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Descriptions
of complex care systems such as hospital pain control, chronic
disease care by primary care physicians, or end of life
care across multiple settings are arbitrary constructs.
The persons describing the system choose the level of detail,
the boundaries, and the method of description. The description
is in the context of the aim of the improvement effort.
For example, the description of a system of pain management
will extract elements of nursing care that impinge on the
aim of reducing pain. What to extract and illustrate and
what to leave as background is a reflection of the current
understanding of what is important for the control of pain
(Nolan, 1998). (For a
detailed discussion of issues related to the design of clinical
trials for pain management, click
here.)
This
flowchart, for example, outlines the structure of a pain
management system for surgical in-patients.
| Figure
3.1 Structure of a Pain Management System for
Surgical In-Patients
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The
diagram is relatively linear and attempts to describe the
system of pain management by connecting pain management
activities to the surgical processes that already exist.
For instance, the first box does not specifically describe
the pre-hospital information that is needed but only states
that pain management information should be included. The
diagram provides some direction for the team: insert the
proper elements of a pain management system into the existing
surgical system.
Here
is a different--and more insightful--view of a pain control
system:
| Figure
3.2 Post-Surgery Aspects of a Pain Management
System
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This
second flowchart focuses on the post-surgery aspects of
the system and on methods of reliable pain management. It,
therefore, includes the feedback loops necessary for a dynamic,
responsive system. This diagram reflects much deeper knowledge
about what makes a pain management system reliable and effective
and demonstrates what can happen as a quality improvement
team improves its understanding of a system. Such evolution
in knowledge is typical. Rarely does a researcher know all
elements of the current system or the full specification
of interventions prior to study.
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