Presentation to CCHA/CCS NICU Improvement Project

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

Thomas P Huber, MS ECS

September 18 & 25, 2006

Aim of Presentation

Introduce the Clinical Microsystem Improvement Framework as a way of

continually improving unit performance as well as enhance your understanding of quality improvement methods, theories,

tools, and techniques.

AGENDA

1. A Brief Introduction

2. So . . . What’s a Microsystem?

3. Dartmouth - RWJ Study on Microsystems

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

5. Improvement Tools, Advising Approach, and some key Learning's over the years!

• DefinitionDefinition• A Picture View A Picture View • Examples Examples • Shrek’s “Onion Persective” of Shrek’s “Onion Persective” of

Microsystems Microsystems • The Current Reality ProblemThe Current Reality Problem

So . . . What’s a Microsystem

DefinitionDefinition

A micro-system in health care delivery can be defined as aA micro-system in health care delivery can be defined as a small small groupgroup of people who work together on a regular basis to provide care of people who work together on a regular basis to provide care to discrete subpopulations ofto discrete subpopulations of patientspatients. . It has clinical and businessIt has clinical and business aimsaims, linked, linked processesprocesses, shared, shared informationinformation environment and produces environment and produces performanceperformance outcomesoutcomes. . They evolve over time and are (often)They evolve over time and are (often) embeddedembedded in larger organizations. in larger organizations.

Building a Team to M anage A Panel of Prim ary Care PatientsM Iss ion : The D a rtm ou th -H itchcock C lin ic exis ts to se rve the hea lth ca re needs o f ou r pa tien ts .

Very H igh R isk

Chronic

Very H igh R isk

Healthy

Healthy

Healthy

Chronic

Assign toPCP

O rient toTeam

Assess &Plan Care

Functional& R isks

Bio log ical

Costs

Expectations Chronic ++

Very H igh R isk +++

Healthy

Prevention Acute EducateChronic

P A C E

P A C E

P A E

P A C E

Functional& R isks

Bio log ical

Costs

Satisfaction

People w ithhealthcare

needsPeople w ithhealthcareneeds m et

Phone,Nurse F irst

PhysicalSpace

Info System s& Data

BillingReferralsPharm acyRadio logyLaboratoryM edicalRecords

Scheduling

Departm ent

Division and Com m unity

Southern Region

Hitchcock Clinic System

M easuring Team Perform ance & Patient Outcom es and Costs

M easure Current Target M easure Current Target

Panel S ize Adj.

D irect P t. Care Hours:M D/Assoc.

% Panel Seeing O wnPCP:

Tota l PM PM Adj.PM PM -Team

Externa l Referra l Ad j.PM PM -Team

Patient Satisfaction

Access Satisfaction

Staff Satisfaction

TEAM M EM BERS:

Skill M ix: M Ds _2.8_ RNs _6.8_ NP/PAs __2__ M A _4.8 LPN _____ SECs __4_M icro-System Approach 6/17/98Revised: 1/27/00

c Eugene C . Nelson, DSc, M PHPaul B . Bata lden, M DDartmouth-H itchcock C lin ic, June 1998

1 2 3

5 6 7 8 9 10 11 12 13 14

4

Sherm an Baker, MD

Leslie Cook, MD

Joe Karpicz, MD

Deb Urquart, NP

Ron Carson, PA

Erica, RN

Laura, RN

Maggi, RN

Missy, RN

Diane, RN

Katie, RN

Bonnie, LPN

Carole, LPN

Nancy, LPN

Mary Beth, MA

Lynn, MA

Am y, Secretary

Buffy, Secretary

Mary E llen, Secretary

Kristy, Secretary

Charlene, Secretary

Nashua Internal M edicine

Microsystems are the building blocks that come together to form Macro-organizations

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

• An Emergency Care Center

• Asthma and Allergy Clinic

• Day Surgery Center

• A Nutrition Clinic

• A Neonatal Intensive Care Unit

The “Onion” Perspective on Levels The “Onion” Perspective on Levels of Quality Improvement!of Quality Improvement!

Community, Market,

Social Policy System

Macro-organization

System

Micro-systemIndividual care-giver & patient System

Self-care

System

The Current The Current Reality ProblemReality Problem

When we connect things that don’t When we connect things that don’t match...match...

The Economist

• The searchThe search for 20 high performing for 20 high performing microsystemsmicrosystems

• How we How we studied and workedstudied and worked with the with the microsystemsmicrosystems

• A fewA few Examples Examples of Excellenceof Excellence• The Results:The Results: The 10 Success Characteristics The 10 Success Characteristics

of high performing microsystems & the 5 P of high performing microsystems & the 5 P FrameworkFramework

Dartmouth - RWJ Foundation Microsystem Study (2000 - 2003)

Joint Commission Journal Article in your Packet.

