Chapter 2 Summary
Engineering and the Healthcare Delivery System
Chapter Authors
Proctor P Reid - National Academy of Engineering
W. Dale Compton - Former professor at Perdue University, and a past VP of Research at Ford Motor Company
The engineering profession can make important contributions to ongoing efforts to make healthcare delivery safe, efficient, patient-centred, timely, and equitable.
The authors make the case, that engineers play an important role in helping fix healthcare.
1. Engineering Systems
Systems are: “large numbers of entities that operate collectively to meet a set of objectives”. For example: telecommunications systems, trucking systems, energy systems, manufacturing systems.
“A well defined, efficient operating system requires that the overall objectives be clearly understood by all elements of the system, that feedback loops be supported by good communications and controls, and that some entity be in charge of the system and responsible for ensuring that its performance meets its stated goals”
“The reason we seldom hear about a healthcare delivery “system” is that healthcare delivery was never designed as a system and does not operate as one. Rather, as David Lawrence notes in the pervious chapter, healthcare delivery as a whole is fragmented, disorganized, and unaccountably variable”
2. Quality of Healthcare
Per IOM 2000, “every year, more than 98,000 Americans die and more than one million patients are injured as a result of broken healthcare processes and system failures”
“The gulf between a rapidly advancing medical knowledge base and its application to patient care is growing. Little more than half of U.S. patients are treated with known 'best practices'"
“Poor quality is costly. Lawrence estimates that $0.30 to $0.40 of every dollar spent on healthcare, more than a half trillion dollars per year, is spent on costs associated with “overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency”
What principles should guide how to improve things? The 2001 Institute of Medicine Crossing the Chasm: A New Health System for the 21st Century report suggested six guiding principles
- Safe
- Effective
- Patient-centred
- Timely
- Efficient
- Equitable
Equitable here is defined as, "providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status"
3. System Tools
The contribution of engineers in industries outside of healthcare is widespread, in the ares of systems engineering, industrial engineering, operational research, human-factors engineering, financial engineering/risk analysis, materials/microelectromechanical systems engineering.
Alan Pritzker defines a system approach as: “a methodology that seeks to ensure that changes in any part of the system will result in significant improvements in total system performance”
Ideally, in healthcare we can build systems analysis that will demonstrate how the system is performing, how it will respond to changes, and inform us when it is getting off track.
4. Challenges
4a. LACK OF DATA
The challenge to creating systems, is the lack of data. There is practically no operational performance data available. The information technology systems do not provide it. Therefore this needs to be collected manually. The intervention is performed. And then the operational data recollected. This is a major barrier to widespread change.
4b. FRAGMENTATION
The authors refer to healthcare as a Cottage Industry. I have always liked this term and use it myself. To me it perfectly describes the fragmentation, variation in quality, lack of operational excellence, and extremely high cost in the delivery of healthcare - similar to that of textile production prior to the industrial revolution. The authors go on to apply the term to the 700,000 clinicians in the United States of which over 80% practice in groups of ten or fewer.
4c. CHRONIC CARE
Three quarters of American healthcare spending is on chronic conditions. Such conditions require integrated, longitudinal care, distributed over many providers, with multiple functions and specialized knowledge that needs to be integrated over time. The current system is not set up to deliver this type of care.
5. Barriers to Cooperation
Doctors & engineers don’t understand or trust each other. This isn’t unexpected given the two professions have been educated entirely separate from each other, with different methodology, vocabularies, approaches, and ethical values.
Engineers should first focus on short term projects in healthcare on issues everyone can agree need to be fixed - such as the scheduling of appointments in clinics with high no show rates. As engineers gain further trust and demonstrate their utility within the healthcare system they will gain trust to solve higher level systems problems.
6. Engineers can help in the IT systems in healthcare.
The Building A Better Delivery System: A new Engineering./Healthcare Partnership NAE/IOM report calls for 30-50 multidisciplinary centres be created at universities where “systems-engineering tools, information technologies, and complementary social-science, congitive-sicence, and business/manamgnet knowledge” comes together with clinical knowledge in healthcare delivery to do (a) basic research, (b) solve real problems and (c) train and educate others.
Ultimately, a systems approach to healthcare needs to be integrated into the curriculum of physicians, clinicians, engineers, managment, and public health schools.
Some Commentary
This is an obvious chapter to place at the start of a book written by the engineering school: that engineers can help in healthcare. I agree.
I love the term Cottage Industry. It perfectly describes the fragmentation, variation in quality, lack of operational excellence, and extremely high cost in the delivery of healthcare - similar to that of textile production prior to the industrial revolution. We still await the industrial revolution to happen in healthcare.
Agreed - healthcare clinicians and engineers need to learn how to work together. I've seen problems bringing systems engineers into clinics and muck things up by not properly understanding how doctors think. And similarly, we've all seen problems putting physicians in management and logistics leadership positions - lacking any ability to make decisions in such an arena. Lets put this behind us, and learn how we can design systems that are safe, efficient, patient-centred, timely, and equitable.