Microsystems in health care: Part 2. Creating a rich information environment

An evaluation of the clinical microsystems approach in general practice quality improvement

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.

Is postgraduate leadership education a match for the wicked problems of health systems leadership? A critical systematic review

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.

Learning from a clinical microsystems quality improvement initiative to promote integrated care across a falls care pathway

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.

Using patient-reported outcomes in routine practice: three novel use cases and implications

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.

Across the divide: "Primary care departments working together to redesign care to achieve the Triple Aim"

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.

Approaches and challenges to optimising primary care teams' electronic health record usage

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.

The gas cylinder, the motorcycle and the village health team member: a proof-of-concept study for the use of the Microsystems Quality Improvement Approach to strengthen the routine immunization system in Uganda

Background

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.

Methods

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.

Results

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.

Conclusions

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.

Developing a toolkit for panel management: improving hypertension and smoking cessation outcomes in primary care at the VA

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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

ClinicalTrials.gov, NCT01677533.

Considering context in quality improvement interventions and implementation: concepts, frameworks, and application

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.

Using infection prevention data for improvement: the infection prevention control team as a clinical support micro-system

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.

Deciphering the crystal ball in spine care: can preoperative patient variables predict postoperative functional outcomes and risks?

Meredith DS, Huang RC, Nguyen J, Lyman S. Obesity increases the risk of recurrent herniated nucleus pulposus after lumbar microdiscectomy. Spine J 2010;10:575-580 (in this issue). Yadla S, Malone J, Campbell PG, et al. Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures. Spine J 2010;10:581-587 (in this issue).

Healthcare governance and organizational barriers to learning from mistakes

PURPOSE

The purpose of this article is to advance critical debate in relation to a very critical issue in current healthcare management--namely "patient safety". This is currently a very high profile issue. In its various guises such as clinical governance, integrated governance and healthcare governance the question of avoiding or at least minimising harm to patients is attracting a huge amount of attention. Considerable resources especially within the acute sector are allocated to the problem. But, despite the systematic attention, progress in healthcare compared with certain other sectors is slow and mistakes continue to occur. Hospital acquired infections and clinical errors have become a matter of acute public concern. Evaluations of the health service are critically influenced by adverse judgements on this dimension of care.

DESIGN/METHODOLOGY/APPROACH

The authors draw primarily upon relevant literature in order to make sense of recent empirical research in eight acute hospital trusts in the UK. The analysis, however, is relevant to healthcare systems around the world.

FINDINGS

The authors reveal how the massive investment in systems, service improvement mechanisms and clinical government regimes may not in themselves be enough. One reason why they may not be enough is that there can be a problem of gaining acceptance and legitimacy. Staff may see such managers as "policing" and "interfering". There is then the danger of a vicious circle--more control but less effective control because of a feeling of alienation. The policing element is at best a final safety net not the prompt for improvement. They then identify six barriers and each is accompanied by a recommendation for its resolution.

PRACTICAL IMPLICATIONS

There are a number of implications for practice and for systems reform, which stem from the analysis. Two main recommendations stand out: they need to be handled together. First, the traditional model of the autonomous professional needs to be challenged by subjecting clinical practice to shared clinical governance procedures. Second, and simultaneously, there is a need to attend to underlying values. There is a need to revisit the issue of underpinning values so that clinical values and system-wide/managerial values are congruent rather than separate or even in conflict. At this point, governance and leadership should come together.

ORIGINALITY/VALUE

This paper provides useful information from the literature on current healthcare management.

Quality improvement in small office settings: an examination of successful practices

Background

Physicians in small to moderate primary care practices in the United States (U.S.) (<25 physicians) face unique challenges in implementing quality improvement (QI) initiatives, including limited resources, small staffs, and inadequate information technology systems 23,36. This qualitative study sought to identify and understand the characteristics and organizational cultures of physicians working in smaller practices who are actively engaged in measurement and quality improvement initiatives.

