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 staff, a clinical microsystem is at work.
Microsystems are the places where patients and families and health care teams meet. Microsystems are the unit of action—the sharp end of the health care system. It follows then, that if a health care wishes to produce high-quality health care, care that meets the needs of the individual, then it must have high-quality microsystems that are always on—perpetually able to discern what a person wants and needs and able to design and deliver the care that best matches that person's needs. This relationship is shown in Figure 1.1 in Chapter One. Donald Berwick and the Institute of Medicine (IOM) subcommittee responsible for the report Crossing the (Quality Chasm depicted the pivotal and determinate position of the microsystem when they made the health care "chain of effect" diagram (Institute of Medicine. . . , 2001).
All large health systems (macroorganizations) have microsystems as their basic building blocks. These microsystems make health care real, and they vary widely in their ability to do the job—to give all patients what they want and need exactly when they want and need it (Institute for Healthcare Improvement, 2000). Improving requires learning grounded in the experience and daily reality of the work of health care in that frontline context.
So we focus on frontline systems because the only way to design and deliver care that consistently and efficiently meets people's needs is to grow the capability of the microsystems to realize their mission by providing high quality to each person they serve. Excellent service and care every time for every . . . patient— if this is the aim, new learning and new ways of thinking and acting and interacting are required to achieve it. If the aim has merit and is fundamentally in line with people's needs for health care, then most people in most microsystems will need to embark on a developmental journey to build their capability.
We have seen that scores of clinical microsystems have found it possible to set out on their own developmental journeys and to make great progress in improving their ability to provide highly reliable, high-quality, high-value care. This journey toward peak performance is challenging, enjoyable, engaging, empowering, and transformational. Its chief hallmarks are action learning and discovery and also the emergence of inside-out motivation and action to make a superior thing.
Understanding the Role of Experiential Learning in the Improvement of Care
Jerome Bruner (1960), a famous educator, believed that more people act their way into believing than believe their way into acting. He was a proponent of using action learning to advance education. David Kolb (1984) has advanced and popularized the idea of action learning; his model of the experiential learning cycle is shown in Figure 10.3. He believes that the way most people learn most things is by running through a cycle (or ascending spiral) made up of the interplay of four things—concrete experience, reflective observation, abstract conceptualization, and active experimentation:
1. A person experiences something, and
2. Reflects on what he has experienced and on what he or she has observed and tries to make sense out of it, and
3. Turns this sense-making activity into an abstract concept that might be used to guide future action, and
FIGURE 10.3. EXPERIENTIAL LEARNING MODEL.
FIGURE 10.3. EXPERIENTIAL LEARNING MODEL.
4. When circumstances arise in the future, he or she tests out the abstract concept on a particular case in point, which leads once again to a new experience and the start of a new cycle.
We can further enrich our understanding of this learning by studying how professionals such as airplane pilots, physicians, nurses, and architects learn. Donald Schön, an authority on adult learning and the ways that professionals learn, has used the architectural studio course to demonstrate the most effective means for helping professionals move towards mastery of their field (Schön, 1983).
Architectural students gain knowledge, insight, and skill in powerful learning environments called studio courses; these courses are at the core of the students' professional education experience. Studio courses challenge architects-in-training to design a project, such as a town hall, a cathedral, an elementary school, or a fire station. By the end of the term most students have succeeded at doing something they were not capable of doing earlier. They have met the design challenge, usually more or less successfully, because the conditions for learning have been well designed. The conditions for learning in a studio course consist of a rich mix of ingredients:
• A specific goal set for the learner that becomes a worthwhile challenge that engages the learner's creativity
• An informal learning place to interact with faculty and other students
• A studio course master who can guide and challenge the learner
• The development of blueprints and models to graphically illustrate plans and ideas
• Open and honest critique of the learner's work by faculty and fellow learners
• The learner's effort to design a superior thing by drawing on his or her own insights and reflection, past and present learning, creativity, and intelligence
In this environment, over time, the architectural students increase their capability to design a superior building that meets the needs of their clients, fits into the local context and culture, and can be built at an affordable cost.
