What Does a Deployment Flowchart Look Like

A deployment flowchart shows the process flow in relation to the people or groups involved in each step (see Figure 17.5). This type of flowchart shows how people fit into the process sequence and how they relate to one another. Deployment flowcharts highlight places in a process where work moves from one group or person to another and reveals how groups or individuals relate to one another throughout the process. The deployment flowchart is particularly useful when the goal is to optimize...

Why Use Meeting Skills and Roles

Members of a frontline clinical unit have limited amounts of time for holding meetings and being involved in the improvement of their microsystem. Without discipline, meetings can be disorganized, have limited member participation, end without having set clear next steps, and be perceived as a waste of time. Identifying common meeting roles helps members of the interdisciplinary team become more aware of their work together and more skilled in essential meeting tasks. It is...

What Are Effective Meeting Roles

The four essential meeting roles are The leader of the meeting prepares the agenda, helps the group move through the agenda, and elicits participation from all members. The team's formal leader does not necessarily hold this role all the time because the real purpose of the role is to guide the team through a planned agenda. The meeting leader is also a group member and contributes ideas, interprets data, and participates with other members in making team decisions. The timekeeper works to keep...

Acknowledgments

We are indebted to many wonderful people and outstanding organizations that helped make this book possible. Although it is impossible to recognize everyone who contributed to this endeavor, we would like to make mention of some individuals and organizations that merit special attention, and we ask forgiveness from those that we should have mentioned but somehow overlooked. This book was inspired by the groundbreaking scholarship of James Brian Quinn, professor emeritus at Dartmouth's Tuck...

What Are Some Tips for Using the PDSA o SDSA Method

Always start with a specific aim statement. Answer the question, What are we trying to accomplish The question, How will we know if this is an improvement can only be answered with data. Small tests of change done in short periods of time accelerate learning and pave the way to rapid improvement. For example Sample every other patient or process Designate someone to oversee the test and be the ears, eyes, and support to those engaged in it. Offer participants the opportunity to...

What Does a Microsystems Developmental Journey Look Like

Some move from a relatively low level of self-awareness to a high level of awareness and functional capability by taking several steps that can be thought of as a journey (as represented graphically in Figure 11.5). A frontline unit's awareness that it is a microsystem often begins with an external provocation. Someone might ask a staff member, Could you draw me a picture of how your microsystem works, or, Could you help me understand the flow of daily activities...

Three Fundamental Processes of Leading What Clinical Microsystem Team Members Observe and Report

Through observing and listening to leaders at work, three fundamental processes of leading can be recognized (1) building knowledge, (2) taking action, and (3) reviewing and reflecting (Batalden & Splaine, 2002). As described in this chapter, employing helpful tools, such as those found in the second section and the Appendix of this book (and at http www.clinicalmicrosystem.org), can increase a leader's knowledge of a microsystem in an organized fashion. The comments of the individuals we...

How Do You Maintain Your Playbook

Playbooks evolve over time as you test processes and identify new best practices. It is important to refresh your playbook at predetermined intervals and when improvement cycles are done. Not only should the playbook be refreshed but critical review of the SDSA processes over time will often identify the need to move from SDSA back to PDSA, because of new knowledge, new equipment, or new technology. A key principle of the PDSA SDSA method is the notion that ongoing improvement work shifts back...

Conclusion

Patients and payers demand better quality, better safety, and better value for their money. This pressure will likely intensify, which generates the widespread need to transform health systems, which in turn requires excellent leadership at all levels of the system the macro-, meso-, and microlevels. System thinking at all levels can help leaders make this transformation. Using the image of the inverted pyramid, which places patients and frontline staff at the apex of the pyramid, leaders can...

References

Dictionary of word origins (1st U.S. ed.). New York Arcade. Barnhart, R. (2000). Dictionary of etymology. New York Chambers. Batalden, P., & Leach, D. C. (2005). The inner and outer life in medicine. In S. M. Intrator (Ed.), Living the questions Essays inspired by the work and life of Parker J. Palmer (pp. 210-217). San Francisco Jossey-Bass. Batalden, P., & Splaine, M. (2002). What will it take to lead the continual improvement and innovation of health care in the 21st...

Follow Through On Improvement

Storyboards, Data Walls, and Playbooks Aim. To make plans to tell the improvement story, measure progress over time, and sustain improvement using standard processes. Objectives. At the completion of this unit, you will be able to Describe the improvement fundamentals needed to maintain and sustain improvement. Identify where improvement data can be posted for viewing by all microsystem members to increase their knowledge about purpose, progress, and priorities. Design a microsystem playbook...

Why Use a Fishbone Diagram

The fishbone diagram is an important scientific tool used to identify and clarify the causes of an effect of interest. When lead improvement team members construct such a diagram, it allows them to build a visual theory about potential causes and effects that can be used to guide improvement work. The fishbone diagram can stimulate the formation of hunches worth empirically testing, using plan-do-study-act (PDSA) cycles. In addition, the fishbone diagram promotes a disciplined use of major...

How Do You Make a Run Chart

You may find it helpful to use a data collection tool for making run charts and control charts (see Figure 22.5). Here are some general steps for making a run chart. 1. Select a measure that can answer a critical question. 2. Document your operational definition to explain the details of how you will collect data on the measure. 3. Make a plan (who does what, when, in following which process) to collect data on the measure at set intervals, such as hourly, daily, weekly, or monthly. 4. Collect...

