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QUALITY BY DESIGN

A Clinical Microsystems Approach

 

Eugene C. Nelson

Paul B. Batalden

Marjorie M. Godfrey

 

Editors

Foreword by Donald M. Berwick

 

 

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TABLES, FIGURES, AND EXHIBITS

Tables

  1. 1.1 Scope of Primary Success Characteristics and Illustrative Underlying Principles
  2. 1.2 Specific Examples of the Primary Success Characteristics
  3. 1.3 Illustrative Best Practices Used by High-Performing Clinical Microsystems
  4. 3.1 Building Knowledge in Clinical Microsystems: Views on Leading Quoted from Our Interviews
  5. 3.2 Taking Action in Clinical Microsystems: Views on Leading Quoted from Our Interviews
  6. 3.3 Reviewing and Reflecting in Clinical Microsystems: Views on Leading Quoted from Our Interviews
  7. 4.1 Leadership Frameworks and Challenges
  8. 4.2 Bolman and Deal’s Four Complementary Leadership Frameworks, with Barriers and Strategies
  9. 4.3 Highlights of Robert Greenleaf’s Dartmouth College Lectures
  10. 4.4 Either-Or States of Organizational Change
  11. 4.5 System Examples Associated with Loose and Tight Coupling
  12. 4.6 Matching Change Strategies to the Coupling Situation
  13. 5.1 Workstation Assignments at MGH Downtown
  14. 5.2 Evaluation Sheet for Performance Evaluation Program (PEP), Showing Categories and Definitions
  15. 5.3 Staff Comments That Support the Human Resource Value Chain Concept
  16. 5.4 Staff Comments That Support Success Characteristics
  17. 5.5 Examples of Skills Addressed in a Personal Skills Assessment
  18. 6.1 Evergreen Woods’s Additional Success Elements and Their Links to the 5 P’s
  19. 6.2 Know the P’s for Clinical Microsystems Across the Health Continuum
  20. 6.3 Practice Core and Supporting Processes Assessment
  21. 6.4 Assessing Your Practice Discoveries and Actions: The P’s
  22. 6.5 Assessing Your Practice Discoveries and Actions: Common Oversights and Wastes
  23. 7.1 Common Myths Rejected by Effective Clinical Microsystems
  24. 7.2 Attributes of Planned Care
  25. 8.1 Linkage Between Microsystem Characteristics and Patient Safety
  26. 9.1 Tips for Fostering a Rich Information Environment
  27. 10.1 Dartmouth Microsystem Improvement Curriculum
  28. 21.1 Langley’s Change Concepts

