possible to think of an organization as learning—increasing its competence and responsiveness and improving its work Davies and Nutley, The committee believes moving toward the health system of the 21st century will require that health care organizations successfully address the challenge of becoming learning organizations.

This idea has been incorporated in the work of many companies, most outside of health care—such as 3M, Boeing, the Cadillac Division of General Motors, Fedex, Motorola, and Xerox—whose drive to reduce defects and improve quality and customer service has been recognized by the Malcolm Baldrige National Quality Award National Institute of Standards and Technology, b.

In health care it might involve efforts to decrease waiting time for follow-up appointments for patients who have an abnormal laboratory test result. An example of double-loop learning is rethinking and reorganizing all ancillary and specialty medical services for women in a breast care center to eliminate any waiting between reporting of abnormal mammographic findings, definitive diagnosis, and therapy.

The committee is convinced that a major tool for accomplishing this critical function is the investment in and use of an effective information infrastructure to develop a balanced set of measures on, for example, clinical and financial performance, patient health outcomes, and satisfaction with care Nelson et al. It is important that such measures be balanced—that they include a variety of measures so that when changes are made in processes, such as to increase efficiency, other outcomes, such as patient health, are not adversely affected.

Clinical practices that participated in the IOM study of exemplary practices Donaldson and Mohr, described how routine measurement has become part of their production process. Ideally, such measures can be aggregated for external reporting, whether to support contract discussions or to help patients make choices about where and from whom to seek care.

OE Library

Building measurement into the production process can counter the perception on the part of many health care leaders that reporting is a burden. Such a perception results when organizations must respond to numerous demands from external groups for quality measures, especially if those measures lack specificity or relevance to the clinical teams that must generate them.

Measures need not involve expensive, large-scale, long-term evaluation projects to be useful. New methods that use sampling and small-scale rapid-cycle testing, modification, and retesting are proving useful in dynamic settings such as patient care units Berwick, ; Langley et al. As other world-class businesses have learned, including American industry giants Walton and Deming, , attention to improving quality includes continuous monitoring, often based on small samples of events, that can provide organizations with timely data at the front lines to manage the processes of concern James, ; Rainey et al.

In the IOM study of exemplary practices, several health care teams described their use of such methods to manage their care processes Donaldson and Mohr, It's an incredible relief to try small changes on a small scale. It's so simple it's brilliant. We had been managing indigent diabetic patients for years and didn't think we could do any better.

The providers believed that these people are so hard. But the patients responded to the changes we made. You have to craft something that is doable. You have to look for the simplicity in complex things. We get information on the census in the ER, the status of the patients, the x-ray cycle, etc. We know where in the process not only the patient is, but where the system is. Each process measured is summarized on the screen by graphs. All we have to do to obtain data is touch the screen. The graphs are equipped with goal lines that are based on customer satisfaction, for example waiting time.


The key word to describe a micro-system is homeostasis. A micro-system is always changing and adapting, just like the human body. It is powerful, yet very predictable. Think about two downstream processes, x-ray cycle time and getting patients to the floor. If the downstream [processes] get out of control, there are predictable changes in the system. Occupancy in the ER goes up, the number of new patients seen in the ER goes down, the number of free beds in the ER goes down, and the cycle time between a patient's arrival to a bed goes up.

Eventually, every measurement goes up. When we obtain three consecutive minute intervals going the wrong way, we realize that something needs to be done. The role of leaders is to define and communicate the purpose of the organization clearly and establish the work of practice teams as being of highest strategic importance. Leaders must be responsible for creating and articulating the organization's vision and goals, listening to the needs and aspirations of those working on the front lines, providing direction, creating incentives for change, aligning and integrating improvement efforts, and creating a supportive environment and a culture of continuous improvement that encourage and enable success.

Learning organizations need leadership at many levels that can provide clear strategic and sustained direction and a coherent set of values and incentives to guide group and individual actions. Indeed, strong management leadership in hospitals is positively associated with greater clinical involvement in quality improvement Weiner et al. Leaders of health care organizations may need to provide an environment for innovation that allows for new and more flexible roles and responsibilities for health care workers; and supports the accomplishments of innovators despite regulatory, legal, financial, and sometimes interprofessional conflict Donaldson and Mohr, Leaders need to provide such an environment because the learning, adaptation, and incorporation of best practices needed to effect engineering changes requires energy that is scarce in a demanding and rapidly changing environment.

At the level of front-line teams, leaders should encourage the members of the team to engage in deliberate inquiry—using their own observations and ideas to improve safety and quality. The individual who serves as leader may not be constant over time or across innovative efforts, or be associated with a particular discipline, such as medicine.

What is important is for the leader to understand how units relate to each other—a form of systems thinking—and to facilitate the transfer of learning across units and practices. Leaders of health care organizations must fill a number of specific roles. First, they must identify and prioritize community health needs and support the organization's ability to meet these needs. Addressing community needs might involve collaboration with other community or health care organizations and the creation of new services.

Examples include providing CPR training for a major employer and identifying and alerting the community to patterns of injury, such as the number of children with head injuries from bicycle accidents, or a newly appearing occupational illness. Other examples include addressing the more complex needs for coordinated local social and health services presented by low-income ill elderly individuals or the need for more accessible substance abuse treatment facilities.

