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

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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
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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.

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AGENDA

1. A Brief Introduction
2. So . . . Whats a Microsystem?
3. Dartmouth - RWJ Study on Microsystems
4. The Clinical Microsystem Action Guide the 5 Ps
   Framework
5. Improvement Tools, Advising Approach, and some
   key Learning's over the years!

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So . . . Whats a Microsystem

• Definition
• A Picture View
• Examples
• Shreks Onion Persective of Microsystems
• The Current Reality Problem

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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.
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(No Transcript)
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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

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The Onion Perspective on Levels of Quality
Improvement!
Community, Market, Social Policy System
Self-care System
Macro-organization System
Micro-system
Individual care-giver patient System
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The Current Reality Problem
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When we connect things that dont match...
The Economist
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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

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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.

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The 20 Finalists

• Inpatient Care and Same Day Surgery
• Henry Ford-NICU, Detroit, MI
• IHC Shock Trauma Unit, Salt Lake City, UT
• Shouldice Hospital, Hernia Repair, Toronto,
  Canada
• Mayo Luther-Midelfort, Behavioral Health, Eau
  Claire, WI
• Nursing Home and Hospice Care
• On Lok SeniorHealth, San Fran, CA
• Iowa Veterans Home, Marshaltown, IA
• Bon Secours Maria Manor Nursing Center,
  St.Petersburg, FL
• Hospice of Iowa, Mason City, IA
• Home Health Care
• Gentiva, Rehab without Walls, East Lansing, MI
• Visiting Nursing Service of NYC,
• New York, NY
• Interim Healthcare, Pittsburgh, PA

• Ambulatory Care (Primary)
• MacroMedical MGH, Boston, MA
• Norumbega Medical, Bangor, ME
• ThedaCare Family Practice,
• Kimberly, WI
• Grace Hill CHC, St. Louis, MO
• Ambulatory Care (Specialty)
• Intermountain Ortho, Boise, ID
• Overlook Hospital Emergency Department, Summit,
  NJ
• Sharpe Diabetes Center, San Diego, CA
• Spine Center, DHMC, Lebanon, NH
• Washington Cancer Institute, Orthopedic Oncology,
  Washington, DC

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How good is good? a few results.

• Mass General Hospital Primary Care
• Waiting Room time how many minutes?
• Shouldice Hernia Hospital
• OR turnaround how many minutes?
• Disposable costs per operation?

8 Minutes or the Co-Pay is waived
1 Minute and 30 Seconds versus 90 min
17. 50 versus national average 500
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Study Results

• 10 Success Characteristics of High Performing
  Clinical Units
• Step 1 Review Handout and complete the
  Microsystem Assessment
• The 5 Ps Purpose, Patients, Professionals,
  Processes, and Patterns
• Step 2 Review document and work on
  Professionals and Process Handout

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We found 10 Success Characteristics that are
associated with high performance

1. Strong Leadership
2. Great Organizational Support
3. Focus on Staff (Professionals)
4. Education and Training of Staff
5. Interdependence of Care Team
6. Performance Result Focused
7. Process Improvement Focused
8. Patient-Centered (Patient Focus)
9. Community and Market Focus
10. Information Information Technology Orientation

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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 my job and leave little room for innovation and autonomy. Overall, they dont always foster a positive culture. Leaders struggle to find the right balance between reaching performance goals and supporting and empowering the staff. Leaders maintain constancy of purpose, establish clear goals and expectations, and foster a respectful positive culture. Leaders take time to build knowledge, review and reflect, and take positive action in the Microsystem and the larger organization
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The 5 Ps 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)

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Purpose
Processes
Patients
Patterns
Professionals
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The 5 Ps 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
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The 5 Ps 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?
• List your top 10 Diagnosis
• Pt. Population Census
• Additional patient information, ______________?
• Family Surveys, Capturing patient information on
  an ongoing basis . . .

PGS 59 70 in Action Guide
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The 5 Ps 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

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The 5 Ps 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)
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The 5 Ps 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
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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

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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

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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
• Complete Microsystem Assessment Tool.
• Pick Options in action guide, which Tools to
  use, set goals (What, Who, and How of project).
• Phase 2 Gather Data, Flowcharting Mapping
  Processes
• Do a site visit interviews, and capture key
  Q, , Process Measures.
• Patient IT Flowcharting, Small work group
  meetings.
• Foster MS Improvement Culture.

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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
• Crunch and analyze the data (project specific
  measures).
• KEEP ENERGY HIGH for project, support support
  support!
• Provide on-going feedback of measures (Patterns).
• Phase 4 Finish Work, Present Outcomes, Work on
  Spread
• Congratulate and Celebrate Successes.
• Review what we learned, provide feedback, and
  document changes.
• Plan for next phase (Intra-Unit and Inter-Unit
  Spread), Utilize High Energy from project for
  spread.

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Learning from Eight Years of Microsystem and CQI
Work

• IHI workshops, symposium, teaching, and training
• Microsystem assessments, and CQI work at various
  Clinics
• Culture Redesign e.g., NICU Dartmouth Lahey
  Hospital

• Strong Vision and Mission is needed - at the unit
  level (Purpose). We need strong local and senior
  leadership for real change to happen.
• Do interviews, gather objective data, manage the
  process, be alert for hidden gems (LHF). Work at
  the microsystem level for effective lasting
  change .
• Include the right staff, facilitate conversation,
  be open to surprises. Emphasize fluidity and
  flexibility during the spread of change.

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Learning from Eight Years of Microsystem and CQI
Work

• Redesign, IT Infrastructure, Change Management
  27 Kaiser Intensive Care Units
• Patient and Information Flow (lean thinking)
  e.g., Keene Clinic Redesign
• Technology Adoption UCSF - Stanford Hospitals

• The Planning Phase is crucial in PDSA, and
  critical for HER. First map the processes then
  implement the HER.
• Mapping processes creates energy, highlights
  areas for change, and gets staff buy-in. Having
  an outside support person is helpful in lean
  thinking mapping.
• Work with underlying (hidden) agendas to make
  changes. Use the creativity of the
  Professionals(they know what needs to be done).

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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.

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Questions and Comments
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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)

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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
  199975-87.

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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.