The Search for High Performance?Dartmouth-RWJ Study: Batalden, Nelson, Huber,

Mohr, Wasson, Headrick. 2000 - 2003

• Identified 250 high performing healthcare microsystems via a multi-stratified approach.

• Screen 75 microsystems using (MS Assessment Tool and 30-Min Telephone Semi-Structured Interview (Q, $, and Process).

• Selected 20 microsystems across the healthcare spectrum: Ambulatory, Inpatient, Nursing Homes, and Home Health.

The 20 Finalists

Ambulatory Care (Primary)• MacroMedical MGH, Boston, MA• Norumbega Medical, Bangor, ME • ThedaCare Family Practice,

Kimberly, WI• Grace Hill CHC, St. Louis, MOAmbulatory Care (Specialty)• Intermountain Ortho, Boise, ID• Overlook Hospital Emergency

Department, Summit, NJ• Sharpe Diabetes Center, San Diego,

CA• Spine Center, DHMC, Lebanon,

NH• Washington Cancer Institute,

Orthopedic Oncology, Washington, DC

Inpatient Care and Same Day Surgery• Henry Ford-NICU, Detroit, MI• IHC Shock Trauma Unit, Salt Lake

City, UT• Shouldice Hospital, Hernia Repair,

Toronto, Canada• Mayo Luther-Midelfort, Behavioral

Health, Eau Claire, WINursing Home and Hospice Care• On Lok SeniorHealth, San Fran, CA• Iowa Veterans Home, Marshaltown,

IA• Bon Secours Maria Manor Nursing

Center, St.Petersburg, FL• Hospice of Iowa, Mason City, IA Home Health Care• Gentiva, Rehab without Walls, East

Lansing, MI• Visiting Nursing Service of NYC,

New York, NY• Interim Healthcare, Pittsburgh, PA

How good is good? a few results.

• Mass General Hospital Primary Care– Waiting Room time – how many minutes?

• Shouldice Hernia Hospital– OR turnaround – how many minutes?

– Disposable costs per operation?

8 Minutes or the Co-Pay is waived

1 Minute and 30 Seconds versus 90 min

$17. 50 versus national average $500

Study Results

10 Success Characteristics of High Performing Clinical Units

Step 1: Review Handout and complete the Microsystem Assessment

The 5 P’s: Purpose, Patients, Professionals, Processes, and Patterns

Step 2: Review document and work on Professionals and Process Handout

We found 10 Success Characteristics that We found 10 Success Characteristics that are associated with high performanceare associated with high performance

LEADERSHIP STAFF

PERFORMANCE PATIENTS

Ÿ LeadershipŸ Organizational

Support

Ÿ Staff FocusŸ Education and

TrainingŸ Interdependence

of Care Team

Ÿ Patient FocusŸ Community and

Market Focus

Ÿ PerformanceResults

Ÿ ProcessImprovement

Informationand

InformationTechnology

1. Strong Leadership

2. Great Organizational Support

3. Focus on Staff (Professionals)

4. Education and Training of Staff

5. Interdependence of Care Team

6. Performance Result Focused

7. Process Improvement Focused

8. Patient-Centered (Patient Focus)

9. Community and Market Focus

10. Information & Information Technology Orientation

Clinical Microsystem Assessment ExerciseClinical Microsystem Assessment ExerciseInstruction: each of the “ 10 success characteristics” (e.g., leadership) is crucial for high

performance. Below each of the characteristics is defined and is followed by a ranking from 1 – 5 (low – high) as well as 3 descriptions (low – high performance). For each characteristic please circle a number 1 – 5 that best describes your current Microsystem.

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

1 2 3 4 5

Leaders often tell me how to do my job and leave little room for innovation and autonomy. Overall, they don’t always foster a positive culture.

Leaders struggle to find the right balance between reaching performance goals and supporting and empowering the staff.

Leaders maintain constancy of purpose, establish clear goals and expectations, and foster a respectful positive culture. Leaders take time to build knowledge, review and reflect, and take positive action in the Microsystem and the larger organization

The 5 P’s of The 5 P’s of Micro-systems include ...Micro-systems include ...

