Mills, A.E., & Spencer, E.M., (2005) Values based decision making: a tool for achieving the
goals of healthcare. HEC Forum, 17, 18 -32
Mills and Spencer define values-based decision making as decision making based on values of the organization with less emphasis on rules and allowing for decisions that are complex when a goal is to provide patient centered care at a reasonable cost. Governance and management's understanding of values-based decision making is key to its success. The authors suggest that an ethics program can support implementation of values-based decision making by "ensuring that stakeholders are aware of the values and goals of the healthcare organization and motivate stakeholders to base their decisions on the values and goals of the organization." The authors point out that informal or "shadow" relationships influence decisions that an organization makes and usually depend on personal and social relationships. Such relationships can undermine the goals of the organization so the authors suggest that governance's role is to encourage communication and collaboration between stakeholders. Management must create an environment where informal rules and formal rules support achieving the healthcare organizations goals. Rules can "constrain and interfere with care, undermine morale, cause resentment and ultimately lower expectations of both employees and the organization." The authors sum up their points in "Roles and Rules - or Goals and Values." If leaders have both clinical and administrative skills, ideally governance and managers can "encourage relationships and adaptive, creative and flexible goal-oriented activity." Decision making which can suspend rules implies that its organization trusts and empowers its stakeholders to lead. It impacts the culture and climate of the organization.
Background regarding the authors was not provided. The article was printed in the Netherlands but the information is transferrable, not specific to Netherlands healthcare system. The article provides practical information for applying the theoretical model.

Kirch, D.G., Grigsby, K., Zolko, W.W., Moskowitz, J., Hefner, D.S., Souba, W.W., Carubia,J.M., &Baron, S.D., (2005) Reinventing the academic health center. Academic Medicine, 80, 980-989
The authors layout nine factors which they believe were critical in transforming an academic medical center after a "near death" following a failed merger. They performed a "campus-wide cultural assessment and acted decisively on the information found." They implemented a quarterly meeting with president/ dean and executive director of the medical center which all faculty and staff were invited to and every question on the evaluation forms received a respectful, written response, modeling the behavior and attitudes expected of others. Making values explicit and an active part of everyday decisions was another component. It was announced widely that organizational values would be implemented at all levels. Actions like providing parking, illuminating the historic building proved to be a great return on investment in regaining trust and proving value-based culture. Persons that weren't preforming or did not perform with the values in mind were replaced; those who consistently spoke disrespectfully to subordinates. Resources and productivity were realigned. "Aligning corporate structure and governance to unify academic activities and health system" was the third concept. They created a Sr VP/ dean and CEO so there was no longer splitting between the school and health system. Next, aligning the next tier of administrative structure and function was important. Although separate legally, leadership had school and health system responsibilities. Foster collaboration and accountability - "the creation of unified campus teams was another strategy for reinventing the health system." The creation of Mission Teams: Research, Academic and Clinical; Connectivity Teams: Information Resources and Strategic Relations and Resource Teams: Physicial Resources, Financial Resources and Human Resources were formed. "Articulating a succinct, highly focused, and compelling vision and strategic plan" was a response to faculty and staff wanting to know what the future would be. An 18 page document emerged in 4 months out of the work of the teams and distributed to all. "Using the tools of mission-based management to realign resources" was achieved by the mission teams establishing performance measures and removing artificial barrier of department and cost centers "resting on their own bottom." Finally, focus was put on "leadership recruitment on organizational fit" and ""Growing your own" through broad based leadership development." A focus was placed on building human connections, creativity and collaboration and resource exchange. In order to focus on quality, must have morale, mission productivity and financial performance in check. Outcomes have been improvement in student satisfaction, sponsored funding increased by 80%, patient satisfaction increase, increased philanthropic giving and improved employee morale.

The authors are the senior vice president for health affairs at Pennsylvania State
and Dean of Penn State College of Medicine and other senior members of the leadership team, persons qualified to recount the process that Penn State Medical Center went through following a failed merger. Particularly useful information for person working in an academic healthcare environment. Like the NCMedical Journal Article, it provides very practical information and processes that could be replicated similarly in another academic environment. Emphases cultural assessment, values in every day decisions, collaboration, articulating vision and strategic plan and mission based management.

