System Redesign and the Health Care Workforce
An interdisciplinary panel of experts from health care management, economics, and nursing came together at LDI’s 50th Anniversary Symposium to discuss their perspectives on how “organizational innovation” can be used to redesign health care systems and care delivery.
Linda Aiken, PhD, RN, University of Pennsylvania
L. Robert Burns, PhD, MBA University of Pennsylvania
Mary Naylor, PhD, RN, FAAN, University of Pennsylvania
David Meltzer, MD, MBA, University of Chicago
John K. Iglehart, New England Journal of Medicine
Discussed in greater detail below, key messages that emerged during the discussion were the need for health care delivery innovation to engage front line workers in process redesign; provision of comprehensive, team-based care; interdisciplinary collaboration that capitalizes upon the strengths of each discipline; and activation of patients and families as members of the health care team.
Engaging front line health care workers in organizational innovation
Panelists agreed that engaging the health care workforce is key to organizational innovation. Physicians, nurses, and other staff on the front lines of patient care should be actively involved in health system redesign. Organizational changes that are not embraced by health care workers will ultimately be unsuccessful. Furthermore, to improve outcomes for patients, the health system should support clinicians’ autonomy while recognizing the complexity of their jobs. A focus on health care process redesign is often more cost-effective than structural redesign. For instance, magnet hospitals that focus on improving work environment and supporting nurse autonomy achieve better patient outcomes.
Improving transitions between inpatient and outpatient care
According to Dr. Meltzer, the hospitalist model, in which a group of physicians focus all of their time on management of hospitalized patients, has the disadvantage of disrupting continuity between inpatient and outpatient care. Although hospitalists fill a role that many primary care providers are no longer able to do, patient outcomes may suffer under this model due to increased fragmentation of care. The Comprehensive Care Physician Model, in which providers see high-risk patients for comprehensive care in both the clinic and the hospital, may improve outcomes for patients most susceptible to issues related to fragmentation of care.
Dr. Naylor described the essential role advanced practice registered nurses (APRNs) play in post-acute care transitions. The APRN-driven Transitional Care Model (TCM), developed and demonstrated effective over time by Dr. Naylor, helps to bridge discontinuities between inpatient and outpatient care for high-risk patients transitioning between various health care settings and providers. This model capitalizes on the strengths of each discipline, with APRNs acting as the primary coordinator of care. With extensive evidence to support the benefits of this model for improving patient outcomes, the TCM needs to be translated into mainstream practice.
Activation of patients and family caregivers
Panelists also stressed the need to promote patient and family engagement in care. All agreed that as the population ages, investment in family caregivers as part of the care team is becoming increasingly important. Expansion of team-based primary care models such as the patient-centered medical home can facilitate patient and family involvement in health care decision making in a collaborative environment.
The future of health care is interdisciplinary, and organizational innovation needs to begin “from the bottom up,” with front line staff driving process changes. Investing in the health workforce, seeking their input in policy decisions, and creating a positive and supportive work environment are necessary to achieve high quality patient care.
Jordan Harrison is a postdoctoral fellow at the Center for Health Outcomes and Policy Research and a member of the National Clinician Scholars Program 2017-2019 cohort.