The What and The Why

A system of care (SOC) is a detailed and systematic plan by which health services are delivered for an important health care condition in a particular setting. The SOC describes how health services are organized, provided, and monitored; it specifies roles, processes, tools, and record keeping. Unlike a Practice Guideline, which arrives broadly applicable standards and procedures for a health condition, a SOC is about how we will actually get the job done HERE. In our setting. With our people. With our unique strengths and limitations. Our concept of a SOC is that is starts where Practice Guidelines leave off. In fact, we consider SOCs to be "the missing link" from Practice Guidelines to actual practice.

Docs need SOCS. That is, our health care teams need systematic and detailed plans, plans that are actually followed, for important clinical problems in order to achieve dramatic improvements in process and outcome.

There is a philosophy that the way to achieve quality health care processes is to hire well-trained and conscientious physicians and get out of their way. Abundant health services research demonstrates the flaw in this approach. Good people can fail in bad systems. We believe even the best docs need SOCs.

To achieve effective and efficient systems of care REDESIGN is needed. In fact, the SOC planning process can and should be thought of as a redesign tool. Health care teams must identify important health care problems, identify the key processes of care for these problems, redesign these processes where necessary, then weave them into an overall efficient and effective system of care. The awareness of the need for redesign is becoming pervasive in American industry as it strives to remain competitive in the global economy. We are all discovering that the public sector of primary care is not immune from these global economic effects.

The Bureau of Primary Health Care (BPHC) of the Public Health Service has embarked on a major redesign QI initiative in collaboration with leading groups in the HMO industry such as the NCQA and the Institute for Health Improvement. This initiative is taking many forms including the funding, of "Breakthrough Collaboratives" (network redesign projects) for the patient visit and for diabetes care. More are planned. A BPHC Quality Center has been formed. This effort also includes major revision of the "Clinical Outcome Measures" to be more aligned with HEDIS indicators and more tied to redesign and the achievement of "dramatic improvement". The BPHC along with its private sector partners is sending us a very

clear message: Measurement is not enough. Redesign and reengineering to achieve dramatic improvements in quality are required to remain competitive in the current era.

The Soc Planner

So how do you actually do it? Essential ingredients are determination, teamwork, cooperation, imagination, and just the right amount of technical assistance (outside ideas). Trial and error. Blood, sweat, and tears. It's a process that takes so much effort, that you want to pick your targets and pick your path very wisely. The "SOC Planner", Figure 3.1, is a tool to help guide your teams through the SOC design process.

This SOC Planner can be used in several ways. First, it's a list. The 11 steps defined here are ones that we have found important in planning and redesigning systems of care. We consider 7 of these steps (the ones in BOLD print) to be essential requirements of a Basic SOC. We consider the other four (5, 6, 9, 11) to be highly desirable but able to be added later.

Second, it's a planning tool, a brainstorming tool for the planning process. Column 3 of the table (the wide blank area) can be used to scribble thoughts and ideas as you work individually and together to plan your systems. When you reach consensus about important parts of your system, type up a draft on this form and distribute it at a team meeting to stimulate further discussion.

Third, it's a format for compact description of your completed SOC. At the end of this section are examples of actual SOCs developed by work groups for Diabetes, Tuberculosis, Chronic Pain, and Indigent Drug Programs. Note that each of these SOCs has attachments that describe numerous tools and processes that are parts of the larger system. These are not included here. We have also included a process diagram developed by a workgroup seeking to redesign and improve the process of breast cancer screening. Tools to describe, diagram, and analyze processes are found in the "Memory Jogger" Q1 book which is being distributed with this manual to WVPCA clinical leaders (Medical Directors, DON, Administrator). Remember that the SOC Planner is a broad overview of a system of care. Within that system, there may be a few or many distinct processes, all of which should be identified, some of which may need major redesign.

Fourth, the SOC planner can be used as a self-evaluation tool. Column 2 is titled, "Present? 0-2". The purpose of this is to allow evaluation of where your group is in the development of each SOC element and thus where more work is needed. A good group process is to ask each member of a workgroup or team to complete this self-evaluation then to share and discuss responses. This is what the four WVPCA QI workgroups did as their first step in SOC development. Their reports are presented in Chapter 5. Likewise, you can see how the NRHA workgroups evaluated progress for each element in two of the examples provided here.

Pick the Problems Carefully

Which clinical conditions should you design SOCs for? It depends on the population you serve, identified subgroups within that population, and the special needs of those subgroups. Certain payors and funding agencies require you to meet performance measures for conditions such as Diabetes, Prenatal Care, Asthma, Cancer Screening, Pediatric Immunization. These are excellent potential topics. But your clinical teams or management may perceive the need in your center for other SOC initiatives. This part of SOC development fits very well with the Community-Oriented Primary Care (COPC) approach used by many health centers for community diagnosis and program planning.

One way to think about picking problems for SOC design is shown in Table 3.2, SOC Sorter.

 Table 3.2

SOC Sorter

The column Headings for this table come from the World Health Organization definition of Primary Care. The Row Headings come from the U.S. Public Health Service "Life Cycle" concept.

Usually SOCs are developed only for health problems that are serious, prevalent and require high intensity or effort.

In this table, possible SOC topics are classified by life cycle and by dimension of primary care. Such an approach is useful because it can help your team identify important clinical issues that span the full spectrum of primary care. You can't design and consistently apply SOCs for everything. But it makes sense to select clinical problems that address the needs of different life-cycle groups and meet the challenges of different dimensions of primary care.

The actual topics included in this table are important. They come from topics given high priority by the WVPCA clinical leaders who were polled during this project and by ongoing, NRHA clinical QI efforts. But they are just one of many possible sets. Just as interesting would be use of this SOC Sorter to classify the HEDIS Clinical Quality Indicators or the BPHC Clinical Outcome Measures.

Sample SOC Planners:

• Diabetes
• Indigent Drug Programs
• Chronic Pain
• Flow Chart for Breast Cancer Screening

Go to Chapter 4