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Microsystems In Health Care: Part 2. Creating A Rich Information Environment
Abstract
A rich information environment supports the functioning of the small, functional, frontline units--the microsystems--that provide most health care to most people. Three settings represent case examples of how clinical microsystems use data in everyday practice to provide high-quality and cost-effective care.
At The Spine Center at Dartmouth, Lebanon, New Hampshire, a patient value compass, a one-page health status report, is used to determine if the provided care and services are meeting the patient's needs. In Summit, New Jersey, Overlook Hospital's emergency department (ED) uses uses real-time process monitoring on patient care cycle times, quality and productivity indicator tracking, and patient and customer satisfaction tracking. These data streams create an information pool that is actively used in this ED icrosystem--minute by minute, hourly, daily, weekly, and annually--to analyze performance patterns and spot flaws that require action. The Shock Trauma Intensive Care Unit (STRICU), Intermountain Health Care, Salt Lake City, uses a data system to monitor the "wired" patient remotely and share information at any time in real time. Staff can complete shift reports in 10 minutes.
Information exchange is the interface that connects staff to patients and staff to staff within the microsystem; microsystem to microsystem; and microsystem to macro-organization.
... The metrics can provide accurate, timely, and easily accessible information on (1) patient needs and expectations; (2) care and services to be provided; (3) clinical outcomes; and (4) performance of care pathways in real time and in a scalable manner. 2,4,[10][11][12] Another way to describe the CMS approach is with a high-level diagram that portrays a typical microsystem's structure, which Godfrey et al. 7 call the "5 P's": purpose, patients, professionals, process, and patterns. Recently, another important element appeared in the literature, namely the sixth "P," a reference to educational intention and learning strategies. ...
... Recently, another important element appeared in the literature, namely the sixth "P," a reference to educational intention and learning strategies. [12][13][14] Despite widespread implementation of the CMS approach across multiple countries, 3,4,[15][16][17][18][19] general practice (GP) clinics, 3,15,[20][21][22][23][24][25][26][27][28][29][30][31][32] specialized care units, 16,18,19,23,[33][34][35][36][37][38][39][40][41] and emergency and ambulatory units, 10,34,42 the published evaluations of CMS performance in terms of tangible results remain unclear. To the best of our knowledge, no systematic review has documented, critically appraised, and synthesized the best available evidence on the effectiveness of implementing CMS within health care settings, and evaluated the ability of CMS to achieve the goals for which they were developed. ...
... We identified the themes reported in Table 2. Twentyseven of the 35 studies were conducted in the United States, 4,10,21-36,38-42,51,52 including 11 4,10,16,23,28,29,31,34,41,52 by researchers affiliated with the Dartmouth Institute, developer and pioneer of the CMS approach. Various methodological approaches were used by the authors. ...
... The metrics can provide accurate, timely, and easily accessible information on (1) patient needs and expectations; (2) care and services to be provided; (3) clinical outcomes; and (4) performance of care pathways in real time and in a scalable manner. 2,4,[10][11][12] Another way to describe the CMS approach is with a high-level diagram that portrays a typical microsystem's structure, which Godfrey et al. 7 call the "5 P's": purpose, patients, professionals, process, and patterns. Recently, another important element appeared in the literature, namely the sixth "P," a reference to educational intention and learning strategies. ...
... Recently, another important element appeared in the literature, namely the sixth "P," a reference to educational intention and learning strategies. [12][13][14] Despite widespread implementation of the CMS approach across multiple countries, 3,4,[15][16][17][18][19] general practice (GP) clinics, 3,15,[20][21][22][23][24][25][26][27][28][29][30][31][32] specialized care units, 16,18,19,23,[33][34][35][36][37][38][39][40][41] and emergency and ambulatory units, 10,34,42 the published evaluations of CMS performance in terms of tangible results remain unclear. To the best of our knowledge, no systematic review has documented, critically appraised, and synthesized the best available evidence on the effectiveness of implementing CMS within health care settings, and evaluated the ability of CMS to achieve the goals for which they were developed. ...
... We identified the themes reported in Table 2. Twentyseven of the 35 studies were conducted in the United States, 4,10,21-36,38-42,51,52 including 11 4,10,16,23,28,29,31,34,41,52 by researchers affiliated with the Dartmouth Institute, developer and pioneer of the CMS approach. Various methodological approaches were used by the authors. ...
Objectives
Faced with the increased expectations on the quality and safety of health care delivery systems, a number of stakeholders are increasingly looking for more efficient ways to deliver care.
This study was conducted in order to provide a critical appraisal and synthesize the best available evidence on the impact of implementing clinical microsystem (CMS) on quality of care and safety of the health care delivery.
Data sources
A comprehensive and systematic search of six electronic databases, from 1998 to 2018, was conducted to identify empirical literature published in both English and French, evaluating the impact of implementing CMS in healthcare settings.
Data extraction
Independent reviewers screened abstracts, read full texts, extracted data from the included studies, and appraised methodological quality assessments.
Results
Of the 1,907 records retrieved, 35 studies met the inclusion criteria. The settings included general practice clinics (n=18), specialized care units (n=14), and emergency and ambulatory units (n=3). The implementation of CMS helped to develop the patient-centered approach, to promote interdisciplinarity and quality improvement skills, to increase the fluidity of the clinical acts performed, and to increase patient safety. It contributed to increasing patients’ and clinicians’ satisfaction, as well as reducing hospital length of stay and reducing hospital-acquired infections. The implementation of CMS also contributed to the development and refinement of diagnostic tools and measurement instruments.
Conclusion
The CMS is unique, because of the primacy given to the quality of care offered and the safety of patients over any other consideration and its ability to redesign the health care delivery systems. Efforts still need to be made to legitimize the approach in various healthcare settings worldwide.
... A microsystem is a team of healthcare staff who regularly work together to provide care to patients. Such frontline teams, when supported by a trained improvement coach, can play an important role improving the quality of care [23][24][25][26]. The Clinical Microsystem approach has resulted in improvements in a wide range of areas including hypertension control [27], cystic fibrosis [28], and perinatal care. ...
... In 2011 CHCI began using the Clinical Microsystems quality improvement methodology [22,[24][25][26][31][32][33][34] as part of an agency-wide effort to improve the quality of patient care and empower frontline staff to play an active role in systems redesign. A Clinical Microsystem is a team whose members work together on a regular basis providing clinical care or other services and have been provided with appropriate training, support, and guidance to work together to improve performance. ...
Objective: Care coordination is a core competency for primary care nurses and an essential element of the Patient Centered Medical Home (PCMH) model. Implementing care coordination in primary care is challenging and requires changes in roles, staffing, and culture. Clinical Microsystems are frontline teams of healthcare staff that, when engaged in quality improvement, can make important contributions towards practice redesign. We used a Microsystem team to develop an effective model to integrate nurse care coordinators into a busy primary care center.
Methods: A Clinical Microsystem team, supported by an improvement coach, met weekly for one year to develop and test a new nurse staffing model in a large Federally Qualified Health Center. Intervention uptake and impact on workflow was tracked by direct observation of nurses and by measuring volume of nursing visits and virtual contacts. Nurses in a non-participating site with similar characteristics served as a comparison group.
Results: The Microsystem team developed and implemented a new nurse care coordination model for their site. The intervention emphasized patient self-management, independent nursing visits, and hospital and emergency room transition support. The nurse care coordinator in this new role managed 335 patients over a nine-month study period. The nurse in this new role spent 276 minutes over two days of observation engaged in direct care coordination work while two nurses at the comparison site spent only 94 minutes and 149 minutes, respectively, over the same time period.
Conclusion: Engaging front line staff is an effective way for organizations to make changes in delivery systems, improve quality and spread innovations. In this study, a Microsystem team developed a model to provide key components of care coordination to support PCMH practice redesign at a large community health center.
... The microsystem has sufficient capacity and resources to carry out its tasks but also to continuously improve the quality of its work. Batalden et al. (2003), but also Nelson et al. (2002, p. 474, emphasis in original) provide a definition of microsystems: ...
... Obviously, the capacities of a microsystem team and the way the team continuously learns to improve its capacity are of outmost importance for a sustainable work system. Previous research has identified several factors, crucial for team learning, in a microsystem context (Batalden et al. 2003;Mohr and Donaldson 2000). A first such crucial factor is the team's access to the results of its performance, feeding this information into iterative dialogues, the purpose of which are to learn in order to continuously improve the work of the team. ...
