At each level of a health care system, leaders can take actions that will create the conditions for quality and excellence in microsystems—the places where patients and families and health care teams meet.
Moving from Improvement Projects to Improving Systems
Donald Nielsen, a physician and expert on health care quality, has worked with many leading health care organizations and is a student of what works and what fails in transforming health systems to achieve high levels of performance. He uses the diagram shown in Figure 10.1 to explain what he sees happening (and what needs to happen) if health systems are to be successful in achieving and sustaining a culture of quality.
• Project focus. The first phase of improvement focuses on projects, as the health system seeks to improve quality by running a variety of projects in areas of high
FIGURE 10.1. EVOLUTION IN APPROACHES TO IMPROVING HEALTH SYSTEM QUALITY: FROM PROJECTS TO MESOSYSTEMS TO MACROSYSTEMS.
FIGURE 10.1. EVOLUTION IN APPROACHES TO IMPROVING HEALTH SYSTEM QUALITY: FROM PROJECTS TO MESOSYSTEMS TO MACROSYSTEMS.
interest. Many projects are successful, some fail, some are at first successful but fail to hold their gains. In this phase, quality work is viewed as special, ad hoc work by most staff members. The project participants often work extra hard, learn new skills, and take well-deserved pride in their accomplishments; usually they also know there is a clear start and a clear end to the project. Most health systems and provider organizations in the United States are in this phase. They will make real progress here and there, but it will be limited to whatever area was selected as the focus. Improvements arising from projects are sometimes difficult to sustain and are unlikely to spread and to transition on their own to the next challenge.
• Microsystem focus. The second phase of improvement focuses on microsystems, as the health system makes tactical use of microsystem thinking to build the habit for improvement into the fabric of some frontline systems. In this phase senior leaders promote improvement from the inside out in certain clinical microsystems. They encourage individual microsystems to develop their own capability to plan and make changes as part of their regular work routines. Frontline staff in the best-performing units have a sense that they work in a unique place with a wonderful group of people who care for a very special
EXHIBIT 10.1. LETTER TO THE EDITOR ABOUT A CLINICAL PROGRAM WITH A LOCAL AND NATIONAL REPUTATION.
To the Editor:
I have just completed treatment at a medical jewel more people in the Upper Valley should know about—the Spine Center at Dartmouth-Hitchcock Medical Center. In this innovative center, a team of world-class specialists in all aspects of back and spine care—from neurosurgery and orthopedics to psychology and physical therapy—assemble to review all aspects of any complex case. No more waiting and roaming from one source to another and obtaining conflicting views over a long period of time. Instead, different specialists exchange views face to face, backed by the most powerful diagnostic equipment and delivery techniques currently in use. All information is shared in a way that lets patients join appropriately in making the best decision.
I know of no other rural area that enjoys such capable specialists along with the most advanced technological and research facilities available anywhere. Just as important is the friendly and personal way the care is delivered. A small team knew my case intimately, provided the personal attention and follow-up associated with a small practice, and patiently responded to all the frightening questions—and analysis of alternatives—a person facing the possibility of back surgery wants answered.
All back sufferers in the Upper Valley are blessed to have this marvelous institution and its outstanding people.
James Brian Quinn Hanover
Source: Quinn, 1999.
group of patients and families. These breakaway or standout microsystems might be considered pockets of gold. They have a good reputation, and stories are told and letters are written about the extraordinary care that this practice or that unit or clinical program provides (see, for example, Exhibit 10.1). There are some health systems in this phase of improvement, and their numbers are growing due to the attractive nature of the approach taken by these standout microsystems and the success they are achieving.
