HE380.0.1 Managed Healthcare Assignment 4

A Framework for Describing Health Care Delivery Organizations and Systems Ileana L. Piña, MD, MPH, Perry D. Cohen, PhD, David B. Larson, MD, MBA, Lucy N. Marion, RN, PhD, MN, Marion R. Sills, MD, MPH, Leif I. Solberg, MD, and Judy Zerzan, MD, MPH

Describing, evaluating, and conducting research on the questions raised by

comparative effectiveness research and characterizing care delivery organiza-

tions of all kinds, from independent individual provider units to large integrated

health systems, has become imperative. Recognizing this challenge, the Delivery

Systems Committee, a subgroup of the Agency for Healthcare Research and

Quality’s Effective Health Care Stakeholders Group, which represents a wide

diversity of perspectives on health care, created a draft framework with domains

and elements that may be useful in characterizing various sizes and types of care

delivery organizations and may contribute to key outcomes of interest. The

framework may serve as the door to further studies in areas in which clear

definitions and descriptions are lacking. (Am J Public Health. 2015;105:670–679.

doi:10.2105/AJPH.2014.301926)

Recent and ongoing innovation in systems for the delivery and reimbursement of health care in the United States have broadened stakeholders’ need for standardized methods to describe, measure, compare, and evaluate delivery system changes. A common taxonomy of delivery system characteristics would allow for improved communication and transparency regarding these changes, potentially enhancing the quality of decisions and care for patients, providers, researchers, policymakers, payers, and other stakeholders.1---5 The comparative effectiveness of delivery system characteristics is ranked as a top priority by the Institute of Medicine, which has defined comparative ef- fectiveness research (CER) as “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clini- cal condition or to improve the delivery of care.”6(p203) Yet, there is no standard way to describe care delivery units or systems that encompasses their breadth, ranging from in- dependent individual provider units to large integrated health systems.7 Thus, the absence of a common parlance for describing delivery systems hinders stakeholders from determining the generalizability of a study or an innovation introduced in 1 setting. The effectiveness of an intervention may be quite different depending

on whether the setting is a large integrated care system or a small independent practice and whether providers are paid on production or salaried. We propose a preliminary framework for description of health care delivery systems that will allow health care stakeholders to better understand, evaluate, disseminate, and imple- ment delivery system innovation in a more informed, transparent, and stakeholder-centered fashion and permit comparisons among them. Our objective is to present the domains and elements of the framework, the methods that were used to derive it, and examples of its potential application in diverse settings.

METHODS

Our proposal builds on previous taxonomic descriptions of the US health care system. In response to the increasing complexity and het- erogeneity of health care delivery systems, the Agency for Healthcare Research and Quality (AHRQ) funded development of a taxonomy of organizations, categorized by shared structural and strategic elements.8 The resulting taxon- omy8 categorized 70% of health networks and 90% of health systems into clusters using 3 dimensions—differentiation, integration, and centralization—and applied the same dimensions to hospital services, physician arrangements,

and provider-based insurance activities. In 2004, the taxonomy was updated to include a redefinition of centralization and updated descriptors of health care systems because of the continued evolution of organizations.9,10

In 2006, Luke11 noted that taxonomies de- rived from local systems were not appropriate for large multihospital systems and recom- mended that further taxonomic studies were needed. Subsequent taxonomic approaches broadened the role of a systems approach, giving primacy to the interrelationships, not to the elements of the system alone.12,13

The pieces (elements) of the framework we describe will certainly become further complex as organizations other than medical care groups (e.g., public health agencies) enter the arena of health care delivery. Rather than describe the lack of an element in a specific organization, one must consider the integration of other organizations bringing the missing elements with them. In parallel to the work of Bazzoli et al.10 and Luke,11 Mays et al.14 concurrently described methodology to classify and com- pare public health systems on the basis of elements of organization and defined 7 configurations with 3 tiers on the basis of their level of dif- ferentiation. Also paralleling Bazzoli et al.,10

Mays et al.14 found that public health systems were in a state of fluidity from 1998 to 2006.

Fragmentation

The escalating complexity and heterogeneity of health care delivery systems has led to in- creased fragmentation of how and where health care is delivered and has created new and often ill-defined relationships between fragments. The Commonwealth Fund Commission on a High Performance Health System has described traditional health care in the United States as a cottage industry wherein fragmentation oc- curs at the federal, state, and local levels.15

Fragmentation can contribute to unnecessary,

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redundant utilization and poorer quality of care.

Recognizing the challenges of a complex, dynamic, and often fragmented health care delivery system, the AHRQ’s Effective Health Care Stakeholders Group (SG) decided to draft an updated framework for describing health care delivery systems, with domains and elements that might be useful for characterizing various sizes and types of care delivery organizations.

The SG was a part of AHRQ’s Community Forum initiative, funded by the American Re- covery and Reinvestment Act, to formally and broadly engage stakeholders and to enhance and expand public involvement in its entire Effective Health Care Program. Nomination of individuals for the SG occurred via a public process (a Federal Register notice) and was broadly inclusive. A committee composed of representatives from AHRQ reviewed all nominations and selected stakeholders to rep- resent a diversity of perspectives, expertise, geographical locations, gender, and race/ethnicity. The group represented broad constituencies of stakeholders including patients, caregivers, and advocacy groups; clinicians and profes- sional associations; hospital systems and med- ical clinic providers; government agencies; purchasers and payers; and health care industry

representatives, policymakers, researchers, and research institutions.

The Delivery Systems Committee (DSC), a subgroup of the SG, consisted of 7 members including clinicians, policymakers, patient ad- vocates, and researchers who were involved with a variety of care delivery organizations and represented diverse perspectives. The DSC convened to address a specific objective of interest to AHRQ: to develop guidance for AHRQ on how to approach CER on health delivery organizations and systems by devel- oping a framework that could be used to char- acterize potentially important differences in structure and function. DSC discussions were facilitated by 2 members of the AHRQ Com- munity Forum. All meetings were attended by at least 1 AHRQ staff member who provided feedback. The charges of both the SG and the DSC are detailed in the box below.