The aim of this chapter is to suggest some ways in which the promotion of social and human sustainability at work may contribute positively to a work system’s ecological and economic sustainability. We also explore conceptual and practical ways to encourage the sustainability of social and human resources in contemporary working life. Throughout the chapter, we exemplify our arguments with case illustrations from the Skaraborg Hospital Group in Sweden. We discuss how the unwavering goals of protecting and regenerating various resources in work-system operations are critical hallmarks of a sustainable work system. We also outline some worldviews and ways of thinking that seem to underlie the operations of sustainable work systems. We then delineate the implications of the resource regeneration goals and sustainability-minded ways of thinking for work-system actors. Most importantly, we propose that sowing seeds for sustainability involves engaging co-workers with different knowledge and professional backgrounds in on-going learning dialogues concerning the actual development of the whole system.
... Moreover, successful microsystems often share a culture of respect and common values, providing an inviting community to new co-workers. A patient focus is equally important, where the patient and his/her relatives could be regarded as parts of the clinical microsystem (Batalden et al., 2003). From studying 40 efficient microsystems in the US, Mohr & Donaldsson (2000) could identify some common features. ...
... The team has drawn on three quite distinct logics functioning simultaneously as a shop for care provision on discrete medical conditions, as a chain for ensuring that these are coherently integrated and consistent with patient needs as well as working within the broader network that comprises the healthcare system of the area as a whole. We have argued in the chapter that this team can be seen as an instructive illustration of a clinical microsystem (Batalden et al., 2003). ...
Purpose – This chapter examines the developmental journey toward a sustainable health care system in the West of Skaraborg County in Sweden from 2008 to the present by proposing and illustrating the concept of a clinical microsystem to capture the work of a mobile team to care for elderly people with multiple diseases in its embedded context.
Design – An action research approach was adopted that entailed four researchers, one of whom was also a health care practitioner, engaging in iterative dialogues with the mobile team. This aimed at catalyzing joint learning in repeated action-reflection cycles at least three times a year over a period of 3 years. Data from patient databases were also drawn upon as additional resources for reflection.
Findings – The outcome of the initial periods of the team's work in the microsystem dramatically improved the care of these patients, significantly increasing quality of life and stabilizing their medical situation. It has also led to decreased resource utilization, not just by the team, but elsewhere in the wider health system.
Originality/value – We draw on and develop the concept of clinical microsystems to argue that such systems have a team at their core, but their work practices and patient outcomes require us to look beyond the team itself and take into account its interactions with patients and actors in the wider health care system. We also draw on the framework of Christensen, Grossman, and Hwang (2009) to propose that each microsystem has three distinct value configurations, namely shops, a chain, and a network. In terms of design, we suggest that the clinical microsystem can be seen as a parallel learning structure to that of the established health care bureaucracy.
... One of the most compelling benefits of the CFFPR to CF care providers is the value it brings during the clinical encounter for both patients and providers. 24 CF centre staff can download patient reports from PortCF that provide structured data on clinic visits, hospitalisations, and longitudinal displays of microbiology, nutritional measures and lung function ( figure 4). These reports are used by clinicians to prepare for patient visits at preclinic meetings, and may also be shared with patients to help initiate discussions to promote disease self-management. ...
... which they are providing intended care and attaining target outcomes. 24 They can generate histograms of key outcomes and processes (similar to those shown in figure 2) with up-to-date data they have entered into the CFFPR, providing real-time tracking of any process improvement efforts. Port CF contains tools to easily obtain a variety of preformatted reports, such as a list of patients who have not been seen in clinic in 3 months (the recommended interval) and 6 months; patients due for a nutrition or social work visit; patients who meet guideline recommendations for different therapies and whether they have been prescribed those therapies; and patients who meet entry criteria for various multicenter clinical trials being Figure 3 Programme-specific reports available to the general public at http://www.cff.org/LivingWithCF/CareCenterNetwork/ ...
The US Cystic Fibrosis Foundation (CFF) began in 1955 with a mission to support the development of new drugs to fight the disease, improve the quality of life for those with cystic fibrosis (CF), and ultimately to find a cure for this disease.1 The CFF does this by supporting basic science and clinical research in CF, supporting the care of CF patients through accredited CF centres nationwide and advocating for CF patients at the state and national level.
Recognising the critical role of data collection and measurement of outcomes to better understand the natural history of CF, the CFF created a patient registry in 1966, the CFF Patient Registry (CFFPR).2 The CFFPR has evolved over the years from a few demographic variables including vital status to a comprehensive database that gives healthcare providers, researchers, policy makers and change agents data to support epidemiological and clinical research as well as efforts to improve quality of care.
The specific purpose of this commentary is to describe the CFFPR and primarily to focus on how the CFFPR and its associated tools are being used for quality improvement (QI) activities, with the hope that it may help CF healthcare teams in the USA who are not familiar with the registry's capabilities, CF providers outside the USA with registries at various stages of development, and others interested in how a patient registry has been used to improve care.
The CFFPR contains detailed demographic and diagnostic data dating back to 1986 with current annual and encounter-based data on over 300 unique variables including outcomes (eg, microbiology, lung function and nutritional metrics, CF complications) and care processes (eg, hospitalisations, medications, surveillance measures) for each of its more than 27 000 participants in 2012; in all, there are over 46 000 unique individuals’ data in the registry.3 …
... In a previous paper the need for infection prevention and control teams (IPCT) to be 'data driven' was emphasised (Curran and Wilson, 2008). In the same paper the authors suggested that IPCT consider using the clinical microsystem (CMS) to aid their work (Nelson et al, 2003). A clinical microsystem is the smallest clinical unit in a healthcare system (Nelson et al, 2002). ...
... Effective CMSs are also involved in interpreting data. Data should be considered as the cog which enables systems to constantly assess performance and modify processes to optimise and attain reliability (Nelson et al, 2003). Data collection should not be burdensome. ...
Process and outcome data are essential to evaluate the effectiveness of infection prevention and control teams (IPCT). Data are used for: the identification of possible outbreaks, surveillance of healthcare associated infections, monitoring the epidemiology of alert organisms, monitoring IPC practices, creating arguments for the need to change practices, and demonstrating whether the changes in practices have been effective in improving outcomes. Today the IPCT can be data rich without being intelligence rich. It is critical that IPCT are able to generate targets for improving patient safety. Also the IPCT must be able to easily read, interpret and discuss data so that the effects of change can be measured, communicated and understood. This paper details a 10-point plan to make straightforward the use of data in creating arguments for, and the measuring of, system change to drive improvements and reduce infection outcomes.
... SRQ is one example where the model is associated with improved clinical outcomes [22]. The model has evolved in parallel with, and been influenced by, Clinical Microsystem theory and practice [23], approaches to shared decision-making (SDM) [24] and the Clinical Value Compass framework [25]. The model has been visualized in different versions with the latest shown in Figure 1 [21]. ...
Background
Co-production of health is defined as ‘the interdependent work of users and professionals who are creating, designing, producing, delivering, assessing, and evaluating the relationships and actions that contribute to the health of individuals and populations’. It can assume many forms and include multiple stakeholders in pursuit of continuous improvement, as in Learning Health Systems (LHSs). There is increasing interest in how the LHS concept allows integration of different knowledge domains to support and achieve better health. Even if definitions of LHSs include engaging users and their family as active participants in aspects of enabling better health for individuals and populations, LHS descriptions emphasize technological solutions, such as the use of information systems. Fewer LHS texts address how interpersonal interactions contribute to the design and improvement of healthcare services.
Objective
We examined the literature on LHS to clarify the role and contributions of co-production in LHS conceptualizations and applications.
Method
First, we undertook a scoping review of LHS conceptualizations. Second, we compared those conceptualizations to the characteristics of LHSs first described by the US Institute of Medicine. Third, we examined the LHS conceptualizations to assess how they bring four types of value co-creation in public services into play: co-production, co-design, co-construction and co-innovation. These were used to describe core ideas, as principles, to guide development.
Result
Among 17 identified LHS conceptualizations, 3 qualified as most comprehensive regarding fidelity to LHS characteristics and their use in multiple settings: (i) the Cincinnati Collaborative LHS Model, (ii) the Dartmouth Coproduction LHS Model and (iii) the Michigan Learning Cycle Model. These conceptualizations exhibit all four types of value co-creation, provide examples of how LHSs can harness co-production and are used to identify principles that can enhance value co-creation: (i) use a shared aim, (ii) navigate towards improved outcomes, (iii) tailor feedback with and for users, (iv) distribute leadership, (v) facilitate interactions, (vi) co-design services and (vii) support self-organization.
Conclusions
The LHS conceptualizations have common features and harness co-production to generate value for individual patients as well as for health systems. They facilitate learning and improvement by integrating supportive technologies into the sociotechnical systems that make up healthcare. Further research on LHS applications in real-world complex settings is needed to unpack how LHSs are grown through coproduction and other types of value co-creation.