Methods

We undertook a qualitative study, based on semi-structured, open-ended interviews conducted with practices (N = 39) that used performance data to drive quality improvement activities.

Results

Physicians indicated that benefits to performing measurement and QI included greater practice efficiency, patient and staff retention, and higher staff and clinician satisfaction with practice. Internal facilitators included the designation of a practice champion, cooperation of other physicians and staff, and the involvement of practice leaders. Time constraints, cost of activities, problems with information management and or technology, lack of motivated staff, and a lack of financial incentives were commonly reported as barriers.

Conclusion

These findings shed light on how physicians engage in quality improvement activities, and may help raise awareness of and aid in the implementation of future initiatives in small practices more generally.

The logic of relations and the logic of management

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.

CONCLUSION

Service organisations need to create structural conditions for the efficacy of direct support teams in terms of client relationships and relevant client outcomes. At the same time, the need for administrative and control processes can not be denied. The concept of 'microsystems', application of a Quality of Life framework and the use of new instruments, such as the Supports Intensity Scale, can contribute to an organisational solution for the present conflicting logic of relations and management.

Using data effectively to prevent and control infection

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.

Residency education, preventive medicine, and population health care improvement: the Dartmouth-Hitchcock Leadership Preventive Medicine approach

In 2003, Dartmouth-Hitchcock Medical Center (DHMC) inaugurated its Leadership Preventive Medicine residency (DHLPMR), which combines two years of leadership preventive medicine (LPM) training with another DHMC residency. The aim of DHLPMR is to attract and develop physicians who seek to become capable of leading change and improvement of the systems where people and health care meet. The capabilities learned by residents are (1) leadership -- including design and redesign -- of small systems in health care, (2) measurement of illness burden in individuals and populations, (3) measurement of the outcomes of health service interventions, (4) leadership of change for improvement of quality, value, and safety of health care of individuals and populations, and (5) reflection on personal professional practice enabling personal and professional development. The DHLPMR program includes completion of an MPH degree at The Dartmouth Institute for Health Policy and Clinical Practice (formerly the Center for Evaluative Clinical Sciences) and a practicum during which the resident leads change to improve health care for a defined population of patients. Residents also complete a longitudinal public health experience in a governmental public health agency. A coach in the resident's home clinical department helps the resident develop his or her practicum proposal, which must then be approved by a practicum review board (PRB). Twelve residents have graduated as of July 2007. Residents have combined anesthesia, family medicine, internal medicine, infectious disease, pain medicine, pathology, psychiatry, pulmonary and critical care medicine, surgery, gastroenterology, geriatric psychiatry, obstetrics-gynecology, and pediatrics with preventive medicine.

Using a Malcolm Baldrige framework to understand high-performing clinical microsystems

BACKGROUND, OBJECTIVES AND METHOD: The Malcolm Baldrige National Quality Award (MBNQA) provides a set of criteria for organisational quality assessment and improvement that has been used by thousands of business, healthcare and educational organisations for more than a decade. The criteria can be used as a tool for self-evaluation, and are widely recognised as a robust framework for design and evaluation of healthcare systems. The clinical microsystem, as an organisational construct, is a systems approach for providing clinical care based on theories from organisational development, leadership and improvement. This study compared the MBNQA criteria for healthcare and the success factors of high-performing clinical microsystems to (1) determine whether microsystem success characteristics cover the same range of issues addressed by the Baldrige criteria and (2) examine whether this comparison might better inform our understanding of either framework.

RESULTS AND CONCLUSIONS

Both Baldrige criteria and microsystem success characteristics cover a wide range of areas crucial to high performance. Those particularly called out by this analysis are organisational leadership, work systems and service processes from a Baldrige standpoint, and leadership, performance results, process improvement, and information and information technology from the microsystem success characteristics view. Although in many cases the relationship between Baldrige criteria and microsystem success characteristics are obvious, in others the analysis points to ways in which the Baldrige criteria might be better understood and worked with by a microsystem through the design of work systems and a deep understanding of processes. Several tools are available for those who wish to engage in self-assessment based on MBNQA criteria and microsystem characteristics.

