Chapter 7 Systems-Based Practice
Very few doctors understand what is happening to the health care system in which they practice, why the system is changing so rapidly, and what they can do about it.1
Systems-based practice is widely regarded as one of the most challenging competencies to understand and implement. The Accreditation Council for Graduate Medical Education (ACGME) requires that all residents demonstrate an “awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.”2 To better understand this concept, we must ask the following question: How can we best provide safe, effective, efficient, equitable, and patient-centered care? Within the answer to this question lies the essence of systems-based practice.
Definitions of Systems-Based Practice
Systems-based practice is formally defined by the ACGME as “the use of health-care services for patient care, and how the costs of providing those services can affect the delivery of care.”3 This competency, stated simply, concerns the business of health care. Effective and efficient patient care is at the root of systems-based practice. Physicians can best provide optimal care by understanding the structure, process, economics, and politics of the health-care industry.
Strategies for Learning Systems-Based Practice
Patient Care Review Projects
Patient safety is the driving force for much of the systems-based practice competency. Assessment of patient care delivery and its impact on patient safety can aid in the learning of systems-based practice. Tomolo and colleagues4 developed an educational tool, named the Outcomes Card, to assist residents in this process. Residents were asked to identify cases in which patient safety was at risk and to track several important factors (type of case, type of event, error type, systems involved, and system failures). The use of outcomes cards can help demonstrate the complexities of the systems involved and the impact the health-care system has on patient care delivery.
Allen and colleagues also suggest that independent learning projects are effective in teaching systems-based practice.5 Residents in their internal medicine program independently identified a health-care system or delivery issue. They used seminars to initially educate residents about health-care systems, followed by reinforcement via active learning through their own projects, called the Health Systems Independent Study Project (HSISP). Participating residents found that these projects help them relate systems-based practice with their own clinical practice and gain a focused understanding of their health-care system.
Students and residents can also gain exposure to systems-based problems associated with errors through involvement with hospital-wide Morbidity and Mortality (M&M) committees/conferences as well as quality improvement (QI) committees/projects.3,6 At Children’s Mercy Hospital, we have implemented a systems-based approach to evaluating cases submitted for M&M conference. A multidisciplinary committee, involving nursing staff and physicians with various specialties, ranging from QI to evidence-based medicine, evaluates all cases in a systematic fashion to identify where within our system we may best be able to institute further “checks and balances” to ensure high-quality patient care.
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