Exercise 5.1
CHAPTER
65
5VISUALIZING SYSTEM RELATIONSHIPS Learning Objectives
After completing this chapter, you should be able to
• recognize the benefit of viewing system components when managing quality,
• explain how parts of the health services delivery system are interconnected,
• contrast four different models for illustrating system relationships, and • describe the management implications of different system relationship
models.
J ust as a road map provides a picture of how places are connected in a geographic area, models can provide a picture for managers of how elements may be connected in and between systems. These models are valuable managerial tools for revealing and providing insight about systemic structure. Similar to one’s preference for an electronic map over a paper map, managers may prefer one model over another depending on their work settings, backgrounds, and individual preferences. Numerous models provide healthcare managers with a picture of the organizational system in which they work to help them recognize, understand, and anticipate how the parts of the systems are related and interact to form the whole.
The most basic system may be characterized by three elements: input(s), a conversion process, and output(s). These elements are demonstrated visually in this simple diagram:
Input(s) → Conversion process → Output(s)
In a health services organization, examples of inputs are patients, personnel, supplies, equipment, facilities, and capital. Examples of conversion processes are diagnostic processes, clinical treatments, operational activities, and business management functions. Examples of outputs are a patient’s health status and an organization’s business performance.
Applying Qual i ty Management in Healthcare: A Systems Approach66
Often, quality efforts focus on managing the inputs and conversion process that make up the system. The healthcare field regulates the quality of personnel inputs by various means, including licensure requirements, continuing education, and performance appraisals. Clinical trials and US Food and Drug Administration approval are two examples of ways to control the quality of technology inputs such as drug therapies. Clinical guidelines, process improvement, and standardization help maintain high standards for conversion processes. Controlling the quality of the inputs and conversion processes is intended to improve the quality of the outputs, such as patient clinical and functional status, satisfaction with services, cost-effectiveness, employee behaviors, and organizational culture.
Adding a feedback loop creates a more dynamic process—one that leads to a more mature quality management approach. Feedback about the quality of the outputs guides efforts to improve the quality of the inputs and the conversion processes (see exhibit 5.1). Continuous feedback promotes continuous improvement. The Donabedian (1980) categories of medical quality measures and their relationship (structure → process → outcomes) support this continuous improvement model.
In chapter 3, systems thinking is defined as “a view of reality that emphasizes the relationships and interactions of each part of the system to all the other parts” (McLaughlin and Olson 2012, 39). A systems thinking approach to quality management involves improving the quality of the parts and understanding and improving the quality of the relationships between the parts. This systems thinking approach requires managers to view health services organizations in a systems context. Four models are presented in this chapter to help managers better understand system relationships: the interconnected systems model, the three core process model, the Baldrige Performance Excellence Program framework, and the socioecological framework.
Feedback
Improve Conversion ProcessesImprove Inputs Outputs
Source: Adapted from Tagg (2007).
EXHIBIT 5.1 Quality
Management System
Chapter 5: Visual iz ing System Relat ionships 67
Interconnected Systems Model
Ferlie and Shortell (2001) offer a systems view of healthcare that illustrates the interconnected clinical delivery system: the environment, the organization, the microsystem, and the patient (exhibit 5.2). The environment (e.g., government regulations, accreditation policies) has a significant impact on the delivery system. The organization’s infrastructure influences how patient care is delivered. The infrastructure is shaped in part by external stakeholders, such as the federal government’s push for adoption of electronic health records (EHRs). Ensuring the workforce has the right equipment and skills to properly care for patients are important elements of the infrastructure. The patient care microsystem, in this model, is “the level of healthcare delivery that includes providers, technology, and treatment processes” (McLaughlin and Olson 2012, 9).
