Healthcare changes continuously

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Study data come from interviews with Swedish health care professionals physicians, registered nurses, assistant nurses. In the Swedish health care system, residents are insured by the government, with equal access to health care for the entire population, although private health care also exists.

We conducted semi-structured individual interviews with 11 physicians, 12 registered nurses and seven assistant nurses — 30 health care professionals total Table 1.

The health care professionals were employed in six different health care units located in small- to mid-sized cities in south-eastern Sweden populations of 67,, , and , inhabitants, respectively.

To achieve a sample of health care professionals that represented a broad spectrum of perceptions and experiences concerning changes in health care — i. To recruit frontline health care professionals, we used an e-mail that briefly described the study. We sent the e-mail request to the manager of each work unit, with a request that they forward our request to physicians, registered nurses and assistant nurses.

We then sent an informational letter describing the study to those who responded to our email. No one declined to participate after receiving the information letter. We scheduled interviews at a time between January and September and in a location convenient to participants, where they could feel comfortable about speaking honestly e.

We used an inductive approach to data collection, with a semi-structured interview guide developed by the authors. The interview guide is available as an Additional file. As such, instead of asking about specific changes or providing lists or examples of changes, we allowed the participants to discuss any changes they considered to be relevant to their work; this approach reflects research that shows that experiences of are often individual e.

We began each interview with questions about the participant, the content of their work, and their workplace. We then asked participants to describe examples of organizational changes that they considered to be successful. We asked a final open-ended question to capture any other reflections that participants had.

In two interviews, we pilot tested the questions to assess their meaningfulness and clarity of concepts. We included the two pilot interviews in the study. Individual interviews were conducted by all the authors except SB, who does not speak Swedish, and were digitally recorded. Before the start of an interview, the participant was asked to re-read the information letter and give written informed consent to participate.

The interviews were transcribed verbatim by a professional transcription agency and were then reviewed by the researcher who conducted the interview. All authors except SB read the transcripts of the interviews individually to create a holistic view of the material. In the next step, each researcher performed a first analysis condensing meaning-bearing units and creating codes and subcategories. Tentative findings were reported to and discussed with SB.

This discussion led to a proposal concerning the categories of analysis, which was then fed back to SB for her comments. Eventually, consensus was reached on the categories and PN suggested labels which were accepted by the whole group. Finally, SB, whose first language is English, reviewed the English-language quotations for clarity.

The findings regarding these characteristics were equally applicable to the physicians, registered nurses and assistant nurses, with few notable differences among the three professional categories.

The quotes are attributed to the physicians P , registered nurses RN and assistant nurses AN , who were interviewed, numbered from 1 to The health care professionals emphasized the importance of having the opportunity to influence organizational changes that are implemented.

Changes that were initiated by the professionals themselves were considered the easiest and rarely encountered resistance on the part of health care professionals. It is from there, I think, most often the smartest ideas will emerge, but then it is important to ensure that you are responsive and assess [the ideas]. According to the health care professionals, organizational changes that were clearly communicated to allow for preparation increased the chances for successful changes.

We had two weeks to develop new systems and that results in considerable consequences. We had to solve it anyway. The changes might otherwise be perceived as meaningless and unjustified, which may create change resistance. In particular, health care professionals valued and perceived as successful organizational changes with a patient focus, with clear benefits to patients.

Change is pervasive in modern health care. This study aimed to identify characteristics of successful organizational changes from the perspective of health care professionals at the frontline level of health care. The importance of individual responses to organizational changes has been increasingly emphasized [ 25 ]. Three categories i. Many of the statements by the participants were representative of more than one category, suggesting an interdependency between the three categories of this triad of successful change characteristics.

For example, a slower change allows for preparation, which facilitates involvement and influence, thus enabling an appreciation for the change. Alternatively, recognizing the value of a change, e. This interdependence implies that successful change is more likely if more than one of the three categories is accounted for when planning and implementing changes.

The importance of preparation for and involvement in a change has been associated with decisional latitude [ 26 ] and valuing the change in terms of experiencing personal gains has been linked with involvement in the change [ 27 ]. However, we have not been able to find any previous study, either in health care settings or in other environments, which has identified the relevance of this particular triad of characteristics or how they are interlinked.

