Framework for Describing HCO

7/25/2019 Framework for Describing HCO

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F R A M I N G H E A L T H M A T T E R S

A F r a m e w o r k f o r D e s c r i b i n g H e a l t h C a r e D e l i v e r y O r g a n i z a t i o n s

a n d S y s t e m s| lleana L. Pina, MD, MPH, Perry D. Cohen, PhD, David B. Larson, MD, MBA, Lucy N. Marion, RN, PhD, MN, Marion R. Sil ls, MD, MPH, Leif I. Solberg, MD,

and Judy Zerzan, MD, MPH

Desc r ib ing , eva lua t ing , and conduc t ing resea rch on the ques t ions ra ised by

comparat ive e f fec t iveness research and character iz ing care de l ivery organiza-

t ions o f a ll k inds , f rom indep enden t ind iv idua l p rov ide r un i ts to la rge in teg ra ted

heal th sys tems, has beco m e im perat iv e. Recogniz ing th is cha l leng e, the Del ivery

Sys tems Co m m i t tee , a subgro up o f the Agency fo r Hea l thca re Research and

Qua l i t y ' s E f fec t i ve Hea l th Care S takeho lde rs Group , wh ich rep resen ts a w ide

d ive rs i ty o f pe rspec t ives on hea lth ca re , c reated a d ra f t f ram ewo rk w i th d om a ins and e lemen ts that m ay be usefu l in character iz ing var iou s s izes and types of care

de l i ve ry o rgan iza t ions and m ay con t r ibu te to key ou tcom es o f in te res t. The

f ram ewo rk m ay se rve as the doo r to fu r th e r s tud ies in areas in wh ich c lear

de f in i t ions and desc r ip t ions a re lack ing . [Am J Public Health. 2015;105:670679.

doi :10.2105/AJPH.2014.301926)

Recent and ongoing innovation in systems

for the delivery and reimbursement of health

care in the United States have broadened

stakeholders need for standardized methods

to describe, measure, compare, and evaluate

delivery system changes. A com mon taxonomy

of delivery system characteristics would allow

for improved communication and transparency

regarding these changes, potentially enhancing

the quality of decisions and care for patients,

providers, researche rs, policymakers, payers,

and other stakeholders.1-5 The comparative

effectiveness of delivery system characteristics

is ranked as a top priority by the Institute of

Medicine, which has de fined comparative ef

fectiveness research (CER) as the generation

and synthesis of evidence that compares the

benefits and h arms of alternat ive methods to

prevent, diagnose, trea t, and mo nitor a clini

cal condition or to improve the delivery of

care.6 203) Yet, there is no s tand ard way to

describe care delivery units or systems that

encompasses their breadth, ranging from in

dependent individual provider units to large

integrated he alth systems.7 Thus, the absence

of a common parlance for describing delivery

systems hinders stakeholders from determining

the generalizability of a study o r an innovation

introduced in 1 setting. The effectiveness o f an

intervention may be quite different depending

on wh ether the setting is a large integrated care

system or a small independent practice and

whether providers are paid on production or

salaried. We propose a preliminary framework

for description of health care delivery systems

that will allow health care stakeholders to betterunderstand, evaluate, disseminate, and imple

ment delivery system innovation in a more

informed, transparent, and stakeholder-centered

fashion and permit comparisons among them.

Our objective is to present the domains and

elements of the framework, the methods that

were used to derive it and examples of its

potentia l application in diverse settings.

M E T H O D S

Our proposal builds on previous taxonomic

descriptions of the US health care system. In

response to the increasing complexity and het

erogeneity o f health care de liveiy systems, the

Agency for Healthcare Research and Qualify

(AHRQ) funded dev elopment of a taxonomy of

organizations, categorized by shared structural

and strategic elements.8 The resulting taxon

omy8 categorized 70 % of health networks and

90% of health systems into clusters using 3

dimensionsdifferentiation, integration, and

centralizationand applied the same dimensions

to hospital services, physician arrangements,

and provider-based insurance activities. In

200 4, the taxonomy was updated to include

a redefinition of centralization and updated

descriptors of health care systems because of

the continued evolution of organizations.9 1,1

In 20 06 , Luke11n oted that taxonomies de

rived from local systems were not appropriate

for large multihospital systems and recom

mended that further taxonomic studies were

needed. Subsequent taxonomic approaches

bro adened the ro le of a systems approach, giving

primacy to the inter relationships, no t to the

elements of the system alone.12,13

The pieces (elements) of the framework we

describe will certainly become furthe r complex

as organizations other than medical care groups

(e.g., public health agencies) e nter the aren a

of health care delivery. Rather than describe

the lack of an element in a specific organization,one must consider the integration of other

organizations bringing the missing elements

with them. In parallel to the work o f Bazzoli

et al.10 and Luke,11Mays e t al.14 concurren tly

described m ethodology to classify and com

pare public health systems on the basis of elements

of organization and defined 7 configurations

with 3 tiers on the basis of their level of dif

ferentiation. Also paralleling Bazzoli et al.,10

Mays et al.14 found tha t public hea lth systems

were in a state of fluidity from 1998 to 2006.

Fragmen ta t ion

The escalating complexity and heterogeneity

of health care delivery systems has led to in

creased fragmentation of how and w here health

care is delivered and has created new and often

ill-defined relationships between fragments.

The Commonwealth Fund Commission on a

High Performance Health System has described

traditional health care in the United States as

a cottage industry wherein fragmentation oc

curs at the federal, state, and local levels.15

Fragmentation can contribute to unnecessary,

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F R A M I N G H E A L T H M A H E R S

redundant utilization and poorer quality of

care.