Figure 23 Icn Median Cost Per Infant Admitted In 19961997 Intensive Care Nursery

80,000 70,000 60,000 S0,000 40,000 B0,000 20,000 10,000 0 11 1B 15 17 19 21 2B 25 27 29 31 Site Median at your hospital Median across institutions Note The geographical adjustment adjusts for area differences in input prices that is, cost for each hospital is measured as though that hospital faced average U.S. input prices. related discharge criteria, and management of infants' transitions to oral feeding. These and other subsequent changes (for example, reducing unnecessary diagnostic tests,...

What Are the Benefits of Using PDSA

The focus of PDSA is experimentation such as testing out new change ideas to PDSA offers a disciplined model for testing improvements based on four steps plan, do, study, act. All too often ideas for change are acted on without detailed planning and organization. There is a saying, The devil is in the details. The discipline of PDSA will help you think through and plan for the devilish details of the idea you wish to test. Using this approach will increase your chances of successfully and...

Figure A10 Primary Care Practice Patient Cycle Time

Scheduled Appointment Time Provider You Are Seeing Today Time staff member left you in the exam room. Review, adapt and distribute the following Core and Supporting Processes evaluation form (Figure A.11) to all practice staff. Be sure the processes list on the form is accurate for your practice and then ask staff to evaluate the current state of these processes. Rate each process by putting a tally mark under the column heading that most closely matches your overall understanding of the...

How Do You Interpret Control Chart Results

As we mentioned earlier, you can interpret your control chart results using the same approach used for run charts except that now you have another way to identify possible special cause signals in your data. You will know you have a likely special cause signal when one or more points fall outside the upper or lower control limits. Figures 22.13, 22.14, and 22.15 illustrate special cause signals occurring in control charts. FIGURE 22.13. SPECIAL CAUSE SIGNAL EIGHT CONSECUTIVE POINTS ON SAME SIDE...

Leadership Frameworks Some of the Best Approaches

Most successful macrosystem leaders know that the patient care their system provides is only as good as the clinical microsystems that make the care. Macrosystem leaders help create the environment inside the organization that enables, or diminishes, the work of the mesosystems and microsystems. Macrosystem leaders know that improvement means change. What is the work of senior leaders and how might it be done Many general leadership frameworks have been developed and popularized. Some of them...

Low Tech Example for Ambulatory Services CARE Vital Signs

The technology-rich microsystem examples of the Spine Center, STRICU, Norumbega, and On Lok might support the myth that advanced information systems are a prerequisite for excellent patient-centered care. We now describe a process called CARE Vital Signs to illustrate how microsystem services and staff resources can improve their matching with ambulatory patient needs without employing expensive technology. CARE is an acronym for Check, Activate, Reinforced, Engineering. Each column signals...

Planning Patientcentered Care

Godfrey, Eugene C. Nelson, Julie K. Johnson, Paul B. Batalden Background. Clinical microsystems are the essential building blocks of all health systems. At the heart of an effective microsystem is a productive interaction between an informed, activated patient and a prepared, proactive practice staff. Support, which increases the patient's ability for self-management, is an essential result of a productive interaction. This chapter describes how high-performing...

Huddle in Plastic Surgery

During the IHI IDCOP collaborative, many primary care practices adapted the military crew resource management concept of huddles to their own practice to take advantage of the benefits of huddles, such as preplanning for the day and review of roles, processes, and updates, to name a few benefits. The design of the huddle was adapted from the IDCOP (idealized design of clinical office practices) literature on primary care huddles and the benefits of huddles to the practice and patients. Drawing...

Case Studies

Intermediate Cardiac Care Unit (ICCU) The ICCU's lead improvement team brainstormed ideas on where to focus improvement. Once the team members had all contributed their ideas, they multi-voted, which led them to a decision to focus on morning rounds. They learned FIGURE 21.2. CHANGE CONCEPTS APPLIED TO A CLINICAL PROCESS. FIGURE 21.2. CHANGE CONCEPTS APPLIED TO A CLINICAL PROCESS. that morning rounds were not interdisciplinary and that the clinical team often did not know the specific care...

Analysis and Improvement of Processes

A general internal medicine practice analyzed current processes and identified improvements that could lead to better efficiencies and reductions in waste. Every member of the practice including physicians, nurse practitioners, nurses, and secretaries completed the Practice Core and Supporting Processes Assessment (Table 6.3). This revealed that the diagnostic test reporting process needed to be improved by shortening the time taken to report results to providers and patients. After...

How Do Run Charts Fit in the Overall Improvement Process

As represented in the improvement ramp (Figure 22.1), one place that run charts fit into the overall improvement process is to show if the changes being made are causing an aim-related outcome measure to move into the targeted zone of success. Consequently, as soon as a general aim is established it is important to find a way to measure current performance of a measure related to that aim and to track movement in this measure over time as changes are planned and executed. What you want to do is...

What Does a Completed Fishbone Look Like

Figure 19.4 is a fishbone diagram that shows many of the factors that contribute to the undesirable result of medical appointments that last much longer than needed. The main causal categories are people, equipment, materials, environment, and process. The details within each category reflect why the category is a FIGURE 19.4. FISHBONE DIAGRAM SHOWING CAUSES OF LENGTHY APPOINTMENTS. No one responsible for patient flow Support staff not trained Patients arrive with more needs than originally...