• Mesosystem focus. The third phase of improvement focuses on the mesosystem. At this stage, the good work done by individual microsystems to improve care begins to spread to other related microsystems. Mesosystems can be thought of as an interrelated set of "peer microsystems" that provide care to certain patient populations or support the care provided to these populations. Sometimes an individual microsystem that has made good progress on improving quality will start to "reach out" to other related microsystems to work on the way they connect with one another to transfer the patient from one microsystem to another or to work on the flow of supporting services and information. Another impetus for mesosystem development is for a health system to make it a priority to improve care for patients that "move through" many different but related microsystems. For example, patients with chronic problems—such as heart failure, or diabetes—or with serious acute problems—such as acute myocardial infarction or pneumonia—often receive care from many assorted outpatient and inpatient clinical units. Consequently, if every patient is to get the right care in the right place in the right time, then it is necessary to organize and improve care in the mesosystem that consists of all the different microsystems that contribute to the care of "this" kind of patient. Yet another trigger for mesosys-tem development is a decision to target particular "clinical service lines" such as cardiovascular care or spine care or women's health as strategic areas for growth and development. Creating a center of excellence for patient populations such as these requires extensive work to improve or redesign care within and between all the related microsystems and thereby calls for the development of a superior mesosystem. • Macrosystem focus. The fourth phase of improvement focuses on the whole system, or macrosystem, as all parts of the system and all levels of the system get it, as they become aligned with the goal of organization-wide improvement. This whole-system approach is strategic and operational. In this phase leaders and staff are working to improve performance both within and between all the microsystems in the organization and to align all levels of the organization to improve quality, reduce real costs, and engage all staff members in both doing their work and improving their work. An important aspect of this leadership work is to focus on making smooth, safe, and effective connections between and across related microsystems and supporting systems; this involves improving and redesigning the functioning of mediating, midlevel systems, or mesosystems, such as clinical service lines, programs, or divisions. Horizontal and vertical alignment is essential.
The Baldrige National Quality Program (2006) framework provides one excellent approach for mobilizing the whole system to work on quality and performance and has been applied to health care. Chapter Four in Part One of this book discusses this approach at length and introduces the major leadership frameworks and specific suggestions for moving in this direction. A small number of health systems and frontline (microsystem) providers are in this phase of improvement, and there is much to learn from them.
We believe, fundamentally, that populations will have high-quality health care systems only when their health care delivery organizations take a systems-based approach to attaining and sustaining high-quality health care. We believe that macro-, meso-, and microsystem thinking can provide just such a systems-based approach for improving the quality of a whole health system with a vertical and horizontal alignment of strategy and actions. But to carry out such an approach requires synchronized action at all levels of a health care delivery organization. Improvement needs to be led from the inside out for microsystems and from the outside in for leaders creating the conditions for improvement. Paul Batalden reminds us that "every system is perfectly designed to get the results it gets" (personal communication to Donald Berwick, IHI president and CEO, 1996). Alignment of system levels with systems-based improvement offers the prospect of a better system and better results.
Using the M3 Matrix to Guide Actions at All Health System Levels
Figure 10.2 shows the M3 Matrix. It is called the M3 Matrix because it spells out actions that leaders can take at the three main levels of a health system:
• Macrosystem: actions taken by the senior leaders who are responsible for organization-wide performance
• Mesosystem: actions taken by the midlevel leaders who are responsible for large clinical programs, clinical support services, and administrative services
• Microsystem: actions taken by the leaders of frontline clinical systems who engage in direct patient care, provide ancillary services that interact with patient care, or provide administrative services that support patient care
The M3 Matrix displays actions not only according to the three system levels but also according to time frame, suggesting actions to consider taking immediately (within months one to six), in the short term (months seven to twelve), and in the long term (months thirteen to eighteen).
We believe that leaders of health care systems can use the M3 Matrix for developing a specific eighteen- to twenty-four-month action plan and for beginning to progress up "Nielsen's curve" (Figure 10.1) by making the transition from improvement based on projects to improvement based on microsystems to improvement based on mesosystems and the macrosystem—all the small systems coming together to make the whole system—and finally to the completion of a transformative journey.
Organizations cannot transform themselves without positive engagement of the workforce. The next two sections offer methods for (1) setting clear expectations on the need for everyone to take on improvement as part of daily work, and (2) making the need for dramatic improvements relevant and attractive by putting a specific human face on the imperative for change.
