Challenges Change and Innovation in Health Care Delivery - Innovation Supports Quality Health Care Delivery

The health care industry is awash in wave after wave of new technologies, models of service delivery, reimbursement formulae, legislative and regulatory changes, and increasingly specialized personnel ranks. Creating change in hospitals and other health care organizations requires an understanding of diffusion—the process and channels by which new ideas are communicated, spread, and adopted throughout institutions or organizations.

Diffusion of technology involves all of the stakeholders in the health care system. Policymakers and regulatory agencies establish safety and efficacy; government and private payers determine reimbursement; vendors of the technology are compared and one is selected; hospitals and health professionals adopt the technology and are trained in its use; and consumers are informed about the benefits of the new technology.

The decision to adopt new technology involves a five-stage process beginning with knowledge about the innovation. The second stage is persuasion, the period when decision makers form opinions based on experience and knowledge. Decision is the third phase, when commitment is made to a trial or pilot program, and is followed by implementation, the stage during which the new technology is put in place. The process concludes with the confirmation stage, the period during which the decision makers seek reinforcement for their decision to adopt and implement the new technology.

Communicating Quality

The IOM report on health care quality (Crossing the Quality Chasm: A New Health System for the 21st Centuty, Washington DC: Academy Press, 2001) set forth six aims for improvement and ten rules for redesign of the U.S. health care system. These ten rules are:

1. Care is based on continuous healing relationships.
2. Care is customized according to patient needs and values.
3. The patient is the source of control.
4. Knowledge is shared and information flows freely.
5. Decision-making is evidence-based.
6. Safety is a system priority.
7. Transparency is necessary.
8. Needs are anticipated.
9. Waste is continuously decreased.
10. Cooperation among clinicians is a priority.

This chapter has described some of the efforts currently underway to address and comply with these rules within the existing health care system, and concludes with a discussion of rule number seven, the need for transparency. Transparency refers to the need for public accountability for the quality of the health care system. Health care consumers should be given information that allows them to make thoughtful, informed choices and decisions about health insurance plans and providers. Although family, friends, and health care providers remain consumers' primary sources of information about quality of health services, a Kaiser Family Foundation and Agency for Healthcare Research and Quality survey, National Survey on Americans as Health Care Consumers: An Update on the Role of Quality Information (Washington, DC: December 2000), found 37% of consumers willing to contact a health plan representative or read materials to obtain quality information; 28% wanted to access information online. The information provided must be understandable and should focus on performance measures of the plan or provider that show its commitment to safety, evidencebased practice, and patient satisfaction.

The requirement for transparency requires health care providers and plans to disclose information they previously did not share among themselves or with consumers. Furthermore, many health care plans and providers have found that in order to compete successfully for health care consumers, they not only must demonstrate the ability to deliver health care services effectively but also to document and communicate measures of clinical quality and fiscal accountability.

Publication of medical outcomes report cards and disease and procedure-specific morbidity and mortality rates has attracted widespread media attention and sparked controversy. Advocates of the public release of clinical outcomes and other performance measures contend that despite some essential limitations, these studies offer consumers, employers, and payers the means for comparing health care providers.

Some skeptics question the clinical credibility of scales such as surgical mortality as incomplete indicators of quality. Others cite problems with data collection or speculate that the data is readily manipulated by providers to enhance marketing opportunities sufficient to compromise the utility and validity of published reports. Long-term, the effect of published comparative evaluation of health care providers on network establishment, contracting, and exclusion from existing health plans is uncertain and in many instances may be punitive. Hospitals and medical groups may be forced to compete for network inclusion on the basis of standardized performance measures.

Despite legitimate concern about the reliability, validity, and interpretation of data, there is consensus that scrutiny and dissemination of quality data will escalate. To date, consumer interest has focused on individual providers—local hospitals and physicians. Employers, choosing between health plans involving the same group of participating hospitals and physicians, are requesting plan-specific information to guide their decisions. Companies and employer-driven health care coalitions seeking to assemble their own provider networks rely on physician and hospital-specific data, such as the quality data provided by Healthgrades, Inc., during the selection process. By July 2004, the Leapfrog Group, an employer-based coalition with strong interest in health care quality, was composed of more than 150 member companies that purchase coverage for about thirty-four million people.

The most beneficial use of the data is not punitive, but as inspiration and incentive to improve health care delivery systematically. When evidence of quality problems is identified, health plans and providers must be prepared to launch a variety of interventions to address and promptly resolve problems.