The Microsystem Festival 2012 - A4. Basic …...Microsystem Assumptions • Many have heard of the idea and have various notions of what it means • We all have more experience living

Continual Imp. of Health Care

Session #2

Basic Knowledge of Clinical Microsystems and Success Characteristics of

Great Clinical Microsystems

Marjorie M. Godfrey, PhD(c) RNDoctoral Student, Jönköping University

Co-Director, The Dartmouth InstituteMicrosystem Academy

Eugene C. Nelson, DSc, MPHProfessor, The Dartmouth Institute

Director, Population Health and MeasurementDartmouth-Hitchcock Medical Center

Topics

1. Health care systems & microsystems2. Success characteristics of microsystems3. Developing microsystems to sustain high

performance 4. Resources to improve your

microsystems


Session #2

1. Health Care Systems& Microsystems

• Every day, every where around the world, patients and families enter or activate health care systems.

• The results?

Variations in practice and spendingThe Dartmouth Atlas: Medicare per-capita spending

Los Angeles, CA $10,810San Bernardino, CA $9,702San Francisco, CA $8,331San Diego, CA $8,004Sacramento, CA $7,324Seattle, WA $7,218Spokane, WA $6,975Portland, OR $6,552Bend, OR $6,324Honolulu, HI $5,311

$6000 to $17,000


Session #2

Percent of Diabetic Medicare Enrollees Receiving Annual HbA1c

Testing

>80% to <20%

International Variation


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“Every system is perfectly designed to get the results it gets.”

Paul B. Batalden, MD

Founding Director, Healthcare Improvement Leadership Development

The Dartmouth Institute for Health Policy and Clinical Practice

Co-Founder Institute for Healthcare Improvement

We all have health care experience stories

What if we deeply immersed ourselves in the clinical microsystems of care?


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9

Meet Amy!

& Leslie

10


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Meso Meso

©2005, Trustees of Dartmouth College, Nelson, January

1-NT1

1-NT2

OP ED IP OP

Patient Experience: Within, Between, Across

MacroMacro

MicroMicro

How children move

Through CCHMC,

e.g., asthma

Coordinationor

Fragmentation?

12

The “True” Structure Of The Delivery System?

• As experienced by the patient ….– People working together (or against each other)– In front line clinical teams (or tangles)– Often embedded in larger organizations (or

Byzantine bureaucracies)– That are more or less loosely connected (or totally

disjointed)– And provide more or less perfect (or deadly

dreadful) care


Session #2

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Systems of practice, intervention, measurement, policy

Self-care

system

Individual care-giver

system

MicrosystemMesosystem

Macrosystem

Market / Geopolitical system

14

Health Care System:The “Must Do’s”

1. Better patient outcomes …including costs & value of care

2. Better system performance …including professional development

3. Better professional development …including new learners and lifelong learning


Session #2

Microsystem Assumptions

• Many have heard of the idea and have various notions of what it means

• We all have more experience living in, working in, and using them; than we have studying, changing, and leading them

• They exist now…

-17-

DefinitionA health care clinical microsystem can be defined as the combination of a small group of people who work together in a defined setting on a regular basis—or as needed—to provide care and the individuals who receive that care (who can also be recognized as members of a discrete subpopulation of patients.)It has clinical and business aims, linked processes, ashared information environment and produces services and care which can be measured as performanceoutcomes. These systems evolve over time and are (often)embedded in larger systems/organizations.As any living adaptive system, the microsystem must: (1) do the work, (2) meet staff needs, (3) maintain themselves as a clinical unit.


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How can we see the “clinical microsystem?”

• A small population of patients• Small group of doctors, nurses, other

clinicians• Interdependent for a common aim• Some administrative support• Some information and information

technology

19


Session #2

Clinical Microsystem• Clinical reflects the essential priorities of health

and care giving • Micro reflects the smallest replicable unit of

health care delivery • System reflects that this frontline unit has an aim

and is composed of people, processes, technologies, and patterns of information that interact and dynamically transform one another

• The clinical microsystem is the place where patients, families, and caregivers meet

• It is the locus of value creation in health care

22

Microsystems Are The Building Blocks That Come Together To Form Macro-organizations

The health system can be no better than the

small systems …


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Basic Concepts

• The Microsystem is the place where patients and families & health care teams meet

• The Mesosystem is the “collection”of other systems that facilitate processes in the index microsystem.