We have designed a learning program for members of clinical microsystems— the Dartmouth Microsystem Improvement Curriculum (DMIC)—that builds on the ideas of leading educators such as Bruner, Kolb, Schön, and others. This learning program aims to do for microsystem members what a studio course does for architectural students. The curriculum invites microsystem members— health professionals, administrative and support staff, patients, and families—into shared experiences that challenge them to make a superior thing (high-quality and high-value health care). Together they increase their capability to improve performance by acquiring knowledge, skills, principles, and concepts that they adapt to their own unique microsystems. The curriculum and structure also provide a setting for busy microsystem members to learn to work together in new and different ways. They use this learning to understand and to test new ways to provide care and services that can better meet people's needs for high-quality, affordable health care.
Using Experiential Learning to Advance the Developmental Journey of Microsystems
Whether they have recognized it or not, all microsystems are on a developmental journey. It is the nature of clinical microsystems, as "living, adaptive" systems (one form of complex, adaptive systems) (Zimmerman, Lindberg, & Plsek, 1999) to be constantly changing and adjusting to internal forces and external conditions. Old patterns of thinking and acting evolve over time, and new patterns emerge (slowly or rapidly, depending on the conditions) as a microsystem attempts to adjust to changing conditions in an ever-changing world.
The goal of the DMIC is to expedite and to guide a clinical microsystem's developmental journey toward peak performance. We have deliberately modeled the DMIC on Kolb's, Bruner's, and Schon's ideas about how professionals learn. We try to create rich conditions for learning by setting up a studio course for clinical teams that include interdisciplinary members of microsystems.
A brief description of the DMIC learning process follows:
Preparation: Getting Ready
• Secure macro- and mesosystem senior leader support and encouragement at macrosystem and mesosystem levels.
• Define the microsystem that is ready to begin its developmental journey, and its members. Identify the different member roles (patient, family, physician, nurse, technician, receptionist, transport staff, social worker, and so forth).
• Assemble a lead improvement team that represents all the member roles. It is highly desirable to have at least one person to represent each role that plays a part in the microsystem.
• Begin the learning by providing a common frame of reference and introducing microsystem thinking. Lead improvement team members may do some reading before the first session.
• Determine a clear multimedia communication plan that describes how lead improvement team members are to reach the other members of the microsystem.
Baseline Assessment: Discovering the Microsystem
• Discover your microsystem. See what you have never seen before by viewing the clinical program as a small system that can be understood by studying its 5 P's—purpose, patients, professionals, processes, and patterns—and the ways in which its parts interact with one another.
• Use the 5 P's framework for assessing the clinical setting as a small system. Just as you can assess, diagnose, and treat a patient, you can assess, diagnose, and treat your microsystem.
• Make a wall poster to summarize the 5 P's assessment and to illustrate the gross anatomy of the microsystem and some of the detail that is embedded—the fine structures and key processes and vital patterns and core outcomes.
• Review metrics that matter (Figure A.14 in the Appendix) specific to your population of patients.
Primary Diagnosis: Selecting a Worthwhile Challenge for Improvement
• Following the assessment, you have an invitation to make a diagnosis.
Identify the strengths of your microsystem, and celebrate them.
Identify improvement opportunities revealed by your assessment.
Determine what the organization's strategic needs are that your microsystem could or should address.
Determine national professional group recommendations.
Review the Institute of Medicine's six quality aims—safe, timely, effective, efficient, equitable, and patient-centered.
• In light of the previous steps, make your primary diagnosis.
Although there may be multiple worthy themes that identify areas for improvement, select a single, important, and worthwhile theme to focus your (first or next) improvement work on for the next six to twelve months.
This theme becomes the focus for the shared learning. This represents your studio course programmatic challenge.
Primary Treatment: Using the Scientific Method to Make and Sustain Improvements
• Now that the assessment and diagnosis have been made, it is time to take action and to move into the improvement work.
• In this phase of the learning the members of the lead improvement team learn how to work together effectively as an interdisciplinary team and to
Establish clear, measurable aims that are aligned with the overall theme for improvement.
Analyze the current process using flowcharts.
Use cause and effect thinking by making a fishbone diagram.
Use the scientific method to rapidly test changes (plan-do-study-act) and to maintain gains once the aim has been reached (standardize-do-study-act). Build data collection and practical methods for measuring and monitoring into daily work.
• As this action learning progresses, fundamental principles and basic improvement techniques are introduced to help all involved make the journey of building improvement capability smooth and successful.