What Is Multi Voting

Multi-voting is a method that engages all members of the team in agreeing on the best ideas to focus the improvement work on. It involves voting to reduce the idea list generated during a brainstorming session to the top choices. This is accomplished through a series of votes, each round of voting reducing the list and finally resulting in a consensus on a few top ideas to focus on next. The word consensus comes from a Latin verb meaning to share thoughts and feelings. Consensus does not mean...

Bolman and Deal

Lee Bolman and Terrence Deal (2003) assert that macrosystem leaders should begin their jobs by recognizing the uncertain and ambiguous nature of work today. Leaders must take a flexible approach to learning and taking action. They invite attention to the critical skill of framing and reframing work. Bolman and Deal use four frameworks structure, human resource, political, and symbolic to illustrate different ways of leading. Each framework has a unique set of assumptions, and each offers...

How Do You Make a Storyboard

There are many ways to construct a storyboard. You can make one the old-fashioned way, using boards and graphics and pictures on paper. Increasingly, however, people are choosing to use Microsoft PowerPoint to create a storyboard as a PowerPoint slide, and then to print that slide as a poster, using a large format printer. This method allows you to import data and other graphics directly into PowerPoint and to create the poster without rework. Materials often used for a storyboard include Foam...

Figure A1 Microsystem Assessment Of Data Sources And Data Collection Actions Continued

Data Source or Data Collection Action Personal skills assessment (Figure A.8) Patient cycle time tool (Figure A.10) Core and supporting processes (Figure A.11) Most significant pattern (Figure A.2) Unplanned activity tracking card (Figure A.12) Telephone tracking log (Figure A.13)

Figure Ai Microsystem Assessment Of Data Sources And Data Collection Actions

Data Source or Data Collection Action Estimated age distribution of patients (Figure A.2) Estimated number of unique patients in practice (Figure A.2) Disease-specific health outcomes (Figure A.2) Top diagnoses and conditions (Figure A.2) Patients who frequent practice (Figure A.2) Patient satisfaction scores (Figures A.2) Patient point of service survey (Figure A.3) Patient viewpoint survey (Figure A.4) Care for chronic conditions survey (Figure A.6) Patient population census (Figure A.2)...

Figure A12 Primary Care Practice Unplanned Activity Tracking Card

Place a tally mark (1) for each occurrence of an unplanned activity Place a tally mark (I) for each occurrence of an unplanned activity Patterns can be found through tracking the volumes and types of telephone calls. Review the categories on the telephone tracking log (see Figure A. 13) adapt them if necessary to ensure they reflect the general categories of calls your practice receives. Then ask clerical staff to track the telephone calls over the course of a week to find the patterns for each...

Case Study Planning Services for Subpopulations of Patients to Best Provide Care for Individual Patients

One clinical microsystem, Evergreen Woods, a primary care practice that is part of Norumbega Medical in Bangor, Maine, has been evolving for more than a decade to plan for the future by designing services that are there on demand to provide outstanding care for individual patients when they need it. When a patient calls the office with a medical problem, a patient representative triages him or her using the Triage Coupler. This software program is driven by protocols that can handle a broad...

Cecs

Center for the Evaluative Clinical Sciences at Dartmouth Copyright 2007 by The Health Care Improvement Leadership Development Program. All rights reserved. Published by Jossey-Bass A Wiley Imprint 989 Market Street, San Francisco, CA 94103-1741 www.josseybass.com No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or...

Microsystem Patient Safety Scenario

Figure 8.1 illustrates a hypothetical scenario that volume authors Julie K.Johnson and Paul Barach have used to connect patient safety principles with clinical microsystems thinking. In this scenario the patient is Allison, a five-year-old preschooler with a history of wheezy colds. As we follow the scenario, it is clear that Allison and her mother interact with several microsystems as they navigate the health care system in an attempt to address Allison's illness the hypothetical...

How Do You Create a Playbook

Once you have completed testing changes to a process, you can create the final (SDSA) version of how that process should be executed all the time. It is usually best to use a deployment flowchart to show what actions should be taken by whom and in what order. In addition to flowchart(s), the playbook can include tools that support the process, such as Blank forms such as huddle sheets and report forms Pictures of how to complete a process There are three basic steps to making a playbook 1....

What Is an Action Plan

An action plan is a list of tasks specific to the next steps that need to be completed to achieve your stated improvement goals. The action plan is a simple, helpful organizing tool to keep improvement activities on track over time. It is often created at the end of the weekly improvement meeting to ensure that all the steps that need to be completed before the next meeting are achieved and to document additional action steps and timelines. The action plan changes weekly and is updated as tasks...

What Are the Theme Selection Considerations

To develop ideas for worthy themes, take into consideration Your 5 P's assessment data and information Your performance metrics and gaps between your results and best-practice results Your staff views of what is intolerable in daily practice Your patient and family views of what is delightful and what is unacceptable in the delivery of care and services Your organization's strategic goals and priorities Aligning your microsystem's improvement themes with the macrosystem's strategic priorities...

