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The fourth and final habit is self-study. Beyond ensuring that their clinical practices are consistent with the most recent science, these organizations also examine positive and negative deviance in their own care and outcomes, seeking new insights and better outcomes for their patients.5 By contrast, most health care organizations treat clinical knowledge as a property of the individual clinician, “managing” knowledge only by hiring and credentialing competent professional staff.

High-value organizations treat clinical knowledge as an organizational as well as individual property. They create knowledge and innovations with the use of some common tools (sentinel-event reporting and root-cause analysis) and some less common ones (monitoring of protocol overrides and rapid-cycle experimentation). Some have units — for instance, the Mayo Clinic’s See-Plan-Act-Refine-Communicate (SPARC) program — that are dedicated to developing innovations in-house, and most have academies to teach leaders and staff the principles and techniques for improving the value of care and to support the application of these principles to high-priority clinical programs and processes. Most important, these organizations deliberately nurture a culture that supports learning by encouraging dissenting views and overriding of specified clinical decision rules (habit 1).

These habits are not unique to high-value health care organizations. Many delivery organizations engage in some of them — designing clinical pathways and reporting on quality and safety, for instance. But high-value organizations are distinct in two important ways. First, they engage in all four habits systematically. For them, these activities are truly habits, baked into their structures, culture, and routines, not simply short-lived projects. Second, the habits are integrated into a comprehensive system for clinical management that is focused more on clinical processes and outcomes than on resources. A consensus is emerging about how to manage clinical care.

Each organization expresses these four habits differently. Each faces a unique regulatory and reimbursement environment and has different resources, so each uses different tools and terminologies, varying in the details of how they specify decisions or measure clinical processes. Still, the habits are the same. As we seek models for achieving high-value health care, we must look past the particularities of local structures and tactics to the habits they reflect. Although a “dominant” delivery model may not be transferrable, the habits of high-value health care may be.

The specification of choices, transitions, subgroups, and patient pathways represents a substantial investment in advance planning. It contrasts sharply with the common practice of focusing management planning on the utilization of expensive resources, such as tests, procedures, and bed-days, rather than on the problems these resources are designed to solve. Many hospitals and clinicians do not plan care processes in advance in such detail; instead, they treat each new patient or problem as a random draw from a heterogeneous population and must therefore reinvent the strategy for solving it.

A second common habit is infrastructure design. High-value health care organizations deliberately design microsystems3 — including staff, information and clinical technology, physical space, business processes, and policies and procedures that support patient care — to match their defined subpopulations and pathways. Thus, different conditions or patient groups have different microsystem designs. The various tasks of care are allocated to different members of a clinical team (including the patient), with the skill and training of each staff member matched to the work. Such organizations make thoughtful use of assistive personnel and alternative providers, and they ensure that each has the necessary resources by carefully designing the supply chain of equipment and information, simplifying workflow, and reducing work stress. They also harmonize the parts of their management system so that budgets, incentives, data, goals, clinical processes, educational programs, and team structures are all mutually reinforcing.4 Unit-level routines, such as joint ward rounds, team meetings, and executive “walk-arounds,” help tie microsystem components together.

Attention to microsystem design and integration represents an important shift away from general-services-organization designs that use a single platform to meet the needs of many different patient groups and that focus on maximizing the use of scarce resources, such as operating-room slots, ICU beds, and physicians.

The third habit is measurement and oversight. For many, measurement of clinical operations is driven by external audiences: payers, regulators, and rating agencies. Although high-value organizations share this reporting obligation, they primarily use measurement for internal process control and performance management. They collect more (and more detailed) measurements than those required for external reporting, selecting those that inform staff about clinical performance. For instance, of the 200-plus measurements used by Intermountain, more than two thirds were developed or refined internally rather than imported unmodified from external agencies. Moreover, such organizations integrate their measurement activities with other organizational priorities such as pay for performance, annual target setting, and improvement activities, making measurement an integral part of accountability and performance management. For example, each year Intermountain’s board selects a different group of measurements from the institution’s overall measurement set to use for annual quality and efficiency bonuses.

