13 - 16 Subsequently, attention expanded to patient safety and high reliability organization (“HRO”) thinking, 17 - 20 then broadened to “implementation science” and “service innovation,” 21, 22 including recent concepts of “deimplementation” (removing what is no longer effective practice and organization) 23, 24 and improvement leadership methods. 11, 12 Intentionally building quality into the health system gained momentum with tools and principles adapted from manufacturing practice (e.g., Shewhart's statistical process control charts, Juran's Total Quality Management, Demings' Continuous Quality Improvement). 10 Accompanying a focus on measurement, the science of intervention has its own set of potentially applicable theories of behavior change and diffusion of knowledge. This combined science for improving quality started with early data-driven health care professionals (Semmelweis, Nightingale, Codman) 7 - 9 and built further with conceptual developments for quality measurement (i.e., Donabedian's structure, process, and outcome framework). The pursuit of better health and health care quality challenges the research field to bridge the gap between medical thinking and social science thinking. A key question in both medical and health services science concerns the ways that altering one part of a system-either the human body or the health system-produces desired results. Similarly, social science applied to health systems studies the complex web of health services to understand interactions and behaviors, with the aim of improving policy and practice in ways that translate into better health for a society's population. Medical science studies the human body system carefully to understand biologic cause and effect, with the aim of curing or ameliorating illness. While challenging to study, these systems must be understood in order to guide effective improvement efforts. 6 In practical terms, the health care system consists of complex interrelations among people (patients, their caregivers, and providers) organizations (clinics, hospitals, insurers, payers, etc.) technologies (pharmaceuticals, devices, imaging, etc.) and processes (diagnostic workups, treatments, procedures, admissions, discharges, visits, referrals, surveillance, etc.). The Institute of Medicine (IOM) defined six key dimensions of high-quality care: that it be safe, effective, patient centered, timely, efficient, and equitable. Although most patients have an intuitive sense of what constitutes high-quality care, quality is complex conceptually because it must encompass many different attributes and perspectives (e.g., patient, family, provider, health system, society). The challenge in achieving quality is conceptual as well as practical. Despite the significant resources devoted toward health care, high-quality high-value care in the United States remains elusive, with half of patients, on average, receiving suboptimal care.
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