High Performing Healthcare Systems

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

2009-01-01T15:33:00.000-08:00

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?

Chapter 2: Birmingham East and North Primary Care Trust and Heart of England Foundation Trust - Birmingham, UK

2008-12-19T05:36:00.000-08:00

Citation Information
Baker, G.R., A. MacIntosh-Murray, C. Porcellato, L. Dionne, K. Stelmacovich and K. Born. 2008. "Birmingham East and North Primary Care Trust and Heart of England Foundation Trust." High Performing Healthcare Systems: Delivering Quality by Design. 27-64. Toronto: Longwoods Publishing.

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• Download the entire book for free as a PDF file.
• Order the printed paperback version.

Highlights of recent achievements

In 2005 and 2006 the Birmingham East and North Primary Care Trust (BEN PCT) was short-listed for the Health Service Journal award for Primary Care Trust of the Year (Health Service Journal Awards 2005, 2006).
BEN PCT's orthopaedic triage service won the Health Service Journal's access award in 2005 for its work in managing referrals to orthopaedics in primary care settings, decreasing patient waits and increasing patient satisfaction and access (Health Service Journal Awards 2005).
BEN PCT changed from the worst-performing area in the country for over-prescription of antibiotics to winning an award from the Royal Pharmaceutical Society for its achievement in reducing prescribing levels (Birmingham East and North Primary Care Trust 2006b).
Good Hope Hospital's redesign of its vascular surgery clinic and community leg ulcer service won the National Health Service (NHS) Innovation Award for Service Delivery in 2004 and the Healthcare IT Effectiveness Award's Best Use of IT in the Health Service and Best Innovative Use of Technology awards in 2005 (Healthcare IT Effectiveness Awards 2005).
The Heart of England Foundation Trust (HEFT) won the Acute Care Trust of the Year award in 2006 (Health Service Journal Awards 2006).

The system and its environment

BEN PCT is one of 152 primary care trusts (PCTs) in the NHS (see Appendix A for background information on the NHS). Responsible for improving the health of their registered populations within their geographic boundaries, PCTs commission services from providers to meet health needs following NHS service principles (i.e., universal cradle-to-grave coverage that is free at point of use). The potential providers with which they contract range from foundation trusts (hospitals) and provider trusts (district general hospitals and community services) to the voluntary and independent sectors.

Part of the West Midlands Strategic Health Authority, BEN PCT was formed in 2006 by combining the former Eastern Birmingham and Northern Birmingham PCTs. Birmingham is the second largest city in England and BEN PCT serves a diverse population of 433,000 in the eastern half of the city. The effects of socio-economic disparities in this area pose considerable healthcare challenges, with striking contrasts between the better-off Sutton wards in the north ("much more wealthy, middle class, and white" with "better infrastructure") and wards in the east that are among the "most deprived" in England (remarks from a slide presentation by the BEN PCT chief executive officer [CEO] on November 2, 2006). In the eastern wards the Southeast Asian population tends to have higher mortality and morbidity rates, such as lower life expectancy and higher cardiovascular mortality rates among males and above-average infant mortality (BEN PCT 2006). Cultural factors influence care-seeking as well as what type of care is considered culturally appropriate, needed and available in the community.

The PCT contracts for the full continuum of health services for the population within its boundaries as well as providing some services directly. The PCT also pays for independent general practitioners (GPs), dentists, pharmacists and optometrists. For BEN PCT this includes 84 GP practices (237 GPs), 46 dental practices, 95 pharmacies and 83 optometrists. According to a slide presentation by the BEN PCT CEO on November 2, 2006, the PCT has a core annual budget of £560 million ($1.28 billion CAD) and approximately 1,700 employees (BEN PCT 2007a). In addition it hosts £600 million of specialized services commissioning, covering low-volume, high-cost services for the 5 million people of the West Midlands.

BEN PCT is governed by a board composed of a chairman, seven lay members, members of the PCT executive and representatives of the PCT's professional executive committee (PEC). The PEC is the formal clinical leadership group, taking executive responsibility for clinical strategy and policy (BEN PCT 2007b).

HEFT, which includes Heartlands Hospital, Solihull Hospital and Good Hope Hospital NHS Trust, is one of the provider organizations from which BEN PCT commissions services. As a high-performance hospital trust, HEFT was granted foundation trust status in 2005, a designation that gives more autonomy and independence from government control (although HEFT is still subject to regulatory standards and review) (Department of Health 2007a).

HEFT is one of the largest trusts in England, with over 6,000 staff members treating 84,000 in-patients, over 350,000 out-patients and approximately 140,000 emergency cases each year (HEFT 2007). HEFT hospitals provide national and regional clinical services as well as specialized acute care, emergency and elective care.

As separate organizations accountable to different regulatory agencies, BEN PCT and HEFT have each developed their own successful approaches to organizational performance improvement. In addition, the extensive and unusual level of collaboration between the PCT and the foundation trust has resulted in joint programs of work to build primary care capacity and improve chronic care management. Their collaborative approach, which they call Working Together for Health, is based on values captured in three catchphrases:

Patients as partners
Promoting self-care
Care in the right place

Method: Exploring a system capable of improvement

In October-November 2006 a team of researchers from the University of Toronto's Department of Health Policy, Management and Evaluation visited BEN PCT and HEFT. This site visit was part of an initiative called Quality by Design, which aims to identify and define elements of healthcare systems capable of improvement with a view to helping to inform strategic investments in improvement capability in Ontario. Quality by Design is funded primarily by the Ontario Ministry of Health and Long-Term Care in partnership with the University of Toronto's Department of Health Policy, Management and Evaluation.

BEN PCT (including HEFT) was one of five healthcare systems selected from a short list of high-performing systems nominated by a panel of international leaders and experts. In Birmingham the team met with and interviewed administrative and clinical leaders, improvement team leaders and members, as well as support staff working to make improvements. This case study highlights the findings of that site visit.

Examples of improvement initiatives

Clinical improvement projects

The following projects are examples of clinical improvement projects currently underway as part of the joint program of work between BEN PCT and HEFT (BEN PCT and HEFT 2006):

The trusts are among the national pilot sites for the Making the Shift project, which is an initiative of the NHS Institute for Innovation and Improvement (the Institute). Making the Shift aims to move needed services from hospitals to primary care in order to better integrate access to services in the community (see Appendix A, sections 7.1 and 7.3, for more information about the Institute). Three project teams are working on lower-back pain management, heart failure and integrated continence service. They have designed clinics and care paths to coordinate care in the community by using providers from several disciplines and patient education programs as well as by decreasing wait times and unnecessary referrals to specialists.
Assertive Case Management (see next sub-section)
Diabetes: To deliver a community-based glucose tolerance testing service and patient education
Chronic obstructive pulmonary disease (COPD): To identify the prevalence of COPD in the region and create a self-management pathway for the patients
Healthy Hearts Programme: To create a clinic offering specialized treatment plans and education for those at high risk of cardiovascular disease (CVD)
Elderly Care Assessment Unit: To further develop the unit as a rapid access assessment unit for elderly patients needing short-term medical intervention
Hospice at Home: To improve palliative care in the home by redesigning positions for "health care assistants with specialist interest in palliative care"
Integrating Health and Social Care: To redesign an integrated service model for day services across health and social care and the voluntary sector

Partners in Health Centre

The Partners in Health Centre is located near the HEFT Heartlands Hospital, in one of the most economically disadvantaged wards of the PCT. Opened in 2005 the building itself is "a neutral meeting space," a physical symbol of the partnership between the PCT and the foundation trust and a place where teams can collaborate on improvement and care redesign projects as part of the Working Together for Health initiative. The centre provides a focus and home for holistic, multi-provider care programs aimed at self-care and education of patients so that they can take responsibility for their own health. The programs mix clinicians from primary and secondary care (spanning both organizations) and provide support services not available in hospitals or primary care for patients with chronic conditions such as diabetes, COPD, heart failure and degenerative musculoskeletal disease. The centre also provides a base for the orthopaedic triage service.

Musculoskeletal orthopaedic triage service with choice

This award-winning service (Health Service Journal Awards 2005) is based on screening and intervention by extended scope physiotherapists who triage patients for all conditions for which a GP feels an orthopaedic consultation is required (see Appendix A, section 2.2, for more about role redesign). The service began with screening hip and knee conditions and expanded its scope in 2005 to full musculoskeletal triage. The team mapped processes across primary and secondary care, building a database for more rigorous data collection and reports on referral patterns, wait times and outcomes. Team members designed and implemented care pathways that expand primary care and incorporate alternative care choices for patients (compared to traditional surgical or medical treatment), including acupuncture, mobility groups, exercise programs, pain management clinics and expert-patient programs. The service has reduced wait times and routine referrals to orthopaedics and has resulted in improved access and patient satisfaction levels. In line with national policy directions it has also increased the choice of providers for patients (see Appendix A, section 3.2, for more about the patient choice policy).

Vascular clinic and telemedicine system

Leg ulcers are a chronic condition that benefit from careful and timely management by specialist out-patient services. In Good Hope Hospital, Simon Dodds, a vascular surgeon skilled in methods of value stream analysis and process design, led the redesign of the booking system and flow in the vascular clinic, eliminating 12 weeks of delays and adding 40% capacity (Dodds 2005, 2006). In addition, Dodds and his team designed a secure shared e-record, an electronic linkage with the PCT nurses providing wound care in the community. The system enables rapid referral, digital images and access to remote expert advice and follow-up. In a presentation on November 2, 2006, Dodds reported that changes have resulted in improved healing rates of 64% at 12 weeks (compared to studies that have shown healing rates of 22% at 12 weeks for community care and 40% with the addition of specialist out-patient care) and significantly reduced costs.

Birmingham OwnHealth^®

Launched in April 2006, Birmingham OwnHealth^® involves telephone-based care management in the community for over 900 patients with chronic conditions (diabetes, heart failure and coronary heart disease [CHD]). The service - commissioned by BEN PCT from NHS Direct - was developed as a partnership between the PCT, Pfizer Health Solutions and NHS Direct. It is based on an earlier Pfizer initiative called Florida: A Healthy State, which was undertaken in conjunction with the State of Florida's Agency for Health Care Administration. NHS Direct is the national 24-hour health and illness information service provided by telephone and on-line (NHS Direct 2007).

Birmingham OwnHealth^® is based in one of NHS Direct's call centres and is staffed by 12 care managers who have experience in telephone nursing services and who have been trained by NHS Direct. The care managers can support up to 200 patients each, educating them about their conditions and beneficial lifestyle changes and helping them set and monitor their health status and treatment goals. The care managers' objective is to promote self-management of patients' conditions, thereby reducing avoidable morbidity and mortality as well as reliance on acute services.

Birmingham OwnHealth^® is tracking outcomes, including clinical measures (e.g., blood pressure, HbA1c, body mass index, depression scores), unscheduled admissions and patient satisfaction. To measure progress toward self-care and health promotion, case managers assess the stage of change that participants have reached (i.e., pre-contemplation, contemplation, preparation, action, maintenance). After three months over 52% of patients had improved their stage of change for diet and 22% had increased their exercise levels. In just under six months Birmingham OwnHealth^® has demonstrated a decrease in unscheduled care utilization (acute care admissions and accident and emergency [A&E] department and GP visits), although it should be noted that this is based on a very early-stage evaluation. Ninety percent of participants reported satisfaction with the quality of the service (Birmingham OwnHealth 2006).

Assertive case management

To better manage and prevent hospital admission for chronic diseases, clinical leaders at BEN PCT adapted Kaiser Permanente's three-level model for population management (i.e., level 1: the 70%-80% of the chronic care population that requires usual care with support; level 2: high-risk patients requiring assisted care or care management; level 3: highly complex patients requiring intensive care or case management). Launched in 2004 this model of care provides a systematic approach for prioritizing and stratifying patients according to risk and for applying a step-up and step-down approach to match skills and resources to patient need. Specifically, the model uses entry and exit criteria for three risk segments and progressive involvement and intensity of care providers with patients able to move up and down to accommodate changing clinical needs (i.e., high: district nursing teams; higher: assertive case managers; highest: advanced nurse practitioners). GPs use a validated and computerized system to routinely identify and refer patients who are appropriate for assertive case management, and specialist nurses follow up with a validated and computerized risk prediction system.

The model emphasizes cascading clinical leadership and collaboration with supervision and shared care starting from GPs. It also employs a hospital alert system to track the case-managed patients' use of hospital services. In addition, in order to build capability for this model and encourage career progression BEN PCT has integrated specialist training for case management for chronic conditions into its competency and training framework.

Among a pilot population this model has led to a 50% reduction in unplanned hospital admissions, a 55% reduction in A&E visits, a reduction in polypharmacy and an increase in patient satisfaction and compliance. Over the last year the PCT's emergency admissions to hospital were slightly reduced against a national 8% increase, and attendance at A&E stayed the same against national growth.

The strategy: Align improvement processes with system strategy, culture and operations

"We have to keep agile and nimble, with the right principles in mind."
- Sophia Christie, CEO of BEN PCT

Leaders in a complex change environment

The two CEOs, who have credibility, authority and very different - yet complementary - leadership styles, have played a central role in shaping the trusts' improvement journeys. The PCT CEO, Sophia Christie, recounted that as they began Working Together for Health she wanted wholesale change "yesterday," whereas the HEFT CEO, Mark Goldman, cautioned, "Steady, we are dealing with physicians." The Department of Health placed "incredible pressures on NHS executives; going too quickly would have destroyed the projects, yet going too slowly would have destroyed us."

The BEN PCT and HEFT CEOs worked hard with their boards to ensure they would see how their plans could be "pro-patient care," despite the financial disincentives and national policies that created obstacles. For example, the trusts are collaborating to avoid in-patient admissions by providing more comprehensive community-based services, yet the acute care trust stands to lose revenue by doing so (see Appendix A, section 3.1, for more about the payment system). In the PCT leaders decided that "even if changes we made put us financially at risk, we would do so to make sure we were providing the right services" (PCT CEO). The BEN PCT and HEFT "partnership plans were a bit contrary to the Department of Health (DOH) rules. ... When we developed the approach it was against national policy. National policy moved towards us, not the other way around!" (HEFT CEO).

There is an increasing policy emphasis in the United Kingdom (UK) on, as the BEN PCT CEO put it in a slide presentation on November 2, 2006, "providing services where they give best value." However, financial mechanisms are not aligned with this goal. The HEFT CEO stressed the difficulties encountered in his trust's "attempts to hold open the doors of the hospital to let patients go to primary care" in the face of adverse financial consequences for the hospital. When HEFT became a foundation trust in May 2005 their collaborative effort "almost came off the wheels" due to the scrutiny of Monitor (the regulatory agency for foundation trusts) and the pressure of Monitor's expectations for the trust's financial growth (see Appendix A, section 3.3, for more about Monitor).

Complicating their management responsibilities even further, significant restructuring occurred around this time in both trusts. The amalgamation of Eastern Birmingham PCT and Northern PCT raised cultural issues, the lack of a shared acute care strategy and resistance from Northern PCT to dealing with patients from the eastern wards. HEFT took over responsibility for (and has since merged with) Good Hope Hospital Trust, which had considerable financial problems. Both CEOs observed that they sacrificed progress in the trusts for which they were originally responsible as they worked to straighten out issues arising from the later additions. However, their work has proven to be part of a politically astute strategic vision for integrating care and improving patient access, outcomes and choice.

Approach to change

"Adapt improvement tools to use them in a situation that is already prepared."
- Sophia Christie, CEO of BEN PCT

Investment in organizational development

The Eastern Birmingham PCT had a history of investing significant time and energy in organizational development based on a "large system approach" using "whole system events" (Beedon and Christie 2006). With the assistance of an organizational development consultant the PCT CEO works in a very hands-on fashion to ensure as many staff members as possible are engaged in a meaningful way in shaping the organization. This approach has been continued successfully during the strategic integration of BEN PCT, with the involvement of large numbers of staff and stakeholders in the design process for the new organization's strategic goals and values. Participants were encouraged to come up with "great, big, hairy, audacious goals" (Collins and Poras 1994) and the CEO promised, "Whatever you come up with, we will live with and do."

This participatory process resulted in the following core purpose and goals, which are their touchstones for planning decisions, measurement and improvement efforts:

Purpose

Working in partnership to tackle inequalities and improve the health and well-being of local people.

Goals

To be so responsive to the population we serve that no one waits for the healthcare they need.
That the health and well-being of the population will have improved so much that people will enjoy 10 more years of quality life.
Our communities will be the most involved, informed and empowered in the country.
That people regard us as the first choice organization to work with and for.

HEFT has likewise launched Moving Forward Together, a "massive, fully integrated organizational development program" (HEFT CEO). This program will develop the vision, values and behaviours of the newly merged organization as well as the skills and competencies required of staff through "skills based programs, local facilitated problem solving initiatives, and leadership development" (HEFT 2006a, 2006b).

The members of both executive teams stressed the importance of paying attention to organizational culture and preparing the organizations for change so that improvement tools and interventions can be used effectively. In the PCT CEO's words, "Adapt improvement tools to use them in a situation that is already prepared." HEFT is developing its own "Lean academy" on site and is training staff in Lean improvement methods and process mapping; however, "cascading it through will be a slow process over several years as we train people" (senior clinical leader). BEN PCT is a pilot site for the Institute's shifting care initiative; therefore, staff members involved in those projects use improvement methods adapted by the Institute.

Members of both organizations cautioned, "It is more than just a formula that you can apply from the Institute; you need the formula, but you need to adapt it and work with it" (senior leader). They observed that the former Modernisation Agency "was not successful because it focused its efforts on the improvement processes within projects led by single champions, but outside of the [organizational] culture, and it could not move the projects into the rest of the industry" (see Appendix A, section 7.1, for more about the Modernisation Agency). "The reason that we have been able to do what we have is because we have the processes - the project-level processes and improvement skills - aligned with the system, strategy and leadership" (PCT CEO).

Managing the tensions between short-term projects and long-term vision

The trusts had six or seven years of experience with earlier change efforts, which helped them to understand how to manage the tension between project-specific goals and the long-term vision. This enabled them to make the joint projects work more quickly in a short time frame. Both CEOs commented on the need for early gains through quick interventions: "We emphasize getting on with it instead of talking about it for ages. ... This approach is transactional as compared to transformational. If you start with small projects and keep expanding, eventually there will be no turning back. The best way to create sustained change is to do it on this evolutionary, project-by-project, phase-by-phase approach" (HEFT CEO).

As an example of the phase-by-phase approach, the trusts started their Working Together for Health collaboration with small-scale projects in diabetes care management. A review showed that their Asian population had severe diabetes complications, yet no coordinated management program was in place for them in primary care. The PCT's director of health improvement worked on a management plan to create a community diabetes service, a link between primary care GPs and specialists. The trusts conducted a chart review to gather needed data (there had been no data collection in the past, so they were missing information on 1,000 diabetic patients). The diabetes care management program is flexible, with an aim of building capacity within primary care to handle the care provision for the target community. The service includes a consultant nurse, two specialist nurses, educators who speak more than one language and a physician consultant (a joint appointment between BEN PCT and HEFT).

A senior clinical leader noted that one of the challenges they face is "how to grow the right, skilled population of care providers; that is, taking those who are used to giving care to individual patients and turning them into consultants who advise." The interventions require extensive education, yet physicians (who often work in large, busy practices of one or two GPs) are far too busy to attend outside sessions. Trust staff therefore take these improvement programs to the practices.

Funding improvement work "is not a simple thing" (PCT CEO). The PCT has opportunities to bid for external funding, but not a lot is available; therefore, "We've dragged in money from here and there in different ways. ... We have been in a good position to bid opportunistically on some opportunities because of good results and experience." Their Working Together for Health initiative is staffed by a program director, who supports its projects, attends meetings, helps with data collection when necessary and has made use of the strategic partnership with the organization development (OD) consultancy to continue developing expertise in improvement tools and cultural change.

Links with "mentor" organizations and individuals

BEN PCT and HEFT have actively sought out other organizations, both within and outside healthcare, from which they could learn. For example, BEN PCT representatives visited the Body Shop chain to learn about franchising models and then had sessions with the trust's GPs aimed at helping them to look at their practices as franchises. The knowledge - "the idea that you didn't get money for nothing, that there are standards and expectations" - made a big difference with GPs. The trust began to tie incentives to clinical practice change, for example, to encourage inclusion of smoking cessation and diet counselling as well as preventive care. This funding strategy has been broadened by the new NHS Quality and Outcomes Framework (QOF), which includes quality standards and indicators monitoring in the general and medical services' contracts for primary care (BEN PCT 2006: 35) (see Appendix A, section 3.3, for more about the QOF).

Kaiser Permanente

Perhaps the most significant external influence on Working Together for Health has been Kaiser Permanente. This large, integrated health organization and health plan from the United States (US) has played a major role as a resource that provides ongoing support and contact. "We cannot overemphasize the importance of Kaiser, the influence of seeing their plans and work and the encouragement that we could get there too, that it was possible. It was a mentorship relationship. We could not have done it without them" (senior clinical leader).

The trusts' relationship with Kaiser Permanente began in 2003, when the Department of Health offered several NHS trusts the opportunity to participate in an initiative facilitated by Professor Chris Ham of the University of Birmingham, a study tour site visit to Kaiser Permanente with the intent of working together to adapt lessons learned (Ham 2006). The PCT CEO decided to invite a multidisciplinary clinical team chosen from across the trusts to attend the first site visit. Upon the team's return, the trusts began implementing small-scale projects with GPs who were interested in doing things differently with their particular groups of patients (an "artisan approach"), with project support from the newly appointed project manager. The trusts' collaborative program, Working Together for Health, was born.

Some medical staff, as well as some community members who did not want "American healthcare," reacted negatively to the thought of adopting Kaiser Permanente's approaches, such as the view that less costly, more effective care can be delivered closer to home. Adoption of Kaiser Permanente's approaches was controversial enough that at the beginning team members were advised not to use "the K word." As a result, when they started work on their first four clinical areas (diabetes, COPD, orthopaedics and heart failure) using the Kaiser approach, members "rebadged" it to make it their own.

Later, in 2004, the two CEOs and the chair of the PEC spent four days visiting Kaiser Permanente. Both CEOs highly valued this exposure and planning time, which resulted in the agreement that they needed to make a visible commitment personally to the change initiative that their organizations had undertaken together. "We decided to stay with it until it would be unstoppable." In January 2005 they involved 26 clinicians in a week-long workshop with their Kaiser partners. Since then there have been multiple visits to Kaiser; ongoing linkages include annual meetings with Kaiser staff as well as telephone contact. Senior leaders in the PCT and HEFT described the relationship with Kaiser as "incredibly invigorating," adding, "there is a great deal of largesse about how they have related to us."