... Many doctors have become incrementally exhausted and have adopted a detached state of mind which may have led to marginalisation (British Medical Association, 2013). The consultants do their work in established ways without significant regard for management control systems, metrics-based performance management and competitiveness (Farrell & Morris, 1999, 2003. Having a detached state of mind takes effort and discursive justification. ...
The substantive area explored in this article is hospital consultants in an English Acute NHS hospital dealing routinely with increasing managerialism. Data were drawn from 49 interviews with hospital consultants, at one English Acute NHS hospital Trust. The classic grounded theory named "Rolling with the Punches" that emerged was enriched by literature relating to everyday resistance, labour process theory, institutional complexity and organisation studies by considering public and private (internal) scripts. Interpretation of the emergent theory also drew from everyday resistance narratives from rural peasantry applied to the highly qualified public sector hospital professionals. The theory reiterates the role of discursive resistance in the workplace.
... Most of the CMS literature stems from a series of papers in different areas of healthcare in North America (Nelson et al., 2002;Nelson et al., 2003;Godfrey et al., 2003;Wasson et al., 2003;Mohr et al., 2003;Kosnik and Espinosa, 2003;Huber et al., 2003;Nelson et al., 2008;Wasson et al., 2008;Godfrey et al., 2008;McKinley et al., 2008). More recent UK and global examples are largely within the hospital environment Likosky, 2014) and it is difficult to ascertain what improvements are directly attributable to the approach . ...
Background
Changes to the general practice (GP) contract in England (April 2019) introduced a new quality improvement (QI) domain. The clinical microsystems programme is an approach to QI with limited evidence in primary care.
Aim
To explore experiences of GP staff participating in a clinical microsystems programme.
Design and setting
GPs within one clinical commissioning group (CCG) in South East England. Normalisation process theory informed qualitative approach.
Method
Review of all CCG clinical microsystems projects using pre-existing data. The Diffusion of Innovation Cycle was used to inform the sampling frame and GPs were invited to participate in interviews or focus groups. Ten practices participated; 11 coaches and 16 staff were interviewed.
Results
The majority of projects were process - driven activities related to administrative systems. Projects directly related to health outputs were fewer and related to externally imposed targets. Four key elements facilitated practices to engage: feeling in control; receiving enhanced service payment; having a senior staff member championing the approach; and good practice–coach relationship. There appeared to be three key benefits in addition to project-specific ones: improved working relationships between CCG and practice; more cohesive practice team; and time to reflect.
Conclusion
Small projects with clear parameters were more successful than larger ones or those spanning organisations. However, there was little evidence suggesting the key benefits were unique attributes of the microsystems approach and sustainability was problematic. Future research should focus on cross-organisational approaches to QI and identify what, if any, added value the approach provides.
... Because of the interactive nature of supports, the structure and the culture of DSS teams are pivotal. In the author's view, the concept of 'microsystems' proposed by Nelson et al. (2002Nelson et al. ( , 2003Nelson et al. ( , 2007 and Batalden & Splaine (2002) may present a solution. Microsystems refer to functional front-line teams that provide direct services to a well-defined group of clients. ...
Background Increasing emphasis on financial and administrative control processes is affecting service culture in support organisations for persons with intellectual disability. This phenomenon is currently obvious in Dutch service organisations that find themselves in transition towards more community care and at the same time under pressure from new administrative and funding managerial bureaucracy. As a result, the logic of management is becoming more dominant in direct support settings and risk to overshadow the logic of relationships between staff and clients. Method The article presents a reflection on this phenomenon, starting from a description of service team characteristics as found in the literature. Next, findings about direct support staff (DSS) continuity are summarised from four Dutch studies. Following up these findings, the concept of 'microsystems' is explored as a possible answer to the organisational challenges demonstrated in the studies. Results Team characteristics, especially team size and membership continuity for DSS, appear relevant factors for assuring supportive relationships and service quality in direct support teams. The structure of the primary support team shows to be of special interest. The organisational concept of 'microsystems' is explored with respect to transcending the present conflict between bureaucratic managerial pressure and the need for supportive relationships.
Buntinx, W. (2008). The logic of relations and the logic of management. Journal of Intellectual Disability Research, 52 (7), 558-597
... The CMS approach is based on the assumption that the quality of care provided by a health system can be no better than that delivered by the functional units of which the system is composed. The CMS methodology is designed to enable transformation of care through engaging frontline multi-professional healthcare staff in the microsystem, along with patients and carers (Nelson and Batalden, 2003). ...
Aim
To identify learning from a clinical microsystems (CMS) quality improvement initiative to develop a more integrated service across a falls care pathway spanning community and hospital services.
Background
Falls present a major challenge to healthcare providers internationally as populations age. A review of the falls care pathway in Sheffield, United Kingdom, identified that pathway implementation was constrained by inconsistent co-ordination and integration at the hospital–community interface.
Approach
The initiative utilised the CMS quality improvement approach and comprised three phases. Phase 1 focussed on developing a climate for change through engaging stakeholders across the existing pathway and coaching frontline teams operating as microsystems in quality improvement. Phase 2 involved initiating change by working at the mesosystem level to identify priorities for improvement and undertake tests of change. Phase 3 engaged decision makers at the macrosystem level from across the wider pathway in achieving change identified in earlier phases of the initiative.
Findings
The initiative was successful in delivering change in relation to key aspects of the pathway, engaging frontline staff and decision makers from different services within the pathway, and in building quality improvement capability within the workforce. Viewing the pathway as a series of interrelated CMS enabled stakeholders to understand the complex nature of the pathway and to target key areas for change. Particular challenges encountered arose from organisational reconfiguration and cross-boundary working.
Conclusion
CMS quality improvement methodology may be a useful approach to promoting integration across a care pathway. Using a CMS approach contributed towards clinical and professional integration of some aspects of the service. Recognition of the pathway operating at meso- and macrosystem levels fostered wider stakeholder engagement with the potential of improving integration of care across a range of health and care providers involved in the pathway.
... Drs. Paul Batalden and Eugene Nelson adapted Deming's and Quinn's work to health care organizations, publishing a series of articles on Bclinical microsystems^ [38][39][40][41][42][43][44][45][46][47][48][49][50]. Our own institution adapted the Bclinical microsystem^model, combined with an emphasis on training front-line, unit-based leaders in quality improvement and leadership skills [49,[51][52][53]. ...
Opinion statement
ᅟThe USA has one of the most expensive health care delivery systems in the world. As a result, US hospitals are focusing on improving operational efficiency and safety in order to deliver higher value, in terms of outcomes, experiences, and costs. The kinds of change that are required are transformational in nature. Transformational change is a kind of continuous change that represents a fundamental shift in the priorities, strategies, and culture of an organization. Herein, we will review the concept of operational excellence as one management approach that has been used to achieve transformational change. Operational excellence is really about achieving process reliability through continuous process improvement, which translates to better outcomes, better experiences, and lower costs.
... UW Health, a large Midwestern academic medical center, underwent a comprehensive primary care redesign which included strategies at the system, clinic, and care team levels. At the care team level, the redesign initiative adopted a microsystem approach, [18][19][20][21] using trained coaches to support team and QI skill development across five team cohorts over 4 years. It turned to consultants at the Center for Patient Partnerships (CPP), a patient advocacy center housed at the University of Wisconsin-Madison, to collaboratively develop a program which engaged volunteer patients as part of team QI efforts. ...
... De svar som avspeglar att man inte testat sina reservrutiner, att man inte diskuterar dessa visar på en bristande delaktighet som medarbetarna måste ha i ett väl fungerande microsystem (Wasson et al, 2003). Har man inte en engagerad medarbetare i arbetsgruppen ändrar man inte arbetssättet (Kotter, 1996). ...
... De menar att det gäller att samla den kompetens som finns kring de individer vården finns till för och skapa dynamiska team för att bidra till en effektiv och god vård, och att denna typ av förändringspsykologi är viktig att tillämpa hos medarbetare och grupper för att kunna skapa en välfungerande verksamhet som helhet. Batalden et al. (1993) och Langley et al. (1996) (Nelson et al., 2002;Nelson et al. 2003). ...
... 11 In this model, information is the feeder system to support the four key factors for success in a microsystem: leadership, staff, patients and performance. 12 These factors formed the conceptual foundation for understanding how variance in clinical microsystem may affect changes in barriers of care or system success. ...