Recognizing the challenges of a complex,

dynamic, and often fragmented health care

delivery system, the AHRQs Effective HealthCare Stakeholders G roup (SG) decided to d raft

an updated framework for describing health

care delivery systems, with domains and elements

that might be useful for characterizing various

sizes and types of care delivery organizations.

The SG was a par t of AHRQs Community

Forum initiative, funded by the American Re-

covery and Reinvestment Act, to formally and

bro adly engage stakeholders and to enh ance

and expand public involvement in its entire

Effective Health Care Program. Nomination of

individuals for the SG occurred via a publicprocess (a Federal Registernotice) and was

broadly inclusive. A com mittee composed

of representatives from AHRQ reviewed all

nominations and selected stakeholders to rep-

resen t a diversity of perspectives, expertise,

geographical locations, gender, and race/ethnidty.

The group re presented broad constituencies

of stakeho lders including patients, caregivers,

and advocacy groups; clinicians and profes-

sional associations; hospital systems and med-

ical clinic providers; government agencies;

purchasers and payers; and health care industry

representatives, policymakers, researchers, and

research institutions.

The Delivery Systems Committee (DSC),

a subgroup of the SG, consisted of 7 members

including clinicians, policymakers, patient ad-vocates, and researchers who were involved

with a variety of care delivery organizations

and rep resented diverse perspectives. The DSC

convened to ad dress a specific objective of

interest to AHRQ: to develop guidance for

AHRQ on how to approach CER on health

delivery organizations and systems by devel-

oping a framework that could be used to char-

acterize potentially important differences in

structure and function. DSC discussions were

facilitated by 2 members of the AHRQ Com-

munity Forum. All meetings were attended byat least 1 AHRQ staff member who provided

feedback. The charges of both the SG and the

DSC are detailed in the box below.

The DSCs initial work focused on defining

the basic unit of consideration: the health care

organization or system. Common definitions

for health care delivery systems generally refer

to all the components providing health care in

a country or locality. Fo r example, the World

Health Organization16 has def ined a health

system as all organizations, people and actions

whose primary intent is to promote, restore

or maintain health. The framework presented

here is meant to be broadly descriptive. To-

ward th at end, the DSC developed an elements

framework with 28 key elements grouped by

6 domains that characterize organizationsand delivery systems and may contribute to

key outcomes o f interest. The DSC tested the

framework for face validity among SG stake-

holders rep resenting a broa d variety o f systems

of care.

For the purposes of this article, we defined

a health care delivery system as the organiza-

tion o f people, institutions, and resources to

deliver health care services to meet the health

needs of a target population, whether a single-

provid er prac tice or a large health care system.

Approa ch

For each step in the development of the

framework, the DSC used 2 approaches: review

of the literature and the Delphi method, in-

cluding facilitated group discussions and itera-

tive rounds of individual written feedback on

successive drafts o f the framework. Descrip-

tions of conflict and reso lution were recorded

in detailed meeting notes and in framework

drafts, preserving an audit trail.

Although the DSC (at facetoface meetings)

did prioritization exercises, substantial discussion

Charges of the Stakeho lder Group and the Delivery Systems Comm ittee in Developing a Framework

to Describe Health Care Delivery Organizations and Systems

S t a k e h o l d e r G r o u p

P r o v id e g u i d a n c e o n p r o g r a m i m p l e m e n t a t i o n , in c l u d i n g

1 . Q u a l i ty i m p r o v e m e n t ,

2 . O p p o r t u n i t ie s t o m a x i m i z e im p a c t a n d e x p a n d p r o g r a m r e a c h ,

3 . E n s u r i n g s t a k e h o l d e r i n t e r e s t s a r e c o n s i d e r e d a n d i n c l u d e d , a n d

4 . E v a l u a t i n g s u c c e s s

P r o v i d e in p u t o n i m p l e m e n t i n g E f f e c t i v e H e a l t h C a r e P r o g r a m r e p o r t s a n d f in d i n g s i n p r a c t i c e

a n d p o l i c y s e t ti n g s .

I d e n t i fy o p t i o n s a n d r e c o m m e n d s o l u t i o n s t o i s s u e s id e n t i fi e d b y E f f e c t i v e H e a l t h C a r e

P r o g r a m s t a f f.

P r o v i d e i n p u t o n c r i t i c a l r e s e a r c h i n f o r m a t i o n g a p s f o r p r a c t i c e a n d p o l ic y , a s w e l l a s r e s e a r c h

m e t h o d s t o a d d r e s s t h e m . S p e c i f i c a ll y ,

1 . I n f o r m a t i o n n e e d s a n d t y p e s o f p r o d u c t s m o s t u s e f u l to c o n s u m e r s , c li n i c i a n s ,

a n d p o l i c y m a k e r s ;

2 . F e e d b a c k o n E f f e c t iv e H e a l t h C a r e P r o g r a m r e p o r t s , r e v ie w s , a n d s u m m a r y g u i d e s :

3 . S c i e n t i f i c m e t h o d s a n d a p p l i c a t i o n s ; a n d

4 . C h a m p i o n o b j e c t iv i t y , a c c o u n t a b i l i t y , a n d t r a n s p a r e n c y in t h e E f f e c t i v e H e a l t h C a r e p r o g r a m .

D e l iv e r y S y s t e m s C o m m i t t e e

H o w t o c o m p a r e d i f f e r e n t w a y s o f d e l i v e r i n g c a r e , i n c l u d i n g t o s u b p o p u l a ti o n s

W h a t a r e t h e i n g r e d ie n t s o r e l e m e n t s n e e d e d f o r c o m p a r i s o n o f w a y s t o d e l i v e r c a r e ?

C a n t h o s e e l e m e n t s b e e x a m i n e d a c r o s s d e l iv e r y o r g a n i z a t i o n s a n d s y s t e m s t o

g e t a s e n s e o f w h a t w o r k s b e s t f o r p a t ie n t s ?