Getting the data right: information accuracy in pediatric emergency medicine

OBJECTIVES

(1) To identify the extent to which information provided by parents in the pediatric emergency department (ED) can drive the assessment and categorization of data on allergies to medications, and (2) to identify errors related to the capture and documentation of allergy data at specific process level steps during ED care.

METHODS

An observational study was conducted in a pediatric ED, combining direct observation at triage, a structured verbal interview with parents to ascertain a full allergy history related to medications, and chart abstraction. A comparative standard for the allergy history was established using parents' interview responses and existing guidelines for allergy. Errors associated with ED information management of allergy data were evaluated at five steps: (1) triage assessment, (2) treating physician's discussion with parent, (3) treating nurse's discussion with parent, (4) use of an allergy bracelet, and (5) documentation of allergy history on medication order sheets.

RESULTS

256 parent-child dyads were observed at triage; 211/256 parents (82.4%) completed the structured verbal interview that served as the basis for the comparative standard (CS). Parents reported a total of 59 medications as possible allergies; 56 (94.9%) were categorized as allergy or not based on the CS. Twenty eight of 48 patient cases were true allergies by guideline based assessment. Sensitivity of triage for detecting true medication allergy was 74.1% (95% confidence interval (CI) 53.7 to 88.9). Specificity of triage personnel for correctly determining that no allergy existed was 93.2% (95% CI 88.5 to 96.5). Physician and nursing care had performance gaps related to medication allergy in 10-25% of cases.

CONCLUSIONS

There are significant gaps in the quality of information management regarding medication allergies in the pediatric ED.

Understanding the complexity of redesigning care around the clinical microsystem

The microsystem is an organizing design construct in which social systems cut across traditional discipline boundaries. Because of its interdisciplinary focus, the clinical microsystem provides a conceptual and practical framework for simplifying complex organizations that deliver care. It also provides an important opportunity for organizational learning. Process mapping and microworld simulation may be especially useful for redesigning care around the microsystem concept. Process mapping, in which the core processes of the microsystem are delineated and assessed from the perspective of how the individual interacts with the system, is an important element of the continuous learning cycle of the microsystem and the healthcare organization. Microworld simulations are interactive computer based models that can be used as an experimental platform to test basic questions about decision making misperceptions, cause-effect inferences, and learning within the clinical microsystem. Together these tools offer the user and organization the ability to understand the complexity of healthcare systems and to facilitate the redesign of optimal outcomes.

Critical Success Factors for Performance Improvement Programs

BACKGROUND

Most health care organizations struggle with the design and implementation of effective, systemwide improvement programs. In 2000, the University HealthSystem Consortium initiated a benchmarking project to identify the organizational elements that predict a successful perfermance improvement (PI) program and that are best suited to support change initiatives.

METHODS

Forty-one organizations completed a survey about the presence of critical components, processes used to improve performance, and organizational PI structures. Follow-up site visits were conducted at three organizations. CRITICAL SUCCESS FACTORS FOR A PI PROGRAM: Eight organizational success factors for an effective performance improvement program were identified: (1) Strong Administrative Fxecutive and Performance Improvement Leadership, (2) Active Involvement of the Board of Trustees, (3) Effective Oversight Structure, (4) Expert Performance Improvement Staff, (5) Physician Involvement and Accountability, (6) Active Staff Involvement, (7) Effective Use of Information Resources-Data Used for Decision Making, and (8) Effective Communication Strategy.

DISCUSSION

The approach offered is grounded in the belief that effective organizational structures and processes are prerequisites to improving health care delivery. Although some empirical support for the proposed model is provided, additional research will be required to determine the effectiveness of this approach.

Integrating patient safety into the clinical microsystem

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.

