Learning Organizations

I have long been interested in the link between how we organize our services in health care and its impact at the individual patient level. Much has been written about these linkages in the works of Knaus, Flood, and Leape, among others. I discussed these issues in a previous editorial.

Nationally, integrated delivery systems are struggling. There are few systems that have reached what Shortell calls the “third and final stage of integration”—that is, “clinical integration.” Clinical integration describes a setting where physicians, across multiple institutions, have completed a rigorous self-evaluation and have arrived at agreed-upon ways of implementing care processes. In short, clinical integration means a health system has figured out what works and has tossed out what does not work. Clinicians will embrace clinical integration if they believe that the outcome at the patient level will improve, and that their own practice lives will become more efficient (and possibly even fun).
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Barnsley and his colleagues went one step further and created a classification scheme that shows how integrated delivery systems can actually become learning organizations. As previously described in this column, Barnsley’s view is one of a shared vision, facilitative leadership, and communication channels all linked together to help integrated delivery systems become accountable for defined populations of patients.

In reflecting on the hard work of our own system, the Jefferson Health System (JHS) in the Philadelphia area, I have been benchmarking our accomplishments against the writings of these national thought leaders. Although I am sure our structure is not unique, the JHS, now comprised of 13 hospitals, has created a loose framework for clinical integration. Many of the constituent hospitals have a chief medical officer or vice president for medical affairs with operational responsibilities for quality. These physicians from each institution serve on an overarching committee at the system level appropriately named The Quality Council. The JHS Quality Council is chaired by the system’s chief medical officer. The Quality Council reports to the JHS Board of Trustees Committee, which is charged with oversight of the quality agenda.

Is there a connection, then, between this organizational structure and improvement in pharmacy practice? I believe there is a direct connection. A parallel committee to the Quality Council is the JHS Pharmacy Taskforce, also ably chaired by our system’s chief medical officer. The JHS Pharmacy Taskforce has representatives not only from the pharmacies in each of the constituent hospitals, but also from the group purchasing organizations with which our system collectively engages.
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The JHS Pharmacy Taskforce has tackled very difficult issues, ranging from a top-down review of our policies toward pharmaceutical representatives to an inventory of our multiple group purchasing contracts for everything from cardiac stents to antibiotics. Most recently, the taskforce has begun to look at ways in which we might improve the delivery of pharmaceutical care across the entire system.