W h a t c o m p o n e n t s o f d e l i v e ry o r g a n i z a t i o n s a n d s y s t e m s d o r e s e a r c h e r s n e e d t o

1 . Id e n t i fy a n d e l a b o r a t e , a n d

2 . R e l a t e to t h e p a t ie n t - c e n t e re d o u t c o m e s t h a t a r e m o s t im p o r t a n t ?

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FIGURE 1-Delivery systems methods f lowchart of the creation of a draft framework to

describe health care delivery organizations and systems.

occurred by e-mail and in conference calls,

which resulted in additional edits and revisions

to the framework. The richness of those dis

cussions contributed significantly to the final

product. Each step of the process involved all

3 methods: literature review, facilitated group

discussions, and synthesis of individual written

feedback.

Process

The DSC initially constructed a framework

consisting of elements of health care organiza

tions, focusing on outcomes of interest broadly

defined as quality, cost, equity, and patient

centeredness. Next, it identified several com

mon medical conditions, for example, diabetes,

as basic examples for developing the list of

elements relevant to outcomes for the selected

conditions. These elements were grouped into

domains on the basis of commonalities, with

the resulting framework initially consisting of

30 elements categorized according to 4 domains:

structure, resources, culture, and function-process.

A reiterative process initially resulted in 35

elements housed in 7 domains: physical assets,

human assets, the customer, financial aspects,

culture, process-function-system structure,

and integration, with each element assigned

to 1 domain only.

Each member applied the framework to the

delivery system with which they were most

familiar to test its goodness of fit. Comments

from this validation exercise were used to further

reorganize the framework into 26 elements in

6 domains: capacity, organizational structure,

finances, patients, care processes and infra

structure, and culture. The model of these

processes is shown in Figure 1.

The full SG was subsequently asked to pro

vide feedback regarding the domains, elements,

and definitions and to prioritize the elements.

Feedback from the SG included 2 primary re

commendations. First, it was valuable to have

the full set of elements available rather than

to eliminate elements or designate a core set

of measures. On the basis of this feedback,the DSC decided to allow future users of the

framework to select elements relevant to their

individual application of the framework. Sec

ond, the SG recommended including both ex

amples of the application of each element and

information about measurability of each ele

ment. The DSC responded to these suggestions

by adding more information about measur

ability, including (1) whether the element is

feasible to measure and, if so, providing ex

amples of instruments or formats for this mea

surement and (2) whether the measure of the

element involves description or increasing value

(i.e., is more better?). The DSC decided to use

both generic and specific instruments, when

possible, for measurement of the elements, with

the understanding that additional instruments

may currently exist or be developed.

R E S U L T S

The elements of the framework were divided

into 6 domains and their respective elements.

Descriptions of the elements and potential

examples of possible measures are presented

in Table 1, and summarized here.

1. Capacity:the physical assets and their own

ership, personnel, and organizational characteristics of a delivery system that determine

the number of individuals and breadth of

conditions for which the system can pro

vide care. Elements include size, capital

assets, and comprehensiveness of services.

2. Organizational structure:the components

of an organization, both formal and in

formal, that describe functional operations

in terms of hierarchy of authority and

the flow of information, patients, and re

sources. Elements include organizational

configuration; leadership, structure, andgovernance; research and innovation; and

professional education.

3. Finances:mechanisms by which a health

care delivery system is paid for its services

and the financial arrangements and prac

tices of the system and organizations

within the system to allocate those funds,

as well as the systems financial status.

Elements include payment received for

services, provider payment systems, own

ership, and financial solvency.

4. Patients:demographic characteristics, aswell as wants, needs, and preferences of

individuals and families of individuals

who receive health care services from

a health care delivery system. Elements

include patient characteristics and geo

graphic characteristics.

5. Care processes and infrastructure:the meth

ods by which a health care delivery system

provides health care services to its cus

tomers and patients as well as the degree of

coordination of those methods. Elements

include integration, standardization, performance measurement, public reporting,

quality improvement, health information

systems, patient care teams, clinical de

cision support, and care coordination.

6. Culture:The long-standing, largely implicit

shared values, beliefs, and assumptions

that influence behavior, attitudes, and

meaning in an organization.21 Elements

include patient centeredness, cultural

competence, competition-collaboration

continuum, community benefit, and inno

vation diffusion and working climate.

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The selected domains were chosen in an

effort to cluster those e lements that describe

similar aspects of the delivery system. By its

nature, an elem ent may no t fit perfectly within

a domain or, conversely, may be related toaspects of multiple domains. Rather than rep eat

elements in multiple domains, committee

members placed each element in the single

domain that the majority felt best represented

that element. Many of the elem ents are simply

descriptive rather than normative, such as

organizational size, configuration, or type of

pay men ts received. In oth er words, no or little

inherent value is generally ascribed to having

a large versus small staff, employment versus

partners hip model, or receiving paym ent on

a fee-for-service versus capitation basis, forexample. The descriptive nature of these elements

is expected to result in relative ease of mea

surement and protection from manipulation.

However, some elements are inherently

normative or value based, such as care co

ordination, patient centeredness, and cultural

competence. In oth er words, it is inherently

desirable for a health care delivery system to

effectively coordinate care, be patien t centered,

and be sensitive to patients cultural back

ground. These elements also tend to describe

less tangible characteristics of the organizationand are thus less easily measured and poten

tially more subjective and vulnerable to bias.

Furthermore, they tend to describe charac

teristics that are more structural, cultural, or

longitudinal. Nevertheless, the DSC decided

to include these elements despite their ac

knowledged limitations because they represen t

important aspects of care delivery, with the

expectation that objective measures may al

ready be accessible or will evolve over time.

