# Presentation: 544024

## Readiness Curriculum’s May Call TopicDesigning “Great” Clinical Practices:Orientation to Clinical Microsystems

*Marjorie Godfrey, MS RN*
*Adjunct Instructor*
*The Dartmouth Institute for Health Policy and Clinical Practice*
*Dartmouth Medical School*
*May 28, 2008*
*www.clinicalmicrosystem.org*

## Objectives

- Provide background and research of clinical microsystems
- Review the fundamentals to assess, diagnose and treat your clinical microsystem *“The Green Book”*
- Discuss examples from colleagues to gain insights and tips

## “They give me exactly what I want (and need) exactly when I want (and need) it . . . . . . While maintaining and improving a joyful work environment and a financially viable organization.”

- - Don Berwick, MD
- President, CEO
- Institute for Healthcare Improvement (IHI)

- A great practice.

##  Introduction to microsystem thinking

- “Every system is perfectly designed to get the results it gets.”
- Your practice is a small system
- A complex adaptive system
- A clinical microsystem

## Assumptions

- Everyone has heard of the idea and has various notions of what it means.
- We all have more experience living in, working in, and using them than we _*have studying, changing, and leading them*_.

## What is a clinical microsystem?

*How did this idea get started and how is it being used?*

## Understanding health care as a system

- Understanding health care as a system

## The Chain of Effect inImproving Health Care Quality

- I

- Patient and the Community

- II

- Micro-system

- III

- Organizational context

- IV

- Environmental Context

## Evolution of “Clinical Microsystems”

- J. Brian Quinn, PhD

- World-wide research and study of best-of-best service organizations
- Batalden, Nelson Research and Knowledge Development
- Deming
- Caring for Pts & Populations
- Clinical Value Compass

- 1992

- 2000
- IOM and Julie Mohr and Molla Donaldson

- 2001
- Robert W. Johnson Foundation Study

- 8  Success Characteristics

- 2001
- IOM 21st Century

- Future

- 1998
- Hierarchy of Systems

- late 1970’s & 1980’s

- mid-90’s
-  CECS course on Micro-units
-  HFHS “panels” of patients

- 2001
- Website
- Formed

- 2002-3
- JQI Articles

- 2003

- 2005
- AHA
- Microsystem
- Toolkits

- 2006
- Microsystem
- Textbook

- European
- Clinical
- Microsystem
- Network

- Fall
- Invitational

- CF Foundation Action Guide 07/2006

- 2006

## Dartmouth Study 2002

*Dartmouth Study 2002*

- Eugene C. Nelson, DSc, MPH
- Paul B. Batalden, MD
- Thomas P. Huber, MS
- Julie J. Mohr, MSPH, PhD
- Marjorie M. Godfrey, MS, RN
- Linda A. Headrick, MD, MS
- John H. Wasson, MD

## High performing clinical microsystems 

## Definition

*A health care clinical microsystem can be defined as the combination of a** **small team** **of people who work together on a regular basis—or as needed—to provide care and the **individuals** who receive that care (who can also be recognized as members of a discrete **subpopulation of** **patients**.)*
*It has clinical and business** **aims**,** **linked **processes**,** **a** **shared** **information** environment and produces services and care which can be measured as performance** **outcomes**.** **These systems evolve over time and are (often)** **embedded** in larger systems/organizations.** *
*As any living adaptive system, the microsystem must: (1) do the work, (2) meet staff needs, (3) maintain themselves as a clinical unit.*

## A Picture of a Clinical Microsystem

- A Picture of a Clinical Microsystem

-  The Anatomy

## Patients

- Professionals

- Processes

- Patterns

- Purpose

## A Picture of a Microsystem

- A Picture of a Microsystem

-  The Physiology

## A “Generic” Clinical Microsystem model

- Entry,
- Assignment

- Orientation

- Initial
- Work-up,
- Plan for care

- Disenrollment

- Beneficiary knowledge, including knowledge of life
- while not in direct contact with the health care system

- Satisfaction of need, monitoring, assessment of outputs

## Exploring the external context of the clinical microsystem for improving the health of 

- _a given subpopulation of patients..._

*Place a bold line around the “most important contributors” rectangles to the improved health of the subpopulation.  Illustrate the relationships with a blue line.  Add an arrow head if the direction of the relationship is clear.  If the relationship can be significantly improved, use red for the line.*

- © 2/10/03 Ruth Kennedy , NHS, UK/MM Godfrey, Trustees of Dartmouth College

## What is a “clinical microsystem?”

- Small group of doctors, nurses, other clinicians
- Some administrative support
- Some information, information technology
- A small population of patients
- Interdependent for a common aim, purpose

## Physician,

- Care-giver

- Mid-level
- Practitioner

- Clinical
- Support

- Administrative
- Support

- Information
- Technology

- Need, aim

- Care

- Few Other
- Physicians

- The clinical microsystem

## Physician,

- Care-giver

- Mid-level
- Practitioner

- Clinical
- Support

- Administrative
- Support

- Information
- Technology

- Need, aim

- Care

- Few Other
- Physicians

- A primary care clinical microsystem

## Slide 21

## The Short Version...

- The “_Place_” where patients and families and health care teams meet.

