When working on processes consider -

Mapping the key processes as flowcharts

Identifying supporting microsystems and how they interact with core processes

Observing and measuring cycle times—how long process steps take

Professionals

Every member of the microsystem who provides or

contributes to the care of patients should be thought

of as a professional. Learning more about the staff,

what they do, when they work and what they think

and how they rate the workplace is an important part

of understanding any microsystem. A staff survey is

often a good way to find out what would make the

service better for patients and the team.

Patterns

Patterns exist in every microsystem

but often are unnoticed. Patterns exist

in many dimensions and questions to

consider are—

What are the metrics that

matter to this microsystem—

the outcome measures?

What are the trends over

time?

What would you want to change in Renal OPD?

0% 20% 40% 60% 80% 100%

Clinical Outcome

Customer Care

Hospital environment - Cleanliness

Hospital environment - Layout

Hospital environment - Furniture

Clinc appointment scheduling

Information available in outpatients

Waiting time for patients

Seeing the appropriate staff member

Time of day clinic held

Room use/allocation

Staff working patterns

Available equipment

% of replies

1 - No change required 2 3 4 5 - Large change required

Clinic VC147B Tuesday 1/11/11

8.3

0

8.4

5

9.0

0

9.1

5

9.3

0

9.4

5

10

.00

10

.15

10

.30

10

.45

11

.00

11

.15

11

.30

11

.45

12

.00

12

.15

12

.30

12

.45

13

.00

13

.15

13

.30

13

.45

14

.00

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6

Patient 7

Patient 8

Patient 9

Patient 10

Patient 11

Patient 12

Patient 13

Patient 14

Patient 15

Patient 16

Patient 17

Patient 18

Patient 19

Patient 20

Patient 21

Patient 22

Patient 23

Patient 24

Patient 25

Patient 26

Patient 27

Patient 28

Patient 29

Patient 30

Patient 31

Patient 32

Patient 33

Patient 34

Patient 35

Patient 36

Patient 37

Patient 38

Patient 39

Patient 40

Processes—Gantt

Chart showing

cycle times

Processes

The microsystem members participate in various

processes and steps to care for patients. Often the

team have never taken the time to review these

processes and different views and perspectives

emerge when the team create a flowchart of these

core processes. This lack of knowledge often leads to

waste and unreliability

What are the communication and social patterns within the microsystem?

Do the team meet and review these patterns to improve care?

Resources

Further information about collecting and understanding the 5Ps can be found in—

Quality by Design (2007) Nelson, Batalden, Godfrey, Ch 6 & 13

Dartmouth Microsystem Academy Action guides

www.clincalmicrosystem.org CLICK Materials

www.sheffieldmca.org.uk

4 ©2013 Trustees of Dartmouth College, Sheffield Microsystem Coaching Academy

Assessing Your Microsystem using the 5Ps

‘A one page book’

‘To do things differently, we must see things differently’

John Kelsch, Xerox 1990

The 5Ps framework is a tested and useful method for microsystem members to begin to

see their microsystem in a new way and begin to ask new questions. This process should

actively involve the microsystem team to build understanding and ownership. The

discoveries made in the 5Ps help the team create and select their theme(s) for

improvement. (See resources pg 4)

Purpose

High performing microsystems have a clearly stated purpose and mission. Writing a

purpose statement during the 5Ps allow the team to consider—why does our microsystem

exist? Do we all share a common goal and aim? Active discussion of this connects

individual members with the microsystem purpose.

To promise and deliver

reliable, patient-

centered, evidence

based care for every

patient, every time. (IDCOP Berwick 2001)

To provide an essential clinical support

service to ensure local and regional

patients with an endocrine condition

receive the highest quality clinical

outcomes (EIU, STH 2012)

‘To enable people with CF to live

as normal a life as possible’

(STH CF Team 2011)

Patients

General population knowledge and facts are often not shared by all members of the

microsystem team, even though many will have individual knowledge of the patients they

provide care to. Things to consider are

What subpopulations exist within your patient group?

What are the demographics, age, gender?

Where do your patients travel from?

What do patients think about the service? What do they think we can do better?

