Success Characteristics Of Highperforming Microsystems

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Learning from the Best

Eugene C. Nelson, Paul B. Batalden, Thomas P. Huber, Julie K. Johnson, Marjorie M. Godfrey, Linda A. Headrick, John H. Wasson

Chapter Summary

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 services generated by the small systems of which it is composed.

Methods. A wide net was cast to identify and study a sampling of the best-quality, best-value small clinical units in North America. Twenty microsystems, representing a variety of the component parts of a health system, were examined from December 2000 through June 2001, using qualitative methods supplemented by medical record and finance reviews.

Results. The study of these twenty high-performing sites generated many best-practice ideas (processes and methods) that microsystems use to accomplish their goals. Their success characteristics were related to high performance and include leadership, macrosystem support of microsystems, patient focus, community and market focus, staff focus, education and training, interdependence of care team, information and information technology, process improvement, and performance results. These ten success factors were interrelated and together contributed to the microsystem's ability to provide centered, high-quality, safe, and efficient health system cannot be realized

Conclusions. A seamless, patient-

superior, cost-effective care and at the same time create a positive and attractive working environment.

without transformation of the essential building blocks that combine to form the care continuum.

The health care system in the United States can, under certain conditions, deliver magnificent and sensitive state-of-the-art care. It can snatch life from the jaws of death and produce medical miracles. The case of Ken Bladyka, presented later in this chapter, is one positive example of the health care system's performance. Yet the system is often severely flawed and dysfunctional. The Institute of Medicine (IOM) report Crossing the (Quality Chasm: A New Health System for the 21st Century (Institute of Medicine [U.S.], Committee on Quality of Health Care in America, 2001), makes the point of system failure clear:

• "Health care today harms too frequently and routinely fails to deliver its potential benefits"(p. 1).

• "Tens of thousands of Americans die each year from errors in their care, and hundreds of thousands suffer or barely escape from nonfatal injuries that a truly high quality care system would largely prevent" (p. 2).

• "During the last decade alone, more than 70 publications in leading peer-reviewed clinical journals have documented serious quality shortcomings" (p. 3).

• "The current system cannot do the job. Trying harder will not work. Changing systems of care will" (p. 4).

This chapter introduces the concept of the clinical microsystem, summarizes recent research on twenty high-performing microsystems sampled from the care continuum, and stresses the strategic and practical importance of focusing health system improvement work specifically on the design and redesign of small, functional clinical units.

Qualitative research methods were used to analyze 250 hours of conversations with microsystem personnel; these conversations were augmented by chart reviews and financial data. Principles, processes, and examples were gleaned from the interviews to describe what these exemplary microsystems are doing to achieve superior performance.

So, what is the true nature of our health system? Sometimes it works well, but all too often it fails to deliver what is needed.

True Structure of the System, Embedded Systems, and Need to Transform Frontline Systems

The true structure of the health system the patient experiences varies widely. Patients in need of care may find

• Clinical staff working together—or against each other

• Smooth-running frontline health care units—or units in tangles

• Information readily available, flowing easily, and in a timely fashion—or not

• Health care units that are embedded in helpful larger organizations—or cruel, Byzantine bureaucracies

• Health care units that are seamlessly linked together—or totally disjointed

• High-quality, sensitive, efficient services—or care that is wasteful, expensive, and at times harmful or even lethal

In brief it can be said that the true structure of the health system is composed of a few basic parts—frontline clinical microsystems, mesosystems, and overarching macrosystems. These systems have a clinical aim and are composed of patients, staff, work patterns, information, and technology, and they exist in a context. These elements are interrelated to meet the needs of patient subpopulations needing care. As the Bladyka case will illustrate, "it is easy to view the entire health care continuum as an elaborate network of microsystems that work together (more or less) to reduce the burden of illness for populations of people" (Nelson et al., 2000, p. 669).

Here are three fundamental assumptions about the structure of the health system:

1. Bigger systems (macrosystems) are made of smaller systems.

2. These smaller systems (microsystems) produce quality, safety, and cost outcomes at the front line of care.

3. Ultimately, the outcomes of a macrosystem can be no better than the outcomes of the microsystems of which it is composed.

