Patient safety, improvement in quality, and standardization of care have become the major focus within healthcare systems. Currently, there is wide variability of how healthcare systems work and how they incorporate system level change. Globally, billions of dollars are spent each year in the public and private sectors on biomedical, clinical, and health research, healthcare professional training and continuing education, quality improvement, and patient safety. Despite this, healthcare systems have failed to provide cost-effective programs and services to those in the community (Grimshaw, Eccles, Lavis, Hill, & Squires, 2012).

Specifically, healthcare systems have done poorly with implementing programs to effectively treat patients who are experiencing pain. Research has demonstrated that only a third of patients on sick leave for musculoskeletal symptoms and 48% of patients presenting with low back pain (LBP) are receiving evidence-based interventions (Nilsing, Söderberg, & Öberg, 2012; Wåhlin, Ekberg, Persson, Bernfort, & Öberg, 2012). Furthermore, clinicians continue to utilize interventions that they consider to be relevant despite the lack of evidence about the effects (Bernhardsson, Öberg, Johansson, Nilsen, & Larsson, 2015).

As discussed earlier in this text, pain is one of the most common reasons for seeking medical care across all age groups (National Institutes of Health, 2016). The burden of pain on the individual, family, community, and society is often underestimated. It is estimated that 23.4 million American adults, 10.3%, experience a significant amount of pain and an estimated 126 million adults, 55.7%, have reported some type of pain in the past 3 months (Nahin, 2015).

Undertreatment of pain resulting in physiologic, psychosocial, and economic consequences continues despite targeted improvement approaches (Freburger et al., 2009; Pransky, Borkan, Young, & Cherkin, 2011).

Within this chapter, we will discuss: (1) the concept of system level change within the healthcare environment; (2) what system level change entails; (3) considerations when planning and implementing a system level program; (4) pros/facilitators of system level change; (5) cons/barriers of system level change; (6) a specific example of system level change within a healthcare system; and (7) physical therapy-based treatment for acute spine pain within a healthcare system.

Understanding of the complexity of healthcare systems has grown over the past years (Braithwaite, Clay-Williams, Nugus, & Plumb, 2013; Clay-Williams, 2012), and from an evaluation of the various systems, an emphasis on system level changes is the emerging trend (Braithwaite, Westbrook, & Travaglia, 2008). To date, the focus on system level change has been on local change, quality improvement, and patient safety initiatives, which have shown limited benefits to patients (Schouten, Hulscher, Everdingen, Huijsman, & Grol, 2008) with effect sizes of 10% to 20% at best (Grimshaw et al., 2012).

The Centers for Disease Control and Prevention defines health systems change as “a change in organizational or legislative policies or in environmental supports that encourages and channels improvement(s) in systems, community, and individual-level health outcomes” (Minta, Todd, & Jernigan, n.d.). A recent example of system level change in the healthcare setting familiar to both clinicians and patients would be the implementation of electronic medical records. Several goals of the implementation of electronic medical records were to standardize the electronic capture of patient demographics, clinical orders, and results and improving quality of care through the ease of access to patient information.

A consistent finding in clinical and health services research is the failure to translate research into practice and policy (Grol, 2001; McGlynn et al., 2003). This failure results in evidence-based practice gaps and variability in the quality of care provided within the same system and contending systems. This results in patients failing to benefit from the advances in healthcare resulting in a decreased quality of life and loss of productivity at both personal and societal levels. Furthermore, evidence demonstrates that patients routinely receive care that is not needed or that could potentially be harmful (Almeida et al., 2013; Kale, Bishop, Federman, & Keyhani, 2013; Levine, Linder, & Landon, 2016; Schuster, McGlynn, & Brook, 1998). The apparent lack of guideline adherent and evidence-informed care serves to further underscore the importance of coordination of care across disciplines within healthcare systems, which may be accomplished through system level program development.

When developing a program for patients in pain, utilizing a biopsychosocial model is of vital importance. As discussed in Chapter 1, this model provides a framework for understanding the interactions between the biologic, psychological,
and sociocultural factors that impact pain. Typically, healthcare systems take on a predominantly biomedical approach in the management of patients presenting with pain (Wade & Halligan, 2004). During the developmental stages of a system level program, it will be important to keep in mind that psychological and social factors will have an impact on each individual’s pain experience. It has been shown that low educational status, worry, anxiety, depression, high psychological stress, poor self-rated health, frequent use of health or social services, and concurrent pain in other areas are factors that can affect outcomes in changing each individual’s pain experience (Carragee, Alamin, Miller, & Carragee, 2005; Docking et al., 2011; Hoy, Brooks, Blyth, & Buchbinder, 2010; Jarvik et al., 2005; Power, Frank, Hertzman, Schierhout, & Li, 2001).

System level changes will have a higher chance of success if a wide range of staff are involved in the design, implementation, and monitoring. From an employee perspective, work factors such as job dissatisfaction, low levels of social support in the workplace, and lack of control over job tasks also need to be taken into consideration (Bigos et al., 1991) as they may reduce employee buy-in to the program, potentially leading to its failure or ineffectiveness.

During the developmental and planning stages of programs aimed at system level changes, those involved should be aware of the complexity associated with successful design, implementation, and maintenance of such a program. Following validated guidelines during the developmental stages may enhance success. Essential areas of importance during the process are building partnerships, establishing goals, developing a plan or process, and implementing, monitoring, and evaluating the plan. Figure 12-1 highlights important aspects that should be taken into consideration during healthcare program development, implementation, and evaluation.

The complexity associated with successful implementation of system level change has been demonstrated within the literature and current research demonstrates that there is variability in the uptake of system-wide healthcare interventions (Braithwaite et al., 2010; Hillman et al., 2005; Landrigan et al., 2010). When developing and implementing a system level program, it is vital to have an understanding of the possible barriers to, and facilitators of, the success or failure of the program (Slade et al., 2016). Table 12-1 lists possible barriers and facilitators.