• Purpose - Our aim and mission.• Patients - Our reason for doing our work.• Professionals - Our staff who work in the

trenches to take care of patients.• Processes - Our system of inter-related

events that constitute the microsystem.• Patterns - Our way of doing our work

(Measurements, Data, Run Charts)

Building a Team to Manage A Panel of Primary Care PatientsMIssion: The Dartmouth-Hitchcock Clinic exists to serve the health care needs of our patients.

Very High Risk

Chronic

Very High Risk

Healthy

Healthy

Healthy

Chronic

Assign toPCP

Orient toTeam

Assess &Plan Care

Functional& Risks

Biological

Costs

Expectations Chronic ++

Very High Risk +++

Healthy

Prevention Acute EducateChronic

P A C E

P A C E

P A E

P A C E

Functional& Risks

Biological

Costs

Satisfaction

People withhealthcare

needsPeople withhealthcareneeds met

Phone,Nurse First

PhysicalSpace

Info Systems& Data

BillingReferralsPharmacyRadiologyLaboratoryMedicalRecords

Scheduling

Department

Division and Community

Southern Region

Hitchcock Clinic System

Measuring Team Performance & Patient Outcomes and Costs

Measure Current Target Measure Current Target

Panel Size Adj.

Direct Pt. Care Hours:MD/Assoc.

% Panel Seeing OwnPCP:

Total PMPM Adj.PMPM-Team

External Referral Adj.PMPM-Team

Patient Satisfaction

Access Satisfaction

Staff Satisfaction

TEAM MEMBERS:

Skill Mix: MDs _2.8_ RNs _6.8_ NP/PAs __2__ MA _4.8 LPN _____ SECs __4_Micro-System Approach 6/17/98Revised: 1/27/00

c Eugene C. Nelson, DSc, MPHPaul B. Batalden, MDDartmouth-Hitchcock Clinic, June 1998

1 2 3

5 6 7 8 9 10 11 12 13 14

4

Sherman Baker, MD

Leslie Cook, MD

Joe Karpicz, MD

Deb Urquart, NP

Ron Carson, PA

Erica, RN

Laura, RN

Maggi, RN

Missy, RN

Diane, RN

Katie, RN

Bonnie, LPN

Carole, LPN

Nancy, LPN

Mary Beth, MA

Lynn, MA

Amy, Secretary

Buffy, Secretary

Mary Ellen, Secretary

Kristy, Secretary

Charlene, Secretary

Nashua Internal Medicine

PurposePurpose

ProfessionalsProfessionals

ProcessesProcesses

PatternsPatterns

PatientsPatients

The 5 P’s of Micro-systems The 5 P’s of Micro-systems include ... Purposeinclude ... Purpose

The purpose is our aim and mission: What are we trying to accomplish?

An explicit statement summarizing what is expected to be achieved from the improvement initiative.

Helps to maintain focus on a specific opportunity or problem during the project.

Helps to identify appropriate members of the improvement team.

Pgs 103, 104 in Action Guide

The 5 P’s of Micro-systems The 5 P’s of Micro-systems include ... Patientsinclude ... Patients

Patients are the reason for doing our work.What is the target population age distribution?Ave. Length of Stay?Mortality Rate?List your top 10 DiagnosisPt. Population CensusAdditional patient information, ______________?Family Surveys, Capturing patient information on an

ongoing basis . . .

PGS 59 – 70 in Action Guide

The 5 P’s of Micro-systems The 5 P’s of Micro-systems include ... People (Professionals)include ... People (Professionals)Professionals - Our staff who work in the

trenches to take care of patients.

Complete the Handout Pgs 11 – 15, including:Who is part of your team, list out staff and %FTEComplete Staff Satisfaction SurveyComplete Inpatient Unit Personal Skills AssessmentComplete Inpatient Unit Activity Survey Sheet

The 5 P’s of Micro-systems The 5 P’s of Micro-systems include ... Processesinclude ... Processes

Processes - Our system of inter-related events that constitute the microsystem.

Inpatient Unit Patient Cycle time, Handout Pgs. 16Inpatient Unit Know Your Process - Core and

Supporting Processes, Handout pg. 17Flowchart core process related to nosocomial

infections

See Handout Pgs 16,17 & Action Guide Pgs. 116 – 122 (Detailed Overview of Flowcharting)

The 5 P’s of Micro-systems The 5 P’s of Micro-systems include ... Patternsinclude ... Patterns

Patterns - Our way of doing our work (Measurements, Data, Run Charts)

Capture key clinical data related to nosocomial infections, and line infection rates

What measurements are being captured? Definitions, Data Owner, Current and Target Values, Action Plan and Process Owner