Figures

  1. 1.1 Chain of Effect in Improving Health Care Quality
  2. 1.2 Flowchart of Ken Bladyka’s Journey Through the Health System
  3. 1.3 Anatomy of a Clinical Microsystem
  4. 1.4 Research Design for Study of Twenty Clinical Microsystems
  5. 1.5 Success Characteristics of High-Performing Clinical Microsystems
  6. 2.1 Value Compass for the DHMC Intensive Care Nursery
  7. 2.2 Noise Levels in the ICN Intermediate Care Unit Before and After Quiet Pleases
  8. 2.3 ICN Median Cost per Infant Admitted in 1996–1997 Intensive Care Nursery
  9. 2.4 Longitudinal Trends in Number of Days ICN Infants Spend on Mechanical Ventilation
  10. 2.5 A Model for a Microsystem’s Developmental Journey
  11. 4.1 A View of the Multilayered Health System
  12. 4.2 The Health Care System as an Inverted Pyramid
  13. 4.3 Bossidy and Charan’s Framework for Execution
  14. 4.4 The Baldrige Process of Improvement
  15. 4.5 The Toyota Pyramid
  16. 4.6 Eight Frames for Exploring Microsystems
  17. 5.1 Clinical Microsystem Short Staff Survey
  18. 6.1 High-Level View of a Primary Care Clinical Microsystem
  19. 7.1 Schematic of the Planned (Chronic) Care Model
  20. 7.2 Planning Care and Patient Self-Management: Service and Information Flow in a Microsystem
  21. 7.3 Example of Using a CARE Vital Signs Form
  22. 8.1 Microsystem Patient Safety Scenario
  23. 8.2 Haddon Matrix Analyzing an Auto Accident
  24. 8.3 Completed Safety Matrix for Allison’s Scenario
  25. 9.1 Patient Value Compass for a Typical Spine Patient
  26. 9.2 Feed Forward and Feedback in a Microsystem: The Spine Center Design for Information Flow
  27. 9.3 Patient Value Compass: Spine Center Herniated Disk Patients
  28. 9.4 Balanced Scorecard for the Spine Center
  29. 10.1 Evolution in Approaches to Improving Health System Quality: From Projects to Mesosystems to Macrosystems
  30. 10.2 The M3 Matrix: Suggestions for Leadership Actions at Three Levels of a Health System
  31. 10.3 Experiential Learning Model
  32. 11.1 Health Care Viewed from a Systems Perspective
  33. 11.2 Health Care Is an Open System, Capable of Continual Improvement
  34. 11.3 The Embedded Systems of Health Care
  35. 11.4 The Physiology of a Microsystem: A Generic Model
  36. 11.5 A Microsystem’s Self-Awareness Journey
  37. 11.6 Improvement Ramp
  38. 12.1 Improvement Ramp: Meeting Skills
  39. 12.2 Sample Meeting Agenda Template
  40. 12.3 Rhythm of Improvement
  41. 12.4 Sample ICCU Meeting Agenda
  42. 13.1 Improvement Ramp: Assessment
  43. 13.2 ICCU Wall Poster for the 5 P’s Microsystem Assessment
  44. 13.3 Plastic Surgery Section Access Patterns
  45. 14.1 Improvement Ramp: Model for Improvement
  46. 14.2 Model for Improvement
  47. 14.3 Themes, Aims, Processes, and PDSA Cycles
  48. 14.4 The Complete PDSA Cycle
  49. 14.5 The Back-and-Forth Relationship of PDSA and SDSA
  50. 14.6 The Complete SDSA Cycle
  51. 14.7 The ICCU’s PDSA Ramp of Tests
  52. 15.1 Improvement Ramp: Theme
  53. 15.2 Key Themes and Components of Ideal Practices
  54. 16.1 Improvement Ramp: Global Aim
  55. 16.2 Template for Writing a Global Aim Statement
  56. 17.1 Improvement Ramp: Process Mapping
  57. 17.2 Flowchart Symbols
  58. 17.3 High-Level Flowchart of a Medical Office Visit
  59. 17.4 Detailed Flowchart of Treatment Process for Cystic Fibrosis–Related Diabetes (CFRD)
  60. 17.5 Section of Deployment Flowchart for Enrollment in Outpatient Cystic Fibrosis Clinic
  61. 17.6 High-Level Flowchart of ICCU Admission Process
  62. 17.7 High-Level Flowchart for Beginning of Breast Reduction Process
  63. 18.1 Improvement Ramp: Specific Aim
  64. 18.2 Template for Writing a Specific Aim Statement
  65. 19.1 Improvement Ramp: Cause and Effect Diagrams
  66. 19.2 Web of Causation
  67. 19.3 Fishbone Diagram
  68. 19.4 Fishbone Diagram Showing Causes of Lengthy Appointments
  69. 19.5 Fishbone Diagram for ICCU Bed Assignment
  70. 19.6 Fishbone Diagram for Plastic Surgery Appointment Backlog
  71. 20.1 Improvement Ramp: Brainstorming and Multi-Voting
  72. 20.2 Brainstorming and Multi-Voting Example
  73. 21.1 Improvement Ramp: Change Ideas
  74. 21.2 Change Concepts Applied to a Clinical Process
  75. 22.1 Improvement Ramp: Measurement
  76. 22.2 Run Chart Displaying Fasting Blood Sugar Levels
  77. 22.3 Run Chart Displaying No Shows
  78. 22.4 Run Chart Displaying Days to Third Next Available Appointment
  79. 22.5 Worksheet for Collecting Data to Measure a Key Variable
  80. 22.6 Gross Anatomy of a Run Chart
  81. 22.7 Gross Anatomy of a Control Chart
  82. 22.8 Control Chart for Individuals with Diabetes in a General Medicine Practice
  83. 22.9 Normal Distribution, AKA the Bell Curve
  84. 22.10 Control Chart in Relation to Normal Distribution
  85. 22.11 Gross Anatomy of an XmR Chart
  86. 22.12 XmR Chart Showing Fasting Blood Sugar Variance in One Patient over One Month
  87. 22.13 Special Cause Signal: Eight Consecutive Points on Same Side of Center Line
  88. 22.14 Special Cause Signal: Six Consecutive Points Trending in the Same Direction (Upward in This Case)
  89. 22.15 Special Cause Signal: A Point Outside a Control Limit
  90. 23.1 Improvement Ramp: Action Plans and Gantt Charts
  91. 23.2 Example of a Gantt Chart
  92. 23.3 Gantt Chart for the ICCU’s Overall Seven-Month Improvement Strategy
  93. 24.1 Playbook Checklist Template
  94. 24.2 Storyboard Display of the ICCU Improvement Journey
  95. 24.3 Plastic Surgery Section Data Wall
  96. A.1 Microsystem Assessment of Data Sources and Data Collection Actions
  97. A.2 Primary Care Practice Profile
  98. A.3 Point of Service Survey: Patient/Family Satisfaction with Primary Care Practice Access
  99. A.4 Primary Care Practice Patient Viewpoint Survey
  100. A.5 Through The Eyes of Your Patients
  101. A.6 Assessment of Care for Chronic Conditions
  102. A.7 Primary Care Staff Satisfaction Survey
  103. A.8 Primary Care Staff Personal Skills Assessment
  104. A.9 Primary Care Staff Activity Survey Sheets
  105. A.10 Primary Care Practice Patient Cycle Time
  106. A.11 Primary Care Practice Core and Supporting Processes
  107. A.12 Primary Care Practice Unplanned Activity Tracking Card
  108. A.13 Primary Care Practice Telephone Tracking Log
  109. A.14 Primary Care Practice Metrics That Matter
  110. A.15 PDSA ↔ SDSA Worksheet
  111. A.16 Huddle Worksheet

