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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Resources and Services Administration

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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 impact that redesigning a system within a health care organization has on overall quality. The module exemplifies how an organization can  assesses its current system and make changes that improve quality.

Why Redesign Current Systems

Many healthcare organizations have already made important advances in the design and performance of their current systems of care. Despite these improvements, however:

  • Many improvements remain unused, fragmented, and isolated
  • Clinicians often feel overworked, and unable to take on new work
  • Patient are dissatisfied, and
  • Patient wait times 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 improve care delivery as evaluated by 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 highlights an approach critical pathway, frequently hospital setting. Within the various modules focusing specifically on the clinical quality measures, the toolkit links practical changes that  to facilitate improvement of the care systems.

As quality improvement teams become more experienced, it is helpful to have additional tools and strategies available. Many organizations will want to take advantage of QI techniques to intentionally improve multiple systems, which 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 do not revert back to their original form. This work is also known as sustaining the changes of redesign. In addition, if the improvements are focused on a particular care team, one site of a clinic or 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.

Models to Redesign Current Systems

Quality improvement can be overwhelming without an organized approach. Over time, models have been developed that 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 together. Which models to use depends in large part on 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 successful models, a brief description and the redesign perspective 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 Exit Disclaimer.
How to Develop a Lean Six Sigma Deployment Plan Exit Disclaimer. Exit Disclaimer.
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. Lean Concepts Inc Exit Disclaimer.
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 Exit Disclaimer.

Note: Organizations 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.

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