Levine, J.F., Herbert, B., Mathews, J., Serra, A., & Rutledge, V., (electronically published 2011, September 25) Use of triple aim to improve population health. NCMEDICALJOURNAL.COM 72, 201-204
The author's invited commentary provides a description of CaroMont's plan and process to realize their vision "to be a nationally recognized leader and valued partner in promoting individual health and vibrant communities" within the context or era of the Affordable Care Act. They focused on moving from a volume based business model to one that is value based. They focused on three core competencies " redesign of the care system, with enhanced coordination; clinical integration with health care professionals; and an understanding of the community needs as they relate to population health." The board of trustees revised their vision statement to read "We are a nationally recognized leader and valued partner in promoting individual health and vibrant communities." Their first steps were to improve the organizations employee health and created two positions to focus on this. The goals were aligned with the ACA,Triple Aim. They also recognized that collaboration with many county organizations was going to be necessary to address the major health concerns of the region so they formed the Gaston County Health Coalition and the Coalition adopted the mission to use the employee based strategies to which were a success to impact community health. This also provided feed back from community regarding "what healthcare looks like." The feedback assisted the medical center in knowing what they needed to do to affect patient experience in accordance with the Triple Aim. The process informed the system in what an important role primary care physicians play in new models of health care delivery therefore physician led multidiscipline councils were formed to breakdown the traditionally "hospital centric" services lines and were charged with "developing strategies to coordinate and improve care while understanding the importance of bending the healthcare cost curve." Administration provided providers the education necessary to understand performance indicators, market share data, costs need to do their work in transforming. The system simultaneously implemented a robust electronic record and all primary care clinics received National Committee for Quality Assurance Level III designation as Primary Care Medical Home. The authors stress the importance of collaborating with various stake holders such as primary care, FQHCs and public health departments.

Although electronically published and no impact value I found this article very useful. The authors of the article are the chief medical officer, director of managed care, associate vice president for quality (RN), vice president of research and development and the chief executive officer and president. The article provides a step by step account of how the organization aligned it's mission and values in order to achieve the triple aim - changing from volume to value and population focused. Although the authors do not give a theoretical model for decision making or systems change as in other articles the straight forward account of their process is very informative. They give enough detail that their processes could generally be replicated.

Craigei, F.C., & Hobbs, R.F., (2004) Exploring the organizational culture of exemplary community health center practices. Family Medicine, 36, 733-738
This article is a follow up piece to a 1999 study that implied that the culture of a practice potentially has an effect on providers and patients and what are the components of positive medical organizations. Two practices were selected using an involved process. Their findings were consistent with the management literature and prior study. The one departure from prior findings was" Physicians take the lead in creating a positive climate, or spirit, for patients and staff." The authors suggest that physicians clearly play a role but administrators and other members of the team play a key role in creating the climate and had a responsibility as well. They also point out that language is important in obtaining "transcendent qualities of an organization" and the language can be inclusive of terms such as culture, spirit, climate, tone and atmosphere. A possible limitation mentioned is that the two practices studied were community health centers which perhaps have a different mission than "private practices." Other limitations are that the patients' view was not included in the data and there was no comparison to poorly functioning practices. Key findings of exemplary practices are enthusiastic engagement of staff in mission of organization, providers and staff are involved in leadership, regular staff meetings for community building and problem solving. Also," the organization culture reflected a strong spirit of egalitarianism, hardwork, collaboration, joy and personal investment and caring." It was also pointed out that difficulties were dealt with "above board" and without personal accusations and all employees believed that the culture/spirit of the organization benefited patients.

Dr. Craigie was with the Maine-Dartmouth Family Practice Residency. Although not earth shaking information, nice to have confirmation through qualitative research regarding the importance of organizational positive culture. Article relevant as it points out the shift from MD as only leader that impacts to culture to others including administration. Informs how one goes about system change and need to create congruency in espoused and practiced values.

