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Achieving a High Performance Health System: High Reliability Organizations Within a Broader Agenda

In the Literature

Despite spending more than any other country, the U.S. health care system is marked by significant shortcomings in efficiency, quality, access, safety, and affordability. The consequences are serious: widespread disparities in health based on insurance status, income, and race; patients not receiving recommended care; and thousands of Americans dying yearly from lapses in safety.

In their commentary, "Achieving a High Performance Health System: High Reliability Organizations Within a Broader Agenda," (Health Services Research, Aug. 2006), The Commonwealth Fund's Anne K. Gauthier, Karen Davis, and Stephen C. Schoenbaum argue for a major transformation of current methods of health care financing and delivery in the United States.

While examples of "high performance" health care exist, such practices are not widely disseminated, they say. It is not enough for individual organizations to perform well; each institution, whether a small physician practice, a large hospitals system, a health plan, or a nursing home, must be tied together into a coordinated system of care. In the article, the authors review the dimensions of a high performance system and outline the changes required—on the part of the private and public sectors, as well as private foundations—to foster improvement and innovation within the health care system.

Each component of change will require commitment from multiple players, the authors say. For example, organizing health care and care information around the patient will oblige insurers and providers to promote shared decision-making through tools, counseling, and education. Health care purchasers can be involved, as well, by rewarding health plans that emphasize patient-centered care. The other changes outlined—enhancing the quality and value of care, expanding primary care and preventive services, expanding the use of information technology, aligning payment incentives and rewarding performance, and encouraging collaboration among stakeholders—will similarly entail involvement from physicians, health care delivery organizations, insurers, purchasers, and patients, as well commitment from the government.

One of the keys to creating a high performance health system, the authors argue, is striving for "high reliability," by developing and implementing systems, simplifying complex processes, and having effectively functioning teams. While much of the focus on high reliability has related to patient safety, effective care is of equal importance. "More lives are lost each year in the United States from failure to deliver effective care as from medical error," the authors say. High reliability organizations, they add, must be backed by strong internal leadership, a supportive external environment, and shared information on best practices and comparative performance.

Faced with these challenges, the Fund established the Commission on a High Performance Health System in July 2005. The Commission's first task has been to outline a framework that organizes the myriad public and private financing and delivery mechanisms in the U.S. into a more cohesive system. The second effort is development of an annual health system "scorecard," which will track performance along multiple dimensions of care. In concluding comments, the authors state that the "Commission's work will be pivotal in moving the nation toward a high performance health system, one that offers better access, improved quality, and greater efficiency to all Americans."

Publication Details



A. K. Gauthier, K. Davis, and S. C. Schoenbaum, Achieving a High Performance Health System: High Reliability Organizations Within a Broader Agenda, Health Services Research,August 2006 41(4p2):1710–20