The DSC’s initial work focused on defining the basic unit of consideration: the health care organization or system. Common definitions for health care delivery systems generally refer to all the components providing health care in a country or locality. For example, the World Health Organization16 has defined a health system as all organizations, people and actions whose primary intent is to promote, restore

or maintain health. The framework presented here is meant to be broadly descriptive. To- ward that end, the DSC developed an elements framework with 28 key elements grouped by 6 domains that characterize organizations and delivery systems and may contribute to key outcomes of interest. The DSC tested the framework for face validity among SG stake- holders representing a broad variety of systems of care.

For the purposes of this article, we defined a health care delivery system as the organiza- tion of people, institutions, and resources to deliver health care services to meet the health needs of a target population, whether a single- provider practice or a large health care system.

Approach

For each step in the development of the framework, the DSC used 2 approaches: review of the literature and the Delphi method, in- cluding facilitated group discussions and itera- tive rounds of individual written feedback on successive drafts of the framework. Descrip- tions of conflict and resolution were recorded in detailed meeting notes and in framework drafts, preserving an audit trail.

Although the DSC (at face-to-face meetings) did prioritization exercises, substantial discussion

Charges of the Stakeholder Group and the Delivery Systems Committee in Developing a Framework to Describe Health Care Delivery Organizations and Systems

Stakeholder Group Delivery Systems Committee

Provide guidance on program implementation, including How to compare different ways of delivering care, including to subpopulations

1. Quality improvement,

2. Opportunities to maximize impact and expand program reach,

3. Ensuring stakeholder interests are considered and included, and

4. Evaluating success

Provide input on implementing Effective Health Care Program reports and findings in practice

and policy settings.

What are the ingredients or elements needed for comparison of ways to deliver care?

Identify options and recommend solutions to issues identified by Effective Health Care

Program staff.

Can those elements be examined across delivery organizations and systems to

get a sense of what works best for patients?

Provide input on critical research information gaps for practice and policy, as well as research

methods to address them. Specifically,

What components of delivery organizations and systems do researchers need to

1. Information needs and types of products most useful to consumers, clinicians,

and policymakers;

1. Identify and elaborate, and

2. Feedback on Effective Health Care Program reports, reviews, and summary guides; 2. Relate to the patient-centered outcomes that are most important?

3. Scientific methods and applications; and

4. Champion objectivity, accountability, and transparency in the Effective Health Care program.

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occurred by e-mail and in conference calls, which resulted in additional edits and revisions to the framework. The richness of those dis- cussions contributed significantly to the final product. Each step of the process involved all 3 methods: literature review, facilitated group discussions, and synthesis of individual written feedback.

Process

The DSC initially constructed a framework consisting of elements of health care organiza- tions, focusing on outcomes of interest broadly defined as quality, cost, equity, and patient centeredness. Next, it identified several com- mon medical conditions, for example, diabetes, as basic examples for developing the list of elements relevant to outcomes for the selected conditions. These elements were grouped into domains on the basis of commonalities, with the resulting framework initially consisting of 30 elements categorized according to 4 domains: structure, resources, culture, and function---process. A reiterative process initially resulted in 35 elements housed in 7 domains: physical assets, human assets, the customer, financial aspects, culture, process---function---system structure, and integration, with each element assigned to 1 domain only.

Each member applied the framework to the delivery system with which they were most familiar to test its goodness of fit. Comments from this validation exercise were used to further reorganize the framework into 26 elements in 6 domains: capacity, organizational structure,

finances, patients, care processes and infra- structure, and culture. The model of these processes is shown in Figure 1.

The full SG was subsequently asked to pro- vide feedback regarding the domains, elements, and definitions and to prioritize the elements. Feedback from the SG included 2 primary re- commendations. First, it was valuable to have the full set of elements available rather than to eliminate elements or designate a core set of measures. On the basis of this feedback, the DSC decided to allow future users of the framework to select elements relevant to their individual application of the framework. Sec- ond, the SG recommended including both ex- amples of the application of each element and information about measurability of each ele- ment. The DSC responded to these suggestions by adding more information about measur- ability, including (1) whether the element is feasible to measure and, if so, providing ex- amples of instruments or formats for this mea- surement and (2) whether the measure of the element involves description or increasing value (i.e., is more better?). The DSC decided to use both generic and specific instruments, when possible, for measurement of the elements, with the understanding that additional instruments may currently exist or be developed.

RESULTS

The elements of the framework were divided into 6 domains and their respective elements. Descriptions of the elements and potential

examples of possible measures are presented in Table 1, and summarized here.

1. Capacity: the physical assets and their own- ership, personnel, and organizational char- acteristics of a delivery system that determine the number of individuals and breadth of conditions for which the system can pro- vide care. Elements include size, capital assets, and comprehensiveness of services.

2. Organizational structure: the components of an organization, both formal and in- formal, that describe functional operations in terms of hierarchy of authority and the flow of information, patients, and re- sources. Elements include organizational configuration; leadership, structure, and governance; research and innovation; and professional education.

3. Finances: mechanisms by which a health care delivery system is paid for its services and the financial arrangements and prac- tices of the system and organizations within the system to allocate those funds, as well as the system’s financial status. Elements include payment received for services, provider payment systems, own- ership, and financial solvency.

4. Patients: demographic characteristics, as well as wants, needs, and preferences of individuals and families of individuals who receive health care services from a health care delivery system. Elements include patient characteristics and geo- graphic characteristics.

5. Care processes and infrastructure: the meth- ods by which a health care delivery system provides health care services to its cus- tomers and patients as well as the degree of coordination of those methods. Elements include integration, standardization, per- formance measurement, public reporting, quality improvement, health information systems, patient care teams, clinical de- cision support, and care coordination.

