1. clinicalmicrosystem.org What is a clinical microsystem? How did this idea get started and how is it being used? 1

2. clinicalmicrosystem.org Assumptions Many have 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 2

3. clinicalmicrosystem.org How we improve what we make What society needs How we create, make health care Understanding Health Care as a System 3

4. clinicalmicrosystem.org Which system is the unit of practice, intervention, measurement, policy? Self-care system Individual care-giver & patient system Microsystem Mesosystem Macrosystem Market / Geopolitical system 4

5. clinicalmicrosystem.org 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 5

6. clinicalmicrosystem.org High Performing Clinical Microsystems Information & Information Technology Staff Staff focus Education & Training Interdependence of care team Patients Patient Focus Community & Market Focus Performance results Process improvement Leadership Organizational support 6

7. clinicalmicrosystem.org Definition A health care clinical microsystem can be defined as the combination of a small group 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. 7

8. clinicalmicrosystem.org A Picture of Embedded Systems The Anatomy 8

9. clinicalmicrosystem.org Patients Professionals Processes Patterns Purpose 9

10. A Picture of a Microsystem The Physiology 10

11. clinicalmicrosystem.org A “Generic” Clinical Microsystem Model Entry, Assignment Orientation Initial Work-up, Plan for care Disenrollment Biological Functional Satisfaction Costs Beneficiary knowledge, including knowledge of life while not in direct contact with the health care system Satisfaction of need, monitoring, assessment of outputs Acute care Chronic care Preventive care Palliative care Biological Functional Expectations Costs 11

12. clinicalmicrosystem.org 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 It’s where everything happens with, for and to the patient and family 12

13. clinicalmicrosystem.org Physician, Care-giver NP, RN Clinical Support Administrative Support Information Technology Need, aim Care Few Other Physicians The Clinical Microsystem 13

14. clinicalmicrosystem.org Family Practice 14

15. clinicalmicrosystem.org 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 15

16. clinicalmicrosystem.org 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 16

17. clinicalmicrosystem.org What do we really know about our patients and families? (or patients/customers if a supporting microsystem) What do we know about our work? –How do we get things done? What do we know about our context? What are the patterns we may talk about but we do not study to learn more deeply? How do we know what the results of our efforts are? What should we be looking for? As An Interdisciplinary Group… 17

18. clinicalmicrosystem.org Assess & Diagnose Your Clinical Microsystem Main Idea … Build Capacity from Inside Out The 5 “Ps” Use the Clinical Microsystems Workbook to continue to diagnose the strengths of your microsystem and to start identifying improvement opportunities 18

19. clinicalmicrosystem.org Global Aim 1 2 3 Assessment Theme Global Aim Change Ideas Specific Aim Measures SDSA P DS A P D S A P DS A PDSA 1 3 2 Dartmouth Microsystem Improvement Curriculum Flowcharts Fishbones DMIC and The “Ramp” Meeting Skills/Group Dynamics 19

20. clinicalmicrosystem.org So, how might you improve your own microsystem? It’s just like patient care –To improve a patient’s health status … You assess, diagnose, treat, and follow-up based on biomedical and care science –To improve a microsystem’s “health” status … You assess, diagnose, treat, and follow-up based on improvement science and the science of clinical practice 20

21. clinicalmicrosystem.org Patients Professionals Processes Patterns Purpose 21

22. clinicalmicrosystem.org Assessing Your Practice “The Green Book” Primary Care Specialty Care Others www.clinicalmicrosystem.org 22

23. clinicalmicrosystem.org Know Your P urpose Have you EVER discussed with your interdisciplinary team WHY your microsystem exists? What is the purpose of your microsystem that everyone understands and supports? 23

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25. clinicalmicrosystem.org Know Your Patients 25

26. clinicalmicrosystem.org Know Your P rofessionals 26

27. clinicalmicrosystem.org Know Your P rocesses Cycle Time Tool 27

28. clinicalmicrosystem.org CF Initial Visit 28

29. clinicalmicrosystem.org CYCLE TIME TOOL 29

30. clinicalmicrosystem.org Core and Supporting Processes Assessment 30

31. clinicalmicrosystem.org Providence Hospital Anchorage Alaska 31

32. clinicalmicrosystem.org Know Your P atterns 32

33. clinicalmicrosystem.org Metrics That Matter 33

34. clinicalmicrosystem.org “I thought I knew my practice…but I didn’t. I now know and see new things.” - Angie Hilton, Practice Manager IM/FP UC Davis 34

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