Recent attention to the question of value in health care — the ratio of outcomes to long-term costs — has focused on problems of definition and measurement: what outcomes and which costs? Less attention has been given to an equally difficult but important issue: how do health care delivery organizations reliably deliver higher value?

It would certainly simplify health care reform if we could show the superiority of a dominant delivery model (e.g., the accountable care organization or the medical home) and roll it out nationwide, developing and proving new approaches to creating value only once. However, experience suggests that not only do new delivery models — for example, integrated networks — not necessarily live up to their promise, but they are surprisingly difficult to transfer, even when successful; those that succeed in one U.S. region haven’t always done well in another. Organizations considered to be among the nation’s highest performers, such as the members of the new High Value Healthcare Collaborative, often have unique personalities, structures, resources, and local environments. Given the health care sector’s mixed record of disseminating clinical innovations and system improvements, how do we learn from leading organizations?

Although high-value health care organizations vary in structure, resources, and culture, they often have remarkably similar approaches to care management. Specific tactics vary, but their “habits” — repeated behaviors and activities and the ways of thinking that they reflect and engender — are shared. This is important because experience suggests that such habits may be portable.

The first common habit is specification and planning. To an unusual extent, these organizations specify decisions and activities in advance. Whenever possible, both operational decisions, such as those related to patient flow (admission, discharge, and transfer criteria), and core clinical decisions, such as diagnosis, tests, or treatment selection, are based on explicit criteria. Criteria-based decision making may be manifest in the use of clinical decision support systems and treatment algorithms, severity and risk scores, criteria for initiating a call to a rapid-response team or triggering the commitment of a future resource (e.g., a discharge planner, preprocedure checklists, and standardized patient assessments), and for patients, shared decision making.

Specification also applies to separating heterogeneous patient populations into clinically meaningful subgroups — by disease subtype, severity, or risk of complications — each with its own distinct pathway. For example, Dartmouth’s Spine Center uses a detailed intake assessment that combines the 36-Item Short-Form Health Survey, computerized visual aids, and shared decision making to sort patients according to the likelihood that they will do better with either medical or surgical care. Similarly, genomic testing has allowed oncology units to divide patients into separate groups according to their probable response to specific therapies (for instance, KRAS testing for cetuximab therapy). And at Intermountain Healthcare in Utah and Idaho, the needs of psychiatric patients are divided into mild (routine care by a primary care physician), moderate (team care), and severe (specialist referral), with a scoring system based on published guidelines. Some organizations, such as Children’s Hospital Boston, are developing standard approaches to uncommon and complex conditions.

The fourth and final habit is self-study. Beyond ensuring that their clinical practices are consistent with the most recent science, these organizations also examine positive and negative deviance in their own care and outcomes, seeking new insights and better outcomes for their patients.5 By contrast, most health care organizations treat clinical knowledge as a property of the individual clinician, “managing” knowledge only by hiring and credentialing competent professional staff.

High-value organizations treat clinical knowledge as an organizational as well as individual property. They create knowledge and innovations with the use of some common tools (sentinel-event reporting and root-cause analysis) and some less common ones (monitoring of protocol overrides and rapid-cycle experimentation). Some have units — for instance, the Mayo Clinic’s See-Plan-Act-Refine-Communicate (SPARC) program — that are dedicated to developing innovations in-house, and most have academies to teach leaders and staff the principles and techniques for improving the value of care and to support the application of these principles to high-priority clinical programs and processes. Most important, these organizations deliberately nurture a culture that supports learning by encouraging dissenting views and overriding of specified clinical decision rules (habit 1).

