Microsystems evolve over time. 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 from the perspective of the patient and family?" This picture is often the beginning of awareness of how people work together. It also often reveals some foolishness, things that people are not very proud of or things they recognize as not very dependable. With that recognition of some foolishness they might take action to minimize its impact in the microsystem. If they are successful in eliminating the foolishness, they often experience a sense of self and self-awareness that leads in turn to an understanding that the microsystem can improve itself and that change is possible without permission from anybody else.
This new sense of responsibility and awareness often gives staff important insights into the daily workings of the microsystem and the recognition that it is possible to change one's own work environment and that things are going along better than before. Eventually, someone will ask, "Why do we do what we do," and, "What is our purpose?"
A conversation begins about the patients who benefit from the microsystem's work. The microsystem staff begin to explore their own purpose in relation to the
FIGURE 11.5. A MICROSYSTEM'S SELF-AWARENESS JOURNEY.
needs of patients. Making the purpose of the microsystem explicit is an important developmental step on the journey toward awareness of the microsystem as a system. The purpose, the interdependent members, the information and technology—all contribute to the functioning of this microsystem. This awareness then becomes people's basis for understanding the usual work of the microsystem when strategic improvement is introduced; the members of the microsystem can now begin to process the improvement against their knowledge of their own microsystem and the patients it serves. The path to systematic, sustained improvement is more than a recipe with steps to be followed. Microsystem members can complete the steps for short-term change but often cannot sustain the new way of doing things if they are not aware of themselves as making up a functioning system—a system now changed in a way that makes sense. Conversely, gains from change efforts are often sustained and further explored by the self-aware microsystem. The microsystem members become increasingly curious about the functioning of their microsystem and the ways they might change it. They often want to measure performance and understand who benefits and how much change is actually occurring. The process of change also feeds people's curiosity about the daily work in microsystems that understand their work as a system, particularly the work in other clinical units that they engage with to provide patients with all needed care. This curiosity leads a microsystem to interactions with peer microsystems and to explore the inputs it receives; staff work further to discover the expectations of the populations they care for and these populations' needs. These self-aware microsystems begin to work much more consciously on the relationship of their microsystem to its larger context, the mesosystems and macrosystem that contribute to its identity.
It's important to note that the steps and events just described may not happen in this order. They may not happen within any particular time period. However, these events, however ordered and timed, do often happen in microsystems that begin to get a sense of themselves and to build their own capability to improve themselves and to become better and better at self-organizing and self-improving.
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