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.