One such example is organizational culturea

domain tha t is easier to describe than to measure.

Yet, various instruments are already available,

albeit with some limitations, as reviewed by

Scott et al.22 and Zazzali et al.,23who surveyed

physician cul ture and found great variability

within groups. Another less tangible element,

bu t equally as essential , is care coord ination.

The Care Coordination Measures Atlas24 pub

lished by AHRQ introduces a framework for

structure and processes that influence care

coordination and can be used today.

Although many o f the value-based measures

are directional (i.e., more is be tter), improving

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1 desirable attribute may come at the expense

of anoth er desirable attribute, such as financial

solvency versus comprehensiveness o f services

and community benefit or standardization

versus patient centeredness and research andinnovation. The framework as a whole is meant

to be used in such a way as to balance such

competing values. Elements were chosen as

aspects of health care delivery systems that,

in the stakeholders opinion, were likely to

contribute to a delivery organizations ability

to fulfill its mission. The DSC acknowledged

that the elements do not necessarily capture

every important aspect of a care delivery system

bu t include enough to serve as a basis for a

framework describing health care organiza-

tions. Conversely, not all elements are neces-

sarily nee ded to describe a given organization.

In addition, the DSC intentionally focused on

elements and domains rather than specific

measures or measurement systems; measures

included in Table 1 serve only as examples.

DISCUSSION

In this article, we present a draft framework

created for describing important differences

in health care delivery organizations of all sizes

and types, one th at might facilitate und er-

standing as we study and move from traditional

models of care to a systemoriented approach

while maintaining a patientcentered focus. In

the process, the DSC considered the current

status of the health care sector, medical prac-

tices in the United States, and current innova-

tive models of care and the overall importance

of patient centeredness, which traverses all of

the domains.

C u r r e n t H e a l t h C a r e S e c t o r

The num ber of singlephysician practices

dropped from 69% in 2003 and 11% with

2 physicians to 33% in solo or 2physician

practices in 2 0 08 .25 In 20 08 , 9 2% were single

specialty and 8% multispecialty; 15 % were

in practices of 3 to 5 physicians, and 19%

were in groups of 6 to 50 physicians. Thirteen

perce nt practiced in hospi tal settings, with 4 4%

of hospitalbased physicians working in office

prac tices or clinics and the rema ind er split

evenly between emergency rooms and hospital

staff.26 Of the physicians, 3% worked in com-

munity health centers and 4% in group or


staffmodel health maintenance organizations.

From the aspect of specialties, 79 % w ere in

singlespecialty practices, and only 21 % were

in multispecialty groups.27 Therefore, creating

this framework only for large health care orga-nizations would be myopic. The DSCs inten-

tion has been to provide domains and elements

that could also be applied to organizations of

all sizes, from very large to very small, from

single providers to groups of providers. Fur-

thermore, this work was intended to bring an

organized set of domains and elements that

have been created by all stakeholders (i.e.,

providers, administ rators, policymakers, and

health care consumers) under the auspices of

AHRQ. The inclusion of this diverse group

of stakeholders is in accordance with the In-stitute of Medicine report, which emphasizes

their inclusion in CER to ensure its relevance

to health care delivery.6 Health care delivery

systems also include those responsible for the

public health .

The Commonwealth Fund Commission re-

po rt15 has described th e characteristics of high

per form ing systems, which include access to

information, active management, interdepen-

dent accountability, patient access to care, and

continuous innovation. The reader may find

several of these attributes among the domains

and elements we present that can serve re-

searchers as a roadmap to add definitions and

borde rs to their work. Consequently , the cur-

ren t fragmentation of care fur ther highlights

the need for the draft framework presented

here. One o f the key and controversial features

of care delivery organizations, primarily large

ones, is the extent to which the care they provide is

integrated.2830 This observation is especially

true because many studies of care delivery

redesign and qualify have been conducted in

large integrated organizations such as the Veterans

Health Administration, Group Health, Kaiser

Permanente, and Health Partners, among others.

There are many definitions of integration,

bu t w e have chosen the one deve lop ed by

Shortell et al.31 and Gillies et al.32 (see Table 1,

Domain V). Using this definition, Solberg

et al.18,33 demonstrated that, among 100 large

medical groups nationally, the re was a positive

correlation between functional integration

and the presence of practice systems that have

been associated w ith higher quality of ca re

and, yet, a lot of diversity existed in integration

among these apparently similar organizations.

Solberg et al.18 created a set of measures of

functional, structural, and financial aspects of

integration from the organizational point of

view, whereas Singer et al.34 instead builtmeasu res from the patien ts perspective. In

spite of these measures, no consensus has be en

reached on how best to measure integration.

Less controversial than integration is the

importance of team care as an essential com-

po nent of bet ter quality, although whether it

also decreases costs is less clear. For example,

the collaborative care model for major depres-

sion has clearly been demonstrated to produce

higher quality, although it takes 3 to 4 years

to have any impact on costs.35 38 This model

is based not only on having a care managerin the primary care practice but also on regular

consultation visits by a psychiatrist. The de-

velopment of effective team care for quality

improvement in chronic illness has been ex-

plored by Shortell et al.39 and suggests the

importance of patient satisfaction. Similarly, the

chronic care model by W agner et al.40 presents

the importance of patient engagement as part

of the team for chronic care, such as in diabetes.

Team care is also a key feature of many of the

elements of the medical home. Hence, it seems

an impo rtant compon ent of this framework (seeTable 1, Domain V).41"43

I n n o v a t i v e C a r e M o d e l s

In fight of the creation o f innovative care

systems, the DSC believed tha t it was important

to make this framework capable of describing

the key features of organizations of all sizes

so that organizational structure and function

can more consistently be incorporated into re-

search design, publication, and policy decisions.