Physician leadership

Physicians hold major leadership roles in the trusts. For example, HEFT has implemented "a very medical model." The HEFT CEO, who is a surgeon by training, remarked, "We learned this from Kaiser: if you don't have the physicians on board with you, you can't succeed." One of the senior managers observed, "We have a pretty powerful clinical management system. Most of the money is in the hands of doctors."

In HEFT the three medical directors have operational line responsibility, and financial responsibility has been decentralized to these directorates. Physicians lead many of the clinical programs as well as improvement initiatives. The attitude of the nurses and allied health staff to this is quite interesting; according to several nurses in key positions, nurses are content to work alongside the physicians and behind the scenes, while letting the physicians take the lead. On the other hand, expanded roles for nurses and allied health professionals appear to be well accepted by medical staff. In addition, BEN PCT adapted the national PEC model to create clinical directors who have lead responsibility for core strategies.

Performance management: Competing demands and financial pressures

The pace and frequency of restructuring, intense scrutiny from regulatory agencies as well as the financial crisis in the NHS create a difficult working context for the trusts. Both BEN PCT and HEFT invest considerable amounts of time and resources in performance measurement and reporting. PCTs are subject to annual assessments by the Healthcare Commission against a set of core standards and targets (see Appendix A, section 4.2). BEN PCT has adapted these measures to fit their balanced scorecard (see Appendix B); each measure is discussed in detail in its performance report updates.

Although HEFT's independent status grants it more operational freedom, this freedom comes with an immense financial pressure: "As a foundation trust, you can fall over completely and no one will save you. ... That has hardened our business approach; it's much more commercial" (senior leader). HEFT operates as a large healthcare enterprise, intent on expanding its market share to include more patients in the region, such as through its merger with Good Hope NHS Trust. It is also developing a range of commercial interests, such as the Heartlands Medipark, which will house a medical innovation development and research unit (MIDRU) as well as clinical and laboratory facilities.

Fiscal discipline is a hallmark of HEFT; as one senior leader commented, "We're not a toxic organization but there is accountability." This foundation trust has devised a strategy map of its high-level goals and measures (see Figure 1), which are compiled in a scorecard. All measures are tracked monthly (in some cases weekly) and published in the trust's "red book," which is its performance monitoring information pack filled with detailed tables of indicators and measures by directorate. HEFT develops RADAR plans for its indicators (HEFT 2006a). (RADAR, an action planning tool from the European Foundation for Quality Management [EFQM)], stands for "determine the results required; plan and develop approaches; deploy approaches; assess and review.")

[Figure 1]

Because of their contractual relationship as service commissioner and service provider, BEN PCT and HEFT also work together on performance measurement and management. The trusts, with the addition of representatives from neighbouring Solihull PCT, hold Tripartite Performance Management meetings every three weeks to review scorecard targets and action plans, assess market changes and impacts of national policies and agree on ways of implementing primary care pathways. The directors that staff the committee report directly to the CEOs. These meetings are often very challenging; as the CEO of the BEN PCT commented, "It's the edgy bit where the arguments happen." Potentially conflicting interests arising from national policies create significant tensions; for example, an increase in hospital admissions might be positive as a revenue generator for the acute trust but is red-flagged as a cost increase for the PCT.

BEN PCT's multiple roles also contribute to the tension. As a commissioner, BEN PCT is responsible for monitoring how costs and income are managed; as a partner, for maintaining constructive relationships with providers; and, as a provider of some services in the area, for avoiding perceptions of conflict that could arise from being both fund holder and service provider. However, because the trusts have invested so much in developing their partnerships they are able to have productive discussions about the strategic issues that cut across the region, while avoiding breaching NHS rules about collusion.

Conclusion

BEN PCT and HEFT have worked hard to develop partnerships necessary for improving care in the complex UK healthcare environment (see Figure 2). Several key factors have shaped the growth of BEN PCT and HEFT as systems capable of improvement: for example, strong, capable leaders with clear vision and determination to stay the course; ongoing investment in organizational development and improvement skills that prepared the way for change; and a serendipitous learning opportunity that turned into a continuing mentoring relationship with Kaiser Permanente. The trusts have also shifted away from traditional care delivery within specialist silos in dominantly acute care settings to redesign and integrate care based on the needs of their entire population. The PCT is also working to extend its network of partnerships to include social services, a move that adds to its complex responsibilities but also offers the opportunity to integrate further services to meet population needs (see Appendix A, section 2.4, for more about health and social care integration).

To accomplish these changes the trust leaders encourage local innovation and collaboration with external resources, including industrial partners such as Pfizer Health Solutions. They have also built a robust business case for their approach to improvement, redesigning services in an effort both to meet population needs and to reduce costs in the face of the immense financial pressure felt throughout the NHS.

The trusts continue to face significant challenges in the ever-changing UK healthcare environment. The focus on financial discipline in the NHS, for example, has continued to escalate, resulting in sizeable budget challenges for the trusts and the PCT facing the need to reduce costs by £26 million in one year (a challenge it has successfully met).

The productive partnership between BEN PCT and HEFT has been shaped by the strong working relationship between their current leaders, individuals who have undertaken to stay in their roles until the improvement momentum is "unstoppable." Although one CEO commented, "We are almost there," it remains to be seen whether the cultural transformations will be sustained as leadership positions change in the future.

[Figure 2]

Notes to Figure 2

For more background information about the institutions in the numbered boxes in Figure 1, see the following sections in Appendix A:

Strategic Health Authority: Section 1.0: Background; Section 5.0: Regional Accountability
Healthcare Commission: Section 4.2: Performance Reporting and External Assessment
Quality and Outcomes Framework: Section 3.3: Financial Incentives
Monitor: Section 3.3: Financial Incentives
Institute for Innovation and Improvement: Section 7.1: Modernisation Agency; Section 7.3: Institute for Innovation and Improvement
NHS Information Systems and Dr. Foster: Section 4.2: Performance Reporting and External Assessment; Section 6.0: Information Technology

Appendix A. National Health Service: Health system context

1.0. Background

Introduced in 1948 in the aftermath of the Second World War, the NHS is the UK's healthcare system and Europe's largest employer (the NHS employs 1.3 million people across England, Wales, Scotland and Northern Ireland). Financed largely from general taxation, the NHS was originally founded on the principles that healthcare is free at the point of delivery, available to all who need it and based on clinical need and not ability to pay. The Department of Health has political responsibility for the NHS, managing it at the top through policies and programs and under the leadership of the secretary of state for health. The NHS was initially structured with three arms: hospital services by regional hospital boards, primary care with GPs (dentists, opticians and pharmacists) as independent contractors and community care services managed by local authorities (for a history of the NHS, visit http://www.nhs.uk/england/aboutTheNHS/history/default.cmsx).

Today, the structure of care delivery in the NHS emphasizes local decision-making, as shown in Figure 3. PCTs - local groups of planners and providers of primary care - hold over 80% of the NHS budget. These trusts are responsible for assessing local needs, planning and commissioning both primary and secondary care services to meet these needs and providing some primary care. Hospitals, ambulances, specialist providers and providers of mental health and other health and social care are also organized into trusts that contract with PCTs. The over 150 PCTs report directly to 10 strategic health authorities (SHAs). These authorities are the key link between the NHS and the Department of Health, and are responsible for managing and monitoring the performance of local services and ensuring that these local services are aligned with national priorities.

Since its inception the NHS has evolved into a £96 billion-budget organization and has undergone several periods of reform. Following a steady pace of change, the past 15 years have brought an unprecedented scale of transformation to the structure, financing and way in which care is delivered in the NHS. For the most part "a crisis of confidence in the NHS" - and specifically in quality of care - is seen as the driver of such large-scale reform (SteelFisher 2005). The crisis in quality was illustrated by long wait times, higher than average mortality rates for key conditions and notable tragedies, such the death of 29 children at the Bristol Royal Infirmary. Observers have attributed this crisis to several factors, in particular, to an underinvestment in capacity (e.g., healthcare providers, equipment), a lack of standards and incentives for higher quality care, outdated boundaries between sectors and providers, overcentralization and disempowered patients (Enthoven 2000).

Over the past few decades the NHS's most significant transformation efforts were launched by white papers and other key consultation documents that outlined a series of interdependent reforms and priorities. Appendix A(a) describes a selection of these documents.

[Figure 3]

Overall the NHS's policy context has been shaped by several key reforms. The extent to which these reforms have been levers for improving quality varies. A discussion of these reforms follows.

2.0. Supply-side reforms

2.1. Investments in capacity and a plurality of providers

Growth in funding and capacity has played a key role in the supply-side reforms of the NHS in the past two decades. To bring investment to a level equivalent with other European systems, NHS funding increased by "one half in cash terms and by one third in real terms" over five years. This increase funded investments in new NHS facilities (e.g., 100 new hospital schemes; 2,100 additional general and acute beds; 500 new primary care centres) and staff (e.g., 2,000 more GPs; 20,000 extra nurses; 1,000 more medical school places) (Department of Health 2000).

Such capacity growth was viewed as necessary but insufficient to relieve pressures on hospital beds, staff and wards, and to achieve and sustain the national targets for reducing wait times. Therefore, parallel strategies were put in place to develop a permanent increase in the volume of services delivered to patients. Typically commissioned from independent sector companies, these strategies included independent treatment centres that provide scheduled day and short-stay surgery and diagnostic procedures, overseas teams that carry out high-volume and non-complex surgery in high-pressure specialties such as orthopaedics and ophthalmology and an overseas treatment option for patients who choose to undergo orthopaedic, ophthalmological and cardiac procedures in France, Germany and Belgium (Department of Health nd a). By harnessing these strategies NHS leaders aimed to develop an independent sector that could carry out up to 15% of procedures each year for NHS patients, paid for by the NHS. To support the growth in "independent sector" options and a plurality of providers, NHS leaders also increased the number of physicians entitled to discretionary private sector payments. These independent sector options are subject to audit to ensure they provide extra capacity for care overall (rather than limiting capacity in the NHS), offer value for money and meet high clinical standards. Although there are ongoing debates about the disintegration of the NHS as a result of the growing independent sector (McGauran 2004) the NHS's success in streamlining access to care and reducing wait times is widely attributed to this strategy.

2.2. Service and role redesign

In addition to growth in actual capacity, several national reforms have focused on service and role redesign in the NHS as a means to improve productivity and, ultimately, to improve quality. One of the most profound changes is the increase in flexibility and removal of boundaries across traditional roles in primary care, especially between physicians and nurses and allied healthcare providers. Several professions have extended their scopes of practice and accompanying specialist skills training. For example, since 2005 physiotherapists, radiographers, podiatrists, optometrists and pharmacists have had prescribing authority, and some of these professionals are able to perform minor procedures previously limited to specialist physicians (Department of Health nd b).

2.3. Practice-based commissioning

Several NHS reforms have focused on developing a primary care-led system and increasingly devolving influence and control of budgets and planning to front-line healthcare providers. These reforms have included GP fundholding in the early 1990s, which was eventually abolished; commissioning by PCTs, which has remained the dominant model for the past decade; and the recently introduced policy of practice-based commissioning (PBC). PBC is currently positioned as "the engine for change" in the NHS and gives GP practices their own "notional" budgets to purchase care for their patients, including emergency care, out-patient and in-patient treatment and drugs (King's Fund 2006). This policy aims to raise GPs' awareness of the financial implications of their prescriptions and referrals and motivate them actively to redesign innovative, cost-effective and responsive services for patients.

There are examples of trusts that, by embracing PBC, have emerged as "care entrepreneurs" in the redesign of care. Such redesign includes partnering with social care and other providers to help manage chronic diseases and avoid hospital admissions by leveraging healthcare team members who have specialist training for procedures that would normally occur in hospital and by purchasing diagnostic technology for use in the community. Under this scheme, GP practices are accountable to PCTs, which directly administer funds and remain legally responsible for them as well as provide GP practices with data on their patients' utilization of services (e.g., diagnostic tests, prescribing, hospital and emergency care) and the cost of this care. Incentives are available for practices that take up commissioning, including the ability to reinvest surplus funds.

PBC has several perceived benefits, including improved coordination of primary, intermediate and community support services; clinical engagement in redesign of care and services; better collaboration between practices; more efficient and appropriate prescribing, referral and utilization of services; and care in more convenient settings for patients (Greener and Mannion 2006). However, as the Department of Health hopes to further spread and implement this policy across GP practices in the NHS there is considerable debate about whether PBC will overcome issues associated with the earlier fundholding model and whether it will be a lever to achieve change and improvement. Some observers raise concerns about the management and transactions costs. Others raise questions about whether there is sufficient evidence to support some of the key assumptions underpinning the model, including the belief that patients should choose providers (rather than commissioners) and that purchasers should commission based on population and geography (rather than individuals) (Higgins 2007).

2.4. Integration of health- and social care

With the launch of the 10-year NHS Plan in 2000, leaders articulated a vision for better-integrated health and social care (Department of Health 2000). Social care (i.e., social services) in the UK is managed by local authorities. Since the original vision was articulated several models for joining health and social care have evolved.

In 2002 the NHS piloted a new type of organization - care trusts. These bodies integrate health- and social care under a single organizational structure with multidisciplinary teams providing streamlined cross-disciplinary assessments. Conceived as a "new level" of PCT, these trusts aim to commission and deliver care to patients who require complex health- and social care in several parts of the continuum (e.g., acute, intermediate, home) and who would normally need to navigate two different systems. Patients who stand to benefit most from care trusts include those requiring mental health care, the elderly and the disabled. There are currently 10 care trusts in the NHS, fewer than initially forecasted. Observers remain divided about their value. Some see them as a structural innovation that improves access and delivers more flexible and holistic care. Others see them as an overemphasis on structural change when other partnership models would suffice (Glasby and Peck 2005).

Several other reforms are under way to help facilitate more joint commissioning of health- and social care without extensive structural integration. These include a procurement model and best-practice guidance to underpin a joint commissioning framework; streamlined budgets and planning cycles based on a shared, outcome-based performance framework; aligned performance assessment and inspection regimes; and more joint health- and social care appointments. At local levels some PCTs are now partnering with local authorities to shape the way health- and social care are delivered for patients with chronic conditions. Most recently, in an attempt to enhance patient choice in new models of health- and social care the government announced a pilot of "individual budgets." This is a scheme that would enable people needing social care to design that support and give them the power to decide the nature of the services they need (Department of Health 2006a).

3.0. Demand-side reforms

3.1. Payment by results

Historically, trusts were paid lump sums based on block contracts and locally agreed prices. Introduced in 2004 as a pilot in several trusts and expanded across the NHS for non-elective and elective care in 2006, payment by results is an activity-based payment system, adjusted for case-mix that reimburses providers with a fixed national price or tariff for each case treated. Designed to be open and transparent, and underpinned by the principle that money follows patients, the system's goal is to increase productivity, reward efficiency and support patient choice (Department of Health nd c).

Reports have shown that early implementation of the system exposed several weaknesses, including issues with data quality and accuracy of coding; inadequate involvement of clinicians in defining the tariffs, especially for complex cases and highly specialized care; and financial instability in some trusts. In addition, clinicians have expressed concern that by encouraging productivity within local organizations this system will fragment care and discourage collaboration across sectors for issues such as chronic disease prevention and management, and may lead to gaming or "upcoding" (King's Fund 2005; Dixon 2004). It is still too early to evaluate the impact of further expansion of this payment scheme.

3.2. Patient choice

In conjunction with the tariff system, patient choice has been a key part of the NHS's recent policy reforms. As of January 2006 all eligible patients across England have the right to choose where and when they get hospital treatment. Through the Choose and Book initiative patients are offered the choice of at least four hospitals or clinics for further non-emergency treatment. One of these options is a private sector provider. People are able to book the time and date of their out-patient appointments at their GPs' offices through an online system that shows where and when appointments are available. In order to inform their choices, patients are provided with information on each of the options, such as details about transportation, parking and disabled access; information about the performance of the organization on key national targets; and patient satisfaction.

Additional strategies are also under way to help support patient choice in the NHS. These include an online system called HealthSpace that allows patients to record their lifestyle and healthcare preferences on electronic medical records and an electronic prescribing service that enables patients to pick up repeat prescriptions from pharmacies of their choice (Department of Health nd d).

By enhancing patient choice in the context of money following patients, the NHS hopes to reduce variations in quality, promote faster and better access across the NHS and ensure that NHS services continue to reflect patients' needs and priorities. The extent to which choice is actually a lever for improving quality remains uncertain. There is some debate that these reforms were too narrow in their application to elective services, given their irrelevance to other significant areas of healthcare, including care for chronic conditions or emergency treatment (Appleby 2004).

3.3. Financial incentives

The Quality and Outcomes Framework (QOF) (see http://www.nhsemployers.org/primary/primary-890.cfm) is a new system of financial incentives for GP practices designed to improve GP recruitment and retention. Historically, GP practices have been paid according to the number of patients on their registers, and they were required to be available outside normal working hours. Introduced in 2004 as part of the General Medical Services (GMS) contract, the framework allows GPs to opt out of providing services after hours, rewards practices for providing high-quality care and helps to promote further investment in improvements in the delivery of care.

The QOF measures quality of practice against evidence-based national standards in four areas:

1) clinical standards linked to the care of patients with chronic conditions; 2) organizational standards relating to records and information, communicating with patients, education and training, medication management and clinical and practice management; 3) additional services covering cervical screening, child health surveillance, maternity services and contraceptive services; and 4) patient experience based on patient surveys and length of consultations.

Points and payments are awarded according to levels of achievement. QOF data are collected through patients' electronic records and fed into a national quality management database (see http://www.ic.nhs.uk/services/qof). Although participation in the QOF is voluntary, a large majority of general practices participate in the scheme. Clinicians and observers consider the framework to be a strong lever for improving quality, given its focus on rewarding general practice teamwork, allowing flexibility to choose specific targets and providing upfront funding to help raise quality standards.

In addition to GP incentives the government developed a new type of incentive for NHS trusts in 2004. Trusts that demonstrate strong performance - in particular financial performance - are invited to apply for designation as foundation trusts. These trusts are independent public benefit corporations and are free from central government control and regional performance management. Independently authorized and regulated by an organization called Monitor, foundation trusts are free to innovate for the benefit of their local communities and patients, to independently decide and make capital investments, to retain any surpluses they generate and to borrow in order to support investments (on Monitor, see http://www.monitor-nhsft.gov.uk/about.php). There are presently over 70 foundation trusts in the NHS. Current policy envisions that all hospitals will evolve to become foundation trusts.

4.0. National guidance, standards and targets

4.1. Priorities and targets

Several of the reforms outlined in this section were explicitly designed to help meet national priorities and targets, especially for wait times. In the late 1990s the government set several targets for reducing wait times: six months on in-patient lists, 13 weeks on out-patient lists, 48 hours for an appointment with a GP and four hours before being treated, admitted or discharged from A&E departments. Virtually all these targets were reached by 2005, with a new target set for 2008: 18 weeks from GP referral to visit.

While most observers agreed that wait times needed urgent attention and central investment, many now feel that some of the mechanisms for addressing these issues damaged morale and produced distortions in the system. For example, failure to meet targets led to executive replacement and, eventually, a significant turnover of leadership in the system (the link between targets and performance assessment is highlighted in the next section). In addition, the pressure to meet earlier wait time targets, which were virtually all focused on a patient's journey after diagnosis, produced longer "hidden waits," such as time to diagnosis. Clinicians and managers also worried that a disproportionate focus on wait times led to the treatment of less urgent and complex cases and a distortion of clinical priorities (King's Fund 2005b).

In its 2004 Improvement Plan the government articulated its vision of shifting away from national targets and central regulation to local target-setting and performance management and to a focus on a new set of priorities. In addition to a strong emphasis on wait times there were many other NHS standards, targets and guidance rules, elements that overwhelmed many leaders and providers. In 2004 the government announced it would reduce the number of national healthcare standards and targets from 600 or more to 24 (Frith 2004). Among the new set of national priorities was a focus on prevention and support for individuals with long-term (i.e., chronic) conditions such as diabetes, heart disease, asthma and depression.

The most recent priorities outlined in the 2007/2008 NHS operating framework (Department of Health 2007b) include the following:

Achieving a maximum wait of 18 weeks from GP referral to start of treatment
Reducing rates of methicillin-resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections
Reducing health inequalities and promoting health and well-being
Achieving financial health

4.2. Performance reporting and external assessment

The national system for assessing and reporting the performance of NHS organizations evolved in conjunction with other reforms, particularly the focus on national priorities, targets and incentives. Introduced in 2001 the "star rating" system used over 50 different standards to award hospital trusts up to three stars for performance. Top-performing trusts (three stars) were awarded cash bonuses, additional freedom from central control and the option of becoming a foundation trust. Lower-performing trusts (zero stars) that did not improve over time were threatened with the replacement of their executives and other consequences.

This system of assessing and reporting performance was controversial; many observers felt it was too crude and unfairly punished hospitals and leaders. In 2004, when the Healthcare Commission for Audit and Inspection (formerly the Commission for Healthcare Improvement) - the independent inspection body for both the NHS and independent healthcare - undertook responsibility for performance assessment, it began the development of a new and more rigorous system. In March 2005 the Healthcare Commission launched the Annual Health Check. This performance assessment and reporting system measures NHS organizations against standards in seven categories: safety; clinical and cost effectiveness; governance; patient focus; accessible and responsive care; care environment and amenities; public health). In each of these areas the commission assesses and publicly reports whether organizations are meeting basic expected levels of performance and whether they are improving. In addition to developing the Annual Health Check, the commission regulates the registration of independent healthcare providers and conducts independent reviews of NHS complaints as well as value-for-money audits (Healthcare Commission 2005).

As noted earlier, Monitor independently authorizes and regulates NHS foundation trusts. Private industry in the UK is also involved in measuring and reporting the performance of healthcare in the NHS. Dr. Foster, launched in 2001, is a commercial provider of information about the performance of NHS healthcare providers, including physicians, hospitals and other care centres. While the Healthcare Commission's performance assessments are publicly available, their primary audiences are NHS providers and the government. The target audience for Dr. Foster's service guides is the general public. Dr. Foster is widely considered to be a successful endeavour.