Although our findings suggest these interdependencies, we did not collect data to specifically investigate the underlying mechanisms; thus, exploring these interdependencies would be an important area for future research. The health care professionals in our study attached great importance to being able to influence changes that may influence their work.

Many of the health care professionals complained about the power differential between those who are affected by the changes and higher management and political levels of the health care system who usually decide on what changes to implement. Physicians in Sweden have often raised complaints that policy making and decisions concerning the medical profession are made without physicians or their professional organizations being involved in the decision-making process [ 28 ].

These findings underscore the importance of changes having frontline support and being perceived as legitimate among the employees affected by the changes. Organizational research has shown that participation in changes can yield increased acceptance. Indeed, widespread participation in the change process is perhaps the most frequently cited approach to overcoming resistance to change [ 29 , 30 ].

Even assuming a well-justified and well-planned change initiative, research underscores the importance of managers building internal support for change by means of employee participation in the change process [ 31 ]. These are common findings in organizational research in general, but they seem particularly applicable in health care organizations because of the strong professional discretion in performing the work.

Health care professionals emphasized the importance of predictability for them to perceive organizational changes as successful. Individuals are better able to adjust their behaviour accordingly when they are prepared [ 3 ].

However, despite the relevance of predictability, many changes in our study seemed to be characterized by a lack of preparation. When individuals are unprepared, they have difficulties aligning their thoughts, feelings and behaviours with the expectations of those who lead the changes [ 12 , 32 ].

Contextual factors such as resources and culture also influence their preparedness to implement change [ 33 ]. The importance of management communicating the motives for changes was stressed by the health care professionals in our study.

Consistent with our findings, organizational change research has demonstrated that changes have a greater chance of succeeding if employees consider them to be well thought out and respect the managers responsible for the changes, whereas resistance to changes is more likely if employees consider the changes to have little or no value for themselves [ 31 ].

The organizational change literature also stresses the importance of change initiatives resting on coherent and sound causal thinking [ 34 , 35 , 36 ]. The health care professionals in our study argued that the changes must benefit patients to have value. The overall findings of our study may reflect a tension between the traditional logic of professionalism and the managerial logic introduced into health care with the emergence of NPM. Whereas the logic of managerialism assumes that work should be management led to achieve organizational goals, health care professionals tend to be loyal to their profession and their emotional rewards at work are primarily associated with their patients [ 9 ].

NPM has led to an increase in the use of management systems, e. According to professional theory, true professionals such as physicians and lawyers independently treat individual cases e.

Research suggests that physicians due to their stronger identification with professional logic are more likely than nurses to be critical of management-initiated changes [ 9 ].

Several studies have shown how physicians respond with scepticism or suspicion to different forms of management-led changes in health care [ 44 , 45 ]. Sweden has seen a lively public debate on NPM in recent years, with many scholars, policy makers and both physicians and registered nurses critiquing core NPM principles and their consequences for health care professionals [ 46 , 47 , 48 , 49 , 50 ]. This initiative is new and we are not aware of any studies of the concept, but research is warranted to investigate how this concept is realized in practice.

Future research should assess whether health care professionals perceive changes as more successful under trust-based governance than under NPM principles. The results of our study should be evaluated in the context of the methods that we chose to address our study question. We chose a qualitative approach because little is known about responses to changes in Swedish health care. For this reason, we considered interviews with physicians, registered nurses, and assistant nurses to gain a deeper understanding of the topic.

Participation was voluntary; the interviewees were selected and asked by their respective supervisors about participation in the study, which means that the participants may have been particularly interested in the subject.

The multidisciplinary research team was a strength of the study, because it allowed different perspectives on the issue of changes in health care.

Regardless, this enabled us to use quotations from many different participants, adding transparency and trustworthiness to the findings. While many findings of the study are in line with existing research on organizational changes, no previous study has identified this particular triad of interdependent characteristics. The study provides important knowledge for health care organizations to plan and implement changes with better chances of being successful.

In conclusion, organizational changes in health care are more likely to succeed when health care professionals have the opportunity to influence the change, feel prepared for the change and recognize the value of the change, including perceiving the benefit of the change for patients. Although changes in health care organizations are inevitable, there are more or less effective ways to carry out changes.

Our results provide important implications for health care organizations concerning how changes in health care can be planned, implemented and managed to increase the chances that they will be supported by health care professionals, which is crucial for successful changes.

