Expanding the Evidence BaseThis case is intended to focus your thoughts on the nature of scientific evidence in health care both in terms of stability and strength of evidence.

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Case 18 Stents VS Bypass: Expanding the Evidence BaseThis case is intended to focus your thoughts on the nature of scientific evidence in health care both in terms of stability and strength of evidence. Continuous clinical quality improvement will have to take into account the changing nature of the evidence, the importance of learning-by-doing, and the adjustments that need to be made to individual patient differences including comorbidity and genetic variability in responses to treatment. Almost any given set of evidence can be interpreted in multiple ways. As we strive for improved clinical performance, these will be key variables and frequent distractions to our efforts to win over the professionals and the public. Remember that the development of new types of stents has continued as well. However, we cannot ignore the importance of learning-by-doing along with our concerns about the influences of economic rewards and the influences of vendors on clinical choices.This brief case has many twists and turns. The hospital is a large community hospital, but one of the Top 100 in cardiac care according to Solucient. There is a stent maker in Elyria and the hospital staff is associated with published research. The comparative analysis of frequencies of interventions is based on the Dartmouth Atlas which has been involved in a number of controversial debates, include the conclusions about care in McAllen, Texas in the New Yorker by A. Gawande. But the debate between using stents versus angioplasty continues to rage on and is argued in many major studies. Thus, the case has two stages. The first is one of small area variations. The second pertains to how strong and definitive data has to be before change can reasonably be expected. A third issue is one of organizational learning that might take place when a particular technique is used intensively by a large practice.CASE 20: THE HOUSTON MEDICAL CENTER BED TOWER: QUALITY AND THE BUILT ENVIRONMENTThe need for healthcare facilities designed for safety and improved working conditions for health providers are resulting in new types of space. There are many ways that the planning and design processes can be improved. Often the built environment is a process constraint that is hard to remove without major capital expenditures. This case illustrates that the use of process analysis and process-improvement techniques not often cited in the healthcare literature, such as time and distance layout studies and computer simulations to analyze the impact of alternative designs that cannot be tested directly in the work setting. Such techniques borrowed from industrial engineering, management science, or systems analysis offer important gains for transforming healthcare settings and enhancing the safety of patients and the well-being of providers.