How Relying on Systems Rather Than People Can Drive Healthcare Quality

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Hospitals and health systems are facing pressure to improve quality before penalties for are implemented. Hospitals can't afford to waste time on ineffective initiatives, as changes in reimbursement, physician relationships and regulations also need their attention. It is thus essential that hospitals target their quality improvement projects on areas most likely to return value. While people play a crucial role in quality improvement at hospitals and health systems, long-lasting improvements should focus more on systems of care designed to prevent adverse events, according to J. Deane Waldman, MD, MBA, professor of pediatrics, pathology and decision science at the University of New Mexico in Albuquerque.

Focus on systems

"What matters is not the number of people or even (to a degree) the quality of the people. What matters is that we recognize that it is the system that can deliver the best value with the fewest bad outcomes, not the people within it," Dr. Waldman says. Systems, or processes, within the hospital can help prevent human error in healthcare delivery by creating standard functions or actions and preventative feedback. For example, requiring physicians and staff to follow a checklist for each surgical procedure can prevent people from forgetting a step that could cause the patient harm.


One system that many hospitals and health systems are implementing is computerized provider order entry. Prescriptions are ordered electronically and the software can alert physicians when there are adverse medication interactions. This automatic system provides a safeguard against prescribing medication that may interact with another drug and harm a patient. While physicians, nurses and other providers are trained in medication interactions, they are human and sometimes make mistakes. "The real issue is to stop relying on individual memory, to stop depending on perfect nurses and doctors — because they don't exist," Dr. Waldman says.

Systems of care can expose inefficient processes and a lack of standardization, all of which can present opportunities for quality improvement. "The quality officer of the institution should look at the actual system by which the care is delivered, not the individuals within that system," Dr. Waldman says. "[He or she should] not blame people, but find places where the system falls down and then try to embed good communication within the system." One place to start is by examining past medical errors to determine the cause(s) and create systems that could prevent people from making the same error in the future.

Boost prevention efforts
In addition to examining the past, hospitals need to envision possible future adverse events and then create systems to prevent them from occurring. In systems thinking, this is called dissolving the root cause.

Proactively looking for potential breakdowns and developing systems to prevent them can help hospitals improve quality. Dr. Waldman says hospitals can use computer simulation to practice and prepare for adverse events. For example, he says a virtual reality program at Stanford (Calif.) University trains surgeons not only how to operate but also how to react in disaster situations, such as if an incision is made in the wrong place. The program allows surgeons to practice and learn without endangering a real patient.

Cultural barriers to a systems focus

Moving to a systems approach to quality can be challenging due to cultural beliefs about the delivery of healthcare. Dr. Waldman says one cultural issue is the belief held by healthcare providers that each individual is unique. While true in terms of their value as a person, individuals are not unique in their healthcare needs for different conditions. In fact, evidence has shown there are processes of care that work for the majority of patients. Failing to recognize these common processes can hinder the implementation of standard systems and put both patient safety and quality at risk.

Every system must have the flexibility to change depending on atypical patients, according to Dr. Waldman. "As long as you have the ability to break that protocol for atypical patients, you should have a protocol for the typical patient," he says. For example, he says a hospital can institute a policy under which heart attack patients automatically receive a beta blocker to reduce heart damage unless something in the individual's background or history indicates the drug would be harmful.

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