Quality By Design

A Clinical Microsystems Approach

Eugene C. Nelson, Paul B. Batalden, Marjorie M. Godfrey, Eugene C. Nelson, Paul B. Batalden, Marjorie M. Godfrey

• Publisher: Jossey-Bass
• Year: 2011
• ISBN:
  9781118046838
• Edition: 1
• Topic: Medicina
• Subtopic: Salud pública, administración y atención

Quality by Design reflects the research and applied training conducted at Dartmouth Medical School under the leadership of Gene Nelson, Paul Batalden, and Marjorie Godfrey. The book includes the research results of high-performing clinical microsystems, illustrative case studies that highlight individual clinical programs, guiding principles that are easily applied, and tools, techniques, and methods that can be adapted by clinical practices and interdisciplinary clinical teams. The authors

• describe how to develop microsystems that can attain peak performance through active engagement of interdisciplinary teams in learning and applying improvement science and measurement;
• explore the essence of leadership for clinical Microsystems;
• show what mid-level leaders can do to enable peak performance at the front lines of care;
• outline the design and redesign of services and planning care to match patient needs with services offered;
• examine the issue of safety;
• describe the vital role of data in creating a rich and useful information environment;
• provide a core curriculum that can build microsystems' capability, provide excellent care, promote a positive work environment, and contribute to the larger organization.

Ancillary materials for use in classroom teaching, training, or coaching are available at https://clinicalmicrosystem.org/

PART ONE
CASES AND PRINCIPLES

CHAPTER ONE
SUCCESS CHARACTERISTICS OF HIGH-PERFORMING MICROSYSTEMS
Learning from the Best

Eugene C. Nelson, Paul B. Batalden, Thomas P. Huber, Julie K. Johnson, Marjorie M. Godfrey, Linda A. Headrick, John H. Wasson

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Chapter Summary

Background. Clinical microsystems are the small, functional frontline units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients, families, and careteams meet. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed.

Methods. A wide net was cast to identify and study a sampling of the best-quality, best-value small clinical units in North America. Twenty micro systems, representing a variety of the component parts of a health system, were examined from December 2000 through June 2001, using qualitative methods supplemented by medical record and finance reviews.

Results. The study of these twenty high-performing sites generated many best-practice ideas (processes and methods) that microsystems use to accomplish their goals. Their success characteristics were related to high performance and include leadership, macrosystem support of microsystems, patient focus, community and market focus, staff focus, education and training, interdependence of care team, information and information technology, process improvement, and performance results. These ten success factors were interrelated and together contributed to the microsystem’s ability to provide superior, cost-effective care and at the same time create a positive and attractive working environment.

Conclusions. A seamless, patient-centered, high-quality, safe, and efficient health system cannot be realized without transformation of the essential building blocks that combine to form the care continuum.

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The health care system in the United States can, under certain conditions, deliver magnificent and sensitive state-of-the-art care. It can snatch life from the jaws of death and produce medical miracles. The case of Ken Bladyka, presented later in this chapter, is one positive example of the health care system’s performance. Yet the system is often severely flawed and dysfunctional. The Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Health System for the 21st Century (Institute of Medicine [U.S.], Committee on Quality of Health Care in America, 2001), makes the point of system failure clear:

• “Health care today harms too frequently and routinely fails to deliver its potential benefits”(p. 1).
• “Tens of thousands of Americans die each year from errors in their care, and hundreds of thousands suffer or barely escape from nonfatal injuries that a truly high quality care system would largely prevent” (p. 2).
• “During the last decade alone, more than 70 publications in leading peer-reviewed clinical journals have documented serious quality shortcomings” (p. 3).
• “The current system cannot do the job. Trying harder will not work. Changing systems of care will” (p. 4).

This chapter introduces the concept of the clinical microsystem, summarizes recent research on twenty high-performing microsystems sampled from the care continuum, and stresses the strategic and practical importance of focusing health system improvement work specifically on the design and redesign of small, functional clinical units.

Qualitative research methods were used to analyze 250 hours of conversations with microsystem personnel; these conversations were augmented by chart reviews and financial data. Principles, processes, and examples were gleaned from the interviews to describe what these exemplary microsystems are doing to achieve superior performance.

So, what is the true nature of our health system? Sometimes it works well, but all too often it fails to deliver what is needed.

True Structure of the System, Embedded Systems, and Need to Transform Frontline Systems

The true structure of the health system the patient experiences varies widely. Patients in need of care may find

• Clinical staff working together—or against each other
• Smooth-running frontline health care units—or units in tangles
• Information readily available, flowing easily, and in a timely fashion—or not
• Health care units that are embedded in helpful larger organizations—or cruel, Byzantine bureaucracies
• Health care units that are seamlessly linked together—or totally disjointed
• High-quality, sensitive, efficient services—or care that is wasteful, expensive, and at times harmful or even lethal

In brief it can be said that the true structure of the health system is composed of a few basic parts—frontline clinical microsystems, mesosystems, and overarching macrosystems. These systems have a clinical aim and are composed of patients, staff, work patterns, information, and technology, and they exist in a context. These elements are interrelated to meet the needs of patient subpopulations needing care. As the Bladyka case will illustrate, “it is easy to view the entire health care continuum as an elaborate network of microsystems that work together (more or less) to reduce the burden of illness for populations of people” (Nelson et al., 2000, p. 669).

Here are three fundamental assumptions about the structure of the health system:

1. Bigger systems (macrosystems) are made of smaller systems.
2. These smaller systems (microsystems) produce quality, safety, and cost outcomes at the front line of care.
3. Ultimately, the outcomes of a macrosystem can be no better than the outcomes of the microsystems of which it is composed.

The concept of clinical microsystems is spreading and has been used in many national and international programs: the IOM’s Crossing the...