In addition, the DSCs intent has been to help

compare health care organizations across dif-ferent settings and provide a framework that

will facilitate CER of care delivery functions

and outcomes. There is no better example of

distinct and different settings than the current

care delivery reform emphasis on the medical

home and accountable care organizations,

encompassing both large and small care orga-

nizations.42 Much of the res earch on these and

other care redesign topics is being conducted

among dim es of varying size and ownership,

often members of practicebased research net-

works.44 The Kaiser Permanente system, as

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compared with independent traditional prac-

tices, offers a mod el o f a physician organization

that has adopted value and qualityoriented,

systemlevel care tools to deliver more effective

care.45 To understand whether the resultsapply to any particular practice, it is essential to

understand whether the clinics involved are

similar or, if they are not, to decide w hether the

differences affect generalizability.

R o l e o f P u b l i c H e a l t h i n C o m p a r a t i v e

E f f e c t i v e n e s s R e s e a r c h

Health issues that have the greatest impact at

the population health level and how to com-

pare them should also be pa rt of CER. Teutsch

and Fielding46 argued that comparative effec-

tive assessments of public health interventions canpositively influence health at all levelstha t is,

the individual and the populat ion as a wholeand

that studies should also focus on the develop-

ment of research methodology applied to public

health. However, most of the current published

CER work has centered on the comparison of

2 or more interventions focused on or targeted

to disease management or therapies. Other

studies, however, must explore the relevance

of this work to public health efforts so that in-

terventions can and should be studied not only

within systems of care but at the populationlevel. Certainly, the application of CER meth-

odology to public hea lth will present challenges

because, for example, randomization as in con-

trolled clinical trials may not always be possi-

ble. However, these challenges may lead to

more innovative statistical techniques, such as

propensity matching.

The taxonomy presented here could be

adapted to public health approachessome of

which are easier to identify than others. For

example, the patient domain may be translated

to the community of patients or population atlarge with a certain disease entity. The organi-

zational structure domain, as anoth er example,

could apply to public health services available

or desirable to improve a specific aspect of

populations.

Dubois and Graff47 recognized these diffi-

culties and the magnitude and variety of tasks

that are presented when considering CER at

the public health level. They offered a frame-

work, complementary to the taxonomy pre-

sented here, for prioritization o f CER efforts

with a series of elements. Among these elements

are the involvement of multiple stakeholders

and th e dissemination of the process. In parallel

with their framework, the domains of DSCs

framework were constructed by multiple stake-

holders who included representatives of patientgroups. Correspondingly, this article, and a

detailed repor t to AHRQ, represen t its dissem-

ination. Future involvement by public health

researchers, particularly in these early stages of

CER development and application, will enrich

this work by adapting and adding methodology

to the domains presented here.

As such, this work has focused on CER

priorities in the United States, which, according

to the Congressional bill that introduced CER,

states that findings should n ot be construed

as mandates, guidelines, or recom mendationsfor payment, coverage, or treatment... for

any public or private payer.48 By contrast,

the Commonwealth Fund has reviewed the

use o f CER in 4 countriesAustralia, France,

Germany, and th e United Kingdomin which

the research is driven by demand for informa-

tion by those making health care policy and

practice decis ions.49 Thus, involvement by

multiple stakeholders, including policymakers,

should occur earlier, rather than later, after

a CER plan is developed. Whether driven by

the public need for policy and allocation ofresources or by the need to improve quality

of care for patients directly, the framework

pre sented here is broad eno ugh to be applica-

ble to eith er process.

P a t i e n t C e n t e r e d n e s s

In 20 01 , the Institute of Medicine4 observed

that health care has traditionally been pro vider

and payment centered and that a shift in

paradigm was critical to the survival of the

US health care system. Th at change was a shift

in paradigm to one tha t was patient centered.Accordingly, the DSC considered patient cen-

teredness to be a critical component of current

care that should thus be given special attention.

Patient centeredness, when describing health

systems, reflects an undergirding and dom inant

value of attending to patient needs and pref-

erences in planning a nd delivering care.50 The

emphasis on qualify of care has resu lted in

a strong focus on patient centeredness and is

driving the efforts at defining the construct

and m easuring its antecedents and outcomes 46

Furthermore, the awareness of health disparities

based on race/ethnic ity, gender, age, and o the r

factors has increased, centering on the indi-

vidual patient and family members, th eir satis-

faction, and health care processes and outcomes.

AHRQ, in addition to many qualityorientedorganizations and regulatory agencies, has

supp orted and disseminated patientcenteredness

research findings and tools based on the r e-

search. So far, consensus is lacking for standard

measurement models or operational defini-

tions, but considerable research and dissemi-

nation are ev ident in the quality litera ture.51

Saha et al. presen t the 7 primary dimensions of

patien tcente red care as originally defined by

the Picker Commonwealth program: respect for

patientsvalues; preferences and expressed

needs; coordination and integration of care;information, communication, and education;

physical comfort; emotional support and allevia-

tion of fear and anxiety; involvement o f family

and friends; and transition and continuity.50

Currently, the tools most frequently used to

measure patient centeredness are patient sat-

isfaction surveys, such as the PressGaney

Medical Practice Survey and the Consumer

Assessment of Health Providers and Perfor-

mance Systems for hospitals, and adaptations

for othe r health care settings such as longterm

care facilities (https://www.cahps.ahrq.gov).52The w ork of identifying patient centeredness or

need there of by patient advisory teams and

peer pa tient coaches has led to reform in

several innovative systems and in health pol-

icy. 3 Hence, patient centeredness, as a value, can

be assessed in each of the elements spelled out in

this article and should remain in the back-

ground of any work using this framework.