4.3. NICE and National Service Frameworks

In 1998 A First Class Service - Quality in the New NHS outlined new initiatives and tools for setting, delivering and monitoring standards for a high-quality, cost-effective NHS (Department of Health 1998). The National Institute for Health and Clinical Excellence (NICE) and the National Service Frameworks (NSFs) are two successful initiatives that have emerged from the NHS's national quality agenda.

Launched in 1999 NICE uses evidence-based clinical guidelines and associated clinical audit methods to provide authoritative appraisal and national guidance on new and existing healthcare in the areas of public health, health technologies and clinical practice. In prioritizing treatments and innovations as well as in developing and disseminating guidelines, NICE considers clinical evidence, cost-effectiveness and NHS priorities (see http://www.nice.org.uk/).

Starting in 1998 a rolling program of NSFs began, focusing on priority conditions including cancer, CHD, diabetes, mental health and services for older people. NSFs provide evidence-based service models and standards that outline what care patients can expect to receive from the NHS for high-priority conditions. NSF models and standards also offer implementation strategies and support and performance measures to assess progress (Department of Health nd e). NICE and the NSFs are considered critical foundations for quality improvement and remain highly regarded by clinicians and leaders across the NHS and around the world. In large part their success is attributed to the transparency of and strong clinical and expert (including patient) engagement in their development.

5.0. Regional accountability

NHS organizations (except for foundation trusts) have regional accountability to SHAs, which play a liaison role between the organizations and the Department of Health. In 2006 the government announced a new architecture for the SHAs, reducing their number from 28 to 10. This restructuring was aimed at streamlining management and administration, redirecting resources to patient care, cutting out unnecessary bureaucracy and giving SHAs a more strategic role.

SHAs have traditionally played a central role in performance management, monitoring how well PCTs and other trusts perform and taking action to improve failing services. Given the enhanced role of the Healthcare Commission in performance management, the SHAs' role is shifting to strategic planning and support in the development of local service delivery plans and improvement. The extent to which this shift is actually occurring is unclear. Observers have reported that some SHAs are playing a critical role in ensuring the strategic integration of national and local priorities in local planning and that they have used resources to develop infrastructure to support quality improvement initiatives such as "improvement academies." Such changes, however, are occurring in only a few SHAs.

6.0. Information technology

An effort to modernize information technology (IT) in the NHS is being led by one of the world's largest IT programs. NHS Connecting for Health is the single national IT provider for the NHS, delivering an ambitious national program to create an integrated information system to connect and facilitate secure communication among providers and to provide timely decision support. The program has several components, including infrastructure to connect GPs to hospitals, universal access to information-rich resources, electronic patient records with detailed summaries of episodes of care and a lifelong summary of important information. Additional enhancements include electronic booking and prescribing services and a HealthSpace for patients (NHS Connecting for Health nd). Connecting for Health is positioned as a critical lever for improving quality in the NHS. Some sceptics are concerned about the ambitious scope of the project and the need to ensure ongoing clinical involvement in its development (Humber 2004).

7.0. Support for quality improvement

7.1. Modernisation Agency

The Modernisation Agency was established in April 2001 in order to support the NHS reforms. The agency's origins date back to 1999, when four initiatives that were struck to improve quality and efficiency in areas of national strategic priority came together: the National Patient Access Team, the National Primary Care Development Team, Action On and the Clinical Governance Support Team.

The Modernisation Agency's goals were to help enhance patient experiences and outcomes, improve access, increase local support, raise standards of care and capture and share knowledge expansively. Some of the agency's most widely recognized work is its leadership and coordination of large, multi-organization collaboratives (especially in the areas of access and wait times, and the development of some of its products, including the Leadership Guides and the 10 High-Impact Changes document). Over a period of four years the agency grew rapidly in size, budget and scope, including over 700 improvement staff, a budget of £200 million and an aim to support a large number of NHS priorities and standards.

Despite its successes and the critical role it played to support quality improvement and provide training to enhance capacity and capability across the NHS, the Modernisation Agency came under heavy criticism. Critics pointed to its excessive bureaucracy and size. They also lamented the lack of clinical engagement or relevance in some of its activities and products, which were seen as largely management oriented, and the lack of real integration and implementation of its activities and programs into service delivery planning at the local level. As part of a review of arm's length bodies, the Modernisation Agency was abolished in 2005 (Department of Health nd f).

7.2. Clinical Governance Support Team

The Clinical Governance Support Team (CGST) was formed in 1999 by the chief medical officer in the Department of Health following the introduction of clinical governance in the Department of Health's consultation document A First Class Service. As of 2001 the CGST was enveloped under the Modernisation Agency. It remained in existence as its own entity following the agency's abolition in 2005.

Clinical governance is defined as a "framework through which NHS organizations are accountable for continuously improving the quality of their healthcare services and safeguarding high standards of care by creating an environment in which excellence in care can flourish" (Department of Health 1998). In an October 2006 presentation, the NHS clinical governance support team observed that, backed by a new statutory duty for quality for trusts, the clinical governance framework emphasized the need to instill quality at a local level and includes several components: patient, public and carer involvement; strategic capacity and capability; risk management; staff management and performance; education, training and continuous professional development; clinical effectiveness; information management; communication; leadership; and team and partnership working.

Over time the function of the CGST evolved, from one of supporting the development of clinical governance across the NHS through board and clinician training and other programs, to one of providing remedial support to low-performing trusts. Some observers remark that this shift in focus was underpinned by the lack of a clear mission, purpose and strategy for the CGST, especially in the context of other support resources and ongoing reforms in the NHS.

Although there are several reports of the successful implementation of aspects of clinical governance throughout the NHS, the extent to which clinical governance is still a dominant framework for improving quality across the system remains unclear. In 2006, the CGST underwent a review by the Office for Strategic Health Authorities. The CGST's future remains uncertain.

7.3. Institute for Innovation and Improvement

Following the Modernisation Agency's abolition in 2005, the Department of Health developed the Institute for Innovation and Improvement. Based at the University of Warwick, the Institute was created as a special health authority (at arm's length from government) to support the spread and uptake of new ways of working, new technology and world-class leadership in the NHS. Learning from the experience of the Modernisation Agency, the Institute operates as a compact, lean organization with 50 staff members and a budget of £80 million. It attempts to leverage the broader healthcare environment and focuses on improving outcomes on a few key national priorities that are agreed upon with the Department of Health: no delays (18-week wait), healthcare-associated infections, primary care/long-term conditions, and delivering quality and value (NHS Institute for Innovation and Improvement 2006a, 2006b).

The Institute is underpinned by specialist competencies in leadership, learning, service transformation, and technology and product innovation. Its primary work centres on identifying innovations and improvements from a number of sources and then co-designing and disseminating high-impact products to support implementation in the field. The Institute has developed a hypothesis-driven problem-solving process for all of its work in creating high-impact, innovative solutions. Figure 4 shows the four distinct phases in the Institute's work process.

[Figure 4]

This design-focused role represents a shift in focus from the roles of the Modernisation Agency and the CGST by coordinating large collaborative initiatives and providing more direct support and capability for improvement. One of the initial reasons for this shift was the belief that there may now be adequate capability to facilitate uptake of such tools in the field as a result of the redistribution of former Modernisation Agency staff and funding across trusts and SHAs. Some observers, however, remain sceptical about the actual extent of improvement capability across the NHS.

Recognizing this, the Institute has begun to test strategies to better leverage and work with leaders and improvement staff across the NHS to support implementation. For example, the Institute recently engaged a former SHA CEO as a "field force" relationship manager to act as a bridge between the Institute and the field.

Appendix A(a). Key government policy papers
Year	Document	Brief Description
1989	Working for Patients	The Conservative government's white paper that outlines a plan to create an internal market and competition in the system through a split between purchasers and care providers and the introduction of fundholding for GPs to allow them to purchase care for their patients (NHS nd b).
1997	The New NHS - Modern, Dependable (Department of Health 1997)	A white paper by the new Labour government that sets out a plan to modernize the NHS. The new approach is "based on partnership and driven by performance." It preserves the principle of a primary care-led NHS but moves away from the internal market and outright competition. The paper outlines six principles underpinning this new approach, including taking quality as a driving force for decision-making at every level.
1998	A First Class Service - Quality in the New NHS (Department of Health 1998)	A consultation document that outlines new initiatives and tools for setting, delivering and monitoring standards for a high-quality, cost-effective NHS. These include NICE, an independent body responsible for providing authoritative appraisal and national guidance; NSFs, evidence-based service models and standards; clinical governance, a new framework backed by trusts' statutory duty for quality and through which organizations are accountable for continuously improving the quality of their healthcare services and safeguarding high standards of care; and the Commission for Healthcare Improvement (CHI), a statutory body established to provide independent scrutiny of local efforts to improve quality and report publicly on the performance of local organizations.
2000	The NHS Plan - A Plan for Investment, A Plan for Reform (Department of Health 2000) Delivering the NHS Plan - Next Steps on Investment, Next Steps on Reform (Department of Health 2002)	This ten-year plan, and its follow-up progress report, helped to bring into focus the government's strategies to modernize the NHS. The plan outlines substantial growth in the NHS budget (i.e., by one half in cash terms) and investments in capacity (e.g., facilities, staff, medical school places); an increase in the number of physicians entitled to discretionary payments in the private sector; and reforms aimed at devolving power from government to the local health service in a system of "earned autonomy." These reforms include PCTs holding the majority of the NHS budget and having the freedom to purchase care from most appropriate provider (public, private, voluntary); national targets, public performance ratings (especially for wait times) and incentives for high-performing local organizations, including administrative autonomy through designation as a foundation trust and consequences for poor-performing organizations, such as executive replacement; quality-based contracts for GPs and cash incentives to physicians for high-quality care; changes in job design, such as extended scopes of practice for nurses and therapists; a Modernisation Agency to provide technical support to spread best practices; a new hospital payment system called payment by results that uses a regional tariff or case-mix system; an integrated and modernized electronic health information system; and better integration between health and social care.
2004	The NHS Improvement Plan: Putting People at the Heart of Public Services (Department of Health 2004)	Building on progress to date to continue the push to meet national targets to reduce wait times, this paper outlines shifts in priorities (to 2008) toward prevention and management of chronic conditions and local target-setting and performance management, especially for high-performing trusts. In addition, this plan outlines additional priorities such as greater personal choice for non-emergency care, an electronic booking system and the right to choose from at least four or five different healthcare providers; an Expert Patients' Programme designed to help empower patients to manage their own conditions; innovations such as NHS Direct (nursing-led telephone advice); and additional IT enhancements, including electronic booking and prescribing services and a HealthSpace for patients.
2006	Our Health, Our Care, Our Say: A New Direction for Community Services (Department of Health 2006a)	This white paper focuses on advancing a vision for better health and social care that "puts people more in control, makes services more responsive, focuses on those with complex needs and shifts care closer to home, while achieving better value for money." Specific actions for change outlined in the paper include: PBC, which gives GPs more responsibility for local health budgets, in conjunction with individual budget pilots to test how users can take control of social care and changes to payment-by-results tariffs to support these changes; a guarantee of registration with a GP practice list and incentives for GP practices to offer convenient opening times and appointments; more care in more local and convenient settings, including the home, by working with royal colleges to define clinically safe pathways within primary care; better infrastructure to support the integrated commissioning of health and social care between PCTs and local authorities; and an increase in the quantity and quality of primary care in under-served and deprived areas, including through the removal of barriers to entry for the "third sector" as primary care providers.

Appendix B. Healthcare Commission performance indicators
Existing:	Access to a GP (not including walk-in centres) Access to a primary care practice (not including walk-in centres) All cancers: 2-week wait All cancers: 31-day diagnosis to treatment Ambulance: category A calls meeting 19-minute target Ambulance: category A calls meeting 8-minute target Ambulance: category B calls meeting 19-minute target Commissioning a comprehensive CAMHS Commissioning of crisis resolution/home treatment services Convenience and choice: facilities in place to support choice Convenience and choice: PCT booking Delayed transfers of care Diabetic retinopathy screening Number of in-patients waiting longer than the standard Number of out-patients waiting longer than the standard Patients waiting longer than 3 months for revascularization Practice-based registers: patients called for review Thrombolysis: 60 minutes call to needle time Total time in A&E: 4 hours or less
New:	Access to genito-urinary medicine clinics Access to reproductive health services Blood pressure Breast cancer screening for women aged 50-70 years Cancer: implementation of NICE IOGs CVD mortality rate (per 100,000) Cancer mortality rate (per 100,000) Childhood obesity: data quality Cholesterol levels Commissioning of assertive outreach services Community equipment Community matrons CPA 7-day follow-up Data collection: referral to treatment waiting times Data quality on ethnic group Drug misusers sustained in treatment Emergency bed days Experience of patients Four-week smoking quitters GP recording of body mass index (BMI) status Infant mortality: breastfeeding initiation rates Infant mortality: smoking during pregnancy Infection control In-patient waiting times: 18-week milestone Number of drug misusers in treatment Number of very high-intensity users Older people's mental health: assessment of needs and services Out-patient waiting times: 18-week milestone Practice-based registers Smoking status aged 15-75 years Teenage conception rates Wait times for MRI and CT scans Wait times for other diagnostic tests

BEN PCT Scorecard indicators by strategic objective
Strategic Objective	Indicator
Efficient use of resources.	Financial balance Non-elective admissions (not maternity, practice-based registers only) Out-patient GP attendances (New OP, BPR only) A&E attendance Achievement of savings plan: BEN PCT combined figure
To be so responsive to the population we serve that no one waits for the healthcare they need.	Access to a GP (not including walk-in centres) Access to a primary care practice (not including walk-in centres) Cancer wait times: 2 weeks, 1 month, 2 months Ambulance: category A calls meeting 19-minute target Ambulance: category A calls meeting 8-minute target Ambulance: category B calls meeting 19-minute target Delayed transfers of care In-patient wait times Out-patient wait times Thrombolysis: 60 minutes call to needle time Total time in A&E: 4 hours or less Patients waiting longer than 3 months for revascularization Access to genito-urinary medicine clinics Access to reproductive health services Waiting times for MRI and CT scans Waiting times for other diagnostic tests
That the health and well-being of our population will have improved so much that people will enjoy 10 more years of quality life, wherever they live.	Diabetic retinopathy screening Four-week smoking quitters Practice-based registers: patients called for review Blood pressure Cholesterol levels Infant mortality: breastfeeding initiation rates Infant mortality: smoking during pregnancy Drug misusers sustained in treatment Number of drug misusers in treatment Number of very high-intensity users Practice-based registers Smoking status aged 15-75 years Emergency bed days GP recording of BMI status
Our communities will be the most involved, informed and empowered in the country.	Number of MRSA infections (primary care) Number of MRSA infections (acute) Convenience and choice: PCT booking Community equipment Community matrons Patients with CHD, etc., who smoke, offered smoking cessation advice Percentage of population served by practices achieving 80%+ QOF points (LAA) Number of patients recruited to Expert Patients' Programme (LAA) Percentage of complaints resolved within 25 days
That people regard us as the first-choice organization to work with and for.	Achievement against HCC core and developmental standards Commissioning of crisis resolution/home treatment services Commissioning of assertive outreach services CPA 7-day follow-up Full-time equivalent staff in post (FIMS workforce return) Older people's mental health: assessment of needs and services

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Chapter 3: Veterans Affairs New England Healthcare System (Veterans Integrated Service Network 1) - New England, US

2008-12-13T19:48:00.000-08:00

Citation Information
Baker, G.R., A. MacIntosh-Murray, C. Porcellato, L. Dionne, K. Stelmacovich and K. Born. 2008. "Veterans Affairs New England Healthcare System (Veterans Integrated Service Network 1)." High Performing Healthcare Systems: Delivering Quality by Design. 71-114. Toronto: Longwoods Publishing.

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The reengineering of the Veterans Health Administration appears to have resulted in dramatic improvements in the quality of care provided to veterans. Many of the principles adopted by the VA in its quality-improvement projects, including emphasis on the use of information technologies, performance measurement and reporting, realigned payment policies and integration of services to achieve high-quality, effective, and timely care, have been recently recommended for the health system as a whole by the Institute of Medicine. (Jha et al. 2003: 2226)

Twelve years ago the Veterans Health Administration (VHA) began the radical transformation process Jha et al. refer to above. What can we learn from the VHA's experience of becoming a high-performing healthcare system? How do the re-engineered processes and improvement efforts work at the regional and local levels?

Method: Exploring a system capable of improvement

To answer these questions, in September 2007 a team of researchers from the University of Toronto's Department of Health Policy, Management and Evaluation visited the Veterans Affairs New England Healthcare System (VISN 1). These site visits were part of an initiative called Quality by Design, which aims to identify and define the elements of healthcare systems capable of improvement with a view to helping to inform strategic investments in improvement capability in Ontario. Quality by Design is funded primarily by the Ontario Ministry of Health and Long-Term Care in partnership with the Department of Health Policy, Management and Evaluation based at the University of Toronto.

VISN 1 was one of five healthcare systems selected from a short list of high-performing systems nominated by a panel of international leaders and experts. The research team spent time at the VISN 1 headquarters in Bedford, Massachusetts (MA), as well as at two of the network's medical centres: the VA Boston Healthcare System (VA Boston) in West Roxbury, MA, and the VA Medical Center White River Junction (WRJ VAMC) in White River Junction, Vermont. At each site the team met with and interviewed administrative and clinical leaders, and improvement team leaders and members as well as support staff members working to make improvements. This case study highlights the findings of the site visits.

VISN 1 and its environment

VISN 1 is one of 21 Veterans Integrated Service Networks (VISNs) across the United States (US) that provide healthcare services to American veterans. Through its network of eight medical centres, more than 35 community-based out-patient clinics (CBOCs), six nursing homes and four domiciliaries (residences for sheltering homeless veterans and for the treatment and rehabilitation of veterans needing such care), VISN 1 serves over 237,000 of the 1.2 million veterans in the six New England states (see map, Figure 1). With 1,895 in-patient beds, VISN 1 handles over 23,000 hospital admissions as well as 2.4 million out-patient visits per year (US Department of Veterans Affairs 2007a). (See Table 1 for a glossary of abbreviations.)

The VHA's mission - "Honor America's veterans by providing exceptional health care that improves their health and well-being" - encompasses patient care, education of health services providers, research and support for disaster response (US Department of Veterans Affairs 2007b). This is a special patient population that evokes strong values when staff members describe their work; these people regard caring for veterans as a noble mission (VA Medical Center White River Junction 2007). As VISN 1's chief medical officer observed, "Vets are wonderful patients, very patient with teaching and the residents."

Table 1. Abbreviations used in this case study
ACA	Advanced clinic access
CBOC	Community-based out-patient clinic
CECS	Center for the Evaluative Clinical Sciences, Dartmouth Medical School
CPG	Clinical practice guideline
ED	Emergency department
EPRP	External peer review program
IHI	Institute for Healthcare Improvement
NCPF	National Center for Patient Safety
NQSFP	National Quality Scholars Fellowship Program
PDCA	Plan-Do-Check-Act
QI	Quality improvement
QMO	Quality management officer
RCA	Root cause analysis
VA	Veterans Affairs
VAMC	Veterans Administration Medical Center
VHA	Veterans Health Administration
VISN	Veterans Integrated Service Network
WRJ	White River Junction

Staff members' positive regard appears to be reciprocated. Patient surveys reflect high satisfaction levels with the overall quality of care: in a 2006 survey, 83.6% of out-patients and 81.1% of in-patients rated overall quality as "very good" or "excellent" (VA New England Healthcare System 2006a).

The veterans present a challenging set of needs and circumstances. "We really do take care of the poor," said VISN 1's network director. Veterans' average salary is lower than that of civilians outside the VA and the military. Between 35% and 40% of the homeless in the US are veterans; consequently, the VA healthcare system often acts as a social safety net for these people (Kizer et al. 2000). How this safety net is funded and what kinds of care are covered are somewhat complicated issues and have varied over the years.

The Veterans Equitable Reimbursement Allocation (VERA) system distributes care funding to VISNs for different categories of patients. As a priority, all service- and combat-connected conditions are covered, as is the care of other enrolled veterans. If a veteran has private insurance, the VHA can bill the insurer (but not Medicare/Medicaid) for care provided for conditions not related to military service. In the past, not all potential billings were collected; centres have therefore implemented initiatives to streamline their billing processes to increase third-party billing revenue.

[Figure 1]

A proportion of the veteran population chooses to seek medical care outside the VHA. These people may, however, still take advantage of the system's drug benefits. VISNs are accountable for tracking the care and outcomes of such "co-managed patients." As a result, VA physicians are responsible for getting information about such care, data that are then entered into the VHA's electronic health records.

"A profound change": Improvement in an integrated system

VISNs were established in the mid 1990s by then-Under Secretary Kenneth Kizer, architect of the VHA's massive re-engineering (Kizer 1995, 1996). The VHA has undergone "a profound change" from being a hospital care system to becoming a health care system (VISN 1 chief medical officer). In other words, the VHA transformed from a very acute care-centric model dominated by individual hospitals to an integrated regional system that emphasizes primary care in the community.

Since 2000, Dr. Jeannette Chirico-Post has been VISN 1's network director (prior to that, she was its acting medical director and acting network director). Chirico-Post has been with the VA for 32 years. In the 1980s she ran VA Boston's quality program and was a member of an early VHA performance improvement committee under Kizer. Chirico-Post reflected on Kizer's style and, with a smile, recalled his "I'll give you the tools, now go away and do it" approach. The Kizer principles fit with Chirico-Post's own philosophy, for example, an emphasis on care in the community. Chirico-Post therefore started working from day one on primary care, because it offered "the biggest bang for our buck" due to duplications and gaps in care processes.

Consistent with Kizer principles emphasizing national regulations, standards and practice guidelines, VISN 1 has adopted standardization and systematization as its watchwords. Teams in the medical centres working on clinic access and patient flow processes have made strides in reducing wait times and missed appointments (see later section on the VA Boston initiatives and graphs in Appendix A). From her systems view of the network, Chirico-Post described local examples of patient access and flow problems, as well as equipment and process issues that VISN 1 continues to address - including, for example, the distances that some veterans must travel for radiation therapy.

The network structure presented opportunities to streamline and rationalize supports, including equipment, throughout all levels of care. Standardization also continues to provide several benefits; for instance, it promotes safety and saves resources. With standardized infusion pumps and defibrillators, for example, VISN 1 has to offer only one training course instead of multiple courses tailored to specific models. It is also easier and safer for staff members to move around within the system when they are familiar with the equipment. This flexibility is particularly important because the VISNs' mission also includes disaster response support in the event of local and national emergencies.