Learning from failure in health care: frequent opportunities, pervasive barriers

The notion that hospitals and medical practices should learn from failures, both their own and others', has obvious appeal. Yet, healthcare organisations that systematically and effectively learn from the failures that occur in the care delivery process, especially from small mistakes and problems rather than from consequential adverse events, are rare. This article explores pervasive barriers embedded in healthcare's organisational systems that make shared or organisational learning from failure difficult and then recommends strategies for overcoming these barriers to learning from failure, emphasising the critical role of leadership. Firstly, leaders must create a compelling vision that motivates and communicates urgency for change; secondly, leaders must work to create an environment of psychological safety that fosters open reporting, active questioning, and frequent sharing of insights and concerns; and thirdly, case study research on one hospital's organisational learning initiative suggests that leaders can empower and support team learning throughout their organisations as a way of identifying, analysing, and removing hazards that threaten patient safety.

Integrating patient safety into the clinical microsystem

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.

Learning from failure in health care: frequent opportunities, pervasive barriers

The notion that hospitals and medical practices should learn from failures, both their own and others', has obvious appeal. Yet, healthcare organisations that systematically and effectively learn from the failures that occur in the care delivery process, especially from small mistakes and problems rather than from consequential adverse events, are rare. This article explores pervasive barriers embedded in healthcare's organisational systems that make shared or organisational learning from failure difficult and then recommends strategies for overcoming these barriers to learning from failure, emphasising the critical role of leadership. Firstly, leaders must create a compelling vision that motivates and communicates urgency for change; secondly, leaders must work to create an environment of psychological safety that fosters open reporting, active questioning, and frequent sharing of insights and concerns; and thirdly, case study research on one hospital's organisational learning initiative suggests that leaders can empower and support team learning throughout their organisations as a way of identifying, analysing, and removing hazards that threaten patient safety.

The role of perceived team effectiveness in improving chronic illness care

BACKGROUND/OBJECTIVES

The importance of teams for improving quality of care has received increased attention. We examine both the correlates of self-assessed or perceived team effectiveness and its consequences for actually making changes to improve care for people with chronic illness. STUDY SETTING AND METHODS: Data were obtained from 40 teams participating in the national evaluation of the Improving Chronic Illness Care Program. Based on current theory and literature, measures were derived of organizational culture, a focus on patient satisfaction, presence of a team champion, team composition, perceived team effectiveness, and the actual number and depth of changes made to improve chronic illness care.

RESULTS

A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among culture values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care. The variables examined explain between 24 and 40% of the variance in different dimensions of perceived team effectiveness; between 13% and 26% in number of changes made; and between 20% and 42% in depth of changes made.

CONCLUSIONS

The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness.

The asthma kiosk: a patient-centered technology for collaborative decision support in the emergency department

The authors report on the development and evaluation of a novel patient-centered technology that promotes capture of critical information necessary to drive guideline-based care for pediatric asthma. The design of this application, the asthma kiosk, addresses five critical issues for patient-centered technology that promotes guideline-based care: (1) a front-end mechanism for patient-driven data capture, (2) neutrality regarding patients' medical expertise and technical backgrounds, (3) granular capture of medication data directly from the patient, (4) formal algorithms linking patient-level semantics and asthma guidelines, and (5) output to both patients and clinical providers regarding best practice. The formative evaluation of the asthma kiosk demonstrates its ability to capture patient-specific data during real-time care in the emergency department (ED) with a mean completion time of 11 minutes. The asthma kiosk successfully links parents' data to guideline recommendations and identifies data critical to health improvements for asthmatic children that otherwise remains undocumented during ED-based care.

Microsystems in Health Care: Part 9. Developing Small Clinical Units to Attain Peak Performance

BACKGROUND

This last Microsystems in Health Care series article focuses on what it takes, in the short term and long term, for clinical microsystems--the small, functional, front-line units that provide the most health care to the most people--to attain peak performance.

CASE STUDY

A case study featuring the intensive care nursery at Dartmouth-Hitchcock Medical Center illustrates the 10-year evolution of a clinical microsystem. Related evolutionary principles begin with the intention to excel, involve all the players, use measurement and feedback, and create a learning system.