L i m i t a t i o n s

The DSC understands that there are limita-

tions to this framework and other aspects thatare outside the scope of this article. For ex-

ample, we have not discussed organizational

boundaries , which are defined as the charac-

teristics of participation in an organization

that determine whether a person is within the

organization and subject to th e influence of its

rules, processes, and culture. Yet, boundaries

may be important to organizations reaching

their mission. The com mittee also unders tands

that som e domains, for example, culture, have

elements tha t are not easily or objectively

measurable and serve as an illustration of the

April 20 15 , Vol 10 5, No. 4 | American Journ al of Public HealthPina et al. | Peer Reviewed | Framing Health Matt ers | 67 7
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difficulty inherent in creating a classification

of human designs for organizations to imple-

ment evidencebased decisions about their

management. Indeed, the human element raises

uncertainty, as defined by the larger SG.

Summary

This framework presentation recognizes the

continuous evolution of health care systems,

particularly in light of the need for CER. To

compare health care organizations in 1 or many

aspects, there is a need for a foundation of

commonality in language for areas that are well

defined and further work for those that are not.

The framework can be used to characterize

potentially important differences in structure

and function of health care delivery organiza-tions and systems. To that end, researchers

could use the framework to clearly describe the

delivery setting for a study, facilitating under-

standing of whether the results are applicable

in specific settings and situations.

The DSC members understand that this work

is preliminary but believe that it is a step in

the right direction because there is currently

considerable organizational diversity and com-

plexity in health care. Future reports may con-

tinue to develop and elaborate on the domains

captured here, whether 1 at a time or in groups.This framework of 26 elements in 6 domains

may allow for more unders tandable studies

and descriptions of delivery system changes

to improve the health of people in the United

States. We have reflected on the domains and

elements presented here and fully recognize

the need for further work in many areas. How-

ever, there are others in which definitions were

readily available and agreed upon. It is in these

areas of agreement that work can be initiated

today.

A b o u t t h e A u t h o r sReana L. Pina is with A lber t Einstein College of Medic ine

and Montefiore-Einstein Medical Center, Bronx, NY.

Perry D. Cohen is with the Parkinson Pipeline Project,

Washington, DC. David B. Larson is with the Department

o f Radiology, Cincinnati Childrens H ospital Medical Cen

ter, Cincinnati, OH. Lucy N. Marion is with the Medical

College o f Georgia School o f Nursing, Macon. Marion R.

Sills is with the University o f Colorado School o f Medicine,

Denver. L ei f I. Solberg is with HealthPartners Medical

Group and Clinics, Minneapolis, MN. Judy Zerzan is

with the Colorado Department o f Health Care Policy and

Financing, Denver.

Correspondence concerning this article should be sent

to Re am L. Pina, MD, MPH, 111 Eas t 21 0t h Street, North

2-S ilve r Zone, Bronx, N Y 1 04 67 (e-mail: ilppina@aol.

com). Reprints can be ordered at http://www.ajph.orgby

clicking the "Reprintslink.

This article was accepted February 2, 2014.

C o n t r i b u t o r sAll of the authors were part of the Delivery Systems

Committee an d participated in facetoface meetings,

conference calls, and emails pertaining to the creation of

the taxonomy. Each author worked on specific sections

and circulated them among the rest of the committee.

I. L. Pina served as the chair of the committee and drafted

the first version of the article. The rem aining authors were

involved in iterations, edits, corrections, and comments

leading to the final version.

A c k n o w l e d g m e n t sWe gratefully acknowledge the assistance of Christine

Chang, MD, MPH, of the Agency for Healthcare Research

and Quality (AHRQ), and Jill Yegian, PhD, and Diane

Martinez, MPH, of the Am erican Institute for Researchfor their guidance and support during meetings, confer-

ence calls, and emails. We also appreciate AHRQs role

in convening the Stakeholders Group and the Delivery

Systems Committee. We also thank Ms. Patricia Peralta

for her review and editing.

R e f e r e n c e s1. Conway PH, Clancy C. Transformation o f health care

at the front line./AM4. 2009,301 (7):763765.

2. Averill RF, Goldfield NI, Vertr ees JC, McCullough

EC, Fuller RL, Eisenhandler J. Achieving cost control,

care coordination, and quality improvement through

incremental payment system reform .] A mbul Care

Manage.2010;33(l) :223.

3. Grundy P, Hagan KR, Hansen JC, Grumbach K. The

multistakeholder movement for primary care renewal

and reform.Health A ff (Millwood).2010;29(5):791798.

4. Institute of Medicine. Crossing the Quality Chasm:

A New Health System fo r the 2 1s t Century.Washington,

DC: National Academy Press; 2001.

5. Nolan T. Institute for Healthcare Improvement Board

of Directors. US Health Care Reform by Region.Cambridge,

MA: Institute for Healthcare Improvement; 2010 .

6. Sox HC, Greenfie ld S. Compa rative effectiveness

research: a report from the Institute of Medicine. An n

Intern Med. 2009;151(3):203205.

7. Olsen L, Grossm an C, McGinnis JM. Learn ing W hat

Works: Infrastructure Required for Comparative Effec-

tiveness Research: Workshop Summary. Washington,DC: The National Academies Press; 2011.

8. Bazzoli GJ, Shor tell SM, Dubbs N, Chan C, Kralove c P.

A taxonomy of health netw orks and systems: bringing order

out of chaos. Health Serv Res. 1999;33(6):1 683 1717.

9. Dub bs NL, Bazzoli GJ, Shortel l SM, Kralovec PD.

Reexamining organizational configurations: an update,

validation, and expansion of the taxonomy of health

networks and systems. Health Serv Res. 2004;39(1):

207220 .

