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					Micro-Systems in Health Care: Essential Building
Blocks for the Successful Delivery of Health Care
in the 21st Century



         Thomas P Huber, MS ECS
         September 18 & 25, 2006


            Presentation to CCHA/CCS
            NICU Improvement Project
     Aim of Presentation

  Introduce the Clinical Microsystem
   Improvement Framework as a way of
continually improving unit performance as
  well as enhance your understanding of
 quality improvement methods, theories,
           tools, and techniques.
                  AGENDA
1. A Brief Introduction

2. So . . . What’s a Microsystem?

3. Dartmouth - RWJ Study on Microsystems

4. The Clinical Microsystem Action Guide & the 5 P’s
   Framework

5. Improvement Tools, Advising Approach, and some
   key Learning's over the years!
     So . . . What’s a Microsystem

•   Definition
•   A Picture View
•   Examples
•   Shrek’s “Onion Persective” of
    Microsystems
•   The Current Reality Problem
                        Definition

A micro-system in health care delivery can be defined as 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, shared information environment and produces
performance outcomes. They evolve over time and are (often)
embedded in larger organizations.
                                                                    Building a Team to Manage A Panel of Primary Care Patients
                                                   MIssion: The Dartmouth-Hitchcock Clinic exists to serve the health care needs of our patients.


                  People with
                  healthcare                                                                                                                                                                                                                People with
                    needs                                                                                                                                                                                                                   healthcare
                                                                                                                                           4
                                                                                                                                                       P            A            C          E                                               needs met
                                                                                                                                                    Prevention     Acute      Chronic     Educate

            Health             Chronic
              y                                                                                                                                                         PACE
                 Very High Risk
                                                                                                                                                                 Very High Risk +++

                                                                                                                Functional                                                                                                     Functional
                                                       1                     2                3                                                                         PACE                                                    & Risks
                                  Health                                                                         & Risks
      Very High Risk                y
                                                  Assign to          Orient to      Assess &                                                                                                                         Biological             Satisfaction
                                                                                                      Biological            Expectations                            Chronic ++
                                                    PCP               Team          Plan Care
                                                                                                                   Costs                                                                                                           Costs
                                                                                                                                                                           PAE


            Health                                                                                                                                                    Healthy
              y               Chronic




                                           5           6                 7              8              9                10                     11                    12                   13                    14

                                   Info Systems    Phone,                           Medical                                                                                                                 Physical
                                                                    Scheduling                     Laboratory       Radiology         Pharmacy                    Referrals             Billing
                                      & Data      Nurse First                       Records                                                                                                                  Space




                                                                                                           Department
                                                                                                  Division and Community
                                                                                                     Southern Region
                                                                                                  Hitchcock Clinic System


                                     Nashua Internal Medicine                                                                     Measuring Team Performance & Patient Outcomes and Costs
TEAM MEMBERS:
Sherman Baker, MD                Missy, RN                      Amy, Secretary                          Measure                    Current                            Target                           Measure                       Current                 Target

Leslie Cook, MD                  Diane, RN                      Buffy, Secretary                      Panel Size Adj.
                                                                                                                                                                                                External Referral Adj.
                                                                                                                                                                                                    PMPM-Team
Joe Karpicz, MD                  Katie, RN                      Mary Ellen, Secretary
                                                                                                   Direct Pt. Care Hours:
                                                                                                                                                                                                    Patient Satisfaction
Deb Urquart, NP                  Bonnie, LPN                    Kristy, Secretary                        MD/Assoc.


Ron Carson, PA                                                  Charlene, Secretary                 % Panel Seeing Own
                                 Carole, LPN                                                                                                                                                      Access Satisfaction
                                                                                                          PCP:
Erica, RN                        Nancy, LPN
                                                                                                     Total PMPM Adj.
                                                                                                                                                                                                     Staff Satisfaction
Laura, RN                        Mary Beth, MA                                                        PMPM-Team


Maggi, RN                        Lynn, MA
                                                                                                             Micro-System Approach 6/17/98                                                                                c   Eugene C. Nelson, DSc, MPH
Skill Mix: MDs _2.8_ RNs _6.8_ NP/PAs __2__ MA _4.8 LPN _____ SECs __4_                                      Revised: 1/27/00                                                                                                 Paul B. Batalden, MD
                                                                                                                                                                                                                              Dartmouth-Hitchcock Clinic, June 1998
    Microsystems are the building blocks that
    come together to form Macro-organizations

Walk around in a health delivery system with microsystem
glasses what might you find?