Leaders of organizations can support accountability to individual patients while also assuming responsibility for accountability to public bodies and the community at large for the populations they serve. Second, leaders can help obtain resources and respond to changes in the health care environment, which have been rapid and unrelenting.

Leaders must ensure that their organization has the ability to change. Yet many leaders now view their role as shielding and protecting the organization from environmental pressures that may require them to change. Leadership should support innovation and provide a forum so that individuals can continuously learn from each other. Organizations must invest in innovation and redesign. Third, and perhaps the most difficult leadership role, is to optimize the performance of teams that provide various services in pursuit of a shared set of aims.

In any complex organization, there is danger in supporting some clinical services perhaps those that are most profitable to the detriment of the whole system. Leaders must strive to align the strategic priorities of their organization, its resources financial and human , and support mechanisms e. Balancing these elements can be extremely difficult and requires leaders to have a performance measurement capability that includes measures of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

Fourth, leaders can support reward and recognition systems that are consistent with and supportive of the new rules set forth in Chapter 3 and that facilitate coordination of work across sets of services as necessary. Organizations should support an environment in which incentives to provide effective care are not distorted before they reach caregivers.

An example of distortion is a payment system based solely on the numbers of home care visits made by a visiting nurse per day. This sort of productivity measure prevents nurses from focusing on patient needs. A system based on effectively caring for a given number of patients recognizes that a predictable mix of needs will occur over a period of time, and can encourage small teams to organize themselves to meet those needs.

Such decision making can be very difficult, especially in the current economic environment and payment system see Chapter 8. Fifth, leaders need to invest in their workforce to help them achieve their full potential, both individually and as a team, in serving their patients. The resulting interpersonal and technical competence can produce the synergies and improved outcomes that emerge from collaborative work.

Although the leadership roles described are not novel, the orientation toward facilitating the work of health care teams represents a fundamental shift in perspective. The new rules set forth in Chapter 3 and the engineering principles described in this chapter will require strong and visible leadership with corresponding reward structures.

All organizations must overcome their inherent resistance to change. It is role of leaders to surmount these barriers by visibly promoting the need for improvement, becoming role models for the required new behaviors, providing the necessary resources, and aligning recognition and reward systems in support of improvement goals. Leadership's role in promoting innovation, gathering feedback, and recognizing progress is essential to successful and sustained improvement.

Finally, leaders must recognize the interdependence of changes at all levels of the organization—individual, group or team, organizational, and interorganizational—in addressing the six challenges discussed in this chapter. For example, providing additional training in error correction or technical skill development to individuals without recognizing that they work as part of a team will have little impact.

Similarly, working to develop more effective teams without recognizing that they are part of a complex organization with frequently misaligned incentives will have little effect on improving quality. Likewise, trying to redesign organizational structures and incentives and revise organizational cultures without taking into account the specific needs of teams and individuals is likely to be an exercise in frustration.

And attempting to make changes at any of these levels without recognizing the larger interorganizational networks that include other providers, payers, and legal and regulatory bodies as discussed in subsequent chapters is likely to result in the waste of well-intended plans and energy. Turn recording back on. National Center for Biotechnology Information , U. Search term. Recommendation 7: The Agency for Healthcare Research and Quality and private foundations should convene a series of workshops involving representatives from health care and other industries and the research community to identify, adapt, and implement state-of-the-art approaches to addressing the following challenges: Redesign of care processes based on best practices.

Use of information technologies to improve access to clinical information and support clinical decision making. Incorporation of performance and outcome measurements for improvement and accountability. Stage 1 Stage 1 is characterized by a highly fragmented delivery system, with physicians, hospitals, and other health care organizations functioning autonomously. Stage 2 Stage 2 is characterized by the formation of well-defined referral networks, greater use of informal mechanisms to increase patient involvement in clinical decision making, and the formation of loosely structured multidisciplinary teams.

Stage 3 In Stage 3, care is still organized in a way that is oriented to the interests of professionals and institutions, but there is some movement toward a patient-centered system and recognition that individual patients differ in their preferences and needs. Stage 4 Stage 4 is the health care system of the 21st century envisioned by the committee.

Whatever their form, organizations will need to meet six challenges, see Figure 5—1 , that cut across different health conditions, types of care such as preventive, acute, or chronic , and care settings: FIGURE 5—1 Making change possible. Design for Safety When lab results are returned by e-mail, they come back by provider, and I can attach them to the patient's chart.

Mass Customization Mass customization involves combining the uniqueness of customized products and services with the efficiencies of mass production. Continuous Flow When a patient calls to make an appointment, our philosophy is: If your doctor is here today, you will see your doctor. Production Planning We reorganized into teams 2 years ago. Managing Clinical Knowledge and Skills We have an intranet throughout the system that enables physicians to see the latest guidelines and recommendations about screening and to find out where each of their patients is in this care process.

Developing Effective Teams There has been a radical change since we introduced teams. Coordinating Care Across Patient Conditions, Services, and Settings Over Time That is fundamental to what is important to me—that the focus be on the individual—a complex person—and you try to do the best you can for them.

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