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The Clinical Microsystem Framework: Its Impact on Process Improvement with Practical and Measurable

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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

2
The Issue in Healthcare
  • The current care systems cannot do the job.
    Trying harder will not work. Changing systems of
    care will.
  • IOM

3
Healthcare 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

4
Trends 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

5
Improvement Activities in Healthcare
6
System 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)

7
Baldrige 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

8
IHI 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

9
Six 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

10
Clinical 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

11
Caring 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)

13
Clinical 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.
14
Clinical 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.
15
Military Health System
16
Clinical 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

17
Microsystem 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

18
Microsystem Improvement Model
  • Patients
  • Professionals
  • Processes
  • Patterns
  • Outcomes

Initial Work-up, Plan for care
Entry, Assignment
Orientation
Disenrollment
19
Microsystem 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
21
Clinical Microsystem Outcomes
22
Outcomes
  • 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

23
Unexpected 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

24
Facilitates Understanding Use of
25
Understand 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
26
Healthcare 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

27
Command 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.

28
Command 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).

29
  • Questions
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