See Action Guide: Pgs 70 - 82

• Tools in the Clinical MS Action GuideTools in the Clinical MS Action Guide

• MS Advising ApproachMS Advising Approach

• Key Learnings from Microsystem WorkKey Learnings from Microsystem Work

• A Concluding RemarkA Concluding Remark

Healthcare Improvement Tools and Our Advising Approach

Microsystem Tools and Resources

• A Clinical Microsystem Action Guide (www.clinicalmicrosystem.org) Tools and Resources - A Map for Improvement– (General) Clinical Microsystem Profiler, Pg 14 – (Professionals) Practice Staff Profiler, (see handout)– (Process) PDSA, Plan Do Study Act, Pg. 112 - 114– (Patients) Patient Flowcharting, Pg. 15– (Big Picture) Clinical Microsystem Picture, Pg. 22– (Patterns) Performance Patterns: Measurement and Monitoring, Pgs 70 -

82– (Process) Fishbone Diagrams, Pgs 115 - 116– (Big Picture) Clinical Microsystem Assessment Tool, Pgs 16 - 19– (Safety) External Environment, Health Professional Education Pgs 102,

103– (Purpose) Aim Statement, Vision and Mission Journal, Pg 103, 104– (Professionals) Meeting Agenda Graphic, Pgs. 103 - 109

Microsystem Advising ApproachThe Clinical Microsystem Action Guide along with years of accumulated knowledge in CQI projects creates a ROADMAP for improving care at the Unit Level.

Phase 1: Build MS Awareness via Assessment & Diagnostic Tools1. Complete Microsystem Assessment Tool. 2. Pick Options in action guide, which Tools to use, set goals (What, Who, and How of project).

Phase 2: Gather Data, Flowcharting & Mapping Processes• Do a site visit & interviews, and capture key Q, $, & Process Measures.• Patient & IT Flowcharting, Small work group meetings.• Foster “MS & Improvement Culture”.

Microsystem Advising ApproachThe Clinical Microsystem Action Guide along with years of accumulated knowledge

in CQI projects creates a ROADMAP for improving care at the Unit Level.

Phase 3: Data Crunch, Analyze Q, $, & Process Measures6. Crunch and analyze the data (project specific measures).7. KEEP ENERGY HIGH for project, support support support!8. Provide on-going feedback of measures (Patterns).

Phase 4: Finish Work, Present Outcomes, Work on Spread 9. Congratulate and Celebrate Successes. 10. Review what we learned, provide feedback, and document changes.11. Plan for next phase (Intra-Unit and Inter-Unit Spread), Utilize High Energy from

project for spread.

Learning from Eight Years of Microsystem and CQI Work

• IHI workshops, symposium, IHI workshops, symposium, teaching, and trainingteaching, and training

• Microsystem assessments, and Microsystem assessments, and CQI work at various ClinicsCQI work at various Clinics

• Culture Redesign: e.g., NICU Culture Redesign: e.g., NICU Dartmouth Lahey HospitalDartmouth Lahey Hospital

• Strong Vision and Mission is needed - at the unit level (Purpose). We need strong local and senior leadership for real change to happen.

• Do interviews, gather objective Do interviews, gather objective data, manage the process, be data, manage the process, be alert alert for hidden gems (LHF)for hidden gems (LHF). . Work at the microsystem level for effective lasting change .

• Include the Include the right staff, facilitate right staff, facilitate conversation, conversation, be open to be open to surprises. surprises. Emphasize fluidity and flexibility during the spread of change.

Learning from Eight Years of Microsystem and CQI Work

• Redesign, IT Infrastructure, Redesign, IT Infrastructure, Change Management: 27 Change Management: 27 Kaiser Intensive Care UnitsKaiser Intensive Care Units

• Patient and Information Flow Patient and Information Flow (lean thinking): e.g., Keene (lean thinking): e.g., Keene Clinic RedesignClinic Redesign

• Technology Adoption: UCSF - Technology Adoption: UCSF - Stanford HospitalsStanford Hospitals

• The Planning Phase is crucial in PDSA, and critical for HER. First map the processes then implement the HER.

• Mapping processes creates Mapping processes creates energyenergy, , highlights areas for highlights areas for changechange, and gets , and gets staff buy-instaff buy-in. . Having an outside support person is helpful in lean thinking mapping.

• Work with underlying Work with underlying (hidden) (hidden) agendasagendas to make changes. to make changes. Use the creativity of the Professionals(they know what needs to be done).

Concluding Remark

Healthcare organizations might not be utilizing the term micro-system, but it is clear that many high quality and cost-efficient providers are organizing themselves around functional front-line teams & professionals that have the right information at the right time, to deliver the best care possible.