• The Macrosystem is the global system in which care is provided.

A Picture of a Clinical Microsystem

The AnatomyThe Anatomy


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26

PatientsPatients

ProfessionalsProfessionals

ProcessesProcesses

PatternsPatterns

PurposePurpose

Microsystem

The PhysiologyThe Physiology


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28

Entry,Assignment Orientation

InitialWork-up,

Plan for care

Disenrollment

Biological

Functional

Expectations

Costs

Biological

Functional

Satisfaction

Costs

Beneficiary knowledge, including knowledge of life while not in direct contact with the health care system

Satisfaction of need, monitoring, assessment of outputs

A “Generic” Clinical Microsystem Model

Acute care

Chronic care

Preventive care

Palliative care

Supporting Microsystems

Very HighRisk

People with Healthcare Needs Met

Functional & Risks

Biological

Costs

Satisfaction

Functional& Risks

Biological

Costs

Expectations

People with Healthcare

Needs

Chronic

Healthy

PreventionAcute

Chronic

Palliative

EnrollmentAnd

Assignment

Initial and ContinuousOrientation

Assess & PlanClinical Care

Access System

Clinical IssueTriage: visit vs. non-visitNon-visit managementOpen access schedulingPrescription RefillFollow-up

InformationTelephoneWebPrinted Material

Shape Demand

Very HighRisk

Chronic

Healthy

Other Care Locations

HospitalHome HealthED/Urgent CareNursing HomeOther Clinical Offices

PhysicalSpaceBillingReferrals

PharmacyRadiologyLaboratoryMedical

RecordsSchedulingPhoneNurseFirst

InfoSystems& Data


Session #2

Supporting Microsystems Have Many Roles:Within their own

microsystemand as members of other

microsystems

PhysicalSpaceBillingReferralsPharmacyRadiologyLaboratoryMedical

RecordsSchedulingPhoneNurseFirst

InfoSystems& Data

Med/Surg Clinical Pharmacy OR

ICU

Neuroscience

Same DayPACUCT Surgery

Cardiology

Orthopedics

OB

Pediatrics


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At The End of the Day…

• Patient care is only as good as the care that is delivered by frontline staff. • The “front line staff” are in places

where patients, families and care teams meet which we call Clinical Microsystems

-33-

Microsystem ≠ Team

1. Providers + beneficiaries2. People + Information Technology3. People, Work in a setting4. Purpose

Oh, by the way


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J. Brian Quinn, PhDJ. Brian Quinn, PhD

WorldWorld--wide research and study of bestwide research and study of best--ofof--best service organizationsbest service organizations

Batalden, Nelson Research and Batalden, Nelson Research and Knowledge DevelopmentKnowledge Development

••DemingDeming

••Caring for Pts & PopulationsCaring for Pts & Populations

••Clinical Value CompassClinical Value Compass

19921992 20002000

IOM and Julie IOM and Julie Mohr and Molla Mohr and Molla

DonaldsonDonaldson

20012001Robert W. Robert W. Johnson Johnson

Foundation Foundation StudyStudy

Information&

Information Technology

Staff• Staff focus• Education & Training

• Interdependence of care team

Patients• Patient Focus• Community & Market Focus

Performance• Performance results• Process improvement

Leadership• Leadership• Organizational

support

10 Success 10 Success CharacteristicsCharacteristics

8 Success 8 Success CharacteristicsCharacteristics

20012001IOM 21st CenturyIOM 21st Century

FutureFuture

Evolution of Evolution of ““Clinical MicrosystemsClinical Microsystems””