The concept of clinical microsystems is spreading and has been used in many national and international programs: the IOM's Crossing the Quality Chasm report, the Institute for Healthcare Improvement's Idealized Design of Clinical Office Practice program and also its Pursuing Perfection program (Kabcenell, 2002) and Transforming Care at the Bedside program (Rutherford, Lee, & Greiner, 2004), the Cystic Fibrosis Foundation's Accelerating Improvement in CF CareCollaborative, the Vermont Oxford Network of Neonatal Intensive Care Units ("Your Ideal NICU") program, the United Kingdom's health system renewal program, and so on.

FIGURE 1.1. CHAIN OF EFFECT IN IMPROVING HEALTH CARE QUALITY.

Iom Crossing The Quality Chasm Report

Source: Donald M. Berwick. Used with permission.

Donald Berwick's "chain of effect in improving health care quality" (Berwick, 2001) (see Figure 1.1) shows the major elements that need to work well and work together well for high-quality care to be delivered, and highlights the pivotal role played by the microsystems of care delivery. Clinical microsystems are the places where patients and families and health care teams meet, and consequently they are positioned at the sharp end of the health care delivery system, where care is delivered, medical miracles happen, and tragic mistakes are made. Our approach in this book is focused primarily on this microsystem level, where frontline clinical teams interact with patients and produce outcomes.

To bring about fundamental change of the magnitude required in the health system, our country needs a systematic transformation at all levels of the system. This requires a system-based approach, one that recognizes the reality and functional integrity of human systems. Although many attempts have been made to change the health system—by focusing on the individual patients, the individual physicians serving these patients, the larger provider organizations, the payment system, and other aspects of health care policy—there have been very few efforts to understand and change the frontline clinical units that actually deliver the care. To move toward a perfected macrosystem of care, the performance of each individual microsystem must be optimized within that system's context and the linkages between all the various clinical microsystems must be seamless, timely, efficient, and thoroughly reliable. Although change is required at all levels of the system, the powerful new idea here is that the microsystem concept offers an opportunity to transform health care at the front line of service delivery.

Describing Clinical Microsystems

Microsystems involve people in varying roles, such as patients and clinicians; they also involve processes and recurring patterns—cultural patterns, information flow patterns, and results patterns. This book defines microsystems in health care in the following way:

A clinical microsystem is 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, and a shared information environment, and it produces performance outcomes. Microsystems evolve over time and are often embedded in larger organizations. They are complex adaptive systems, and as such they must do the primary work associated with core aims, meet the needs of their members, and maintain themselves over time as clinical units.

Microsystems, the essential building blocks of the health system, can be found everywhere and vary widely in terms of quality, safety outcomes, and cost performance. A microsystem is the local milieu in which patients, providers, support staff, information, and processes converge for the purpose of providing care to individual people to meet their health needs. If a person were to explore his or her local health system, he or she would discover myriad clinical microsystems, including a family practice, a renal dialysis team, an orthopedic practice, an in vitro fertilization center, a cardiac surgery team, a neonatal intensive care unit, a home health care delivery team, an emergency department, an inpatient maternity unit, a rapid response team, and an extended care facility. Clinical microsystems are living units that change over time and always have a patient (a person with a health need) at their center. They come together to meet patients' needs—and they may disperse once a need is met (for example, a rapid response team, or a fast squad, forms quickly, comes together around the patient for a short period of time, and disperses after the patient has been stabilized or transported).

As described in the Bladyka case in the following box and illustrated in Figure 1.2, these individual microsystems are tightly or loosely connected with one another and perform better or worse under different operating conditions. Our ability to see them as functional, interdependent systems is challenged by our conventions of compartmentalizing and departmentalizing, considering separately, for example, human resources, accounting, and information technology. Our commitment to professional disciplines and specialties as a prime organizing principle often creates barriers that impede the daily work of clinical microsystems.

The Bladyka Case

Ken Bladyka is a thirty-nine-year-old resident of New Hampshire who has a wife, two children, and a sixth degree black belt. He has earned several national and international karate championships. Last summer, while attending the Amateur Athletic Union National Karate Championships to watch his son compete, he noticed bruises on his arm. When he got home he noticed more bruises and petechiae on his legs, and Paige, Ken's wife, was horrified when she saw severe bruises on his back as well. This happened on the Fourth of July, and the following sequence of activities transpired over the next three months:

• 7/4: Ken calls his family physician, his primary care provider, to report findings.

• Family physician sees Ken and Paige that same day.

• Family physician refers Ken to Dartmouth-Hitchcock Medical Center (DHMC) hematology department in Lebanon, New Hampshire.