6. Culture: The long-standing, largely implicit shared values, beliefs, and assumptions that influence behavior, attitudes, and meaning in an organization.21 Elements include patient centeredness, cultural competence, competition---collaboration continuum, community benefit, and inno- vation diffusion and working climate.

Phase 1: Initial Development

35 elements

7 domains: Physical

Assets, Human Assets, The

Customer, Financial

Aspects, Culture,

Process/Function/System

Structure, and Integration

Activity: Literature scan,

application of framework

to Committee members’

organizations

Phase 2: Committee and Full Stakeholder Group Prioritization Exercise

28 elements

6 domains: Capacity,

Organizational Structure,

Finances, Patients, Care

Processes and Infrastructure,

and Culture

Activity: Rank order process

for prioritization of elements;

elimination of core vs

supplemental designation

Phase 3: Finalization of Elements Table

26 elements

6 domains: Capacity,

Organizational Structure,

Finances, Patients, Care

Processes and Infrastructure,

and Culture

Activity: Renamed

elements, consolidated

elements, revisited measures

FIGURE 1—Delivery systems methods flowchart of the creation of a draft framework to

describe health care delivery organizations and systems.

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TA B LE

1 — D e sc ri p ti o n o f F ra m e w o rk

D o m a in s a n d E le m e n ts , W it h E xa m p le s o f P o ss ib le

M e a su re s

D om ai n/ El em en t

D es cr ip tio n

M ea su re s (I llu st ra tiv e Ex am pl es )

I. Ca pa ci ty (p hy si ca l an d hu m an

as se ts )

Si ze

Th e sy st em ’s pr od uc tiv e ca pa ci ty

M et ric s of sc al e, su ch

as nu m be r of cl in ic ia ns , nu m be r of be ds , nu m be r of ou tp at ie nt

en co un te rs , nu m be r of pa tie nt s se rv ed

M et ric s of ou tp ut , su ch

as nu m be r of pa tie nt en co un te rs in a tim

e pe rio d

Ca pi ta l as se ts

Th e pr op er ty , fa ci lit ie s, ph ys ic al pl an t an d th e pr op er ty ’s ow ne rs hi p, eq ui pm en t, an d ot he r

in fr as tr uc tu re us ed

to pr ov id e an d m an ag e he al th ca re se rv ic es

N um be r an d ty pe

of fa ci lit ie s

Ad di tio na l co ns id er at io ns

th at af fe ct th e as se ts , su ch

as fa ci lit y an d eq ui pm en t ag e,

ac ce ss ib ili ty , co st , de pr ec ia tio n

Co m pr eh en si ve ne ss of se rv ic es

Th e sc op e an d de pt h of se rv ic es av ai la bl e in te rm s of se tt in g, sp ec ia lty , an ci lla ry se rv ic es , an d

ac ui ty of ca re

Sc op e of se tt in gs in w hi ch

ca re is pr ov id ed , su ch

as ho sp ita l, ho m e, cl in ic , nu rs in g ho m e,

re ha bi lit at io n fa ci lit y, ho sp ic e

Sc op e an d nu m be r of ca re pr ov id er s, su ch

as pr im ar y ca re , sp ec ia lty , an d su bs pe ci al ty

(e .g ., m ed ic al , su rg ic al , be ha vi or al he al th , pa lli at iv e ca re )

Sc op e an d nu m be r of pr ov id er s of an ci lla ry se rv ic es , ca te go riz ed

as di ag no st ic , th er ap eu tic ,

an d cu st od ia l (b as ed

on a st an da rd lis t of an ci lla ry se rv ic es )

Sc op e of se rv ic es pr ov id ed ,s uc h as pr ev en tiv e, ac ut e, ch ro ni c, lo ng te rm ,h os pi ce ,a nd re ha bi lit at io n

II. O rg an iz at io na l st ru ct ur e

Co nfi gu ra tio n

Th e ar ra ng em en t of th e fu nc tio na l un its

in th e sy st em

in te rm s of w or kfl ow , hi er ar ch y of

au th or ity , pa tt er ns

of co m m un ic at io n, an d re so ur ce

flo w s am on g th em

D ia gr am s of no de s or fu nc tio na l un its

an d di re ct io na l lin es se rv in g as lin ks be tw ee n un its

fo r

an y ty pe

of in te ra ct io n– re so ur ce

flo w , co m m un ic at io n, or in st ru ct io n

So ci al ne tw or k an al ys is to ca lc ul at e in di ce s fr om

a m at rix of lin ka ge s am on g th e un its ,s uc h as

th e ce nt ra lit y of an y no de

in th e ne tw or k, th e ce nt ra liz at io n of th e ne tw or k, or th e de ns ity of

in te ra ct io ns

Le ad er sh ip st ru ct ur e an d go ve rn an ce

Th e le ve l of fo rm al de ci si on -m ak in g au th or ity

fo r an

of fic e ho ld er in te rm s of th e sc op e of

de ci si on s th at ca n be

m ad e in de pe nd en tly

an d w ith

co nc ur re nc e of ot he rs

Fo rm al or ga ni za tio na l au th or ity , m ea su re d by hi er ar ch ic al le ve l an d th e sc op e of de ci si on s at

th at le ve l

Po w er an d in flu en ce ,d et er m in ed

by th e in te rd ep en de nc ie s be tw ee n un its fo r cr iti ca lr es ou rc es ,

su ch

as th e ra tio

of re so ur ce s pr ov id ed

to th e to ta l, an d th e ra tio

of re so ur ce s re ce iv ed

to

th e to ta l

Re se ar ch

an d in no va tio n

Th e ex te nt to w hi ch

pa rt ic ip at io n in cl in ic al an d ba si c sc ie nt ifi c re se ar ch

an d he al th ca re

in no va tio n is a fe at ur e of th e m is si on

an d ac tiv iti es of th e or ga ni za tio n

Ra tio

of re se ar ch

ac tiv ity

to cl in ic al ac tiv ity

or to ta l ac tiv ity

on a va rie ty of di m en si on s

Th e nu m be r of in no va tiv e pr oc es se s, di ag no st ic pr oc ed ur es , pr od uc ts , an d te ch no lo gi es