These habits are not unique to high-value health care organizations. Many delivery organizations engage in some of them — designing clinical pathways and reporting on quality and safety, for instance. But high-value organizations are distinct in two important ways. First, they engage in all four habits systematically. For them, these activities are truly habits, baked into their structures, culture, and routines, not simply short-lived projects. Second, the habits are integrated into a comprehensive system for clinical management that is focused more on clinical processes and outcomes than on resources. A consensus is emerging about how to manage clinical care.

Each organization expresses these four habits differently. Each faces a unique regulatory and reimbursement environment and has different resources, so each uses different tools and terminologies, varying in the details of how they specify decisions or measure clinical processes. Still, the habits are the same. As we seek models for achieving high-value health care, we must look past the particularities of local structures and tactics to the habits they reflect. Although a “dominant” delivery model may not be transferrable, the habits of high-value health care may be.

The specification of choices, transitions, subgroups, and patient pathways represents a substantial investment in advance planning. It contrasts sharply with the common practice of focusing management planning on the utilization of expensive resources, such as tests, procedures, and bed-days, rather than on the problems these resources are designed to solve. Many hospitals and clinicians do not plan care processes in advance in such detail; instead, they treat each new patient or problem as a random draw from a heterogeneous population and must therefore reinvent the strategy for solving it.

A second common habit is infrastructure design. High-value health care organizations deliberately design microsystems3 — including staff, information and clinical technology, physical space, business processes, and policies and procedures that support patient care — to match their defined subpopulations and pathways. Thus, different conditions or patient groups have different microsystem designs. The various tasks of care are allocated to different members of a clinical team (including the patient), with the skill and training of each staff member matched to the work. Such organizations make thoughtful use of assistive personnel and alternative providers, and they ensure that each has the necessary resources by carefully designing the supply chain of equipment and information, simplifying workflow, and reducing work stress. They also harmonize the parts of their management system so that budgets, incentives, data, goals, clinical processes, educational programs, and team structures are all mutually reinforcing.4 Unit-level routines, such as joint ward rounds, team meetings, and executive “walk-arounds,” help tie microsystem components together.

Attention to microsystem design and integration represents an important shift away from general-services-organization designs that use a single platform to meet the needs of many different patient groups and that focus on maximizing the use of scarce resources, such as operating-room slots, ICU beds, and physicians.

The third habit is measurement and oversight. For many, measurement of clinical operations is driven by external audiences: payers, regulators, and rating agencies. Although high-value organizations share this reporting obligation, they primarily use measurement for internal process control and performance management. They collect more (and more detailed) measurements than those required for external reporting, selecting those that inform staff about clinical performance. For instance, of the 200-plus measurements used by Intermountain, more than two thirds were developed or refined internally rather than imported unmodified from external agencies. Moreover, such organizations integrate their measurement activities with other organizational priorities such as pay for performance, annual target setting, and improvement activities, making measurement an integral part of accountability and performance management. For example, each year Intermountain’s board selects a different group of measurements from the institution’s overall measurement set to use for annual quality and efficiency bonuses.

Recent attention to the question of value in health care — the ratio of outcomes to long-term costs — has focused on problems of definition and measurement: what outcomes and which costs? Less attention has been given to an equally difficult but important issue: how do health care delivery organizations reliably deliver higher value?

It would certainly simplify health care reform if we could show the superiority of a dominant delivery model (e.g., the accountable care organization or the medical home) and roll it out nationwide, developing and proving new approaches to creating value only once. However, experience suggests that not only do new delivery models — for example, integrated networks — not necessarily live up to their promise, but they are surprisingly difficult to transfer, even when successful; those that succeed in one U.S. region haven’t always done well in another. Organizations considered to be among the nation’s highest performers, such as the members of the new High Value Healthcare Collaborative, often have unique personalities, structures, resources, and local environments. Given the health care sector’s mixed record of disseminating clinical innovations and system improvements, how do we learn from leading organizations?

Although high-value health care organizations vary in structure, resources, and culture, they often have remarkably similar approaches to care management. Specific tactics vary, but their “habits” — repeated behaviors and activities and the ways of thinking that they reflect and engender — are shared. This is important because experience suggests that such habits may be portable.