Exhibits

  1. 4.1 Kotter’s Eight-Step Process for Leading Large-Scale Change
  2. 4.2 Toyota’s Fourteen Principles
  3. 4.3 Leading the Mesosystem
  4. 10.1 Letter to the Editor About a Clinical Program with a Local and National Reputation
  5. 10.2 Improving Patient Flow: The Esther Project in Sweden

FOREWORD

Donald M. Berwick

It is remarkable, and sad, that a large proportion of health care professionals today—maybe a majority—would likely describe the environment of their work in terms that bespeak alienation. They might call themselves “battered,” “pressured,” “hassled,” and, deeply, “misunderstood.” I do not think they would generally say that about their clinical work; these are not their feelings about their relationships with patients—their experience of trying to help and to heal. These are their feelings about those who set in place the conditions of their work—the rule makers, the paymasters, and to some extent the institutional executives.

It is also remarkable, and sad, that those who shape the environment—the rule makers, the paymasters, and many executives—feel no less pressured than the clinicians do. I believe that many of them feel hassled by their own sense of ineffectiveness. They have hard jobs, involving the navigation of a no-man’s-land of goals while also guarding limited resources and pursuing the great ambitions of modern medicine. They are the stewards of possibility, and they seem to me perplexed that the clinical forces so often misunderstand them.

I sat once in a meeting at the highest level in an academic medical center and heard the chief of surgery refer, in public, to the chief finance officer as a “pointy-headed dweeb.” The distance between them was vast and the damage to spirit incalculable. This is not at all a one-way problem. How many times have you heard—even laughed at—the unfunny assertion that leading doctors is like “herding cats?” What does the doctor feel who hears that? At least the physicians and nurses have the quiet refuge of the consulting room to retreat to in search of their own meaning. Where does the executive, so abused and so misunderstood, go for renewal?

I sometimes call this the line-in-the-carpet problem. I was walking through a multibillion-dollar major medical center once with its powerful CEO. He wanted to introduce me to a clinical leader and brought me to that physician’s outpatient clinical office. But the CEO did not walk into the clinical area. At the margin, where the carpet changed color from the deep tan of the waiting area to the lighter tan of the clinical suite, the CEO brought his toes exactly up to the carpet seam, like a racer at the starting line, and leaned awkwardly into the clinical space, asking a passing nurse if Dr. X could be found. He did not set a single foot in the place of patient care. It was as if the CEO of Boeing did not walk into the factory or the CEO of McDonald’s avoided the kitchen.

Perhaps it was simply a sign of respect for the flow of work or the confidentiality of patients. But I think not. I think it was a symbol of the torn fabric of health care, deeply divided along the seam between the work of care and the work of shaping the environment of care. Much respected health care management teaching has, I believe, instructed the executives of the future to stay out of the clinical arena—to leave the care to the doctors and nurses—while they, the executives, run the organization that supports the clinicians’ work. Elaborate structures involving divided governance, medical staff rituals, hospital bylaws, and even clothing keep the parties on their respective sides of no-man’s-land. “Working well” means that neither troubles the other too much and that treaties are fashioned and honored. “Working poorly” leads to open talk of dweebs and cats.

But, even when it produces organizations that are “working well” by these measures, the two-worlds theory of the proper leadership of health care holds the seeds of a disruptive, insulting, dispiriting harvest. When resources are evidently abundant and when patients are generously forgiving, then apparently we can get by. We have so far. In effect we can buy ourselves peace through the allocation of waste. The radiologist gets his (not-truly-needed) new MRI, and the medical staff vote reluctant approval of the hospital’s marketing plan. Elaborate medical staff dinners host the visit of the CEO to congratulate retiring physicians and to report on how healthy the organization is. Elaborate executive dinners host the visit of the newly recruited chief of oncology to meet management and tell about the magic of modern chemotherapy in a thirty-minute summary.

But cut the budget, reduce the cash, spend a year or two in red ink, and watch the fabric tear. Misunderstanding takes charge. The clinicians become convinced that the managers could care less about the patients, and the managers become convinced that these “cats” are narcissists who want to have it all.