FIGURE 10.2. THE M3 MATRIX: SUGGESTIONS FOR LEADERSHIP ACTIONS AT THREE LEVELS OF A HEALTH SYSTEM.
Microsystems Developmental Journey: The Stages
1. Create awareness of our clinical unit as an interdependent group of people with the capacity to make change.
2. Connect our routine daily work to the high purpose of benefiting patients; see ourselves as a system.
3. Respond successfully to a strategic challenge.
4. Measure the performance of our system as a system.
5. Successfully juggle multiple improvements while taking care of patients, . . . and continue to develop our sense of ourselves as a system.
Inside Out 0-6 Months
Prework. At www.ciinicaimicrosystem.org, read Parts 1, 8, 9 of series (click publications in left-hand menu, select readings from Journal of Quality, Safety Improvement Microsystems in Healthcare; watch Batalden streaming video
• Form an interdisciplinary lead improvement team.
• Begin the Dartmouth Microsystem Improvement Curriculum.
• Learn to work together using effective meeting skills.
• Rehearse within studio course format.
• Practice in clinical practice.
• Hold daily huddles, weekly lead improvement team meetings, monthly all-staff meetings.
• Conduct learning sessions (monthly).
• Hold conference calls (between sessions).
Creating the Conditions
• Link strategy, operations, and people—make it happen.
• Support and facilitate meso- and microsystem protected time to reflect and learn.
• Identify resources to support meso-and microsystem development, including information technology and performance measure resources.
• Develop measures of microsystem performance.
• Address roadblocks and barriers to micro- and mesosystem improvements and progress.
• Set goals and expectations.
• Develop clear visions and missions for meso- and microsystems.
• Set goals for improvement.
• Design meso- and microsystem manager and leadership professional development strategy.
• Engage board of trustees with improvement strategies.
• Expect all senior leaders to be familiar and involved with meso- and microsystem improvement.
• Provide regular feedback and encouragement to meso- and microsystem staff.
• Encourage patient and family involvement in improvement.
• Reinforce staff by leadership.
• Engage in colleague reinforcement.
• Develop new habits through repetition.
• Put improvement science into action.
• Add more improvement cycles.
• Build measurement into practice.
• Increase use of measures, dashboards, and data walls.
• Use playbooks and storyboards.
• Understand and develop relationships (linkages) between microsystems.
• Improve use of PDSA and SDSA approaches.
• Incorporate best practices, using value stream mapping or lean design principles.
• Convene mesosystem and microsystems to work on linkages and handoffs.
• Facilitate system coordination.
• Link with electronic medical records.
• Link business initiatives or strategic plan to microsystem level.
• Attract cooperation across health professions, even if traditionally highly separate.
• Track and tell stories about improvement results and lessons learned at meso- and microsystem levels.
• Schedule rounds regularly at the microsystem level.
• Make improvement a regular agenda item.
• Inquire about results and data specifics to set goals and improvement.
• Expect improvement science and measured results from meso- and microsystems.
• Develop whole-system measures and targets or goals.
• Attract cooperation across health professions, even if traditionally highly separate.
• Design review and accountability quarterly meetings for senior leaders.
• Track and tell stories about improvement results and lessons learned at meso- and microlevels.
• Develop budgets to support and develop strategic improvement.
• Ensure resources (such as information technology) to support meso- and microsystems.
• Plan time in schedule to conduct rounds at meso- and microsystem levels to observe improvements and progress.
• Continue "new way of providing care, continuously improving and working together."
• Actively engage more staff involvement.
• Ensure that multiple improvements are occurring.
• Network with other microsystems to support efforts.
• Coach network and development.
• Develop leadership.
• Conduct annual review, reflect, and plan retreats.
• Conduct quarterly system review and hold accountability meetings with meso- and macrosystem leadership.
• Link performance management to daily work and results.
• Support and coach microsystem leadership development.
• Provide resources to support microsystem development.
