Title: The Clinical Microsystem Framework: Its Impact on Process Improvement with Practical and Measurable
1- The Clinical Microsystem Framework Its Impact on
Process Improvement with Practical and Measurable
Change
2The Issue in Healthcare
- The current care systems cannot do the job.
Trying harder will not work. Changing systems of
care will. - IOM
3Healthcare Paradigm Shift
- Yesterday
- Relationship 11
- Care based upon a visit
- Treatment of mono-disease
- Physician autonomy
- Reaction to patient needs
- Professional knowledge
- Do no harm
- Secrecy
- Cost reduction
- Professional individualism
- Today
- Relationship multiple1
- Care based on continuum
- Alleviate burden of illness
- Patient centered
- Anticipation of patient needs
- Evidence-based decisions
- Safety is a system issue
- Transparency
- Waste reduction/Add value
- Teamwork
4Trends Shaping Healthcare
- Consumerism
- Patient-centered care
- Transparency
- Everyone knowing how you are doing
- Value
- Quality and safety in relation to cost
- Metrics
- Developing gold standard metrics
- Information technology
- Real time data on the patient, processes system
5Improvement Activities in Healthcare
6System Transformation
- Leadership must create the conditions for
frontline excellence quality, value, flexibility - Many ways to transform healthcare based
- Baldrige Model
- IHI Model
- Six Sigma
- Clinical Microsystem Framework
- All models are based upon the principals and
tools of Total Quality Management (TQM)
7Baldrige Model
- Top down approach
- Macrosystem
- Self- assessment improvement based on specific
criteria - National competition (optional) with judging on
dimensions of high performance - Leadership
- Strategic planning
- Focus on stakeholders
- Measurement, analysis knowledge management
- Staff focus
- Process management
- Organizational performance results
8IHI Model
- Drives healthcare systems toward getting things
done - Uses points of leverage
- Establish, oversee, communicate system-level aims
for improvement - Align system measures, strategy, projects
leadership learning system - Leadership attention at system-level improvement
- Find the right leadership team
- CFO quality champion
- Engage physicians
- Build improvement capability, agility,
accountability transparency
9Six Sigma
- Zero defects in processes
- Proven to work in process intensive manufacturing
industries - Statistically based management methodology
- Includes the tools and concepts of TQM
- Data-driven method for achieving near perfect
quality - Reduces variation in products produced
- 3.4 parts per million or 99.9997
- Focus on any element of production or service
- Strong emphasis on statistical analysis
10Clinical Microsystem Model
- Bottom up approach
- Driven by frontline staff
- Who understand the process of care
- Uses critical thinking skills of healthcare
professionals - A few simple tools and concepts of TQM
- Creates a common language about the work
- Integrates processes improvement into the daily
work - Use a scientific approach to
- Small tests of change and measurement
- Experimenting with new approaches and ideas
11Caring for Americas Heroes
- Requires that we focus on healthcare as a system
- Measurably improve patient outcomes and
satisfaction - Engages all staff in improvement
- Continually remove real costs, waste rework
- Discover a way to restore pride and joy in work
of medical and nursing staff
12- All models are wrong, some are useful.
- George EP Box
- Statistics for experimenters An introduction to
design, - data analysis, and model buildings (1997)
13Clinical Microsystem Theory
- Systems Theory
- Large organizations are composed of many smaller
systems - Overall quality of the macrosystem is the sum of
the quality of each microsystem - Quality, safety, and cost outcomes are produced
at the microsystem level
Nelson, E.C., et al., Microsystems in health
care Part 1. Learning from high-performing
front-line clinical units. Jt Comm J Qual Improv,
2002. 28(9) p. 472-93.
14Clinical Microsystem Definition
- A small group of people who work together on a
regular basis to provide care to discrete
subpopulations of patients. - It has clinical and business aims, linked
processes, and a shared information environment,
and it produces performance outcomes.
Nelson, EC, Batalden, PB, et al (2002).
Microsystems in Health Care Learning from
High-Performing Front-Line Clinical Units. J. on
Quality Improvement vol. 28, no. 9, 472-497.
15Military Health System
16Clinical Microsystems
- Basic building block of healthcare as a system
- Manageable unit for improvement and change
- Must operate well to maximize the knowledge,
skills and values of the healthcare professionals
- Focused on the needs of the patient
17Microsystem Approach
- Assessment
- Diagnosis
- Treatment
- Follow-up
- Pre-work
- Reflection and analysis of the pre-work
- Creating a Focus
- Small Tests of Change
- Monitoring, measuring, improving
18Microsystem Improvement Model
- Patients
- Professionals
- Processes
- Patterns
- Outcomes
Initial Work-up, Plan for care
Entry, Assignment
Orientation
Disenrollment
19Microsystem Knowledge
- What is the purpose of what you do?
- Clinical Aim
- Who are your patients?
- Patient Characteristics
- Who do you work with?
- Professionals
- How do you do the work?
- Processes
- How do you improve?
- Culture
- How do you know how you are doing?
- Measures
20- The quality, safety and value of care for any
single patient (or cohort of patients) is a
function of the sum of each interaction the
patient has with the system
Provider
SRU
Patient
21Clinical Microsystem Outcomes
22Outcomes
- Resulted in 50 reduction in time to process
soldiers readiness - Documentation of patient encounters in CHCS
AHLTA improved 230 in three months - 95 of Tricare demographics documented correctly
- Process standardization
- Improved RVU capture
- Improve RVUs by 38-212
- Improved ICD-9 coding failures resulting in
capture of 1,200-4,000 for mother/baby stay - Improved patient flow
- Improved medication administration/management
- Improved admissions to inpatient unit
23Unexpected Outcomes
- Others ask to participate in improvement
- Engages physicians
- Other departments become engaged
- Microsystems took down any internally perceived
barriers, leading us more towards how can we do
this? and away from I dont think we can do
this. Team Member - If we make these techniques into habits, we will
naturally spread the word on and on throughout
the system. MTF CO
24Facilitates Understanding Use of
25Understand That
- Every system is perfectly designed to get the
results it gets. - If we persist in holding the beliefs we have
always held, and - Insist on taking the action we have always taken,
- We should expect to continue to get the same
results we have always gotten.
Paul Batalden, MD Director Health Care
Improvement Leadership Development The Dartmouth
Institute Co-Founder Institute for Healthcare
Improvement
26Healthcare Professionals must Recognize
- Improvement requires a new mental model
- About the work
- About process
- About change
- Success in the past has no implication for
success in the future.the formulas for
yesterdays success are almost guaranteed to be
formulas for failure tomorrow. - Improvement, safety and quality must continually
be re-invented
27Command Perspective
- Advantageous process because similar in sequence
to FOCUS PDCA, or evaluate, plan, reevaluate care
process. - Simplistic with no special training needed for
metrics graphing or diagramming. - Lends itself well to a health care system, rather
than adapting a process geared toward industry
products. - Easy to apply to a small system/command.
28Command Perspective
- Seemingly large team accomplished quick
interdepartmental improvements with little time
investment. - Leadership support aided quick implementation of
solutions, avoiding frustrations among the team
(software purchase).
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