As practice recommendations and guidelines accumulate, the healthcare system continues to depend on clinician heroes to work harder and faster to meet increasing demands. Population health management requires healthcare to move towards systems based designs, and move away from depending on individual patient visits. However, the implementation of a change in care delivery has to be endorsed by providers or it is doomed to fail, and frontline providers can singularly provide critical insight into the successes and failure of the system. The Diabetes-Depression Care-management Adoption Trial (DCAT) is evaluating an automated telephonic assessment tool for depression in a primary care setting. The technology tool was designed to shift routine depression screening and symptom monitoring from providers to machines and used the information to automatically alert providers of those patients in need of follow-up. Therefore, providers can have more time dedicated to proactive, compassionate care. This article first proposes a conceptual framework for evaluating provider responses to such system-based redesign of healthcare delivery. The conceptual framework focuses on barriers to providing recommended care, the success of the information system implementation, and the role of cultural and organizational characteristics.
... The Dartmouth Institute for Health Policy and Clinical Practice pioneered the development of improvement science as it applies to health systems [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]. This knowledge is encapsulated in the Microsystems Quality Improvement Approach, a comprehensive approach to quality improvement (QI) practice grounded in systems thinking and coupled with intensive coaching. ...
Although global efforts to support routine immunization (RI) system strengthening have resulted in higher immunization rates, the World Health Organization (WHO) estimates that the proportion of children receiving recommended DPT3 vaccines has stagnated at 80% for the past 3 years (WHO Fact sheet-Immunization coverage 2014, WHO, 2014). Meeting the WHO goal of 90% national DPT3 coverage may require locally based strategies to support conventional approaches. The Africa Routine Immunization Systems Essentials-System Innovation (ARISE-SI) initiative is a proof-of-concept study to assess the application of the Microsystems Quality Improvement Approach for generating local solutions to strengthen RI systems and reach those unreached by current efforts in Masaka District, Uganda.
The ARISE-SI intervention had three components: health unit (HU) advance preparations, an action learning collaborative, and coaching of improvement teams. The intervention was informed and assessed using qualitative and quantitative methods. Data collection focused on changes and outcomes of improvement efforts among five HUs and one district-level team during the intervention (June 2011-February 2012) and five follow-up months.
Workshops and team meetings had a 95% attendance rate. All teams gained RI system knowledge and implemented changes to address locally identified problems. Specific changes included: RI register implementation and expanded use, Child Health Card provision and monitoring, staff cross-training, staffing pattern changes, predictable outreach schedules, and health system leader-community leader meetings. Several RI system barriers prevalent across Masaka District (e.g., lack of backup HU gas cylinders, inadequate outreach transportation, and village health team underutilization) were successfully addressed. Three of five HUs significantly increased the vaccines administered. All improvements were sustained 5 months post-intervention. External evaluation validated the findings of high levels of participant engagement, empowerment to make change, and willingness to sustain improvements.
The Microsystems Quality Improvement Approach is a comprehensive approach, grounded in systems thinking, and coupled with intensive coaching. It provides a robust framework for engaging teams in the development of unique local solutions that strengthen RI systems in resource poor settings. The sustained improvements in local RI systems from this study provide evidence that this approach may be an effective framework for enhancing the WHO's Reaching Every District (RED) immunization strategy.
... This study was conducted as part of a formal evaluation of a primary care team building and quality improvement initiative based on the Dartmouth Clinical Microsystems approach. [26][27][28][29][30][31][32][33][34] Training primary care teams to make full use of technology are one of the organisational goals for this initiative. Two optimisation analysts were funded to work (1.8 full-time equivalent) with participating primary care teams to increase their competency in using the EHR. ...
Background:
Although the presence of an electronic health record (EHR) alone does not ensure high quality, efficient care, few studies have focused on the work of those charged with optimising use of existing EHR functionality.
Objective:
To examine the approaches used and challenges perceived by analysts supporting the optimisation of primary care teams' EHR use at a large U.S. academic health care system.
Methods:
A qualitative study was conducted. Optimisation analysts and their supervisor were interviewed and data were analysed for themes.
Results:
Analysts needed to reconcile the tension created by organisational mandates focused on the standardisation of EHR processes with the primary care teams' demand for EHR customisation. They gained an understanding of health information technology (HIT) leadership's and primary care team's goals through attending meetings, reading meeting minutes and visiting with clinical teams. Within what was organisationally possible, EHR education could then be tailored to fit team needs. Major challenges were related to organisational attempts to standardise EHR use despite varied clinic contexts, personnel readiness and technical issues with the EHR platform. Forcing standardisation upon clinical needs that current EHR functionality could not satisfy was difficult.
Conclusions:
Dedicated optimisation analysts can add value to health systems through playing a mediating role between HIT leadership and care teams. Our findings imply that EHR optimisation should be performed with an in-depth understanding of the workflow, cognitive and interactional activities in primary care.
... A front-line view focuses on what some have termed the clinical microsystem, where patient and provider encoun- ters occur, and from which the following additional contexts may affect QII implementation success: staff factors (eg, focus on hiring decisions and integration into team, performance expectations, education and training, interdependence of care team), patient factors (focus on patient needs, focus on community needs), performance factors (data feedback systems process improvement strat- egies), and information factors (technology, communica- tion). 26,27 The specific innovation processes contained in a QII typically occur at the micro level by individuals or groups of health care professionals; these micro level processes are supported, enhanced, or prevented by the macro condi- tions. 28 The interactions between micro and macro levels can influence the QII's success during early stages of im- plementation and especially during scale-up and spread of the intervention. ...
Growing consensus within the health care field suggests that context matters and needs more concerted study for helping those who implement and conduct research on quality improvement interventions. Health care delivery system decision makers require information about whether an intervention tested in one context will work in another with some differences from the original site. We aimed to define key terms, enumerate candidate domains for the study of context, provide examples from the pediatric quality improvement literature, and identify potential measures for selected contexts. Key sources include the organizational literature, broad evaluation frameworks, and a recent project in the patient safety area on context sensitivity. The article concludes with limitations and next steps for developments in this area.
... Panel management holds promise as a model that shifts a practice's focus from visit-based care to population-based care [7,8]. Panel management is defined as "a set of tools and processes for population care that are applied systematically at the level of the primary care panel, with physicians directing proactive care for their patients" [9]. With panel management, practices systematically identify patients from their panel with gaps in indicated care and use targeted outreach interventions to fill these gaps. ...
As primary care practices evolve into medical homes, there is an increasing need for effective models to shift from visit-based to population-based strategies for care. However, most medical teams lack tools and training to manage panels of patients. As part of a study comparing different approaches to panel management at the Manhattan and Brooklyn campuses of the VA New York Harbor Healthcare System, we created a toolkit of strategies that non-clinician panel management assistants (PMAs) can use to enhance panel-wide outcomes in smoking cessation and hypertension.
We created the toolkit using: 1) literature review and consultation with outside experts, 2) key informant interviews with staff identified using snowball sampling, 3) pilot testing for feasibility and acceptability, and 4) further revision based on a survey of primary care providers and nurses. These steps resulted in progressively refined strategies for the PMAs to support the primary care team.
Literature review and expert consultation resulted in an extensive list of potentially useful strategies. Key informant interviews and staff surveys identified several areas of need for assistance, including help to manage the most challenging patients, providing care outside of the visit, connecting patients with existing resources, and providing additional patient education. The strategies identified were then grouped into 5 areas -- continuous connection to care, education and connection to clinical resources, targeted behavior change counseling, adherence support, and patients with special needs.
Although panel management is a central aspect of patient-centered medical homes, providers and health care systems have little guidance or evidence as to how teams should accomplish this objective. We created a toolkit to help PMAs support the clinical care team for patients with hypertension or tobacco use. This toolkit development process could readily be adapted to other behaviors or conditions. Trial registration: NCT01677533 (www.clinicaltrials.gov).
... From the CAS perspective, strategies aim to stabilize the system through self-organization. Self-organization within a CMS requires continual flow of information and interaction among interrelated elements (Barach & Johnson, 2006;Batalden, Nelson, Edwards, Godfrey, & Mohr, 2003;Batalden, Nelson, Gardent, & Godfrey, 2005;Begun & Kaissi, 2004;Begun, Zimmerman, & Dooley, 2003;Clancy & Delaney, 2005;Holden, 2005;Nelson et al., 2003;Penprase & Norris, 2005;Yourstone & Smith, 2002;Zimmerman, Lindberg, & Plsek, 1998). ...