• Provide feedback and encouragement to microsystems.
• Expect patient and family involvement in improvement.
• Encourage and support the search for best practices.
• Develop professional development strategies across all professionals.
• Design HR selection and orientation process linked to identified needs of macro-, meso-, and microsystems.
• Consider incentive programs for reaching targets or goals.
• Create system to link measurement and accountability at the micro-, meso-, and macrolevel.
• Develop a Quality College for ongoing support and capability building throughout the organization.
FIGURE 10.2. THE M3 MATRIX: SUGGESTIONS FOR LEADERSHIP ACTIONS AT THREE LEVELS OF A HEALTH SYSTEM. (Continued)
Some Questions for Leaders at All Levels to Consider
• How does this microsystem work? Who does what to whom? What technology is part of what you regularly do?
• What is the main or core process of the way work gets done here? How does it vary?
• What are some of the limitations you encounter as you try to do what you do for patients?
• When you want to change the clinical care because of some new knowledge, how does that work?
• What are the helpful measures you regularly use here? How are those measures analyzed and displayed?
• What are the things people honor as traditions around here? if you had to single out a few things that really contribute to and mark the identity of this clinical microsystem, what might you point to?
• What do people ask questions about around here? Who asks? Who gets asked?
• What does it take to make things happen around here? When did it work well? Who did what?
• How do information and information technology get integrated into the daily work and new initiatives around here?
• How do the organization's messages move?
• How does the macrosystem strategy connect to the microsystems? What helps people adapt to and respond to it?
• How do the microsystems link strategy, operations, and people needed for successful execution?
• What is the process for identifying and orienting the microsystem leaders? For helping set their expectations? For reviewing their performance and for holding each clinical microsystem accountable for its performance?
• What helps maintain a steadfast focus on "improved patient care outcomes by more reliable and more efficient systems that are regularly reflected on and redesigned?"
• What about your personal style of work speaks more convincingly than your words about the desired way of work in the organization?
• How do you yourself facilitate improvement across microsystems and encourage patient and family focus?
• What do you yourself regularly do to learn of improvements in the microsystems?
• How does this work bring help or value to the patients? What stories illustrate that?
• What are the values that are part of the everyday work?
• What helps people grow, develop, and become better professionals here?
• What helps people personally engage the never-ending safeguarding and improving of patient care?
• What connects this whole place— from the patient and those working directly with the patient down to the macrosystem leaders?
• What helps the processes of inquiry, learning, and change within, between, and across microsystems and mesosystems?
• What helps people do their own work and improve patient outcomes, year after year?
• What might be possible? What are some of the current limits the organization faces?
• What are some of the most relevant external forces for this macrosystem and its micro- and mesosystems?
• Do you have the measurements and feedback necessary to make it easy for you to monitor and improve the quality of your performance?
When you add new people here, how do you go about it?
How are things noticed around here?
If you were to point to an example of respect among all staff here, what might you point to?
How do the leaders get involved in change here?
How are patients and families brought into the daily workings and improvement of the clinical microsystem? Do people have a good idea of each other's work? How is that brought about?
Do you discuss the common patterns of the way you work? The ways you test changes in them?
What can you yourself do to be present in microsystems? What are the cultural supports for measurably improving the quality, reliability, and value of care in the microsystems?
What are the cultural changes required to measurably improve the quality, reliability, and value of care at the front lines?
Are you treated with dignity and respect everyday by everyone you encounter, without any regard for hierarchy?
Are you given the opportunity and tools that you need to make a contribution that gives meaning to your life?
Does someone notice when you've done the job you do? As you think about what you do and your ability to change it—what gains have been made in the past 12 months?
How do you actually do what you do? What changes have you been able to make? What changes are you working on now?
What changes that you've tried haven't worked?
Do people feel compelled to regularly justify or rationalize things that happen around here?
