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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

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The Equation

Microsystem1 + Microsystem2 + Microsystem3-n

= Health System

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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?

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Systems

• It is the nature of systems that smaller systems are embedded in bigger systems

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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

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The Chain Of Effect InImproving Health Care Quality

I Patient

II Microsystem of care delivery

III Macro-organization

IV Environmental ContextIOM framework

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What is a clinical microsystem?

• How did idea develop?

• What are they?

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What society needs

How we create, make health care

Understanding Health Care As A System

How we improvewhat we make

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“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 systemsEmbedded in Big systems

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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

Information&

Information Technology

Staff• Staff focus• Education & Training

• Interdependence of care team

Patients• Patient Focus• Community & Market Focus

Performance• Performance results• Process improvement

Leadership• Leadership• Organizational

support

10 Success Characteristics8 Success

Characteristics

2001

IOM 21st Century

Fu

ture

Fu

ture

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

2001WebsiteFormed

www.clinicalmicrosystem.org

2001

Fall Invitational

2002-3

JQI Articles

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DefinitionA 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.

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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.

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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, purposeA schematic figure

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Physician,Care-giver

Mid-levelPractitioner

ClinicalSupport

AdministrativeSupport

InformationTechnology

Need, aim

CareFew OtherPhysicians

The Clinical Microsystem

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Physician,Care-giver

Mid-levelPractitioner

ClinicalSupport

AdministrativeSupport

InformationTechnology

Need, aim

CareFew OtherPhysicians

Who is the neonatal ICU clinical microsystem?

Some PhotosSome Photos

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Patient

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Aimee, Nurse

19Dion, Discharge Nurse using electronic and paper information

20William Edwards, M.D., Neonatologist

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Parent and Drs. Edwards and Little

22Rounding team, including parents

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Theresa, Receptionist

24Information technology (monitors)

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A Picture Of EmbeddedParts in

Microsystems

The Anatomy The Anatomy

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Building a Team to Manage A Panel of Primary Care PatientsMIssion: The Dartmouth-Hitchcock Clinic exists to serve the health care needs of our patients.

Very High Risk

Chronic

Very High Risk

Healthy

Healthy

Healthy

Chronic

Assign toPCP

Orient toTeam

Assess &Plan Care

Functional& Risks

Biological

Costs

Expectations Chronic ++

Very High Risk +++

Healthy

Prevention Acute EducateChronic

P A C E

P A C E

P A E

P A C E

Functional& Risks

Biological

Costs

Satisfaction

People withhealthcare

needsPeople withhealthcareneeds met

Phone,Nurse First

PhysicalSpace

Info Systems& Data

BillingReferralsPharmacyRadiologyLaboratoryMedicalRecords

Scheduling

Department

Division and Community

Southern Region

Hitchcock Clinic System

Measuring Team Performance & Patient Outcomes and Costs

Measure Current Target Measure Current Target

Panel Size Adj.

Direct Pt. Care Hours:MD/Assoc.

% Panel Seeing OwnPCP:

Total PMPM Adj.PMPM-Team

External Referral Adj.PMPM-Team

Patient Satisfaction

Access Satisfaction

Staff Satisfaction

TEAM MEMBERS:

Skill Mix: MDs _2.8_ RNs _6.8_ NP/PAs __2__ MA _4.8 LPN _____ SECs __4_Micro-System Approach 6/17/98Revised: 1/27/00

c Eugene C. Nelson, DSc, MPHPaul B. Batalden, MDDartmouth-Hitchcock Clinic, June 1998

1 2 3

5 6 7 8 9 10 11 12 13 14

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Sherman Baker, MD

Leslie Cook, MD

Joe Karpicz, MD

Deb Urquart, NP

Ron Carson, PA

Erica, RN

Laura, RN

Maggi, RN

Missy, RN

Diane, RN

Katie, RN

Bonnie, LPN

Carole, LPN

Nancy, LPN

Mary Beth, MA

Lynn, MA

Amy, Secretary

Buffy, Secretary

Mary Ellen, Secretary

Kristy, Secretary

Charlene, Secretary

Nashua Internal Medicine

PatientsPatients

ProfessionalsProfessionals

ProcessesProcesses

PatternsPatterns

PurposePurpose5 P’s

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A Picture Of A Microsystem

The Physiology The Physiology

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Entry,Assignment

OrientationInitial

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

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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

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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.

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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 …

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“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, PhDProfessor EmeritusTuck School of Business AdministrationDartmouth CollegeDecember 2004

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Microsystems Are The Building Blocks That Come Together To Form Macro-organizations

Mesosystem

Macrosystem

Microsystem

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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

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High Performing Clinical Microsystems

Information&

Information Technology

Staff• Staff focus• Education & Training • Interdependence of care team

Patients• Patient Focus• Community & Market Focus

Performance• Performance results• Process improvement

Leadership• Leadership• Organizational

support

Not single bulletBut rather a Special blend.

Read letterTo the editor.

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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

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Clinical Microsystem Work Underway

Panoramic view

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Toronto, ON

Lebanon, NH

Canada

Mexico

Sacramento, CABoston, MA

United States of AmericaDanville, PA

Denver, CO

IHI

AHA

VHA

Cystic Fibrosis

Vt. Oxford Network

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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

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Karim Laaribi

Martial Favre

Goran Henrik

Helen Bevan

Peter Wilcock

Ian Golton

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Karim Laaribi

Karim Laaribi

Mary Taylor

Cris Hammond

Jashar Ramadani

Genc YmerhaliliChristian von Plessen

Per Hjortdal

Hans Asbjørn Holm

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Many Ways To Be Connected!

• www.clinicalmicrosystem.org

• www.qulturum.com