Reflection and Celebration
• At the conclusion of this initial cycle of learning, the members of the microsystem's lead improvement team
Reflect on what they have achieved and on what they have learned along the way. Celebrate their successes.
Begin making plans to tackle a new theme and to extend improvement knowledge and skills to all the members of their microsystem. Review the M3 Matrix to make a detailed plan for the next six to twelve months in order to continue the developmental journey and to further increase their capability to do their work, improve their work, and take pride in their work.
For convenience, we divide the learning into several modules that have a logical order and flow one into another. The remaining chapters in Part Two of this book provide details on the Dartmouth Microsystem Improvement Curriculum that we have just described. Table 10.1 outlines each chapter: the topic, aim, and learning objectives and the between-sessions work.
The DMIC has been used by many leaders in varying settings. It works best when it is adapted to fit local conditions and each system's unique requirements. Some of these different approaches to using DMIC to build capability in frontline, interdisciplinary microsystem teams are described next.
The formal DMIC learning sessions are often attended by six to twelve microsystem lead improvement teams. These sessions are also usually attended by the mesosystem leaders who supervise the leaders of the participating
Chapter and Purpose
Chapter 10: To promote organization-wide improvement, through the introduction of an approach the (M3 Matrix) for building improvement capability at all levels of a health system, and to preview an action-learning program for frontline staff
Chapter 11: To describe the origin of clinical microsystem thinking and the research on it, and to identify microsystems in your health care system
1. Describe the current state of health care and the relevance of the Institute of Medicine's publication Crossing the Quality Chasm.
2. List specific, phased actions for leaders to take at the macrosystem, mesosystem, and microsystem levels to create the conditions for performance improvement.
3. Describe why a microsystem approach to improving performance is system based and engages the entire health system.
4. State the value of using a story about a patient to engage staff at all levels of a health system.
5. Outline the elements of an action-learning program for frontline staff.
6. Identify the reasons why a lead improvement team (an interdisciplinary team representing all roles in a microsystem) makes an important contribution to anchoring improvement work in the real work of frontline microsystems.
1. Define and identify the clinical microsystems in your health care system.
2. Describe how systems thinking is connected to microsystems.
3. Link systems thinking with the microsystem.
1. Review the M3 Matrix and develop an organized, specific strategy for the three levels of your system.
2. Specify the frontline microsystem development strategy.
3. Identify lead improvement teams for microsystem development.
4. Select a patient population for a primary focus, and write your own "Esther" story.
1. Begin to develop a microsystem wall graphic that models your own system and also offers the physical space to display what people are learning, additional information, and results of the improvement work and the efforts to change.
Chapter and Purpose
Between Learning Sessions Work
Chapter 12: To identify concepts and methods for holding effective and productive meetings with a lead improvement team
Chapter 13: 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
4. Describe the microsystem connections to research from the service industry and the Institute of Medicine.
1. List the four common roles and functions for effective meetings.
2. Describe the meeting process and the seven steps in the agenda template.
3. List the work to be done before meetings.
4. List the processes to be followed during meetings.
5. Create a draft list of ground rules for your lead improvement team members to use when learning how to work together in a meeting.
6. Describe the steps for maintaining the rhythm of improvement.
1. Organize your microsystem assessment so it is systematic.
2. Describe your deeper knowledge of your microsystem purpose, patients, professionals, processes, and patterns.
3. Identify key tools and methods for gaining deeper knowledge.
4. Engage all members of your clinical microsystem in the process of assessment and awareness building.
5. Review, analyze, and draw conclusions about the relationships among the 5 P's.
6. Identify strengths and opportunities for improvements based on the
5 P's assessment.
2. Identify a communication strategy.
1. Conduct sixty-minute meetings with an interdisciplinary lead team using effective meeting skills.
2. Use an agenda to hold a meeting to brainstorm a draft set of ground rules.
3. Identify a place and time to hold weekly lead improvement team meetings.
1. Review the 5 P's, and determine which data and information can be obtained from your organization and which data and information will be collected through other means, such as the microsystem workbook, tools, and forms.