Service lines

Based on analyses of patients' needs and the services they used, care delivery was organized into five clinical service lines that are integrated across VISN 1:

Primary care
Specialty and acute care
Mental health care and behavioural science
Spinal cord injury care
Geriatrics and extended care

Four support service lines include sensory and rehabilitation care, information management, business office and local management at the eight medical centers (Figure 2). Patients are assigned to primary care teams that coordinate their preventive care, disease management and referrals within the continuum of care, as required (VA New England Healthcare System 2007).

Within each service line, local service line managers report both to their chiefs of staff and facility directors, as well as to a network-level service line director. In-patient nurses report to facility nursing directors, while out-patient and community nurses report through their service line managers, individuals who are also responsible for day-to-day operations. Credentialing and certification of clinical competencies fall under the central nursing structure.

A variety of meetings are held to facilitate communication within and between service lines. Each service line has its own executive committee and regular meetings. Service line directors, nurse executives and chiefs of staff for all eight medical centres meet monthly as the Clinical Leadership Committee (see network committee structure in Figure 3). This gives them a chance to hear presentations (e.g., about improvement initiatives) and to "rub shoulders," as VISN 1's chief medical officer explained.

Although creation of the VISNs decentralized decision-making from the national level to regional networks, VISNs also had the effect of centralizing budgets and integrating planning within the network structure. Network leaders commented that the restructuring has not always been easy and it has taken a while to develop the VISN 1 organization with roles and responsibilities matched to current needs. VISN 1's leaders undertook a year-long self-examination and realigned roles, responsibilities and power distribution in order to address more effectively the network's operating environment.

[Figure 3]

Performance measurement and accountability

When he established the VISNs, Kizer also introduced stronger accountability, with an emphasis on standardizing and quantifying performance. "What Ken did for us was to ensure that from Caribou to California we were doing the same thing," observed Chirico-Post.

Kizer believed in stretch goals and setting targets for all to meet. Detailed performance contracts with agreed-upon goals and standardized measures were implemented first between VHA headquarters and the network directors and program officials. Now, there are similar contracts throughout all levels, right down to local service line managers within the facilities. Each network monitors a basic set of measures for the same elements of quality, cost and access: "We know from June '07 what the basic contract for '08 will look like" (Chirico-Post). When they began in the 1990s, they worked with 20 measures. "Now we are tracking hundreds" (Chirico-Post). The number of measures used reflects evolving views in the VHA about organizational priorities and the range of issues that can reasonably be managed.

VISN 1's quality management officer (QMO) is responsible for preparing and disseminating performance measurement data through the system. Each of the network's medical centres has a quality manager, most of whom have a nursing background. All quality managers at the centres and the network QMO have monthly conference calls and they meet face to face on a quarterly basis. VISN 1's QMO also works with a network performance improvement committee that was formed in order to track and analyze performance data more effectively and to make recommendations for actions that support the senior leadership team. As an example of its work, the performance improvement committee redesigned VISN 1's scorecard under the leadership of one of the network's service line directors. The quarterly reports include an array of in-patient and out-patient clinical, process and satisfaction measures (see Appendix B). Approximately one third of these measures relates to wait times and missed appointments, indicators that are linked to national access goals.

Indicators are derived from data collected from chart audits carried out by the VHA External Peer Review Program (EPRP) (US Department of Veterans Affairs 2001) (see Figure 4). Through the national EPRP, third-party reviewers audit a monthly sample of electronic and paper records in all VA medical centres. These reviewers scrutinize preventive indicators and clinical practice guideline compliance, such as HbA1c control in diabetes management or timing of prophylactic antibiotic administration in surgery (see examples of results in Appendix C). VISN 1 has a full-time analyst who prepares the reports (not all networks have invested in such a support position). In addition to the VISN scorecard, each service line has standardized monthly reports that focus on a "vital few measures" relating to quality, revenue and cost. They also include a description of what the service line is doing to add value to the service line and for its affiliates. The power of the service line structure, VISN 1's chief medical officer said, "is that it allows clinical disciplines to be focused and develop metrics of excellence specific to the service line."

The performance measurement system figures dominantly in any conversation about quality and improvement in VISN 1. Discussion invariably circles back to performance review of the measures and targets on the quarterly comparative scorecard, the "Christmas tree report," a nickname derived from the gold, green and red flags for scores that exceed, meet or fail to meet targets. The VHA's national office sets performance targets for all the performance measures. In addition, it establishes a "floor." If any facility does not meet the "floor" target, the network fails the measures.

[Figure 4]

VISN 1's director and QMO meet quarterly with facility directors to go over their Christmas tree reports. The QMO emphasizes improvement over compliance in discussions of action plans. He finds out from high-performers what they are doing well and generates a lessons-learned list that he circulates across the network. "My concern," he reported, "is improving. How do we get to the next level of performance?"

The VISN 1 service lines also conduct quarterly reviews with the intent of discussing and capturing improvement opportunities arising from the reports. The QMO noted that "the point is that any measurement system needs to focus on meeting the target as a marker of good clinical care. It should be about the care, not about the numbers."

VISN 1's service line directors use the quarterly reports to review the performance of all local service line managers. Outstanding performance is defined as being better than the national and the VISN average. A facility director can overrule the performance review decisions of the service line directors; however, that rarely happens. One service line director noted, "You have to make the metric. ... The metric part of the job is not negotiable." Service line directors hold monthly meetings with managers and telephone conversations with each one individually. Near the end of 2007, one service line director explained that he was focusing on measures that were close to the target (one percentage point away) because he could "push those over the edge." He said he had deferred working on tobacco counselling, for example, because he could not influence the more than 20% gain that would be required by year-end. However, he was working on the system issues behind that measure, discussing with managers what was going on and how to fix the process during the upcoming reporting year.

About 60% of the indicators are new each year and/or targets are changed. Some measures count for the whole year and some relate only to a specific quarter, such as immunization rates in the winter quarter.

Information technology: Electronic medical records and clinical reminders

The VHA is a recognized leader in the implementation of information technology that has enabled both indicator measurement systems and coordinated patient care management. Nationally, the VHA's clinical patient record system (VistA) won the 2006 Innovations in American Government Award presented by the Ash Institute in Harvard University's Kennedy School of Government (US Department of Veterans Affairs 2006e, 2006f).

Setting the same standards and using electronic health records have been central to integration throughout the VISNs. In VISN 1, for example, early in her tenure Chirico-Post recognized the importance of standardizing information technology across the network. As a result, between $25 million and $30 million were set aside for new computers, which enabled the move to electronic health record-keeping. There was some initial resistance to mandatory electronic charting; however, VISN 1 staff members did make the switch, although dictation of operative notes and discharge notes is still allowed.

The VHA's electronic record system made possible the implementation of clinical practice guidelines (CPGs) and clinical reminders, which are mandated for primary care by the CPG committee and reminders subcommittee. The same requirement was then applied to mental health and specialty and acute care (e.g., for acute myocardial infarctions). The VHA's Office of Quality and Performance develops clinical practice guidelines for the system (US Department of Veterans Affairs 2006d, 2007d; see Appendix D for a description of their functions). In VISN 1, the goals are to standardize reminders across the eight sites and to reduce reminder overload. A service line sponsor and subject matter expert is assigned for each reminder that is developed. The system can produce reminder reports by provider within each facility and make comparisons across centres. The reminders and positive feedback help to improve clinical care. They also encourage a bit of "healthy competition," the program manager noted, because no one wants to be seen as not responding to reminders.

The reminder system is so well advanced that the VISN has reached a saturation point, prompting the need to explore new approaches to continue to improve compliance with guidelines. For example, the VISN is considering use of support staff rather than physicians to carry out preventive care with patients, such as checking immunization status. The reminder program has been very successful: since the inception of the program in 2004, VISN 1 has been first or second in the VHA primary care performance measures.

Electronic medical records and physician accountability

The use of electronic medical records is an important factor facilitating physician accountability. "Our ability to do performance measurement, monitoring, physician accountability [and] workload measurement is all grounded in the electronic medical record. How you would do this without it, I don't know," commented one service line director. "If it's not all integrated it loses a lot of its power. ... The clinical information system can produce information that the decision support system can't."

The VHA has developed a standardized staffing model for all primary care clinics. A VHA advisory group on physician productivity and staffing (chaired by VISN 1's chief medical officer) developed strict business model guidelines for and definitions of what constitutes a patient panel, and used a combination of number of exam rooms, number and types of support staff and patient mix to determine expected or model panel sizes. It is now possible to carry out sophisticated studies of the relationships between panel size, quality, access and patient satisfaction. This innovation also helps to reduce variation.

Most VISN 1 physicians are salaried employees, although some are on contract and may be paid on a fee-for-service basis, especially in scarce specialties such as neurosurgery, obstetrics and gynaecology. An element of pay-for-performance is included in the physician reimbursement plan if a physician meets performance targets, such as quality measures or access. The incorporation of pay-for-performance is seen as only part of the solution to improved performance.

Clear goals and performance measures

Chirico-Post summed up VISN 1's improved performance thus: "My legacy: when we started we met one third of the performance measures. Now we are in the top tier of percentage met."

VISN 1's leaders emphasized the importance of articulating clear goals. Early on, the senior leadership team set a goal of clinical and research excellence, wanting to be number one. "We wanted to be the leading academic network in the country, measured by the number and value of research grants," the chief medical officer noted. "We are a leading academic program in spinal cord injury and we are a leader in mental health." This position helps with staff recruitment because it draws top investigators and clinicians to the network.

How do local centres deal with national and network expectations? Implementation tensions and adjustments

While VISN 1 has demonstrated significant gains, there are tensions inherent in how integration, standardization and performance measurement have unfolded within the system. VISN medical centres are by no means homogeneous; neither are their approaches to improvement. Individual centres have had their own struggles with how to implement the nationally mandated performance measures and standards. The experiences of VA Boston and WRJ VAMC illustrate these challenges. As part of a large, complex, hierarchical system, their facilities' leaders have found ways of adapting the system's requirements to fit with strategies they believe are needed to meet local population needs. With characteristic good humour, WRJ VAMC Director Gary De Gasta summarized the challenge: "How do we do what we need to do in the context of a national organization where we do share the same goals, but where we sometimes need to do something a bit different - and not get into trouble!"

VA Boston

VA Boston, the largest consolidated facility in VISN 1, encompasses three main campuses and six out-patient clinics within a 40-mile radius of the greater Boston area. The consolidated facility consists of the Jamaica Plain Campus, the West Roxbury Campus and the Brockton Campus (US Department of Veterans Affairs 2007e). VA Boston grew out of the integration of two large centres in 2000: Jamaica Plain and West Roxbury/Brockton (the latter the result of an earlier merger in 1983). "At integration it was really hard; we started from zero because we didn't have common quality programs," commented the associate director of nursing. "We needed to rethink two very different sets of organizations, processes and cultures," said the quality manager.

VA Boston's current approach to improvement incorporates the VHA and VISN performance measurement system. It also includes formal change initiatives, such as participation in collaboratives run by the Institute for Healthcare Improvement (IHI).

Performance measurement

VA Boston is responsible for the same basic mix of population health measures as other VISN 1 facilities, including immunization rates and percentage of patients who smoke, as well as clinical process, access and patient satisfaction measures. Director Michael Lawson asserted, "You need some mandatory measures and to hold people accountable for them."

But use of the measures and other means to stimulate performance have changed over time, as the organization has come to understand better what motivates its employees. For example, VA Boston leaders debated the merits of financial rewards for compliance with the required measures. The chief of staff argued that reimbursement mechanisms can be a powerful incentive. In the last year, the centre introduced an element of pay-for-performance for physicians, a $1,500 bonus for meeting some percentage targets. Director Lawson did not see money as the only motivator: "If the only leverage you have is money, you are in a very difficult situation. ... Culture is important - pride in doing things well." The chief of staff concurred, "It is the performance measures and the information and feedback to people in the right culture, where people care." He continued, "The Hawthorne effect is very important; when you measure something, people pay attention." However, the performance measure review at the local level can, one senior leader noted, generate "pressure and competitiveness; no one wants to be on the lowest rung." Lawson said, meanwhile, "We know who is number one and where we are; we are very competitive and we want to do better and be the best."

With regard to the development of the measures themselves, the chief of staff commented that most staff members understand intuitively the literature and evidence behind the measures. Some disagreements do arise: for example, the monotherapy guideline for hypertension was not perceived to be correct (some patients and physicians were reluctant to add a medication if a patient's blood pressure was stable) and an antibiotic guideline for patients presenting with pneumonia was not seen to be working; as a result, these guidelines will be reviewed.

Evidence-based reviews and the flexibility to re-examine performance measures over time are important factors that have encouraged acceptance of performance measures. Centrally developed evidence-based directives must be locally adapted for implementation. "It is 10 years into performance measurement and we are still getting to agreement," summed up one senior leader. VISN 1's QMO noted that "the overarching issue is for the organization to achieve balance between the art and science of medicine; some measures ... will ... have more evidence than others and some patients' conditions are complex enough to not fully match a given guideline. Also, there are technicalities with how measures are defined, gathered, etc., so that a couple to a few each year get pulled or modified to work out details."

The measures continue to evolve, expanding to include development of nursing-specific indicators. VA Boston is a pilot site for the VA Nursing Outcomes database. The system will, for example, soon provide national comparative data on decubitus ulcers, medication issues and falls. Currently, unit managers have a quarterly report card with these measures reported by unit, which they review with their staff members (see Appendix E). The nursing measures are reported to VA Boston's quality manager as part of its quality improvement (QI) plan.

Implementing changes

Adaptation, monitoring and review of the measures are preliminary steps in the performance measurement system; changes must be implemented to achieve improvement. VA Boston leaders invest to make changes when services or clinics demonstrate need based on the measures. For example, the dermatology clinic management staff and clinical leaders maximized process improvements to reduce wait times, which allowed for a more accurate supply and demand analysis that demonstrated the need for more staff members (who were subsequently hired).

VA Boston follows systematic processes to implement changes and make improvements. Teams apply an evidence-based approach, noted the associate director of nursing: "We make changes based on what is in the research literature." According to the quality manager, "The big change in approach that allowed improvement in the performance measures was assigning teams and supporting them, and the encouragement." The VA Boston system pays a lot of attention to how teams and committees operate in order to promote efficient and productive meetings that make good use of staff time and enthusiasm. The need for staff involvement is discussed with managers in advance to ensure their understanding and support for staff participants before projects are launched. Four different nursing unions represent VA Boston staff, a situation that can present challenges for improvement efforts. Earlier, unions required that changes to work processes that were perceived to affect job responsibilities be negotiated in advance before the changes were even tested; however, this has become less of an issue over time.

"We are very thoughtful about who we select for physician leaders and participants, and we are also very clear about endpoints and expectations. We are very clear about who we want, why we want them and what we want them to do," the quality manager commented. Most physicians are employees and are part of the system, which sometimes makes a difference in physician engagement, but the issue is not payment structures alone. "Some of my most enthusiastic members are fee-for-service [physicians] ... who see where the improvements can be made."

Project team processes are designed to respect staff members' time and to use their talents; this design encourages participation. The chief of staff (or associate) and the quality manager meet once a year with each committee chair to find out how things are going, whether there are any issues and how they can support the committees' work.

Lawson advised, "Pick demonstration projects and start where there is some promise." He cautioned that implementing best practices may be problematic, as changes have to be tailored locally. "What works in Boston may not have a chance in Maine."

Participation in IHI improvement collaboratives

VA Boston's formal change efforts include multi-centre collaborative improvement projects. The centre has a long history of participating in IHI Breakthrough Series collaboratives. VA Boston teams have participated in the access collaboratives since 1999 and have engaged in several each year for the past five years, including collaboratives on flow, patient medication safety and transforming bedside care.

The influence of the IHI methods and the rapid cycle model for improvement are pervasive in the centre, which emphasizes interdisciplinary teams and action plans. "It's always 'What are you going to do by next Tuesday?' (an improvement mantra derived from a talk by Don Berwick). Rapid cycle methodology made so much sense and was intuitively appealing to the front-line staff and teams," the quality manager said. All management team members (i.e., service chiefs and senior leaders) have been trained in rapid cycle methods, change concepts and improvement strategies. Team members are taught how to map their current processes and the concepts of value stream mapping. They use rapid cycle improvement methods, planning and testing change cycles. The goal is to have the actual teams do the work; they therefore emphasize short meetings or 15-minute huddles and do as much as possible by e-mail.

Although many network facilities participate in IHI collaboratives, the extent of VA Boston's involvement in IHI initiatives is somewhat unusual within VISN 1. This is a strategic investment and significant commitment due to the cost of IHI collaboratives, which average $20,000 a year plus travel per team. As the quality manager commented, "We always take our whole team to the collaborative meetings, plus the leadership sponsor; it signals the importance [of the initiatives]."

Access collaborative

In 1999 the VHA began a major national initiative with the IHI to improve patients' access to out-patient clinics by reducing wait times for appointments (Institute for Healthcare Improvement nd; Parlier 2003). "It took about a year before we saw dramatic results locally. ... Within two years we were at the top of our VISN and within three years we were in the top three nationally. ... At the start our actual [performance] was 60 to 90 days, and our current is 14 days and we are working towards open access," recollected the out-patient access coordinator.

The VA Boston access coordinator is the medical centre's local point of contact with the national advanced clinic access (ACA) initiative. She works alongside physician champions with the centre's ACA steering committee and participates in VISN-wide meetings. Their work with specialist clinics has been a success. In the access coordinator's words, "Even in orientation, new medical staff are told what the expectations [on access] are, and that delays are not acceptable."

The access team identified an initial list of about 10 high-volume, high-priority clinics, such as primary care, cardiology, audiology, surgical, mental health and orthopaedics. Based on that experience, the team is now expanding the initiative to the top 50 clinics. A clinical champion and an expert in advanced clinic access were identified for each clinic, and the committee set an access goal that patients will have an appointment to be seen within 30 days.

By focusing on what can be done, staff members become more engaged in accomplishing goals. If staff members say, "'No, we can't do that,' we ask, 'Okay, what can you do?'" said the access coordinator. The team also pairs similar clinics so they can learn from the experience of the ones who have been successful. "The whole VHA system is open to sharing accomplishments and tools," and because they share components of the information systems teams "do not have to start from scratch."

VA Boston's access collaborative teams follow the IHI Breakthrough Series model, especially its data requirements, although the data and information commitment can be very demanding. Over time, local data systems have become more flexible, reducing the need for "stubby pencil" work. "It can be hard to get the team members to stop and gather the data and measure and huddle, but once they see results it helps," noted the access coordinator.

Across the 21 VISNs there have been national-, network- and local-level collaboratives on access. By meeting together on a network-wide basis, audiologists, for example, were able to share ideas for changing the design of their audiology clinic processes.

Improving patient flow

VA Boston is one of the most successful participants in the IHI Breakthrough Series flow collaborative. As the largest acute care centre for VISN 1, VA Boston was under pressure to improve patient flow; the centre therefore joined the IHI initiative in 2002. Currently, VA Boston has flow teams working on in-patient, operating room, emergency department (ED) and long-term care flow issues.

Among VA Boston's West Roxbury units, the ED was one of the first areas to start and has also been the most successful. Their results:

No ambulance diversions in 16 months
Less than 1% of patients leave without being seen
Average wait from triage to disposition: 2 hours and 53 minutes
Exceed the IHI goal of less than one hour from decision to admit to admission to an in-patient bed

The West Roxbury units achieved these results by developing standardized order sets and implementing a fast-track system to handle less complicated patients. Initially, not all the changes were readily accepted: "Redesign was vigorously resisted where it was seen to interfere with clinical autonomy," noted the ED medical director. The ED information system provides the data needed to monitor productivity; West Roxbury's leaders were therefore able to show staff that changes were leading to improvement. As the nurse manager commented, "Data speaks volumes" and was sufficient to persuade most staff members. Even at that, some among the medical staff did not immediately recognize the benefit of seeing the fast-track patients, preferring not to interrupt their focus on the more acute patients. The ED flow team moved the fast-track room to the front of the computer terminals as a way to heighten awareness of the fast-track patients and their needs. In addition, staff members call the few patients who leave without being seen the next morning; patients are pleased and surprised by this attention.

The ED leaders commented that the flow team has made a real difference in ED culture. ED staff members brainstorm ideas, develop implementation plans and try them out the next day. Everyone involved has a say and all staff members vote on priorities, based on the ideas that are within their control to implement and that are a priority for their patients.

The in-patient flow coordinator and the out-patient access coordinator are looking at forming a joint steering committee to focus on the linkage and coordination of in-patient and out-patient flow and access issues and changes. This will create a more comprehensive system redesign committee.

Patient safety

VA Boston has been involved in a variety of patient safety initiatives for some time. "We have been ahead of the curve because we started in advance voluntarily, before we were required to," noted the Patient Safety Committee chair, a cardiovascular surgeon. Boston was a pilot site for medical team training and briefings designed by the National Center for Patient Safety, as well as IHI's perioperative safety program.

The Patient Safety Committee also oversees the implementation of the IHI 100k Lives initiatives, which have presented a variety of challenges. "None of this was easy," observed a cardiologist member of the team. The physician leaders emphasize the importance of letting everyone discuss proposed changes, noting "eventually you have to move on and implement." The Patient Safety Committee chair recounted the example of glucose control for surgery patients, saying it took a year to implement a modified Portland protocol. "You can't eliminate individual variation and make everyone follow one protocol." Data on the Portland outcomes were stressed as important. All involved staff members were part of the change process, and some variation was allowed in how they got there. Now glucose levels are controlled for 94% of in-patients.

Participants emphasized that, at times, the improvement work could be very challenging and taxing for everyone involved. "The changes were not all smooth. There were a lot of blood, sweat, and tears," laughed the patient safety coordinator. "But now people say 'may as well do it because it will be required in a few years.' That's a real change."

Resident training: Patient safety and QI rotation

VA Boston is affiliated with both Boston and Harvard universities' medical schools and 500 to 600 residents per year complete six-week clinical rotations at the centre's facilities. In 2006 VA Boston's General Internal Medicine program started a new patient safety and QI rotation as an optional elective open to approximately 12 third-year residents per year. The hospitalist who designed the program with the patient safety coordinator commented that physicians tend to be trained in individual decision-making as opposed to systems thinking, noting that, "It's not fair to expect people to be involved in quality and patient safety if we don't train them in it."