•   An Emergency Care Center
•   Asthma and Allergy Clinic
•   Day Surgery Center
•   A Nutrition Clinic
•   A Neonatal Intensive Care Unit
         The “Onion” Perspective on Levels
              of Quality Improvement!
 Self-                                       Community,
 care                                          Market,
System                                       Social Policy
                                               System


                                                Macro-
                                             organization
                                               System




Individual                              Micro-system
care-giver
 & patient
 System
 The Current
Reality Problem
When we connect things that don’t
           match...




                                    The Economist
 Dartmouth - RWJ Foundation
Microsystem Study (2000 - 2003)
 Joint Commission Journal Article in your Packet.
   • The search for 20 high performing
     microsystems
   • How we studied and worked with the
     microsystems
   • A few Examples of Excellence
   • The Results: The 10 Success Characteristics
     of high performing microsystems & the 5 P
     Framework
         The Search for High Performance?
             Dartmouth-RWJ Study: Batalden, Nelson, Huber,
                  Mohr, Wasson, Headrick. 2000 - 2003




•   Identified 250 high performing healthcare
    microsystems via a multi-stratified approach.
•   Screen 75 microsystems using (MS Assessment Tool and
    30-Min Telephone Semi-Structured Interview (Q, $, and
    Process).
•   Selected 20 microsystems across the healthcare spectrum:
    Ambulatory, Inpatient, Nursing Homes, and Home Health.
                     The 20 Finalists
                                       Inpatient Care and Same Day Surgery
Ambulatory Care (Primary)              • Henry Ford-NICU, Detroit, MI
• MacroMedical MGH, Boston, MA         • IHC Shock Trauma Unit, Salt Lake
• Norumbega Medical, Bangor, ME           City, UT
• ThedaCare Family Practice,           • Shouldice Hospital, Hernia Repair,
                                          Toronto, Canada
  Kimberly, WI
                                       • Mayo Luther-Midelfort, Behavioral
• Grace Hill CHC, St. Louis, MO           Health, Eau Claire, WI
Ambulatory Care (Specialty)            Nursing Home and Hospice Care
• Intermountain Ortho, Boise, ID       • On Lok SeniorHealth, San Fran,
• Overlook Hospital Emergency             CA
  Department, Summit, NJ               • Iowa Veterans Home,
• Sharpe Diabetes Center, San Diego,      Marshaltown, IA
  CA                                   • Bon Secours Maria Manor Nursing
• Spine Center, DHMC, Lebanon,            Center, St.Petersburg, FL
  NH                                   • Hospice of Iowa, Mason City, IA
• Washington Cancer Institute,         Home Health Care
  Orthopedic Oncology, Washington,
  DC                                   • Gentiva, Rehab without Walls, East
                                          Lansing, MI
                                       • Visiting Nursing Service of NYC,
                                          New York, NY
                                       • Interim Healthcare, Pittsburgh, PA
   How good is good? a few results.

• Mass General Hospital Primary Care
  – Waiting Room time – how many minutes?
  8 Minutes or the Co-Pay is waived
• Shouldice Hernia Hospital
  – OR turnaround – how many minutes?
   1 Minute and 30 Seconds versus 90 min
  – Disposable costs per operation?
   $17. 50 versus national average $500
            Study Results

10 Success Characteristics of High
Performing Clinical Units
    Step 1: Review Handout and complete
    the Microsystem Assessment

The 5 P’s: Purpose, Patients, Professionals,
Processes, and Patterns
   Step 2: Review document and work on
   Professionals and Process Handout
We found 10 Success Characteristics that
are associated with high performance
                                                    1.   Strong Leadership
                                                    2.   Great Organizational Support