Go to www.clinicalmicrosystem.org, click on "streaming videos" on the left-hand menu bar of the home page, then select from the Clinical Microsystems streaming video series "A Microsystem's Self-Awareness Journey, Paul Batalden, MD." The videos are best viewed by RealOne Player.
Ask for Two Jobs: Providing Quality Services and Improving the Quality of
Service. We all sense that people who enjoy their work, who are excited by and engaged in their work, are likely to do better work than others and to enjoy their work. We all know that staff satisfaction is related to patient satisfaction (Denove & Power, 2006; Nelson et al., 1992). We know that people who feel empowered and important in their work are more likely than others to find ways to improve their work and to take pride in their work (Buckingham & Clifton, 2001; Deming, 1986). We know that most people go into health care for one reason—they want to make a difference in the lives of people with real needs.
We know that leaders, at all levels of the organization, create the conditions for improvement to flourish and for excellence to emerge. The question, then, is, What might leaders do to engage staff and to bring forth the energy and creativity of the whole person in her or his everyday work? Of course there is no one simple answer; however, there are some things that leaders can do to fully engage staff. Here are two that are basic:
• Set clear expectations. Let everyone in your organization or area know that the mission is to deliver high-quality, high-value services and that the task is so big that everyone really has two jobs—to do the work and to improve the work. This goes to the heart of fostering a culture of quality, safety, and excellence. You are saying that everyday work involves both doing well what needs to be done and testing ways to improve the quality of what is done. Improvement is everyone's responsibility and needs to be a basic job expectation.
• Foster relevant learning. Improving work requires knowledge, skills, and effort, just as doing the work requires knowledge, skill, and effort. One way to make this expectation clear, and to promote the fundamental improvement of knowledge and skill, is to foster relevant learning. One way to accomplish this is to adapt the DMIC to fit into your health system's leadership and human resource development process.
The second section of the M3 Matrix (Figure 10.2) provides questions that leaders might ask themselves about each level of the health system (some of these questions might also be considered when engaging staff). Many leaders have found this starter list of questions and perspectives helpful for reframing their health care system and ensuring alignment for improvement.
Use Esther's Story: Engage the Head, the Hand, and the Heart. John Kotter is a noted authority on leading change. He has studied organizations that have succeeded and those that have failed at making transformational change. He teaches, consults, studies, and writes on this topic (Kotter, 1996; Kotter & Cohen, 2002).
Clearly, there is a great deal that goes into transforming an organization and creating the conditions for sustained excellent performance, but one aspect of success that stands out and is worth highlighting is this. Organizations that succeed at mobilizing and engaging their staff succeed (in part) because they are able to engage the whole person—her or his intellect, efforts, and values. The successful organization finds ways to engage the head, the hands, and the heart.
Paul Bate, chair of Health Services Management at University College London, in the United Kingdom, another authority on organizational change, and his colleagues at the Rand Corporation have studied high-performing health systems (at both the microsystem and macrosystem levels) in North America and the United Kingdom. This research has given Bate an understanding of the power of storytelling, and other methods of dramatization, to illuminate the patient's experience and to ignite improvement work in organizations that are achieving unprecedented levels of quality and safety (Bate, 1994).
One technique for engaging the energy and creativity of the whole person is to make use of stories and storytelling. In health care we believe that stories about patients that dramatize an individual's experiences and the person's and family's efforts to cope with the burden of illness can be a powerful source of insight and motivation. Because most health care professionals enter health care to make a difference, telling patient stories can even invite the reengagement of discouraged staff (Hurwitz, Greenhalgh, & Skultans, 2004).