In vo lv em en t in cl in ic al tr ia ls

A ce nt ra liz ed

of fic e fo r te ch no lo gy tr an sf er or in te lle ct ua l pr op er ty

Th e ex te nt to w hi ch

sc ie nt ifi c re se ar ch , ne w th er ap ie s, an d in no va tio n ar e im po rt an t pa rt s of

th e m is si on

an d ac tiv iti es

of th e sy st em

an d its

un its

Pr of es si on al ed uc at io n

Th e ex te nt to w hi ch

pr of es si on al ed uc at io n an d tr ai ni ng

is a fe at ur e of th e m is si on

an d

ac tiv iti es of th e or ga ni za tio n

Ra tio

of ed uc at io na l ac tiv ity

to cl in ic al ac tiv ity

or to ta l ac tiv ity

N um be r of he al th pr of es si on al st ud en t or tr ai ne e po si tio ns

m ai nt ai ne d by th e or ga ni za tio n

Th e ex te nt to w hi ch pr of es si on al ed uc at io n is an

im po rt an t pa rt of th e m is si on

an d ac tiv iti es of

th e sy st em

an d un its

w ith in th e sy st em

III . Fi na nc es

Pa ym en t re ce iv ed

fo r se rv ic es

Th e ca te go ric al ty pe s of pa ym en tr ec ei ve d, th e ap pr oa ch to ac co un ta bi lit y fo rs er vi ce s pr ov id ed ,

th e pr op or tio n of ea ch

pa ym en t ty pe , an d th e de gr ee

of fin an ci al ris k he ld

Pr op or tio n of pa ym en ts re ce iv ed

fo r pa tie nt ca re th at ar e fe e fo r se rv ic e, bu nd le d pa ym en ts ,

fu lly ca pi ta te d, or pa rt ia lly ca pi ta te d

C on tin ue d

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TA B LE

1 — C o n ti n u e d

Pr ov id er pa ym en t sy st em s

Th e ca te go ric al ty pe s of pa ym en t to in di vi du al pr ov id er s fo r th ei r se rv ic es an d th e pr op or tio n of

ea ch

pa ym en t ty pe

Pr op or tio n of pr ov id er pa y th at co m es fr om

sa la ry or ba se pa y, pr od uc tiv ity

or re la tiv e va lu e

un its , qu al ity

pe rf or m an ce

m ea su re s, pa tie nt sa tis fa ct io n

O w ne rs hi p

Th e co rp or at e st at us an d he al th ca re in du st ry af fil ia tio n of th e ow ne r of th e he al th ca re sy st em

G ov er nm en t, fo r- pr ofi t, or no np ro fit en tit y

H ea lth

pl an , ho sp ita l, ph ys ic ia n, or gr ou p of ph ys ic ia ns

or cl in ic ia ns

Fi na nc ia l so lv en cy

Th e ex te nt to w hi ch

th e or ga ni za tio n’ s fin an ci al re so ur ce s ex ce ed

th e or ga ni za tio n’ s cu rr en t

lia bi lit ie s an d lo ng -t er m ex pe ns es

O rg an iz at io n’ s op er at in g m ar gi n as

a pr op or tio n of ex pe ns es an d de bt

W he th er th e or ga ni za tio n op er at es at a su rp lu s, br ea k ev en , or a lo ss

IV . Pa tie nt s

Pa tie nt ch ar ac te ris tic s

Pr op or tio n of pa tie nt s w ith

di ffe re nt ch ar ac te ris tic s, he al th co nd iti on s, an d co ve ra ge

ty pe s

D em og ra ph ic in di ca to rs su ch

as ag e, ge nd er , ra ce , et hn ic ity , ed uc at io n, an d in co m e

Pr op or tio n of pa tie nt s w ith

M ed ic ar e, M ed ic ai d, co m m er ci al , an d no

in su ra nc e

M ea su re of di ve rs ity

of sy st em

an d pa tie nt po pu la tio n si ze

M ea su re s of m ed ic al co m pl ex ity ,s uc h as th e Ch ar ls on

Co m or bi di ty In de x or th e Ca se M ix In de x

Pa tie nt Ac tiv at io n M ea su re 1 7

G eo gr ap hi c ch ar ac te ris tic s

G eo gr ap hi c lo ca tio n as w el la s th e ty pe

of co m m un ity in w hi ch th e he al th ca re de liv er y sy st em

fu nc tio ns

an d th e si ze of th e ca tc hm en t ar ea

U rb an , su bu rb an , ru ra l, or fr on tie r

G eo lin ke d ch ar ac te ris tic s of th e ca tc hm en t ar ea , su ch

as po pu la tio n de ns ity

an d m ed ia n

ho us eh ol d in co m e

V. Ca re pr oc es se s an d in fr as tr uc tu re

In te gr at io n

Th e ex te nt to w hi ch a ne tw or k of or ga ni za tio ns or un its w ith in 1 or ga ni za tio n pr ov id es or ar ra ng es

to pr ov id e a co or di na te d co nt in uu m of se rv ic es to a po pu la tio n an d is w ill in g to be he ld cl in ic al ly

an d fis ca lly ac co un ta bl e fo r th e ou tc om es an d he al th st at us of th e po pu la tio n se rv ed

Fu nc tio na l In te gr at io n m ea su re ,1 8 w hi ch

is a pi lo t m ea su re of th e 3 in te gr at io n do m ai ns :

st ru ct ur e, fin an ce , an d fu nc tio n

St an da rd iz at io n

Th e ex te nt to w hi ch

th e he al th ca re de liv er y sy st em

re du ce s un ne ce ss ar y va ria tio n w hi le

en co ur ag in g di ffe re nc es di ct at ed

by di ve rs ity am on g pa tie nt s in th ei r co nd iti on s an d pr ef er en ce s