Maxwell, N.A. (2007) Shaping humane healthcare systems. Nursing Administration Quarterly,31, 195-201
DOI: 10.1097/01.NAQ.0000278932.26621.51
The author reviews the role that nurses should play in creating "humane" healthcare systems. She points out that administrators have "walled off" specialties in effort to simplify and manage a complex healthcare system. In doing so individual systems of care have become fragmented. She suggests it is time to reassemble. The persons we serve are complex as are the systems we needed to care for them. Nursing can put the "AND" back in our systems - Bridging specialties -because no matter which specialty we practice in, our nursing care and concerns for patients bridge specialties. Maxwell states that our technical skills, although important, alone within our specialty areas are not what are going to improve outcomes, it is nurses' ability to communicate and collaborate. She suggests that individually we need to take the anger that often comes with change and become curious for finding effective solutions. She suggests nurses approach redesign by flattening the hierarchy, through shared governance by including patients in the transformation. This will improve consumer and staff satisfaction. She also encourages identifying ways of influencing the system rather than trying to control. Focus on making small changes which align with the mission and values of the organization. She encourages sharing of information, even when you don't think people are interested. She encourages learning from other disciplines to come up with innovative solutions. Maxwell points out that the most cited reason for burnout among nurses is an imbalance between responsibility and authority - shared governance provides means for demonstrating that "with power comes responsibility." Finally the author emphasizes that with shared mission and personalization, each one of our patients could be our family member, then we become connected to the humanistic mission of our organizations. Maxwell gave examples from the transformation of the public mental health system.

Maxwell is an APRN, Mental Health and Behavioral Sciences Services VAHealthcare. This particularly relevant to my practice in BH since examples are from BH. Relating mission and values to very practical human qualities is useful. The article is a bit wordy.

Mitch Morris, MD, Vice Chairman and National Healthcare Provider Lead, Deloitte LLP and author of this article points out that MDs have been working with EHRs for 25+ years and if asked today would say that they might help with analytics and that they support value-based care but that they "waste" time and that their potential has not been realized. This is of concern bc without full implementation of "Meaningfull Use" - or buy in from users/ MDs healthsystems have a lot to loose. Morris suggests that organizations not do a quick, cheap implementation which some are doing to be in compliance but rather when implementing an EHR do so to "enhance clinical systems already in place; this could help organizations meet challenges faced with shrinking reimbursement, rising consumerism, the move from volume to value and enabling population health management." He summarizes by saying that organizations should not implement MU just because it is required by in a way in which it helps the organization achieve its vision.

Morris is with Deloitte LLP, consulting firm. His perspective is very helpful given prior from JONA article regarding the usefulness of IT/ EHR systems. He points out the pitfalls of needing buyin and reinforces what is needed in an EHR.

Morris, M., (2014, September 16) My take: chasing the vision of safe, high-quality, effective and efficient care. The Wall Street Journal. Retrieved from http://deloitte.wsj.com/cfo/2014/09/16/health-care-current-september-16-2014/tab/print/

George Velianoff, PhD, RN, AACHE, ANEF, the author of this article makes the point that a "robust information systems with the capabilities to push information and provide valid analytics and decision support utilizing point-of-care data are required to achieve a complex, person-centered, lifetime-focused model." This is necessary as systems adjust to comply with the Affordable Care Act; health systems transformation which evaluates Triple Aim outcomes. Data collected on the population being served can provide real time feedback which impacts individuals. He provides useful schematics to depict the population health model, person- focused framework and access points. First steps in movement towards obtaining the data desired is to define what is the evidence desired for best practices, documentation to be obtained at point-of-care, data entry and how information will be gathered. Example of diabetes is provided. IS must support the complex model of care.

The author is an Executive, Cerner Corporation so the information could be biased although he doesn't reference Cerner specific products.

The information is useful as IS is not my expertise and vitally important to tracking outcomes. It is particularly relevant to my Case Study bc IS platform, as pointed out in the article, pulls together what is taking place in a complex system (including multidisciplinary care) and allows the opportunity to analyze outcomes and adjust in real time.

Velianoff, G.D. (2014) Advancing the evolution of healthcare: information technology in a person-focused population health model