What Are Some Tips for Creating a Deployment Flowchart

Start by drawing a table with columns for the people, roles, or groups that the process flows through. Enter the name of a person, role, or group at the top of each column. After you have created the table, insert the sequential flowchart steps to show which person, role, or group is responsible for which action. The horizontal lines define internal customer-supplier relationships. Correct identification of these FIGURE 17.5. SECTION OF DEPLOYMENT FLOWCHART FOR ENROLLMENT IN OUTPATIENT CYSTIC...

Step 4 Treat Your Primary Care Practice

Draft a specific aim statement and a way to measure that aim using improvement models PDSA (plan-do-study-act) and SDSA (standardize-do-study-act). Now that you've made your diagnosis and selected a theme worthy of improving, you are ready to begin using powerful change ideas, improvement tools, and the scientific method to change your microsystem. This change begins with clearly identifying a specific aim and using the plan-do-study-act (PDSA) method, which is known as the modelfor...

Specific Examples of Success Characteristics

The site interviews provide many varied and rich examples of the ways that the primary success characteristics manifest themselves in these clinical microsystems. Table 1.2 provides some examples from the original interview notes for each of the primary success characteristics. For example, here is a typical statement revealing patient focus At first you think you would miss the big cases that you had at a general hospital, and you do at first, but then after a while you realize they were just...

Tables Figures And Exhibits

1.1 Scope of Primary Success Characteristics and Illustrative Underlying Principles 22 1.2 Specific Examples of the Primary Success Characteristics 24 1.3 Illustrative Best Practices Used by High-Performing Clinical Microsystems 27 3.1 Building Knowledge in Clinical Microsystems Views on Leading Quoted from Our Interviews 55 3.2 Taking Action in Clinical Microsystems Views on Leading Quoted from Our Interviews 59 3.3 Reviewing and Reflecting in Clinical Microsystems Views on Leading Quoted from...

What Are the Benefits of Using a Control Chart Instead of a Run Chart

The primary benefit of using a control chart is that it provides another guideline for identifying special cause signals. When you see a run chart, you will often see a point that looks extremely high or extremely low relative to the other points. You might be tempted to say that something special is happening. But absent calculated control limits, it is not possible to know from the chart itself whether this apparently very high or very low point is likely to be due to chance variation or...

Review Questions

How would you describe a web of causation 3. What are the benefits of using cause and effect diagrams as an improvement tool 4. What is a common structure used to draw cause and effect diagrams 5. How do you make a fishbone diagram when you are in an improvement team 6. How might you engage all members of your microsystem in creating and FIGURE 19.6. FISHBONE DIAGRAM FOR PLASTIC SURGERY APPOINTMENT BACKLOG. FIGURE 19.6. FISHBONE DIAGRAM FOR PLASTIC SURGERY APPOINTMENT BACKLOG.

Step 3 Diagnose

With the interdisciplinary lead team review the microsystem's 5 P's assessment and metrics that matter. Also consider your organization's strategic plan. Then select a first theme, (for example, access, safety, flow, reliability, patient satisfaction, communication, prevention, or supply and demand) for improvement. The purpose of assessing is to make an informed and correct overall diagnosis of your microsystem. First, identify and celebrate the strengths of your system. Second, identify and...

What Is a Clinical Microsystem

A clinical microsystem is the place where patients, families, care teams, and information come together. Whenever and wherever there is a patient who is being cared for by a clinician or a clinical team, there is a microsystem with that patient at its center. It is the place where quality, safety, outcomes, satisfaction, and staff morale are created. You know it as a primary care practice, an emergency department, an inpatient unit, or an extended care facility. A microsystem also exists where...

What Are Some Tips for Creating a Fishbone Diagram

Review the specific aim that you want to work on. Clarify the effect. It is important that everyone involved is clear about the effect, or the outcome of interest, which can be stated as an undesired result (such as lengthy appointments) or as a desired result (such as a hypertensive patient whose blood pressure is under control) or as a neutral result (such as the amount of time it takes to place a patient ready to be discharged from the emergency department in an inpatient unit bed.)...

Using Real Case Studies and Practical Applications of Microsystem Thinking Methods and Tools

Throughout Part Two of this book we will provide two case examples of microsystems using the tools and methods introduced in each chapter. These cases will present concrete examples of the Dartmouth Microsystem Improvement Curriculum in action. One case study looks at a hospital inpatient unit an Intermediate Cardiac Care Unit and the second case study examines a busy ambulatory practice within a Section of Plastic Surgery. The progression of each group's lead improvement team through the tools...

What Are the Commonly Used Flowchart Symbols

Many of the symbols commonly used to make flowcharts are shown in Figure 17.2. The oval indicates the beginning point and the ending point of the process you are mapping. When you first start to make a flowchart of a process, it becomes very obvious why having a global aim statement with a clearly stated start point Connector (for example, to another page) and end point is fundamental to process improvement work. The beginning and the end of the process, as specified in this statement, define...

When Do You Recalculate Control Chart Values

As you start using control charts and run charts in your microsystem and as you measure processes and make changes that lead to improvement you will also need to know when to recalculate the values (the average value and the upper and lower control limits) on your control charts. For example, once you have ascended the improvement ramp and your microsystem has achieved a new level of performance, you should consider recalculating the center line and the control limits, using the new pattern of...