A pr el im in ar y m ea su re ,t ho ug h di ffi cu lt to op er at io na liz e, of th e pr op or tio n of th e m ed ic al ca re

pr ov id ed

by th e or ga ni za tio n th at is co ve re d by pr ot oc ol s an d gu id el in es

Pe rf or m an ce

m ea su re m en t, pu bl ic

re po rt in g, an d qu al ity

im pr ov em en t

Th e ex te nt to w hi ch th e or ga ni za tio n co nd uc ts re gu la r m ea su re m en t of pe rf or m an ce w ith

pu bl ic

re po rt in g, fe ed ba ck , an d a sy st em at ic pr oc es s of im pr ov em en t

N um be r of cl in ic al pe rf or m an ce

m ea su re s as se ss ed

at le as t ye ar ly

Pr op or tio n of th os e m ea su re s wi th re su lts re po rt ed to th e pu bl ic an d th os e pr ov id in g m ea su re d ca re

Pr op or tio n of th os e m ea su re s w ith

ac tiv e ac tio n pl an s fo r im pr ov em en t

H ea lth

in fo rm at io n sy st em

Th e ex te nt to wh ic h cl in ic al an d ad m in is tra tiv e in fo rm at io n is or ga ni ze d an d av ai la bl e to th os e wh o

ne ed

it in a tim el y wa y an d th e ex te nt to wh ic h th ey ha ve el ec tro ni c su pp or t fo r th os e fu nc tio ns

W he th er cl in ic al in fo rm at io n sy st em

is pa pe r on ly , pa pe r w ith

so m e el ec tr on ic or de rin g or da ta

sy st em s, el ec tro ni c wi th se pa ra te or de r an d da ta sy st em s, or el ec tro ni c th at ha nd le s al l fu nc tio ns

Pa tie nt ca re te am

Ex te nt to w hi ch

pa tie nt ca re is de liv er ed

by cl in ic ia ns an d st af f w ho

re gu la rly w or k to ge th er in

an in te gr at ed

w ay to se rv e pa tie nt s an d th ei r fa m ili es .

AH RQ

Te am ST EP PS

an d Te am w or k At tit ud es Q ue st io nn ai re 1 9

Cl in ic al de ci si on

su pp or t

Ex te nt to w hi ch

cl in ic al gu id el in e- ba se d re m in de rs an d de ci si on

ai ds

ar e in co rp or at ed

in th e

pr oc es s of pa tie nt ca re

E- cl in ic ia n su rv ey s

Av er ag e nu m be r of re m in de rs or su gg es tio ns pr ov id ed au to m at ic al ly to cl in ic ia ns du rin g pa tie nt

vi si ts th at ar e pe rc ei ve d by th em

as va lu ab le

Ab ili ty of el ec tr on ic m ed ic al re co rd sy st em

to lin k fr om

w ith in th e sy st em

to es ta bl is he d cl in ic al

gu id el in es

Ca re co or di na tio n

Th e de lib er at e or ga ni za tio n of pa tie nt ca re ac tiv iti es

be tw ee n ‡ 2 pa rt ic ip an ts in vo lv ed

in

a pa tie nt ’s ca re to fa ci lit at e an d m ax im iz e th e ap pr op ria te de liv er y of he al th ca re se rv ic es to

ac hi ev e op tim

al pa tie nt ex pe rie nc e an d ou tc om es

Ap pr ox im at e nu m be r of pe rs on ne l an d cl in ic ia ns w ho se jo b is pr im ar ily to co or di na te se rv ic es

fr om

di ffe re nt pr ov id er s fo r pa tie nt s

AH RQ ’s C ar e C oo rd in at io n M ea su re s At la s2 0 th at in cl ud es m ea su re s of th e pa tie nt an d fa m ily

pe rs pe ct iv e, he al th ca re pr of es si on al pe rs pe ct iv e, an d sy st em s re pr es en ta tiv es

pe rs pe ct iv e

N at io na l Q ua lit y Fo ru m ’s 24

pr ef er re d pr ac tic es

fo r ca re co or di na tio n2 0

C on tin ue d

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The selected domains were chosen in an effort to cluster those elements that describe similar aspects of the delivery system. By its nature, an element may not fit perfectly within a domain or, conversely, may be related to aspects of multiple domains. Rather than repeat elements in multiple domains, committee members placed each element in the single domain that the majority felt best represented that element. Many of the elements are simply descriptive rather than normative, such as organizational size, configuration, or type of payments received. In other words, no or little inherent value is generally ascribed to having a large versus small staff, employment versus partnership model, or receiving payment on a fee-for-service versus capitation basis, for example. The descriptive nature of these elements is expected to result in relative ease of mea- surement and protection from manipulation.

However, some elements are inherently normative or value based, such as care co- ordination, patient centeredness, and cultural competence. In other words, it is inherently desirable for a health care delivery system to effectively coordinate care, be patient centered, and be sensitive to patients’ cultural back- ground. These elements also tend to describe less tangible characteristics of the organization and are thus less easily measured and poten- tially more subjective and vulnerable to bias. Furthermore, they tend to describe charac- teristics that are more structural, cultural, or longitudinal. Nevertheless, the DSC decided to include these elements despite their ac- knowledged limitations because they represent important aspects of care delivery, with the expectation that objective measures may al- ready be accessible or will evolve over time. One such example is organizational culture—a domain that is easier to describe than to measure. Yet, various instruments are already available, albeit with some limitations, as reviewed by Scott et al.22 and Zazzali et al.,23 who surveyed physician culture and found great variability within groups. Another less tangible element, but equally as essential, is care coordination. The Care Coordination Measures Atlas24 pub- lished by AHRQ introduces a framework for structure and processes that influence care coordination and can be used today.