                                 STAFF
                                                    3.   Focus on Staff (Professionals)
     LEADERSHIP
  Ÿ Leadership                  Ÿ Staff Focus
  Ÿ Organizational
    Support
                                Ÿ Educationand
                                  Training
                                                    4.   Education and Training of Staff
                                Ÿ Interdependence
                                  of Care Team
                  Information
                      and
                  Information
                                                    5.   Interdependence of Care Team
                  Technology
PERFORMANCE                       PATIENTS
  Ÿ Performance
    Results
                                Ÿ Patient Focus
                                Ÿ Community and
                                                    6.   Performance Result Focused
  Ÿ Process                       MarketFocus
    Improvement
                                                    7.   Process Improvement Focused
                                                    8.   Patient-Centered (Patient Focus)
                                                    9.   Community and Market Focus
                                                    10. Information & Information Technology
                                                        Orientation
Clinical Microsystem Assessment Exercise
 Instruction: each of the “ 10 success characteristics” (e.g., leadership) is crucial for high
      performance. Below each of the characteristics is defined and is followed by a ranking
      from 1 – 5 (low – high) as well as 3 descriptions (low – high performance). For each
      characteristic please circle a number 1 – 5 that best describes your current Microsystem.



 1. Leadership: The role of leaders is to balance setting and reaching collective
     goals, and to empower individual autonomy and accountability, through
     building knowledge, respectful action, reviewing and reflecting.

              1                   2                  3                     4               5

Leaders often tell me how to do       Leaders struggle to find the right       Leaders maintain constancy of
my job and leave little room for      balance between reaching                 purpose, establish clear goals and
innovation and autonomy. Overall,     performance goals and supporting         expectations, and foster a
they don’t always foster a positive   and empowering the staff.                respectful positive culture.
culture.                                                                       Leaders take time to build
                                                                               knowledge, review and reflect,
                                                                               and take positive action in the
                                                                               Microsystem and the larger
                                                                               organization
          The 5 P’s of
     Micro-systems include ...
• Purpose - Our aim and mission.
• Patients - Our reason for doing our work.
• Professionals - Our staff who work in the
  trenches to take care of patients.
• Processes - Our system of inter-related
  events that constitute the microsystem.
• Patterns - Our way of doing our work
  (Measurements, Data, Run Charts)
  Purpose                                                              Building a Team to Manage A Panel of Primary Care Patients
                                                      MIssion: The Dartmouth-Hitchcock Clinic exists to serve the health care needs of our patients.


                    People with
                    healthcare                                                                                                                                                                                                                 People with
                      needs                                                                                                                                                                                                                    healthcare
                                                                                                                                              4
                                                                                                                                                          P            A             C         E                                               needs met
                                                                                                                                                       Prevention     Acute      Chronic     Educate

     Healthy                        Chronic
                                                                                                                                                                           PACE
                   Very High Risk
                                                                                                                                                                    Very High Risk +++

                                                                                                                   Functional                                                                                                     Functional
                                                          1                     2                3                                                                         PACE                                                    & Risks
                                    Healthy                                                                         & Risks
  Very High Risk                                     Assign to          Orient to      Assess &
                                                                                                         Biological            Expectations                            Chronic ++                                       Biological             Satisfaction
                                                       PCP               Team          Plan Care
                                                                                                                      Costs                                                                                                           Costs
                                                                                                                                                                              PAE

                                                                                                                                                                           Healthy
           Healthy
                                Chronic




Patients                                      5           6                 7
                                                                                    Processes
                                                                                           8              9                10                     11                    12                   13                    14

                                      Info Systems    Phone,                           Medical                                                                                                                 Physical
                                                                       Scheduling                     Laboratory       Radiology         Pharmacy                    Referrals             Billing
                                         & Data      Nurse First                       Records                                                                                                                  Space




                                                                                                              Department
                                                                                                     Division and Community
                                                                                                        Southern Region


      Professionals                    Nashua Internal Medicine
                                                                                                     Hitchcock Clinic System
                                                                                                                                                            Patterns
                                                                                                                                     Measuring Team Performance & Patient Outcomes and Costs
 TEAM MEMBERS:
 Sherman Baker, MD                  Missy, RN                      Amy, Secretary                          Measure                    Current                            Target                           Measure                       Current                 Target

 Leslie Cook, MD                    Diane, RN                      Buffy, Secretary                      Panel Size Adj.
                                                                                                                                                                                                   External Referral Adj.
                                                                                                                                                                                                       PMPM-Team
 Joe Karpicz, MD                    Katie, RN                      Mary Ellen, Secretary
                                                                                                      Direct Pt. Care Hours:
                                                                                                                                                                                                       Patient Satisfaction
 Deb Urquart, NP                    Bonnie, LPN                    Kristy, Secretary                        MD/Assoc.


