1. 1 義守大學醫務管理學系 曲延棣 副教授 2007.03.12. Clinical Microsystems: Some of the Basics

2. 2 The Equation Microsystem 1 + Microsystem 2 + Microsystem 3-n = Health System

3. 3 Clinical Microsystems What are all these systems? What are microsystems? Why are microsystems key leverage points for whole system transformation? What does microsystem research show about high performance?

4. 4 Systems It is the nature of systems that smaller systems are embedded in bigger systems

5. 5

6. 6 The Way We Work To “Make” Health Care Community, Market, Social Policy System Macro- organization System Clinical Microsystem Individual care-giver & patient System Self- care System

7. 7 The Chain Of Effect In Improving Health Care Quality IPatient IIMicrosystem of care delivery IIIMacro-organization IV Environmental Context IOM framework

8. 8 What is a clinical microsystem? How did idea develop? What are they?

9. 9 What society needs How we create, make health care Understanding Health Care As A System How we improve what we make

10. 10 “Dr. Batalden’s Pediatric Practice” Theresa Baker, M.D. Mary Beth Hanson, RN, PNP Connie Van der Top, LPN Barb Malzahn, and Paul Batalden, M.D. In a department of 36 pediatricians, etc. In the Park Nicollet medical center of 280 MDs, etc. In the MedCenters Health Plan in west MSP metro area Small systems Embedded in Big systems

11. 11 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 10 Success Characteristics 8 Success Characteristics 2001 IOM 21st Century Future Evolution of “Clinical Microsystems” 1998 Hierarchy of Systems late 1970’s & 1980’s mid-90’s CECS course on Micro-units HFHS “panels” of patients 2001 Website Formed www.clinicalmicrosystem.org 2001 Fall Invitational 2002-3 JQI Articles

12. 12 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 assemble as needed around the patient -- 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 complex adaptive system, the microsystem must: (1) do the work, (2) meet staff needs, (3) maintain themselves as a clinical unit & contribute to the larger organization.

13. 13 The Short Version… The “Place” where patients and families and health care teams meet. “The patient and the doctor are part of the same system.” L. Henderson of the Henderson/Hasselback equation.

14. 14 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 A schematic figure

15. 15 Physician, Care-giver Mid-level Practitioner Clinical Support Administrative Support Information Technology Need, aim Care Few Other Physicians The Clinical Microsystem

16. 16 Physician, Care-giver Mid-level Practitioner Clinical Support Administrative Support Information Technology Need, aim Care Few Other Physicians Who is the neonatal ICU clinical microsystem? Some Photos

17. 17 Patient

18. 18 Aimee, Nurse

19. 19 Dion, Discharge Nurse using electronic and paper information

20. 20 William Edwards, M.D., Neonatologist

21. 21 Parent and Drs. Edwards and Little

22. 22 Rounding team, including parents

23. 23 Theresa, Receptionist

24. 24 Information technology (monitors)

25. 25

26. 26 A Picture Of Embedded Parts in Microsystems The Anatomy

27. 27 Patients Professionals Processes Patterns Purpose 5 P’s

28. 28 A Picture Of A Microsystem The Physiology

29. 29 Entry, Assignment Orientation Initial Work-up, Plan for care Disenrollment Biological Functional Expectations Costs 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 A “Generic” Clinical Microsystem Model Acute care Chronic care Preventive care Palliative care

30. 30 Why is the microsystem a key leverage point for system transformation? It’s the sharp end It’s the front line It’s where everything happens to and for the patient

31. 31 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.

32. 32 What does the research show about microsystems and high performance? Quinn’s ground breaking book on best in world service organizations IOM study by J. Mohr & M. Donaldson Dartmouth study on high performing clinical microsystems Quinn: Wild org charts … very successful … front office focus on frontline … SRUs customers needs met … iterative redesign … info environment …

33. 33 “The only way to get quality, and value and flexibility (to innovate and to meet this patient’s needs right now) is to organize the frontline using microsystem methods that have been developed in the best-in-class service organizations”. James Brian Quinn, PhD Professor Emeritus Tuck School of Business Administration Dartmouth College December 2004

34. 34 Microsystems Are The Building Blocks That Come Together To Form Macro-organizations Mesosystem Macrosystem Microsystem

35. 35 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

36. 36 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 Not single bullet But rather a Special blend. Read letter To the editor.

37. 37 Where are microsystem ideas being applied? Professional organizations –AHA, VHA, Cystic Fibrosis, Vt-Oxford NICUs US health systems –Geisinger, Exempla, Denver Health, UC Davis, Cincinnati Children’s, Johns Hopkins, et al International health systems –Sweden, UK, France, Kosovo, Norway, Tunisia, Lebanon, Canada, et al Institute for Healthcare Improvement –Workforce development, Vitality

38. 38 Clinical Microsystem Work Underway Panoramic view

39. 39 Toronto, ON Lebanon, NH Canada Mexico Sacramento, CA Boston, MA United States of America Danville, PA Denver, CO IHI AHA VHA Cystic Fibrosis Vt. Oxford Network

40. 40 Micro Système Clinique El Micro Sistema Clinico How many ways can you say Clinical Microsystem? How many ways can you say Clinical Microsystem? Kliniska Mikrosystem Mikrosistem Klinik

41. 41 Karim Laaribi Martial Favre Goran Henrik Helen Bevan Peter Wilcock Ian Golton

42. 42 Karim Laaribi Mary Taylor Cris Hammond Jashar Ramadani Genc Ymerhalili Christian von Plessen Per Hjortdal Hans Asbjørn Holm

43. 43 WWW.CLINICALMICROSYSTEM.ORG

44. 44

45. 45

46. 46

47. 47

48. 48

49. 49

50. 50 Many Ways To Be Connected! www.clinicalmicrosystem.org www.qulturum.com