• Doctor on call sees Ken and orders labs.

• Ken starts his own medical record.

• Ken admitted to DHMC with diagnosis of aplastic anemia complicated by autoimmune disease.

• Inpatient care—daily labs and transfusions—provided under direction of hematologist.

• Ken discharged to home, receives outpatient daily labs and transfusions as needed, and readmitted to DHMC hematology service as needed.

• Ken's four siblings tested for bone marrow matches at DHMC, and at health care facilities in Hartford, Connecticut, and San Francisco, California.

• One sibling, his sister Mary, has a positive match.

• Ken begins a search for "best place with best outcomes in world" and selects Fred Hutchinson Cancer Research Center (FHCRC) in Seattle, Washington.

• 8/23: Ken, Paige, and Mary fly to Seattle, and on 8/24 Ken is admitted to FHCRC.

• 9/3: Chemotherapy is begun at FHCRC.

• 9/10: Bone marrow transplant procedure done at FHCRC.

• 9/12: Ken celebrates his fortieth birthday while an inpatient at FHCRC.

• 9/27: Ken transferred to Paul Gross Housing unit for 100 days of follow-up care.

• 10/3: Testing at FHCRC reveals that bone marrow transplant has started to produce positive results.

• Ken continues to recover and recuperate while residing at Paul Gross Housing unit and anxiously awaiting his return to home and family and work. . . .

Figure 1.2 uses a flowchart to depict Ken's health system journey. It shows the frontline clinical units, the different small groups of people who worked directly with Ken at each step of his care, such as the office of his primary care provider (PCP), the DHMC hematology inpatient unit, and the bone marrow testing units. These small, frontline clinical units are what this book calls clinical microsystems. Figure 1.2 also

FIGURE 1.2. FLOWCHART OF KEN BLADYKA'S JOURNEY THROUGH THE HEALTH SYSTEM.

FIGURE 1.2. FLOWCHART OF KEN BLADYKA'S JOURNEY THROUGH THE HEALTH SYSTEM.

High Performing Clinical Microsystems

shows the larger umbrella organizations, or macrosystems—the Dartmouth-Hitchcock Medical Center, and the Fred Hutchinson Cancer Research Center—that played a part in Ken Bladyka's care. This case study provides a glimpse of the true structure of the health system. Before examining this structure further it is important to emphasize some facts that arise from the Bladyka case:

• This could happen to your family and friends.

• Ken needed high-quality, safe, and affordable care.

• Ken found frontline health systems that met his special needs, but these pockets of gold were spread across the country.

• We need a solid-gold system—meaning a high-quality, high-value, high-reliability system—throughout the nation to serve all Americans.

Another way to describe clinical microsystems is with a high-level diagram that portrays a typical microsystem's anatomy—the set of elements that come together, like biological structures that work together toward a common goal, to form the microsystem organism. Figure 1.3 illustrates the anatomy of a typical internal medicine practice. This clinical microsystem, like all others, has a mission, or core purpose—in this case, to achieve the best possible outcomes for patients— and is composed of patients who form different subpopulations (such as healthy, chronic, and high risk). The patients interact with professionals, including clinicians and support staff, who perform distinct roles, such as physician, nurse, nurse practitioner, medical assistant, and so on. The patients and staff work to meet patients' needs by engaging in direct care processes, such as accessing systems, assessing needs, diagnosing problems, establishing treatment plans, and following up over time. These direct care processes are assisted by supporting processes that involve distinct tools and resources, such as medical records, scheduling, diagnostic tests, medications, and billing. The results of the interactions between patients and staff and clinical and support processes can be used to produce patterns of critical results, such as biological and safety outcomes, functional status and risk outcomes, patient perceptions of goodness of care, and cost outcomes, that combine to represent the value of care. The patterns of results also include the elements of practice culture, what it feels like to work in the clinical unit, as well as elements important to business success, such as direct costs, operating revenues, and productivity.

Another important feature of the clinical unit is that it has a semipermeable boundary that mediates relationships with patients and families and with many support services and other microsystems. Furthermore it is embedded in, influences, and is influenced by a larger organization that itself is embedded in a particular environment—a payment environment; a regulatory environment; or

FIGURE 1.3. ANATOMY OF A CLINICAL MICROSYSTEM.