19981998Hierarchy of Hierarchy of

SystemsSystems

late 1970late 1970’’s & 1980s & 1980’’s s midmid--9090’’ss

•• CECS course on CECS course on MicroMicro--unitsunits

•• HFHS HFHS ““panelspanels”” of of patientspatients

20012001WebsiteWebsiteFormedFormed

www.clinicalmicrosystem.orgwww.clinicalmicrosystem.org

20022002--33JQI ArticlesJQI Articles

20032003 20052005AHA AHA

MicrosystemMicrosystemToolkitsToolkits

20062006MicrosystemMicrosystem

TextbookTextbook

EuropeanEuropeanClinical Clinical MicrosystemMicrosystemNetworkNetwork

Fall Fall InvitationalInvitational

CF Foundation CF Foundation Action Guide Action Guide 07/200607/2006

20062006

Clinical Microsystems

“The Place Where Patients, Families and Clinical Teams Meet”

Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice

www.clinicalmicrosystem.org

Purpose

Processes

Professionals

Patterns

Patients PatientsDRAFT

Studying, teaching, developing

2. Success Characteristics of High Performing

Microsystems

• Quinn & world’s best service organizations

• Dartmouth study of North America’s best microsytems


Session #2

Insert photo. Jet breaking sound barrier

Health systems will have to break into new space for High Q & V &This will take high performing clinical teams … or clinical microsystems

HighQuality & Value

Space

J Brian Quinn

• World’s best of the best service organizations culminated in publication of the seminal work, Intelligent Enterprise.

• Quinn discovered the world’s most successful service organizations placed a major focus on what he called the smallest replicable units (SRUs) or minimum replicable units (MRUs) within their enterprise.

• These were the places where true value transfer took place, where suppliers interacted directly with the customers, and where service was delivered.


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At Same Time, Brian Quinn Was Asking:

“Why are some service organizations enjoying explosive growth and margins?”

He found that the “big” focus on the “smallest replicable units” AKA “microsystems”

• Front office fixated on front line perfection

• Quality, efficiency, timeliness, service excellence designed into front line

• Value and loyalty created at customer-provider interface

Quinn ResearchThe front office was fixated on the ongoing perfection of frontline services

within SRUs because value and loyalty are created at the customer-provider interface.

Quality, efficiency, timeliness, service excellence, and innovation were designed into frontline work processes of SRUs.

Information flows were engineered into frontline work of SRUs to create supportive, real-time information environments that facilitated swift and correct delivery of services.

The smallest units of activity within frontline SRUs were measured and tracked over time for monitoring, managing, and improving performance.

Increasingly rich information environments were created for the frontline SRUs. Data systems were designed to feed information forward and to feed information back so the right information was at the right place at the right time at the right level of aggregation.

Based on systemic learning, ongoing improvements, and standardization of most effective practices, these best in the world service sector leaders could rapidly grow by replicating frontline SRUs through time and across space, reliably extending the delivery of high-value services.


Session #2

4141

Dartmouth Study 2002

Eugene C. Nelson, DSc, MPH

Paul B. Batalden, MD

Thomas P. Huber, MS

Julie J. Mohr, MSPH, PhD

Marjorie M. Godfrey, MS, RN

Linda A. Headrick, MD, MS

John H. Wasson, MD

Case 1. STRICU

High Performing Clinical Microsystems Exist for a Set of

ReasonsTerry Clemmer & Vicki Spuhler


Session #2

Site Visit Reveals Best Practices• HIT enabled interdisciplinary rounds for care plan and

treatment goals• Computer assisted vent management using 80 parameters• Local epidemiological surveillance of micro-organisms to

aid Abx selection• Routine use of PDSA tests of change leading to ….• Best practice notebook: continuous development of best

practice protocols in 1 page summaries • Data on walls for public display: run charts, dashboards• Outreach to smaller hospitals on guidelines for appropriate

and timely transfer of patients to and from STRICU• (But if you walked down the hall to the next ICU … you

would have seen few of these innovations in use)