What is it like in daily life to have the condition(s) you treat

16-25 26-35 36-45 46-55 56-65 66-75 76-85 86+

Age 0.6% 2.2% 9.0% 20.2% 28.1% 27.0% 10.7% 2.2%

0.6%2.2%

9.0%

20.2%

28.1%27.0%

10.7%

2.2%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

What is your age group?55 years old

Married

3 children—1 at University

Still at work

Husband not very supportive

Only 2 treatment options—

no option for operation

Referred straight to hospital

for chemotherapy

Anxious and fearful

Has no nurse specialist or

other support

Rosie— A typical patient (fictional)

1

An example 5Ps—Cystic Fibrosis at Sheffield Teaching Hospitals

PURPOSE

PROCESSES

PROFESSIONALS

PATIENTS PATTERNS

______________________________________

PURPOSE

PROCESSES

PROFESSIONALS

PATIENTS PATTERNS

______________________________________

CF OPD Purpose - To enable people with CF to live as normal a life as possibleTotal number of patients

0

20

40

60

80

100

120

140

2003/

04

2004/

05

2005/

06

2006/

07

2007/

08

2008/

09

2009/

10

2010/

11

Band 6

Band 5

Band 4

Band 3

Band 2

band 1

Do you have any comments regarding the CF Outpatient Service?

”Less waiting around please”“I feel the clinic could do with updating”

“The unit is old-the rooms are small”“Dated room requires some TLC”

“Would prefer it to be quicker”“Not enough rooms as when busy have to wait in waiting room not separate room.”“CF unit is small for the amount of patients…the no. of patients have outgrown the facilities.”

“Written and formalized Annual Review results and summary from clinics allows patients to track own health; essential!”

“A good comprehensive service delivered by friendly & supportive staff.”“All the staff are caring and lovely, even the cleaners. They exceeded expectations.”“Having the new ward has made it a lot easier to stay in hospital.”

“All staff are lovely, helpful, experienced and patient.”“I think the ward is very good, all the nurses were great and made me feel really welcome and the

facilities were really good!”“Outpatient facility could be improved. The rooms are too small and outdated.”“ Not enough Community support”

“long wait for admission – at least 3 days”“Can’t always see the physiotherapist. psychologist and social worker when you want to”

Where do your patients come from?

How do we compare—registry data

What do your patients think? - Survey

PROCESSES

Diagnosis at Birth

Managed by SCH until

aged 16

Visit Outpa-

tients, vari-able fre-

quency

Annual Re-view on Birth-

day

PFT Weight—BMI Sputum Sam-

ple/Swab

GTT Test

Dr or SPR Re-view

Dietician Re-view (Most

Patients)

Nurse, Port Flush, Blood

Sample

Physio (Some Patients)

Visit Phar-macy for

Meds

Admission to CF Ward, ITU

or HDU

X Ray Social Worker Ultra Sound Bone Scan (Metabolic

Bone)

Pharmacy

Combined

clinics, Diabe-tes, Met

Bone,

Lung Trans-

plant (Newcastle/

Papworth/

Elsewhere)

Transition Clinic

Psychologists

Cashiers Of-fice (Some)

Patient Trans-port

PURPOSE

PROCESSES

PROFESSIONALS

PATIENTS PATTERNS

______________________________________

Role Name Role Name Role Name

Respiratory Consultant Frank Edenborough Physiotherapy manager Cheryl Harman Ward/Outpatient CF Matron Ruth Marrison

Respiratory Consultant Martin Wildman Physiotherapy Clinical Specialist Ward Manager Susan Lloyd

Secretary to Frank Wendy Skelton Psychologist Gemma Field Ward Matron Alison Lee

Secretary to Martin Joanne Andrews SpR Sally Davies Health Care Assistant Michelle Lowther

Nurse Specialist Yvonne Locke SpR Aldrin Adeni Volunteer (HCA’s mum) Shelia Foster

Nurse Specialist Shirley Murray SpR Kate Gasgoyne Senior Dietician Sarah Thornton

Nurse Specialist Julie Boadle Social Worker Dorothy Langman Dietician Alisia Milne

Patient representative Lynsey Morton Social Worker Louise Martin Dietician Nina Singaroyan

Service Manager Lisa Needham Pharmacist Amanda Plummer Dietician Jenny Leyland

Assistant Service Manager Claire Walker Pharmacist Tim Gleeson Clerical Officer Marjorie Frater

Pathway Coordinator Julie Key Medicines Management Technician Suzanne Wilkinson

Role Name Role Name Role Name

Respiratory Consultant Frank Edenborough Physiotherapy manager Cheryl Harman Ward/Outpatient CF Matron Ruth Marrison

Respiratory Consultant Martin Wildman Physiotherapy Clinical Specialist Ward Manager Susan Lloyd

Secretary to Frank Wendy Skelton Psychologist Gemma Field Ward Matron Alison Lee

Secretary to Martin Joanne Andrews SpR Sally Davies Health Care Assistant Michelle Lowther

Nurse Specialist Yvonne Locke SpR Aldrin Adeni Volunteer (HCA’s mum) Shelia Foster