10. Bazzoli GJ, Shortell SM, Dubbs NL. Rejoinde r to

taxonomy of health networks and systems: a reassess-

ment. Health Serv Res.2006;41(3 pt l) :629639.

11. Luke RD. Taxonomy of health networks and

systems: a reassessment. Heal th Serv Res. 2006;

41(3 pt l ) :618628 .

12. Donabed ian A. Quality assurance: corporate re-

sponsibility for multihospital systems. QRB Qual Rev Bull.

198 6;1 2(1 ):3 7.

13. Donabed ian D. Wh at students should know about

the health and welfare systems. Nurs Outlook. 1980;28

(2):12 2125.14. Mays GP, Scutchfield FD, Bhandari MW, Smith SA.

Understand ing the organization of public health delivery

systems: an empirical typology. Milbank Q. 2010;

88( 1): 81111.

15. Shill A, Davis K, Schoenba um S, et al. Organizing the

US Health Care Delivery System fo r High Performance.

New York, NY: Comm onw ealth Fund; 20 08 .

16. Wo rld Health Organization. The W orld Health Report

20 0 0 Health Systems: Improving PerformanceGeneva,

Switzerland: W orld Health Organization; 2000 .

17. Hibbard JH, Stockard J, Mahoney ER, Tusler M.

Developmen t of the Patient Activation Measure (PAM):

conceptualizing and m easuring activation in patients and

consumers. Health Serv Res.2004;39 (4 pt 1): 100 510 26.

18. Solberg LI, Asche SE, Shortell SM, et al. Is integra tion

in large medical groups associated with quality?Am J

Manag Care. 2009;15(6):e34e41.

19. AHRQ TeamSTEPPS and Teamw ork Attitudes

Questionnaire. AHRQ, editor. 2014. Available at: http://

www.ahrq.gov/professionals/education/curriculum

tools/teamstepps/instructor/index.html. Accessed April

22, 2014.

20. National Quality Forum. Preferred Practices and

Performance Measures for Measuring and Reporting Care

Coordination: A Consensus Report.Wa shington, DC:

National Quali ty Forum; 20 10 .

21. Morgan G.Images of Organization. Thousand Oaks,

CA: Sage; 20 07.

22. Scott T, Mannion R, Davies H, Marshall M. The

quantitative measurement of organizational culture in

health care: a review of the available instruments.Health

Serv Res. 2003;38(3):923945.

23. Zazzali JL, Ale xande r JA, Shortell SM, Bum s LR.

Organizational culture a nd physician satisfaction with

dimensions o f group practice.Health Serv Res.2007;

42(3 pt 1):11501176.

24. McDonal d KM, Schultz E, Albin L, et al. Care

Coordination Adas Version 3 (Prepared by Stanford

University under subcontract to Battelle on Contract

No. 29 0 04 0 02 0) . A HRQ Publ icat ion No .l 1 00 23 EF.

Rockville, MD: Agency for Healthcare Research and

Quality; 2010.

25. Boukus E, Cassil A OMalley AS. A snapsho t of U.S.

physicians: key findings fr om t he 200 8 Hea lth Tracking

Physician Survey.Data Bul l (Cent Stu d Health Sys t Change)

2009;111.

26. Hing E, Burt CW. Officebased medical practices:

methods and estimates from the National Ambulatory

Medical Care Survey. Adv Data. 2007;(383):115.

27. Kane CK. The Practice Arrangements of Patient Care

Physicians 20 07-2 008 .Chicago, IL: American Medical

Association; 2009.

28. Budetti PP, Shortel l SM, Wa ters TM, et al. Physician

and health system integration. Health A f f (Millwood).

200 2;21(1) :20 32 10.

29. Shields MC, Sacks LB, Patel PH. Clinical integra tion

provid es the key to qua lity improvem ent : st ruc tur e f or

change. A m J Med Qual. 2008;23(3):161164.

67 8 | Framing Health Matte rs | Peer Reviewed | Pina et al. American Journal of Public Hea lth | April 20 15 , Vol 10 5, No. 4
http://www.ajph.org/http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.htmlhttp://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.htmlhttp://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.htmlhttp://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/index.htmlhttp://www.ajph.org/


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30. Enth oven AC, Tollen LA. Competition in health care:

it takes systems to pursue quality and efficiency. Health

A f f (Millwood).2 005;(suppl web exclusives) :W 5-42 0-

W5-4233.

31. Shortell SM, Bazzoli GJ, Dubbs NL, Kralovec P.

Classifying health networks a nd systems: managerial an d

policy impl ications. Health Care Manage Rev.2000;

2 5(4) :9 -17.

32. Gillies RR, Shortell SM, Ander son DA, Mitchell JB,

Morgan KL. Conceptualizing and m easuring integration:

findings from the hea lth systems integration study.

Hosp Health Serv A dm. 1993;38(4):467-489.

33. Solbe rg LI, Asche SE, Pawlson LG, Scholle SH, Shih

SC. Practice systems are associated with high-quality care

for diabetes. Am JM an ag Care. 2008;14(2):85-92.

34. Singer SJ, Burgers J, Fried berg M, Rose nthal MB,

Leape L, Schneider E. Defining and measuring integrated

pa tient care : pro mo tin g th e nex t f ron tie r in healt h care

delivery. Med Care Res Rev. 20 11;68(1):112-127.

35. Un utze r J, Katon WJ, Fan MY, et al. Long-term cost

effects o f collaborative care for late-life depression. A m JMa nag Care. 2008;14(2):95-100.

36. Un utze r J, Katon W, Callahan CM, et al. Collab

orative care management of late-life depression in the

prima iy c are sett ing: a ran dom ize d con trolled trial. JAMA .

2002;288(22):2836-2845.

37. Gilbody S, Bow er P, Fletcher J, Richard s D, Sutton

AJ. Collaborative care for depression: a cumulative

meta-analysis and review of longer-term outcomes.

