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Micro-Systems in Health Care: Essential Building Blocks for the Successful Delivery of Health Care in the 21st Century

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Title: Micro-Systems in Health Care: Essential Building Blocks for the Successful Delivery of Health Care in the 21st Century


1
Micro-Systems in Health Care Essential Building
Blocks for the Successful Delivery of Health Care
in the 21st Century
  • Thomas P Huber, MS ECS
  • September 18 25, 2006

Presentation to CCHA/CCS NICU Improvement
Project
2
Aim of Presentation
  • Introduce the Clinical Microsystem Improvement
    Framework as a way of continually improving unit
    performance as well as enhance your understanding
    of quality improvement methods, theories, tools,
    and techniques.

3
AGENDA
  1. A Brief Introduction
  2. So . . . Whats a Microsystem?
  3. Dartmouth - RWJ Study on Microsystems
  4. The Clinical Microsystem Action Guide the 5 Ps
    Framework
  5. Improvement Tools, Advising Approach, and some
    key Learning's over the years!

4
So . . . Whats a Microsystem
  • Definition
  • A Picture View
  • Examples
  • Shreks Onion Persective of Microsystems
  • The Current Reality Problem

5
Definition
A micro-system in health care delivery can be
defined as 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,
shared information environment and produces
performance outcomes. They evolve over time and
are (often) embedded in larger organizations.
6
(No Transcript)
7
Microsystems are the building blocks that come
together to form Macro-organizations
  • Walk around in a health delivery system with
    microsystem glasses what might you find?
  • An Emergency Care Center
  • Asthma and Allergy Clinic
  • Day Surgery Center
  • A Nutrition Clinic
  • A Neonatal Intensive Care Unit

8
The Onion Perspective on Levels of Quality
Improvement!
Community, Market, Social Policy System
Self-care System
Macro-organization System
Micro-system
Individual care-giver patient System
9
The Current Reality Problem
10
When we connect things that dont match...
The Economist
11
Dartmouth - RWJ Foundation Microsystem Study
(2000 - 2003)
Joint Commission Journal Article in your Packet.
  • The search for 20 high performing microsystems
  • How we studied and worked with the microsystems
  • A few Examples of Excellence
  • The Results The 10 Success Characteristics of
    high performing microsystems the 5 P Framework

12
The Search for High Performance?Dartmouth-RWJ
Study Batalden, Nelson, Huber, Mohr, Wasson,
Headrick. 2000 - 2003
  • Identified 250 high performing healthcare
    microsystems via a multi-stratified approach.
  • Screen 75 microsystems using (MS Assessment Tool
    and 30-Min Telephone Semi-Structured Interview
    (Q, , and Process).
  • Selected 20 microsystems across the healthcare
    spectrum Ambulatory, Inpatient, Nursing Homes,
    and Home Health.

13
The 20 Finalists
  • Inpatient Care and Same Day Surgery
  • Henry Ford-NICU, Detroit, MI
  • IHC Shock Trauma Unit, Salt Lake City, UT
  • Shouldice Hospital, Hernia Repair, Toronto,
    Canada
  • Mayo Luther-Midelfort, Behavioral Health, Eau
    Claire, WI
  • Nursing Home and Hospice Care
  • On Lok SeniorHealth, San Fran, CA
  • Iowa Veterans Home, Marshaltown, IA
  • Bon Secours Maria Manor Nursing Center,
    St.Petersburg, FL
  • Hospice of Iowa, Mason City, IA
  • Home Health Care
  • Gentiva, Rehab without Walls, East Lansing, MI
  • Visiting Nursing Service of NYC,
  • New York, NY
  • Interim Healthcare, Pittsburgh, PA
  • Ambulatory Care (Primary)
  • MacroMedical MGH, Boston, MA
  • Norumbega Medical, Bangor, ME
  • ThedaCare Family Practice,
  • Kimberly, WI
  • Grace Hill CHC, St. Louis, MO
  • Ambulatory Care (Specialty)
  • Intermountain Ortho, Boise, ID
  • Overlook Hospital Emergency Department, Summit,
    NJ
  • Sharpe Diabetes Center, San Diego, CA
  • Spine Center, DHMC, Lebanon, NH
  • Washington Cancer Institute, Orthopedic Oncology,
    Washington, DC

14
How good is good? a few results.
  • Mass General Hospital Primary Care
  • Waiting Room time how many minutes?
  • Shouldice Hernia Hospital
  • OR turnaround how many minutes?
  • Disposable costs per operation?