44

High Performing Clinical Microsystems

Information& Information Technology

Staff• Staff focus• Education &

Training • Interdependence

of care team

Patients• Patient Focus• Community &

Market Focus

Performance• Performance

results• Process

improvement

Leadership• Leadership• Organizational

support

A Special Blend


Session #2

STRICU Key Lesson

High performing clinical microsystems exist for a set of

reasons … but they do not spread automatically

3. Developing Microsystems

“Microsystems are the vital component in any execution strategy”

Uma Kotagal, MD

Cincinnati Children’s Hospital Medical Center

46


Session #2

Case 2. 4W & 6N

Average Clinical Microsystems Can Be Improved

Laurie Bausk, Greg Morgan & Maren Batalden

Nested Systems of Care Delivery

Public health and health care policyCHA institutional policy/ leadershipSupporting microsystems within hospitalInpatient unit (4W or 6N)Outpatient primary care teamPatient and family


Session #2

Rapid Review of Path Forward• Maren Batalden visits Cooley Dickinson Hospital• Participates in Coach the Coach program• Meets with organization leaders to set expectations• Partners with nursing leaders for each unit• Begins applying principles and methods in 4W & 6N• Establishes rhythm and discipline:

daily huddles, weekly team meetings, monthly all staff meetings, monthly meetings with COO and CNO

• Starts working the “ramp of improvement”• 5 P assessment• PDSAs• Story boards and data walls• Early victories

Microsystem Development at CHA: First Year Timeline

10/09

Physician Leadership Academy

12/09

Field trip

2/10

Leadership position

Unit-level assessment

1/10

Planned pilot on 2 units

3/10

6th floor team

Coach the coach

4/10

4th floor team

Retreat

6th floor PDSA #1: Room

ready

5/10

4th floor PDSA #1-Whiteboards

6-8/10

Multiple rapid cycles related to first two PDSA projects

6-8/10

Planning for second PDSA projects: multidisciplinary rounding, AIDET communication training

9-10/10

Multiple rapid cycles related to second PDSA cycles (rounding, AIDET)

9-11/10

Initiation of new PDSA cycles: labs for discharge, admission orders conference


Session #2

Effective Meeting Skills

Cause and Effect Diagrams

Process Mapping

Dartmouth Clinical

Microsystems Toolkit

A Path to Healthcare Excellence

Toolkit

www.clinicalmicrosystem.org

www.jcrinc.org


Session #2

“Green Books”

• Cystic Fibrosis• Home Health• Primary Care• Specialty Care• Brain Trauma• NICU, Etc.

Unit Based Improvement in a Community Teaching HospitalStarting Where You are with a

Clinical Microsystems Approach

Maren Batalden, MD MPH

Greg Morgan, RN


Session #2

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38

14 10 6 1 1 1 1 1

80%84%

41%

66%

65% 69%58%

53%47% 45%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

10

20

30

40

50

60

70

80

90

100

% C

hoos

ing

Top

Box

Ans

wer

Perc

entil

e R

ank

Patient Satisfaction: HCAHPS Data4 Med Surg (Oct-Dec 2009)

Patient Satisfaction: HCAHPS Data4 Med Surg (April-June 2010)

9994

90

67

52 50 49 37

32 19

70%60%

77%

65%

78%

85%77%

70%65% 67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

10

20

30

40

50

60

70

80

90

100


Session #2

Ready Room Initiative DataRoom Ready Process Tracking

020406080

100

5/27/2

010

6/3/20

10

6/10/2

010

6/17/2

010

6/24/2

010

7/1/20

10

7/8/20

10

7/15/2

010

Dates

% complete

% accurate% room ready

4W & 6N Key Lesson

Average clinical microsystems can be improved … but it takesleadership and knowledge and

rhythm and discipline


Session #2

To do things differently, we must

see things differently. When we

see things we haven’t noticed

before, we can ask questions we

didn’t know to ask before.

