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The importance of culture is often emphasized for continuous learning and quality improvement within health care organizations. Limited empirical evidence for cultivating a culture that supports continuous learning and quality improvement in health care settings is currently available.

The purpose of this report is to characterize the evolution of a large division of physical therapists and occupational therapists in a pediatric hospital setting from 2005 to 2018 to identify key facilitators and barriers for cultivating a culture empowered to engage in continuous learning and improvement.

An ethnographic methodology was used including participant observation, document review, and stakeholder interviews to acquire a deep understanding and develop a theoretical model to depict insights gained from the investigation.

A variety of individual, social, and structural enablers and motivators emerged as key influences toward a culture empowered to support continuous learning and improvement. Features of the system that helped create sustainable, positive momentum (e.g., systems thinking, leaders with grit, and mindful design) and factors that hindered momentum (e.g., system uncertainty, staff turnover, slow barrier resolution, and competing priorities) were also identified.

Individual-level, social-level, and structural-level elements all influenced the culture that emerged over a 12-year period. Several cultural catalysts and deterrents emerged as factors that supported and hindered progress and sustainability of the emergent culture.

Cultivating a culture of continuous learning and improvement is possible. Purposeful consideration of the proposed model and identified factors from this report may yield important insights to advance understanding of how to cultivate a culture that facilitates continuous learning and improvement within a health care setting.

Purpose – The numbers of health care transparency initiatives are increasing. Despite the growing availability of quality data, there seems to be a shortage of evidence about the effects and effectiveness of such initiatives. The aim of this systematic review is to document the effects of transparency, defined as the public release of quality performance data, on hospital care outcomes.

Design/methodology/approach – Through a review of the literature, we chose 46 keywords to use in our searches and focused on empirical studies published in English between 2010 and 2015. The use of combinations of these keywords in searches of four databases (PubMed, Scopus, Web of Science, and the Cochrane Library) generated 13,849 publications. The removal of duplicates and exclusion of studies that were not empirical or not relevant to transparency and quality resulted in 39 studies to be reviewed.

Findings – Our review of the literature confirmed the growth of health care transparency efforts, led by the United States, and found mixed results regarding the effects of transparency on hospital care outcomes. For example, mortality, the most frequently researched performance measure (n = 15), exhibited this mixed pattern by having studies showing a reduction (n = 4), increase (n = 1), mixed findings (n = 4), and no significant relationship (n = 6) as a result of public release. We also found a limited number of articles related to unintended consequences of public reporting. When compared with earlier systematic reviews, there seems to be a trend in the reduction of unintended consequences. Therefore, we recommend exploration of this potential trend in future studies empirically.

Practical Implications – The research findings summarized in this systematic review can be used to understand the results of existing transparency efforts and to develop future transparency initiatives that may better enhance hospital quality performance.

Originality/value – This is the latest and most comprehensive systematic review summarizing the effects of transparency of quality metrics on hospital care outcomes.

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

Clinical front-line staff are best positioned within the organizations to identify patient safety problems and craft solutions. However, in traditional models, safety committees are led by senior executives who are not clinically responsible for patients. This top-down approach can result in missed opportunities to address patient-centered challenges and better manage the health of the defined populations served by these organizations.

To foster teamwork, enhance empowerment, and improve the patient care environment, Operations Councils led by trained front-line staff were deployed in 15 clinical areas at the Ohio State University Wexner Medical Center (OSUWMC) as a performance improvement tool.

Standardized training of Council facilitators was designed and implemented to guide the performance improvement process. Balanced scorecards were developed in each Council based on the risks and concerns of that particular clinical area. After initial implementation of the Operations Councils, patient safety events declined and team engagement improved by over 34% across the medical center; the highest changes were seen in areas where Operations Councils had been deployed. Additionally, outcome metrics including area-specific and system-wide mortality and readmissions improved after implementation.

We suggest that this type of approach may be an appropriate strategy to consider in other health care organizations as such institutions are challenged to better manage the health of their defined patient populations.

We discuss the impact of complexity science on the design and management of health care organizations over the past decade. We provide an overview of complexity science issues and their impact on thinking about health care systems, particularly with the rising importance of information systems. We also present a complexity science perspective on current issues in today’s health care organizations and suggest ways that this perspective might help in approaching these issues.

We review selected research, focusing on work in which we participated, to identify specific examples of applications of complexity science. We then take a look at information systems in health care organizations from a complexity viewpoint.

Complexity science is a fundamentally different way of understanding nature and has influenced the thinking of scholars and practitioners as they have attempted to understand health care organizations. Many scholars study health care organizations as complex adaptive systems and through this perspective develop new management strategies. Most important, perhaps, is the understanding that attention to relationships and interdependencies is critical for developing effective management strategies.

Increased understanding of complexity science can enhance the ability of researchers and practitioners to develop new ways of understanding and improving health care organizations.

This analysis opens new vistas for scholars and practitioners attempting to understand health care organizations as complex adaptive systems. The analysis holds value for those already familiar with this approach as well as those who may not be as familiar.