 Ron Carson, PA                                                    Charlene, Secretary                 % Panel Seeing Own
                                    Carole, LPN                                                                                                                                                      Access Satisfaction
                                                                                                             PCP:
 Erica, RN                          Nancy, LPN
                                                                                                        Total PMPM Adj.
                                                                                                                                                                                                        Staff Satisfaction
 Laura, RN                          Mary Beth, MA                                                        PMPM-Team


 Maggi, RN                          Lynn, MA
                                                                                                                Micro-System Approach 6/17/98                                                                                c   Eugene C. Nelson, DSc, MPH
 Skill Mix: MDs _2.8_ RNs _6.8_ NP/PAs __2__ MA _4.8 LPN _____ SECs __4_                                        Revised: 1/27/00                                                                                                 Paul B. Batalden, MD
                                                                                                                                                                                                                                 Dartmouth-Hitchcock Clinic, June 1998
     The 5 P’s of Micro-systems
         include ... Purpose
The purpose is our aim and mission: What are we
  trying to accomplish?

An explicit statement summarizing what is expected
  to be achieved from the improvement initiative.
Helps to maintain focus on a specific opportunity or
  problem during the project.
Helps to identify appropriate members of the
  improvement team.
                                   Pgs 103, 104 in
                                   Action Guide
     The 5 P’s of Micro-systems
         include ... Patients
Patients are the reason for doing our work.
What is the target population age distribution?
Ave. Length of Stay?
Mortality Rate?                 PGS 59 – 70 in
                                Action Guide
List your top 10 Diagnosis
Pt. Population Census
Additional patient information, ______________?
Family Surveys, Capturing patient information on an
  ongoing basis . . .
   The 5 P’s of Micro-systems
include ... People (Professionals)
Professionals - Our staff who work in the
  trenches to take care of patients.

Complete the Handout Pgs 11 – 15, including:
Who is part of your team, list out staff and %FTE
Complete Staff Satisfaction Survey
Complete Inpatient Unit Personal Skills Assessment
Complete Inpatient Unit Activity Survey Sheet
     The 5 P’s of Micro-systems
        include ... Processes
Processes - Our system of inter-related events
  that constitute the microsystem.
Inpatient Unit Patient Cycle time, Handout Pgs. 16
Inpatient Unit Know Your Process - Core and
  Supporting Processes, Handout pg. 17
Flowchart core process related to nosocomial
  infections

See Handout Pgs 16,17 & Action Guide Pgs. 116 – 122
(Detailed Overview of Flowcharting)
     The 5 P’s of Micro-systems
         include ... Patterns
Patterns - Our way of doing our work
  (Measurements, Data, Run Charts)
Capture key clinical data related to nosocomial
  infections, and line infection rates
What measurements are being captured? Definitions,
  Data Owner, Current and Target Values, Action
  Plan and Process Owner

