Anatomy of Healthcare Delivery Model: How a Systematic Approach Can Transform Care Delivery

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INTRODUCTION

Healthcare in the United States is and always has been a complex system. This complexity is ever increasing as value-based purchasing and population health management transform our hospital-centric industry into one focused on the continuum of care.

Additionally, healthcare organizations are being asked to deliver better, more efficient care with fewer resources. This task wouldn’t have been simple in an acute care-centric industry, and it is even more difficult now. So how can an organization drive cost and quality improvements in the evolving environment?

The answer is to systematize care delivery one step at a time. We refer to the way we deliver healthcare as a system; however, in reality, it’s surprisingly unsystematic.

This paper introduces the Anatomy of Healthcare Delivery, a framework that outlines how the healthcare delivery system operates and pinpoints opportunities for improvement. Understanding and following this framework will enable healthcare organizations to reduce variation in clinical and operational processes to drive sustainable, enterprise-wide cost and quality gains.

HOW HEALTHCARE ISN’T REALLY A SYSTEM

For the purposes of this paper, we will consider the term “healthcare system” to be a misnomer. You could argue that healthcare is indeed set up as a system. It is, after all, a set of parts that connect to form a complex whole.

But when it comes to care delivery — how decisions about care are actually made — this idea of a system breaks down. Healthcare reveals itself to be largely a collection of individual clinicians making care decisions based on their unique apprenticeships. There is no great evidence of “systemness” in healthcare delivery.

To illustrate this lack of systemness, consider the difference between the healthcare industry and the airline industry. You’ve likely seen ads in airline magazines that tout the “Best Doctors in America” or the “Best Surgeons in New York.” But why do we not see ads for “The Best Pilots in America” while thumbing through the magazines in our doctor’s office? Don’t we care about the qualifications of the person responsible for taking us 40,000 feet above the ground at 600 miles per hour? Pilots, after all, are likely to hold our life in their hands more often than our physicians.

The answer lies in the fact that, unlike healthcare, the airline industry has continually routinized its approach to travel delivery. Individuals in charge of transporting some 1.73 million people a day in the U.S. are following standardized, well-understood routines with the aid of useful information available at their fingertips, such as cockpit checklists.

Figure 1 – The Evolution of Process Management from Craftsmanship to a System of Production

Figure 1 – The Evolution of Process Management from Craftsmanship to a System of Production

When it comes to managing decision-making processes, the difference between the airline industry and healthcare is that the airlines have moved towards a system of production. Healthcare, in contrast, is a system of craftsmanship where successful outcomes largely depend on the native intelligence and memory capacity of an individual provider.1

One hundred years ago, a pilot didn’t have much technology or information support in the cockpit. His ability to fly the plane depended on his own skill. However, if you look at the cockpit of an airplane today, you see hundreds of data points coming at the pilot in real time, providing continuous feedback. Pilots are well-trained on standard, routine methods of doing things. When the aircraft is landing, they have a system of checks to make sure the landing gear is down. Because of these systems, we have confidence that one pilot will get us from point A to point B as well as the next pilot.

The same can’t be said of healthcare. Positive outcomes really do depend on which doctor you see. As noted by the Dartmouth Atlas of Health Care,2 this lack of systemization in healthcare results in:

  • Unwarranted variation in the practice of medicine and in the use of medical resources
  • Underuse of effective care
  • Misuse of care
  • Overuse of care provided to specific patient populations
  • Quality of care that’s dependent upon geography and where a patient receives care

A call for systematization in clinical decision making isn’t about eliminating critical thinking. It’s about introducing a standardized, evidence-based approach to care delivery that brings all care up to the same, high standard. It’s about giving clinicians support to make the most clinically sound, safest, cost-effective decisions. Even the most dedicated and brilliant doctors don’t have time to keep up with all the latest medical literature. In today’s industry, it takes years for best practices to become common practice. By better systematizing care delivery, we can significantly reduce that time lag.

THE ANATOMY OF HEALTHCARE DELIVERY: VISUALIZING OUR HEALTHCARE SYSTEM

The key to applying better systematization is to first understand the flow of care delivery. We have developed the Anatomy of Healthcare Delivery for that purpose.

The Anatomy of Healthcare Delivery is essentially a conceptual model of how care delivery works. It takes the complexity of healthcare and distills it into a simple, actionable framework. It breaks healthcare into a small number of domains and subdomains and shows how care flows through them.

Modeling the care delivery process in this way makes it easier to see how and where to improve it.

Figure 2 - The Anatomy of Healthcare Delivery

Figure 2 – The Anatomy of Healthcare Delivery

As Figure 2 shows, care delivery begins with symptoms (a chief complaint) or positive findings from a screening. This in turn leads to a diagnostic workup, out of which flows a provisional diagnosis.