2. Identify who will collect which data and information.
3. Create a timeline for collecting data and reporting on the assessment work.
Chapter 14: 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
Chapter 15: 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
Chapter 16: To create a global aim statement to focus the improvement work based on the theme the lead improvement team selected
1. Define the model for improvement.
2. Describe the two components of the model for improvement.
3. List the detailed steps of PDSA.
4. Develop a clear plan to test a change.
5. Describe the point at which a PDSA cycle becomes a SDSA cycle.
6. State where PDSA^SDSA cycles fit in the improvement process.
7. Use the PDSA^SDSA worksheet to guide actions.
1. Define a theme for improvement.
2. Describe the benefit of identifying a theme for improvement.
3. Describe what to consider when selecting a theme for improvement.
4. Describe how theme selection is connected to assessment information and data.
5. Identify where theme selection fits in the overall improvement process.
6. Describe the process of identifying and selecting a theme for improvement.
1. Define a global aim.
2. Identify the importance of the relationship between the global aim, the improvement process flow, and theme selection.
3. Describe how to manage new ideas and topics within the context of writing a global aim.
4. Write a global aim statement using a template.
1. Review and discuss the model for improvement, to clarify the path forward for the lead improvement team.
2. Review the PDSA^SDSA worksheet to gain insight into the next steps.
Select a theme to focus your improvement work; base your choice on
1. Your 5 P's assessment data and information.
2. A review of information from external forces such as the Institute of Medicine, Institute for Healthcare Improvement, and Joint Commission for Accreditation of Healthcare Organizations (JCAHO).
3. A review of your own organization's strategic priorities.
1. Write a global aim for improvement based on your theme selection
2. Share all global aim progress and drafts with all members of the microsystem.
Chapter and Purpose
Between Learning Sessions Work
Chapter 17: To define process-mapping techniques, with a specific focus on high-level flowcharts and deployment flowcharts
Chapter 18: To create a detailed specific aim statement based on the selected theme and the global aim statement to further guide and focus improvement activities
Chapter 19: To define cause and effect diagrams and the process of creating them to gain deeper knowledge of the factors that contribute to end results
1. Define process mapping.
2. Describe the differences between high-level flowcharts and deployment flowcharts.
3. Describe the relationship between the global aim statement for improvement and the flowcharting process.
4. Create a high-level flowchart or deployment flowchart using several techniques.
5. Develop a process to engage all members of the microsystem in the creation and modification of the flowchart.
1. Define what a specific aim is.
2. Describe the connections between specific aim, process flow, global aim selection, and theme.
3. Use the specific aim template.
4. Describe the improvement ramp that leads microsystem members to meet overall improvement aims.
1. Define cause and effect diagrams (fishbone diagrams).
2. Describe the principle of the web of causation in relation to a fishbone diagram.
3. Create a cause and effect diagram specific to the outcome you are studying.
4. Describe the function of cause and effect diagrams in the big picture of improvement.
1. Draft a flowchart of the process identified in your global aim statement.
2. Display the flowchart draft for all the staff to review and add to.
3. Modify the flowchart based on feedback.
1. Create your specific aim, based on your flowchart.
1. Create a fishbone diagram to show the causes that contribute to your specific aim.
2. Display the draft fishbone diagram for all to review and modify.
3. Make the modifications to the fishbone based on feedback.
Chapter 20: To define the process that a lead improvement team can use to develop a large list of ideas for improving a process and then to systematically reduce the number to the very best ideas
Chapter 21: To understand how change concepts can contribute to developing new change ideas for improvement
Chapter 22: To understand how to make and interpret run charts and control charts, two methods for measuring and displaying data trends over time
5. Develop a process to engage all staff in the creation and modification of a fishbone diagram.
1. Define the methods and describe the steps in the process of brainstorming and multi-voting.
2. Describe the differences between interactive brainstorming, silent brainstorming, and nominal group techniques.
3. Apply brainstorming and multi-voting to a topic in order to select a specific change idea to test.
4. Develop a process to engage all staff in the review and consideration of the results of the brainstorming and multi-voting session.
1. Define a change concept.
2. List common change concept categories.
3. Identify when change concepts enter the overall improvement process.
4. Describe how a change concept can lead to specific change ideas.
5. Describe a clinical example of a change concept applied to a change idea.
1. Describe how plotting data over time and using run charts and control charts fit into the improvement process.
2. Make and interpret a run chart.
1. Brainstorm and multi-vote to choose a change idea to test that is related to your specific aim statement.
2. Develop a process to engage all staff in the review and consideration of the results of the brainstorming and multi-voting work.