Although many of the value-based measures are directional (i.e., “more is better”), improving

TA B LE

1 — C o n ti n u e d

VI . Cu ltu re

Pa tie nt ce nt er ed ne ss

Th e de gr ee

to w hi ch

he al th ca re de liv er y is de si gn ed

to se rv e th e in te re st s of pa tie nt s

(v s pr ov id er s)

Co or di na tio n of ca re m ea su re s

Ve rs io ns

of th e CA H PS

pa tie nt ex pe rie nc e su rv ey s, es pe ci al ly PC M H

Sh ar ed

de ci si on -m ak in g

Va rio us

pr ov id er co nt in ui ty m ea su re s

Cu ltu ra l co m pe te nc e

Ab ili ty of sy st em s to pr ov id e ca re to pa tie nt s w ith

di ve rs e va lu es , be lie fs , an d be ha vi or s,

in cl ud in g ta ilo rin g de liv er y to m ee t pa tie nt s’ so ci al , cu ltu ra l, an d lin gu is tic

ne ed s

Av ai la bi lit y of in fo rm at io na l m at er ia ls an d tr an sl at or s

W he th er cu ltu ra l co m pe te nc e go al s ar e id en tifi ed

in st ra te gi c pl an

W he th er th er e ar e st ra te gi es to re cr ui t, re ta in , an d pr om ot e a di ve rs e le ad er sh ip an d st af f

N at io na l Q ua lit y Fo ru m ’s 45

pr ef er re d pr ac tic es

fo r m ea su rin g an d re po rt in g cu ltu ra l

co m pe te nc y

Co m pe tit io n– co lla bo ra tio n co nt in uu m

W he re th e or ga ni za tio n fa lls on

a sc al e fr om

co m pe tit iv e to co lla bo ra tiv e in re la tio n to ot he r

or ga ni za tio ns

in its

lo ca le

N um be r an d sc op e of co lla bo ra tiv e in iti at iv es

w ith

co m pe tit or s

Co m m un ity

be ne fit

Ex te nt to w hi ch

th e or ga ni za tio n is co nc er ne d ab ou t th e he al th of th e lo ca l co m m un ity

an d

ta ke s ad va nt ag e of co m m un ity

se rv ic es fo r its

pa tie nt s th ro ug h co lla bo ra tio n

Le ve l of un co m pe ns at ed

ca re pr ov id ed

N um be r an d va lu e of fo rm al co m m un ity

pa rt ne rs hi ps

Ex is tin g m ec ha ni sm

to as se ss an d pr io rit iz e lo ca l he al th ca re ne ed s

Co lla bo ra tio ns

w ith

lo ca l or ga ni za tio ns

an d pu bl ic he al th to im pr ov e co m m un ity

he al th

Fi na nc ia l co nt rib ut io ns

to lo ca l co m m un ity

or ga ni za tio ns

In no va tio n di ffu si on

Th e de gr ee to w hi ch th e he al th ca re de liv er y or ga ni za tio n or sy st em

is fo cu se d on

cr ea tin g an d

ad op tin g ne w w ay s to pr ov id e ca re an d ac co m pl is h its

m is si on

Im pl em en ta tio n of re gu la r pr oc es s im pr ov em en t vi a qu al ity im pr ov em en t m ec ha ni sm s su ch

as

pl an –d o– st ud y– ac t

W or ki ng

cl im at e

Th e de gr ee

to w hi ch

th e or ga ni za tio n’ s em pl oy ee s pe rc ei ve an

en vi ro nm en t of op en ne ss an d

fa ir pr oc es s

Em pl oy ee

sa tis fa ct io n su rv ey

Pr op or tio n of em pl oy ee s w ho

re po rt fe el in g

in fo rm ed

ab ou t w he re th ei r co m pa ny is go in g

es pe ct ed

fo r th ei r co nt rib ut io ns

at w or k

in vo lv ed

in m ak in g ch an ge s to im pr ov e ca re , se rv ic e, an d ef fic ie nc y

N ot e. AH RQ

= Ag en cy fo r H ea lth ca re Re se ar ch an d Q ua lit y; CA H PS = Co ns um er As se ss m en t of H ea lth

Pr ov id er s an d Pe rfo rm an ce Sy st em s; PC M H = Pa tie nt Ce nt er ed

M ed ic al H om e. A he al th ca re de liv er y sy st em

is an

or ga ni za tio n of pe op le ,

in st itu tio ns , an d re so ur ce s to de liv er he al th ca re se rv ic es to m ee t th e he al th ne ed s of a ta rg et po pu la tio n.

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1 desirable attribute may come at the expense of another desirable attribute, such as financial solvency versus comprehensiveness of services and community benefit or standardization versus patient centeredness and research and innovation. The framework as a whole is meant to be used in such a way as to balance such competing values. Elements were chosen as aspects of health care delivery systems that, in the stakeholders’ opinion, were likely to contribute to a delivery organization’s ability to fulfill its mission. The DSC acknowledged that the elements do not necessarily capture every important aspect of a care delivery system but include enough to serve as a basis for a framework describing health care organiza- tions. Conversely, not all elements are neces- sarily needed to describe a given organization. In addition, the DSC intentionally focused on elements and domains rather than specific measures or measurement systems; measures included in Table 1 serve only as examples.

DISCUSSION

In this article, we present a draft framework created for describing important differences in health care delivery organizations of all sizes and types, one that might facilitate under- standing as we study and move from traditional models of care to a system-oriented approach while maintaining a patient-centered focus. In the process, the DSC considered the current status of the health care sector, medical prac- tices in the United States, and current innova- tive models of care and the overall importance of patient centeredness, which traverses all of the domains.