Nurses have a key role in keeping patients safe from medical errors because they work at the point of care where most errors occur. Nursing work at the intersection of patients and health care systems requires high levels of cognitive activity to anticipate potential problems and effectively respond to rapidly evolving and potentially harmful situations. The literature describes nursing work at the intersection of patient and health care system as well as barriers to providing safe patient care. However, little is known about the systems knowledge nurses use to negotiate the health care system on their patients’ behalf, or how this systems information is exchanged between nurses.
Using the clinical microsystem as the conceptual framework, this qualitative descriptive investigation identified and described: 1) the components of systems knowledge needed by nurses, 2) how systems information is exchanged between nurses, and 3) systems information exchanged between staff nurses and travel nurses. Data were collected from a stratified maximum variation sample of 18 nurse leaders, staff nurses, and travel nurses working within a high-functioning neonatal intensive care nursery within a large academic medical center in New England. Data collection methods included participant observation, document review, individual interviews, and a focus group session. Data were analyzed through constant comparison for emerging themes and patterns. Findings were compared for commonalities and differences within and across groups.
Three components of systems knowledge emerged: structural, operational, and relational. Systems information exchange occurred through direct and indirect means. Direct means included formal and informal mechanisms. The formal mechanism of orientation was identified by each participant. Informal mechanisms such as peer teaching, problem solving, and modeling behaviors were identified by participants from each of the three nurse groups. Travel nurses’ descriptions of the common themes focused on individual efficacy. Staff nurses focused on fostering smooth unit functioning. Nurse leaders described common themes from a perspective of unit development. Four overarching domains of systems information were exchanged between staff nurses and travel nurses: practice patterns; staffing patterns and roles; tips, tricks, tidbits, and techniques; and environmental elements. Communication emerged as a common theme across nurse groups and domains of systems information exchanged. These findings have implications for nursing orientation and staff development, continuous improvement at the local level, and curriculum development.
Background:
Systematic patient-reported outcome measure (PROM) collection is challenging for clinics, particularly when patients are not in the office. The Arthritis care through Shared Knowledge (ASK) study deployed multimodal approaches to collect PROMs using a clinical microsystem framework.
Conceptual model:
Informed by the clinical microsystem model, the authors coached 12 orthopedic practices to implement shared processes to support best practices for PROM collection and use. Orthopedic sites collected PROMs from new patients before the first office visit; patients completed the PROM from home via an online assessment in a personalized e-mail. Site staff placed follow-up phone reminders. At 6 and 12 months after the visit, PROMs were collected from home, prompted by an e-mail or phone call.
Performance outcomes:
Of the 25,043 new patients identified by clinical sites during the study enrollment, approximately 60% completed a pre-visit PROM-36.6% completed the online PROM after receiving a single automated e-mail, and an additional 31.1% completed the PROM after receiving a text, an e-mail, or a phone call from the staff. The remaining 32.2% of PROMs were collected on arrival at the office. Of patients completing PROMs, 11,140 were eligible to participate in longitudinal collection, and 51.3% consented. Of these, approximately 84% completed a 6-month survey, more than 83% completed a 12-month survey, and more than 91% completed either a 6-month PROM, a 12-month PROM, or both.
Learning:
This study illustrates that a multimodal approach to PROM collection using a clinical microsystem approach sustainably supports PROM completion rates. Further efforts are needed to define strategies to engage all patients in understanding and reporting PROMs to inform their care.
La notion de la complexité, appliquée en secteur de la santé, est l'objet de cette thèse. Trois sujets majeurs, interconnectés, ont été sélectionnés pour étudier la pertinence de cette notion, sa plus-value et son application : les maladies chroniques, la coordination et l'intégration des soins et les soins de proximité. Quatre parties forment cette thèse : 1. Une partie introductive de la notion de la complexité et sa pertinence en secteur de la santé. La revue de la littérature et les expériences étrangères ont permis d'approuver l'hypothèse de la complexité et la vitalité du système de santé, un système capable de s'adapter à la complexité (CAS). Le système de santé est une chaine d'effets : patient et communauté - microsystème -macro organisation- environnement (légal, éthique, financier, social, et régulateur, etc.). Cet effet domino et chacune de ses pièces sont déterminants. Les pièces clés sont les microsystèmes,des petites cellules ou les unités fonctionnelles de soins, en interaction avec la population. Ils produisent les soins et sont la source du changement, de la vitalité et de la transformation du système. 2. la 2eme partie rapproche le (CAS) aux maladies chroniques. Les valeurs, les acteurs, le malade, la durée et le caractère des soins, les pratiques et la médecine même subissent des évolutions et nécessitent un changement des comportements. La compréhension et l'étude des modèles récurrents de relations entre acteurs apportent une première réponse d'ordre éthique : tout commence par le sentiment de dépendance du malade et la redéfinition du modèle « rapport patient - médecin ». Un effet domino transforme tout le système de santé. L'empowerment est une notion essentielle pour un processus long de micro-changements (i) des malades (pour accepter, vivre et mieux gérer leur maladie) et (ii) des équipes de soins (médecin compris, pour revoir leurs rapports avec le malade et leurs rapports mutuels). Ces micro-changements se passent dans le microsystème. 3. la 3eme partie rapproche le (CAS) aux questions de la coordination et à l'intégration des soins pour les pathologies chroniques. Les questions de coordination préoccupent souvent le législateur français qui n'a pas hésité à créer les réseaux de santé. Selon un modèle reconnu, cette partie étudie les facteurs favorables à l'intégration (coordination) et réalise que le (CAS) est un pilier inéluctable : le parcours d'un malade se produit et s'orchestre dans le microsystème. Elle donne une explication au bilan mitigé des réseaux de santé: ils ne peuvent être des (CAS). Les résultats dégagés des deux études observationnelles avec des méthodes qualitatives menées sur les deux composantes principales du réseau - l'hôpital; la ville: (i) l'existence d'un esprit de (CAS) hospitalier à des niveaux variables de vitalité. Le microsystème, le plus vital, noue des interactions évidentes génératives avec tous les acteurs, en interne et avec la ville. Favorable au partage et à la coopération, il participe à la gestion des cas complexes. (ii) la méfiance et la compétition entre plusieurs acteurs de la ville freinent tout esprit de (CAS). 4. La 4eme partie rapproche la notion du (CAS) des communautés professionnelles territoriales de santé (CPTS) - et des plateformes territoriales d'appui (PTA), créées par le législateur français en 2016. Elle expose les étapes pour faire émerger un (CAS) de proximité. Elle apporte enfin des réponses aux interrogations relatives aux relations -réseau de santé- (PTA), aux modalités d'évaluation et d'amélioration. L'intégration des financements des soins de proximité semble incontournable pour réussir ce nouveau défi.
The idea of implementing specific interventions throughout the perioperative period to improve patient recovery has been proven to be beneficial. Whereas many approaches to enhanced recovery after surgery (ERAS) implementation may seem straightforward, careful advanced planning, multiple stakeholder involvement, and addressing other contextual constraints needed for program scale-up and sustainability are complex. The lack of clarity and descriptions of the implementation strategies, report on implementation variables, and the context under which the implementation occurs hinders learning and spread. Without the detailed context in which it was implemented, one is often led to disappointment or outright failure of spread and scale-up efforts. This chapter provides a framework and guidance on how clinicians and health-care leaders can work together to design, implement, and learn about ERAS improvement interventions more effectively, thus enhancing the scale-up, spread and return on investment in ERAS.
Purpose
There have been a growing number of leadership education programs for physicians. However, debates about the value and efficacy of leadership education in medicine persist, and there are calls for systematic and critical perspectives on medical leadership development. Here, we review evidence on postgraduate leadership education and discuss findings in relation to contemporary evidence on leadership education and practice.
Method
We searched multiple databases for papers on postgraduate leadership development programs, published in English between 2007 and 2017. We identified 4,691 papers; 31 papers met the full inclusion criteria. Data regarding curricular content and design, learner demographics, instructional methods, and learning outcomes were abstracted and synthesized.
Results
There was modest evidence for effectiveness of programs in influencing knowledge and skills gains in select domains. However, the conceptual underpinnings of the ‘leadership’ training delivered were often unclear. Contemporary theory and evidence on leadership practice was not widely incorporated in program design. Programs were almost exclusively uni-professional, focused on discrete skill development, and did not address systems-level leadership issues. Broader leadership capacity building strategies were underutilized. A new wave of longitudinal, integrated clinical and leadership programming is observed.
Conclusions
Our findings raise questions about persistent preparation-practice gaps in leadership education in medicine. Leadership education needs to evolve to incorporate broader collective capacity building, as well as evidence-informed strategies for leadership development. Barriers to educational reform need to be identified and addressed as educators work to re-orientate education programs to better prepare budding physician leaders for the challenges of health system leadership.