Lessons for Healthcare Managers The interconnected systems model is the only approach that clearly shows the patient at the center of the health system. The manner in which each layer of the system interacts with the others has a direct impact on the patient. Improving the effectiveness of clinical care requires process changes at the patient care microsystem level and in the infrastructure. For example, implementation of evidence-based treatment guidelines can help ensure patients receive appropriate treatments at the correct time. Making this goal a reality often requires changes in the organizational infrastructure. Tools such as computerized physician order
patient care microsystem “the level of healthcare deliv- ery that includes providers, technol- ogy, and treat- ment processes” (McLaughlin and Olson 2012, 9)
Organization Level C
Microsystem Level B
Patient Level A
Environment Level D
Source: Reprinted from Ransom, Joshi, and Nash (2005). Based on Ferlie and Shortell (2001).
EXHIBIT 5.2 Interconnected Systems View of Healthcare
Applying Qual i ty Management in Healthcare: A Systems Approach68
entry and treatment plans, together with electronic prompts or alerts built into the EHR, help remind providers of the guidelines at the point of care.
The subsystems in the interconnected systems often have feedback mechanisms that reinforce or balance system performance. Exhibit 5.3 illustrates how a change in the environment level ripples throughout the other three levels of the system.
Three Core Process Model
The three core process model shown in exhibit 5.4 represents a “horizontal” view of a health services delivery organization. All processes in the organization (represented by the arrows) should operate in an aligned fashion toward improving performance. The model starts on the right of the exhibit by defining desired results using a balanced set of outcomes: the patient’s clinical outcomes, functional status, satisfaction, and cost of services.
In the three core process model, the many processes that take place in a health services organization are grouped into three core categories: (1) clinical, medical, and technical processes; (2) operational or patient-flow processes; and (3) administrative processes.
Clinical, medical, and technical processes are the fundamental reasons individuals seek the assistance of a health services organization—that is, to take care of some need that involves diagnosis, treatment, prevention, or palliative care. Physicians and nonphysicians provide these services. The processes may be medical, such as surgery; mental health related, such as counseling or therapy; connected to daily care, such as nursing care after a stroke; or required by special treatments, such as obtaining oxygen or other durable medical equipment for the home.
Payers want to reduce costs for chemotherapy
Clinical Microsystem
Environment PatientOrganization
New payment method for
chemotherapy is created
Chemotherapy treatment needs
to be more efficient to meet payment levels
Changes are made in care
processes and support systems
to maintain quality while
reducing costs
Source: Reprinted from McLaughlin and Olson (2012, 12). Used with permission.
EXHIBIT 5.3 Linkages in the Interconnected
Clinical Delivery System:
Chemotherapy
Chapter 5: Visual iz ing System Relat ionships 69
Operational or patient-flow processes enable an individual to access the clinical, medical, and technical processes. This category includes processes such as registering patients, scheduling activities, and coordinating services. Administrative decision-making processes occupy two positions in the exhibit, above and below the other two core processes. In this way, the model illustrates how administrative processes influence the overall organization. These processes include decision making, communication, resource allocation, and performance evaluation. The arrows linking the three core processes reflect the interdependence of the processes.
Lessons for Healthcare Managers The three core process model teaches managers several lessons. First, the interdependent relationships between the three core processes suggest that improvement in any one of these processes has the potential to increase the value of the service provided. However, the concurrent targeting of these core processes provides a synergy that can accelerate the achievement of improved outcomes. “An efficient clinical process supported by an inefficient operational process, or vice versa, is still an inefficient process. . . . In addition, if . . . changes are made independent of clinician involvement, the likelihood of implementation is reduced. It is therefore necessary to have decision-making processes that actively engage clinicians in change efforts” (Kelly et al. 1997, 127–28).
