Reflections on 3 Years of Innovation: Recognizing the Need for Innovation Beyond the Clinical Care Pathway.

The Susan and Richard Levy Healthcare Delivery Incubator is designed to bring about rapid, sustainable, scalable, and transformational health care redesign. All 10 projects in the initial 3 cohorts of teams embraced the Incubator process-forming diverse teams and following a design-thinking informed curriculum-and each successfully implemented improvements or innovations by the end of their project. The purpose of this article is to identify the key features of teams' work that may help account for projects' success. For the 10 projects completed, findings from debrief interviews and staff observations were examined to identify processes key to project's success. Analysis highlighted cross-project learnings that indicate nonclinical aspects of care delivery that play a critical role in project innovation success. Innovating health care delivery requires considering social and political determinants of health. The Incubator's process and structures enable teams to identify and respond to a broad range of health determinants.

The global role of health care delivery science: learning from variation to build health systems that avoid waste and harm.

This paper addresses the fourth theme of the Indiana Global Health Research Working Conference, Clinical Effectiveness and Health Systems Research. It explores geographic variation in health care delivery and health outcomes as a source of learning how to achieve better health outcomes at lower cost. It focuses particularly on the relationship between investments made in capacities to deliver different health care services to a population and the value thereby created by that care for individual patients. The framing begins with the dramatic variation in per capita health care expenditures across the nations of the world, which is largely explained by variations in national wealth. The 1978 Declaration of Alma Ata is briefly noted as a response to such inequities with great promise that has not as yet been realized. This failure to realize the promise of Alma Ata grows in significance with the increasing momentum for universal health coverage that is emerging in the current global debate about post-2015 development goals. Drawing upon work done at Dartmouth over more than three decades, the framing then turns to within-country variations in per capita expenditures, utilization of different services, and health outcomes. A case is made for greater attention to the question of value by bringing better information to bear at both the population and individual levels. Specific opportunities to identify and reduce waste in health care, and the harm that is so often associated with it, are identified by learning from outcome variations and practice variations.

Development of instruments to measure the quality of breast cancer treatment decisions.

BACKGROUND: Women with early-stage breast cancer face a multitude of decisions. The quality of a decision can be measured by the extent to which the treatment reflects what is most important to an informed patient. Reliable and valid measures of patients' knowledge and their goals and concerns related to breast cancer treatments are needed to assess the decision quality. OBJECTIVE: To identify a set of key facts and goals relevant to each of three breast cancer treatment decisions (surgery, reconstruction and adjuvant chemotherapy and hormone therapy) and to evaluate the validity of the methods used to identify them. METHODS: Candidate facts and goals were chosen based on evidence review and qualitative studies with breast cancer patients and providers. Cross-sectional surveys of patients and providers were conducted for each decision. The accuracy, importance and completeness of the items were examined. RESULTS: Thirty-eight facts (11-14 per decision) and 27 goals (8-10 per decision) were identified. An average of 17 patients and 21 providers responded to each survey. The sets of facts were accurate and complete for all three decisions. The sets of goals and concerns were important for surgery and reconstruction, but not chemotherapy/hormone therapy. Patients and providers disagreed about the relative importance of several key facts and goals. CONCLUSIONS: Overall, breast cancer patients and providers found the sets of facts and goals accurate, important and complete for three treatment decisions. Because patients' and providers' perspectives are different, it is vital that instrument development should include items reflecting both views.

A perspective on the patient's role in treatment decisions.

There is considerable evidence, across different clinical contexts, that treatment decisions are characterized by poor communication, significant knowledge gaps, and a lack of attention to patients' preferences for different health states. Over the past two decades, patient decision aids have been shown to be an effective means to improve the quality of decisions. More recently, the Internet has increased expectations about the impact of information and decision aids on the involvement of patients in decisions. However, there are several challenges to effective dissemination and implementation of decision support interventions, through the Internet or other media. The authors recommend specific policy and research initiatives to facilitate the local and system-level changes necessary to support patients more effectively in making treatment choices. More attention to measurement and policy-level interventions will be required to increase the use of proven tools and to achieve significant improvements in the quality of treatment decisions.

Developing instruments to measure the quality of decisions: early results for a set of symptom-driven decisions.