Current Health Care Sector

The number of single-physician practices dropped from 69% in 2003 and 11% with 2 physicians to 33% in solo or 2-physician practices in 2008.25 In 2008, 92% were single specialty and 8% multispecialty; 15% were in practices of 3 to 5 physicians, and 19% were in groups of 6 to 50 physicians. Thirteen percent practiced in hospital settings, with 44% of hospital-based physicians working in office practices or clinics and the remainder split evenly between emergency rooms and hospital staff.26 Of the physicians, 3% worked in com- munity health centers and 4% in group- or

staff-model health maintenance organizations. From the aspect of specialties, 79% were in single-specialty practices, and only 21% were in multispecialty groups.27 Therefore, creating this framework only for large health care orga- nizations would be myopic. The DSC’s inten- tion has been to provide domains and elements that could also be applied to organizations of all sizes, from very large to very small, from single providers to groups of providers. Fur- thermore, this work was intended to bring an organized set of domains and elements that have been created by all stakeholders (i.e., providers, administrators, policymakers, and health care consumers) under the auspices of AHRQ. The inclusion of this diverse group of stakeholders is in accordance with the In- stitute of Medicine report, which emphasizes their inclusion in CER to ensure its relevance to health care delivery.6 Health care delivery systems also include those responsible for the public health.

The Commonwealth Fund Commission re- port15 has described the characteristics of high- performing systems, which include access to information, active management, interdepen- dent accountability, patient access to care, and continuous innovation. The reader may find several of these attributes among the domains and elements we present that can serve re- searchers as a roadmap to add definitions and borders to their work. Consequently, the cur- rent fragmentation of care further highlights the need for the draft framework presented here. One of the key and controversial features of care delivery organizations, primarily large ones, is the extent to which the care they provide is integrated.28---30 This observation is especially true because many studies of care delivery redesign and quality have been conducted in large integrated organizations such as the Veteran’s Health Administration, Group Health, Kaiser Permanente, and Health Partners, among others. There are many definitions of integration, but we have chosen the one developed by Shortell et al.31 and Gillies et al.32 (see Table 1, Domain V). Using this definition, Solberg et al.18,33 demonstrated that, among 100 large medical groups nationally, there was a positive correlation between functional integration and the presence of practice systems that have been associated with higher quality of care and, yet, a lot of diversity existed in integration

among these apparently similar organizations. Solberg et al.18 created a set of measures of functional, structural, and financial aspects of integration from the organizational point of view, whereas Singer et al.34 instead built measures from the patient’s perspective. In spite of these measures, no consensus has been reached on how best to measure integration.

Less controversial than integration is the importance of team care as an essential com- ponent of better quality, although whether it also decreases costs is less clear. For example, the collaborative care model for major depres- sion has clearly been demonstrated to produce higher quality, although it takes 3 to 4 years to have any impact on costs.35---38 This model is based not only on having a care manager in the primary care practice but also on regular consultation visits by a psychiatrist. The de- velopment of effective team care for quality improvement in chronic illness has been ex- plored by Shortell et al.39 and suggests the importance of patient satisfaction. Similarly, the chronic care model by Wagner et al.40 presents the importance of patient engagement as part of the team for chronic care, such as in diabetes. Team care is also a key feature of many of the elements of the medical home. Hence, it seems an important component of this framework (see Table 1, Domain V).41---43

Innovative Care Models

In light of the creation of innovative care systems, the DSC believed that it was important to make this framework capable of describing the key features of organizations of all sizes so that organizational structure and function can more consistently be incorporated into re- search design, publication, and policy decisions. In addition, the DSC’s intent has been to help compare health care organizations across dif- ferent settings and provide a framework that will facilitate CER of care delivery functions and outcomes. There is no better example of distinct and different settings than the current care delivery reform emphasis on the medical home and accountable care organizations, encompassing both large and small care orga- nizations.42 Much of the research on these and other care redesign topics is being conducted among clinics of varying size and ownership, often members of practice-based research net- works.44 The Kaiser Permanente system, as

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compared with independent traditional prac- tices, offers a model of a physician organization that has adopted value- and quality-oriented, system-level care tools to deliver more effective care.45 To understand whether the results apply to any particular practice, it is essential to understand whether the clinics involved are similar or, if they are not, to decide whether the differences affect generalizability.

Role of Public Health in Comparative

Effectiveness Research

Health issues that have the greatest impact at the population health level and how to com- pare them should also be part of CER. Teutsch and Fielding46 argued that comparative effec- tive assessments of public health interventions can positively influence health at all levels—that is, the individual and the population as a whole—and that studies should also focus on the develop- ment of research methodology applied to public health. However, most of the current published CER work has centered on the comparison of 2 or more interventions focused on or targeted to disease management or therapies. Other studies, however, must explore the relevance of this work to public health efforts so that in- terventions can and should be studied not only within systems of care but at the population level. Certainly, the application of CER meth- odology to public health will present challenges because, for example, randomization as in con- trolled clinical trials may not always be possi- ble. However, these challenges may lead to more innovative statistical techniques, such as propensity matching.

The taxonomy presented here could be adapted to public health approaches—some of which are easier to identify than others. For example, the patient domain may be translated to the community of patients or population at large with a certain disease entity. The organi- zational structure domain, as another example, could apply to public health services available or desirable to improve a specific aspect of populations.

Dubois and Graff47 recognized these diffi- culties and the magnitude and variety of tasks that are presented when considering CER at the public health level. They offered a frame- work, complementary to the taxonomy pre- sented here, for prioritization of CER efforts with a series of elements. Among these elements

are the involvement of multiple stakeholders and the dissemination of the process. In parallel with their framework, the domains of DSC’s framework were constructed by multiple stake- holders who included representatives of patient groups. Correspondingly, this article, and a detailed report to AHRQ, represent its dissem- ination. Future involvement by public health researchers, particularly in these early stages of CER development and application, will enrich this work by adapting and adding methodology to the domains presented here.

