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Micro-Systems in Health Care: Essential Building Blocks for the Successful Delivery of Health Care in the 21 st Century. Thomas P Huber, MS ECS September 18 & 25, 2006. Presentation to CCHA/CCS NICU Improvement Project . Aim of Presentation. - PowerPoint PPT Presentation
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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 ECSSeptember 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.
AGENDA1. 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 io n : The D a rtm o uth -H itch co ck C lin ic exis ts to se rve th e he a lth care ne ed s o f ou r p a tie n ts .
Very H igh Risk
Chro nic
Very H igh R isk
Healthy
Healthy
Healthy
Chro nic
Assign toPCP
O rien t toTeam
Assess &Plan Care
Functional& R isks
Bio logical
C osts
Expectations Chro nic ++
Very H igh Risk +++
H ealthy
Prevention Acute EducateChronic
P A C E
P A C E
P A E
P A C E
Functio nal& Risks
Bio logical
Costs
Satis faction
People w ithhealthcare
needs People w ithhealthcareneeds m et
Phone,Nurse F irs t
PhysicalSp ace
Info Systems& D ata BillingReferralsPharm acyRad io logyLaborato ryM ed ica l
Reco rd sScheduling
Departm entDivision and Com m unity
Southern RegionHitchcock Clinic System
M easuring Team Perform ance & Patient Outcom es and Costs
M easure Current Target M easure Current Target
Panel Size Adj.
D irect P t. Care H ours:MD /Assoc.
% Panel S ee ing O wnPCP:
Tota l PM PM Ad j.PM PM -Team
External Referra l Adj.PMPM -Team
Patient Sa tis faction
Access Satisfaction
Sta ff Sa tis fac tion
TEAM M EM BERS:
Skill M ix: MDs _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. Ne lson , D Sc, M PHPau l B . Ba ta lden, MDDartmouth-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 Ellen, Secretary
Kris ty, 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
needs People withhealthcareneeds met
Phone,Nurse First
PhysicalSpace
Info Systems& Data BillingReferralsPharmacyRadiologyLaboratoryMedical
RecordsScheduling
DepartmentDivision and Community
Southern RegionHitchcock 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 Kaiser Change Management: 27 Kaiser Intensive Care UnitsIntensive 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.