Introduction:
The collection of patient-reported outcomes (PROs) in routine clinical practice provides opportunities to "feed-forward" the patient's perspective to his/her clinical team to inform planning and management. This data can also be aggregated to "feedback" population-level analytics that can inform treatment decision-making, predictive modeling, population-based care, and system-level quality improvement efforts.
Methods aiding interpretation and acting on results:
Three case studies demonstrate a number of system-level features which aid effective PRO interpretation: (1) feed-forward and feedback information flows; (2) score interpretation aids; (3) cascading measurement; (4) registry-enabled learning health care systems; and (5) the maturational development of information systems.
Discussion:
The case studies describe the developmental span of feed-forward PRO programs-from simple to mature applications. The Concord Hospital (CH) Multiple Sclerosis Neurobehavioral Clinic exemplifies a simple application in which PRO data are used before and during clinic visits by patients and clinicians to inform care. The Dartmouth-Hitchcock (D-H) Spine Center exemplifies a mature program which utilizes population-level analytics to provide decision support by predicting outcomes for different treatment options. The Swedish Rheumatology Quality (SRQ) Registry epitomizes an exceptional application which has spread to multiple systems across an entire country.
Key points:
Feed-forward and feedback PRO information systems can better inform, involve, and support clinicians, patients and families, and allow health systems to monitor and improve system performance and population health outcomes. Ideal systems have the capability for multilevel analyses at patient, system, and population levels, and an information technology infrastructure that is linked to associated workflows and a supportive practice culture. As systems mature, they progress beyond the ability to describe and inform towards higher level capabilities including prediction and decision support. Finally, there is additional promise for the integration of patient-reported information that is adjusted (or weighted) by preferences and values to guide shared decision-making and inform individualized precision health care in the future.
Background and objectives:
Primary care physician compensation structures have remained largely volume-based, lagging behind changes in reimbursement that increasingly include population approaches such as capitation, bundled payments, and care management fees. We describe a population health-based physician compensation plan developed for two departmental family medicine faculty groups (residency teaching clinic faculty and community clinic faculty) along with outcomes before and after the plan's implementation.
Methods:
An observational study was conducted. A pre-post email survey assessed satisfaction with the plan, salary, and salary equity. Physician retention, panel size, and relative value unit (RVU) productivity metrics also were assessed before and after the plan's implementation.
Results:
Before implementation of the new plan, 18% of residency faculty and 33% of community faculty were satisfied or very satisfied with compensation structure. After implementation, those numbers rose to 47% for residency physicians and 74% for community physicians. Satisfaction with the amount of compensation also rose from 33% to 68% for residency faculty and from 26% to 87% for community faculty. For both groups, panel size per clinical full-time equivalent increased, and RVUs moved closer to national benchmarks. RVUs decreased for residency faculty and increased for community faculty.
Conclusions:
Aligning a compensation plan with population health delivery by moving rewards away from RVU productivity and toward panel management resulted in improved physician satisfaction and retention, as well as larger panel sizes. RVU changes were less predictable. Physician compensation is an important component of care model redesign that emphasizes population health.
Comment trouver et utiliser les connaissances qui peuvent assurer que l’amélioration débouche sur un accroissement de la valeur ? Des connaissances actionnables sont la base de la pratique du leader de l’amélioration de la valeur et le fondement pour un service qui poursuit cet objectif. Une capacité à trouver et à utiliser efficacement des connaissances pratiques sera déterminante pour le succès de l’amélioration de la valeur et du service.
Background:
Primary care is considered the foundation of an effective health care system. However, primary care departments at academic health centers have numerous challenges to overcome when trying to achieve the Triple Aim.
Methods:
As part of an organizational initiative to redesign primary care at a large academic health center, departments of internal medicine, general pediatrics and adolescent medicine, and family medicine worked together to comprehensively redesign primary care. This article describes the process of aligning these three primary care departments: defining panel size, developing a common primary care job description, redesigning the primary care compensation plan, redesigning the care model, and developing standardized staffing.
Results:
Prior to the initiative, the rate of patient satisfaction was 85%, anticoagulation measurement 65%, pneumococcal vaccination 85%, breast cancer screening 79%, and colorectal cancer screening 69%. These rates all improved to 87%, 75%, 88%, 80%, and 80% respectively. Themes around key challenges to departmental integration are identified: (1) implementing effective communication strategies; (2) addressing specialty differences in primary care delivery; (3) working within resource limitations; and (4) developing long-term sustainability.
Conclusions:
Primary care in this large academic health center was transformed through developing a united primary care leadership team that bridged individual departments to create and adopt a common vision and solutions to shared problems. Our collaboration has achieved improvements across patient satisfaction, clinical safety metrics, and publicly-reported preventive care outcomes.
Implications:
The description of this experience may be useful for other academic health centers or other non-integrated delivery systems undertaking primary care practice transformation.
Nurses working in hospitals with paper-based systems often face the challenge of inefficiency in providing quality nursing care. Two areas of inefficiency are shift-to-shift communication among nurses, and access to information related to patient care. An integrated IT system, consisting of Pocket PCs and a desktop PC inter-faced to a hospital's mainframe system, was developed. The goal was to use mobile IT to give nurses easier access to patient information. This chapter describes the development of this system and reports the results of a pilot study: a comparison of time spent in taking and giving shift reports before and after the study and nurses' perceptions of the mobile IT system. Results showed a significant difference in taking shift reports and no significant difference in giving shift reports. Nurses stated that quick and easy access to updated patient information in the Pocket PC was very helpful, especially during mainframe downtime.
Purpose – This chapter frames the topic of organizing for sustainable health care in terms of the environmental trends that have rendered current health care approaches unsustainable, the embeddedness of health care in society's triple bottom line, and the need to build adaptive capability within the complex health care ecosystem.
Design/methodology/approach – We synthesize documented trends and empirical findings regarding the viability of current approaches to health care, and provide a theoretically framed treatment of the adaptation process in the complex health care system that can lead to the emergence of sustainable approaches.
Findings – There is a misfit between current approaches to delivering health care and the requirements and trends in contemporary society. Fundamental transformation is required that entails a broadening of purpose, a future orientation, and a rethinking of how health care adds value and how it is embedded in society.
Originality/value – By reconceptualizing health care reform as intricately related to societal sustainability and the triple bottom line, we open the possibility of transcending a narrow focus on reengineering to create more efficient organizations and work processes that consume fewer resources and deliver greater value. We invite health care practitioners and scholars to rethink all the connections in the health care ecosystem, and the need to build in self-organizing capabilities and adaptive capacity. The cases in this book provide knowledge from systems engaged in fundamental transformation, analyzed through the lenses of theoretical frameworks that help us better understand essential dynamics involved in creating sustainable health care systems.
It has been estimated that 234 million operations are performed worldwide every year, a rate higher than childbirth. Since the Institute of Medicine’s report “To Err is Human”, there has been a sharp increase in interest in programs to decrease medical errors, especially in surgical care. Complications from operative care result in 11% of total disease burden, of which nearly half is estimated to be preventable. Despite numerous efforts to improve patient safety, rates of errors, and complications continue to rise nationwide.
Patient-reported outcomes (PROs) can show how patients perceive their illness burden over time. Active use of PROs by clinicians at the point of service can help illuminate the patients' longitudinal changes in outcomes, thereby advancing shared decision making, patient engagement, and self-care. This article offers principles and lessons learned from using PROs and provides 3 case studies to demonstrate how to overcome the challenges in using PROs in routine clinical practice to improve outcomes. These cases demonstrate that it is possible to embed patient-generated data into the flow of care and to track outcomes for improvement and research.
Patient reported outcome measures (PROMs) movement has largely been driven by the agenda of researchers or service payers and has failed to focus effectively on improving the quality of care from the patient’s perspective. We use two examples to show how the use of PROMs in everyday practice has the potential to narrow the gap between the clinician’s and patient’s view of clinical reality and help tailor treatment plans to meet the patient’s preferences and needs.
Many areas of acute care medicine have a low error tolerance and demand high levels of cognitive and technical performance. Growing evidence suggests that further improvements in patient outcomes depends on appre-ciating, measuring and improving system factors, in particular, effective team skills. In recent years, the relationship between surgical team behav-iour and patient outcome has been studied by a number of researchers. Teamwork concerns the communication and coordination processes that are required to bring together the individual knowledge, skills and atti-tudes in the service of a common and valued team goal. Individual surgical team members are highly specialized and have their own functional task-work (e.g., anaesthesia, nursing, surgery and perfusion), yet come together as a team towards the common goal of treating the patient. Interventions focusing on teamwork have shown a relationship with improved teamwork and safety climate. The 'working together' of a clinical microsystem is accomplished by a complex suite of 'nontechnical skills'. Teams that score low on independently observed non-technical skills make more technical errors and in cases where teams infrequently display team behaviours, patients are more likely to experience death or major complications. There is a signifi cant correlation between subjective assessment of teamwork by team members themselves and postoperative morbidity. Good teamwork (in terms of both quality and quantity) is associated with shorter duration of operations, fewer adverse events and lower postoperative morbidity.