Patients

People with health care needs

Healthy lmw\ Chronic High risk

High risk

Healthy

Healthy

Primary Care Practice

Nashua Internal Medicine exists to serve the health care needs of our patients

Purpose

Assign to PCP

Orient to team

Assess & plan care

Functional & risks

- Biological ^^^ Expectations Costs

Processes

Functional & risks

- Biological ^^^ Expectations Costs

Clinical Microsystem

Functional Biological ^^^ Satisfaction Costs

People with health care needs met

Department

Division and Community

Southern Region

Functional Biological ^^^ Satisfaction Costs

Information systems & data

Phone, nurse first

Scheduling

Medical records

Laboratory

Radiology

Pharmacy

Referrals

Billing

Physical space

Professionals

Hitchcock Clinic System

Patterns

TEAM MEMBERS: Nashua Internal Medicine

Sherman, MD

Missy, RN

Amy, Secretary

Leslie, MD

Diane, RN

Buffy, Secretary

|oe, MD

Katie, RN

Mary Ellen, Secretary

Deb, NP

Bonnie, LPN

Kristy, Secretary

Ron, PA

Carole, LPN

Charlene, Secretary

Erica, RN

Nancy, LPN

Laura, RN

Mary Beth, MA

Maggi, RN

Lynn, MA

Skill Mix: MDs 2.8

_RNs 6.8 NP/PAs 2 MA 4.8 LPN

SECs 1

Measuring Team Performance & Patient Outcomes and Costs

Measure

Current

Target

Measure

Current

Target

Panel size adj.

External referral adj. PMPM-Team

Direct pt. care hours: MD/assoc.

Patient satisfaction

% Panel seeing own PCP:

Access satisfaction

Total PMPM adj. PMPM-Team

Staff satisfaction

Source: Nelson, E. C., & Batalden, P. B., unpublished document, 1998.

a cultural, social, and political environment. Thus the clinical microsystem, although a comparatively simple concept, is still in fact a complex, adaptive system that evolves over time.

Complex adaptive systems are found in nature and in human groups. They can be contrasted with mechanical systems, which tend to be more predictable and not subject to emergent behavior. Fritof Capra, a noted physicist and author, suggests that a useful way to analyze complex adaptive systems arising in nature is to use a framework that addresses structure, process, and patterns (Capra, 1996; Nelson et al., 1998). Patterns are the consistent behaviors, sentiments, and results that emerge from the relationships of the parts involved in a complex adaptive system (Zimmerman, Lindberg, & Plsek, 1999).

Previous Research on Microsystems, Organizational Performance, and Quality

The clinical microsystem work described in this chapter represents an extension of the authors' earlier work on improvement in health care. For example, in 1996 the authors wrote a four-part series on clinical improvement that was published in the Joint Commission Journal on (Quality Improvement (Nelson, Mohr, Batalden, & Plume, 1996; Nelson, Batalden, Plume, & Mohr, 1996; Mohr, Mahoney, Nelson, Batalden, & Plume, 1996; Batalden, Mohr, Nelson, & Plume, 1996). That series described concepts and methods for improving the quality and value of care provided for specific subpopulations of patients.

The microsystem work described herein amplifies this earlier work by taking into account the structural units—that is, clinical microsystems—responsible for delivering care to specific patient populations, and the manner in which these microsystems function, which involves the interplay of patients, professionals, processes, and patterns within and between microsystems. The primary emphasis of the authors' former work was on the clinical process that generates outcomes—quality and costs—for patients served by clinical systems. This new body of work retains a strong emphasis on clinical processes and patient-based outcomes but expands the frame to include

• An explicit focus on the local context—that is, the naturally occurring clinical units that form the front line of health care delivery

• Consideration of the information environment that supports or undermines care delivery

• The interactions and relationships among people within microsystems and the interactions between clinical microsystems that work together to provide comprehensive care

• The relationships between clinical microsystems and the larger systems in which they are embedded—for example, the mesosystems, macrosystem, and larger community

The research on microsystems described in this chapter generally builds on ideas developed by Deming (1986), Senge (1990), Wheatley (1992), and others who have applied systems thinking to organizational development, leadership, and improvement. The emerging fields of chaos theory, complexity science, and complex adaptive systems have also influenced our thinking (Arrow, McGrath, & Berdahl, 2000; Hock, 2005; Kelly, 1994; Peters, 1987; Wheatley, 1992).