The first common habit is specification and planning. To an unusual extent, these organizations specify decisions and activities in advance. Whenever possible, both operational decisions, such as those related to patient flow (admission, discharge, and transfer criteria), and core clinical decisions, such as diagnosis, tests, or treatment selection, are based on explicit criteria. Criteria-based decision making may be manifest in the use of clinical decision support systems and treatment algorithms, severity and risk scores, criteria for initiating a call to a rapid-response team or triggering the commitment of a future resource (e.g., a discharge planner, preprocedure checklists, and standardized patient assessments), and for patients, shared decision making.

Specification also applies to separating heterogeneous patient populations into clinically meaningful subgroups — by disease subtype, severity, or risk of complications — each with its own distinct pathway. For example, Dartmouth’s Spine Center uses a detailed intake assessment that combines the 36-Item Short-Form Health Survey, computerized visual aids, and shared decision making to sort patients according to the likelihood that they will do better with either medical or surgical care. Similarly, genomic testing has allowed oncology units to divide patients into separate groups according to their probable response to specific therapies (for instance, KRAS testing for cetuximab therapy). And at Intermountain Healthcare in Utah and Idaho, the needs of psychiatric patients are divided into mild (routine care by a primary care physician), moderate (team care), and severe (specialist referral), with a scoring system based on published guidelines. Some organizations, such as Children’s Hospital Boston, are developing standard approaches to uncommon and complex conditions.

Recommended Lycopene Intakes

Average daily intake levels of lycopene range from 0.70 to 25.20 mg/day but 50% of North Americans consume < 1.86 mg/day of lycopene. Based on human research, recent recommendations for the daily intake of lycopene suggest 7 mg/day. At this level of intake, circulatory lycopene concentration is maintained at a level consistent with that shown to reduce lipid peroxidation and to result in other beneficial effects of lycopene. Health Claims Associated with Lycopene Emphasizing consumption of fruits and vegetables is part of the dietary guidelines recommended for the prevention of chronic diseases.33 Dietary benefits generally associated with increased plant food consumption include lower intakes of energy and fat, and higher intakes of fiber and micronutrients including phytochemicals such as lycopene but also phytosterols, flavonoids, indoles, isoflavones, isothiocyanates, lignans, phytates, soluble and insoluble fibers, terpenoids (saponins) and other carotenoids. The FDA has approved Generally Recognized as Safe (GRAS) status to lycopene. Recently, the FDA has also given a limited health claim declaration for lycopene, stating “Very limited and preliminary scientific research suggests that eating one-half to one cup of tomatoes and/or tomato sauce a week may reduce the risk of prostate cancer.” However, FDA concludes that the evidence in support of lycopene in prostate cancer risk reduction is still not very strong and needs further research.

Conclusion

There is convincing evidence to suggest a causal link between oxidative stress and human chronic diseases. Antioxidants have been suggested as playing an important role in protecting cells and cellular components against oxidative damage. Lycopene is a potent antioxidant carotenoid present in tomatoes, tomato products and other fruits. However, it is not synthesized by animals and humans. Dietary sources and nutritional supplements constitute the major source of lycopene intake. The evidence in support of the role of lycopene in the prevention of chronic diseases is primarily epidemiological in nature up to this stage. However, tissue culture, animal experiments and more recently human intervention studies are providing convincing evidence in support of the epidemiological observations. Although the antioxidant properties of lycopene are considered to drive the major mechanism by which lycopene provides beneficial effects, other mechanisms are also being suggested. A daily intake of 7 mg of lycopene is currently recommended to maintain the circulatory levels of lycopene consistent with reduction in lipid peroxidation. Recent studies also suggest synergistic interactions between lycopene and other phytonutrients in tomatoes and tomato products leading to its beneficial effects. Future research addressing the bioavailability of lycopene, its mechanisms of action and its role in other important human chronic diseases is needed to fully understand the role of lycopene in human health and to take advantage of this important ‘nutraceutical’ product in the management of chronic diseases.