Desired results: • Clinical outcomes • Functional status • Satisfaction • Cost
Operational/Patient & Client Flow Processes
Clinical/Medical/Technical Processes
Administrative Decision-Making Processes
Administrative Decision-Making Processes
EXHIBIT 5.4 Three Core Process Model
Applying Qual i ty Management in Healthcare: A Systems Approach70
For example, in one ambulatory surgery unit, the patient postoperative length of stay—the time the patient leaves the operating room to the time the patient is discharged—was found to be longer than in other, similar ambulatory surgery units. An improvement effort aimed at ameliorating the discharge process was undertaken in hopes of reducing the length of stay. As the improvement effort progressed, the team realized that anesthesia practices were affecting its ability to achieve better results. If patients were being heavily sedated in the operating room and were slow to wake up as a result, the gains from improving the discharge process could not be fully realized. Likewise, if the physicians implemented a new clinical protocol for anesthesia and pain management but patients still had to wait for the nurses to discharge them, gains from improving the anesthesia process could not be fully realized. Recognizing the interdependence of these two processes and targeting the discharge process and the anesthesia protocol for improvement allowed the benefits of both improvement efforts to be achieved. Furthermore, if the administrative processes did not permit employees to be scheduled away from clinical duties so they could be involved in the quality efforts, neither of the improvements could take place.
Second, the three core process model helps promote a patient-focused orientation by recognizing the need for aligning processes and improvement efforts toward the needs of the patient. The conceptual view of operations and administration observes how the patient (or client) moves through the entire system to access a clinical process. For example, a seemingly simple supervisory decision such as scheduling lunch breaks took on new meaning for one emergency department (ED) when the decision was viewed with patient flow in mind. Although scheduling staff lunch breaks at noon seemed reasonable, this practice created unnecessary patient delays and bottlenecks in the patient care processes because patient visits typically increased during the hours of 11:00 am to 1:00 pm. After ED management observed the situation from the patient-flow perspective, the break policy was revised so staff breaks occurred before and after—rather than during—busy patient times.
Third, the model reinforces the different yet necessary and interdependent contributions each core process and each provider (or implementer) of those processes provide to patient care and organizational outcomes. This way, collaboration among the entire care team can be promoted.
Fourth, when the administrative role is viewed as a process rather than a function or a structure, the tools used to improve other types of processes may also be applied to administrative processes. If one of the desired outcomes is patient satisfaction, the administrative decision-making processes must include mechanisms to regularly collect, analyze, report, and evaluate patient satisfaction data and to communicate these results throughout the organization.
Chapter 5: Visual iz ing System Relat ionships 71
Baldrige Performance Excellence Program Framework
The healthcare criteria of the Baldrige Performance Excellence Program (BPEP) provide a well-established systems approach for improving organizational effectiveness. Charleston (WV) Area Medical Center Health System found the criteria provided “an overarching framework for the system. . . . CEO Dave Ramsey reported that . . . ‘Baldrige added ways to achieve quality in our support of the community, our working relationship with vendors, our relationship with the medical staff, medical researchers and the workforce, pretty much everything’” (Asplund 2016). For readers who desire a more in-depth explanation, information about these criteria and examples of how health services organizations address the criteria can be found on the program’s website (www.nist.gov/baldrige).
Exhibit 5.5 illustrates the essential elements in the Baldrige framework and the links between these elements. The following passage explains how to read and interpret the exhibit (BPEP 2015, 1):
The Organizational Profile sets the context for your organization. It serves as the
background for all you do. The performance system consists of the six categories in
the center of the exhibit. These categories define your processes and the results you
Core Values and Concepts
Integration
Workforce
RESULTS
Operations
Measurement, Analysis, and Knowledge Management
Organizational Profile
Leadership
Strategy
Customers
Source: Reprinted from Baldrige Performance Excellence Program (BPEP) (2015).
EXHIBIT 5.5 Organizational Profile: Baldrige Performance Excellence Program Framework for Health Care
Applying Qual i ty Management in Healthcare: A Systems Approach72
achieve. Performance excellence requires strong Leadership and is demonstrated
through outstanding Results. Those categories are highlighted in the exhibit. The word
“integration” at the center shows that all the elements of the system are interrelated.
The leadership triad (Leadership, Strategy, and Customers) emphasizes
the importance of a leadership focus on strategy and customers. The results triad
(Workforce, Operations, and Results) includes your workforce-focused processes, your
key operational processes, and the performance results they yield. All actions lead
to results—a composite of health care and process, customer-focused, workforce-
focused, leadership, and governance, and financial and market results.