The seminal idea for the microsystem in health care stems from work of James Brian Quinn that he summarized in Intelligent Enterprise (Quinn, 1992). In this book he reports on primary research conducted on the world's best-of-the-best service organizations, such as FedEx, Mary Kay Inc., McDonald's, Intel, SAS, and Nordstrom. His aim was to determine what these extraordinary organizations were doing to enjoy such explosive growth, high margins, and wonderful reputations with customers. He found that these service sector leaders organized around, and continually engineered, the frontline interface that connected the organization's core competency with the needs of the individual customer. Quinn called this frontline activity the smallest replicable unit, or the minimum replicable unit, that embedded the service delivery process. The smallest replicable unit idea—or the microsystem idea, as we call it—has critical implications for strategy, information technology, and other key aspects of creating intelligent enterprise. Two excerpts from Quinn's book convey the power and scope of this organizing principle and the need for senior leaders to focus their attention on creating the conditions to continually improve the performance of frontline delivery units.

• On core strategy: "Critical to relevant effective system design is conceptualizing the smallest replicable unit and its potential use in strategy as early as possible in the design process" (p. 104).

• On informatics and improvement: "Through careful work design and iterative learning processes, they both reengineered their processes to use this knowledge and developed databases and feedback systems to capture and update needed information at the micro levels desired" (p. 105).

Donaldson and Mohr (2000) investigated high-performing clinical microsystems; this research provided important background material for the IOM's Committee on Quality of Health Care in America in writing Crossing the (Quality Chasm. Donaldson and Mohr's work was based on a national search for the highest-quality clinical microsystems. Forty-three clinical units were identified, and leaders of those units participated in extensive interviews conducted by the report authors. The results of the interviews were analyzed to determine the characteristics that seemed to be most responsible for enabling these high-quality microsystems to be successful. The results suggested that eight dimensions were associated with high quality:

• Constancy of purpose

• Investment in improvement

• Alignment of role and training for efficiency and staff satisfaction

• Interdependence of care team to meet patient needs

• Integration of information and technology into work flows

• Ongoing measurement of outcomes

• Supportiveness of the larger organization

• Connection to the community to enhance care delivery and extend influence

Our study of clinical microsystems has built directly on Mohr and Donaldson's work.

Study of Clinical Microsystems

The aim of our research study, which we conducted from June 2000 through June 2002, was to identify the success characteristics—the principles, processes, and methods—that high-performing clinical microsystems use to provide care that is characterized by both high quality and cost efficiency. Our method was to identify twenty high-performing clinical microsystems representing different parts of the care continuum and to study their performance through site visits, detailed personal interviews, direct observations, and reviews of medical record and financial information. The research was sponsored by the Robert Wood Johnson Foundation and was conducted by a research team based at Dartmouth Medical School's Center for the Evaluative Clinical Sciences. The research methods are described in more detail in the following section.

Research Design

The research design was an observational study that for the most part used qualitative methods, such as personal interviews and direct observations, with a limited review of medical records and analysis of financial data. Figure 1.4 displays an overview of the research design.

FIGURE 1.4. RESEARCH DESIGN FOR STUDY OF TWENTY CLINICAL MICROSYSTEMS.

Samplmg Data Collection

Selecting high-performing clinical microsystems via a multitiered search pattern

1. Award winners and measured high performance

2. Literature citations

3. Prior research and field experience

4. Expert opinion

5. Best within best

Choosing 20 clinical microsystems for study

1. Assess outcomes of search pattern

2. Create table of sites by search pattern

3. Conduct survey and telephone interview

4. Choosing and inviting sites to participate

Two data collection instruments

Self-administered microsystem survey Self-assessment of performance based on key characteristics

Telephone interview

Examination of delivery processes, the quality of care and services, and cost efficiency and waste reduction

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Responses

  • justine
    WHAT 2 IMPORTANT EFFECTIVE MICROSYSTEMS OF THE 8 DIMENSIONS?
    5 years ago
  • Asmarina Yonatan
    What is the relationship of a complex adaptive systems to microsystems, macrosystems and mesosystems?
    5 years ago
  • Bodo Rumble
    What were the 8 dimensions of effective microsystems identified by donaldson and mohr (2000)?
    4 years ago
  • LAMORAC
    What are the characteristics of microsystem?
    3 years ago
  • Patrick
    What are the 8 success characteristics of a microsystem by quality by design?
    1 month ago
  • Anna
    What are the 8 success characteristics of a microsystem education by quality by design?
    1 month ago

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