Redesigning a System of Care to Promote QI

Part 1: Introduction

Part 2: Tools for System Redesign

Part 3: Sustain and Spread in Quality Improvement

Part 4: References

Part 5: Resources

Part 1: Introduction 

The goal of this module is to highlight the important role that redesigning system within a health care organization has on overall quality. The module exemplifies how an organization establishes assesses their current system and then applies changes to their system supporting QI.

Many healthcare organizations made important advancements in the design and performance of their current systems of care. Despite these improvements:

• Many improvements remain unused, fragmented, and isolated;
• Clinicians often feel overwork, unable to take on new work;
• Patient satisfaction level are not optimal ;
• Wait time for patients continue to increase

The Purpose of a System Redesign

The HRSA Quality toolkit describes a general approach to quality improvement as well as specific changes that can be made to improve care delivery utilizing clinical quality measures. Most often the toolkit described an approach that has been successfully utilized by HRSA grantees organizing changes within the framework of the Chronic Care Model. The toolkit further highlighted an approach using the critical pathway. Critical pathways, also known as clinical pathways have been used successfully by grantees in quality improvement but more frequently they have been used in the hospital setting. Within the various modules focusing specifically on the clinical quality measures, the toolkit has linked practical changes that work from the field to the Care Model or the critical pathway and thus provided detailed technical assistance intended to facilitate improvement of the care systems.

As quality improvement teams become more experienced, it is helpful to have additional tools and strategies available for the quality improvement efforts. Many organizations will want to take advantage of QI techniques to improve many systems within the organization. Improving systems by intentional changes is also called “redesign.” Redesigned systems have the potential to have broad impact to improve the way things work. This module outlines some additional models that are helpful as teams redesign systems as well as tools that are useful in the redesign process.

Following a successful redesign, organizations will want to ensure that the improved systems stay intact and not revert back to their original form. This work is also known as sustaining the changes of redesign. In addition, if the improvements have been focused on a particular care team, one site of a clinic or targeted toward a subpopulation of patients served, organizations may want to expand or “spread” their redesigned systems. The process of sustaining and spreading redesigned systems is a bit different than the process of improvement and will also be covered in this module. Frameworks for Change.

Quality improvement can be overwhelming without an organized approach. Over time, models have been developed to allow teams to intentionally evaluate and make changes to systems. Again, the Chronic Care Model is respected around the world to organize an approach to ambulatory care but there are other models worth understanding that can be used alone or in an adjunctive way. Which model to use depends in large part about what you are trying to accomplish. Although an in-depth description of these models is beyond the scope of this module, Table1 is a list of models used successfully in the field, a brief description and the redesign perspective the model for which the model is intended.

Table 1: Models for Redesigning Systems

Model name	Brief description	Redesign perspective	More Information
Six sigma	Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability in manufacturing and business processes. It uses a set of quality management methods, including statistical methods, and creates a special infrastructure of people within the organization ("Black Belts", "Green Belts", etc.) who are experts in these methods.	Might be considered if there is a wide variability in service delivery – logging of pharmaceuticals, standardizing referral processes	Six Sigma Online How to Develop a Lean Six Sigma Deployment Plan 6sigma.us/
Toyota Production System (AKA Lean)	The main objectives of the TPS are to design out overburden and inconsistency and to eliminate waste). The most significant effects on process value delivery are achieved by designing a process capable of delivering the required results smoothly The tactical improvements of waste reduction are very valuable.	These principles are frequently used by teams once they know what system change will result in an improvement. These principles are helpful to “operationalize” the change to create work flows, handoffs and processes that work over the long term. This framework emphasizes efficient systems that work.	The Toyota Production System [PDF | 5MB] QualityCoach.Net Lean Concepts Inc
Quality by Design	Quality Expert Joseph Juran believed that quality could be planned, and that most quality crises and problems relate to the way in which quality was planned in the first place.	Used in the process planning phase to assure quality is built into the design – most notably used by the FDA to improve the new pharmaceutical application process.	PDA/FDA Joint Regulatory [PDF | 172KB] Implementation of Quality-by-Design: Question-based Review [PDF | 400KB] FDA, Industry Discuss the Fine Points of QbD

Note: Organizations who are considering adopting such improvement models as highlighted in the above chart should consider running PDSA cycles and testing the adoption of a model before implementing. All models may not work in every organization. The key is to focus on a model that works in your organization and your quality improvement project. For additional information please visit the module Testing for Improvement.