Denis Protti reviews "High Performing Healthcare Systems." The book.

High Performing Healthcare Systems (author: Ross Baker et al.)
Review by Denis Protti, Professor,School of Health Information Science,University of Victoria
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Ross Baker and his colleagues have written a fine text on High Performing Healthcare Systems – Delivering Quality by Design. It is well researched, well written and well timed for our Canadian health care system. It should be read by anyone in the pursuit of high quality health care, particularly in our larger health organizations and enterprises. It should also become required reading in our care administration, medical, informatics, and health professional programs across the country.

The authors have built the text around seven case studies of organizations that demonstrated high quality results through a mix of good incentives, clear goals effective accountability systems, sound information management and technology practices and the constant application of quality improvement techniques.

Somewhat surprisingly, three of the case studies are drawn from the United States, a country whose health care system is the most expensive in the world and performs very poorly in most dimensions compared to many other countries (see many studies from the Commonwealth Fund). The five foreign and two case studies are drawn from:

1. US - Veteran’s Health Administration (VHA), the New England System (also known as Veteran’s Integrated Service Network 1) serves 237,000 of the 1.2 million veterans in the 6 New England states in its 8 medical centers and 35 community based outpatient clinics.
2. US - Intermountain Healthcare in Utah provides care across the continuum (except for long term care) in 21 hospitals and 80 outpatient clinics.
3. US - Henry Ford Health System in Michigan modeled after the Mayo clinic has 7 hospitals and 24 ambulatory care centers.
4. Sweden - Jönköping County Council serves 340,000 people in 3 hospitals and 34 care centers (primary care clinics, pharmacies, etc.).
5. England - Birmingham East and North Primary Care Trust (a purchaser of services for over 400,000 people) and the Heart of England Foundation (three hospitals which provide emergency, inpatient and services).
6. Calgary Health Region – the former region which serves 1.2 million people in over 100 locations including 12 hospitals, 40 care centers and a variety of other community settings.
7. Trillium Health Center – two hospital organizations serving over 1 million residents of Mississauga in Ontario.

The cases were chosen from a list developed by a panel of international experts and undoubtedly other facilities such as University Health Network in Toronto and award winning Capital Health Authority in Alberta could have been selected.

The five non-Canadian cases are each accompanied by a commentary from a Canadian health care Chief Executive Officer. All of the commentaries – particular Rick Roger’s assessment of Intermountain Healthcare – provide valuable additional insights into why these organizations have managed to be successful and discuss how the findings could be put into a Canadian context. The text finishes with a hard hitting Afterword by the ever-perceptive Steven Lewis.

The VHA success story is well known and was the subject of complete edition of HealthcarePapers in 2006. The Birmingham facilities in England partnership mutual success stories are less well known but impressive; the case also includes a comprehensive appendix on the British National Health Service. Given that the text is all about leading organizations, it is noteworthy that the Birmingham leaders attribute a significant part of their success to modeling themselves after Kaiser Permanente.

Two major themes permeate almost the entire book, namely leadership and performance management. Information technology is frequently mentioned as well and particularly so in the larger organizations. The Birmingham organizations are known to have “strong capable leaders with clear vision and determination to stay the course”. As Murray Martin wrote in his commentary “Though structures and governance are important enablers for success, perhaps more significant is alignment among providers and the leadership that is in place to make it all happen”.

The VA New England Healthcare System has benefited from the fact that a number of their local medical centers had developed and were using their own measures long before the VA at large “kicked up the performance system”. There is an excellent discussion in the book about the important linkages between performance measurement, accountability and improvement. Like the Birmingham organizations, the New England VA has “benefitted from stability and long tenure of leadership positions”. David Levine points out that, unlike the VA, “one of the greatest challenges facing Canada's healthcare system is how to connect the primary care physicians with the rest of the system and how to develop multidisciplinary primary care teams”. He noted that in the VA, all physicians and other providers in their institutions or private offices use the same software to access and update the patient’s electronic medical record.

Leadership has been critical to the achievements of the Jönköping County Council and its ability to make and sustain improvements in quality. Over the past 18 years the council’s CEO has led their single management system – the longest of any council in Sweden. Of note is that he has managed to overcome the ever present challenge of working in a politically-driven governance structure where power changes every four years and board members are unwilling to maintain an arm's length distance from day-to-day operations. As Maura Davies points out “visible, passionate leadership from the top is essential for quality improvement”. To a large degree, Jönköping’s success is a result of “inspired, persistent, leadership of their CEO and the other senior leaders who he selected to lead the organization”.

Intermountain’s reputation for clinical excellence is based on a strong foundation of evidence-based medicine and clinical process management that has resulted in dramatic improvement in patient outcomes and costs. Over 15 years ago Intermountain’s leaders took specific steps to formally integrate physicians, and health plans in an effort to improve the total process of care. In addition leadership’s commitment to quality improvement as a core strategy, a critical accelerator to improvement across their health system was the evolution of their integrated clinical information system – as has been shown in the VA as well. As their lead clinical informatician has often said “In the long term, the primary purpose of an electronic medical record is protocol support; informatics builds the tools – clinical quality improvement builds the content”. As in most of the other cases in this book “leadership continuity and mission constancy have been critical to success at Intermountain Healthcare”.

The motto at the Henry Ford Health System is “We’re Henry Ford. We can.” In accordance with the motto, the organization has a reputation for excellence and a can do improvement culture. One of the success factors is having local data in addition to credible external data from published studies and collaboratives. Leadership willing to commit the resources necessary for gathering local data and then willing to use the data is one of the keys to improving clinical initiatives. As Jack Kitt pointed out in his commentary, “great leaders articulate a clear vision for their organizations. The Henry Ford leadership demonstrated their commitment to the vision through tangible investments in organizational development, service excellence and a culture of change”.

In closing, it is worth pointing out that Steven Lewis does warn us that “reading these stories about high performing health systems should make Canadians uncomfortable – these narratives describe achievements to which Canada aspires but rarely achieves”. It begs the question - what then is stopping us achieving high quality care when we have so many exemplary models from which to draw?