Questions and CommentsQuestions and Comments

If you want to learn more . . . ReferencesReferences

– Thomas P. Huber, M.S.; Paul B. Batalden, M.D.; Eugene C. Nelson, D.Sc., M.P.H.; Marjorie M. Godfrey, M.S., R.N.: “

Microsystems in Health Care: Developing People and Improving Work Life: What Frontline Staff Told Us.” The Joint

Commission Journal on Quality Improvement, October 2003, Volume 29 Number 10.

– Eugene C. Nelson, D.Sc., M.P.H.; Paul B. Batalden, M.D.; Karen Homa, MS; Marjorie Godfrey, MS RN; Christine

Campbell; Linda Headrick, MD, MS, Thomas Huber, MS; Julie Mohr MSPH, PhD; John Wasson, MD: “ Microsystems

in Health Care: Creating a Rich Information Environment.” The Joint Commission Journal on Quality Improvement,

January 2003, Volume 29.

– Eugene C. Nelson, D.Sc., M.P.H.; Paul B. Batalden, M.D.; Thomas P. Huber, M.S.; Marjorie M. Godfrey, M.S., R.N.;

Linda A. Headrick, M.D.; Julie J. Mohr, Ph.D.; M.S.P.H.; John H. Wasson, M.D.; “ Microsystems in Health Care:

Learning from High-Performing Front-Line Clinical Units.” The Joint Commission Journal on Quality Improvement,

September 2002, Volume 28.

– Godfrey M, Wasson J, Nelson E, Batalden P, Mohr J, Huber T, Headrick L.; “Clinical Microsystem Action Guide –

Improving Health Care by Improving Your Microsystem”, Version 1.1: November 2001.

– Clinical Microsystems provides an on-line version of the Clinical Action Guide. Hanover, NH: Health Care

Improvement and Leadership Development at Dartmouth College. (See Clinicalmicrosystems.org)

If you want to learn more . . .

ReferencesReferences– Langley GJ, et al.: The Improvement Guide - A Practical Approach to Enhancing Organizational Performance. San

Francisco: Jossey-Bass, 1996

– Nelson EC, Batalden PB, Ryer J: Clinical Improvement Action Guide, JCAHO, Oak Brook Terrace, IL, 1998.

– Nelson EC, Wasson JH: "Using Patient-Based Information to Rapidly Redesign Care," Healthcare Forum Journal,

37(4):25-29, July/August 1994.

– Quinn JB: Intelligent Enterprise: A Knowledge and Service Based Paradigm for Industry. New York, NY: The Free

Press, 1992.

– Rother M, Shook J: Learning to See: Value Stream Mapping to Add Value and Eliminate Muda. Brookline, MA: Lean

Enterprise Institute, 1999.

– Nelson EC, Splaine ME, Godfrey MM, Kahn V, Hess AR, Batalden PB, Plume SK: Using Data to Improve Medical

Practice by Measuring Processes and Outcomes of Care. Joint Commission Journal on Quality Improvement, 26(12):667-

685, December 2000.

– Nelson EC, Batalden PB: Knowledge for Improvement: Improving Quality in the Micro-systems of Care. In: Goldfield

N , Nash DB, eds. Managing Quality of Care in Cost-Focused Environment. Tampa, FL: Aspen Publishers; 1999:75-87.

If you want to learn more . . . ReferencesReferences

– Nelson EC, Batalden PB, Mohr JJ, Plume SK: Building A Quality Future. Frontiers of Health Services

Management, 15(1):3-32, Fall 1998.

– Batalden PB, Mohr JJ, Nelson EC, et al.: Continually Improving the Health and Value of Healthcare for a

Population of Patients: The Panel Management Process. Quality Management in Healthcare, 5(3):41-51,

Spring 1997.

– Nelson EC, Mohr JJ, Batalden PB, Plume SK: Improving Health Care, Part 1: The Clinical Value Compass.

The Joint Commission Journal on Quality Improvement, 22(4):243-258, April 1996.

– Nelson EC, Batalden PB, Plume SK, Mihevc NT, Swartz WG: Report Cards or Instrument Panels: Who

Needs What? The Joint Commission Journal on Quality Improvement, 21(4):155-166, April 1995.

– Weinstein JN, Brown PW, Hanscom B, Walsh T, Nelson EC: Designing an Ambulatory Clinical Practice for

Outcomes Improvement: From Vision to Reality - The Spine Center at Dartmouth-Hitchcock, Year One.

Quality Management in Health Care, 8(2):1-20, Winter 2000.