DISCUSSION

A microsystem's typical developmental journey toward excellence entails five stages of growth--awareness as an interdependent group with the capacity to make changes, connecting routine daily work to the high purpose of benefiting patients, responding successfully to strategic challenges, measuring the microsystem's performance as a system, and juggling improvements while taking care of patients. A MODEL CURRICULUM: Health system leaders can sponsor an action-learning program to catalyze development of clinical microsystems. A "green-belt curriculum" can help clinical staff members acquire the fundamental knowledge and skills that they will need to master if they are to increase their capacity to attain higher levels of performance; uses action-learning theory and sound education principles to provide the opportunity to learn, test, and gain some degree of mastery; and involves people in the challenging real work of improving.

Microsystems in health care: Part 7. The microsystem as a platform for merging strategic planning and operations

BACKGROUND

The microsystem, as agent for change, plays a critical and essential role in developing and deploying the macrosystem's strategic plan.

STRATEGIC PLANNING AND MICROSYSTEM THINKING

To effectively deploy a strategic plan, the organization must align the plan's goals and objectives across all levels and to all functional units. The concepts of microsystem thinking were the foundation for the journey on which Overlook Hospital/Atlantic Health System (Summit, NJ) embarked in 1996. Six stages can be identified in the development of the relationship between macrosystems and microsystems. Five critical themes--trust making, mitigation of constraints and barriers among departments and units, creation of a common vocabulary, raising of microsystem awareness, and facilitation of reciprocal relationships--are associated with these stages.

NOTES FROM A MICROSYSTEM JOURNEY

The emergency department (ED) experienced Stage 1--The Emergence of a Self-Aware Microsystem--as it created cultural and behavioral change, which included the actualization of staff-generated ideas and an ongoing theme of trust making. In Stage 3--Unlike Microsystems (Different Units) Learn to Collaborate--the ED's microsystems approach spread to other units in the hospital. Collaboratives addressed x-ray turnaround times, admission cycle times, and safety initiatives.

SUMMARY AND CONCLUSIONS

The microsystem--the small, functional, front-line units--is where the strategic plans become operationalized.

Learning to Leverage Existing Information Systems: Part 1. Principles

BACKGROUND

The success of performance improvement efforts depends on effective measurement and feedback regarding clinical processes and outcomes. Yet most health care organizations have fragmented rather than integrated data systems. Methods and practical guidance are provided for leveraging available information sources to obtain and create valid performance improvement-related information for use by clinicians and administrators.

CASE VIGNETTE

At Virginia Mason Health System (VMHS; Seattle), a vertically integrated hospital and multispecialty group practice, patient records are paper based and are supplemented with electronic reporting for laboratory and radiology services. Despite growth in the resources and interest devoted to organization-wide performance measurement, quality improvement, and evidence-based tools, VMHS's information systems consist of largely stand-alone, legacy systems organized around the ability to retrieve information on patients, one at a time. By 2002, without any investment in technology, VMHS had developed standardized, clinic-wide key indicators of performance updated and reported regularly at the patient, provider, site, and organizational levels.

LEVERAGING EXISTING SYSTEMS

On the basis of VHMS's experience, principles can be suggested to guide other organizations to explore solutions using their own information systems: for example, start simply, but start; identify information needs; tap multiple data streams; and improve incrementally.

Microsystems in Health Care: Part 8. Developing People and Improving Work Life: What Front-Line Staff Told Us

BACKGROUND

The articles in the Microsystems in Health Care series have focused on the success characteristics of high-performing clinical microsystems. Realization is growing about the importance of attracting, selecting, developing, and engaging staff. By optimizing the work of all staff members and by promoting a culture where everyone matters, the microsystem can attain levels of performance not previously experienced.