The system foundation (Measurement, Analysis, and Knowledge Management)
is critical to effective management and to a fact-based, knowledge-driven, agile
system for improving performance and competitiveness. The basis of the Health Care
Criteria is a set of Core Values and Concepts that are embedded in high-performance
organizations.
The center horizontal arrowheads show the critical linkage between the
leadership triad and the results triad and the central relationship between the
Leadership and Results categories. The center vertical arrowheads point to and
from the system foundation, which provides information on and feedback to key
processes and the organizational environment.
Lessons for Healthcare Managers Managers may take several lessons from the Baldrige systems model. First, the model describes the essential elements of organizational effectiveness (represented by the seven boxes in the model) and how they are related. The model recognizes the unique circumstances in which different organizations operate and encourages managers to base decisions, strategies, and interventions on their unique organizational profiles. The overarching nature of the organizational profile promotes ongoing consideration of external influences, such as environmental, regulatory, or market demands.
When viewed in light of the Baldrige model, one can see that the traditional principles of total quality (customer focus, continuous improvement, teamwork), described in chapter 1, touch on some, but not all, of the required elements (customer focus, operations focus, and workforce focus). The Baldrige model visually illustrates that a systems approach to quality management in a healthcare organization requires managers to focus on more than just the three principles of total quality. Achieving organizational effectiveness also requires a focus on the external environment, leadership, strategic planning, measurement, analysis and knowledge management, and on how the workforce members contribute individually and collectively to achieving the desired organizational performance results.
Chapter 5: Visual iz ing System Relat ionships 73
Managers who use this model understand the importance of alignment in the organization. This alignment means that the activities in each box in the model are directed toward achieving the same results and that organizational and management choices are consistent with the organization’s mission, vision, values, strategic direction, and patient and stakeholder requirements. Without alignment, improvement efforts can be less effective. For example, one health services organization offers comprehensive quality improvement training for its managers. Each manager is expected to design and carry out an improvement effort as a requirement of the training, so each selects a topic on which to focus his improvement project. Although each manager demonstrates improvement in the chosen area, the collective improvements of all the training participants may not contribute to the overall organizational objectives. This observation is illustrated by one manager who devoted much time and effort to improving a service area that was eliminated by the organization the following year. Another healthcare organization offering a similar type of training engaged senior leaders to help select improvement topics that would not only provide benefit within the managers’ scope of responsibility but also contribute to the overall organizational strategy.
The Baldrige model also illustrates the link between management and human resource needs. Before implementing a process improvement, managers ask themselves, “What needs to happen to ensure the staff will succeed at implementing the new process?” As a result, when a new process is initially implemented, managers support employees as they learn the new process or their new roles. Adapting to something new takes time, and by anticipating slight disruptions during the transition period, the manager is better prepared to accommodate whatever short-term budget or productivity variances might occur. An understanding of the framework that helps managers realize their role in process improvement also includes ensuring that employees have the information, training, and tools they need to successfully implement improvements in the work setting.
Finally, the Baldrige model illustrates essential linkages in the system. For every key leadership, management, and daily work process of the organization, the Baldrige criteria ask four questions (BPEP 2015):
1. Do you have a systematic approach, tools, and tactics? 2. Is your approach deployed to the people who need to use it? 3. Do you evaluate and improve the approach periodically? 4. Does this particular approach integrate into and align with other
organizational approaches in other areas?
Applying Qual i ty Management in Healthcare: A Systems Approach74
Integration of the leadership and results elements, represented by the arrows, is a vital component of an effective organizational system. For example, one health services manager realized the connection between the leadership triad and the results triad was one-way only. Communication flowed in one direction only with little opportunity for the managers and other staff to provide feedback for consideration in decision making at the organizational level. This realization helped to explain her perceived disconnect between organization- wide initiatives and her department’s local circumstances and needs.