8 Minutes or the Co-Pay is waived
1 Minute and 30 Seconds versus 90 min
17. 50 versus national average 500
15
Study Results
  • 10 Success Characteristics of High Performing
    Clinical Units
  • Step 1 Review Handout and complete the
    Microsystem Assessment
  • The 5 Ps Purpose, Patients, Professionals,
    Processes, and Patterns
  • Step 2 Review document and work on
    Professionals and Process Handout

16
We found 10 Success Characteristics that are
associated with high performance
  1. Strong Leadership
  2. Great Organizational Support
  3. Focus on Staff (Professionals)
  4. Education and Training of Staff
  5. Interdependence of Care Team
  6. Performance Result Focused
  7. Process Improvement Focused
  8. Patient-Centered (Patient Focus)
  9. Community and Market Focus
  10. Information Information Technology Orientation




17
Clinical Microsystem Assessment Exercise
  • Instruction each of the 10 success
    characteristics (e.g., leadership) is crucial
    for high performance. Below each of the
    characteristics is defined and is followed by a
    ranking from 1 5 (low high) as well as 3
    descriptions (low high performance). For each
    characteristic please circle a number 1 5 that
    best describes your current Microsystem.
  • 1. Leadership The role of leaders is to balance
    setting and reaching collective goals, and to
    empower individual autonomy and accountability,
    through building knowledge, respectful action,
    reviewing and reflecting.
  • 1 2 3 4
    5




Leaders often tell me how to do my job and leave little room for innovation and autonomy. Overall, they dont always foster a positive culture. Leaders struggle to find the right balance between reaching performance goals and supporting and empowering the staff. Leaders maintain constancy of purpose, establish clear goals and expectations, and foster a respectful positive culture. Leaders take time to build knowledge, review and reflect, and take positive action in the Microsystem and the larger organization
18
The 5 Ps of Micro-systems include ...
  • Purpose - Our aim and mission.
  • Patients - Our reason for doing our work.
  • Professionals - Our staff who work in the
    trenches to take care of patients.
  • Processes - Our system of inter-related events
    that constitute the microsystem.
  • Patterns - Our way of doing our work
    (Measurements, Data, Run Charts)

19
Purpose
Processes
Patients
Patterns
Professionals
20
The 5 Ps of Micro-systems include ... Purpose
  • The purpose is our aim and mission What are we
    trying to accomplish?
  • An explicit statement summarizing what is
    expected to be achieved from the improvement
    initiative.
  • Helps to maintain focus on a specific opportunity
    or problem during the project.
  • Helps to identify appropriate members of the
    improvement team.

Pgs 103, 104 in Action Guide
21
The 5 Ps of Micro-systems include ... Patients
  • Patients are the reason for doing our work.
  • What is the target population age distribution?
  • Ave. Length of Stay?
  • Mortality Rate?
  • List your top 10 Diagnosis
  • Pt. Population Census
  • Additional patient information, ______________?
  • Family Surveys, Capturing patient information on
    an ongoing basis . . .

PGS 59 70 in Action Guide
22
The 5 Ps of Micro-systems include ... People
(Professionals)
  • Professionals - Our staff who work in the
    trenches to take care of patients.
  • Complete the Handout Pgs 11 15, including
  • Who is part of your team, list out staff and FTE
  • Complete Staff Satisfaction Survey
  • Complete Inpatient Unit Personal Skills
    Assessment
  • Complete Inpatient Unit Activity Survey Sheet

23
The 5 Ps of Micro-systems include ... Processes
  • Processes - Our system of inter-related events
    that constitute the microsystem.
  • Inpatient Unit Patient Cycle time, Handout Pgs.
    16
  • Inpatient Unit Know Your Process - Core and
    Supporting Processes, Handout pg. 17
  • Flowchart core process related to nosocomial
    infections

See Handout Pgs 16,17 Action Guide Pgs. 116
122 (Detailed Overview of Flowcharting)
24
The 5 Ps of Micro-systems include ... Patterns
  • Patterns - Our way of doing our work
    (Measurements, Data, Run Charts)
  • Capture key clinical data related to nosocomial
    infections, and line infection rates
  • What measurements are being captured?
    Definitions, Data Owner, Current and Target
    Values, Action Plan and Process Owner