All interview data analysed during the current study are available from the corresponding author on reasonable request. The impact of new public management on efficiency: an analysis of Madrid's hospitals. Health Policy. Article PubMed Google Scholar. Drotz E, Poksinska B. Lean in healthcare from employees' perspectives. J Health Org Manage. Article Google Scholar. Perceptions of organizational change: a stress and coping perspective. J Appl Psychol. Organizational change, health, and sick leave among health care employees: a longitudinal study measuring stress markers, individual, and work site factors.

Work Stress. Continuity and coordination of care. A practice brief to support implementation of the WHO Framework on integrated people-centred health services. Geneva: World Health Organization; Google Scholar. Stockholm: Sveriges kommuner och landsting SKL ; Gray M. Evidence-based healthcare and public health. Edinburgh: Churchill Livingstone; Pollitt C, Bouckaert G.

Public management reform: a comparative analysis. Oxford: Oxford University Press; Gadolin C. The logics of healthcare: in quality improvement work. Hogan R. Personality and the fate of organizations.

Mahwah: Lawrence Erlbaum; Berry L, Curry P. Nursing workload and patient care. Accessed 10 October Change fatigue: development and initial validation of a new measure. Ead H.

Change fatigue in health care professionals. J Perianesth Nurs. McMillan K, Perron A. Nurses amidst change: the concept of change fatigue offers an alternative perspective on organizational change. Policy Polit Nurs Pract. Epub Apr 2. Organisational change and employee burnout: the moderating effects of support and job control. Saf Sci. Dahl MS. Organizational change and employee stress.

Manag Sci. Miller D. Successful change leaders: what makes them? What do they do that is different? J Change Manage. Why people stay: using job embeddedness to predict voluntary turnover.

Acad Manag J. Hill LA. Managing change. Boston: Harvard Enterprise Faculty Publishing; J Appl Behav Sci. Employee cynicism and resistance to organizational change. J Bus Psychol. Understanding and managing cynicism about organizational change.

Acad Manage Perspect. Bouckenooghe D. Three approaches to qualitative content analysis. Qual Health Res. Grama B. The chapters in this publication provide important perspectives on the changing nature of health care: from the forces driving the need for better medical evidence and the many new challenges confronting patients and providers to opportunities to transform the speed and reliability of new medical evidence and enable an evidence-based healthcare system.

To provide context for these discussions, comments were provided by the meeting co-chairs Mark B. McClellan and Elizabeth G. Nabel and by session moderators Denis A. Cortese, Michael M. Johns, John W. Rowe, and John K. A summary of these perspectives follows. Two core challenges are facing health care and health policy in the 21st century. Healthcare costs are rising and not sustainable, and a tremendous, largely untapped potential exists for much better health through better, more targeted treatments.

In principle, better evidence will result in higher confidence about what works for every patient in the healthcare system. This is a precondition to achieving what health care should be about in the 21st century—care that is based on solid evidence about what will work in particular patients.

With the advent of electronic medical records EMRs , clinical data registries, and other new forms of electronic data, care is becoming rich with information that can reveal patterns of disease mechanisms and markers of risks and benefits. These data also hold promise for instilling a greater confidence in health care than currently exists for a system that offers widely varying medical practices, with possible consequences for outcomes and definite consequences for costs.

In addition, even treatments effective for some may not be beneficial for others and may carry significant risks. With the cost of health care rising along with its benefits, creating an evidence-based system will be critical to achieving the promise of personalized medicine in which treatments are more effectively targeted to those that benefit, an achievement well worth its cost. Although there has been progress toward this goal, attaining such a system remains a distant prospect.

Better disease models and evidence relevant to the treatment of individual patients is lacking, despite publications and news stories that seem to suggest otherwise.

Also, much of the current data are not from traditional randomized controlled trials RCTs , creating a dilemma about the relevance of EBM in clinical practice. Some practitioners believe that if evidence is developed using traditional RCTs, it may not be reflective of the complexities of populations and the delivery settings in real-world practice.

For example, even if different practice methods appear to have a similar effect in an overall population, this may not be the case for different subgroups or different types of patients within that population. The key elements that should inform strategies for change are contained within these pages. As Michael E. Porter notes in Chapter 7 , while simple steps such as price controls or restrictions on access to control costs might seem useful on the surface, they have failed in the past.