OBJECTIVE: To identify a set of critical facts and key goals and concerns for five common medical conditions, benign prostate disease, hip and knee osteoarthritis, herniated disc and spinal stenosis and examine the validity of the method for identifying these items. METHODS: Investigators identified facts and goals through literature reviews and qualitative work with patients and providers. A cross-sectional survey of patients and providers was conducted to examine the accuracy, importance and completeness of the identified items. RESULTS: 42 facts (6-16 per condition) and 31 goals and concerns (4-13 per condition) were identified. 182 responses were obtained from patients (76.5% response rate) and 113 responses from providers (78% response rate). Overall, the facts were accurate, important and complete across all conditions. For one condition (hip osteoarthritis), the goals did not meet the criteria for completeness. There was more disagreement between patients and providers around the ranking of goals than of facts. CONCLUSIONS: Overall, respondents found the identified facts and goals accurate, important and complete. Significant differences between patients' and providers' rankings highlight the importance of including both perspectives. PRACTICE IMPLICATIONS: Instruments to measure whether or not patients are informed and the extent to which treatments reflect patients' goals must balance patients' and providers' perspectives when selecting items to include.

An approach to measuring the quality of breast cancer decisions.

OBJECTIVE: To explore an approach to measuring the quality of decisions made in the treatment of early stage breast cancer, focusing on patients' decision-specific knowledge and the concordance between patients' stated preferences for treatment outcomes and treatment received. METHODS: Candidate knowledge and value items were identified after an extensive review of the published literature as well as reports on 27 focus groups and 46 individual interviews with breast cancer survivors. Items were subjected to cognitive interviews with six additional patients. A preliminary decision quality measure consisting of five knowledge items and four value items was pilot tested with 35 breast cancer survivors who also completed the control preferences scale and the decisional conflict scale (DCS). RESULTS: Preference for control and knowledge did not vary by treatment. The mean of the participants' knowledge scores was 54%. There was no correlation between the knowledge scores and the informed subscale of the DCS (Pearson r = .152, n = 32, p = 0.408). Patients who preferred to keep their breast were over five times as likely to have breast-conserving surgery than those who did not (OR 5.33, 95% CI (1.2, 24.5), p = 0.06). Patients who wanted to avoid radiation were six times as likely to choose mastectomy than those who did not (OR 6.4, 95% CI (1.34, 30.61), p = 0.04). CONCLUSION: Measuring decision quality by assessing patients' decision-specific knowledge and concordance between their values and treatment received, is feasible and important. Further work is necessary to overcome the methodological challenges identified in this pilot work. PRACTICE IMPLICATIONS: Guidelines for early stage breast cancer emphasize the importance of including patients' preferences in decisions about treatment. The ability of doctors and patients to make decisions that reflect the considered preferences of well-informed patients can and should be measured.

Doing the right thing: systems support for decision quality in cancer care.

BACKGROUND: There is considerable evidence of problems with the quality of cancer care. Wide variation in rates of interventions suggests that cancer care decisions may not reflect the preferences of informed patients. PURPOSE: To present a framework for systems support for improving the quality of decisions in cancer. METHODS: We outlined the types of decisions faced by cancer patients and categorized them based on the level of evidence available about effectiveness of choices and the amount of variation in patients' preferences for the key outcomes. Then we describe appropriate strategies to systematically improve the quality of decision making for each category. RESULTS: The types of decisions faced by cancer patients and providers are varied. The appropriate strategy to drive improvements differs for different decisions. For complex, preference-sensitive decisions, improvements in decision quality require increasing patients' knowledge and the match between patients' preferences and treatments. CONCLUSIONS: Decision making in cancer care is complex. Neither patients nor providers can make treatment decisions alone. System support is needed to improve the quality of decisions.

Developing skills for evidence-based surgery: ensuring that patients make informed decisions.

Ensuring that the surgical decisions made by and with patients are fully informed is a challenge. Doctors and patients must work together, and to be successful they need support in the form of knowledge management and decision aids. This article emphasizes the importance of eliciting and honoring patients' personal valuations of alternative future health states, their attitudes to the specific risks and risk differences that are central to surgical decisions,and their attitudes to time trade-offs. The skills and habits necessary to accomplish this critical objective begin with nothing less than a genuine concern for patients and an ability to relate to the unique meaning that the present illness and its treatment have in their lives.

Policy support for patient-centered care: the need for measurable improvements in decision quality.

The phenomenon of practice variation draws attention to the need for better management of clinical decision making as a means of ensuring quality. Different policies to address variations, including guidelines and measures of appropriateness, have had little demonstrable impact on variation itself or on the underlying quality problems. Variations in rates of interventions raise questions about the patient-centeredness of decisions that determine what care is provided to whom. Policies that support the development and routine use of measures of decision quality will provide opportunities to measurably improve the quality of decisions, thereby leading to more patient-centered and efficient health care.

Extending decision support: preparation and implementation.

The shift towards patient-centered care requires innovative, flexible decision-making models. Current decision aids provide information and help patients clarify values. By focusing almost exclusively on these two components, the aids miss some necessary elements that can improve decision quality. We discuss two such elements in this paper. First is avoiding the tendency to move into providing information about options and outcomes before adequate preparation. The second is the tendency to neglect to provide adequate implementation support.