See Action Guide Pgs 70 - 82
25
Healthcare Improvement Tools and Our Advising
Approach
  • Tools in the Clinical MS Action Guide
  • MS Advising Approach
  • Key Learnings from Microsystem Work
  • A Concluding Remark

26
Microsystem Tools and Resources
  • A Clinical Microsystem Action Guide
    (www.clinicalmicrosystem.org) Tools and Resources
    - A Map for Improvement
  • (General) Clinical Microsystem Profiler, Pg 14
  • (Professionals) Practice Staff Profiler, (see
    handout)
  • (Process) PDSA, Plan Do Study Act, Pg. 112 - 114
  • (Patients) Patient Flowcharting, Pg. 15
  • (Big Picture) Clinical Microsystem Picture, Pg.
    22
  • (Patterns) Performance Patterns Measurement and
    Monitoring, Pgs 70 - 82
  • (Process) Fishbone Diagrams, Pgs 115 - 116
  • (Big Picture) Clinical Microsystem Assessment
    Tool, Pgs 16 - 19
  • (Safety) External Environment, Health
    Professional Education Pgs 102, 103
  • (Purpose) Aim Statement, Vision and Mission
    Journal, Pg 103, 104
  • (Professionals) Meeting Agenda Graphic, Pgs. 103
    - 109

27
Microsystem Advising Approach
  • The Clinical Microsystem Action Guide along with
    years of accumulated knowledge in CQI projects
    creates a ROADMAP for improving care at the Unit
    Level.
  • Phase 1 Build MS Awareness via Assessment
    Diagnostic Tools
  • Complete Microsystem Assessment Tool.
  • Pick Options in action guide, which Tools to
    use, set goals (What, Who, and How of project).
  • Phase 2 Gather Data, Flowcharting Mapping
    Processes
  • Do a site visit interviews, and capture key
    Q, , Process Measures.
  • Patient IT Flowcharting, Small work group
    meetings.
  • Foster MS Improvement Culture.

28
Microsystem Advising Approach
  • The Clinical Microsystem Action Guide along with
    years of accumulated knowledge in CQI projects
    creates a ROADMAP for improving care at the Unit
    Level.
  • Phase 3 Data Crunch, Analyze Q, , Process
    Measures
  • Crunch and analyze the data (project specific
    measures).
  • KEEP ENERGY HIGH for project, support support
    support!
  • Provide on-going feedback of measures (Patterns).
  • Phase 4 Finish Work, Present Outcomes, Work on
    Spread
  • Congratulate and Celebrate Successes.
  • Review what we learned, provide feedback, and
    document changes.
  • Plan for next phase (Intra-Unit and Inter-Unit
    Spread), Utilize High Energy from project for
    spread.

29
Learning from Eight Years of Microsystem and CQI
Work
  • IHI workshops, symposium, teaching, and training
  • Microsystem assessments, and CQI work at various
    Clinics
  • Culture Redesign e.g., NICU Dartmouth Lahey
    Hospital
  • Strong Vision and Mission is needed - at the unit
    level (Purpose). We need strong local and senior
    leadership for real change to happen.
  • Do interviews, gather objective data, manage the
    process, be alert for hidden gems (LHF). Work at
    the microsystem level for effective lasting
    change .
  • Include the right staff, facilitate conversation,
    be open to surprises. Emphasize fluidity and
    flexibility during the spread of change.

30
Learning from Eight Years of Microsystem and CQI
Work
  • Redesign, IT Infrastructure, Change Management
    27 Kaiser Intensive Care Units
  • Patient and Information Flow (lean thinking)
    e.g., Keene Clinic Redesign
  • Technology Adoption UCSF - Stanford Hospitals
  • The Planning Phase is crucial in PDSA, and
    critical for HER. First map the processes then
    implement the HER.
  • Mapping processes creates energy, highlights
    areas for change, and gets staff buy-in. Having
    an outside support person is helpful in lean
    thinking mapping.
  • Work with underlying (hidden) agendas to make
    changes. Use the creativity of the
    Professionals(they know what needs to be done).