Healthcare institutions continue to face challenges in providing safe patient care in increasingly complex organisational and regulatory environments while striving to maintain financial viability. The clinical microsystem provides a conceptual and practical framework for approaching organisational learning and delivery of care. Tensions exist between the conceptual theory and the daily practical applications of providing safe and effective care within healthcare systems. Healthcare organisations are often complex, disorganised, and opaque systems to their users and their patients. This disorganisation may lead to patient discomfort and harm as well as much waste. Healthcare organisations are in some sense conglomerates of smaller systems, not coherent monolithic organisations. The microsystem unit allows organisational leaders to embed quality and safety into a microsystem’s developmental journey. Leaders can set the stage for making safety a priority for the organisation while allowing individual microsystems to create innovative strategies for improvement.
Contemporary hospitals fall far short in applying both state-of-the art clinical knowledge and management practices of known effectiveness. Organization and management practices in hospitals are shaped by four factors: their conflicting missions, a distinctive and largely professional workforce, demanding external environments, and a complex day-to-day task environment. This article identifies two critical organizing challenges that hospitals face: organizational learning and implementing effective high involvement management practices. It discusses how findings from organizational research, including articles in this special issue, identify solutions to the problems underlying these challenges. Copyright © 2006 John Wiley & Sons, Ltd.
It is no longer possible to ignore the issue of quality in health care. Care institutions strive to
provide all patients with effective, efficient, safe, timely, patient-centered care. Increased
attention for quality is also found in discussions regarding use of information and
communication technologies (ICTs) in health care processes. In these discussions, ICT is almost
always brought into a direct relationship with improving the quality of care, especially ICTs that
professionals use directly in patient care, which are also known as patient care information
systems (PCIS) [1-4]. Well-known quality reports from the US Institute of Medicine, such as To
Err is Human [5] and Crossing the Quality Chasm [6], identify the lack of and delay in ICT
development and implementation as a partial explanation for quality problems in existing
healthcare systems. Both reports call for wider-scale implementation of PCIS, such as electronic
patient records and computerized physician order entry (CPOE) systems. Such systems
purportedly bring an end to illegible or lost records and forms, and thus reduce the number of
mistakes made. Moreover, intelligent PCIS, such as decision support systems, would potentially
support the care professional in making a diagnosis and determining the best course of action,
which would make medical practice both more evidence-based and efficient [see also 3,7-10]. A
large number of research projects also reflect these positive effects, but the conclusions of
systematic reviews are mixed [11-16].
In our environment, research on health technologies and health care effectiveness is a prominent issue in current knowledge policies. Nevertheless, there is wide consensus on the need for additional efforts to develop the translational component of this kind of research under the hypothesis that taking research into practice is a necessary condition for improving healthcare.The characteristics that facilitate or hinder knowledge transfer in healthcare organizations are analyzed throughout the present text. At the same time, we discuss some successful experiences that illustrate how the chasm can be reduced and healthcare effectiveness (i.e. quality) improved.Among the mechanisms that might either reduce or maintain the chasm are the following: 1) the type of organization (healthcare provider model, teaching status, mix of professionals, the organization's capacity to learn and innovate, etc.); 2) the organization's government (leadership in evidence implementation, capacity to manage professional roles, ability to use economic incentives, availability of an information-rich context, the use of knowledge management, etc.), and 3) the effectiveness of the strategies themselves in translating evidence into practice.Finally, we describe some successful experiences focusing on implementation, on researching the evidence that is needed, and on reinventing the organization to convert information into knowledge.
Data is an essential tool for convincing healthcare workers to accept that problems exist, inspire them to better performance, or demonstrate that their performance is improving. Infection control professionals have access to a wealth of data on healthcare associated infections. Using simple graphical examples this paper illustrates how data can be analysed and presented in accessible ways that will help infection control practitioners to better understand infection problems and to use the information to influence practice.
Healthcare institutions are challenged to provide an environment for safe patient care within increasingly complex organizational and regulatory environments while striving to maintain financial viability. Furthermore, as complex, disorganized, and opaque systems, healthcare organizations may lead to patient discomfort and harm as well as much waste. The clinical microsystem can help organizations learn based on the smallest, fully functioning organizational element. Team-based organizational learning offers a useful and effective model to enhance and affect the culture of large organizations. The clinical microsystem provides a con-ceptual and practical framework for approaching organizational learning and delivery of care that allows organizational leaders to embed quality and safety into a microsystem's developmental journey. Leaders can set the stage for making safety a priority for the organization while allowing individual microsystems to create innovative strategies for improvement. Microsystem theory can help in the evaluation and planning of organi-zational change. This model has implications for planning sustainable growth and stability. The microsytems' team-based approach supports organizational analysis and enhances a culture of interdependency, accountability, shared learning and resources–thus enhancing organiza-tional memory and practice.
Introduction: The literature on chronic care describes a gap between what patients need and what healthcare provides. In rheumatoid arthritis, major medical advances have taken place in recent years which have made it possible to successfully treat more patients. However, these advances have led to organizational challenges in the man-agement of healthcare delivery.
Aim: To explore the challenges in rheumatology care management by studying users’ perceptions of the Feed Forward System (FFS) principles (Study I), simulation model-ing as a tool for chronic care improvement (Study II and Study IV), and a way to test new chronic care processes (Study III).
Method: Qualitative and quantitative research methods were used to explore the chal-lenges faced by providers and their patients at Swedish rheumatology clinics. Methods include interviews, a focus group discussion, questionnaires, a meta-analysis, and simu-lation modeling. Content analysis was used to analyze qualitative data.
Findings: Patients became more involved in and informed about their own care when they used the FFS. Providers said that it offered an overview of past treatments and their effects, as well as support for treatment decisions (Study I). Simulation modeling provided a way to test the effects of moving from time-centric to need-centric processes in rheumatology care (Study III). Simulation modeling was also shown to support healthcare improvement by visualizing the effects of planned changes, communicating these changes to management, and engaging providers to explore and test innovative solutions (Study II and IV).
Discussion: Feed Forward Systems and simulation modeling represent an upgrade of how to manage the challenges inherent to rheumatology care. FFS encourage patient empowerment, self-management, and shared decision making, as well as support learn-ing for patients and providers alike. Simulation modeling helps manage complex prob-lems and facilitates learning for providers and managers. This is enabled through the shared features of FFS and simulation modeling: (1) the transformation of data into knowledge, (2) a mutual communication platform for multiple stakeholder involve-ment, (3) provision of real time feedback that enables action in clinical practice, and (4) self-correction that generates learning opportunities.
Conclusion: The introduction of FFS and simulation modeling has implications at the clinical level and the patient level of rheumatology care. Upgrading chronic care where it is delivered, at both levels, can contribute to improvements in care management – changing the healthcare system from within.
Healthcare is provided to patients by caregivers who give in complex organizational arrangements but the overwhelming amount of their own daily work is part of a clinical microsystem. The concept of clinical microsystem places medical error and harm reduction into the broader context of safety and quality of care by providing a framework to assess and evaluate the structure, processes and outcomes of care. The purpose of this paper is to examine the elements of the clinical microsystem developed by the Institute of Medicine (Godfrey & colleagues, 2004) and how it could be used to improve electronic medical records (EMR) practices in the Malaysian Government Hospitals. Among the critical elements of the clinical microsystem analysed in this paper include leadership roles, teamwork, working environment, patient needs and market focus, the use of electronic tools for patient care improvement, process of changes in implementing EMR and the role of technology in facilitating the integration of healthcare work. The concept of microsystem could provide a new frontier in organizational health services management research. There is an urgent need for research to be carried out to asses how well the government of Malaysia is in a position to provide efficient healthcare services within the context of electronic medical records practices as the government is making a significant investment in healthcare for its citizens.
Today's healthcare crisis offers distinct opportunities for the clinical nurse leader (CNL) to develop and evolve as a community healthcare practitioner delivering high-quality, patient-centered, safe, and efficient care on a microsystem clinical level. Chronic diseases are reaching epidemic proportion in the United States. The risk for several chronic diseases, such as type 2 diabetes, heart disease, stroke, arthritis, asthma, and certain cancers, are attributed to obesity or overweight. Currently, two-thirds of US adults and one-fifth of US children are obese or overweight.
