# Quality and Safety in Nursing/Clinical Microsystems

Clinical Microsystems – Care Coordination
Introduction
The clinical microsystem within a healthcare system comprises those health professionals who work with patients and families directly. This microsystem is typically the location of medical mistakes and errors essentially due to poor communication among care providers. The Joint Commission has identified communication barriers as one of the most common cause of sentinel events, specifically 66% of the events (McDonald & Leyhane, 2005). Conducting care coordination meetings is an innovative way to improve communication and address any problems identified by a member of the interdisciplinary team or the patient.
Body
Our discussion will begin with a definition and explanation of clinical microsystems within healthcare. Within the organizational culture of a system or facility there are multiple microsystems. As defined by Disch (2006) a clinical microsystem is “a small group of people who work together on a regular basis to provide care to discrete subpopulations of patients” (Disch, 2006, p. 13). Disch (2006) comments that these systems are designed to assist healthcare professionals, registered nurses, and physicians, to provide high quality care while maintaining focus on the patients and their families. A few examples of a clinical microsystem include a patient care unit, a heart failure clinic, or even a night shift working in the emergency room (Disch, 2006).
Sollecito & Johnson (2013) explain that a vast majority of “near misses” or sentinel events occur within this clinical microsystem. If the clinical microsystem is functioning well, then most events will be prevented or mitigated. It is at this level that improvements or process changes can be implemented and the greatest impact will be seen regarding patient care and safety (Sollecito & Johnson, 2013).
Care coordination is not a new concept and in fact has been identified as one of the roles of the registered nurse while caring for patients. It has been described as “a process of assessment, planning, implementation, evaluation, monitoring, support, and advocacy to facilitate timely access to services, promote continuity of care, and enhance family well-being” (McAllister, Presler, & Cooley, 2007, p. e726). Multiple efforts have been undertaken to make improvements and develop innovative ideas to increase the communication between healthcare professionals.
Press (2012) suggests healthcare systems can place value on care coordination as they strive to designate time through a shift to conduct care coordination activities. It is even suggested that a formal multi-disciplinary meeting is appropriate to discuss patient issues and address problems (Press, Michelow, & MacPhail, 2012). The introduction of care coordination meetings is not necessarily new to healthcare; however the settings in which it is being conducted are expanding.
Within the past few years, formal care coordination meetings have been established at McKay Dee Hospital in Ogden, Utah. These meetings are held daily in which every patient on the nursing unit is reviewed and discussed in detail. Multiple team members are present and offer their expertise to the care of the patient. Those team members are the registered nurse caring for the patient, physician, unit charge nurse, care management, social worker, pharmacist, dietician, and discharge coordinator. Currently, the patient’s family members are not involved in the meeting; however this would be beneficial in the futures. These meetings are conducted by the unit charge nurse. There is a designated format in which each patient is discussed which includes diagnosis, anticipated discharge date, pressing clinical issues that are keeping the patient in the hospital, potential discharge needs (skilled nursing facility, long term care facility) and dietary issues. Prior to the meeting the registered nurse involves the patient by inquiring about any potential issues or questions the patient may have. The patient questions are also addressed in the meeting. Every team member is allowed time to address any concerns they may have.
These care coordination meetings require some coordination to implement. Nursing administration need to coordinate between each of the disciplines to establish a consistent time during the day in which they are conducted. Through the early phases of this implementation team members need to be held accountable to arrive on time and participate in order to achieve the maximum benefit of the meeting.
As pointed out by Clinch (2012) the American Nurses Association (ANA) has stated in their standards that one of the “nurses’ responsibilities include communication with patient, family, and members of the health care system” (p. 4). This innovative idea meets the standard as effective communication is conducted within the clinical microsystem. An added benefit to these care coordination meetings is presented by Press et al. (2012). They state that role definition for staff members is critical for an organization to have effective collaboration (Press et al., 2012). These meetings allow for reinforcement of role definition to take place and decisions are made regarding what tasks are assigned to each member to streamline the care that is given to the patient. These meetings are also an avenue where potential mistakes can be caught and prevented in a safe and effective manner.
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Chapter Summary
In summary, we have been discussing the role of clinical microsystems within the healthcare system. The initiation of formalized care coordination meetings allow for effective communication to occur with a multi-disciplinary team for the benefit of the patient. These meetings result in the identification of “near misses” and provide an avenue in which patients receive a higher standard of care. It encompasses the idea of including patients in their care as their specific questions are heard and addressed by the care team. Press, et al (2012) stated “Just as good communication with patients is considered to be important, so too should good communication with other healthcare clinicians” (Press et al., 2012, p. 780).
References
Clinch, T. (2012). Care coordination of the future and the nurse’s role. Texas Nursing, 86(1), 4-5.
Disch, J. (2006). Clinical microsystems: The building blocks of patient safety. Creative Nursing, 12(3), 13-14.
McAllister, J. W., Presler, E., & Cooley, W. C. (2007, September 1). Practice-based care coordination: A medical home essential. Pediatrics, 120(3), e723-e733. Doi: 10.1542
McDonald, A., & Leyhane, T. (2005, October). Drill down with root cause analysis; Know the source of the spark while protecting yourself from the fire. Nursing Management, 36(10), 27-32.
Press, M. J., Michelow, M. D., & MacPhail, L. H. (2012, December). Care coordination in accountable care organizations: Moving beyond structure and incentives. The American Journal of Managed Care, 18(12), 778-780.
Sollecito, W. A., & Johnson, J. K. (2013). Continuous quality improvement in health care (4th ed.). Burlington, MA: Jones & Bartlett Learning.