System Levels

Macrosystem

Example

Nursing services

Nursing divisions

Macrosystem

Nursing services

Nursing divisions

Clinical Microsystem Assessment
Source: Göran Henriks, M.A., Chief of Learning and Innovation, and Mats Böjestig, M.D., Chief, Department of Medicine, County Council of Jönköping, Sweden. Presented at the First European Clinical Microsystem Network Meeting, Mar. 1, 2004.

This new era will demand new, adaptive responses from health care; organizations will need to change and evolve, or they will fail. Peter Drucker, who was a leader in modern management thinking, once said about the need for change, "Every organization has to prepare for the abandonment of everything it does" (Gibson & Bennis, 1997).

Figure 4.1, which is based on work done in Jönköping, Sweden, and at Dartmouth-Hitchcock Medical Center in northern New England, provides a glimpse of the complicated, multilayered, and multifaceted job of senior, midlevel, and frontline leaders in health care. The figure represents the three levels in a typical integrated delivery system and gives an example of the linkages between levels.

1. The highest level, which can be referred to as the macrosystem, represents the whole of the organization and is led by senior leaders such as the CEO, chief operations officer (COO), chief financial officer (CFO), chief medical officer (CMO), chief nursing officer (CNO), and chief information officer (CIO) and is guided by a board of trustees.

2. The second level, which may be termed the mesosystem, represents major divisions of the health organization, such as the department of medicine, the department of nursing, and information services as well as clinical service programs such as the oncology, cardiovascular, or women's health programs.

3. The third level, populated by what we call clinical microsystems, represents the frontline places where patients and families and careteams meet. They are the small functional units in which staff actually provide clinical care.

In this model the highest level of the delivery system, sometimes called the blunt end, contrasts with the lowest level, called the sharp end because it is the point where the patient directly contacts the system. The view shown in Figure 4.1 reflects a system of delivery that is exceedingly complex, which makes clear the need for a fresh approach that will reflect the intricacies of today's health care system while still focusing primary attention on the front lines of care where patients, families, and careteams meet.

Figure 4.2 provides another way to frame the challenge faced by health care leaders today. It retains the macro-, meso-, and microsystem format shown in Figure 4.1 but turns the image upside down. This diagram is based on the idea of the inverted pyramid and on Quinn's observations on the requirements needed to become a world-class leader in the service sector (Quinn, 1992). The inverted pyramid representation of a health care organization puts the patients and frontline staff at the top of the system and suggests that the rest of the organization really exists to support the myriad of important interactions that take place at the front line of care.

Clinical microsystems are the naturally occurring building blocks that form the front line of all health systems. These small systems form around the patient to provide care for shorter or longer periods of time, as health needs evolve. For example, if a person has an acute myocardial infarction (AMI) and survives, he or she will typically receive care in a series of clinical microsystems: paramedics stabilize, transport, and begin treatment; the ED diagnoses and treats; the catheterization lab assesses and treats as indicated; the cardiac care unit assesses and treats; the inpatient telemetry unit assesses, treats, and discharges; cardiac rehabilitation services assist with the full recovery; and the cardiology clinical practice, with or without the assistance of home health services in the community, follows the patient over time to minimize risk of a new cardiac event. All these microsystems act as the front line of care for that individual patient.

The quality and value of care for any single patient, or for a cohort of patients, such as people who have had an AMI, fully depends on the quality of

FIGURE 4.2. THE HEALTH CARE SYSTEM AS AN INVERTED PYRAMID.

FIGURE 4.2. THE HEALTH CARE SYSTEM AS AN INVERTED PYRAMID.

European Quality Improvement System

Note: Cath = catheterization lab; CCU = critical care unit; CMS = Centers for Medicare & Medicaid Services; ED = emergency department; IHI = Institute for Healthcare Improvement; IOM = Institute of Medicine; JCAHO = Joint Commission on Accreditation of Healthcare Organizations; NCQA = National Committee for Quality Assurance; NQF = National Quality Forum. Source: Batalden, Nelson, Gardent, & Godfrey, 2005.

Note: Cath = catheterization lab; CCU = critical care unit; CMS = Centers for Medicare & Medicaid Services; ED = emergency department; IHI = Institute for Healthcare Improvement; IOM = Institute of Medicine; JCAHO = Joint Commission on Accreditation of Healthcare Organizations; NCQA = National Committee for Quality Assurance; NQF = National Quality Forum. Source: Batalden, Nelson, Gardent, & Godfrey, 2005.

the health system. The quality of the health system (Qhs) is a function of the quality of care provided within each contributing microsystem (Qm1, Qm2, Qm3, and so forth) plus the quality of the handoffs and integration that occur in the organizational "white spaces" between microsystems (for example, handoffs of the patient, of information and data about the patient, and of services needed for the patient).

Clinical microsystems form the front line of the system—they represent the place where quality is made and costs are incurred. The special knowledge, skills, and resources of the clinical staff can be used in the clinical microsystem to meet the special needs of an individual patient. It is the place where innovation opportunities are most often uncovered. It is the place where, with discretion, things that should be flexible can be customized and where, with discipline, things that should be standardized can be made routine.

The inverted pyramid goes from the level of microsystem to the mesosystem and the macrosystem, respectively. The mesosystem includes the areas that contribute to the care of the patient, such as the following:

• Clinical departments (for example, medicine, nursing, surgery)

• Clinical support departments (for example, radiology, pathology, anesthesiol-ogy, pharmacy, medical information, care management)

• Critical midlevel structures (such as specific service line programs or centers for oncology, cardiovascular health, or women's health)

The macrosystem, at the bottom of the inverted pyramid, is populated by senior leaders (for example, the CEO, CFO, CMO, CNO, and CIO). In Figure 4.2 this section also contains a flag, representing a board of trustees that guides (and oversees) senior leaders in core areas such as vision, mission, values, guiding principles, strategy, and finance. Working down through the inverted pyramid can be compared with working through a root cause analysis that moves progressively away from the sharp end and toward the blunt end of the system as staff ask the why question repeatedly.

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Responses

  • nicole
    What is the TIGER initiative Explain how it impacts the microsystem, mesosystem and macrosystem.?
    1 year ago
  • anja
    What is the macrosystem level of an organization'?
    1 year ago
  • belladonna took
    What is the differances between macrosystem leader, microsystem and mesosystem leader?
    4 months ago
  • Euan
    How can change at the mesosystems level have an impact on the microsystems level?
    3 months ago

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