John Kelsch, Xerox

60

Front Line Development

To grow your microsystem from

the inside out

To improve care &respond to new

pressures for quality

To develop people•Head•Hand•Heart


Session #2

Clinical Microsystems Create the Conditions for Reflection

• Organized, disciplined method for the reflection• Patient and family focus• Systems thinking

– Move from only thinking about assignments and shifts

– Subpopulation focus and study– Process evaluation

• Learning to work in interdisciplinary teams

62

Reflective Practitioner

• Move from task orientation only• Reflect on processes and outcomes

– Notice patterns– System perspective– Population perspective

• Learn to work with other professionals with a focus on the patient and family


Session #2

Interdisciplinary Teams

• Find ways to do better at meeting each patient’s needs

• Make the work experience for every staff person meaningful & joyous

• Increase each staff person’s ability to improve his/her own work & contribute to betterment of system

4. Resources for Improving Microsystems

• What resources can you use to improve and innovate?

Start with www.clinicalmicrosystem.org


Session #2

www.clinicalmicrosystem.orgClick MaterialsClick Toolkits“Getting Started”http://www.clinicalmicrosystem.org/toolkits/getting_started/ Clinical Microsystem

Improvement Workbooks

Greenbook “Discoveries”


Session #2

The Microsystem Academy• Resides in The Dartmouth Institute for Health

Policy and Clinical Practice (TDI) • Actively researching, coaching, and leading

clinical microsystem development since the early 1980s.

• Through the integration of professional experience, empirical and cutting-edge research methodologies and information, “Coach the Coach” offers an exciting, and rigorous curriculum of experiential learning in the art and science of interdisciplinary microsystems coaching. (Web based & Face-to-Face)

Microsystem Academy Education

• There are several existing venues for education related to Clinical Microsystems– TDI course– Coach the Coach Series– LPM Residency– VA Quality Scholars– Meetings

• National (Lake Morey)• International (Sweden)

• Non-Degree On Line Program


Session #2

On Line Non-Degree Programs

http://www.tdiprofessionaleducation.org/

Coaching Health Care Improvement”…Building relationships among people who are

continuously learning about the changing environments in which they live and work,

intervening in and moving to set aside ineffectiveand counter-productive habits, and building new

skills, practices, habits, and platforms for collaborating in this ever changing world.”


Session #2

Team Coaching ModelPre-Phase

Getting ReadyAction Phase

Art & Science of CoachingTransition Phase

Reflection, Celebration & Renew

*Context-Review of past improvement efforts and lessons learned-tools used-Preliminary system review-Micro/Meso/Macro*Site Visit-Resources-Logistics*ExpectationsClarity of aimLeadership & Team discussions about roles and logistics

*Relationships-Helping -Keep on track

*Communication-Virtual -Face-to-Face-Available & accessible -Timely

*Encouragement*Clarifying

- Improvement Knowledge-Expectations

*Feedback*Reframing

- Different perspectives- Possibility

-Group dynamics-new skills*Improvement Technical Skills

- Teaching

Reflection on improvement journey-What to keep doing or not do again-Review measured results and gains-Assess team capability and coaching needs & create coaching transition planCelebration!Renew and re-energize for next improvement focusEvaluate coaching

7171

Godfrey, MM (2012) In Press

Coaching Intensity Over Time

3 6 9 12 18 24MONTHS

INTENSITYHigh

Low

72Godfrey, MM (2012) In Press


Session #2

Action Phase

TransitionPhase

Pre-PhasePre-

Phase

Action Phase

TransitionPhase

Pre-Phase

Action Phase

TransitionPhase

Pre-Phase

Action Phase

TransitionPhase

PrePre--PhasePhase

Action Action PhasePhase

TransitionTransitionPhasePhase

Team Coaching Framework Over TimeTeam Coaching Framework Over TimePrePre--Phase, Action Phase, Transition PhasePhase, Action Phase, Transition Phase

PrePre--PhasePhase

Action Action PhasePhase

TransitionTransitionPhasePhase

73Godfrey, MM (2012) In Press

74

Global Aim

12

3

Assessment

Theme

Global Aim

Change Ideas

Specific Aim

Measures

SDSASDSA

PDS

A

P

DS

A

PDS

A

PDSA

1

3

2

Dartmouth Microsystem Improvement

Curriculum

FlowchartsFlowcharts

FishbonesFishbones

Science of Improvement

Meeting Skills/Group DynamicsMeeting Skills/Group Dynamics


Session #2

February 2011

2007

Final Points


Session #2

Transformation

77

April 2010

Fixing Health Care on the Front Linesby Richard M.J. Bohmer

The only realistic hope for substantially improving care delivery is for the old guard to launch a revolution from within.