One of the most rapidly improving health systems is the Jonkoping County Council Health System (JCCHS) in Sweden. A large, vertically integrated health system, it has the best quality and lowest cost measures in Sweden. It has been a leading participant in the highly regarded Institute for Healthcare Improvement's Pursuing Perfection program (Institute for Healthcare Improvement [IHI], 2006). One thing that JCCHS leaders have done for more than five years is to tell and retell Esther's story (Exhibit 10.2). "Esther" is a fictional, but endearing and believable, elderly woman who lives alone and suffers from chronic obstructive pulmonary disease and other health problems. Whenever Esther's story is told, people immediately recognize the complexity of her care and her case. They see both the strengths and weaknesses in the way care is currently provided. Because Esther could be anyone's grandmother, mother, beloved aunt, or dear neighbor, everyone (physicians, nurses, secretaries, technicians, and administrators) can relate to her story. Having told Esther's story, JCCHS leaders ask a few powerful questions to invite staff to assess current care delivery and to generate ideas to improve and innovate. They ask such questions as these:
• What would Esther want?
EXHIBIT 10.2. IMPROVING PATIENT FLOW: THE ESTHER PROJECT IN SWEDEN.
"Esther" is not a real patient, but her persona as a gray-haired, ailing, but competent elderly Swedish woman with a chronic condition and occasional acute needs has inspired impressive improvements in the ways patients flow through a complex network of providers and care settings in Hoglandet, Sweden.
Esther was invented by a team of physicians, nurses, and other providers who joined together to improve patient flow and coordination of care for elderly patients within a six-municipality region in Sweden. The productive work that has been done on Esther's behalf led the Jonkoping County Council, responsible for the health care of 330,000 residents living around Hoglandet, to become one of two international teams participating in the Pursuing Perfection initiative. This program, launched by the Robert Wood Johnson Foundation, is designed to help health care organizations and hospitals dramatically improve patient outcomes by pursuing perfection in all their major care processes. The Institute for Healthcare Improvement (IHI) serves as the national program office for this initiative.
"I think it is very important that we call this work Esther," says Mats Bojestig, chief of the Department of Medicine at Hoglandet Hospital, Hoglandet, Sweden, one of the developers of the Esther Project and an Institute for Healthcare Improvement (IHI) faculty member. "It helps us focus on the patient and her needs. We can each imagine our own 'Esther.' And we can ask ourselves in our work, 'What's best for Esther?'"
Esther proved inspirational for the team. During the three-year project, they were able to achieve the following improvements:
• Hospital admissions fell from approximately 9,300 in 1998 to 7,300 in 2003.
• Hospital days for heart failure patients decreased from approximately 3,500 in 1998 to 2,500 in 2000.
• Waiting times for referral appointments with neurologists decreased from eighty-five days in 2000 to fourteen days in 2003.
• Waiting times for referral appointments with gastroenterologists fell from forty-eight days in 2000 to fourteen days in 2003.
The Esther Project grew from a need that many U.S. health systems share: to improve the way patients flow through the system of care by strengthening coordination and communication among providers.
Bojestig tells Esther's story this way: "Esther is eighty-eight and lives alone in a small apartment. During the past few nights her breathing has become worse and worse, and her legs have edema so severe that she cannot lie down but sits up all night. She knows she needs health care. She phones her daughter in a nearby town, who tells her to call her home nurse. The home nurse visits and says she needs to see her general practitioner (GP). But Esther lives on the third floor and can't manage the stairs.
"So the nurse calls an ambulance, and Esther goes to the doctor, who says she needs to go to the hospital. Now three hours have passed. An ambulance takes her to the emergency room (ER), where she meets an assistant nurse and waits for three hours. She meets with a doctor, who examines her and orders an X-ray and says she will have to be admitted. She comes to the ward and meets more nurses."
EXHIBIT 10.2. (Continued)
Here Bojestig smiles. "Most days Esther is a little lonely, but today she is happy because she has already met 30 people!"
The Swedish health system is designed in a traditional, functional way: each link in the caregiving chain—the primary care physician (PCP), the hospital, the home care providers, the pharmacy—acts independently according to its function. "But Esther needs it to all fit together," says Bojestig. "It needs to flow like an organized process," he says, so each provider of care can take advantage of what others have done or will do.