As such, this work has focused on CER priorities in the United States, which, according to the Congressional bill that introduced CER, states that findings should not be “construed as mandates, guidelines, or recommendations for payment, coverage, or treatment . . . for any public or private payer.”48 By contrast, the Commonwealth Fund has reviewed the use of CER in 4 countries—Australia, France, Germany, and the United Kingdom—in which the research is driven by demand for informa- tion by those making health care policy and practice decisions.49 Thus, involvement by multiple stakeholders, including policymakers, should occur earlier, rather than later, after a CER plan is developed. Whether driven by the public need for policy and allocation of resources or by the need to improve quality of care for patients directly, the framework presented here is broad enough to be applica- ble to either process.

Patient Centeredness

In 2001, the Institute of Medicine4 observed that health care has traditionally been provider and payment centered and that a shift in paradigm was critical to the survival of the US health care system. That change was a shift in paradigm to one that was patient centered. Accordingly, the DSC considered patient cen- teredness to be a critical component of current care that should thus be given special attention. Patient centeredness, when describing health systems, reflects an undergirding and dominant value of attending to patient needs and pref- erences in planning and delivering care.50 The emphasis on quality of care has resulted in a strong focus on patient centeredness and is driving the efforts at defining the construct and measuring its antecedents and outcomes.46

Furthermore, the awareness of health disparities

based on race/ethnicity, gender, age, and other factors has increased, centering on the indi- vidual patient and family members, their satis- faction, and health care processes and outcomes. AHRQ, in addition to many quality-oriented organizations and regulatory agencies, has supported and disseminated patient-centeredness research findings and tools based on the re- search. So far, consensus is lacking for standard measurement models or operational defini- tions, but considerable research and dissemi- nation are evident in the quality literature.51

Saha et al. present the 7 primary dimensions of patient-centered care as originally defined by the Picker Commonwealth program: respect for patients’ values; preferences and expressed needs; coordination and integration of care; information, communication, and education; physical comfort; emotional support and allevia- tion of fear and anxiety; involvement of family and friends; and transition and continuity.50

Currently, the tools most frequently used to measure patient centeredness are patient sat- isfaction surveys, such as the Press-Ganey Medical Practice Survey and the Consumer Assessment of Health Providers and Perfor- mance Systems for hospitals, and adaptations for other health care settings such as long-term care facilities (https://www.cahps.ahrq.gov).52

The work of identifying patient centeredness or need thereof by patient advisory teams and peer patient coaches has led to reform in several innovative systems and in health pol- icy.53 Hence, patient centeredness, as a value, can be assessed in each of the elements spelled out in this article and should remain in the back- ground of any work using this framework.

Limitations

The DSC understands that there are limita- tions to this framework and other aspects that are outside the scope of this article. For ex- ample, we have not discussed organizational boundaries, which are defined as the charac- teristics of participation in an organization that determine whether a person is within the organization and subject to the influence of its rules, processes, and culture. Yet, boundaries may be important to organizations reaching their mission. The committee also understands that some domains, for example, culture, have elements that are not easily or objectively measurable and serve as an illustration of the

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difficulty inherent in creating a classification of human designs for organizations to imple- ment evidence-based decisions about their management. Indeed, the human element raises uncertainty, as defined by the larger SG.

Summary

This framework presentation recognizes the continuous evolution of health care systems, particularly in light of the need for CER. To compare health care organizations in 1 or many aspects, there is a need for a foundation of commonality in language for areas that are well defined and further work for those that are not. The framework can be used to characterize potentially important differences in structure and function of health care delivery organiza- tions and systems. To that end, researchers could use the framework to clearly describe the delivery setting for a study, facilitating under- standing of whether the results are applicable in specific settings and situations.

The DSC members understand that this work is preliminary but believe that it is a step in the right direction because there is currently considerable organizational diversity and com- plexity in health care. Future reports may con- tinue to develop and elaborate on the domains captured here, whether 1 at a time or in groups. This framework of 26 elements in 6 domains may allow for more understandable studies and descriptions of delivery system changes to improve the health of people in the United States. We have reflected on the domains and elements presented here and fully recognize the need for further work in many areas. How- ever, there are others in which definitions were readily available and agreed upon. It is in these areas of agreement that work can be initiated today. j

About the Authors Ileana L. Piña is with Albert Einstein College of Medicine and Montefiore-Einstein Medical Center, Bronx, NY. Perry D. Cohen is with the Parkinson Pipeline Project, Washington, DC. David B. Larson is with the Department of Radiology, Cincinnati Children’s Hospital Medical Cen- ter, Cincinnati, OH. Lucy N. Marion is with the Medical College of Georgia School of Nursing, Macon. Marion R. Sills is with the University of Colorado School of Medicine, Denver. Leif I. Solberg is with HealthPartners Medical Group and Clinics, Minneapolis, MN. Judy Zerzan is with the Colorado Department of Health Care Policy and Financing, Denver. Correspondence concerning this article should be sent

to Ileana L. Piña, MD, MPH, 111 East 210th Street, North

2---Silver Zone, Bronx, NY 10467 (e-mail: ilppina@aol. com). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted February 2, 2014.

Contributors All of the authors were part of the Delivery Systems Committee and participated in face-to-face meetings, conference calls, and e-mails pertaining to the creation of the taxonomy. Each author worked on specific sections and circulated them among the rest of the committee. I. L. Piña served as the chair of the committee and drafted the first version of the article. The remaining authors were involved in iterations, edits, corrections, and comments leading to the final version.

Acknowledgments We gratefully acknowledge the assistance of Christine Chang, MD, MPH, of the Agency for Healthcare Research and Quality (AHRQ), and Jill Yegian, PhD, and Diane Martinez, MPH, of the American Institute for Research for their guidance and support during meetings, confer- ence calls, and e-mails. We also appreciate AHRQ’s role in convening the Stakeholders Group and the Delivery Systems Committee. We also thank Ms. Patricia Peralta for her review and editing.

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