31
Concluding Remark
  • Healthcare organizations might not be
    utilizing the term micro-system, but it is clear
    that many high quality and cost-efficient
    providers are organizing themselves around
    functional front-line teams professionals that
    have the right information at the right time, to
    deliver the best care possible.

32
Questions and Comments
33
If you want to learn more . . .
  • References
  • Thomas P. Huber, M.S. Paul B. Batalden, M.D.
    Eugene C. Nelson, D.Sc., M.P.H. Marjorie M.
    Godfrey, M.S., R.N. Microsystems in Health
    Care Developing People and Improving Work Life
    What Frontline Staff Told Us. The Joint
    Commission Journal on Quality Improvement,
    October 2003, Volume 29 Number 10.
  • Eugene C. Nelson, D.Sc., M.P.H. Paul B.
    Batalden, M.D. Karen Homa, MS Marjorie Godfrey,
    MS RN Christine Campbell Linda Headrick, MD,
    MS, Thomas Huber, MS Julie Mohr MSPH, PhD John
    Wasson, MD Microsystems in Health Care
    Creating a Rich Information Environment. The
    Joint Commission Journal on Quality Improvement,
    January 2003, Volume 29.
  • Eugene C. Nelson, D.Sc., M.P.H. Paul B.
    Batalden, M.D. Thomas P. Huber, M.S. Marjorie
    M. Godfrey, M.S., R.N. Linda A. Headrick, M.D.
    Julie J. Mohr, Ph.D. M.S.P.H. John H. Wasson,
    M.D. Microsystems in Health Care Learning
    from High-Performing Front-Line Clinical Units.
    The Joint Commission Journal on Quality
    Improvement, September 2002, Volume 28.
  • Godfrey M, Wasson J, Nelson E, Batalden P, Mohr
    J, Huber T, Headrick L. Clinical Microsystem
    Action Guide Improving Health Care by Improving
    Your Microsystem, Version 1.1 November 2001.
  • Clinical Microsystems provides an on-line version
    of the Clinical Action Guide. Hanover, NH Health
    Care Improvement and Leadership Development at
    Dartmouth College. (See Clinicalmicrosystems.org)

34
If you want to learn more . . .
  • References
  • Langley GJ, et al. The Improvement Guide - A
    Practical Approach to Enhancing Organizational
    Performance. San Francisco Jossey-Bass, 1996
  • Nelson EC, Batalden PB, Ryer J Clinical
    Improvement Action Guide, JCAHO, Oak Brook
    Terrace, IL, 1998.
  • Nelson EC, Wasson JH "Using Patient-Based
    Information to Rapidly Redesign Care,"
    Healthcare Forum Journal, 37(4)25-29,
    July/August 1994.
  • Quinn JB Intelligent Enterprise A Knowledge
    and Service Based Paradigm for Industry. New
    York, NY The Free Press, 1992.
  • Rother M, Shook J Learning to See Value Stream
    Mapping to Add Value and Eliminate Muda.
    Brookline, MA Lean Enterprise Institute, 1999.
  • Nelson EC, Splaine ME, Godfrey MM, Kahn V, Hess
    AR, Batalden PB, Plume SK Using Data to Improve
    Medical Practice by Measuring Processes and
    Outcomes of Care. Joint Commission Journal on
    Quality Improvement, 26(12)667-685, December
    2000.
  • Nelson EC, Batalden PB Knowledge for
    Improvement Improving Quality in the
    Micro-systems of Care. In Goldfield N , Nash
    DB, eds. Managing Quality of Care in Cost-Focused
    Environment. Tampa, FL Aspen Publishers
    199975-87.

35
If you want to learn more . . .
  • References
  • Nelson EC, Batalden PB, Mohr JJ, Plume SK
    Building A Quality Future. Frontiers of Health
    Services Management, 15(1)3-32, Fall 1998.
  • Batalden PB, Mohr JJ, Nelson EC, et al.
    Continually Improving the Health and Value of
    Healthcare for a Population of Patients The
    Panel Management Process. Quality Management in
    Healthcare, 5(3)41-51, Spring 1997.
  • 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.
  • Nelson EC, Batalden PB, Plume SK, Mihevc NT,
    Swartz WG Report Cards or Instrument Panels Who
    Needs What? The Joint Commission Journal on
    Quality Improvement, 21(4)155-166, April 1995.
  • 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.
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