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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