The authors describe their study of 20 high-performing clinical units and discuss its practical implications for leaders seeking to improve performance.
In this article Robert S. Kaplan and David P. Norton report on the Balance Scorecard. Before the Balanced Scorecard companies have used various measurement systems that have made incremental improvements and concentrated mostly on the company's financials. The Balanced Scorecard shows you four different perspectives in which to choose measures that can redefine a company's processes measurement system so short term and long term objectives are in balance with each other. When using the Balanced Scorecard a company is no longer needs to worry about small incremental improvements, but a new processes measurement system that will allow a company to get where it wants to go.
Unlabelled:
CLINICAL VALUE COMPASS APPROACH: The clinical Value Compass, named to reflect its similarity in layout to a directional compass, has at its four cardinal points (1) functional status, risk status, and well-being; (2) costs; (3) satisfaction with health care and perceived benefit; and (4) clinical outcomes. To manage and improve the value of health care services, providers will need to measure the value of care for similar patient populations, analyze the internal delivery processes, run tests of changed delivery processes, and determine if these changes lead to better outcomes and lower costs. GETTING STARTED--OUTCOMES AND AIM: In the case example, the team's aim is "to find ways to continually improve the quality and value of care for AMI (acute myocardial infection) patients." VALUE MEASURES--SELECT A SET OF OUTCOME AND COST MEASURES: Four to 12 outcome and cost measures are sufficient to get started. In the case example, the team chose 1 or more measures for each quadrant of the value compass.
Operational definition of measures:
An operational definition is a clearly specified method explaining how to measure a variable. Measures in the case example were based on information from the medical record, administrative and financial records, and patient reports and ratings at eight weeks postdischarge.
Comments:
Measurement systems that quantify the quality of processes and results of care are often add-ons to routine care delivery. However, the process of measurement should be intertwined with the process of care delivery so that front-line providers are involved in both managing the patient and measuring the process and related outcomes and costs.
Traditional approaches to community health initiatives provide guidance on community mobilization, health assessment, planning, and intervention. Yet direction in how to frame the action steps to implement and measure results is often missing. Many community health initiatives find implementation overwhelming and ineffectual. FRAMEWORK FOR COMMUNITY HEALTH-THE CLINICAL IMPROVEMENT MODEL: The process--outcome methodology of continuous quality improvement (CQI) can translate large community aims into manageable projects. The sequential application of the clinical improvement model and the Community Health Value Compass for measuring outcomes-in state of health, quality of life, satisfaction, and costs-provides a link between data and action, thereby producing accountability for the community health initiative. USING THE CLINICAL IMPROVEMENT MODEL IN TWIN FALLS: Healthy Magic Valley (Twin Falls, Idaho) is the vision for long-term improvement in health status and reduction of health risks for the Southcentral Idaho Health Network. Since 1996 the Twin Falls Community Health Collaborative and SAFE KIDS Coalition have used the Value Compass model and CQI methods to decrease the rate of motor vehicle collisions, serious injuries, and deaths involving teens, while reducing the health, educational, legal, and financial consequences associated with teen-involved motor vehicle collisions. In 1993 the Twin Falls collaborative convened to apply CQI methods to the health of the community. The team has since met periodically to address the issues of community health, using the Dartmouth value compass model since 1996. Each sequential application of the process-outcome CQI framework exposes a blueprint for action and the unfolding of a health improvement strategy. The interventions should affect one or more dimensions of the value compass for teenage driving and motor vehicle collisions. CASE STUDY OF THE CLINICAL IMPROVEMENT MODEL: The motor vehicle death in October 1997 of a high school football player, who was not wearing a seat belt, led to a call to action for injury prevention. Implementation of a local community health initiative on seat belt use started in 1998. A strategy was developed to address implementation of the project among high school teens (for immediate impact) and elementary school children (for long-term impact) and to promote collaboration between the school and the rest of the community.
Observed use of seat belts increased from January to September 1998. Data on fatality rates; injury rates; percentages of teens in crashes, of teens injured, and of teen collisions involving use of alcohol; and comprehensive costs are also monitored.
Once coalitions are built and priorities set, the Dartmouth clinical improvement model presents a method that emphasizes measuring the benefits to the individual members of the community. A portfolio composed of a value compass for each health improvement initiative provides ongoing feedback for guiding subsequent strategic planning by the governing community health network.
Today, managing care from the "outside in" is the predominant model for changing health care. The risk of this outside-in approach is that the health care system may lose sight of the people and communities for which it serves and cares. In this article, an "inside-out" model for viewing health care in a geriatric population is presented from the perspective of patients and providers, placing the provider in a proactive rather than reactive role. By focusing attention on the outcomes or value a patient is experiencing, providers are challenged to consider new ways of managing care.
Development of a new program for diagnosis and treatment of spine-related problems provided a unique opportunity to design and implement a new model for delivery of health care incorporating outcomes measurement and improvement. Key features include: application of microsystem thinking and interdisciplinary practice; integration of a uniform outcomes measurement tool, the Dartmouth Clinical Value Compass; and touch pad technology for data collection. This, for the first time, provided clinically meaningful point-of-service data and aggregated information for improvement. A further advantage was the ability to integrate a clinical research program within this microsystem. A multisite clinical research trial, the Spine Patient Outcomes Research Trial (SPORT), modeled on the Spine Center microsystem and funded by The National Institute of Arthritis, Musculoskeletal and Skin Diseases and the Office of Research on Woman's Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention, is currently underway. The significant problems we face today cannot be solved by the same level of thinking that created them.
In addition to strict financial outcomes, healthcare financial managers should assess intangible assets that affect the organization's bottom line, such as clinical processes, staff skills, and patient satisfaction and loyalty. The balanced scorecard, coupled with data-warehousing capabilities, offers a way to measure an organization's performance against its strategic objectives while focusing on building capabilities to achieve these objectives. The balanced scorecard examines performance related to finance, human resources, internal processes, and customers. Because the balanced scorecard requires substantial amounts of data, it is a necessity to establish an organizational data warehouse of clinical, operational, and financial data that can be used in decision support. Because it presents indicators that managers and staff can influence directly by their actions, the balanced-scorecard approach to performance measurement encourages behavioral changes aimed at achieving corporate strategies.
Leading healthcare provider organizations now use a "balanced scorecard" of performance measures, expanding information reviewed at the governance level to include financial, customer, and internal performance information, as well as providing an opportunity to learn and grow to provide better strategic guidance. The approach, successfully used by other industries, uses competitor data and benchmarks to identify opportunities for improved mission achievement. This article evaluates one set of nine multidimensional hospital performance measures derived from Medicare reports (cash flow, asset turnover, mortality, complications, length of inpatient stay, cost per case, occupancy, change in occupancy, and percent of revenue from outpatient care). The study examines the content validity, reliability and sensitivity, validity of comparison, and independence and concludes that seven of the nine measures (all but the two occupancy measures) represent a potentially useful set for evaluating most U.S. hospitals. This set reflects correctable differences in performance between hospitals serving similar populations, that is, the measures reflect relative performance and identify opportunities to make the organization more successful.
Clinical microsystems are the small, functional, front-line units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients and providers meet. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed.
A wide net was cast to identify and study a sampling of the best-quality, best-value small clinical units in North America. Twenty microsystems, representing different component parts of the health system, were examined from December 2000 through June 2001, using qualitative methods supplemented by medical record and finance reviews.
The study of the 20 high-performing sites generated many best practice ideas (processes and methods) that microsystems use to accomplish their goals. Nine success characteristics were related to high performance: leadership, culture, macro-organizational support of microsystems, patient focus, staff focus, interdependence of care team, information and information technology, process improvement, and performance patterns. These success factors were interrelated and together contributed to the microsystem's ability to provide superior, cost-effective care and at the same time create a positive and attractive working environment.
A seamless, patient-centered, high-quality, safe, and efficient health system cannot be realized without the transformation of the essential building blocks that combine to form the care continuum.
Clinical Improvement Action Guide
- Ec Nelson
- Pb Batalden
- Jc Ryer
Nelson EC, Batalden PB, Ryer JC: Clinical Improvement Action
Guide. Oakbrook Terrace, IL: Joint Commission on Accreditation of
Healthcare Organizations, 1998.
Clinical Improvement Action Guide
- E C Nelson
- P B Batalden
- J C Ryer
Nelson EC, Batalden PB, Ryer JC: Clinical Improvement Action
Guide. Oakbrook Terrace, IL: Joint Commission on Accreditation of
Healthcare Organizations, 1998.