In a large multicenter case-control study (EURAMIC), the relationship between adipose tissue antioxidant status (alpha- and beta-carotene and lycopene) and acute myocardial infarction were evaluated in 662 cases and 717 controls. Subjects in this trial were recruited from 10 European countries to maximize the variability in exposure within the study. Adipose antioxidant levels were measured because they are considered to be a better marker of long-term exposure than serum lycopene. After adjusting for a range of dietary variables, higher lycopene but not alpha- or beta-carotene adipose tissue levels were found to be protective against myocardial infarction risk in non-smokers (OR=0.52, P=0.005; OR=0.91, P=0.66; and OR=1.01, P=0.96; respectively). Also related to cardiovascular disease, mildly hypercholesterolemic men and women with grade-1 hypertension taking 15 mg/day of lycopene from tomato oleoresin antioxidant-rich tomato extract had significantly decreased systolic and diastolic blood pressure compared toplacebo.

Lycopene and Bone Health
Recently, lycopene research has begun to explore the potential for this antioxidant carotenoid to work against the onset of bone disease. Although not fully understood, there is evidence that oxidative stress caused by ROS is associated with the pathogenesis of osteoporosis. In a recent in vitro study of bone marrow prepared from rat femurs, it was demonstrated that lycopene, in the absence or presence of parathyroid hormone (PTH), inhibited osteoclastic mineral resorption and formation of tartrate-resistant acid phosphatase (TRAP) positive multinucleated osteoclasts, as well as the ROS produced by osteoclasts.30 The authors suggested that this finding may be important in the pathogenesis, treatment and prevention of osteoporosis. Clinical studies are now being conducted to study the role of lycopene in osteoporosis. Researchers have studied the relationship between lycopene and bone resorption as measured by serum N-telopeptides of type I collagen (NTx) in postmenopausal women. They found higher lycopene intake and higher serum lycopene to be associated with lower bone resorption (p<0.005). Based on the results from this study, the researchers are now conducting a lycopene intervention study with postmenopausal females to evaluate the relationship between lycopene and the risk of osteoporosis. Lycopene and Male Infertility
An area of concern for many men is that of infertility. Infertile men genetically tend to produce higher levels of free radicals. Ongoing research in India is exploring this relationship and the influence of supplementing with lycopene. In one study of 50 volunteers with low active sperm counts, 35 volunteers (70%) experienced an improvement in sperm count, 30 (60%) had improved functional sperm concentrations, 27 (54%) had improved sperm motility, 23 (46%) had improved sperm motility index, and 19 (38%) had improved sperm morphology following consumption of 8 mg/day of lycopene supplementation from tomato oleoresin extract. Further studies are now being undertaken to confirm these preliminary observations and to gain further understanding into the role of lycopene in male infertility.

Oxidative stress induced by highly reactive oxygen species (hROS) is recognized as an important mechanism in the causation of chronic diseases such as cancer, cardiovascular disease, osteoporosis and diabetes. Fruits and vegetables are good sources of several antioxidants including lycopene, of recent interest and available in the diet primarily from tomatoes and tomato products. Popular for its role in prostate health, lycopene also improves markers for and risk of multiple cancers, cardiovascular disease, osteoporosis, diabetes, hypertension, male infertility and macular degeneration. Epidemiological, tissue culture, animal and human studies show a beneficial role for lycopene in the prevention and possibly treatment of chronic diseases. Generally, lycopene intake of North Americans is low (≤1.86 mg/day) compared to 7 mg/day now recommended to maintain circulatory lycopene at levels consistent with providing beneficial effects. Ongoing and future research is warranted to increase our understanding of lycopene’s role in human diseases, its mechanisms of action and its use in the management of public health.