The one-month rotation integrates patient safety and QI education with clinical time in subspecialty clinics. Residents review charts of in-patients for whom they have cared prior to starting the elective, tracking their post-discharge care to look for any iatrogenic complications and care issues as well as changes they could make to their own practices. As an example, the in-patient discharge record was changed to record impending issues. Residents participate in root cause analysis (RCA) reviews and patient safety meetings and also learn about the Joint Commission national patient safety goals and healthcare failure modes and effects analysis.

Staff and patient satisfaction

According to the quality manager, "We spend a lot of time and effort working on staff satisfaction. ... We have very high staff and patient satisfaction. VA Boston was second in the All Employee Survey results for VISN 1, "which is huge, because we were at the bottom seven years ago. In nursing, we are one of the best in the nation," observed the associate director nursing/patient services.

There is a strong emphasis on customer service at VA Boston, spearheaded by the efforts of the Customer Service Committee, formed in 2004 based on needs staff members identified during annual priority planning. The committee has worked on a variety of issues, ranging from improving signage and directions for patients and visitors to arranging for beepers for patients with prolonged care or clinic delays. Committee members review patient satisfaction survey results and patient complaints, and canvas staff for suggestions. There is also an ambassadorship program in which patients are met and greeted in waiting areas. In the past three years, all VA Boston employees have been required to go through customer service training based on a standard program provided by the VISN. In recognition of these efforts, the centre won the 2007 VHA Comprehensive Facility Customer Service Program Award.

White River Junction VA Medical Center, Vermont: A strategic approach to improvement

The WRJ VAMC is a rural, 60-bed primary and secondary care medical centre affiliated with the medical schools at Dartmouth College and the University of Vermont (US Department of Veterans Affairs 2007f). Under Gary De Gasta's leadership it has forged a strategy-driven path to improvement developed over almost 20 years.

In 1994, in a move that predated the VHA's re-engineering initiatives, De Gasta invited Dr. Paul Batalden to help the senior leadership team develop a strategic framework to guide the organization. Batalden is an internationally respected expert in improvement who leads the Health Care Improvement Leadership Development group in the Dartmouth Medical School's Institute for Health Policy and Clinical Practice (formerly Center for the Evaluative Clinical Sciences [CECS]) (Dartmouth College 2002a). Monthly working sessions took place for over two years, building insights that resulted in a profound understanding of White River Junction as a system capable of improvement (Batalden and Mohr 1997; VA Medical Center White River Junction 2007). Batalden insisted that each of the facility's leaders had to take ownership of and personally lead one of the four strategic themes that were identified. Despite initial resistance, WRJ VAMC's senior leadership team took on that task, demonstrating strong constancy of purpose over the years in the face of continuous changes in their environment. "It has created a frame to allow the conversation about quality to happen, and Gary has sustained the focus and the interest in that," Batalden noted.

The conception of WRJ VAMC as a system capable of improvement is compatible with business excellence frameworks such as the Baldrige National Quality Program (2007). The VA's Robert W. Carey Performance Excellence Program, based on the Baldrige criteria, was established to

recognize organizations that have implemented exemplary approaches to systems management that achieve excellent results for America's veterans. The foundation for the awards is the Malcolm Baldrige Criteria for Performance Excellence. These criteria are designed to help organizations use an integrated approach to organizational performance management that results in:

Delivery of ever-improving value to customers and stakeholders, contributing to organizational stability;
Improvement of overall effectiveness and capabilities; and
Organizational and personal learning.
(US Department of Veterans Affairs 2006c: 3)

Not surprisingly, therefore, embarking on the Carey self-assessment process was a logical next step in WRJ VAMC's growth as a learning organization. By 2002 the centre had conducted its first Carey Program organizational assessment and received its first Carey Achievement Award. That experience has formed the foundation of a continuous cycle of self-assessment and recognition:

2003: 2nd Carey Award and Vermont Governor's Award
2004: Carey Trophy Award and 1st Baldrige site visit
2005: First VA Circle of Excellence Award and 2nd Baldrige site visit
2006: Second VA Circle of Excellence Award

In 2007, WRJ VAMC completed its 11th and 12th cycles of Carey and Baldrige applications. "I think it gives us a structure in an environment in a constant state of flux. We have no consistency, so this is the one consistency," remarked De Gasta. "It all fits: the six process chapters and the one results chapter. ... Baldrige involvement has been a big contributor to our financial solvency," he added. However, De Gasta explained, there is a cost to the work involved and the resulting feedback process: "It is so painful to get the feedback report that we ask ourselves every year should we do this. But the opportunities for improvement [identified by the examiners] are rarely a surprise. Two thirds are things we knew about and one third are things we failed to communicate well enough."

A service line director also emphasized the continuity provided by the strategic frameworks:

Adopting the one approach started with Batalden and now continued with Baldrige has been important. ... Over the years we have continued to grow this one process, this pathway. ... During turbulent times we didn't change our process, we stayed with it. We've tried lots of new things, but we put it in that same framework. You start to see that there are places for the entire organization in the Baldrige criteria; by the time you get to chapter seven, you see how it all contributes to quality. ... We've learned that you don't implement a change today and see results tomorrow; it's been a long process for us, over 10 years.

The "turbulent times" referred to by several staff members included a period from 1997 to 1999, when the quality of WRJ VAMC's surgical services was called into question. While an external review showed that the quality was good, the next challenge asserted that it would be less expensive to contract out the services (another external consultant study showed that this was not the case). These challenges were traumatic for the centre and provoked an exodus of medical staff members, from which it took several years to recover.

It is relatively more difficult for an entire network (than a single facility) to be successful in these award review processes. VISN 1 has also adopted the Baldrige framework and uses the principles as the model for its governance committees (VA New England Healthcare System 2006a). The network won a VHA Kizer Quality Achievement Recognition Grant in 2004-2005 and used the award money to fund improvement initiatives in the network facilities (US Department of Veterans Affairs 2006b). Medical centres and community-based out-patient clinics submitted project applications to VISN 1 headquarters, and Dr. Chirico-Post decided to fund all 31 projects by supplementing the Kizer award funds. Although VISN 1 submitted another application in 2007, the network did not advance to be considered for the Carey awards.

Local versus national performance measurement

WRJ VAMC leaders have had to translate the VHA performance measures to fit the Baldrige/Carey framework. The centre balances the expectations and structure of the national/VISN performance measures against its own organizational strategic theme-driven measures and reports. WRJ VAMC has been obliged to manage the national performance measurement system to some degree, while managing by its own report card process. "Performance improvement really came into play when Ken Kizer said, 'No, show us how you are doing.' ... His efforts really changed the face of the VA," noted De Gasta. "'BK' (before Kizer) we had no measures; we said we were good but we didn't really know. 'AK' (after Kizer), we have lots of measures, but we are still not there yet."

De Gasta observed that WRJ VAMC had developed its own performance measures and "stoplight report" before the VA "kicked up the performance measures and we got a lot more." Now it is responsible for hundreds of measures, an obligation that some leaders find difficult to manage. WRJ VAMC therefore developed a strategic themes stoplight report to focus on the important clinical, financial and satisfaction measures (Figure 5). For example, the centre's quality manager noted that on the VISN Christmas tree report there are no employee-related measures, which WRJ VAMC leaders felt were critical. Spurred on by the Baldrige criteria, they added position vacancy and injury rates as measures. Likewise, neither the Christmas tree nor the national performance reports contain measures of ethical performance or community image; therefore, the quality manager said, "we took on more measures over and above those required of us." WRJ VAMC decides which of the 20 to 30 measures in each category are important in relation to the strategic themes. (Each theme includes five or six sub-themes, and some sub-themes are a combination of multiple measures.) The governing board's executive committee then decides which measures are the most critical. "Each year we tweak the list of measures at our annual retreat," reported the quality manager. The goal for WRJ VAMC leaders is to complement the national measure set and align it with local priorities.

Several years ago WRJ VAMC was at the bottom of the VISN Christmas tree report, which required that centres meet at least 80% of all VISN measures. WRJ VAMC executives began a First Friday meeting to discuss with all process owners how the organization was doing and what could be done to improve. Staff members attend these meetings with Plan-Do-Check-Act (PDCA)-type action plans and give progress updates. The chief of staff commented on the collaborative nature of the discussions, noting that "The interdisciplinary discussion of the measures across service lines is valuable." For example, the director supported a system change idea (appointing a new case manager) to help the centre meet multiple performance measure requirements for in-patients, such as smoking cessation counselling and primary care prevention. Measures are also discussed with front-line staff members at staff meetings.

[Figure 5]

"We were pretty well prepared when the focus on measurement came down from the VA," the WRJ VAMC chief of staff remarked. "The philosophy of support from leadership has been key." He recounted how he had "put a team together for every single measure we were responsible for, whether we were doing well or not. I didn't trust the data, so I thought it was safer to work on everything to improve." WRJ VAMC has a mix of more formal project teams; however, QI is integrated into day-to-day operations. "Primary care is probably our most mature, established product line and we have spent a long time trying to do that one thing the best we can. Lots of improvements and standardization have taken place." Examples of other local improvement initiatives include the Care Coordination Home Telehealth program and the Stop Workforce Accidents Team (SWAT) (see Appendix F).

"Over the years we have moved up in the VISN Christmas tree so that we are in the middle and achieve over 80%," reported WRJ VAMC's quality manager. "The difference between a number-one VISN and number eight may be miniscule, but in the eyes of the VHA, if you are number one [in the performance measures], you are number one," said De Gasta. "Would I like us to be number one in those measures? Yes, but I am not going to give up doing [other] things that I believe we need to do in order to accomplish that."

The role of WRJ VAMC's leadership is to balance the needs and priorities of the whole organization. Batalden endorsed De Gasta's approach: "Gary has this right; he preserves the space to work on improvement." Support, attention and time for improvement work are critical. As the union local president pointed out, "You need to be actively involved in a QI process. You can be mandated to collect measures but what will you do with them when you have them?"

"We've had challenges with our performance measures," De Gasta remarked. "We are much more expansive here than just the national quality measures. If you look at the quality measures we're not the star there." "Depends which quarter!" the quality manager countered, suggesting that results need to be looked at over time as opposed to one reporting period when judging performance.

Measurement challenges

"You can argue about the measures, but if you don't meet them and others do you have to ask how come?" commented De Gasta, adding, "It's hard to dink the numbers when you've got outside people gathering the data." (The indicators are based on monthly random samples of charts abstracted through the VHA External Peer Review Program [US Department of Veterans Affairs 2001].)

WRJ VAMC's chief of staff commented that it is hard to argue with the clinical measures, given the good intentions with regard to outcomes. He explained, "For me the issue with the performance measures is sometimes how the results are interpreted, because of the confidence intervals and the sample sizes. For example, the smoking cessation counselling [measure] can be based on six or eight of 27,000 patients." However, increased data pulls are being considered for 2008 and "there are lots of ways to mine the e-records to look at whole panels of patients by provider and their entire course of care, so you don't have to worry so much about sample sizes or confidence intervals."

"We were perceived as close to the worst, now we are perceived as close to the best, and neither is completely true because of difficulties with measurement," cautioned a WRJ VAMC clinician researcher concerned about the dangers inherent in making global judgments of care based on just a few measures. When the VISN focuses on certain measures, there is a strong emphasis on improving those measures, but at what cost? Attention is distracted from elsewhere. "What is the unit of analysis? That is the heart of the issue," the clinician remarked. On this view, there is a bit of a danger in moving to outcomes measures because it has the potential to create perverse incentives. For example, he noted, it is important to focus on how well blood pressure is being controlled in the severely diabetic population, which can be hard to manage. But the easiest way to improve the diabetic measures is to diagnose more diabetics so that fewer sick patients are included in the population. It can also be difficult to create good measures for certain diagnoses, such as psychiatric patient populations, where measures of functional status and an emphasis on recovery models would be needed. Developing information that is "good enough" to guide the organization is still a critical issue for the VA.

E-health record and information system

"You can't do what we do without electronic medical records," observed the chief of staff. WRJ VAMC clinicians participated in a state-wide diabetic collaborative and it took only 10 minutes to identify all their diabetic patients, compared to other organizations for which the process has posed a major challenge. The e-records form an extensive database that can be mined for clinical comparisons. "We are a bit unusual here; we give out comparative information on a provider-specific basis to all physicians, with their names on," said the chief of staff, something that is not done uniformly across the VA or even across VISN 1. This includes detailed information about how physicians are doing on key measures such as HgA1c or lipid levels for their panels of patients. As one clinician remarked, "I like that kind of feedback ... it's a real quantum leap."

Electronic medical records can also be adapted to improve care processes. For example, based on an idea from a national primary care consultant, the chief of staff plans to add a low density lipoprotein (LDL) algorithm with a list of steps and drugs and "one click to the doses." This innovation will encourage staff members to consider multi-therapy for such patients. The system supports WRJ VAMC's extensive use of clinical reminders and, while there is "some reminder fatigue," the chief of staff said, a review showed that they were all important, "so we kept them all."

Clinicians spoke favourably about WRJ VAMC's e-health record system: "It makes a big difference. ... It was such an incredible shift for me to be able to see all the meds a patient is on."

WRJ VAMC and Dartmouth Medical School: "A symbiotic relationship"

WRJ VAMC has ongoing affiliations with 25 to 35 academic organizations, although it can be argued that the influence of contacts with Dartmouth Medical School have been the most significant. The centre has benefited greatly from its relationships with members of Batalden's Healthcare Improvement Leadership Development group, several of whom are based at WRJ VAMC. "We have a symbiotic relationship with Dartmouth Medical School. They need us because we are their primary clinical site," De Gasta said. WRJ VAMC can focus more on teaching than is possible at Dartmouth Hitchcock Medical Center (DHMC) because the clinical productivity pressures may not be as great. (DHMC is the other major teaching hospital associated with Dartmouth Medical School.) A large number of WRJ VAMC medical staff members teach at Dartmouth.

Although it is a relatively small organization, WRJ VAMC hosts a number of national research initiatives. "We have to be innovative and creative," notes De Gasta. "That's why we have that group [of research and national centres leaders] - and it's like herding cats!" Researchers involved in the organization provide benefits because they are, in De Gasta's words, "questioners who throw bombs at the status quo." The research programs, which include the VA Outcomes Group Research Enhancement Award Program, the National Center for Post-Traumatic Stress Disorder and the field office of the VA's National Center for Patient Safety, have $6.0 million annual funding from the VA and the National Institutes of Health. Clinical researchers based at the centre described the VA as a supportive place for clinicians who want to do research and for researchers who want to keep their hand in clinical work.

WRJ VAMC's symbiotic relationship with Dartmouth has produced some remarkable programs and initiatives, including the following:

The VA National Quality Scholars Program

Sponsored by the Office of Academic Affiliations, Department of Veterans Affairs (VA), the VA National Quality Scholars Fellowship Program (NQSFP) is a two-year post-residency QI training program developed and run by Dartmouth's Institute for Health Policy and Clinical Practice. Two fellows at each of six sites across the US are linked electronically for academic and research efforts. Based at one of the six sites, fellows work with senior quality scholars (program directors) and faculty at their site and with the Institute's faculty leaders. The curriculum includes QI theory and research methods as well as completion and publication of clinical QI projects (Dartmouth College 2002b).

WRJ VAMC is the program's lead site. The centre's advanced clinic access in mental health is an example of an idea that began as a quality scholar's project and evolved into an award-winning redesign.

Advanced clinic access in mental health

By embracing an open-access approach and revamping its processes for patient referral, intake and assessment, the WRJ VAMC's mental health clinic has achieved impressive results. While clinic volumes have increased, the wait times to see a mental health specialist have dropped from 33 days to 16.9 minutes, and there are no longer any no-shows. The clinic, which opened in 2004, is located in a primary care clinic; primary care providers are thereby able to bring patients directly to the mental health clinic, with no bookings required. A clerk registers patients and they complete four assessment instruments using touch pads. The data are reviewed by a psychiatrist, the patients are screened to see if any basic tests have been missed (e.g., thyroid) and they have psycho-social interviews with therapists. Upon a patient's first visit, a treatment plan is initiated and, if necessary, a referral is made to the in-patient service.

This collaborative care clinic design is known nationwide as the "White River Model." It has won awards from the VA and the American Psychiatric Association.

VA National Center for Patient Safety field office

WRJ VAMC is a field site for the VA's highly regarded National Center for Patient Safety (NCPS), based in Ann Arbor, Michigan (US Department of Veterans Affairs 2007g). Root causes analysis (RCA) reports from all VHA facilities are forwarded to the NCPS database and are analyzed by a WRJ VAMC physician researcher who heads up the field office and his/her team. The team looks for trends and system vulnerabilities so that action can be taken to mitigate risks. Team members prepare reports and publish their research nationally.

Analyses have identified events that are rare on an institution-specific basis, yet show a pattern when aggregated in the database. For example, a series of near misses with pacemakers was identified across the US; patients were thereupon able to return to have the problem corrected. RCAs are time-consuming to perform, report and analyze, and there has been variation in reporting across the VHA. Because RCAs are valuable for learning, the VHA has implemented a new rule that each facility must annually do four individual RCAs and four aggregate reviews (e.g., of falls or medication errors).

WRJ VAMC is also the hub site for the new VA Interprofessional Fellowship Program in Patient Safety. This program will train two fellows in each of six sites across the US each year (US Department of Veterans Affairs 2006a.)

Leadership in an improvement culture

When listening to WRJ VAMC staff talk about their organization, interesting facets of the organizational culture become evident. In general, it appears to possess an informal, positive and collaborative interpersonal style, yet be driven when it comes to improvement and innovation. "The director is 'Gary'; his first name is known and used by everyone. We are very laid-back here. ... The director is very engaged and interested in what the front line are doing," said the service line director. As an example of this, De Gasta has borrowed an approach from the Marriott corporation, making appointments with randomly selected front-line staff to spend time getting to know what's happening with them. In addition, the entire executive staff has adopted an open-door policy. At the same time, the billings manager commented that "WRJ has a type-A personality; lots of innovation going on."

Systematizing improvement and innovation required an attitudinal shift. "Paul Batalden asked us 'what did you have to unlearn to do Baldrige?' We had to stop being victims. Stop finding excuses," De Gasta remarked. As a humorous reminder, leaders imposed a requirement on themselves to pay a dollar penalty for negative comments: "You have to put a dollar in the pot [at meetings] if you make excuses about not meeting the measures!" De Gasta noted. The chief of staff, meanwhile, said, "I think it is important to break down your processes and understand the parts, but focusing only on negatives makes you think that you are doing really poorly. I tend to an appreciative inquiry approach." He explained how they do medical student reviews, discussing those who are doing poorly first, but ending with those who are doing really well. "I use it more informally; it's more of a psychology of trying to be more positive."

When asked whether the improvement focus would survive the impending turnover in senior leadership positions, a service line director responded, "Try and beat it out of us, good luck! It's part of who we are here ... so embedded in what we do." "Quality improvement is pervasive around here; it's our culture," affirmed the chief of staff.

"We have a collaborative approach here, get the right people involved," but "it has been years of cycles of refinement to get to this point," observed a service line director. Collaboration includes the unions: "The unions are involved in everything," noted the union local president, a WRJ VAMC staff member who is a trained Carey Award examiner. He does presentations about the importance of union involvement in QI. "If you look at a sample of award-winning organizations, you would see that a key to success is strong labour-management relations," he continued. There are now measurable results included in the performance review process for staff, which creates a connection between the system's QI processes and the front-line staff.

A service line director observed,

One of the challenges is to show front-line staff that the little process improvement project that they are doing contributes to the bigger picture. It may be partly a language issue; it's really an education process. The way we get staff engaged is to get them to understand that they can make changes at the lowest level and see results, to be able to see that immediate improvement. When staff say they have no time to participate I say you are already doing it, but not in a systematic way or documenting it, so you're not getting credit.

"You need to show staff that showcase of awards in the hall," said the union local president. Doing so, he claimed, symbolizes the cumulative accomplishment of all the front-line improvement efforts.

Training and education

Building improvement capacity requires ongoing education and skills training. VHA employees have extensive training and leadership development opportunities. Employee and leadership development is crucial for succession planning, because 60% of all managers are eligible to retire by 2008 and 70% of dental staff by 2009 (VISN 1 education services director).

Eight core competencies are expected of all VHA staff:

Systems thinking
Organizational stewardship
Technical competency
Service
Interpersonal effectiveness
Creative thinking
Flexibility/adaptability
Personal mastery

These national expectations are used to frame all training efforts, which also include mandatory training in organizational ethics, cyber security and information security in research. WRJ VAMC has developed a diagram and explanatory table (see Figure 6) documenting its "corporate DNA" to show staff members how the individual core competencies relate to organizational competencies.

[Figure 6]

Although there are national QI education programs available (e.g., Quality 101 and a coaches college), as well as network- and facility-specific training opportunities, improvement training is not standardized across the facilities. VISN 1 network director Chirico-Post cautioned, "You have to be careful about the ice cream flavour of the month." VISN 1's quality management officer added, "We impart the concepts of Lean and Six Sigma, but without the language. All service line directors and many managers have had advanced clinic access training based on IHI's program. The network's education services department has given facilitator training for years, with some overlap between facilitation and improvement tools.

WRJ VAMC leaders have emphasized the importance of continuing education and training to support improvement efforts within their strategic frameworks. According to one service line director, "Senior leaders saw value in training as a Carey examiner, to learn about the Baldrige criteria and process improvement. Now that lots of leadership positions are trained we are starting with the staff." Within the centre, the Future Emerging Leaders (FUEL) program curriculum also includes the Carey/Baldrige criteria and process improvement.

Continuing challenges: Balancing improvement with accountability and compliance in a shifting - and political - environment

VISN 1 has made significant efforts to standardize care processes and performance measurement in order to become a high-performing system. Enabled by the VHA's electronic health records system, the network has implemented numerous CPGs backed by electronic reminders. Processes are monitored through rigorous review of performance measures in quarterly scorecards and reports. Teams from the facilities participating in numerous improvement collaboratives have made gains in patients' access to care, patient safety and preventive measures in primary care.

VISN 1 and its facilities, however, face continuing challenges in their improvement efforts. These challenges arise from various factors:

Operating in the context of a large, complex national government agency
A detailed accountability framework
A shifting patient care environment, including the pressures created by a growing number of veterans from the conflicts in Iraq and Afghanistan

Government rules and relationships

Being part of an immense government bureaucracy entails balancing central "rules" with local autonomy. VISN 1's annual budget is $1.5 billion, yet the network director is accountable to a national-level administrator for $1,000 allocated for training for four new positions.