Effective Meeting Skills I

To identify concepts and methods for holding effective and productive meetings with a lead improvement team. Objectives. At the completion of this unit, you will be able to List the four common roles and functions for effective meetings. Describe the meeting process and the seven steps in the agenda template. List the work to be done before meetings. List the processes to be followed during meetings. Create a draft list of ground rules for your lead improvement team members to use when...

How Did Clinical Microsystem Knowledge Evolve

In the last decade of the twentieth century J. Brian Quinn, professor emeritus of the Amos Tuck School of Business Administration at Dartmouth College, spent years studying the most successful service companies in the world. He observed that the world's fastest-growing, most profitable, and most successful companies such as SAS, Nordstrom, Wal-Mart, McDonald's, and Intel progressively learned to focus on the frontline work in their service organizations and their smallest replicable units...

Figure A2 Primary Care Practice Profile

Purpose Why does your practice exist B. Know your patients. Take a close look into your practice create a high-level picture of the patient population that you serve. Who are they What resources do they use How do the patients view the care they receive B. Know your patients. Take a close look into your practice create a high-level picture of the patient population that you serve. Who are they What resources do they use How do the patients view the care they receive List Your Top 10...

Metrics That Matter

Measures are essential if microsystems are to make and sustain improvements and to attain high performance. All clinical microsystems are awash in data, but relatively few have the rich information environments that allow the daily, weekly, and monthly use of metrics that matter (MTM). The key to having all the data that you actually need is to get started in a practical, doable way and to build out your metrics that matter and their vital use over time. Some guidelines for your consideration...

The Model For Improvement

To understand and apply the model for improvement in conducting disciplined, sequential tests of change for the purpose of making measurable improvements that can be sustained. Objectives. At the completion of this unit, you will be able to Define the model for improvement. Describe the two components of the model for improvement. List the detailed steps of PDSA model. Develop a clear plan to test a change. Describe the point at which a PDSA cycle becomes a SDSA cycle. State where PDSA...

Tips and Principles to Foster a Rich Information Environment

The three cases reviewed in the first half of this chapter give rise to a set of useful tips for leaders who are guiding microsystems, mesosystems, and macrosystems in quests to provide great care (that is, care that meets patients' needs) and to minimize delays and unnecessary costs. These tips are listed in Table 9.1. In addition to the specific tips from the case studies, we have identified four principles concerning information, information technology, data, and performance results. These...

What Are the Next Steps

Once the statement of the global aim for improvement is written and you have checked that it aligns with the selected improvement theme, you and your team should create a high-level flowchart of the process you wish to improve. Be FIGURE 16.2. TEMPLATE FOR WRITING A GLOBAL AIM STATEMENT. Create your aim statement that will help keep your focus clear and your work productive. (Clinical location in which process is embedded) (Name the ending point of the process) By working on the process, we...

Creating A Rich Information Environment

Batalden, Karen Homa, Marjorie M. Godfrey, Christine Campbell, Linda A. Headrick, Thomas P. Huber, Julie K. Johnson, John H. Wasson Background. A rich information environment supports the functioning of the small, functional, frontline units the microsystems that provide most health care to most people. Three settings offer case examples of how clinical microsystems use data in everyday practice to provide high-quality and cost-effective care. Case studies. At the...

Case Study Dartmouth Hitchcock Pain Free Program

JH is a four-year-old white girl with a history of multiple congenital abnormalities. Most notably, she has had developmental delays, unusual facial appearance, and absence of the corpus callosum. She does not have an identifiable syndrome. At home on the day before admission, her mother noticed the onset of three generalized seizures, each seizure lasting ten minutes and terminating on its own. JH was admitted for further evaluation and a magnetic resonance imaging (MRI) scan. Because the MRI...

Why Use Change Concepts

Change concepts can help you clarify your thinking about where in a process a change can be made to result in substantive improvement. Change concepts are useful for jump-starting improvement ideas and offering new perspectives for change that you might not have considered previously. When you are ready to consider changes in a process, using change concepts can enrich your thinking and amplify idea generation. Change concepts have been popularized in two books The Improvement Action Guide A...

How Can You Use Change Concepts in a Process

Figure 21.2 provides a visual example of some ways that change concepts can be used to redesign care. This diagram is based on actual improvement work focusing on hip replacements. The interdisciplinary lead improvement team's aim was to achieve superior clinical and functional health status, satisfaction, and cost outcomes for this population. By first creating a flow diagram and studying the current process of care and then considering change concepts, the team was able to generate specific...

What Does a Meeting Agenda Template Look Like

A sample of a meeting template that you could adapt to your own situation is shown in Figure 12.2. Notice that the roles and meeting steps are listed on the agenda. Many groups complete this template for each meeting to remind themselves of appropriate meeting discipline. With repeated use of this template the meeting roles and process become a habit for the group. Interdisciplinary groups often report that using the meeting template feels awkward for the first few meetings but that with...

Primary Care Workbook

The Place Where Patients, Families and Careteams Meet Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice We have developed this workbook with tools to give ideas to those interested in improving health care. Dartmouth-Hitchcock Medical Center and the developers of this workbook are pleased to grant use of these materials without charge, providing that recognition is given for their development, that any alterations to the documents for local suitability and acceptance are...