Out of this need grew the Esther Project, which has six overall objectives:
1. Security for Esther
2. Better working relations throughout the entire care chain
3. Higher competence throughout the care chain
4. Shared medical documentation
5. Quality throughout the entire care chain
The Esther Project team consisted of physicians, nurses, social workers, and other providers representing the Hoglandet Hospital and physician practices in each of the six municipalities. They were divided into two subgroups: the strategy group and the project management group.
To establish a clear picture of where the problems existed, team members conducted more than sixty interviews with patients and providers throughout the system. Together they analyzed the results, which included such statements as "patients in a nursing home rarely see their doctor" and "a patient getting palliative care at home was in contact with 30 different people during one week."
According to Bojestig the interviews also furnished providers with valuable realizations about the ways their individual work processes did or did not dovetail with the work of their colleagues in the care chain. Figuratively, if not literally, he says, interviewers would exclaim, "Are you doing that? I'm doing that too!"
The result of this lack of coordination, he says, is that even though Esther's social worker knows all about how Esther lives, for example, "still her GP asks her how she lives, and she tells it, and the hospital asks her, and she tells it again, and so on." Lack of coordination of information, particularly where medications are concerned, causes considerable redundancy and waste. In the worst case, it can lead to medical errors and avoidable illness.
The team devised an action plan that spelled out six main projects, designed to correspond to the six goals:
1. Develop flexible organization, with patient values in focus
2. Design more efficient and improved prescription and medication routines
3. Create ways in which documentation and communication of information can be adapted to the next link in the care chain
4. Develop efficient information technology support throughout the whole care chain
5. Develop and introduce a diagnosis system for community care
6. Develop a virtual competence center for better transfer and improvement of competence throughout the care chain
EXHIBIT 10.2. IMPROVING PATIENT FLOW: THE ESTHER PROJECT IN SWEDEN. (Continued)
Bojestig says that as part of its work, the team examined demand and capacity within the system and saw that the inadequate capacity for planned care was forcing patients to seek urgent care in inappropriate settings. "If Esther complains of headaches, and her GP says she should see a neurologist, in our system that referral would take three months. For Esther this is not acceptable. So she goes to the ER, and the doctor there knows that if he puts her in the hospital, the next day there will be a neurologist in to visit her."
Although it appeared that the demand was for inpatient admissions, it was really demand for better access to specialty care. So the team tested a process in which the queue for care was redesigned from two—one for acute care and one for planned care—into one. "Instead of having acute care go into the wards," says Bojestig, "it goes to the team."
This team, which includes the PCP, specialists as appropriate, nurses, and home nurses, has a collaborative relationship, through which team members decide together what's best for each patient. When a patient presents acute care needs, says Bojestig, the PCP can page a specialist on the team, who is expected to respond within two minutes. A telephone consultation may still result in an inpatient admission, but it allows the patient to be admitted directly to the ward without having to endure a visit to the ER, costly in both human and financial terms.
For their part the specialists began working toward open access scheduling, in which patients could be seen on the same day they call or their PCP calls. Closer cooperation among specialists and other providers meant that PCPs and home care nurses were able to do for patients some of the things specialists had been doing.
Additionally, patient education was recognized as a critical element in keeping patients out of the hospital. Nurses were trained to educate heart failure patients, for example, about how to take vital measurements at home and tweak their medication accordingly.
Bojestig says that all 250 providers in the network received training in the project's goals and processes. And the investment paid off. "We have closed about 20 percent of our bed capacity," he says, "and moved that capacity to where the need is bigger."
The continuing focus of the project team's work, says Bojestig, is "how to create value for Esther." He says that the project changed the attitudes among those who work for Esther, because "the focus is on her now."
"The important things for us to ask as leaders or workers in the health care system," says Bojestig, "is can we still continue to work in systems that are not integrated? Is it fair to our knowledge? Is it what we want to do? Is it best for Esther?"
• Can we find a way to just try to do this for Esther?
These simple questions dramatize a recognizable person's health and health care experiences. They serve as an open invitation to become curious about what might be done (the head), to engender the will and energy to get it done (the heart), and to call forth the skill to do what has never been done before (the hand).
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