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National Academy of Engineering (US) and Institute of Medicine (US) Committee on Engineering and the Health Care System; Reid PP, Compton WD, Grossman JH, et al., editors. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington (DC): National Academies Press (US); 2005.

Cover of Building a Better Delivery System

Building a Better Delivery System: A New Engineering/Health Care Partnership.

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Improving Health and Health Care

Lewis G. Sandy

Robert Wood Johnson Foundation

Private foundations like the Robert Wood Johnson Foundation are like venture capitalists for ideas. Today, I'm going to talk about our priorities and strategies for improving the health care system and health care. I will reflect on the challenges we face in implementing our agenda, outline strategic directions, and suggest how engineering and medicine can be linked.

I want to make three points. First, I believe the major problem in health care is not a lack of tools, although we have heard about new tools that could and probably should be developed. The major problem is the way we use existing tools. Second, in thinking about using engineering principles, theory, and knowledge, we must think about health, not just health care. We must think beyond the health care delivery system to using technology to actually improve the health of people. We must think beyond the organization and financing of our current health care system. Third, bringing engineering and medicine together is not predominantly a technical problem; it is a cultural problem.

The Robert Wood Johnson Foundation is one of the largest foundations in the country and the largest foundation devoted to improving health and health care for Americans. We have about $8 billion in assets and award $400 million annually in grants. We use a variety of methods to achieve our goals—such as supporting research projects, demonstrations, training, communications, and workshops. Our work is organized around three goals: (1) ensuring that all Americans have access to care; (2) improving care for people with chronic health conditions; and (3) helping the country deal with substance abuse. General improvement is part of our mission, but the specifics are embodied in our goals. We encourage the health care system to do the right things. In some cases, we support innovations. In addition, we promote the diffusion and adoption of existing best practices.

For example, a program called Improving Chronic Illness Care run by the Group Health Cooperative of Puget Sound focuses on improving care for people with chronic illnesses. Our health care delivery system generally focuses on acute care; the system is geared toward treating infectious diseases and acute traumas. There is a mismatch, however, between that model and the prevalence of disease, predominantly chronic illnesses that require a different model of care with different elements.

A chronic care model of health care delivery includes linkages between the health system and the community, as well as support for self-care and self-management. A health care delivery system organized for chronic care must provide decision-support tools for providers and for patients and families. It must also have a supporting information infrastructure; in addition, the health care delivery team must be redesigned and retrained. The foundation has provided $32 million to support projects, research, and demonstrations and provide technical assistance to promote a health care system configured to treat chronic illnesses.

A program called Smoke Free Families focuses on the dissemination of best practices. The goal of the program is to eliminate, or at least reduce, smoking by pregnant women, one of the most important, modifiable risk factors for premature births. Everyone recognizes that prenatal smoking is a problem, but the adoption of proven, effective interventions has not been successful. We provide instructions for providers to assess the situation and advise women to quit smoking during prenatal visits.

We try to implement and evaluate new models of health care being developed by researchers and idea entrepreneurs. Once a better technology has been developed and demonstrated, the difficulty is in getting individuals to use it. It is even more difficult to create an incentive structure that encourages the entire delivery system to adopt and diffuse innovations. We have tried to increase consumer demand for higher quality care and have worked through vehicles, such as a purchaser institute that brings together public and private purchasers. We know that consumer demand can change systems of care. Consider the changes in obstetrical care, which has changed from a technological, sterile practice to a more humane, patient-centered, caring, warm experience through birthing centers. These changes are the result of consumer demand for changes in care.

Not enough attention has been paid to improving overall health care. The health care system needs a “Toyota,” someone who can do for health care what Toyota did for the auto industry—engineer the product in a fundamentally different way. No health care delivery system yet has been demonstrated to be better in all respects—in technical quality, interpersonal quality, and so on.

The foundation is providing support to the Institute for Health Care Improvement to develop a demonstration program that would lead to a transformational change in health care. The project, called Pursuing Perfection, is focused on analyzing barriers to improving health care. We want to shake up the current system to show that things can be done in a fundamentally different way. We provide grants and technical assistance for the program, and we are creating a learning network and undertaking a communications campaign. Currently, we are visiting 26 sites to choose awardees for 12 planning grants, some on errors in medication, some on access to care and patient flow, and some on nursing, staffing, and human resource management.

The program has generated a great deal of interest, indicating that there is a pent-up demand among providers for a transformational change in health care. In a recent survey, we found that about 30 percent of physicians think improving care is an important problem and that they personally could affect change (IHI, 2001).

Very little production-process thinking is being used in health care. Even those working on improving quality of care are not using applicable engineering tools. We need to open a bridge between medicine and engineering. People in the engineering community know which tools would be helpful for analyzing problems and effecting improvements.

One of the differences between engineering and medicine is that engineers believe in the theoretical possibility of perfection; doctors do not. Even in highly reliable organizations, adverse events happen all the time. We know from the genome project that human beings are riddled with genetic errors. Doctors understand illness and medical care as part of the human condition and the human tragedy.

But we can make changes through process improvement. Medicine is an ancient story about heroes and tragedies that has only been a high-technology scientific enterprise for the past 50 to 75 years. For the first 3,000 or 4,000 years of the history of medicine, it was considered a calling, a profession that dealt with the inexplicable tragedy of the human condition. This long history is built into the socialization of physicians in a fundamental way.

To bridge the culture gap, engineers who work in health care delivery or operations improvement will need cultural training in some aspects of health care. A good resource is On Doctoring by Reynolds and Stone (1991), which is given to all entering medical students by our foundation to socialize them into the practice and culture of medicine.

Physicians also need to be educated in what I call the “engineering culture.” Some efforts are being made to train physicians in principles of operations and improvement. However, we need to develop a language and concepts for health care practitioners interested in this field. We also need a research agenda, such as the one being developed for medical errors and patient safety. Another critical area for research is human factors engineering. The burden of malpractice suits and litigation can hardly be overestimated, and we need to create safe harbors for reporting on adverse events or near misses. We must also develop a national agenda for improvement.

We must consider health care at the macrosystem level, that is, the health of the population, and not just the health care system. The Web and other technologies can be used to provide consumers with information on healthy living and to promote behavioral change. The major modifiable determinants of health are in the environment in which people live, choices in individual behavior. Think about how we can use technology and engineering principles to influence those choices. In addition, we should be thinking about designing communities that encourage people to walk or otherwise stay physically active because we know that even minimal exercise can have a huge health impact. We can promote behavioral change strategies to help improve people's diets and help them deal with stress. New organizations and new functions outside the traditional health care delivery system can improve people's lives.


  1. IHI (Institute for Healthcare Improvement) Pursuing Perfection. 2001 Press release May 8, 2001.
  2. Reynolds R, Stone J, editors. On Doctoring: Stories, Poems, Essays. New York: Simon & Schuster; 1991.
Copyright © 2005, National Academy of Sciences.
Bookshelf ID: NBK22855


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