Relationships with various levels of elected members of government also must be managed. "Congress really are friends of the vets and want to do what's best for them," Chirico-Post noted. As a local example, in this highly politicized environment congressional members (as well as New Hampshire's governor) are considered to be WRJ VAMC stakeholders, and that organization's senior leaders conduct quarterly briefing meetings with them to discuss issues facing the medical centre. Equipment and program placement can be deeply political decisions because congressional members favour local facilities in the areas that they represent.

Budget appropriations can also be affected by issues that reach the national press. The highly publicized problems at the army's Walter Reed Army Medical Center, for example, have brought money from Congress for infrastructural improvements. In contrast to hiring freezes and deficits with which the medical centres have had to deal, they are now faced with having to decide quickly how to spend the unexpected funds, but with restrictions on how the money may be used.

With changes in national policy decisions, benefits entitlement and coverage of particular veteran groups have often tended to transform over the years. These shifts have had consequences for VISN 1's planning and care delivery. For example, since entitlement to drug benefits was opened to all veterans, many patients have opted to get their medications from the VHA system; these same people, however, also seek care outside the system. Approximately 40% of VHA patients are co-managed with private sector providers, from whom they may receive various high-tech procedures. This situation can create safety issues related to medication monitoring and adjustment, for example, when veterans get their post-transplant drugs from the VHA yet their transplant care is delivered elsewhere.

"What is critical to acknowledge is that we operate in a political environment; we have to sing the political song," says De Gasta. An advantage of being part of the network is that while the VISN 1 is accountable for local medical centres' performance, it also recognizes the unique identities of each. The network acts as a buffer between the national level and the local organizations, allowing some latitude for local initiatives and innovation. While all VA medical centres are accountable for their performance on common measures, WRJ VAMC's smaller size and location may also make it easier for it to be something of a maverick. "White River Junction is little enough that they can permit more flexibility compared to larger centres; to let White River Junction run on a longer leash is less risky," Batalden suggested.¹ De Gasta also described his role as a senior leader as being, in part, to protect staff members and help them make sense of national initiatives and changes. Indicative of the frequency of changes his organization confronts, De Gasta commented, "I have a magnetic organization chart board so it can be changed each week instead of paying $400 each time to reprint it when the government changes things!"

Standardization and performance measurement - improvement or compliance?

Across VISN 1 there has been strong emphasis on standardization - of equipment, processes and procedures. However, Chirico-Post noted that this is also a continuing challenge: "How to get what is left in those facilities to a standardized approach?" She also mused about the limitations of performance measurement and the difficulty of knowing how well the network's eight facilities execute care. Because the spinal cord program is so focused, there is relatively good information about how well it is performing; however, in some other service lines (e.g., geriatrics) the measures are not so clear. Despite the emphasis on uniform performance measurement and standardization both nationally and within VISN 1, there are still variations in processes, structures and cultures across its constituent organizations. "If you've seen one network, you've seen one network," Chirico-Post noted.

The strong pressure to meet performance measure targets can stimulate compliance lectures as well as improvement activities. Several VISN 1 staff members commented that preoccupation with the focused set of measures can distract attention from other important issues. A number also said that it can be difficult to keep up with the moving targets.

Aging and decreasing patient population

VISN 1 and its medical centres face numerous pressures in a changing landscape. Between 2007 and 2013, the number of veterans over age 85 in VISN 1 is projected to increase by 47%, while the overall number of veterans in New England is projected to decrease by 42% by 2023 (VA New England Healthcare System 2006c). An aging population requires more intensive and costly services, which increase pressure on the system. WRJ VAMC also faces resource challenges; for example, transportation issues are harder to resolve because it is a rural centre. De Gasta asserted, "The Kizer model assumed there would be cost savings in the shift from acute to primary care, but the resources are not there. We still have to deliver specialty and acute care and we are seeing twice as many patients now." At the same time, the declining population of veterans has prompted discussions about the very future of the VHA system.

Leadership and staff turnover

VISN 1's organizations have benefited from stability and long tenure of leadership positions; however, a number of staff members are eligible to retire in the short term. Succession planning and ensuring that new leaders are developing in the ranks have been intensifying as network priorities. WRJ VAMC's chief of staff noted, for instance, "Normally we've had very little turnover, but people with long institutional memory are retiring." While recruitment may be challenging, WRJ VAMC has been successful in certain areas; for instance, in attracting primary care physicians.

The turnover of leaders and staff will test both VISN 1 generally and WRJ VAMC in particular (Chirico-Post retired in March 2008 and De Gasta retired at the end of 2007). Has the network's improvement culture permeated its organizations or will the long institutional memory leave with key individuals?

In little more than a decade, the VHA has been transformed from an organization under fire for deficiencies in the quality and safety of its care to a high-performing organization that has demonstrated better outcomes than those delivered in non-VA facilities. These achievements commenced with policy initiatives that shifted the VA away from its focus on in-patient care in largely independent facilities with limited accountability for results. The new VA became a results-focused system that has made access to care a priority and that has integrated services across the continuum. The challenges to maintaining improvement in this highly complex service delivery system will require continued strong leadership.

[Appendix A]

Appendix B. VISN 1 performance measures - 2007 (Note: "Missed Opportunities" = missed appointments)
Business Office:	Reducing AR > 90 Days old (lower better) Financial Index Revenue - Collections % of Goal
Geriatrics and Extended Care:	Non-institutionalized Care Target ADC Non-institutionalized Care Telehealth Census
Local Management:	SHEP Satisfaction Overall - Outpatient SHEP Satisfaction Overall - Inpatient Waiting Times - Provider C&P Exam Report Quality Transition Coordination - OEF/OIF Contacts HR - Work Force Planning
Mental Health:	Homeless Contact access to MH/SUD Tobacco Cessation Offered Meds Homeless Program access to Eval & Mgmt SMI - MHICM Capacity Homeless Program F/u in MH/SUD CBOC - % MH specialty access Waiting Times - Established Patients - Mental Health Homeless Program access to MH/SUD Waiting Times - New Patients - Mental Health Substance Use Disorder - Continuity of Care Missed Opportunities - Mental Health (Lower Better) New DX of Depression - Medication Coverage Tob - Used Tobacco past 12 mos (Lower Better) New DX of Depression - Provider Follow-up Tobacco Counseling w/ Referral
Primary Care:	Tobacco Cessation Offered Meds DM - BP < /= 140/90 Cervical CA Screening IHD - LDL-C <>/= 120 (Lower Better) DM-BP >/=160/100 not done (Lower Better) DM - LDL-C <>/=160/100 or not done (Lower Better) Tob - Used Tobacco past 12 mos (Lower Better) Waiting Times - New Patients - Primary Care HTN - Mono-therapy receiving thiazide HTN - Multi-therapy receiving thiazide Tobacco Counseling w/ Referral Influenza Immunization Alcohol Screen - AUDIT-C with doc responses PTSD Screen - with doc responses MDD Screen - PH-Q2 - with doc responses
Sensory and Physical Rehabilitation:	Waiting Times - Established Patients - Audiology Missed Opportunities - Audiology (Lower Better) Waiting Times - New Patients - Audiology
Specialty and Acute Care:	Surg Pts w/ Appropriate Pre-op Hair Removal Waiting Times - New Patients - Orthopedic Resident Supervision - Timely Admit Note - Surg Cardiac-controlled serum glucose-POD1 & POD2 SIP - Correct antibiotic given Waiting Times - Established Patients - Eye Care Waiting Times - Established Patients - Orthopedic Waiting Times - Established Patients - Podiatry IP HF - Rec Discharge Instructions (JCAHO Core) Prophylactic antibiotic Began Timely Waiting Times - New Patients - Podiatry Waiting Times - Established Patients - Dermatology Waiting Times - Established Patients - Urology Missed Opportunities - Dermatology (Lower Better) SIP - Prophylactic Antibiotic Discontinued Timely Waiting Times - Established Patients - GI ACS - LDL Cholesterol Assessment Missed Opportunities - Eye Care (Lower Better) Missed Opportunities - Orthopedic (Lower Better) Missed Opportunities - Podiatry (Lower Better) ACS - Cardiology involvement in 24 hrs ACS - Troponin returned in 60 min of order PN - Blood Cultures before antibiotic dose Waiting Times - Established Patients - Cardiology Waiting Times - New Patients - Cardiology Missed Opportunities - Urology (Lower Better) PN - Antibiotic first dose in 4 hours of Arrival Radiology Reports Verified in 2 Days Waiting Times - New Patients - GI Missed Opportunities - Cardiology (Lower Better) Missed Opportunities - GI (Lower Better) ACS - ECG in 10 min of arrival or 15 min prior. Waiting Times - New Patients - Dermatology Waiting Times - New Patients - Eye Care Waiting Times - New Patients - Urology Colorectal-Post-op Normothermia in 10 min ACS - LDL Lipid Lowering Therapy at Discharge ACS - Reperfusion intervention as Appropriate ACS - Reperfusion - PCI in 90 min. ACS - Reperfusion Thrombolytic Rx in 30 min.
Spinal Cord Injury:	Pneumococcal Immunization Tob - Used Tobacco in past 12 mos (Lower Better) DM - BP < /= 140/90 Tobacco Cessation Offered Meds DM-BP >/=160/100 not done (Lower Better) DM - LDL-C <>
Source: VISN 1 headquarters staff on September 11, 2007. Used by permission.

[Appendix C]

Appendix D. VHA Office of Quality and Performance - April 2001

The mission of the Office of Quality and Performance (OQP) is to support clinicians, managers and employees in providing the highest quality of care for veterans.
Specific areas of service include:

Performance Measurement Program (all "Value-Domains")
- Objectives
  - Assess the process and outcomes of care provided to patients
  - Provide an accountability framework for assessing the performance of the leaders, clinicians and managers in VHA
  - Link VA/VHA strategies with accountability measures to support improvement
- Data Sources
  - Large administrative data-set analysis (links with HCFA)
  - Massive chart review (EPRP)
Clinical Practice Guideline Development
- To improve care by reducing variation in practice and systematizing "best practices"
Accreditation (JCAHO, CARF, NCQA)
- Objective: To provide external validation of quality systems
Credentialing (VetPro)
- Objective: To verify that practitioners' training and certification is consistent with the defined requirements of their clinical appointments, that their licensure is current and unrestricted and that any history of adverse judgments can be identified for further review, thereby improving patient safety
Patient Satisfaction (Durham)
- Objective: To understand patient perceptions with respect to Veteran Service Standard (VSS) commitments in the areas of access, coordination, courtesy, education, emotional support, involvement of family and friends, physical comfort, patient preference, transition, continuity, pharmacy and specialist care
- Patient satisfaction "computers" to support employees
Functional Status
- Objective: To assess and improve the functional status of veterans
Performance Analysis Center for Excellence (PACE)
- Objective: To provide data feedback, satisfaction surveying and other work, but expanding existing functions to emphasize the provision of clinically appropriate and operationally sensitive data interpretation that documents performance, describes effective approaches to improvement opportunities and provides guidance that supports efficient implementation of those approaches
Internal Baldrige-based Awards Programs with USH, VHA, PQA
- Objective: Identify unmet patient needs and improve the organization to better address those needs; identify gaps in supporting best outcomes
Linkages with Quality Scholars Program
Linkages with National Center for Patient Safety
Linkages with HSR&D (QUERI); co-funds translation health systems research
External interfaces related to Quality (e.g., QuIC, NCQA, NQF)

Source: US Department of Veterans Affairs (2007a). Used by permission.

Appendix E. VA Boston Healthcare System nursing report card measures
Restraints:	% restraint free rate
Height and weight:	% height in VS package % weight in VS package on admission/monthly
Pain:	% pain score in VS package % pain qualified as acceptable or unacceptable % unacceptable pain with detailed assessment
PRN effectiveness:	% PRN effectiveness % pain PRN effectiveness documented w/in 30-240 minutes % pain PRN effectiveness documented w/acceptability
Documentation:	% Morse tallied % at risk for fall with plan % Braden tallied % at risk for breakdown with plan % completed Audit-C in admission assessment (AC & MH) % completed monthly summary note (MH) % competed safety intervention section on admission assessment (MH)
Verification of orders:	% orders verified by RN % chart reviewed
Incidence:	# medication errors Assault rate Fall rate Fall w/injury rate # hospital-acquired pressure ulcers
Source: Document provided by associate director of nursing, VA Boston Healthcare System, on September 10, 2007. Used by permission.

Appendix F. Examples of other improvement initiatives at WRJ VAMC

Care Coordination Home Telehealth program

In 2005 WRJ VAMC began a home telehealth monitoring program for heart failure patients who used text messaging to communicate daily with specialized care coordinators. The program now uses a mix of technology - including videophones and "health buddies" (a device programmed with a condition-specific dialogue that prompts patients to enter data) - to allow patients to send in clinical information and status updates. Care coordinators review the updates, discuss care issues with the patients and consult with other providers as needed. About 100 patients participate in the program, including patients with diabetes, hepatitis C, hypertension and spinal cord injuries, as well as those in palliative care. A six-month pre- and post-implementation program review showed that ED visits and in-patient admissions were 25% and 35% lower for this population and that 30-day readmission rates had dropped by 67% (VA New England Healthcare System 2006b).

Stop Workforce Accidents Team (SWAT)

In addition to clinical improvements, WRJ VAMC is participating in a national VHA initiative to develop minimal-manual lift environments to avoid injuries to staff members and patients. An interdisciplinary SWAT team has implemented ergonomic technologies and practices, as well as after-action reviews of accidents and near-miss reviews. As a result, in 2006-2007 WRJ VAMC had only one minor injury reported and no workdays lost to injuries experienced while handling patients. "It just snowballed; staff got involved because of positive results" (SWAT team leader).

Footnotes
¹ After reviewing the case study, VHA officials noted that, while each facility has a unique identity, all its centres are accountable and all must comply with required rules, regulations, directives, guidance and standardization.

References
Baldrige National Quality Program. 2007. National Institute of Standards and Technology. Gaithersburg, MD: Author. Retrieved November 4, 2007. < http://baldrige.nist.gov/ >

Batalden, P.B. and J.J. Mohr. 1997. "Building Knowledge of Healthcare as a System." Quality Management in Health Care 5(3): 1-12.

Dartmouth College. 2002a. Health Care Improvement Leadership Development. Hanover, NH: Author. Retrieved October 7, 2007. < http://www.dartmouth.edu/~cecs/hcild/hcild.html >

Dartmouth College. 2002b. VA National Quality Scholars Program. Hanover, NH: Author. Retrieved October 7, 2007. < http://www.dartmouth.edu/~cecs/fellowships/vaqs.html >

Institute for Healthcare Improvement. nd. Reducing Waiting Times: Veterans Health Administration. Boston: Author. Retrieved October 8, 2007. < http://www.ihi.org/IHI/Topics/OfficePractices/ Access/ImprovementStories/ReducingWaitingTimesVeterans HealthAdministration.htm >

Jha, A.K., J.B. Perlin, K.W. Kizer and R.A. Dudley. 2003. "Effect of Transformation of the Veterans Affairs Health Care System on the Quality of Care." New England Journal of Medicine 348: 2218-2227.

Kizer, K.W. 1995. Vision for Change: A Plan to Restructure the Veterans Health Administration. Washington, DC: US Department of Veterans Affairs. Retrieved October 20, 2007. < http://www..va.gov/vhareorg/VISION/2CHAP1.pdf >

Kizer, K.W. 1996. Prescription for Change: The Guiding Principles and Strategic Objectives Underlying the Transformation of the Veterans Healthcare System. Washington, DC: US Department of Veterans Affairs. Retrieved October 20, 2007. < http://www..va.gov/vhareorg/rxweb.pdf >

Kizer, K.W., J.G. Demakis and J. R. Feussner. 2000. "Reinventing VA Health Care: Systematizing Quality Improvement and Quality Innovation." Medical Care 38(6): I7-I16.

Parlier, R.L. 2003. Improvement Report: Advanced Clinic Access Initiative. Boston: Institute for Healthcare Improvement. Retrieved October 8, 2007. < http://www.ihi.org/IHI/Topics/OfficePractices/ Access/ImprovementStories/MemberReportAdvanced ClinicAccessInitiative.htm >

US Department of Veterans Affairs. 2001. Veterans Health Administration. VHA Directive 2001-015, External Peer Review Program. Washington, DC: Author. Retrieved October 20, 2007. < http://www..va.gov/vhapublications/ ViewPublication.asp?pub_ID=103 >

US Department of Veterans Affairs. 2006a. Office of Academic Affiliations. VA Interprofessional Fellowship Program in Patient Safety. Washington, DC: Author. Retrieved October 8, 2007. < http://www.va.gov/oaa/specialfellows/programs/ SF_patient_safety.asp?p=17 >

US Department of Veterans Affairs. 2006b. VISN 1 Announces Kizer Award Grants Selected for Funding. Washington, DC: Author. Retrieved October 17, 2007. < http://www.va.gov/VISN1/news/ docs/NewsGlance06_11.asp >

US Department of Veterans Affairs. 2006c. VA Office of Policy and Planning. Desk Guides, Training, and Technical Assistance. Robert W. Carey Performance Excellence Award. Judge's Desk Guide. Washington, DC: Author. Retrieved November 4, 2007. < http://www..va.gov/op3/page.cfm?pg=46 >

US Department of Veterans Affairs. 2006d. Office of Quality and Performance. VA/DOD Clinical Practice Guidelines. Washington, DC: Author. Retrieved October 20, 2007. < http://www.oqp.med.va.gov/cpg/cpg.htm >

US Department of Veterans Affairs. 2006e. VA VistA Innovations Award. Washington, DC: Author. Retrieved October 10, 2007. < http://www.innovations.va.gov/ >

US Department of Veterans Affairs. 2006f. VistA, Winner of the 2006 Innovations in American Government Award. Washington, DC: Author. Retrieved October 8, 2007. < http://www.innovations.va.gov/innovations/ docs/InnovationsVistAInfoPackage.pdf >

US Department of Veterans Affairs. 2007a. VA New England Healthcare System. About Us. Washington, DC: Author. Retrieved October 8, 2007. < http://www.visn1.med.va.gov/network/index.asp >

US Department of Veterans Affairs. 2007b. VA New England Healthcare System. Mission, Vision, and Values. Washington, DC: Author. Retrieved October 8, 2007. < http://www.visn1.med.va.gov/network/mission.asp >

US Department of Veterans Affairs. 2007c. VA New England Healthcare System. Service Lines. Washington, DC: Author. Retrieved October 7, 2007. < http://www.visn1.med.va.gov/servicelines/ >

US Department of Veterans Affairs. 2007d. Office of Quality and Performance. About Us. Washington, DC: Author. Retrieved October 20, 2007. < http://www.oqp.med.va.gov/general/about_us.asp >

US Department of Veterans Affairs. 2007e. VA Boston Healthcare System. Washington, DC: Author. Retrieved October 7, 2007. < http://www.boston.va.gov/ >

US Department of Veterans Affairs. 2007f. VAMC White River Junction, VT. Washington, DC: Author. Retrieved October 8, 2007. < http://www.whiteriver.va.gov/about/index.asp >

US Department of Veterans Affairs. 2007g. VA National Center for Patient Safety. Washington, DC: Author. Retrieved October 7, 2007. < http://www.va.gov/NCPS/ >

VA Medical Center White River Junction. 2007. Malcolm Baldrige Award Application. White River Junction, VT: Author. (Document provided by WRJMC staff on September 12, 2007.)

VA New England Healthcare System. 2006a. Annual Report 2006. Bedford, MA: Author. Document provided by VISN 1 headquarters staff on September 11, 2007.

VA New England Healthcare System. 2006b. Care Coordination Home Telehealth Program: Performance Improvement Utilization Report Presented August 2006, OCC Conditions of Participation Review. Bedford, MA: Author. PowerPoint slides provided by program manager on September 12, 2007.

VA New England Healthcare System. 2006c. Stage 2: Strategic Plan for FY 2006-2010. Bedford, MA: Author. Document provided by VISN 1 headquarters staff on September 11, 2007.

VA New England Healthcare System. 2007. The Secretary's Robert W. Carey Performance Excellence Awards. 2007 Application. Bedford, MA: Author. Document provided by VISN 1 headquarters staff on September 11, 2007.

Chapter 4: Jönköping County Council - Småland, Sweden

2008-12-03T17:19:00.000-08:00

Citation Information
Baker, G.R., A. MacIntosh-Murray, C. Porcellato, L. Dionne, K. Stelmacovich and K. Born. 2008. "Jönköping County Council." High Performing Healthcare Systems: Delivering Quality by Design. 121-144. Toronto: Longwoods Publishing.

• Order the printed paperback version.

Highlights of recent achievements

"Jönköping County opens the minds of their peers and offers hope, encouragement, and new ideas. Their superb teamwork and organization have helped us all to think more clearly and to act more boldly."
- Donald Berwick (quoted in Institute for Healthcare Improvement nd a)

For the past decade Jönköping County Council - a county council in southern Sweden serving a population of less than 340,000 - has gained national and international recognition for making and sustaining large-scale improvements in healthcare. For many international leaders in the field of quality improvement, Jönköping exemplifies the innovation, strong and stable performance and social values on which Swedish healthcare was founded, and provides a model of healthcare system transformation that ranks among the best in the world. While Jönköping was a well-kept secret for some time, it has become a popular site to visit for healthcare leaders eager to learn more.

Figure 1 shows that compared to the other 20 county councils in Sweden, Jönköping achieves the best overall ranking on indicators across Sweden's six goals for quality: efficiency, timeliness, safety, patient centredness, equity and effectiveness (Jönköping County Council 2005).
[Figure 1]

Jönköping has dramatically reduced its rates of sepsis and made impressive measurable gains in chronic disease management while reducing staff absenteeism and turnover. The council estimates that its work on efficiencies has led to 80 million SKr savings ($13.5M CAN), or 2% of its net costs (Jönköping County Council 2005). Jönköping has won national recognition by the Swedish quality award for healthcare - Qvalitet, Utveckling, Ledarskap (QUL) - on multiple occasions over the last decade. This award is often referred to as the Swedish Malcolm Baldrige award.