Adverse events in health care became more evident at the beginning of the 21st century, being an emerging problem worldwide and impacting the lives of people receiving health care, contributing to preventable injuries and deaths. This evidence has motivated the development of specific training in the area of patient safety with a strong focus on the education and training of health professionals, and, more recently, it also aimed at patient, informal caregiver and all citizens. In this sense, the use of digital technology for patient safety training has been an important challenge and proves to be a good solution for training and continuous learning, both for professionals and people in general. The use of multimedia, videos, games, simulators, among others, are effectively essential resources to improve people’s health literacy and safety of care.

This chapter presents a narrative review on patient safety training and the contributions of digital technology. The experience report will also be used, presenting some examples of quality improvement projects developed by Portuguese and Brazilian entities, in training contexts, highlighting the importance of investing in the health literacy of professionals, patients/informal caregivers and civil society, through applying specific techniques and using digital technology.

Bundled payments for care are an efficient mechanism to align payer, provider, and patient incentives in the provision of health care services for an episode of care. In this chapter, we use agency theory to examine the evolution of bundled payment programs in private and public payer arrangements, and postulate future directions for bundled payment development as a key component in the provision and payment of health care services.

Purpose: The aim of the study is to consider the use of the Internet as a potential facilitator of positive health-related perceptions. Specifically, we propose that online health information seeking fosters positive perceptions of health. Using path modeling, we theorized several mechanisms through which information seeking could be conducive to positive health perceptions, which we conceptualized into the following four dimensions: (1) sense of empowerment in managing health, (2) self-reported ability to take better care of health, (3) sense of improved health-related quality of life, and (4) self-reported improvement of health.

Methodology: Our sample consisted of respondents who have used the Internet as a resource for health information (n = 710), drawn from the largest national probability-based online research panel. Our comparison subsample consisted of older respondents (age ≥ 60; n = 194). We used Internet-specific measures and employed structural equation models (SEM) to estimate the direct, indirect, and total effects of health-related use of the Internet on subjective health perceptions. Based on our review of the literature, competent health communication with healthcare providers and sense of empowerment in managing personal health were modeled as mediator variables. We assessed whether the proposed mediational relationships, if significant, differed across our indicators of positive health perceptions and whether any differential associations were observed among older adults. We run parallel models for each indicator of positive health perception.

Findings: Provider-patient communication informed by the Internet resources were perceived to impart a greater sense of empowerment to manage health among our respondents, which in turn, was associated with perceived contributions to better self-reported ability to provide self-care, increased health-related quality of life, and improvement in self-reported health. The SEM results revealed a good fit with our full sample and subsample.

Research Implications: Conceptualization of the multidimensional aspects of online health information seeking with separate multi-indicator analyses of the outcome variable is important to further our understanding of how technology may impact the pathways involved in influencing health perceptions and as a result health outcomes.

The adoption of electronic health records (EHRs) and digitization of health data over the past decade is ushering in the next generation of digital health tools that leverage artificial intelligence (AI) to improve varied aspects of health system performance. The decade ahead is therefore shaping up to be one in which digital health becomes even more at the forefront of health care delivery – demanding the time, attention, and resources of health care leaders and frontline staff, and becoming inextricably linked with all dimensions of health care delivery. In this chapter, we look back and look ahead. There are substantive lessons learned from the first era of large-scale adoption of enterprise EHRs and ongoing challenges that organizations are wrestling with – particularly related to the tension between standardization and flexibility/customization of EHR systems and the processes they support. Managing this tension during efforts to implement and optimize enterprise systems is perhaps the core challenge of the past decade, and one that has impeded consistent realization of value from initial EHR investments. We describe these challenges, how they manifest, and organizational strategies to address them, with a specific focus on alignment with broader value-based care transformation. We then look ahead to the AI wave – the massive number of applications of AI to health care delivery, the expected benefits, the risks and challenges, and approaches that health systems can consider to realize the benefits while avoiding the risks.

Purpose – This chapter argues that health care is best conceptualized as a complex adaptive system. Sustainable health care depends on harnessing the complexity of the system by building aligned purpose, flexible pathways to connect people, knowledge and resources, and the capacity for self-organization.

Design/methodology/approach – The case study of the Southern California Region of Kaiser Permanente is based on three years of interviews and archival data collection examining the system's transformational change that began in 2004 and has been aimed at building a sustainable health care system with the guiding principles of value and prevention. The case focuses primarily on the medical care delivery system designed by the Southern California Permanente Medical Group, the capabilities that have been built into the system to continually improve the quality of care and the outcomes of the system, and the results that have been achieved.

Findings – During the period from 2004 to 2011, the region improved significantly in slowing cost acceleration by significantly improving medical care. The implementation of an electronic medical records system and its integration with other clinical information technology systems have enabled: (1) truly integrated, well defined, and easily navigated care delivery systems that are based on evidence; (2) upstream focus on prevention, disease control, patient education, and population health; and (3) management accountability and organizational improvement systems based on transparency of data and feedback. Physician leadership and partnering with the region's administrative and hospital leadership have been critical change enablers.

Originality/value – Embracing the complexity of the system has led to the crafting of pathways and linkages that enable patients to move through the system to flexibly and efficiently connect to the knowledge and resources required to optimize their health. This requires continual self-organization based on well-defined roles and connections. Previous health care improvement approaches have stressed initiatives and organizational changes that may further fragment the health care system.