Malcolm Baldrige National Quality Award

The framework of the Malcolm Baldrige National Quality Award and process (http www.quality.nist.gov) reflects how leaders create conditions across the macrosystem for continuing improvement of daily work. The Baldrige model makes assumptions about what elements are needed to attain excellence and uses an assessment framework with seven criteria for the design, deployment, and continuous improvement of the results of each element. Figure 4.4 illustrates the general model. Source Adapted from...

What Is the Theory Behind Control Charts

The term control chart is short for statistical process control (SPC) chart. What control charts reveal is whether observed variation in a process is consistent with random variation due to innumerable common causes. When variation occurs within control limits, the process is said to be in statis tical control, free from special cause effects or assignable cause variation. The process is subject only to chance factors or random cause variation. As mentioned earlier, calculated upper and lower...

P

Discipline and rhythm PainFree Program, 166, 170-172 Panoramic viewpoint, 76 Paradigm influence of a, 93 new, entering an era featuring a, 72 Parallel processing, 43, 45 Parking lots, 246, 293 Past performance, insight on, providing, 98 Path forward, the conclusion on, 381 continuing, invitation for, 382-383 focusing on the microsystem level in, 215-228 and lessons from the Esther Project, 212-214 overview of, 200 steps in, 388 using real case studies and practical applications for, 200-201...

Essential Change Strategies

Clinical Microsystems

Source Adapted from Bolman & Deal, 2003. senior leaders will find as they use each framework to address organizational change and the making of meaningful work. In the middle of the twentieth century Robert Greenleaf began leadership training under the auspices of AT& T. Over time he worked with many different organizations. In 1969, he gave a series of lectures at Dartmouth College that were to form the basis of his later work on servant leadership and his view of a leader who encourages...

What Is a Data Wall

A data wall is a clearly defined physical space where vital measures of performance can be posted on the wall for all members of the microsystem to review. The posted measures can reflect not only the microsystem's improvement work and performance metrics but also the work and metrics of the larger organization. Chapter Twenty-Two recommends identifying a data captain and building measurement into daily work. It is important to know who will own the data wall and keep it up to date and...

Figure A15 Pdsa Sdsa Worksheet Continued

Standardize Once you have determined this PDSA result to be the current best practice, take action to standardize, do, study, act (SDSA). You will create the conditions to ensure this best practice in daily activities until a new change is identified and then the SDSA moves back to the PDSA cycle to test the idea to then standardize again. 9. Trade-offs What are you not going to do anymore to support this new habit What has helped you in the past to change behavior and help you do the right...

Leading Macrosystems to Foster Strong Microsystems

Outstanding leaders of the large systems in which clinical microsystems are embedded, those who pay attention to the local leadership within discrete microsystems, can enhance the functioning of these microsystems. The way they select the microsystem leaders and help them develop contributes enormously to the total organization's well-being. Leaders of this quality were not always present in the large organizations that hosted the microsystems that were the subject of this research. Some of the...

Introduction

The health care system needs to work well for patients, each time a patient needs help and every time a patient needs help. The health care system needs to work for the professionals and other people who take care of patients, every day of their working life, so they can be proud of the services they provide to patients. In short we need a health care system that works right for patients, families, and staff. Not only this, we need a health care system that is capable of getting better all the...

Leading Large Health Systems to Peak Performance Using Microsystem Thinking

I prefer self-executing or self-implementing systems. Robert Galvin, former ceo of Motorola, personal communication to Paul Batalden, 1997. In this section we provide our own leadership framework for leaders of macrosystems and mesosystems. This framework is based on our reflections on the general leadership frameworks and on our own experiences in working with hundreds of health care leaders who wish to have all parts of their systems provide care that is excellent in quality, safety,...

Improvement Global

To create a global aim statement to focus the improvement work based on the theme the lead improvement team selected. Objectives. At the completion of this unit, you will be able to Identify the importance of the relationship between the global aim, the improvement process flow, and theme selection. Describe how to manage new ideas and topics within the context of writing a global aim. Write a global aim statement using a template. After assessing your microsystem and selecting a theme, it...

System Levels

Source G ran Henriks, M.A., Chief of Learning and Innovation, and Mats B jestig, M.D., Chief, Department of Medicine, County Council of J nk ping, Sweden. Presented at the First European Clinical Microsystem Network Meeting, Mar. 1, 2004. Source G ran Henriks, M.A., Chief of Learning and Innovation, and Mats B jestig, M.D., Chief, Department of Medicine, County Council of J nk ping, Sweden. Presented at the First European Clinical Microsystem Network Meeting, Mar. 1, 2004. This new era will...

What Resources Are Available to Guide the 5 Ps Assessment

The Primary Care Workbook in the Appendix contains a tested and helpful collection of tools to help you assess your microsystem and by so doing to build the knowledge base and system awareness of your interdisciplinary lead improvement team. In addition, the Dartmouth Clinical Microsystem Toolkit (Godfrey, Nelson, & Batalden, 2005a) includes two workbooks that focus on hospital microsystems Improving Care Within Your Inpatient Units and Emergency Department (Godfrey et al., 2005c) and...

Process Mapping

To define process-mapping techniques, with a specific focus on high-level flowcharts and deployment flowcharts. Objectives. At the completion of this unit, you will be able to Describe the differences between high-level flowcharts and deployment flowcharts. Describe the relationship between the global aim statement for improvement and the flowcharting process. Create a high-level flowchart or deployment flowchart using several techniques. Develop a process to engage all members of the...

