Reverse translation in health policy and management: from bedside to bench and beyond.

If there has been one enduring theme in the 21 research meetings of Academy Health and its predecessor organizations, it is the importance of translating new knowledge into practice—the practice of policy makers, of managers, and of the millions of professionals who daily tend to the needs of the sick and the well throughout this country's vast health care system. This translational task is tough and important work. It taxes our imaginations and our stamina. It is in many ways the essence of what we are about. Today, however, I want to take a very different perspective on the translation challenge. I want to explore the equally important, but perhaps less recognized and discussed challenge of reversing the flow of knowledge, of moving insights from practice—in this case clinical practice—into the language and work of health services research and health policy making. This task is about connecting with and learning from the daily work of health care, or what systems analysts and safety theorists call the “sharp end” of the health care enterprise. Every year, like thousands of physician colleagues in academic medicine, I spend a month attending on the medical service of a teaching hospital. I become the physician of record for patients who do not have private physicians. I supervise interns and residents who actually provide the great bulk of the care and make most of the decisions, subject to my (hopefully) gentle and diligent review. Attending is hard work. It adds 5–6 hours a day, six days a week, to the already busy life of—in my case—a health services researcher and academic administrator, a life familiar to many in this audience. But on balance, I get a great deal more than I give. I have a good excuse for saying no to talks and meetings I don't want to give or attend. I learn a tremendous amount of medicine (some of it, unfortunately, once known and since forgotten). I get to know a group of remarkable young people—students and residents—whose intelligence, earnestness and ethnic and racial diversity are exciting and inspiring. I get to regale them with stories about how much harder it was when I was a resident, in the days when training was really tough (and probably less safe for patients). I earn my stripes with my physician colleagues, who, having seen me wandering the halls with seven or eight young people in white coats and scrubs, are reminded that I am still one of the tribe. But most of all, these yearly experiences illuminate for me—personally, indelibly—the ways in which our health care system is changing, its problems, and the shape of potential solutions. Frequently, I am astonished, even stunned, by what I observe as a health services researcher plunged into the maelstrom of inpatient care on a busy hospital teaching service. It occurred to me that if this is true for me after decades of attending, then perhaps some of my nonclinical colleagues in the health services research and health policy world may find these experiences informative as well. Stated in the terminology of our field, my goal is to take advantage of an enduring insight from the theory of continuous quality improvement, an insight that dates back to the seminal early- and mid-20th century work of Shewhart, Deming, Juran, Feigenbaum, and Ishikawa. A profound knowledge of the processes of production in any system is essential to improving it. I would also argue that such an understanding can valuably inform health services research and health policy. Once a year, I immerse myself as a participant observer in the processes of production and care in the system that we call the American teaching hospital. My goal is to share some lessons, large and small, of that experience in the hopes that they may in some way be useful to your work, or at a minimum, entertain you as the 21st Annual Research Meeting draws to a close. In particular, I would like to share observations relevant to three areas of policy and management: workforce policy, safety, and quality; and cost and value management. Let me start with workforce policy.