CASE STUDY

At Massachusetts General Hospital Downtown Associates (Boston), a primary care practice, the human resource processes are specified and predictable, from a candidate's initial contact through each staff member's orientation, performance management, and professional development. Early on, the new employee receives materials about the practice, including a practice overview, his or her typical responsibilities, the performance evaluation program, and continuous quality improvement. Ongoing training and education are supported with skill labs, special education nights, and cross-training. The performance evaluation program, used to evaluate the performance of all employees, is completed during the 90-day orientation and training, quarterly for one year, and annually.

CONCLUSION

Some health care settings enjoy high morale, high quality, and high productivity, but all too often this is not the case. The case study offers an example of a microsystem that has motivated its staff and created a positive and dynamic workplace.

Microsystems in health care: Part 6. Designing patient safety into the microsystem

BACKGROUND

This article explores patient safety from a microsystems perspective and from an injury epidemiological perspective and shows how to embed safety into a microsystem's operations. MICROSYSTEMS PATIENT SAFETY SCENARIO: Allison, a 5-year-old preschooler with a history of "wheezy colds," and her mother interacted with several microsystems as they navigated the health care system. At various points, the system failed to address Allison's needs. The Haddon matrix provides a useful framework for analyzing medical failures in patient safety, setting the stage for developing countermeasures.

CASE STUDY

The case study shows the types of failures that can occur in complex medical care settings such as those associated with pediatric procedural sedation. Six patient safety principles, such as "design systems to identify, prevent, absorb, and mitigate errors," can be applied in a clinical setting. In response to this particular case, its subsequent analysis, and the application of microsystems thinking, the anesthesiology department of the Children's Hospital at Dartmouth developed the PainFree Program to provide optimal safety for sedated patients.

CONCLUSION

Safety is a property of a microsystem and it can be achieved only through thoughtful and systematic application of a broad array of process, equipment, organization, supervision, training, simulation, and team-work changes.

Microsystems in health care: Part 4. Planning patient-centered care

BACKGROUND

Clinical microsystems are the essential building blocks of all health systems. At the heart of an effective microsystem is a productive interaction between an informed, activated patient and a prepared, proactive practice staff. Support, which increases the patient's ability for self-management, is an essential result of a productive interaction. This series on high-performing clinical microsystems is based on interviews and site visits to 20 clinical microsystems in the United States. This fourth article in the series describes how high-performing microsystems design and plan patient-centered care. PLANNING PATIENT-CENTERED CARE: Well-planned, patient-centered care results in improved practice efficiency and better patient outcomes. However, planning this care is not an easy task. Excellent planned care requires that the microsystem have services that match what really matters to a patient and family and protected time to reflect and plan. Patient self-management support, clinical decision support, delivery system design, and clinical information systems must be planned to be effective, timely, and efficient for each individual patient and for all patients.

CONCLUSION

Excellent planned services and planned care are attainable today in microsystems that understand what really matters to a patient and family and have the capacity to provide services to meet the patient's needs.

Microsystems in health care: Part 3. Planning patient-centered services

BACKGROUND

Strategic focus on the clinical microsystems--the small, functional, frontline units that provide most health care to most people--is essential to designing the most efficient, population-based services. The starting place for designing or redesigning of clinical microsystems is to evaluate the four P's: the patient subpopulations that are served by the microsystem, the people who work together in the microsystem, the processes the microsystem uses to provide services, and the patterns that characterize the microsystem's functioning.

GETTING STARTED

DIAGNOSING AND TREATING A CLINICAL MICROSYSTEM: Methods and tools have been developed for microsystem leaders and staff to use to evaluate the four P's--to assess their microsystem and design tests of change for improvement and innovation.

PUTTING IT ALL TOGETHER

Based on its assessment--or diagnosis--a microsystem can help itself improve the things that need to be done better. Planning services is designed to decrease unnecessary variation, facilitate informed decision making, promote efficiency by continuously removing waste and rework, create processes and systems that support staff, and design smooth, effective, and safe patient care services that lead to measurably improved patient outcomes.

CONCLUSION

The design of services leads to critical analysis of the resources needed for the right person to deliver the right care, in the right way, at the right time.