What Are the 5 Ps

The following description of the 5 P's is essential information for microsystem leaders. Moreover, by sharing this information with everyone in the microsystem, leaders can promote learning, understanding, and awareness that is broad and deep this improves the functioning of your microsystem. The purpose of your microsystem may go beyond the microsystem's mission statement. If a mission statement is available, then consider having an active discussion among all the microsystem members to enable...

Assessing Your Microsystem With The 5 Ps

The Step Heart Cure

To do an assessment of your clinical microsystem using the 5 P's framework, a tested analytical method that focuses on purpose, patients, professionals, processes, and patterns. Objectives. At the completion of this unit, you will be able to Organize your microsystem assessment so it is systematic. Describe your deeper knowledge of your microsystem's purpose, patients, professionals, processes, and patterns. Identify key tools and methods for gaining deeper knowledge. Engage all members of...

Measurement And Monitoring

To understand how to make and interpret run charts and control charts, two methods for measuring and displaying data trends over time. Objectives. At the completion of this unit, you will be able to Describe how plotting data over time and using run charts and control charts fit into the improvement process. Make and interpret a run chart. Make and interpret one type of control chart. The focus in this chapter is planning measurement specific to PDSA SDSA cycles to determine whether change...

What Are Some Tips for Conducting Brainstorming

Clarify the objective before starting the brainstorming. If the team is not clear on the purpose of the brainstorming session, the outcome is likely to be less productive than desired. It is also helpful to clarify the ground rules about the process, defining what is desired and what behaviors are to be avoided, for example. Setting a target that expresses the number of fresh ideas expected for example, Let's generate forty ideas in the next ten minutes can boost the number of ideas produced...

Focusing on the Microsystem Level

When people are sick or injured or have a health condition that they cannot manage on their own, they often seek health care from educated and trained professionals. They wish to have a healing relationship or a relationship that protects or promotes their health. Patients and families invite these health professionals physicians, nurses, clinicians into their lives to provide needed assistance. When and where a person with a health need interacts with a health care professional and supporting...

Planning Patientcentered Services

Nelson, John H. Wasson, Julie K. Johnson, Paul B. Batalden Background. Strategic focus on clinical microsystems the small, functional, frontline units that provide most health care to most people is essential to designing the most efficient, patient-centered services. The starting place for designing or redesigning clinical microsystems is to evaluate the 5 P's the purpose of the microsystem, the patient subpopulations that are served by the microsystem, the...

Planning Care Well Exemplary Clinical Microsystems

In this section we provide a brief description of several microsystems that excel at planning care. In planning care the Dartmouth-Hitchcock Spine Center, in Lebanon, New Hampshire, uses a computer with a touch-screen monitor to collect information on each patient's general and disease-specific health status this information then provides a sound basis on which the patient and the clinicians can engage in shared decision making to best match the patient's changing needs with FIGURE 7.1....

Success Characteristics Of Highperforming Microsystems

Batalden, Thomas P. Huber, Julie K. Johnson, Marjorie M. Godfrey, Linda A. Headrick, John H. Wasson Background. Clinical microsystems are the small, functional frontline units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients, families, and careteams meet. The quality and value of care produced by a large health system can be no better than the...

Developmental Journey Beginning to Assess Understand and Improve a Clinical Microsystem

Build knowledge of the core processes and outcomes of your microsystem to foster the continual improvement and innovation necessary to meet and exceed patient needs Nelson, Batalden, Mohr, amp Plume, 1998 . Getting Started Diagnosing and Treating a Clinical Microsystem Methods and tools have been developed for microsystem leaders and staff to use or to adapt to local circumstances to assess their microsystems and design tests of change for improvement and innovation. The aim is to increase each...

Case Study 1 Specialty Care Dartmouth Hitchcock Spine Center

We needed a language to work with our patients. The value compass provides the language that helps our multidisciplinary team work with our patients to get them back to work, back to play, one back at a time. James Weinstein, spine center founder A Typical Illness Episode Health Outcomes Tracking and More A patient comes for his first visit to the Dartmouth-Hitchcock Spine Center in Lebanon, New Hampshire. He is greeted by the receptionist, given a touch-screen computer, and asked to use the...

Selecting Themes For Improvement

To select a worthy theme on which to focus improvement actions based on assessments made using the 5 P's, on organizational strategy, and on consideration of national or professional guidelines and recommendations. Objectives. At the completion of this unit, you will be able to Define a theme for improvement. Describe the benefit of identifying a theme for improvement. Describe what to consider when selecting a theme for improvement. Describe how theme selection is connected to assessment...

Working at All Levels of a Health System

Clinical Microsystems

At each level of a health care system, leaders can take actions that will create the conditions for quality and excellence in microsystems the places where patients and families and health care teams meet. Moving from Improvement Projects to Improving Systems Donald Nielsen, a physician and expert on health care quality, has worked with many leading health care organizations and is a student of what works and what fails in transforming health systems to achieve high levels of performance. He...

What Does the 5 Ps Framework Look Like

The 5 P's framework can be thought of as a structured method of inquiring into the anatomy of a clinical microsystem see Figure 1.3 . Every complex, adaptive system has structure, process, patterns, and outcomes Zimmerman, Lindberg, amp Plsek, 1999 , and you can make these features explicit and analyze them by using the 5 P's framework in your microsystem. It is often useful to create a poster-sized version of the 5 P's diagram to visually display your microsystem's 5 P's facts for all staff to...