Two initiatives stand out among Jönköping County Council's achievements:

Esther

Esther is a persona that clinicians in Jönköping invented to help them improve patient flow and coordination for seniors in six of the county's municipalities. Care for the elderly is a critical issue in Sweden, a country that has the world's oldest population (18% are aged 65 or over). Esther is an 88-year-old Swedish woman who continues to live alone in the community but has a chronic condition and occasional acute needs. Beginning in late 1998 Jönköping clinicians and leaders came together to map Esther's movements through the complex network of care settings and providers. In addition, interviews were conducted with patients like Esther and clinicians who provide care for her across the system.

This exercise provided a starting point for identifying and working on improvements in the way patients flow through the care system. Much work was done to align capacity with demand and to strength coordination and communication among providers. Examples of changes made included a redesigned intake and transfer process across the continuum of care, open access scheduling, team-based telephone consultation, integrated documentation and communication processes and an explicit strategy to educate patients in self-management skills. The Esther project yielded impressive improvements over a three- to five-year period, including an overall reduction in hospital admissions by over 20% (9,300 to 7,300) and a redeployment of resources to the community, a reduction in hospital days for heart failure by 30% (from 3,500 days per year to 2,500) and a reduction by more than 30 days of wait times for referral appointments with specialists such as neurologists (Institute for Healthcare Improvement nd b).

Pursuing Perfection

Pursuing Perfection was an ambitious project funded by the Robert Wood Johnson Foundation and directed by the Institute for Healthcare Improvement (IHI) in the United States (US). The goal was to create system transformation across all major healthcare processes. Seven successful US health system applicants received over $2 million each through a competitive process to participate in this initiative. Jönköping (and several other international health systems) participated without this funding.

Jönköping County Council leaders considered their Pursuing Perfection efforts to be an investment that built on the Esther initiative and helped to transform the way care is provided. Top managers wondered whether it would be possible to develop "a Toyota in healthcare." Their efforts focused on developing new ways of working and tools at three levels: leadership, new designs and innovations, and front-line results. Jönköping leaders and clinicians focused their efforts on systems thinking at all levels (i.e., macro, meso and micro) in several areas, including achieving access in every office, improving patient flow, asthma care, elder care, partnerships for children's services in the county, prevention of influenza and patient safety.

This work led to substantial streamlining of processes and cost savings across the system, including in surgical units and orthopaedic clinics. Key changes included role redesign with occupational therapists and nurse practitioners having more enhanced roles in doing follow-up exams. By bringing together all providers and resources for children with asthma in the county and by mapping and improving processes, Jönköping reduced the number of hospitalizations for pediatric asthma to 7 per 10,000 (Jönköping formerly had 22 hospitalizations per 10,000; the US national average is 30 hospitalizations per 10,000). Jönköping's rate of influenza vaccination increased by 30% (over four years), translating into substantial reductions in acute care hospital admission as well as in morbidity and mortality among the elderly population. Jönköping County was considered the highest performing of all Pursuing Perfection sites, financially and clinically, thereby demonstrating "that gains are possible when innovative design meets rational resourcing" (Institute for Healthcare Improvement nd a).

Setting an example

It is uncommon to be publicly praised and held up as an example to peers in Sweden, where unity, modesty and equality are strongly valued. That is no longer the case for Jönköping County Council. In a report published by Sweden's Department of Finance in 2005, Jane Cederqvist urged other county councils to build on Jönköping's successes in transforming its system and noted the resulting possibility of realizing cost savings across the country:

We have done some calculations, and our evaluation of the counties in Sweden shows that it is possible to save at least 30,000 million SKr [$5 billion Canadian] in a 10 year period. ... It would be very good for Swedish health care if we can start a Pursuing Perfection project in Sweden based on the successes the County Council of Jönköping have achieved in their care. This should develop all of Swedish healthcare a lot, and offer us new learning and the inspiration needed for tomorrow's work in healthcare. (Jane Cederqvist; qtd. in Berwick 2006: 54)

These results are impressive. But beyond what is published in facts and figures - comparative county-level performance rankings, awards, key improvement initiatives and results - little is known about how Jönköping developed into a system capable of improvement.

For the full case please go to:

Chapter 4: Jönköping County Council - Småland, Sweden

For commentary on this case by Maura Davies please to to:

Commentary: Jönköping County Council

Chapter 2: Birmingham East and North Primary Care Trust and Heart of England Foundation Trust - Birmingham, UK

2008-10-31T15:26:00.000-07:00

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Highlights of recent achievements

In 2005 and 2006 the Birmingham East and North Primary Care Trust (BEN PCT) was short-listed for the Health Service Journal award for Primary Care Trust of the Year (Health Service Journal Awards 2005, 2006).
BEN PCT's orthopaedic triage service won the Health Service Journal's access award in 2005 for its work in managing referrals to orthopaedics in primary care settings, decreasing patient waits and increasing patient satisfaction and access (Health Service Journal Awards 2005).
BEN PCT changed from the worst-performing area in the country for over-prescription of antibiotics to winning an award from the Royal Pharmaceutical Society for its achievement in reducing prescribing levels (Birmingham East and North Primary Care Trust 2006b).
Good Hope Hospital's redesign of its vascular surgery clinic and community leg ulcer service won the National Health Service (NHS) Innovation Award for Service Delivery in 2004 and the Healthcare IT Effectiveness Award's Best Use of IT in the Health Service and Best Innovative Use of Technology awards in 2005 (Healthcare IT Effectiveness Awards 2005).
The Heart of England Foundation Trust (HEFT) won the Acute Care Trust of the Year award in 2006 (Health Service Journal Awards 2006).

The system and its environment

Patients as partners
Promoting self-care
Care in the right place

Method: Exploring a system capable of improvement

Examples of improvement initiatives

Clinical improvement projects

The following projects are examples of clinical improvement projects currently underway as part of the joint program of work between BEN PCT and HEFT (BEN PCT and HEFT 2006):

The trusts are among the national pilot sites for the Making the Shift project, which is an initiative of the NHS Institute for Innovation and Improvement (the Institute). Making the Shift aims to move needed services from hospitals to primary care in order to better integrate access to services in the community (see Appendix A, sections 7.1 and 7.3, for more information about the Institute). Three project teams are working on lower-back pain management, heart failure and integrated continence service. They have designed clinics and care paths to coordinate care in the community by using providers from several disciplines and patient education programs as well as by decreasing wait times and unnecessary referrals to specialists.
Assertive Case Management (see next sub-section)
Diabetes: To deliver a community-based glucose tolerance testing service and patient education
Chronic obstructive pulmonary disease (COPD): To identify the prevalence of COPD in the region and create a self-management pathway for the patients
Healthy Hearts Programme: To create a clinic offering specialized treatment plans and education for those at high risk of cardiovascular disease (CVD)
Elderly Care Assessment Unit: To further develop the unit as a rapid access assessment unit for elderly patients needing short-term medical intervention
Hospice at Home: To improve palliative care in the home by redesigning positions for "health care assistants with specialist interest in palliative care"
Integrating Health and Social Care: To redesign an integrated service model for day services across health and social care and the voluntary sector

Partners in Health Centre

Musculoskeletal orthopaedic triage service with choice

Vascular clinic and telemedicine system

Birmingham OwnHealth^®

Assertive case management

The strategy: Align improvement processes with system strategy, culture and operations

"We have to keep agile and nimble, with the right principles in mind."
- Sophia Christie, CEO of BEN PCT

Leaders in a complex change environment

Approach to change

"Adapt improvement tools to use them in a situation that is already prepared."
- Sophia Christie, CEO of BEN PCT

Investment in organizational development

This participatory process resulted in the following core purpose and goals, which are their touchstones for planning decisions, measurement and improvement efforts:

Purpose

Working in partnership to tackle inequalities and improve the health and well-being of local people.

Goals

To be so responsive to the population we serve that no one waits for the healthcare they need.
That the health and well-being of the population will have improved so much that people will enjoy 10 more years of quality life.
Our communities will be the most involved, informed and empowered in the country.
That people regard us as the first choice organization to work with and for.

Managing the tensions between short-term projects and long-term vision

Links with "mentor" organizations and individuals

Kaiser Permanente

Physician leadership

Performance management: Competing demands and financial pressures

[Figure 1]

Conclusion

[Figure 2]

Notes to Figure 2

For more background information about the institutions in the numbered boxes in Figure 1, see the following sections in Appendix A:

Strategic Health Authority: Section 1.0: Background; Section 5.0: Regional Accountability
Healthcare Commission: Section 4.2: Performance Reporting and External Assessment
Quality and Outcomes Framework: Section 3.3: Financial Incentives
Monitor: Section 3.3: Financial Incentives
Institute for Innovation and Improvement: Section 7.1: Modernisation Agency; Section 7.3: Institute for Innovation and Improvement
NHS Information Systems and Dr. Foster: Section 4.2: Performance Reporting and External Assessment; Section 6.0: Information Technology

Appendix A. National Health Service: Health system context

1.0. Background

[Figure 3]

Overall the NHS's policy context has been shaped by several key reforms. The extent to which these reforms have been levers for improving quality varies. A discussion of these reforms follows.

2.0. Supply-side reforms

2.1. Investments in capacity and a plurality of providers

2.2. Service and role redesign

2.3. Practice-based commissioning

2.4. Integration of health- and social care

3.0. Demand-side reforms

3.1. Payment by results

3.2. Patient choice

3.3. Financial incentives

The QOF measures quality of practice against evidence-based national standards in four areas:

4.0. National guidance, standards and targets

4.1. Priorities and targets

The most recent priorities outlined in the 2007/2008 NHS operating framework (Department of Health 2007b) include the following:

Achieving a maximum wait of 18 weeks from GP referral to start of treatment
Reducing rates of methicillin-resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections
Reducing health inequalities and promoting health and well-being
Achieving financial health

4.2. Performance reporting and external assessment

4.3. NICE and National Service Frameworks

5.0. Regional accountability

6.0. Information technology

7.0. Support for quality improvement

7.1. Modernisation Agency

7.2. Clinical Governance Support Team

7.3. Institute for Innovation and Improvement

[Figure 4]

Appendix A(a). Key government policy papers
Year	Document	Brief Description
1989	Working for Patients	The Conservative government's white paper that outlines a plan to create an internal market and competition in the system through a split between purchasers and care providers and the introduction of fundholding for GPs to allow them to purchase care for their patients (NHS nd b).
1997	The New NHS - Modern, Dependable (Department of Health 1997)	A white paper by the new Labour government that sets out a plan to modernize the NHS. The new approach is "based on partnership and driven by performance." It preserves the principle of a primary care-led NHS but moves away from the internal market and outright competition. The paper outlines six principles underpinning this new approach, including taking quality as a driving force for decision-making at every level.
1998	A First Class Service - Quality in the New NHS (Department of Health 1998)	A consultation document that outlines new initiatives and tools for setting, delivering and monitoring standards for a high-quality, cost-effective NHS. These include NICE, an independent body responsible for providing authoritative appraisal and national guidance; NSFs, evidence-based service models and standards; clinical governance, a new framework backed by trusts' statutory duty for quality and through which organizations are accountable for continuously improving the quality of their healthcare services and safeguarding high standards of care; and the Commission for Healthcare Improvement (CHI), a statutory body established to provide independent scrutiny of local efforts to improve quality and report publicly on the performance of local organizations.
2000	The NHS Plan - A Plan for Investment, A Plan for Reform (Department of Health 2000) Delivering the NHS Plan - Next Steps on Investment, Next Steps on Reform (Department of Health 2002)	This ten-year plan, and its follow-up progress report, helped to bring into focus the government's strategies to modernize the NHS. The plan outlines substantial growth in the NHS budget (i.e., by one half in cash terms) and investments in capacity (e.g., facilities, staff, medical school places); an increase in the number of physicians entitled to discretionary payments in the private sector; and reforms aimed at devolving power from government to the local health service in a system of "earned autonomy." These reforms include PCTs holding the majority of the NHS budget and having the freedom to purchase care from most appropriate provider (public, private, voluntary); national targets, public performance ratings (especially for wait times) and incentives for high-performing local organizations, including administrative autonomy through designation as a foundation trust and consequences for poor-performing organizations, such as executive replacement; quality-based contracts for GPs and cash incentives to physicians for high-quality care; changes in job design, such as extended scopes of practice for nurses and therapists; a Modernisation Agency to provide technical support to spread best practices; a new hospital payment system called payment by results that uses a regional tariff or case-mix system; an integrated and modernized electronic health information system; and better integration between health and social care.
2004	The NHS Improvement Plan: Putting People at the Heart of Public Services (Department of Health 2004)	Building on progress to date to continue the push to meet national targets to reduce wait times, this paper outlines shifts in priorities (to 2008) toward prevention and management of chronic conditions and local target-setting and performance management, especially for high-performing trusts. In addition, this plan outlines additional priorities such as greater personal choice for non-emergency care, an electronic booking system and the right to choose from at least four or five different healthcare providers; an Expert Patients' Programme designed to help empower patients to manage their own conditions; innovations such as NHS Direct (nursing-led telephone advice); and additional IT enhancements, including electronic booking and prescribing services and a HealthSpace for patients.
2006	Our Health, Our Care, Our Say: A New Direction for Community Services (Department of Health 2006a)	This white paper focuses on advancing a vision for better health and social care that "puts people more in control, makes services more responsive, focuses on those with complex needs and shifts care closer to home, while achieving better value for money." Specific actions for change outlined in the paper include: PBC, which gives GPs more responsibility for local health budgets, in conjunction with individual budget pilots to test how users can take control of social care and changes to payment-by-results tariffs to support these changes; a guarantee of registration with a GP practice list and incentives for GP practices to offer convenient opening times and appointments; more care in more local and convenient settings, including the home, by working with royal colleges to define clinically safe pathways within primary care; better infrastructure to support the integrated commissioning of health and social care between PCTs and local authorities; and an increase in the quantity and quality of primary care in under-served and deprived areas, including through the removal of barriers to entry for the "third sector" as primary care providers.

Appendix B. Healthcare Commission performance indicators
Existing:	Access to a GP (not including walk-in centres) Access to a primary care practice (not including walk-in centres) All cancers: 2-week wait All cancers: 31-day diagnosis to treatment Ambulance: category A calls meeting 19-minute target Ambulance: category A calls meeting 8-minute target Ambulance: category B calls meeting 19-minute target Commissioning a comprehensive CAMHS Commissioning of crisis resolution/home treatment services Convenience and choice: facilities in place to support choice Convenience and choice: PCT booking Delayed transfers of care Diabetic retinopathy screening Number of in-patients waiting longer than the standard Number of out-patients waiting longer than the standard Patients waiting longer than 3 months for revascularization Practice-based registers: patients called for review Thrombolysis: 60 minutes call to needle time Total time in A&E: 4 hours or less
New:	Access to genito-urinary medicine clinics Access to reproductive health services Blood pressure Breast cancer screening for women aged 50-70 years Cancer: implementation of NICE IOGs CVD mortality rate (per 100,000) Cancer mortality rate (per 100,000) Childhood obesity: data quality Cholesterol levels Commissioning of assertive outreach services Community equipment Community matrons CPA 7-day follow-up Data collection: referral to treatment waiting times Data quality on ethnic group Drug misusers sustained in treatment Emergency bed days Experience of patients Four-week smoking quitters GP recording of body mass index (BMI) status Infant mortality: breastfeeding initiation rates Infant mortality: smoking during pregnancy Infection control In-patient waiting times: 18-week milestone Number of drug misusers in treatment Number of very high-intensity users Older people's mental health: assessment of needs and services Out-patient waiting times: 18-week milestone Practice-based registers Smoking status aged 15-75 years Teenage conception rates Wait times for MRI and CT scans Wait times for other diagnostic tests

BEN PCT Scorecard indicators by strategic objective
Strategic Objective	Indicator
Efficient use of resources.	Financial balance Non-elective admissions (not maternity, practice-based registers only) Out-patient GP attendances (New OP, BPR only) A&E attendance Achievement of savings plan: BEN PCT combined figure
To be so responsive to the population we serve that no one waits for the healthcare they need.	Access to a GP (not including walk-in centres) Access to a primary care practice (not including walk-in centres) Cancer wait times: 2 weeks, 1 month, 2 months Ambulance: category A calls meeting 19-minute target Ambulance: category A calls meeting 8-minute target Ambulance: category B calls meeting 19-minute target Delayed transfers of care In-patient wait times Out-patient wait times Thrombolysis: 60 minutes call to needle time Total time in A&E: 4 hours or less Patients waiting longer than 3 months for revascularization Access to genito-urinary medicine clinics Access to reproductive health services Waiting times for MRI and CT scans Waiting times for other diagnostic tests
That the health and well-being of our population will have improved so much that people will enjoy 10 more years of quality life, wherever they live.	Diabetic retinopathy screening Four-week smoking quitters Practice-based registers: patients called for review Blood pressure Cholesterol levels Infant mortality: breastfeeding initiation rates Infant mortality: smoking during pregnancy Drug misusers sustained in treatment Number of drug misusers in treatment Number of very high-intensity users Practice-based registers Smoking status aged 15-75 years Emergency bed days GP recording of BMI status
Our communities will be the most involved, informed and empowered in the country.	Number of MRSA infections (primary care) Number of MRSA infections (acute) Convenience and choice: PCT booking Community equipment Community matrons Patients with CHD, etc., who smoke, offered smoking cessation advice Percentage of population served by practices achieving 80%+ QOF points (LAA) Number of patients recruited to Expert Patients' Programme (LAA) Percentage of complaints resolved within 25 days
That people regard us as the first-choice organization to work with and for.	Achievement against HCC core and developmental standards Commissioning of crisis resolution/home treatment services Commissioning of assertive outreach services CPA 7-day follow-up Full-time equivalent staff in post (FIMS workforce return) Older people's mental health: assessment of needs and services

References
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Chapter 1: Introduction. Learning from High-Performing Systems: Quality by Design

2008-10-26T08:50:00.000-07:00

[Citation Information
Baker, G.R., A. MacIntosh-Murray, C. Porcellato, L. Dionne, K. Stelmacovich and K. Born. 2008. "Learning from High-Performing Systems: Quality by Design." High Performing Healthcare Systems: Delivering Quality by Design. 11-26. Toronto: Longwoods Publishing.]

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To read the full web version of this chapter click here:
Chapter 1: Introduction. Learning from High-Performing Systems: Quality by Design]

Improvements in science, technology and care have offered the promise of better healthcare and improved health. But many healthcare systems have been unable to cope with the acceleration of knowledge growth, thus creating a gap between the care that is possible and the care that is delivered. Many commentators bemoan the inconsistent quality and increasing costs of current healthcare and fear the future burdens posed by aging populations and the costs of adopting emerging therapeutic and diagnostic innovations. Providing consistent, high-quality care is a challenge even in the countries that spend the most on healthcare (Institute of Medicine 2001). The increasing complexity of healthcare systems in industrialized countries has further exacerbated the quality chasm, thereby leading to a healthcare delivery system that is complicated, inefficient and uncoordinated.

Improving the safety and quality of care is an increasingly important objective in all health systems. Advances in measurement have helped to highlight variations between organizations, and across regional and national health systems. For example, the Commonwealth Fund, a health foundation based in the United States (US), has sponsored multi-country surveys of patients and physicians for 10 years, releasing the results of these surveys annually.1 The results demonstrate that the US system, which is the most expensive of the seven systems studied, performs poorly in most dimensions compared with other countries (see Table 1). The Canadian system is the most expensive of the non-US systems; however, its performance is the lowest on several dimensions of quality, including the provision of appropriate, coordinated and patient-centred care, and next-to-lowest in most other dimensions (Commonwealth Fund 2007). The Organisation for Economic Co-operation and Development (OECD) recently released a report based on administrative data. It revealed wide variations in performance between Canada and the other OECD countries. For example, in 2005 the 30-day mortality rate from acute myocardial infarction was lower in Canada than the average for OECD countries, while the 30-day stroke case fatality rate was higher (Organisation for Economic Co-operation and Development 2007).

Table 1. Commonwealth Fund rankings [see: Chapter 1: Introduction. Learning from High-Performing Systems: Quality by Design]

As these results suggest, no country has succeeded in demonstrating a consistently high level of performance. Moreover, the national variations incorporate a range of performance within each country for different geographic regions and/or health systems. On individual measures, for instance, some regions in countries that rank low may perform better than regions in countries that rank high. Country rankings provide useful indicators of the effectiveness of national policies and structures; however, they are clearly insufficient as guides to the elements of success. Moreover, examining the variations on their own does not explain why some regional systems or hospitals are able to achieve better outcomes than their peers. Indeed, despite agreement on the goal of improving quality in all healthcare systems, there remains considerable disagreement on effective and affordable means to improve performance. Few studies have attempted to examine whether any regional or local systems are capable of achieving consistently better outcomes across different disease programs, levels of care and local delivery organizations.

Identifying such high-performing health systems and understanding the strategies and investments they have made is more than an academic issue. The practices these healthcare systems employ can inform strategy development and guide the allocation of resources in systems seeking to improve their performance. Identifying improvements to current care delivery structures and translating approaches from high-performing systems to local delivery organizations will help to spread more reliable and cost-effect-ive care. While there are many examples of local successes, too often these are "islands of excellence in a sea of mediocrity" (Rogers and Bevan 2002) rather than reflections of consistent approaches to good practice. High-performing healthcare systems are those that have created effective frameworks and systems for improving care that are applicable in different settings and sustainable over time - but is this an achievable goal in systems that are not high-performing?

The search for sustainable and affordable quality is not a problem unique to healthcare. Indeed, in many industries there has been a search for strategies and investments that yield consistently better results. Among notable success stories are the achievements of Toyota Motor Corporation based on the development of the Toyota Production System, an approach to manufacturing that has revolutionized the auto industry (Womack et al. 1990). The critical first step for achieving such high performance levels is to recognize that quality must be defined as a system property and not as a characteristic of individuals who work in a system. Healthcare has traditionally defined excellence in terms of individual physicians or other caregivers. In this view high quality results from the practice of highly trained expert clinicians. Yet patient safety experts such as James Reason (1995) and Lucian Leape (1994) have long argued that safety cannot be improved by urging individual clinicians to be more careful. Instead, we must design systems that reduce the likelihood of errors, make errors more visible and provide the means to remediate before harm occurs.

The same reasoning applies to improving quality. In their seminal report Crossing the Quality Chasm, the Institute of Medicine's Committee on Quality of Health Care in America noted, health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes. (Institute of Medicine 2001: 4)

The recognition that quality is a property of systems and not just individuals or operating units begs several questions:

What aspects of healthcare systems are key to facilitating high performance?

What do we know about the relationships among these elements and among various important outcomes?