 See Action Guide: Pgs 70 - 82
Healthcare Improvement Tools
 and Our Advising Approach
•   Tools in the Clinical MS Action Guide
•   MS Advising Approach
•   Key Learnings from Microsystem Work
•   A Concluding Remark
Microsystem Tools and Resources
• A Clinical Microsystem Action Guide (www.clinicalmicrosystem.org)
  Tools and Resources - A Map for Improvement
    –   (General) Clinical Microsystem Profiler, Pg 14
    –   (Professionals) Practice Staff Profiler, (see handout)
    –   (Process) PDSA, Plan Do Study Act, Pg. 112 - 114
    –   (Patients) Patient Flowcharting, Pg. 15
    –   (Big Picture) Clinical Microsystem Picture, Pg. 22
    –   (Patterns) Performance Patterns: Measurement and Monitoring, Pgs 70 -
        82
    –   (Process) Fishbone Diagrams, Pgs 115 - 116
    –   (Big Picture) Clinical Microsystem Assessment Tool, Pgs 16 - 19
    –   (Safety) External Environment, Health Professional Education Pgs 102,
        103
    –   (Purpose) Aim Statement, Vision and Mission Journal, Pg 103, 104
    –   (Professionals) Meeting Agenda Graphic, Pgs. 103 - 109
Microsystem Advising Approach
The Clinical Microsystem Action Guide along with years of accumulated knowledge
in CQI projects creates a ROADMAP for improving care at the Unit Level.

Phase 1: Build MS Awareness via Assessment & Diagnostic Tools
1. Complete Microsystem Assessment Tool.
2. Pick Options in action guide, which Tools to use, set goals (What, Who,
and How of project).

Phase 2: Gather Data, Flowcharting & Mapping Processes
3. Do a site visit & interviews, and capture key Q, $, & Process Measures.
4. Patient & IT Flowcharting, Small work group meetings.
5. Foster “MS & Improvement Culture”.
Microsystem Advising Approach
The Clinical Microsystem Action Guide along with years of accumulated knowledge
     in CQI projects creates a ROADMAP for improving care at the Unit Level.

Phase 3: Data Crunch, Analyze Q, $, & Process Measures
6.   Crunch and analyze the data (project specific measures).
7.   KEEP ENERGY HIGH for project, support support support!
8.   Provide on-going feedback of measures (Patterns).

Phase 4: Finish Work, Present Outcomes, Work on Spread
9.   Congratulate and Celebrate Successes.
10. Review what we learned, provide feedback, and document changes.
11. Plan for next phase (Intra-Unit and Inter-Unit Spread), Utilize High Energy from
     project for spread.
     Learning from Eight Years of
     Microsystem and CQI Work
• IHI workshops, symposium,      •   Strong Vision and Mission is
  teaching, and training             needed - at the unit level
                                     (Purpose). We need strong local
                                     and senior leadership for real
                                     change to happen.

• Microsystem assessments, and   •   Do interviews, gather objective
  CQI work at various Clinics        data, manage the process, be alert
                                     for hidden gems (LHF). Work at
                                     the microsystem level for
                                     effective lasting change .

• Culture Redesign: e.g., NICU   •   Include the right staff, facilitate
  Dartmouth Lahey Hospital           conversation, be open to
                                     surprises. Emphasize fluidity and
                                     flexibility during the spread of
                                     change.
       Learning from Eight Years of
       Microsystem and CQI Work
• Redesign, IT Infrastructure,   •   The Planning Phase is crucial in
  Change Management: 27 Kaiser       PDSA, and critical for HER. First
  Intensive Care Units               map the processes then implement
                                     the HER.


                                 •   Mapping processes creates
• Patient and Information Flow       energy, highlights areas for
  (lean thinking): e.g., Keene       change, and gets staff buy-in.
  Clinic Redesign                    Having an outside support person
                                     is helpful in lean thinking mapping.

                                 •   Work with underlying (hidden)
• Technology Adoption: UCSF -        agendas to make changes. Use the
  Stanford Hospitals                 creativity of the Professionals(they
                                     know what needs to be done).
        Concluding Remark