Nurse Specialist Shirley Murray SpR Kate Gasgoyne Senior Dietician Sarah Thornton

Nurse Specialist Julie Boadle Social Worker Dorothy Langman Dietician Alisia Milne

Patient representative Lynsey Morton Social Worker Louise Martin Dietician Nina Singaroyan

Service Manager Lisa Needham Pharmacist Amanda Plummer Dietician Jenny Leyland

Assistant Service Manager Claire Walker Pharmacist Tim Gleeson Clerical Officer Marjorie Frater

Pathway Coordinator Julie Key Medicines Management Technician Suzanne Wilkinson

Role Name Role Name Role Name

Respiratory Consultant Frank Edenborough Physiotherapy manager Cheryl Harman Ward/Outpatient CF Matron Ruth Marrison

Respiratory Consultant Martin Wildman Physiotherapy Clinical Specialist Ward Manager Susan Lloyd

Secretary to Frank Wendy Skelton Psychologist Gemma Field Ward Matron Alison Lee

Secretary to Martin Joanne Andrews SpR Sally Davies Health Care Assistant Michelle Lowther

Nurse Specialist Yvonne Locke SpR Aldrin Adeni Volunteer (HCA’s mum) Shelia Foster

Nurse Specialist Shirley Murray SpR Kate Gasgoyne Senior Dietician Sarah Thornton

Nurse Specialist Julie Boadle Social Worker Dorothy Langman Dietician Alisia Milne

Patient representative Lynsey Morton Social Worker Louise Martin Dietician Nina Singaroyan

Service Manager Lisa Needham Pharmacist Amanda Plummer Dietician Jenny Leyland

Assistant Service Manager Claire Walker Pharmacist Tim Gleeson Clerical Officer Marjorie Frater

Pathway Coordinator Julie Key Medicines Management Technician Suzanne Wilkinson

Who are the Multidisciplinary team?

•To be more time efficient, a faster more efficient flow of patients, reduce waiting times•To have better access to the full MDT•To have flexible appointments•Nicer facilities•Things to do while waiting – TV, refreshments•Better building, complete overhaul, decent waiting room, overall nicer environment, cleaner rooms, improve decor•Closer proximity to ward•A unit administrator – to make us more organised & efficient•Less pharmacy wait, rapid access to pharmacy prescriptions•More physio input•More pharmacy input•Quicker clinic visits•Better parking facilities

•To be time efficient, more stream-lined, produce less waste•To have better scheduling of activities, job roles for individuals•To have a nicer environment to work in, better building, more space, up to date equipment and furniture •To improve staffing levels to allow better attendance at clinic for junior trainees•Improved ambulance/ patient transport efficiency – reduce late working hours, angst of patients and families •A doctors room, private room with desk to be able to dictate away from phone/chat•Sluice for dealing with specimens, urine, faeces.•To be closer to CF ward•Better integration between ward and OPD service•Better communication with CF ward•Clarity of roles with all the changes•Patient management system to improve quality of care•Improved time keeping by patients in terms of arrival times and reduced DNA

What are the key processes—flowchart

Who are your supporting microsystems?

2

An example 5Ps—Cystic Fibrosis at Sheffield Teaching Hospitals

PURPOSE

PROCESSES

PROFESSIONALS

PATIENTS PATTERNS

______________________________________

PURPOSE

PROCESSES

PROFESSIONALS

PATIENTS PATTERNS

______________________________________

CF OPD Purpose - To enable people with CF to live as normal a life as possible

PROCESSES

Diagnosis at Birth

Managed by SCH until

aged 16

Visit Outpa-

tients, vari-able fre-

quency

Annual Re-view on Birth-

day

PFT Weight—BMI Sputum Sam-

ple/Swab

GTT Test

Dr or SPR Re-view

Dietician Re-view (Most

Patients)

Nurse, Port Flush, Blood

Sample

Physio (Some Patients)

Visit Phar-macy for

Meds

Admission to CF Ward, ITU

or HDU

X Ray Social Worker Ultra Sound Bone Scan (Metabolic

Bone)

Pharmacy

Combined

clinics, Diabe-tes, Met

Bone,

Lung Trans-

plant (Newcastle/

Papworth/

Elsewhere)

Transition Clinic

Psychologists

Cashiers Of-fice (Some)

Patient Trans-port

PURPOSE

PROCESSES

PROFESSIONALS

PATIENTS PATTERNS

______________________________________

What do the staff think?—Survey

I am treated with respect every day by everyone

that works in clinic

0

2

4

6

8

10

12

14

Strongly agree Agree Disagree Strongly

Disagree

Nu

mb

er

of

res

po

nd

ers

I am given everything I need - Equipment and

encouragement to allow me to do my work to the

best of my ability

0

2

4

6

8

10

12

14

Strongly Agree Agree Disagree Strongly

Disagree

Nu

mb

er

of

res

po

nd

ers

How easy was it to ask anyone a question about the

care we provide?