3. Develop a clear plan to test a change idea.
4. Review the plan with all staff.
5. Determine dates and preparation needed to test the change idea quickly.
6. Use the PDSA^SDSA worksheet to guide actions.
1. Review the change concept list, and use it to stimulate thinking about ways to redesign your process.
2. Research the best-known change ideas for the process you aim to improve.
1. Create a run, or control chart specific to your PDSA cycle.
2. Display "the chart on a data wall" for all staff to see real-time progress.
Chapter and Purpose
Between Learning Sessions Work
Chapter 23: To create a clear action plan of next steps for planning and monitoring improvement activities and progress made
Chapter 24: To make plans to tell the improvement story, measure progress over time, and sustain improvement using standard processes
3. Make and interpret one type of control chart.
1. Describe the importance of an action plan.
2. Differentiate between an action plan and a Gantt chart.
3. Explain the connections among the action plan, the Gantt chart, and your improvement work.
4. Describe how to manage improvement activities over time.
5. Write an action plan or a Gantt chart, or both.
1. Describe the improvement fundamentals needed to maintain and sustain improvement.
2. Identify where improvement data can be posted for viewing by all microsystem members to increase their knowledge about purpose, progress, and priorities.
3. Design a microsystem playbook that documents standard ways of performing processes and that can be used in orientation, performance appraisals, and daily improvement work.
4. Develop a storyboard to document your microsystem's improvement journey and progress made over time.
3. Build measurement into every microsystem member's activities.
1. Write a Gantt chart specific to your long-term improvement plan.
2. Write an action plan each week, to promote between-meeting completion of tasks.
1. Create a storyboard showing your microsystem's current state.
2. Start and maintain a data wall of results, achievements, and processes to be monitored.
3. Create and actively manage your microsystem playbook.
microsystems. The sessions might be held monthly, weekly, or biweekly or be grouped together over the course of a single week. Here are some of the patterns we have seen:
• Monthly sessions bring microsystem lead improvement teams together, under the sponsorship of senior and midlevel leaders, for one full day or one or two half days once a month for six to nine months.
• Weekly or biweekly sessions bring microsystem lead improvement teams together, under the sponsorship of senior and midlevel leaders, for one to two hours once a week or once every two weeks for six to nine months.
• An intensive weeklong workout session brings microsystem lead improvement teams together, under the sponsorship of senior and midlevel leaders, for six to eight hours per day for five consecutive days.
Each of the remaining chapters in Part Two provides topic-specific knowledge from the DMIC. The best format and the most practical pace for teaching this knowledge within the context of an interdisciplinary lead improvement team are determined by the local conditions. Health care systems might also take advantage of toolkits, specially packaged learning materials that target particular kinds of health care organizations, or they might try an applied learning approach.
• Toolkit method. Use a microsystem-based toolkit to guide action learning: for example, Clinical Microsystems: A Path to Healthcare Excellence (Godfrey, Nelson, & Batalden, 2005) is a guide for improving care in hospitals and is sponsored by the Dartmouth Medical School, the American Hospital Association, the Institute for Healthcare Improvement, Premier, Inc., and VHA, Inc. Other toolkits are available on the Web site http://www.clinicalmicrosystem.org. Toolkits can also be used within an academic program to educate health care professional students (physicians, nurses, and administrators).
• Applied microsystem education. Have health professional students work in small groups with the staff of an actual clinical microsystem to go through the 5 P's assessment process or through the diagnosis and treatment process described earlier in the descriptions of the DMIC learning process. This can be done in multiple sessions over the course of an academic term or as an intensive workout.
The DMIC approach for health professional education in academic settings and for leadership and staff development in delivery systems is being used in a variety of health systems worldwide. The Web site http://www.clinicalmicrosystem. org offers more ideas and resources on ways to adapt this way of learning to your own setting.
Understanding the Value and Composition of a Lead Improvement Team
In several places we have suggested establishing a lead improvement team to guide the microsystem's participation in the DMIC. The idea behind this is to make sure that your microsystem education considers all the roles held by all the system's essential members. Every member of a microsystem has an important role to play and offers a unique perspective. Just as you would not wish to coach a baseball team without having all the players present, you should not choose to mentor microsystem team learning without having all the members either present or represented. In health care organizations it is often impossible to have all the members present for action learning, but it is usually possible to have all member roles represented (including current or former patients and families).
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