Figure A16 Huddle Worksheet

What can we proactively anticipate and plan for in our workday or workweek At the beginning of the day, hold a review of the day, review of the coming week, and review of the next week. Frequency of daily review is dependent on the situation, but a midday review is also helpful. This worksheet can be modified to add more detail to the content and purpose of the huddles. Aim To enable the practice to proactively anticipate and plan actions based on patient need and available resources and do...

How Do You Create a Gantt Chart

A Gantt chart tracks the progress of the improvement journey over time. List the steps or tasks in the overall improvement process on the left-hand side of the chart and then create horizontal bars on the right to show when each phase of the improvement process is scheduled to occur see Figure 23.2 . When improvements are begun, it helps to strategize about the improvement activities over the upcoming months. This will help you and your team maintain the pace of improvement. FIGURE 23.2....

What Are the Benefits of Using a Run Chart

There are many advantages to using run charts They are easy to make and easy to interpret. They provide a picture that reveals how the process is performing, communicating more information more clearly than a table that contains the same information. They can be used for several important purposes To detect problems that might otherwise go unnoticed To see if your microsystem is performing at the targeted level To determine if a change or all the changes being made is associated with movement...

Case Study Staff Development at Massachusetts General Hospital Downtown Associates

This case study uses a fictional employee, medical assistant Anne Stirling, to examine the methods used by Massachusetts General Hospital Downtown Associates MGH Downtown , a primary care practice in Boston, for developing its staff and improving staff members' work life. The primary care clinic at MGH Downtown, located in the heart of the financial district of Boston, opened in April 1995. The clinic sees over 16,000 patients a year and has five physicians, one nurse, four medical assistants...

What Are Special Cause and Common Cause Variation

It should be noted here that as you gain knowledge about causes and effects you will also gain knowledge about sources of variation. Deming popularized the idea of two types of variation special cause and common cause. Common cause variation occurs when the system of causes, or the web of causation, is relatively consistent and the variation in outcomes is being produced by chance causes, by random variation in the causal system. Special cause variation occurs when the system of causes, or the...

Action Plans And Gantt Charts

To create a clear action plan of next steps for planning and monitoring improvement activities and progress made. Objectives. At the completion of this unit, you will be able to Describe the importance of an action plan. Differentiate between an action plan and a Gantt chart. Explain the connections among the action plan, the Gantt chart, and your improvement work. Describe how to manage improvement activities over time. Write an action plan or Gantt chart, or both. As your microsystem...

The Editors

Nelson is director of Quality Administration for the Dartmouth-Hitchcock Medical Center DHMC and professor of Community and Family Medicine at Dartmouth Medical School. He is a national leader in health care improvement and the development and application of measures of system performance, health outcomes, and customer satisfaction. He is the recipient of the Joint Commission on Accreditation of Healthcare Organizations' Ernest A. Codman lifetime achievement award for his work on...

Case Study A Decade of Progress for an Intensive Care Nursery

This case draws on a decade of experience, planned change, and growth in the intensive care nursery ICN at Dartmouth-Hitchcock Medical Center DHMC . The ICN serves a mostly rural region of New Hampshire and Vermont, with a total population of approximately 750,000 people. The ICN was started in 1972 and currently has thirty-one beds. In 1992, Gene Nelson and Bill Edwards, the latter a neonatologist and the ICN's medical director, were in conversation about the ICN. When asked about his vision...

Name of Macrosystem

Gentiva Rehab Without Walls Interim Pediatrics Visiting Nursing Service Congregate Care Program, Queens Team 11S Henry Ford Neonatal Intensive Care Unit Intermountain Shock Trauma Respiratory Intensive Care Unit Center for Orthopedic Oncology and Musculoskeletal Research Health Center Massachusetts General Hospital Downtown Associates Primary Care Evergreen Woods Office ThedaCare Kimberly Office Family Medicine

What Is the SDSA Cycle

Sdsa Cycle

Whereas the focus of the PDSA cycle is experimentation, the focus of the SDSA cycle is standardization. The idea behind this is simple and powerful. You run experiments PDSA tests of change until you reach your measured aim. Then, once you are able to achieve the desired level of performance, you want to maintain these gains by continuing to do the right things the right way. This calls for the adoption of a standard method and its continued use until the time comes to make new improvements....

What Is a Cause and Effect Diagram

A cause and effect diagram is an analysis tool that depicts the possible causes that contribute to a single effect. First described in 1968 by a committee of the Japanese Union of Scientists and Engineers JUSE led by Kaoru Ishikawa 1976 , it has also been called an Ishikawa diagram and, because it resembles the skeleton of a fish, afishbone diagram. Brian MacMahon MacMahon amp Pugh, 1970 described exploring causes and effects as creating a web of causation. He noted that outcomes are almost...

Cause And Effect Diagrams

To define cause and effect diagrams and the process of creating them to gain deeper knowledge of the factors that contribute to end results. Objectives. At the completion of this session, you will be able to Define cause and effect diagrams fishbone diagrams . Describe the principle of the web of causation in relation to a fishbone diagram. Create a cause and effect diagram specific to the outcome you are studying. Describe the function of cause and effect diagrams in the big picture of...