Socioecological Framework
The socioecological framework represents a transdisciplinary systems perspective on promoting health and wellness that uses and reflects theory from multiple fields, including medicine, public health, and behavioral and social sciences. Social ecology scholar Daniel Stokols (2000, 27) further describes the underpinnings of the framework:
The healthfulness of a situation and the well-being of its participants are assumed to
be influenced by multiple facets of both the physical environment (e.g., geography,
architecture, and technology) and the social environment (e.g., culture, economics,
and politics). Moreover, the health status of individuals and groups is influenced not
only by environmental factors but also by a variety of personal attributes, including
genetic heritage, psychological dispositions, and behavioral patterns. Thus, efforts
to promote human well-being should be based on an understanding of the interplay
among the diverse environmental, biological, or behavioral factors.
Key to this framework is the recognition of “the complexity of human environments” and the emphasis on multilevel, interrelated influences and multilevel, interrelated interventions influencing health and wellness (Stokols 2000). These multiple levels may be thought of as nested systems within systems, starting with the individual and expanding to include “interpersonal, organization, community, society, supranational” (Kok et al. 2008, 438). Peter Reed illustrates the multiple and interrelated levels of influences (determinants) and interventions in exhibit 5.6. Reading the exhibit top to bottom illustrates the four levels of determinants of health behavior: individual, organization, community, and population (Reed 2001). Reading the exhibit left to right illustrates that for each of these levels of determinants, specific interventions may be implemented and their effects evaluated. For example, the model may be used to better understand smoking behavior.
Chapter 5: Visual iz ing System Relat ionships 75
Individual determinants of smoking behavior include a person’s knowledge of associated health risks and the smoking behavior of family and friends. Individual interventions to reduce smoking behaviors may include smoking cessation classes and pharmacotherapy (e.g., nicotine patches). The impact is measured by whether the person stops smoking or does not start in the first place.
Organizational determinants of smoking behavior include policies regarding smoking in the workplace and the availability of smoking cessation classes as an employee health benefit. Prohibiting smoking, offering limited access to on-site smoking areas, and reimbursing employees for smoking cessation classes are interventions targeted at the organizational level. The proportion of employees who smoke and the “quit rate” are common organizational evaluation measures.
Community determinants of smoking behavior include social norms and beliefs. For example, smoking may be linked to social status and acceptance. Because of the history of tobacco farming in the southeastern United States, smoking has also been associated with the community’s economic livelihood and therefore viewed more favorably. Redefining social norms and recruiting nontobacco economic opportunities would be considered community-level interventions. Impact may be measured in terms of community smoking rates.
Determinant Intervention Evaluation (impact)
Evaluation (outcome)
Individual
Organization
Community
Population
Health and Health
Behaviors
Source: This illustration reprinted with permission by Peter Reed, MPH, JoAnne Earp, ScD, and the instructors of HBHE 131, Introduction to Social Behavior in Public Health, Department of Health Behav- ior and Health Education, University of North Carolina at Chapel Hill, School of Public Health, 2001.
EXHIBIT 5.6 Socioecological Framework
Applying Qual i ty Management in Healthcare: A Systems Approach76
Population determinants of smoking behavior include regulations regarding smoking in public places. No-smoking airline flights, no-smoking buildings, or a “sin tax” on cigarettes are examples of population-level interventions. The effect may be measured by compliance with regulations and population smoking rates.
In exhibit 5.6, the arrows between the levels indicate the interconnectedness of the determinants, interventions, and impact at all levels. While a level-specific intervention may be effective, recognizing the relationships between the levels creates a synergy to enhance desired outcomes. Using the example on smoking, one can understand the limited impact of enrolling a person in a smoking cessation class when he is surrounded by smokers in the family, in the workplace, and in public venues.
Lessons for Healthcare Managers The major lesson from this framework for healthcare managers is that it provides a more expansive view of the nature of health and wellness in general and of health services specifically. In doing so, the model offers a larger context in which to understand interventions designed to improve the quality and safety of services provided by health services organizations and, in turn, to understand complementary and competing interventions within and between levels. This knowledge is particularly important to partners in accountable care organizations that share medical and financial responsibilities for providing coordinated care to a population of patients (Gold 2015).
