Julie J. Mohr

Microsystems in Health Care: Part 1. Learning from High-Performing Front-Line Clinical Units

BACKGROUND 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. METHODS 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. RESULTS 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 microsystems ability to provide superior, cost-effective care and at the same time create a positive and attractive working environment. CONCLUSIONS 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.

Improving safety on the front lines: the role of clinical microsystems

The clinical microsystem puts 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, process, and outcomes of care. Eight characteristics of clinical microsystems emerged from a qualitative analysis of interviews with representatives from 43 microsystems across North America. These characteristics were used to develop a tool for assessing the function of microsystems. Further research is needed to assess microsystem performance, outcomes, and safety, and how to replicate “best practices” in other settings.

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.

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 Ps: 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 microsystems 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 Ps--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.

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 patients 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 patients needs.

Building a quality future.

Summary How can healthcare leaders stay ahead of the curve? What can they do to see what the future holds and to secure a place for their employees and their organizations? They must begin doing today what they need to do to survive tomorrow. Furthermore, they must take wise action today or there will be no tomorrow. This article looks into the future and connects it with what we must see and do today. The article begins with a glimpse of the future and with an exploration of what people really want from health and healthcare. Next, it examines what appear to be inexorable megatrends and healthcare trends that are sweeping through society. This leads us to consider the quality and value imperatives that must be faced to secure a stake in the healthcare delivery. We will discuss a model for managing care for individual patients and small populations by focusing on where patients, populations, and caregivers meet— at the front lines of patient care. We conclude with some advice on how to build sustainable organizations by exploiting the inevitable.

Creating effective leadership for improving patient safety.

Leadership has emerged as a key theme in the rapidly growing movement to improve patient safety. Leading an organization that is committed to providing safer care requires overcoming the common traps in thinking about error, such as blaming individuals, ignoring the underlying systems factors, and blaming the bureaucracy of the organization. Leaders must address the system issues that are at work within their organizations to allow individual and organizational learning to occur.

Building knowledge of health care as a system.

A system is a functionally related group of interacting, interrelated, or interdependent elements forming a complex whole with a common aim. This article presents a method—a 10-step exercise—for building knowledge of the elements of an interdependent system of health care. Those who seek to improve the work of a system can use this exercise for designing and relating new improvement efforts to the general work of the organization.

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 candidates initial contact through each staff members 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.

Continually improving the health and value of health care for a population of patients: the panel management process.

Todays primary care provider faces the challenge of caring for individual patients as well as caring for populations of patients. This article offers a model—the panel management process—for understanding and managing these activities and relationships. The model integrates some of the lessons learned during the past decade as we have worked to gain an understanding of the continual improvement of health care after we have understood that care as a process and system.