To complement the previous case study, which provides some details of one particular microsystem's developmental journey, Figure 2.5 provides a general model for the journey. The model is based on work with and observations of hundreds of clinical microsystems during the past two decades. It calls attention to the following five stages of growth over time.
Stage 1: Create Awareness of Our Clinical Unit as an Interdependent Group of People with the Capacity to Make Changes. Often it is the invitation to describe the work of a clinical microsystem in a diagram that initiates that microsystem's enhanced self-awareness. Members of the clinical microsystem will often note routines, habits, or processes that do not work very well or that do not make sense when they look at the system's functioning as a whole, and they may decide to change them. The experience of working on what some describe as the foolishness of work—the things no one wants to admit to, much less brag about (such as confusion and rework in patient flow)—can lead to staff members' realization that change as a unit is possible. The sense that "we" can take action on "our" unit begins a journey of empowerment for the microsystem.
Stage 2: Connect Our Routine Daily Work to the High Purpose of Benefiting Patients; See Ourselves as a System. Once its members have a sense of agency ("we can take action on our own work"), a team is often able to come to a deeper realization than it had before; it sees that it exists for a purpose: the benefit of patients and families. With this clarification of an aim—to benefit a defined population of patients—it is easier for everyone to see the providers, processes, and patterns as a system (Godfrey, Nelson, Wasson, Mohr, & Batalden, 2003; Wasson, Godfrey, Nelson, Mohr, & Batalden, 2003). This step of relating the needs of a population of patients to the hurly-burly world of everyday work is a challenge clinical microsystems have often skipped over.
Stage 3: Respond Successfully to a Strategic Challenge. When a microsystem that has a sense of itself as a system faces a strategic challenge, such as "eliminate waiting for access to appointments in primary and specialty care," or, "cut costs by reducing LOS in the ICN," it can successfully change its processes and make things work better. However, for a clinical unit lacking this self-awareness, responding to a challenge such as this is often a matter of "following the recipe" or "looking like we are moving forward and attending to the issue when we are really walking in place." The results usually show up later as a slow decline in the changed performance to the previous unsatisfactory level (recipe following) or as no measurable improvement after all (walking in place but looking attentive). Recipe followers often worry about "holding the gains," whereas walkers in place often demand valid measures that will reveal how good the performance really is. Clinical microsystems that have well-developed identities as systems are better able to integrate large and small changes into their regular operations—their identity—and as a result they sustain them over time.
Stage 4: Measure the Performance of Our System as a System. The clinical microsystem that has made some changes, that has developed an explicit sense of itself as a system, and that is producing many important outcomes tends to be curious about its results—it wants to track its performance after making changes. Visual reminders of performance in the form of data walls (large, detailed displays of results) are often present (Nelson et al., 2003).
Data walls are designated areas in the clinical microsystem where data over time specific to the microsystem are displayed for all members of the microsystem to review and take action on. Data walls typically include data over time from
• The larger organization-strategic measures that might be collected by the larger organization, such as patient satisfaction, staff satisfaction
• Service line data, such as time to catheterization laboratory for a cardiac microsystem or infections rates for a surgical service
• Clinical microsystem data that reflect current performance data, such as cycle time from the time a patient enters the microsystem until they leave in an ambulatory practice, length of stay in an inpatient unit, or number of days from last infection to other improvement cycle data specific to current improvement activities
Measurement becomes a friend of forward progress and of the microsystem's enhanced sense of itself. The microsystem often begins to track important indicators of its process for providing services and its outcomes to gain a better understanding of what is happening and to put itself in a better position to manage and improve care. The leaders of the microsystem begin to engage all the staff in the work of improving and innovating.
Stage 5: Successfully Juggle Multiple Improvements While Taking Excellent Care of Patients, . . . as We Continue to Develop an Enhanced Sense of Ourselves as a System. With self-understanding, the ability to change, and the ability to track and reflect on its performance, the clinical microsystem is able to engage its context—the macrosystem in which it works and the other microsystems with which it regularly interacts. It is now in a better position to
• Analyze, modify, and standardize its own operations, such as the internal flows (from input to output).
• Reach out and involve all members of the clinical microsystem, including those who are only marginally connected to this newfound identity.
• Focus renewed energy on finding ways to meet the needs of each individual patient, one by one, and the needs of the population of patients the microsystem serves.
The clinical microsystem finds it is now possible to engage many people in many ways in taking actions to provide and improve care, to run multiple tests of change simultaneously, and to create a work environment that recognizes good work and promotes personal and professional growth (Huber et al., 2003). It finds ways to foster a virtuous cycle, or positive, upward, evolutionary spiral.
A microsystem's developmental journey does not always work this way. "All models are wrong, some are useful," as Box (1978, p. 202) reminds us. The model is depicted in a stagewise, linear fashion. However, the microsystem's developmental journey does not necessarily occur in this sequence; it has interactions and feedback loops. Although the model seems to imply an entity—that is, the clinical microsystem—many clinical microsystems more often resemble a loosely coupled group than a tightly linked interdependent crew (Scott, 1981; Weick, 2001). These caveats notwithstanding, this developmental model has proven helpful for members and leaders of clinical microsystems who are eager to reflect on their work and on their efforts to attain the highest levels of quality, safety, service, and efficiency. A developmental journey is not an overnight occurrence, and leadership that seeks knowledge, takes action, and reviews and reflects can help keep everyone's focus on the journey (Batalden et al., 2003).
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