In 2001, the Institute of Medicine recommended that “the changes needed to realize a substantial improvement in health care involve the health care system as a whole” (20). This recommendation implies understanding not only how organizations work as systems but also how the multiple players and layers involved in the health services sector are interrelated.
Summary
Systemic structures may not be readily visible. System models are valuable managerial tools to help managers identify the elements and connections between those elements in their organizations and the environments in which they operate. Exhibit 5.7 summarizes lessons from the four system models discussed in this chapter. Managers are encouraged to identify, integrate, and continuously apply lessons from each of these models to further develop their skills in understanding systemic structures.
Chapter 5: Visual iz ing System Relat ionships 77
Exercise 5.1 Objective: To practice identifying activities that represent essential elements in the Baldrige Performance Excellence Program (BPEP) framework.
Instructions: Think about your healthcare services work area or area of interest. Identify two activities a manager in this area does to advance organizational excellence in each of the following Baldrige framework categories:
• Strategy • Customers • Workforce • Operations
Examples of what healthcare recipients of the Baldrige National Quality Award have done in these areas can be found online at www.nist.gov/baldrige.
Interconnected Systems Model
Three Core Process Model
Baldrige Performance
Excellence Program Framework
Socioecological Framework
Places the patient at the center of healthcare delivery
Encourages concurrent improvement of interdependent processes
Shows how the components of organizational effectiveness are related
Broadens and expands the manager’s view
Fosters feedback mechanisms that reinforce or balance system performance
Aligns pro- cesses around patient/client/ customer needs
Recognizes the context in which the organization operates
Addresses community and policy influences on health outcomes
Encourages awareness of linkages between major elements affect- ing patient care
Values all pro- vider/employee groups
Promotes alignment of all organizational activities, includ- ing performance measurement
Illustrates the interrelationships among multiple levels involved in improving health outcomes
Illustrates the ripple effect of changes in the environment
Views adminis- trative role as a process rather than a function
Illustrates essential links in the system
Encourages inter- related, multilevel interventions
EXHIBIT 5.7 Systems Models: Lessons for Managers
Applying Qual i ty Management in Healthcare: A Systems Approach78
Companion Readings
Baldrige Performance Excellence Program (BPEP). 2015. 2015–2016 Baldrige Excellence Framework: A Systems Approach to Improving Your Organization’s Performance (Health Care). Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology.
Centers for Disease Control and Prevention. 2015. “Social Ecological Model for the Colorectal Cancer Control Program.” Reviewed October 27. www.cdc.gov/ cancer/crccp/sem.htm.
———. 2015. “Social Ecological Model for Violence Prevention.” Reviewed March 25. www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html.
Health Administration Press. 2015. “The Baldrige Journey: In Pursuit of Excellence” (entire issue). Frontiers 32 (1). www.nist.gov/baldrige/enter/upload/ACHE- FrontiersThe-Baldrige-Journey.pdf.
Ruderman, M. 2013. “The Ecological Model in Public Health.” The Women’s and Children’s Health Policy Center. Published June. www.jhsph.edu/research/ centers-and-institutes/womens-and-childrens-health-policy-center/eco-model/ eco-model.html.
Web Resource
Baldrige Performance Excellence Program Healthcare and National Quality Award Winners: http://patapsco.nist.gov/Award_ Recipients/index.cfm
References
Asplund, J. 2016. “Prestigious Award Program Offers Hospitals a Framework for Bolstering Quality.” H&HN. Published February 26. www.hhnmag.com/ articles/6968-malcolm-baldrige-award-providing-a-framework-for-quality.
Baldrige Performance Excellence Program (BPEP). 2015. 2015–2016 Baldrige Excellence Framework: A Systems Approach to Improving Your Organization’s Performance (Health Care). Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology.
Donabedian, A. 1980. The Definition of Quality and Approaches to Its Assessment. Vol. 1 of Explorations in Quality Assessment and Monitoring. Chicago: Health Administration Press.