Arch In tern Med 2006; 166(21):2314-2321.

38. Williams JW Jr, Gerrity M, Holsinger T, Dobscha S,

Gaynes B, Dietrich A. Systematic review o f multifaceted

interventions to improve depression care. Gen Hosp

Psychiatry.20 07;29(2):91-116.

39. Shortell SM, Marste ller JA, Lin M, et al. Th e role of

pe rce ived te am effectiveness in im proving chr onic illness

care. Me d Care.2004;42(11):1040-1048.

40. Wag ner EH, Austin BT, Davis C, Hindma rsh M,

Schaefer J, Bonomi A. Imp roving chronic illness care:

translating evidence into action. Health A f f (Millwood).

2001 ;20(6):64-78.

41. Bodenh eimer T, Wa gner EH, Grumbac h K. Im

pro vin g pr im ary car e f or pat ien ts with chroni c illness.

JAM A. 2002;288(14): 1775-1779 .

42 . Rosse r WW, Colwill JM, Kasperski J, Wilson L. Progress

of Ontarios Family Health T eam m odel: a patient-centered

medical home. An n Fam Med2 0 1 1;9(2):165171.

43. Schoe n C, Osbo rn R, Squires D, Doty M, Pierson R,

Applebaum S. New 2011 survey of patients with com

plex c are needs in e leven c oun trie s finds that c are is o ften

poorly coo rdinated. Health A f f (Millwood). 2011;30

(12):2437-2448.

44. Tierney WM, Oppen heimer CC, Hudson BL, et al. A

national survey of primary care practice-based research

networks.An n Fam Med. 2007;5(3):242-250.

45. Ritte nhou se DR, Grum bach K, ONeil EH, Dower C,

Bindman A Physician organization and care manage

men t in California: from cottage to Kaiser. Health A f f

(Millwood). 2004;23(6):51-62.

46. Teutsch SM, Fielding JE. Applying comparative

effectiveness research to public and population health

nitiatives. Health A f f (Millwood). 20 11;30(2):349-355.

47. Dubois RW, G raff JS. Setting priorities for compar

ative effectiveness research: from assessing public health

ben efit s to bei ng open wi th the public. Health A f f (Mill-

wood).2 01 1;30(12):2235-2242.

48. United States Code, 20 09 Edition Title 42. The

Public Health and Welfare Chapter 6A. Public Health

Service Subchapter VII. 2009. Agency for Healthcare

Research and Quality Part B-Health Care Improvement

Research Sec 299b-8. Federal Coordinating Council

for Comparative Effectiveness Research From th e US

Governme nt Printing Office.

49. Chalkidou K, Walley T. Using comparative effec

tiveness research to inform policy and practice in the

UK HHS: past, present and future. Pharmacoeconomics.

2010;28(10):799-811.

50. Saha S, Beach MC, Coop er LA. Patien t centeredness,

cultural competence and healthcare quality.J Na tl Med

Assoc. 2008;100(11):1275-1285.

51. Arago n SJ, McGuinn L, Bavin SA, Gesell SB. Does

pedia tric pa tient-centeredness affect family trus t?J Healthc

QuaL 2010;32(3):23-31.

52. AHRQ. Consumer Assessment of Healthcare Pro

viders and Systems. 2014. Available at: https://www .cahps.ahrq.gov. Accessed April 22, 20 14.

53. Sodomka P. Engaging patients and families: a high

leverage tool for health care leaders. Hosp Health Netw.

2006:28-29.

Preventing Childhood Obesity in Early Care andEducation, Second Edition

A pu bl icat ion fr o m Am er ic an Ac ad em y o f Pediatr ics; Am er ican Pub lic Hea lth Assoc iat ion ; and Nat iona l

Resour ce Cent er fo r He al th and Sa fet y in Chil d Car e an d E arl y E du ca tio n

Preventing Childhood Obesity in Early Care and Education, Second Edition is the

new set of national standards describing evidence-based best practices in nutrition,

ph ys ica l activ ity, an d sc re en tim e fo r e ar ly ca re an d ed uc at io n pr og ra m s. Th e st an

dards are for all types of early care and education settings-centers and family child

care homes. These updated standards are part o f the new comprehensive Caring

fo r O ur Ch ildren: Nat iona l H eal th an d S afe ty P erf orma nce S tan dards : Gu ide line s

fo r E arl y C are a nd Educati on Prog ram s, Th ird Ed itio n. New Updates include all

MyP yramid references to MyPlate, and added playing outdoors standard.

Topics include: General nutrition requirem ents, meal and snack patterns, requirements for infants in

cluding supporting breastfeeding, requirements for toddlers and preschoolers, meal service and su pervi

sion, nutrition education, active opportunities for physical activities, outdoo r and indoor play time, care-

givers/teachers' encou ragem ent of physical activity, policies on infant feeding, food and nu trition services,

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O R D E R T O D A Y !

2 0 1 2 , 7 5 p p s o f tc o v er , IS BN 9 7 8 - 1 5 8 1 1 0 - 7 1 4 2

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APHA PRESSAN IMPRINT OFAMERIC AN PUBLIC HEALTH ASSOCIATIO N

April 20 15 , Vol 105, No. 4 | American Journa l of Public HealthPina et al. | Peer Reviewed | Framing Health Mat ters | 67 9
https://www/http://www.aphabookstore.org/mailto:[email protected]:[email protected]://www.aphabookstore.org/https://www/


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C o p y r i g h t o f A m e r i c a n J o u r n a l o f P u b l i c H e a l t h i s t h e p r o p e r t y o f A m e r i c a n P u b l i c H e a l t h

A s s o c i a t i o n a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a

l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t ,

d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .

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