Instead, a new vision is needed, marked by effective evidence and targeted treatments that account for the diverse characteristics—findings, histories, validated biomarkers, and preferences—of the various patient groups in this country. With the complement of secure EMRs, access to these patient and population characteristics will bring relevant evidence to healthcare decision making. This will, in turn, lead to better results and higher value.

Clearly, there will be challenges along the way to gather the evidence necessary for the backbone of this type of healthcare system: data must be consistent; low-cost alternatives to RCTs must be agreed upon; electronic systems should be integrated; and sophisticated longitudinal databases, such as provider-led clinical registries, should be supported.

In addition to studying the discrete interventions of particular drugs or particular modalities in treatments, the performance of healthcare systems themselves should be addressed.

The variations in care discussed by Elliott S. Fisher in Chapter 2 must be aligned. Also, costs will increase and value will be compromised if patients receive care from a number of different providers who do not collaborate effectively. To study these delivery system issues in real-world practices, traditional approaches such as RCTs will not be effective. Policy challenges must also be addressed. As George C. Halvorson acknowledges in Chapter 6 , small shifts in the system will not create fundamental change.

Value and outcomes cannot be achieved by micromanaging practices, but rather by providing support for better care at a lower cost. Rewarding better quality and lower costs will give healthcare professionals the opportunity to deliver quality care and still make ends meet.

This includes changing reimbursements to focus on higher value. Making these changes will provide an opportunity for patients to become more involved, and not simply through cost sharing.

Many opportunities exist for people with chronic diseases to improve their own health, since most care is actually self-care. In our traditional insurance system, these individuals do not always have the opportunity to make choices that can save money. However, recent reforms have begun to allow chronically ill patients in this country to control the services they receive. For example, the tiered benefits in Medicare allow beneficiaries to save money by switching to generic drugs—one of the main reasons that Part D in Medicare is less expensive than projected.

There are a number of programs being implemented around this concept of shared savings, in which healthcare professionals working together reap savings when they document better outcomes at a lower cost.

However those savings are accomplished—through system redesign, information technology IT , or remote monitoring systems—they are a step toward a bundled reimbursement approach that focuses on the effective outcomes in our healthcare system while promoting better care for everyone in it. Clearly, the technical and policy challenges of fulfilling the vision of EBM are great.

In spite of these challenges, the promise of EBM has put it at the forefront of policy making. The Food and Drug Administration is working to implement major new reforms, including plans for a public-private partnership to support a post-marketing surveillance system to gather data on drug risks and benefits. Also, Congress is considering proposals for a major initiative to support the generation of comparative effectiveness information about healthcare interventions.

In addition to work by the federal government, the practice of EBM will require numerous public- and private-sector strategies and collaborations. Needed are new approaches to the evaluation and adoption of medical best practices, new methods for drawing appropriate conclusions from vastly expanded data resources, and new approaches for using evidence to improve care and reduce health costs.

The process will not be easy, but unlike previous times, there are now widespread calls from healthcare leaders for the reforms needed to develop a system that delivers efficient and effective care. The IOM has the opportunity to catalyze that change. Healthcare reform will be one of the top domestic issues of the political agenda in the next presidential election, making our focus on EBM and the changing nature of health care very timely.

The roles and responsibilities of all healthcare stakeholders are undergoing transformative change and—whether we approach reform as providers, payers, researchers, health product developers, or consumers—there is much to learn from all who are involved in these collaborative discussions about how to contend with the rapid changes in the healthcare system. Healthcare providers, whether involved in delivering or reimbursing care, face a unique set of challenges as care is increasingly informed by and organized around rapidly evolving evidence.

Developing better approaches to reimbursement and other mechanisms that support the delivery of quality care are at the forefront for all providers, and many pilot projects are already under way.

A key consideration, as illustrated throughout this report, is the strong influence of local cultures on practice patterns. They can prevent the infiltration of evidence-based decision making, but they can also lead to great innovation to support the application and development of evidence.

The papers by William W. Stead and George C. Halvorson in Chapters 4 and 6 discuss lessons learned from their efforts to harness electronic health record EHR systems for improved application of evidence in practice and improved capacity for research and discovery, respectively. However, these local solutions may need restructuring to succeed at a national level. There has been considerable advocacy for sharing best practices nationwide, but it may be necessary to set goals and work backwards to align the systems.