At this point, providers have to make the important decision about which treatment venue is appropriate for the patient. There are three major domains of clinical management to which a patient may be triaged:

  • Clinic Care Management
  • Acute Medical Management
  • Invasive Management

These domains are depicted as three vertical columns, or streams, in the diagram. As you can see, each domain is also broken into subdomains. For example, clinic care management includes chronic and non-recurrent subdomains, and invasive management includes interventional medical and surgical subdomains.

The following brief examples illustrate how care flows down these vertical streams:

  • Acute Medical Management Stream — A patient is triaged to either a general medical/surgical bed or an ICU. Generally, patients in the hospital need substances, such as antibiotics, pain medication, fluids, electrolytes, and/or blood. Treatment therefore includes substance selection, preparation, and then administration as a part of bedside care.
  • Invasive Management Stream — A patient with an ST elevated myocardial infarction is triaged either to invasive medical or invasive surgical. At that point, substances, such as sedatives, anesthetics, and analgesics are prepared and administered. The procedure is performed. The patient receives post-procedure care in the post-anesthesia care unit and is then discharged home or admitted to the hospital.
  • Clinic Care Stream — A child presents to a clinic with a middle ear infection (acute otitis media). If this is the first ear infection, she/he is treated with the expectation that the illness will resolve and not recur and sent home; however, if the ear infection recurs frequently and/or turns into serous otitis media, she/he becomes a patient with a chronic condition who is monitored to determine whether referral to an ENT specialist for evaluation of possible intervention may be indicated.

That is the basic construct. This framework facilitates identification and discussion of potential improvement opportunities to enhance quality, reduce cost, and improve patient satisfaction.

APPLYING KNOWLEDGE ASSETS TO THE ANATOMY OF HEALTHCARE DELIVERY

The Anatomy of Healthcare Delivery illustrates key decision points in the care delivery process. It is at these decision points that we can better systematize processes by introducing evidence-based knowledge assets.

Such knowledge assets are represented as blue and orange boxes in the Anatomy of Healthcare Delivery diagram in Figure 3.

  • The orange boxes represent population utilization management knowledge assets. These assets have to do with algorithms and criteria for ordering the right tests and care for patients and the frequency of care.
  • The blue boxes represent per case utilization management knowledge assets. These assets have to do with order sets for management of individual patients in inpatient and outpatient settings, with indications  for utilization of substances and supplies, and with protocols to implement the care ordered in the standardized order sets and in routine bedside and invasive care.

Applying knowledge assets at strategic points in the care delivery process is the key to transforming healthcare into a system where decision-making is based on standardized, evidence-based medicine. Developing and implementing these systematic clinical strategies — both blue and orange — is the key to improving clinical effectiveness, cost effectiveness, and the safety of patient care.

Figure 3 - The Anatomy of Healthcare Delivery

Figure 3 – The Anatomy of Healthcare Delivery

Orange Box Examples: Population Utilization Management Knowledge Assets

Knowledge assets represented by orange boxes are designed to standardize a population’s use of the healthcare delivery system. These boxes help ensure that patients who belong to a given disease cohort (patient registry) receive standardized care for their clinical condition.

Screening and Preventive Guidelines

The first orange box in the diagram deals with screening and preventive guidelines. Criteria for screening and immunization schedules live in this orange box, such as age and sex criteria for cancer screening including mammography and colonoscopy. Screening and preventive guidelines should follow the best available evidence for clinical and cost effectiveness. They help clinicians provide effective care in the clinic care environment and help them answer questions like:

  • Who should be screened for breast cancer, at what age, and how often?
  • Who should be screened for colon cancer, at what age, and how often?
  • What immunizations should a child, an adolescent, or an adult have and at what age?

Diagnostic Algorithms and Triage Criteria

The second orange box in the diagram represents diagnostic algorithms. Patients with abnormal results on screening exams and those with clinical symptoms enter the delivery system through diagnostic algorithms. Such algorithms include identifying a chief complaint, taking a history, performing a physical exam, formulating a differential diagnosis, and obtaining appropriate diagnostic tests. The purpose of these algorithms is to arrive at a provisional diagnosis as accurately and efficiently as possible.

The next orange box represents triaging the patient for clinical management based on risk of morbidity or mortality. One of the best-studied examples of a triage criteria knowledge asset is the CURB-65 criteria for community- acquired pneumonia. Documenting how many risk factors are present helps clinicians decide whether it’s safe to treat the patient in the clinic care environment, whether the patient needs to be admitted to a general acute care (med/surg) unit, or whether the patient is sick enough to be admitted to intensive care.

Treatment and Monitoring Algorithms

Treatment and monitoring algorithms guide clinicians

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