Healthcare organizations might not be
utilizing the term micro-system, but it is
clear that many high quality and cost-
efficient providers are organizing
themselves around functional front-line
teams & professionals that have the right
information at the right time, to deliver
the best care possible.
Questions and Comments
          If you want to learn more . . .
References
  –   Thomas P. Huber, M.S.; Paul B. Batalden, M.D.; Eugene C. Nelson, D.Sc., M.P.H.; Marjorie M. Godfrey,
      M.S., R.N.: “ Microsystems in Health Care: Developing People and Improving Work Life: What Frontline
      Staff Told Us.” The Joint Commission Journal on Quality Improvement, October 2003, Volume 29 Number
      10.
  –   Eugene C. Nelson, D.Sc., M.P.H.; Paul B. Batalden, M.D.; Karen Homa, MS; Marjorie Godfrey, MS RN;
      Christine Campbell; Linda Headrick, MD, MS, Thomas Huber, MS; Julie Mohr MSPH, PhD; John Wasson,
      MD: “ Microsystems in Health Care: Creating a Rich Information Environment.” The Joint Commission
      Journal on Quality Improvement, January 2003, Volume 29.
  –   Eugene C. Nelson, D.Sc., M.P.H.; Paul B. Batalden, M.D.; Thomas P. Huber, M.S.; Marjorie M. Godfrey,
      M.S., R.N.; Linda A. Headrick, M.D.; Julie J. Mohr, Ph.D.; M.S.P.H.; John H. Wasson, M.D.; “
      Microsystems in Health Care: Learning from High-Performing Front-Line Clinical Units.” The Joint
      Commission Journal on Quality Improvement, September 2002, Volume 28.
  –   Godfrey M, Wasson J, Nelson E, Batalden P, Mohr J, Huber T, Headrick L.; “Clinical Microsystem Action
      Guide – Improving Health Care by Improving Your Microsystem”, Version 1.1: November 2001.
  –   Clinical Microsystems provides an on-line version of the Clinical Action Guide. Hanover, NH: Health Care
      Improvement and Leadership Development at Dartmouth College. (See Clinicalmicrosystems.org)
       If you want to learn more . . .
References
  –   Langley GJ, et al.: The Improvement Guide - A Practical Approach to Enhancing Organizational Performance. San
      Francisco: Jossey-Bass, 1996
  –   Nelson EC, Batalden PB, Ryer J: Clinical Improvement Action Guide, JCAHO, Oak Brook Terrace, IL, 1998.
  –   Nelson EC, Wasson JH: "Using Patient-Based Information to Rapidly Redesign Care," Healthcare Forum Journal,
      37(4):25-29, July/August 1994.
  –   Quinn JB: Intelligent Enterprise: A Knowledge and Service Based Paradigm for Industry. New York, NY: The Free
      Press, 1992.
  –   Rother M, Shook J: Learning to See: Value Stream Mapping to Add Value and Eliminate Muda. Brookline, MA: Lean
      Enterprise Institute, 1999.
  –   Nelson EC, Splaine ME, Godfrey MM, Kahn V, Hess AR, Batalden PB, Plume SK: Using Data to Improve Medical
      Practice by Measuring Processes and Outcomes of Care. Joint Commission Journal on Quality Improvement, 26(12):667-
      685, December 2000.
  –   Nelson EC, Batalden PB: Knowledge for Improvement: Improving Quality in the Micro-systems of Care. In: Goldfield N
      , Nash DB, eds. Managing Quality of Care in Cost-Focused Environment. Tampa, FL: Aspen Publishers; 1999:75-87.
          If you want to learn more . . .
References

  –   Nelson EC, Batalden PB, Mohr JJ, Plume SK: Building A Quality Future. Frontiers of Health Services
      Management, 15(1):3-32, Fall 1998.
  –   Batalden PB, Mohr JJ, Nelson EC, et al.: Continually Improving the Health and Value of Healthcare for a
      Population of Patients: The Panel Management Process. Quality Management in Healthcare, 5(3):41-51,
      Spring 1997.
  –   Nelson EC, Mohr JJ, Batalden PB, Plume SK: Improving Health Care, Part 1: The Clinical Value Compass.
      The Joint Commission Journal on Quality Improvement, 22(4):243-258, April 1996.
  –   Nelson EC, Batalden PB, Plume SK, Mihevc NT, Swartz WG: Report Cards or Instrument Panels: Who
      Needs What? The Joint Commission Journal on Quality Improvement, 21(4):155-166, April 1995.
  –   Weinstein JN, Brown PW, Hanscom B, Walsh T, Nelson EC: Designing an Ambulatory Clinical Practice for
      Outcomes Improvement: From Vision to Reality - The Spine Center at Dartmouth-Hitchcock, Year One.
      Quality Management in Health Care, 8(2):1-20, Winter 2000.