## So, why focus on the “clinical microsystem?”

- Basic “building block” of health care as a system.
- Unit of clinical policy-in-use.
- Locus of most workplace “motivators” and many “hygiene” factors.

- Most variables relevant to patient satisfaction controlled here.
- Where “good value” and “safe” care is made.
- Where most health professional “formation” occurs after initial preparation.

- Where everything happens with and for the patient and family

## Question & Clarification Pause

## 3 Thread Tactic

- Finding ways to do better at meeting each patient’s needs
- Making the work experience for every staff person meaningful & joyous
- Increasing each staff person’s ability to improve his/her own work & contribute to betterment of system

## Start Here! The First 3 Things To Do

- Start Here! The First 3 Things To Do

- Create shared mental model -- a common mind around more reliable care
- 21st Century Heath care needs to take exceptional care of patients and families and continuously improve
- The big picture from the ground level
- Create useful information environment for microsystems
- Balanced metrics (data walls)
- Feed forward information to make it easy to do right thing
- Start action learning & accountability for improving performance
- Awareness and Development of the microsystem
- Practice (interdisciplinary) to both learn to change and to make change that is lasting and optimizes performance (Action Learning)

## Front Line Development

- To grow your
- microsystem from
- the inside out

- To improve care &
- respond to new
- pressures for quality

- To develop people
- Head
- Hand
- Heart

## Leadership, Discipline, Rhythm and Pace

- Leadership, Discipline, Rhythm and Pace

- Shared Physician/Nurse/Administrator _Leadership_ who role model improvement
- _Discipline_ of Improvement Science
- _Rhythm_
- Daily Huddles
- Weekly Interdisciplinary Improvement Meetings (with patients/families)
- Monthly All Staff Meetings
- _Pace_
- Volume and Acuity
- Summer Vacations

## Getting Started with... YOUR Role in Lead Improvement Group

- Serve as the “bridge” to the others in your role
- Information and data flow back and forth
- Important role to “get everyone in the game” of improvement
- Most documents should be DRAFT until staff have a chance to review and be in engaged in improvement

## Getting Everyone in the Game

- Keep growing staff members
- Engagement
- Multiple improvement cycles
- Staff Leads in “oversight” improvement group on unit
- How to integrate new members-Be very intentional

## Meeting Skills

- Roles
- Processes
- Aimed & Timed Agendas
- Meetings need to be regular time and place that everyone can plan on
- Ground Rules
- Communication Plan

## To do things differently, we must see things differently.  When we see things we haven’t noticed before, we can ask questions we didn’t know to ask before.

*John Kelsch, Xerox*

## Question & Clarification Pause

## Assess & Diagnose Your Clinical Microsystem

*Main Idea  ...**Build Capacity from Inside Out*
- With outside in (front office) supports, encouragement, & incentives
- The 5 “Ps”

## Caring For Patients & Growing Microsystems

- Caring For Patients & Growing Microsystems

- PATIENTS ...
- Assess
- Diagnose
- Treat
- Involving the patient & family in the process

- MICROSYSTEMS...
- Assess
- Diagnose
- Treat
- Involving the microsystem players in the process

## Quality Improvement is NOT Tools and Methods

- Tools and
- Methods

## Use the Assess, Diagnose & Treat Workbook . . . 

- Use the Assess, Diagnose & Treat Workbook . . .

- As a diagnostic tool and to provide a guided discovery of your purpose, patients, people, processes, and patterns to start thinking about improvement.
- Identify and celebrate successes and opportunities for improvement

## The “Green Book”

## Slide 39

## Slide 40

## Slide 41

## Example

- Cherokee adaptation
- Touch Polls
- New software

## As the patient

- Follow the patient
- Video the patient
- *Cherokee Example
- *Wind River

## www.improvingchroniccare.org/

## Slide 45

## Slide 46

## Wind River

- Staff Survey
- Example

## Slide 48

## Examples

- Salina and Cycle Time Tool
- Wind River Cycle Time Tool

## Providence Hospital Anchorage Alaska

## Slide 51

## Slide 52

## Examples

- Cherokee Core and Supporting Process Assessment
- Unplanned Activity Tracking
- Wind River
- Core and Supporting Process Assessment

## Slide 54

## Slide 55

## Slide 56

## Slide 57

## Slide 58

## Slide 59

## Slide 60

## The Greenbook (ADT) & 5P Wall Chart

- The Greenbook (ADT) & 5P Wall Chart

**Notes:**
So, this just quickly illustrates that the Greenbook data collection and observation worksheets were meant to feed directly into the 5P Wall Chart. On the 5P Wall Chart, they should be summarizing their insights from the data and observations in the Greenbook.