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Lycopene has attracted attention for nearly 50 years for its biochemical and physiochemical properties. Since that time, epidemiological, in vitro, and in vivo animal and human experiments have provided support for lycopene’s antioxidant health benefits and its potential to reduce the risk of several cancers and cardiovascular disease (CVD). Lycopene is a natural pigment synthesized by plants and microorganisms, and the diet constitutes the primary source of lycopene for humans. The attractive red color of tomatoes is due to the presence of lycopene; this antioxidant carotenoid can also be found in watermelon, pink grapefruit, apricots and pink guava. Lycopene is an acyclic, highly unsaturated, straight chain hydrocarbon containing 13 double bonds. Lycopene is an isomer of beta-carotene but does not have provitamin A activity. Oxygen-derived free radicals known as reactive oxygen species (ROS) are generated endogenously through normal metabolic activity, lifestyle activities, and diet. ROS-related oxidative stress results in the damage of cellular components including lipids, proteins and DNA. Cellular damage and oxidation of cellular biomolecules has been implicated in the early stages and pathogenesis of various human chronic diseases. In contrast, lycopene is a potent antioxidant that provides protection against cellular damage caused by ROS13 and, therefore, may play an important role in disease prevention. More specifically, because of its high number of conjugated double bonds, lycopene exhibits higher (two and ten times) singlet oxygen quenching ability compared with beta-carotene and alphatocopherol, respectively.

Lycopene: Bioavailability and Isomerization

In human dietary intervention research, serum lycopene levels significantly increase after consuming tomato foods or lycopene supplementation. However, not all sources of lycopene are equally bioavailable. Ingested in its natural trans form, such as is prominent in tomatoes, lycopene is poorly absorbed whereas heat processing of tomatoes and tomato products induces isomerization of lycopene from all-trans to cis configuration in turn increasing its bioavailability. Remaining to be determined, however, is whether or not cisisomers are biologically more effective than trans-isomers once in the body.

This pilot project examined the value of health promotion activities in clinical practice and the personal lives of 28 master’s entry Clinical Nurse Leader (CNL) students in their last semester of education. Data collection involved an open-ended questionnaire and focus group discussion. Students expressed concern about finding time for health promotion and noted that patients were often too sick to be appropriate for health promotion. Participants believed that health promotion was better situated in community-based care. Of great concern to students was the lack of role models for health promotion among faculty and staff. Students also noted a decreased ability to attend to their own health while enrolled in the nursing program.

Nursing is a complex profession that has undergone tremendous change, from the provision of mere kindness and support to work that is based in science but focuses on care and nurturing. To reflect this change and allow for future change, contemporary definitions of nursing broadly define nursing practice as the promotion of health, prevention of illness, and the care of ill, disabled and dying people (ICN, 2003).

Contemporary ad campaigns to attract men and women into nursing depict action scenes of nurses racing through hospital halls with patients on gurneys or stationed at the bedside amidst an array of technology (Wilkinson & Van Leuven, 2007). These images reflect the increasing role of technology in nursing care. In addition, nursing faculty face ever-growing lists of “must cover” topics in nursing curricula. These topics are often driven by the growing knowledge base, and commonly centered on skills and technology. This high-tech fast-paced image cannot be dismissed as it does reflect what is commonly seen in today’s hospitals; but these images largely reflect care of the ill, disabled, and dying rather than health promotion and disease prevention activities. If technology and sick care are advertised and emphasized in nursing programs, what role does health promotion play in clinical practice and in the lives of members of the nursing profession?

This pilot project seeks to address these questions. It is part of a program of research examining attitudes, beliefs, and clinical practice surrounding health promotion among nursing students, practicing nurses, and advance practice nurses. In this phase, data were collected from students enrolled in their final semester of a master’s entry Clinical Nurse Leader (CNL) program.

Methods
Students were approached for participation via announcement during a regularly scheduled class. Students were invited to participate in a pilot study on health promotion by reporting to school one hour prior to a required course the following week. Participation was voluntary and unrelated to any curriculum requirements. One hundred percent of the class returned for participation in this project.