Clinical Microsystems

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• Clinical Microsystems

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Clinical Microsystems-- Definition

• A small group of people who work together on a
  regular basis--or as needed-- to provide care and
  the individuals who receive that care (who can
  also be recognized as a discrete subpopulation of
  patients).

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Clinical Microsystems- Definitions

• It has clinical and business aims, linked
  processes, a shared information environment and
  produces services and care that can be measured
  as performance outcomes. These systems evolve
  over time and are (often) embedded in larger
  systems/organizations.

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Diagram of a Clinical Microsystem
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Systems of Health Care
Community Market, Social Policy System
Self care system
Macro- Organizational System
Individual Caregiver patient System
Microsystem
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Microsystems Self Awareness Journey
Connect work to those who could benefit from
it. Building a sense of the related purpose of
the work
Work on some foolishness to understand change is
possible
Create an awareness of work as a microsystem
Try some strategic change improvement
Build measures of performance
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Going Through the Process

• Tools provide a way for the microsystem to assess
  their work by thinking about
• Purpose
• Patients served
• People who work together
• Processes
• Patterns

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1. Define Where You Are Now

• Know your patients
• Age distribution
• Diseases
• Frequency of use
• Other systems we interact with regularly
• Pt. population (variations)

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1. Define Where You Are Now

• Know your people
• Staff
• Title
• Roll
• Function

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1. Define Where You Are Now

• Know your processes
• Cycle times
• Core and supporting processes

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1. Define Where You Are Now

• Know your patterns
• Does team meet regularly?
• Margin after costs
• What are you most proud of?
• What have you changed successfully?
• Do members of the microsystem meet regularly to
  review and discuss safety and reliability issues?

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2. Flowchart Current Process

• Do a high level flowchart of current process
• Brainstorm change ideas
• Select one test of change to implement
• Develop the PDSA
• Conduct the test
• Revise/Implement the new process

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2. Flowchart Current Process
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2. Flowchart Current Process

• From the flow chart--start to build your own
  microsystem diagram

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Clinical Microsystems
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Clinical Microsystems

• External Context
• Connections with other microsystems
• Resources beyond the microsystem

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Customers

• Six essential principles
• Organization exists to meet patients needs.
• You do not know enough about what they need.
• You need to know patients better than they know
  themselves.
• Patients constantly judge our performance
• Our patients are the ultimate judges of our
  performance.
• Segmentation of patients helps meet needs better.

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Kanos Model
Delighter
Delight
Expected Performance
Degree of Customer Satisfaction
Neutral
Basic Must Have
Dissatisfaction
Fulfilled
Absent
Presence of Characteristic
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Clinical Microsystems

• Kanos take home message
• Satisfaction is dynamic
• Todays excited is
• Tomorrow's expected is
• Next months must have

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Clinical Microsystems

• Gain customer knowledge through
• Observation through my customers eyes
• Survey
• Interviews

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Clinical Microsystems

• Measurement
• Need real time data
• Can use feedback reports
• Patient value compass
• Balanced scorecard
• Data walls

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Linking Microsystems

• Two types of linking
• Microsystem to Microsystem
• Microsystem to Macrosystem

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Linking Microsystems

• Use the Generative Relationship STAR
• Separateness or differences
• Tuning--talking and listening opportunities
• Action opportunities
• Reason to work together

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Linking Microsystems

• low

S

high
low
low
T
R
high
high
low
low
high
A
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Microsystems and Safety

• Principles to embed safety concepts into
  microsystems
• Errors are human nature and will happen
• Microsystem is the unit of training and analysis
• Design system to identify, absorb, and mitigate
  errors
• Create a culture of safety
• Talk and listen to patients

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Microsystems and Safety

• Integrate practices from human factors
  engineering into microsystem functioning
• See handout--linkage of microsystem
  characteristics to patient safety and what this
  might mean for safety

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Clinical Microsystems

• Now we have looked at our problems
• Our knowledge
• Our customers
• External parties
• How do we fix the microsystem?

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Fixing the Microsystem

• Start with an aim statement
• State aim clearly
• Use numerical goals
• Set stretch goals
• Avoid aim drift
• Be prepared to fully change aim statement if
  necessary

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Fixing the Microsystem

• Meetings (just to remember)
• Facilitator
• Timekeeper
• Recorder
• Ground Rules!!!

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Fixing the Microsystem

• This will sound familiar
• PDSA
• Worksheet for Testing Change

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Fixing the Microsystem

• Other tools for the team
• Fishbone (cause and effect)
• Flowcharts (process mapping)
• Deployment Flowcharts (actions across roles)
• Value Stream Mapping ( activities you must do to
  deliver a service to patients)

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Fixing the Microsystem

• Change concepts--ideas that lead to improvement
• You cannot use change concepts as a substitute
  for thinking though your process and your
  problems with that process

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Fixing the Microsystem

• Eliminate waste
• Improve workflow
• Optimize inventory
• Change the work environment
• Enhance the producer/customer relationship
• Manage time
• Manage variation
• Design system to avoid mistakes
• Focus on product or service

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Fixing the Microsystem

• Mental models--another tool
• Images, assumptions and stories we carry in our
  minds--of ourselves, other people, institutions,
  and every aspect of the world
• All, by definition, are flawed in some way
• They shape how we act
• Use tacit knowledge, below the surface of
  awareness

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Fixing the Microsystem

• How to bring these to the surface?
• Six thinking hats
• Ladder of inference

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Exercise

• Ladder of inference

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Performance Patterns

• Again, the familiar
• Run/trend charts
• Control charts
• Pareto charts

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Designing Real Change and Innovation

• Some assumptions about change
• Intentional change benefits from subject and
  improvement knowledge
• Getting good at designing and executing change
  involves a combination of knowing, doing, and
  reflecting
• A great deal is known about change that we can
  learn and apply

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Designing Real Change and Innovation

• Any change program will do -- IF
• It animates people and gets them moving
• Provides direction
• Encourages updating and closer awareness to
  whats really happening
• Facilitates respectful interaction

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Kotters 8 Steps

• 8 steps to transforming your organization
• Sense of urgency
• Creating the guiding coalition
• Create vision and strategy
• Communicate the vision and strategy
• Empowered broad-based action
• Generate short term wins
• Consolidate gains and produce more change
• Anchor new approaches in culture

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Publication No. 8001-OH-066-3/2006. This
material was prepared by Ohio KePRO, the Medicare
Quality Improvement Organization for Ohio, under
contract with the Centers for Medicare Medicaid
Services (CMS), an agency of the U. S. Department
of Health and Human Services. The contents
presented do not necessarily reflect CMS policy.