Existing players must redesign themselves. What does “redesign” mean? Revamping core clinical processes.

It's time for a revolution — led from within.

Fixing Health Care on the Front Linesby Richard M.J. Bohmer

The only realistic hope for substantially improving care delivery is for the old guard to launch a revolution from within.

Existing players must redesign themselves. What does “redesign” mean? Revamping core clinical processes.

It's time for a revolution — led from within.

Developing Microsystems: The Strategic Advantage

“Organizations that have intentionally developed pervasive improvement capability in their microsystems have a

strategic advantage when it comes to accelerating and sustaining system-level improvement. These organizations have an efficient and effective means of getting everyone

involved to accomplish their strategic campaign.”

Source: T. Nolan, Execution Framework, IHI White Paper.


Session #2

Moving beyond projects

“No single initiative or set of unaligned projects will likely be enough to produce system-level results. Even aligned projects alone will not be sufficient. It will be necessary to have a pervasive understanding of work as a collection of processes. The responsibility of managers and supervisors includes continual improvement of work processes under their control.”

Evolution in approaches to improving health system quality: from projects to microsystems to mesosystems to macrosystems

T I M ET I M E

Projects

Microsystems

Macrosystems

Mesosystems

High High ValueValue


Session #2

Selected References1. Nelson EC, Batalden PB, Godfrey MM, Lazar J. Value by Design: Developing Clinical

Microsystems to Achieve Organizational Excellence. Jossey-Bass, in press, 2011.2. Fisher ES. Learning to Deliver Better Health Care. Issues in Science and Technology, NAS

Journal, Spring 2008, p. 58-62.3. Martin LA, Nelson EC, Lloyd RC, Nolan TW. Whole System Measures. IHI Innovations

Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007.4. James B, Lazar J. Sustaining and extending clinical improvements: A health system’s use

of clinical programs to build quality infrastructure. In Practice-Based Learning and Improvement: A Clinical Improvement Action Guide, Second Edition, Joint Commission Resources, 2007.

5. Nelson EC, Batalden PB, Lazar J: Practice-Based Learning and Improvement: A Clinical Improvement Action Guide, Second Edition, Joint Commission Resources, 2007.

6. Nelson EC, Batalden PB, Godfrey MM: Quality by Design: A Clinical Microsystems Approach. Jossey-Bass, 2007.

7. Nelson EC, Batalden PB, Homa K, Godfrey MM, Campbell C, Headrick LA, Huber TP, Mohr, JJ, Wasson JH: Data and Measurement in Clinical Microsystems: Part 2. Creating a Rich Information Environment. Joint Commission Journal on Quality and Safety, 29(1) 5-15, January 2003.

8. Weinstein JN, Brown PW, Hanscom B, Walsh T, Nelson EC: Designing an Ambulatory Clinical Practice for Outcomes Improvement: From Vision to Reality - The Spine Center at Dartmouth-Hitchcock, Year One. Quality Management in Health Care, 8(2):1-20, Winter 2000.

9. Nelson EC, Splaine ME, Batalden PB, Plume SK: Building Measurement and Data Collection into Medical Practice. Annals of Internal Medicine, 128(6):460-466, March 15, 1998.

10. Nelson EC, Mohr JJ, Batalden PB, Plume SK: Improving Health Care, Part 1: The Clinical Value Compass. The Joint Commission Journal on Quality Improvement, 22(4):243-258, April 1996.

11. www.clinicalmicrosystem.org (refer to this for workbooks, tools, articles and other resources and information on using microsystem principles and methods to improve health system performance)

82www.clinicalmicrosystem.org

The Microsystem Festival 2012 - A4. Basic …...Microsystem Assumptions • Many have heard of the idea and have various notions of what it means • We all have more experience living

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