PubMed · 10173499
The source did not provide an abstract. Follow the original record for more information.
Explore connections, maps & timelines
D Sinclair. 1997. Devolution to whom?. https://doi.org/10.1016/s0840-4704(10)60951-9
Cite the original work for its findings. Save a collection to share your selection of sources.
KEEP EXPLORING
Explore the source record for details and available documents.
This paper compares structural components of medical delivery in two major systemwide reform strategies in the United States. Commonly portrayed in terms of opposing ideologies of planning vs. market reform, regional organization and managed competition have promoted similar structural elements and geographic configurations. They both support growth of institution-based specialized teams and hospital consolidation. They both differentiate hospital care into vertically integrated levels, and develop regions as the key production and market area for organized delivery systems. System-wide management or regulation in each has tried to control allocation of resources, capital investment, and competition. Developed in the context of large-scale industrial production, these components have inherent economic dynamics and together they shape the market structure of medical care. The final section briefly considers the locus of power in the two reform approaches and the implication for choosing mechanisms of reform. It also notes that despite their rhetoric, the two strategies do not shape their services according to information about population benefit. The conclusion points out that the commonalities in structure and power demonstrate the dominance of economic organization in medical reform and contribute to the wide acceptance of this business form of organization as an international model.
BACKGROUND: In recent years, health and disease management has emerged as an effective means of delivering, integrating, and improving care through a population-based approach. Since 1997 the University of Pennsylvania Health System (UPHS) has utilized the key principles and components of continuous quality improvement (CQI) and disease management to form a model for health care improvement that focuses on designing best practices, using best practices to influence clinical decision making, changing processes and systems to deploy and deliver best practices, and measuring outcomes to improve the process. Experience with 28 programs and more than 14,000 patients indicates significant improvement in outcomes, including high physician satisfaction, increased patient satisfaction, reduced costs, and improved clinical process and outcome measures across multiple diseases. DIABETES DISEASE MANAGEMENT: In three months a UPHS multidisciplinary diabetes disease management team developed a best practice approach for the treatment of all patients with diabetes in the UPHS. After the program was pilot tested in three primary care physician sites, it was then introduced progressively to additional practice sites throughout the health system. The establishment of the role of the diabetes nurse care managers (certified diabetes educators) was central to successful program deployment. Office-based coordinators ensure incorporation of the best practice protocols into routine flow processes. A disease management intranet disseminates programs electronically. Outcomes of the UPHS health and disease management programs so far demonstrate success across multiple dimensions of performance-service, clinical quality, access, and value. DISCUSSION: The task of health care leadership today is to remove barriers and enable effective implementation of key strategies, such as health and disease management. Substantial effort and resources must be dedicated to gain physician buy-in and achieve compliance. The challenge is to provide leadership support, to reward and recognize best practice performers, and to emphasize the use of data for feedback and improvement. As these processes are implemented successfully, and evidence of improved outcomes is documented, it is likely that this approach will be more widely embraced and that organizationwide performance improvement will increase significantly. CONCLUSIONS: Health care has traditionally invested extraordinary resources in developing best practice approaches, including guidelines, education programs, or other tangible products and services. Comparatively little time, effort, and resources have been targeted to implementation and use, the stage at which most efforts fail. CQI's emphasis on data, rapid diffusion of innovative programs, and rapid cycle improvements enhance the implementation and effectiveness of disease management.