For consumers, access to care is a priority but an additional, emerging challenge will be to ensure that incentives for research and care are properly aligned to support care focused on individual patient needs, circumstances, and preferences.

The very nature of patient-physician relationships is also undergoing a rapid change as healthcare data are increasingly captured and made available in various forms through IT. Patients will be presented with more health information from a variety of sources and, increasingly, they will be pivotal in making decisions about their own health care.

As we are reminded by Peter M. Neupert in Chapter 5 , most of health care is self-care and much of the care delivered throughout this country is family-based.

Family health managers and the availability of secure personal health records will be critical to informing and providing increasingly individualized patient care. EBM will also impact researchers. Methodologies to generate evidence are evolving and need to be continually defined and adapted. EHRs will provide the opportunity to quickly gather large amounts of data from real-world practice and produce evidence in real time, but how these data can be used appropriately and effectively will be a major challenge for researchers and practitioners.

Clearly, developing evidence that draws from and informs real-world care practices is a science, and improved methods for modeling and analyzing work processes and decision management are needed. This may require restructuring of the way we fund research. Federal agencies, such as the National Institutes of Health, the Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Department of Defense, the Veterans Health Administration, the Centers for Disease Control and Prevention, and others, will be essential components of this dialogue and can demonstrate leadership by partnering across agencies, as well as with others in the private sector.

There is no doubt that the work to transform our healthcare system will be challenging. Many healthcare leaders have been working on improving the system for decades; but we all need to get on with finding a solution now.

In the United States the cost of health insurance is rising faster than wages at a rate that is not sustainable, but the quality of care—measured in outcomes, safety, and service—is much lower than it should be. Especially in comparison to other countries, the value of medical care in the United States is low but even among individual states of the United States the variability in the value of health care delivered is dramatic.

Only 10 percent of the states provide high-value care on average, and the value of care in the United States on a whole is well below what should be expected.

Given the current approach to health care, however, these shortfalls are not surprising. Across the healthcare system, competition and rewards are not based on value, and there are scant incentives for patients to seek—or for professionals to provide—high-quality, cost-effective health care. In reality there is no true healthcare system.

There never has been a conscientious attempt to design and maintain a system that would create value. We now have an opportunity to take the steps to develop a vision, create a strategy, and specify goals for a true system of health care in the United States. Yet what should a healthcare system do?

In sum, a healthcare system should improve the quality of life and aim to keep people as well as possible, while ensuring that healthcare expenditures are affordable for both individuals and the nation. In essence, a reformed healthcare system should provide individuals with high-value health and health care.

As outlined in Chapters 2 and 3 , these forces include rising and unsustainable costs, wide variations in the quality and cost of health care delivered across the United States, and the complexity of care introduced by the emerging insights from genetic research and the diversity of new health products.

Many of the issues discussed throughout this publication are important for moving forward with needed healthcare system reform, but my focus is on key considerations for providers and, to some degree, patients.

Most pressing in this respect is an improved understanding of what constitutes good evidence of effective care and outcomes. For a profession that adopted the scientific method about a century ago, there is alarmingly little evidence for the effectiveness of much of what is taught and practiced today. To get to an evidence-based, value-driven health system we have to align all of our professional educational programs to teach new systems and capabilities.

Introduction to key concepts in EBM should begin, at the very least, at the college level. In addition, the dissemination and incorporation of new knowledge into practice must be accelerated so that it does not require a decade or more for the average provider to adopt new knowledge and skills.

As more and better evidence is developed, effective processes and IT systems are needed to ensure that healthcare practice utilizes best evidence. These systems should also have feedback loops to continuously improve on the evidence.

Systems must be interoperable and scalable and must also incorporate the patient into the decision-making and care provision processes. To be effective, systems must include the proper rewards, incentives, and financing for providers, as well as the means to pay for required processes and IT systems and innovations. The general public will need education and support to be able to use the copious medical information becoming available, as well as to gain an appreciation for information that is backed by solid evidence.

Practitioners need to work with the public to help ensure that we find the right health-care solutions for individual patients. The complexity of clinical evidence is daunting even for experienced, trained professionals who diagnose and treat disease; but it is far more challenging to the non-expert.