(We will return to this graphic in a later slide.)

## Completed 5PsMethodist Children’s Hospital

- Completed 5PsMethodist Children’s Hospital

## 59.5

- Very High Risk

- Healthy

- Healthy

- Palliative

- Very High Risk

- Chronic

- P A C PP E

- Functional

- & Risks

- Biological

- Costs

- Satisfaction

- People with

- healthcare

- needs

- People with

- healthcare

- needs met

- Microsystem Approach 6/17/98

- Revised: 03/05

- Prevention

- P

- Acute

- A

- Chronic

- C

- Educate

- E

- Palliative

- PP

- Purpose

- Patients

- Processes

- Patterns

- Professionals

- Healthy

- P A E

- ACPPE

- P A C PP E

- Dartmouth-Hitchcock Medical Center ICCU

- The ICCU will create an environment in which cardiac patients and their families can receive excellent, comprehensive, specialized state of the art quality care.

- Communication of Discharge

- Discharge Planning

- Coordination of Discharge

- Top Diagnoses
- 1. Athrosclerosis=464
- 2. AMI, subendocardial=517
- 3. AMI, inferior wall=101
- 4. AMI, anterior wall=97
- 5. Fibrillation, atrial=110
- 6. Heart Failure=120
- 7. Chest Pain=75
- 8. Dysrhythmias=31
- 9. Tachycardia=48
- 10. AV Block=40

- LOS:  5 days=1,838
-                6-10 days = 257
-              11-20 days= 72
-              21-50 days=14
-         51+ days=1

- Patient Age
- ICCU had 10, 546 patient days FY 2005 (volume)
- 0-18=1
- 19-30=11
- 31-50=258
- 51-64=556
- 65-80=980
- >81=376

- Admission Source
- Acute Care Hospital=739
- Clinic=409
- Clinic Emergency=103
- ED=406
- Nursing Home=1
- Referring Physicians=523
- Skilled Nursing Facility=1

- Discharge Disposition
- Against Medical Advice=11
- Custodial Care=10
- Died=63
- Federal Hospital=10
- Home=1638
- Home with IV drug=2
- Home with VNA=323
- Short Term General Hospital=7
- Rehab Cneter in acute facility=10
- Skilled Nursing Facility=93

- Patient Satisfaction
- The nurses are the best ever
- The wrist band and the staff's scanner left you feeling very secure for all tests and pills.

- PATTERNS:
- Admission Day of the week:
- Monday=376
- Tuesday=360
- Wednesday=364
- Thursday=357
- Friday=303
- Saturday=188
- Sunday=234

- Weekly Wednesday 1:30-2:30 Lead Improvement Team meetings

- Eugene C. Nelson, DSc, MPH

- Paul B. Batalden, MD

- Dartmouth-Hitchcock Clinic, June 1998

- c

- FTEs

## Using the 5Ps to Select Improvement Opportunities

- Every initiative should be based on understanding and input from one or more of the 5Ps
- Should pass the “elevator test” to ensure staff understanding
- If your initiative does not tie to one or more of the 5Ps...
- Should you even be doing it?
- Have you uncovered a new insight into one of the 5Ps
- If so, dialogue about it and formalize it
- The link to the 5Ps should be captured on the global aim statement (It is important to work on this now because... (list imperatives))

**Notes:**
So, what we are saying is... (read the slide)

Then stress the bottom line on this slide to link into another thing we have been asking them to do, the Global Aim Statement... (see next slide)

## Question & Clarification Pause

## Slide 66

## 2

*Flowchart*

*Cause & Effect*

- Follow the “Path Forward” in the *Microsystem Workbooks* up the Ramp of Improvement

## Model for Improvement

- Act

- Plan

- Study

- Do

- What are we trying to accomplish?
- How will we know that a change is an improvement?
- What changes can we make that will result in an improvement?

## The Data Wall

## Quality By Design:  A Clinical Microsystems Approach

- Part One
- Updated original Joint Commission Quality and Safety 9 part series
- Part Two
- Dartmouth Microsystem Improvement Curriculum

## Remember that every clinical microsystem must

- Do the job
- meet patient’s needs
- Meet staff needs
- for respect, challenge, growth, joy, & earnings
- Maintain self as an organization
- mission, values, finances, image

## Summary

- Introduction and Background of Clinical Microsystems
- Overview of the Assess, Diagnose and Treat workbook or the “Green Book”
- Capturing the Head, Hand and Heart of every person in the microsystem

## Slide 73