The authors of this book have spent years now creating a way to heal this rift. Gene Nelson, Paul Batalden, Margie Godfrey, and their colleagues have come to understand that the line-in-the-carpet problem is a deeply embedded cause of the failure of those who give care and those who shape the environment of care to understand themselves, each other, and the mission they share in such a way as to nurture much deeper, authentic respect for all and much more effective action on care itself. What these authors have done is to show us all—clinicians, executives, payers, regulators, and so on—a window through which to understand our shared purpose and our integrated roles. That window is the clinical microsystem. The idea seems to me beautifully simple. If our work, at its core, is “to heal and to help” people in distress, then we can get great benefit and guidance for our actions by seeing the work and then figuring out how we can best help that. The patient’s pain meets the help exactly, and only, at the microsystem—nowhere else. That is in effect the very definition of a clinical microsystem. It is as if all that we do—all that we all do—comes to a point there, and proper judgments about the value of an action or a resource, in the end, can be made only by understanding its effects at that point. Equally, innovations and designs can be judged, in the end, only by tracing them to that point. The microsystem is the exclusive pathway to value. Policy, payment, regulation, clinical training, management training, congressional bills, new drugs, new computers, new architecture, today’s meeting, professional ethics, malpractice reforms, the leader’s act—all of this can be judged best, improved best, by predicting and tracing its effects on the microsystem where the pain meets the helping.

If clinicians, executives, managers, and others who shape the health care system as a whole can master what this book has to teach, we will have begun a crucial process of reunification of the efforts of many who, in my opinion, at the moment deeply misunderstand each other. We can replace the sadness and insult that come from distance if we will stand together at the window on our work that the microsystem view opens. It is what we are about. Improve microsystems, and we improve everything. Microsystems are where we meet not just the patients we serve but each other as well.

January 2007

Boston, Massachusetts

We dedicate this book to

The pioneers—luminaries in the field of improvement, in particular our mentor James Brian Quinn, the “father” of microsystem and macrosystem thinking, and other great thought leaders including W. Edwards Deming, Avedis Donabedian, Parker Palmer, Karl Weick, Donald Schön, and Donald Berwick

All members of the clinical microsystem—all the current and future frontline staff and health care leaders who enjoy the trust of their communities that they will provide the best possible care and caring, as well as all the patients and families who have the potential to benefit from health care done in the right way, in the way they want and need

Our families—all our loved ones who support our passion for excellence in health care, even though it results in peculiar work habits and absences from home

PREFACE

This book is about clinical microsystems—the places where patients and families and careteams meet. It is also about what leaders, at all levels of a health system, need to know and do to create the conditions of excellence in the front lines of care delivery. At the end of the day each patient’s care is only as good as the care that is actually delivered by frontline staff. Is the care . . . correct? timely? caring? desired? efficient? The answers pour forth millions of times a day as real patients interact with real providers in real clinical microsystems, the naturally occurring building blocks of every health care system.

In reading this book and in using this book, you will discover many important things about using microsystem thinking and approaches to make lasting improvements in the quality and value of care. Here’s a list of distinguishing features of clinical microsystems, the relatively small frontline units of health care. A clinical microsystem is a

Health professionals, if they are to be effective, should understand these distinguishing features. Here are further illustrative behaviors related to each one:

Because microsystems are so critically important to patients, families, health care professionals, and the communities they serve, and because they have heretofore been for the most part, overlooked or invisible, we felt it was imperative to write this book. In doing so we hope that the reality and the power of health systems thinking in general—and clinical microsystem thinking in particular—can be unleashed and popularized so that outcomes and value can be improved continuously (from the inside out and from the bottom up) and that health professionals at all organization levels may have a better chance of having their everyday work be in sync with their core values and their strong desire to do the right thing well.

December 2006

Eugene C. Nelson

Lebanon, New Hampshire

Paul B. Batalden

Hanover, New Hampshire

Marjorie M. Godfrey

Hanover, New Hampshire

References

Henderson, L. J. (1935). Physician and patient as a social system. New England Journal of Medicine, 212, 819–823.

Herzberg, F. (1987, September/October). One more time: How do you motivate employees? Harvard Business Review, pp. 109–120.

Schein, E. H. (1999). The corporate culture survival guide: Sense and nonsense about culture change. San Francisco: Jossey-Bass.

Weick, K. E. (2002). The reduction of medical errors through mindful interdependence. In M. M. Rosenthal & K. M. Sutcliffe (Eds.), Medical error: What do we know? What do we do? (pp. 177–199). San Francisco: Jossey-Bass.

Weick, K. E., & Sutcliffe, K. M. (2001). Managing the unexpected: Assuring high performance in an age of complexity. San Francisco: Jossey-Bass.