Reducing this complexity is key to empowering patients—not only as better informed consumers of health care, but also as active partners in improving health outcomes.

In addition, the right kinds of professional support should be made available to patients, whether through health coaches or other sorts of new professionals who can support and educate patients on the best evidence-based processes for health care and healing. It is clear that we are still at a rudimentary level of conceptualization and implementation of an evidence-based, value-driven healthcare system and that we still have a long way to go.

Finding ways in which patients and providers can be proactive in catalyzing and implementing the needed changes is essential. A learning healthcare system is defined as one in which the usual and customary activities associated with the production, distribution, utilization, and financing of healthcare services result in the simultaneous development and capture of data that are essential to the monitoring and evaluation of health care delivered. A wide variety of information is contained in these data including, but not necessarily limited to, patient characteristics e.

Through efficient organization and analysis, and provision of findings at the point of care, these data are a rich resource for informed decision making. Two general categories of decisions require an expanded evidence base. The first category includes the use of drugs, devices, and procedures. The second category concerns the management of care itself, including the organization of care, IT, types and effectiveness of providers, and clinical pathways.

Both categories require not only effectiveness information but also comparative effectiveness information, including cost or value. As emphasized in Chapter 2 , attention is needed on the evaluation of drugs, devices, and procedures, as well as on systems of care and the healthcare professionals that are involved in the provision of the care.

One of the major strategies proposed to hasten development of the required evidence base includes migration away from traditional reliance on RCTs and inclusion of a variety of other approaches and data sources. Is the question really black and white, or are there strategies to enhance the types of data being used to build the evidence while at the same time hedging against the pitfalls of lower quality and less reliability?

The papers featured in Chapter 6 offer insights on the opportunities presented by EHRs and clinical registries, as well as some of the challenges of using these data to inform the development of effective healthcare interventions. Public policy has a major role in shaping and driving the development of an improved healthcare system. The following chapters illustrate the potential of EBM to transform health care, and important policy considerations are detailed in Chapter 7. However, it is vital to keep in mind the substantial challenges inherent to the processes of policy making.

In short, these processes are badly in need of repair because they have been corrupted by the corrosive impact of election campaign finance monies. Today, many members of Congress are in a permanent state of running their campaigns for reelection.

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Cognizant 2018	The closed-ended questions are aimed at investigating the standard dimensions of the patient experience i. Of the 28 RCTs that compared CQI with a non-CQI intervention, 24 RCTs reported clinical process outcomes [ 40434445484950515253545558606163646566read more68707173 ], 17 RCTs reported healthcare changes continuously outcomes [ 4043444546475054555657585961636466 ], and 3 Https://educationmontessoriformation.com/what-to-do-in-baxter-state-park/6642-aldo-group-logo.php reported other outcomes [ 465065 ] Tables 34and 5. Continuous Process Improvement A defining characteristic of modern health care is the rapidly accelerating increase in information that is available to assist with the delivery click care and system management. For evaluations that carry no more than minimal risk, it is https://educationmontessoriformation.com/what-to-do-in-baxter-state-park/1830-kaiser-permanente-veradale.php to determine whether they are routine, appropriate activities of the health care system, or whether they are sufficiently separate from the routine that they should be classified as human-subject research covered by the Common Healthcare changes continuously. Care Quality Commission.
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Healthcare changes continuously	Study selection occurred through two stages. Both healthdare research and continuous-improvement assessments by learning organizations are crucial social goods that should be facilitated, not impaired, in the interest of the public. The vision for increasing clinicians' and patients' real-time access to data, information, and knowledge in a learning health care system is discussed in detail in Chapter 6. J Am Coll Radiol. Time-period: March —February Full size table.
Amerigroup providers list in louisiana	Feedback to healthcare changes continuously front-line staff is a critical component of demonstrating a commitment to safety and ensuring that staff members continue to report safety issues. Leaders who include, support, mentor and ask questions of healthcare changes continuously team rather than issue instructions are the people who can make this happen. Mortality results; pp. This internal benchmarking is an important activity for improving the patient experience [ 23 ] and reducing internal variation [ 43444546 ]. We believe a risk-based framework, in which oversight is commensurate with the level of risk imposed by the study, is the right approach. One setting in which patient cahnges has been applied in health panorama kaiser city radiology permanente is the use of patient streams in emergency departments.
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