0

2

4

6

8

10

12

14

Very Easy Easy Difficult Very Difficult

Nu

mb

er

of

res

po

nd

ers

How would you rate other people's morale and their

attitudes about working here?

0

2

4

6

8

10

12

14

Excellent Very good Good Fair Poor

Nu

mb

er

of

res

po

nd

ers

•To be more time efficient, a faster more efficient flow of patients, reduce waiting times•To have better access to the full MDT•To have flexible appointments•Nicer facilities•Things to do while waiting – TV, refreshments•Better building, complete overhaul, decent waiting room, overall nicer environment, cleaner rooms, improve decor•Closer proximity to ward•A unit administrator – to make us more organised & efficient•Less pharmacy wait, rapid access to pharmacy prescriptions•More physio input•More pharmacy input•Quicker clinic visits•Better parking facilities

•To be time efficient, more stream-lined, produce less waste•To have better scheduling of activities, job roles for individuals•To have a nicer environment to work in, better building, more space, up to date equipment and furniture •To improve staffing levels to allow better attendance at clinic for junior trainees•Improved ambulance/ patient transport efficiency – reduce late working hours, angst of patients and families •A doctors room, private room with desk to be able to dictate away from phone/chat•Sluice for dealing with specimens, urine, faeces.•To be closer to CF ward•Better integration between ward and OPD service•Better communication with CF ward•Clarity of roles with all the changes•Patient management system to improve quality of care•Improved time keeping by patients in terms of arrival times and reduced DNA

Waiting in clinic & other data

patterns?

The Sheffield CF population; the UK population and our closest neighbours (Leeds) This table identifies some outcomes and some process measures that are probably markers of quality.

I have largely used parameters available in PORT CF

Total CF population: 142 currently

PORT CF 136 patients named on end of year survey for 2010 – this value used

Characteristic Sheffield

Leeds

UK

FEV1 *65% *62.5% *64.9%

BMI *20.5 *21.8 *21.8

PEG Feeds

Proportion of adult

clinic receiving PEG

feeds

*15 patients/ 136 =

11.03%

†12% *6.8%

Number of days home

IVs over the year

(averaged across all

adult patients)

*89 pts had home iv’s

No. of iv days = 3538

Average no. iv days for

those who had iv’s=

39.75%

Ave no. iv’s across

total pt population =

26.01%

NA NA

Number of days

hospital IVS over the

year

(averaged across all

adult patients)

*52 pts had hospital

iv’s

No. iv days = 1653

Ave no. for those who

had hosp iv’s = 31.79%

Ave no. across total cf

popn = 12.15%

NA NA

Long term oxygen

prescribed to be used

continuously

*3/ 136 = 2.21% NA *1.9%

NIV (any use) *7/136 = 5.15% NA *3.5%

Treatment for CFRD

(see next table re

breakdown in CFRD)

◊*22/136 = 16.18% NA *26.8%

Patients over 16 on

DNase

*71/136 = 52.21% ¥43.6%

Patients with chronic

pseudomonas on

nebulised antibiotic ₣

*96 patients on

PORTCF with

pseudomonas

₣82%

Patients with

transiently raised

creatinine (important marker of adverse outcome)

Will need to review

hospital ICE system

Data sources *PORT CF 2009 Adults

†Leeds guide

‡ NGH data source ¥ This is an average of the % across 5 year age groups from PORT CF with tendency for older patients to receive less DNAse

₣ Unfortunately it is very difficult to accurately determine this from PORT CF since the data field includes chronic macrolides,

but the UK standard is that 90% of patients with chronic pseudomonas should be on a nebulised antibiotic so it is worth us finding these data. I have reviewed a list of those pt in 2010 with label Pseudomonas on port cF. I have then reviewed Lists of

patients on Tobramycin, and again for Colistin & then Promixin and then collated this information on the 3rd table

Notes re data collection

1. PORTCF is not very intuitive

2. PORTCF data is only as good as the data inputted

Outcome Measures?

Social Patterns

• Weekly MDT meeting discusses patients attending

clinic

• Ad hoc but regular consultant communication

• No formal CF leadership meeting (Dr, Nurse,

Management)

• Thank you‘s displayed in Nurse Area

• No regular improvement meeting

Who are your supporting microsystems?

What are the Team Patterns?

How long do they take?

3