What is the best way to study these issues?

What is a system capable of improvement?

Calling a group of healthcare organizations a "system" has become common practice. As Ackoff (1974, 1994) and others have noted, however, true systems involve a functionally related group of interacting, interrelated or interdependent elements forming a complex whole with a common aim. In simpler terms, system elements must be capable of working together to achieve shared goals; otherwise, they are merely individual parts with separate missions. Batalden and Mohr (1997) devised an exercise to show how improvement activities relate to an organization's daily work. They emphasize the need to understand three sets of interdependent components of any given system (see Figure 1):

Why an organization produces its services - Who are the customers and what are the broader social needs the organization fulfills?

How those services are produced - What are the processes of daily work or, in other words, the means of production?

How the organization improves its services - What are the improvement activities or means of improvement?

Efforts to improve healthcare services are often termed "quality improvement." Quality improvement is an umbrella term that includes many overlapping concepts, such as continuous improvement, organization-wide commitment and worker participation, knowledge of customer needs, systems thinking, systematic analysis of processes, use of scientific data-driven analytic methods and involvement of interdisciplinary and cross-functional teams (Blumenthal and Kilo 1998; Lucas et al. 2005; McLaughlin and Kaluzny 1994; O'Brien et al. 1995; Øvretveit and Gustafson 2002). The knowledge and skills necessary for this improvement work draw from a variety of disciplines. Different improvement methods emphasize different tools, but most quality improvement approaches include methods to analyze and improve (or design) work processes, techniques to collect and integrate information about the needs of patients and other key customers to inform the design of work, and methods for testing and implementing improvements.

Much of the improvement literature describes work at the front lines - or "clinical microsystems of care" - involving caregivers, patients, support staff, the information and materials they need and the activities and outcomes they generate. High-quality care results from the effective practices and interactions of caregivers in such microsystems. A successful microsystem is able to make multiple and sustained improvements in care based on factors such as the following:

Members' understanding of their clinical unit as an interdependent group with the capacity to make changes

The development of a common purpose and collaboration to improve outcomes based on an understanding of current system performance and of the methods and tools necessary to improve performance (Batalden and Splaine 2002; Mohr and Batalden 2002; Nelson et al. 2007)

Efforts to improve performance at the front line depend on a range of supports both within organizations and from the broader environments in which they operate. Because improvements at the local level depend on leadership and action at higher levels, successful leaders of the large systems in which clinical microsystems are embedded need to support local leadership and provide resources to clinical microsystems. While clinical improvement is rooted in high-performing clinical units, the development of fertile cultures and effective unit leadership depend on support from above. This point is made by Ferlie and Shortell (2001: 282), who argue for "a more comprehensive, multi-level approach" to improve the quality and outcomes of care. Changes at any one level must take into consideration the other levels within an organization's strata in order to anticipate and deal with barriers. For example, team-level interventions take place in the context of an organization, which must have the necessary systems and resources in place to support its teams undergoing change. In this context, Berwick (2002) argues that there are four levels of analysis nested within each other:

The experience of the patient
The functioning of the microsystem
The functioning of the organization
The aspects of the broader environment, including policy, payment, regulation and other critical factors that shape the organization's behaviour

Similarly, Walshe and Freeman (2002: 85) note that a receptive organizational context is "a crucial determinant" of the effectiveness of quality improvement initiatives.
What are the key elements that facilitate improvement work?

The relationship between a system's levels and the dependence of microsystems on supportive environments suggests a need to understand what organizational and inter-organizational resources are necessary to promote improvements in care. Although many healthcare systems articulate strategic improvement goals, as Berwick et al. (2003: I35) note, "the ability to change should not be taken for granted. It implies a set of specific organizational processes (the processes that facilitate and manage systemic change), which constitute the organizational infrastructure for improvement." These commentators specify the elements of this organizational infrastructure necessary for improvement, including the following:

The reliable flow of useful information
Education and training for staff in improvement theory, methods and techniques
Understanding of time and change management necessary to change core processes
Alignment of strategic organizational incentives and improvement goals
Leadership to guide and inspire improvement

A number of other authors also discuss the various organizational processes and the ways they interact with one another. For example, Adler et al. (2003) describe five components of capability, including the following:

Skills: Technical, business and social skills
Systems: Organizational systems and information systems
Structures: Performance improvement staff groups and performance improvement project structures
Strategies: Priorities and strategy processes
Culture: Norms, values and identities

Ferlie and Shortell (2001) identify four essential core properties of successful quality improvement work:

Leadership at all levels
A pervasive culture that supports learning through the core process
Emphasis on the development of effective teams
Greater use of information technologies for both continuous improvement work and external accountability

Øvretveit and Gustafson (2002) identify eight important factors that motivate and sustain quality improvement programs. Like Ferlie and Shortell, they include leadership commitment and a supportive culture. They also add a number of structural factors (physician involvement, sufficient resources, careful program management and training) and a strategic focus on customer needs. Other analyses of critical factors supporting improvement have been made based on various data sources (see Barron et al. 2005; Franco et al. 2002; O'Brien et al. 1995). While the names for these critical factors and supportive processes vary, the main elements they contain are largely consistent. Table 2 provides an overview of the nine key attributes and component elements derived from a synthesis of these and other studies.

Table 2. Attributes of successful improvement [see: Chapter 1: Introduction. Learning from High-Performing Systems: Quality by Design]

If scholars in several countries with differing approaches have developed similar lists of key elements, then some might wonder why more healthcare systems have not achieved high levels of performance and reliability. The reasons for this are complex, but they likely stem from several factors. First, many of the elements identified as supporting high performance are difficult to achieve. For example, healthcare organizations must provide relevant and timely data on clinical processes in a format that guides improvement. This requires overcoming substantial technical and logistical challenges. Many organizations have found it difficult to develop skills for improving care and to create environments in which physicians "own" improvement. These components of high-performing healthcare systems are not widely shared, and there are many broader policy and resource barriers to developing them.

Second, in many cases these elements are interdependent. High-performing healthcare organizations are systems of interacting, interrelated and interdependent clinical microsystems. There are also supportive elements and structures that are aligned with (and sometimes pushing against) broader health system policy and structures. Fulfilling only some of the characteristics of successful systems is insufficient for achieving high performance. Instead, high-performing systems need to develop many, if not all, of the characteristics noted above.

Third, the path forward to achieve these attributes is rarely clear. Typically, we assess a system on a set of measures and judge it to be better or worse than others. But such an assessment is inevitably static; it does not tell us which strategies, structures and processes were critical for creating the system's high level of performance. Nor does it detail the leadership processes and strategic investments required over time.

Fourth, when offered a list of attributes associated with high-performing systems, the temptation is to create a checklist to assess other systems that wish to emulate such performance. But reality is more complex than a checklist. Developing a high-performing system is a journey that cannot be judged solely by examining current performance. Instead, we must assess the environment and challenges the organization faced; understand the strategies and investments its leaders made; and assess the learning, mid-course corrections and current efforts made to maintain and spread high performance. Nor can we assume that the decisions one organization made will be appropriate for others that face different challenges and possess different resources.

Exploring systems capable of improvement
The goal of the Quality by Design project was to investigate a small number of high- performing healthcare systems to examine the leadership strategies, organizational processes and investments made to create and sustain improvements in care. Although most comparative health policy literature focuses on differences in national systems (e.g., Anderson and Hussey 2001; Arah et al. 2003; Saltman and Figueras 1998), the variation in performance within national systems suggests that important learning can be gained from assessing strategies used by regional systems or other subnational units that have achieved high performance. And although it is clear that successful improvement must take place at the microsystem level where patients, clinical professionals and other staff members interact, these microsystems depend greatly on the leadership, resources and strategies of leaders in their broader organizations.

Nelson et al. (2007) have recently published a study of high-performing microsystems. Although they discuss the elements of the broader macrosystems that support the work of successful microsystems, their primary focus is on the tools and unit-level strategies for creating improvement at the front lines. By contrast, the emphasis in this study is understanding the strategies and investments of high-performing health systems. This fills a gap in the literature between studies of national healthcare policies, on the one hand, and the analysis of clinical microsystems and the methods and tools used to secure front-line improvements, on the other hand.

This focus is not unique. Several frameworks have been developed in recent years to assess performance excellence in organizations. In the US, the Malcolm Baldrige National Quality Program was created to recognize companies that have been successful in improving the quality of their goods and services and to stimulate improvement in other US firms. The Baldrige awards were first given in 1988 and the first award to a healthcare organization was made in 2002 (National Institute of Standards and Technology 2007). The criteria on which organizations are judged are based on a framework that assesses performance in seven areas: leadership; strategic planning; customer and market focus; measurement, analysis and knowledge management; human resources; process management; and, results. As of 2007 eight healthcare organizations had won the Baldrige Award. Senior leaders from several of these organizations have written detailed accounts of their organization's efforts to improve quality (e.g., Ryan 2007; Stubblefield 2005). Similar awards in Canada (e.g., the National Quality Institute's Canada Awards for Excellence) and Europe (the European Foundation for Quality Management's Excellence Awards) have established similar criteria and processes for judging excellence (European Foundation for Quality Management 2003; National Quality Institute nd). Healthcare organizations have used these awards programs as guides to assessing and improving their performance.

Mary Jean Ryan (2007) and other winners of the Baldrige Award identify the Baldrige framework and criteria as a useful guide to assessing their organizations and helping to direct the leadership of improvement. Many thousands of copies of the Baldrige criteria have been downloaded or purchased, and both Baldrige and other award criteria have been used to inform or evaluate leadership strategies (e.g., Goldstein and Schweikhart 2002; Nabitz et al. 2000). However, by themselves the long lists of criteria and questions in these assessment frameworks are daunting and require considerable effort to complete. Moreover, the frameworks are similar, but not identical (MacIntosh-Murray et al. 2006), and possible gaps in them have been identified (Counte and Meurer 2001). Lastly, many descriptions of award-winning organizations emphasize their current performance rather than the strategies that led to it.

The accounts by Baldrige winners do, however, describe their journeys and are useful sources of ideas. Yet these accounts emphasize different issues and focus only on US organizations. There are, therefore, few studies that have employed consistent methods for assessing high-performing healthcare organizations in different policy environments. Two notable exceptions are the recent book by Bate et al. (2008), who examine quality improvement efforts in seven hospitals in the US and Europe, and McCarthy and Blumenthal's (2006) study of the work of six US organizations that have been leaders in patient safety strategies.

Approach and methods: Selecting and profiling systems capable of improvement
There are no international performance data that rank regional healthcare systems. Therefore, in order to select the systems studied in this project we devised a nomination and selection process that relied on experts to identify health systems that have successfully invested in improvement resources and demonstrated measurable performance improvements over time. We asked 21 international experts in quality improvement and health systems monitoring to nominate health systems (defined as regional authorities, trusts and/or networks/systems of organizations, as opposed to single hospitals) they believed had made significant investments in quality improvement and had achieved demonstrable, measurable improvements as a result of those investments. These experts were chosen according to their reputations in the fields of practice and academia as being knowledgeable about systems that were successful in improvement. Among our experts were individuals from the European Society for Quality in Healthcare, Institute for Healthcare Improvement and the Joint Commission for the Accreditation of Healthcare Organizations International, as well as health system providers, researchers and decision-makers.

Fourteen experts submitted 40 nominations of 22 health systems. Of the 22 systems, 13 were in the US, 5 were in Europe and 3 were located elsewhere. Seven systems were nominated more than once. We examined the accomplishments of these seven systems and selected five based on their capabilities in sustaining quality improvement efforts and results. Our team collected information on the chosen systems through a review of publications and data available on the Internet and from other sources. From May 2006 through September 2007, between two and four team members paid one visit to each of the five sites. In advance of each visit, the researchers reviewed a range of background documents provided by system informants, including, for example, strategic plans, annual reports, terms of reference, improvement reports and Baldrige Award or other detailed applications for public recognition. Site visits included meetings and interviews with system leaders, clinicians, administrators and educators as well as local and national health system leaders and policy-makers.

The case studies were crafted based on thematic analysis of extensive notes recorded during the interviews, integrating details from the strategic and operational documents from each site. Key interview participants at each of the five sites reviewed the draft reports to ensure factual accuracy. A study advisory committee comprised of leaders from health organizations in Ontario and elsewhere in Canada met twice to discuss the study framework as well as case report drafts. Members of this committee provided helpful insights and guidance, and validated the relevance of the major themes in the Canadian context.

In addition to the five international cases, we investigated two Canadian systems. These cases were selected with guidance from members of the study advisory committee as representative of better-performing Canadian healthcare systems that exemplified elements present in the international cases. While none of the systems originally nominated by our experts were Canadian, we included Canadian cases in response to interest from several advisory committee members about whether characteristics of high-performing systems could be identified in Canadian organizations. The two cases provide evidence that Canadian health policies, financial environments and regulatory frameworks do not prevent the emergence of high-performing systems. These two cases were approached in a somewhat different fashion than the five international ones. Two members of the team spent several months on site - one team member at each - as part of practicum experiences for their master's degrees in health administration. During this time they collected information and conducted interviews. Other members of the team collected additional interviews and information, and drafts of the cases were reviewed and revised by several team members.

Drafts of the international and Canadian cases were given to leaders in the respective organizations so they could identify factual errors in our descriptions. In addition, we sought input from external experts who knew the organizations, and we reviewed other case analyses of and literature on the healthcare systems we studied. In a few instances system leaders disagreed with some of the interpretations we made of their organizational strategies. We have duly noted where these disagreements occurred.

As with any study, there are limitations inherent in the Quality by Design approach. For example, the nomination method for systems to study was influenced by expert opinion, health system visibility and case visit feasibility. The choice of other experts might have led us to different systems. However, we do not claim that our study comprises an exhaustive list of high-performing health systems internationally, nor was that our intent.

In each of the cases we discuss a number of areas in which the organizations have been successful, describing the strategies, methods and tools used at a senior leadership level, detailing the organizational infrastructure and approach, and examining the methods and tools used at the front lines of care. Still, none of these systems' representatives would claim their performance is exemplary in all domains, and each one noted areas they are targeting for improvement. One of the characteristics of highly successful healthcare systems is a paradoxical stance toward success. All the organizations we studied were proud of their achievements and often sought recognition of their successes to support further efforts and reward staff members. Yet all were striving to spread their successes throughout their organizations to improve more areas of care. Indeed, an impatience - rather than satisfaction - with current performance appears to be a hallmark of high-performing healthcare systems.

Variations in performance also mean that in some areas these high-performing systems may be merely "average." There is no Toyota in healthcare: no one system clearly outdistances its competitors in virtually all its products and services. In selecting the systems we chose for our case studies, and in collecting and analyzing information on those cases, we sought evidence that the seven organizations had developed robust strategies and approaches. Nevertheless, some performance measures in each organization are not at the level to which system leaders might aspire.

Canadian healthcare policy expert Steven Lewis has observed, "[We need to] become more adept at learning which features of international systems we can and cannot easily import, and recognize that what ails our system originates in design rather than the laws of nature" (Lewis 2007: 19). The focused case study approach allowed us to describe in more detail the developmental stories of five international and two Canadian organizations as they worked to become - and remain - high-performing systems. None of the cases is a precise road map for other systems in Canada or elsewhere. But all provide useful insights into the strategies, investments and lessons learned on the journey to excellence.

A key strength of our approach is that the case narratives highlight details of the how:

The often difficult processes these varied organizations have gone through
What they have done and why
What they believe has worked (or not)

By reading the stories from each system, comparing them with our own organizations and considering the policy environment and resources that provide a context for performance, we can begin to identify ideas to import. Learning from these case studies requires that we acknowledge the differences between policy contexts and timing. Moreover, in addition to recognizing the strategies and ideas that may be transferrable we need to determine the "obstacles that have to be addressed in translating practices from one system to another" (Ham 2005: 192). From country to country - and even within the same country - healthcare systems are widely divergent in terms of histories, contexts, policies, structures and other determining factors. Our study focused on high-performing systems that have very different structures, exist in policy environments that range from highly directive to facilitative and embody very different histories. Despite these differences we believe that careful study of international and local successes better enables us to evaluate the assumptions and decisions in our own environment, aspects of health system planning and operation that sometimes go unquestioned. In other words, the case studies can help us to learn about what we might try to do differently in our own systems' pursuit of quality - not by chance, but by design.

Footnotes1
The Commonwealth Fund surveys began with comparisons of the US, Canada, the United Kingdom, Australia and New Zealand. Results from Germany and the Netherlands have been added more recently.

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High Performing Healthcare Systems

2008-10-16T14:30:00.000-07:00

Foreword to the Book
Adalsteinn Brown

Citation Information
Brown, A. 2008. "Foreword." High Performing Healthcare Systems: Delivering Quality by Design. 9-10. Toronto: Longwoods Publishing.

Quality remains one of the great trade-offs in Canada's healthcare system. Every person working in the system agrees with the importance of quality, and many make it an explicit part of their personal and professional missions. Today, for example, when confronted by clear evidence of poor quality in their own practices and organizations, clinicians and administrators rarely question the validity of the information and they respond quickly to solve the problems identified. At the same time, however, most clinicians and administrators believe that large-scale improvement is unaffordable.

Although quality continues to rise in importance, and nearly every study published identifies room for improvement, something stops us from achieving the high quality we desire. The work of G. Ross Baker - who led the Quality by Design initiative and, with Peter Norton, the landmark study on patient safety in Canada - lays out the challenge clearly. Every day in Canada's healthcare system preventable errors arise in hospitals, long-term care facilities and physicians' offices. These errors lead to extra costs, poor health and, in many cases, avoidable deaths. Yet the pursuit of safety and quality remains the something extra that many of the people working in our system can follow up on only at the end of a busy day.

There are a number of potent examples to the contrary in the case studies that follow. These are portraits of healthcare systems that have made the pursuit of quality and safety a core element of their strategies, a part of everyone's work and the way they differentiate themselves from their competitors. Constant improvements in quality and safety are integral to their workplace cultures and central to what is expected from everyone employed in those systems. In a presentation based on one of the following case studies, Sven-Olof Karlsson, the chief executive officer of Jönköping County Council, put it most succinctly: "Everyone has two jobs: to do their job and to do that job better." In the systems profiled in this book, quality and cost are not opposing goals; rather, quality is one of the ways to improve cost control. Moreover, these systems are not rich healthcare systems or systems that serve only the rich. The examples collected here include Canadian systems, as well as systems from the United Kingdom, Sweden and the United States that offer care to incredibly diverse populations.

The Ontario Ministry of Health and Long-Term Care (MOHLTC) provided a grant for the Quality by Design project because we believed it was important to try to identify the common elements of high-performing healthcare systems from around the world. Our sincere thanks go to the research team and to the leaders of the systems who graciously participated. The MOHLTC's Health Quality Council has defined characteristics of a high-performing healthcare system, attributes that range from equity to efficiency. Each of the systems profiled in this book strives to meet those characteristics. And each provides an example to leaders at all levels of Canada's healthcare system of how to design our structures and processes to achieve the outcomes desired by the people we all hope to serve.

None of the systems discussed in this collection presents the ideal recipe for better quality. Rather, each case illustrates that high quality results only from a mix of good incentives, helpful information technology, clear goals, accountability systems and the constant application of quality improvement techniques made possible through widespread improvement training. Moreover, each system proves that high quality is more the result of a culture that pursues quality than of any single investment or policy. The systems the Quality by Design team profiles in this Book pose a provocative challenge for the rest of us because they overcame familiar obstacles in order to deliver high-quality and sustainable care every day. We must do the same.

About the Author
Adalsteinn Brown
Assistant Deputy Minister, Strategy
Ministry of Health and Long-Term Care
Ontario, Canada

High Performing Healthcare Systems

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

Chapter 2: Birmingham East and North Primary Care Trust and Heart of England Foundation Trust - Birmingham, UK

Highlights of recent achievements

The system and its environment

Method: Exploring a system capable of improvement

Examples of improvement initiatives

Clinical improvement projects

Partners in Health Centre

Musculoskeletal orthopaedic triage service with choice

Vascular clinic and telemedicine system

Birmingham OwnHealth®

Assertive case management

The strategy: Align improvement processes with system strategy, culture and operations

Leaders in a complex change environment

Approach to change

Investment in organizational development

Managing the tensions between short-term projects and long-term vision

Links with "mentor" organizations and individuals

Kaiser Permanente

Physician leadership

Performance management: Competing demands and financial pressures

Conclusion

Notes to Figure 2

Appendix A. National Health Service: Health system context

1.0. Background

2.0. Supply-side reforms

2.1. Investments in capacity and a plurality of providers

2.2. Service and role redesign

2.3. Practice-based commissioning

2.4. Integration of health- and social care

3.0. Demand-side reforms

3.1. Payment by results

3.2. Patient choice

3.3. Financial incentives

4.0. National guidance, standards and targets

4.1. Priorities and targets

4.2. Performance reporting and external assessment

4.3. NICE and National Service Frameworks

5.0. Regional accountability

6.0. Information technology

7.0. Support for quality improvement

7.1. Modernisation Agency

7.2. Clinical Governance Support Team

7.3. Institute for Innovation and Improvement

Chapter 3: Veterans Affairs New England Healthcare System (Veterans Integrated Service Network 1) - New England, US

Method: Exploring a system capable of improvement

VISN 1 and its environment

"A profound change": Improvement in an integrated system

Service lines

Performance measurement and accountability

Information technology: Electronic medical records and clinical reminders

Electronic medical records and physician accountability

Clear goals and performance measures

How do local centres deal with national and network expectations? Implementation tensions and adjustments

VA Boston

Performance measurement

Implementing changes

Participation in IHI improvement collaboratives

Access collaborative

Improving patient flow

Patient safety

Resident training: Patient safety and QI rotation

Staff and patient satisfaction

White River Junction VA Medical Center, Vermont: A strategic approach to improvement

Local versus national performance measurement

Measurement challenges

E-health record and information system

WRJ VAMC and Dartmouth Medical School: "A symbiotic relationship"

The VA National Quality Scholars Program

Advanced clinic access in mental health

VA National Center for Patient Safety field office

Leadership in an improvement culture

Training and education

Continuing challenges: Balancing improvement with accountability and compliance in a shifting - and political - environment

Government rules and relationships

Standardization and performance measurement - improvement or compliance?

Aging and decreasing patient population

Leadership and staff turnover

Appendix D. VHA Office of Quality and Performance - April 2001

Birmingham OwnHealth^®

Birmingham OwnHealth^®