Part 4: System-Level Impact of Local Improvement
Parts 2 and 3 of this article series addressed execution of a portfolio of projects to achieve breakthrough goals — the right side of the triangle in Figure 1, A Framework for Execution. Part 4 addresses the left side of the triangle — the role of local improvement in achieving breakthrough goals and sustaining system performance. These two sides of the triangle are complementary but different.
Figure 1. A Framework for Execution
The execution of system change on the right side of the triangle usually depends on temporary organizations such as project teams. The left side is concerned with existing work units and how they function and continually improve. The execution on the right side usually addresses structural changes that cross departmental boundaries such as inpatient and outpatient. The left side is often concerned with the work processes that are necessary to sustain the structural changes made by project teams. On the right side of the triangle, results are usually recognized as changes in the average level of a system measure — lower mortality, less harm, higher satisfaction, or less cost. Microsystems, in addition to improving their local processes, are often vital to achieving breakthrough goals aimed at reducing the variation in the performance of work units centered on the best-known processes — less variation in mortality, harm, satisfaction, or cost unit to unit. The Framework for Execution describes a system of execution.
Microsystems
Work units in health care include medical practices, home health agencies, patient care units within a hospital, pharmacies, and diagnostic centers. Work units of these types have been called “microsystems” and have been extensively studied by Nelson, Batalden, and colleagues (Microsystems in health care: Part 1. Joint Commission Journal on Quality Improvement. 2002;28(9):472-493). They define a microsystem as follows:
A clinical microsystem is a small group of people who work together on a regular basis to provide care to discrete subpopulations of patients.
Their research identified 20 high-performing microsystems in health care. These microsystems were studied in depth to define their common characteristics. The informal interviews we conducted during this R&D project, as well as IHI’s experience in the Pursuing Perfection initiative and other programs, produced some of the same findings as the research by Nelson and colleagues. Some of the capabilities that we conclude are needed to lead a microsystem effectively are described below.
Capabilities of Effective Leaders of Microsystems
1. Recognizing the work unit as a microsystem
This recognition includes:
- Understanding the purpose of the work unit as it relates to patients, families, or internal customers;
- Measuring performance of the work unit against this purpose; and
- Recognizing that their performance depends on processes and their linkage.
2. Choosing improvement priorities that balance the needs of the work unit and the containing organization
Local work units will have responsibilities to the containing organization, perhaps by contributing to large projects aimed at breakthrough goals. However, they will also have local issues that need attention, for example, consistent complaints from patients or families about the lack of information concerning side effects of medications.
3. Managing Plan-Do-Study-Act (PDSA) cycles
All improvement requires change, but not all change is improvement. The PDSA cycle is a method for testing changes in the work setting to improve performance. Multiple PDSA cycles must be managed in a way that optimizes learning while making efficient use of resources. The leader will be able to help others in the work unit use some standard framework for improvement, for example, the Model for Improvement shown in Figure 2.
Figure 2. Model for Improvement
[Source: Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.]
4. Getting everyone involved
Members of the work unit will vary in their skills for improvement and their desire to get involved. However, all can and should contribute. The path of least resistance is to rely on few to carry the improvement work. Good microsystem leaders have the capability to make improvement work an attractive way for all to accomplish the purpose of the work unit.
5. Fostering cooperation with the microsystem and between microsystems
Patients and families interact with many individuals as they experience care. Effective microsystem leaders form those individuals into a team when they are in the same microsystem. These effective leaders also facilitate coordination of care with other microsystems so that patients and families experience care over time as a coordinated whole.
For more on microsystems, see www.clinicalmicrosystem.org.
Developing a Collection of Strategic Microsystems
Nelson and colleagues discovered that many of the 20 high-performing microsystems that they studied were isolated special cases, not the result of an explicit effort by the organization’s executives to develop a collection of high-performing microsystems. They concluded the following about the executives of large systems in which some of the microsystems resided:
“These system leaders showed some recognition of outstanding performance and some degree of special assistance for the unit, but they lacked a strategic focus on creating the conditions to generate excellent performance in all the microsystems that comprised their health system. In short, they did not make the attainment of microsystem excellence a basic pillar of their management strategy.”
Executives intending to develop pervasive, high-performing microsystems in their organization will take on at least three tasks: setting expectations, providing support and encouragement, and developing leaders for the microsystems. An expectation that a significant part of the job of any manager is improvement of quality and value is reinforced by including this requirement in the job description. Improvement requires intention; therefore, another expectation of all microsystems is that each of them will have a small set of measures (three to seven) by which the performance of the microsystem can be assessed relative to its purpose. These measures can be used to set improvement aims and plans — another important expectation of a microsystem.
A longer-term cultural expectation that was fostered by several of the organizations that we interviewed was that microsystems would adopt standard processes unless patient circumstances or preferences dictated otherwise. Standardization across microsystems was used to reduce complexity and make the spread of good ideas more efficient. Pete Knox, Executive Director of Bellin Medical Group (Green Bay, Wisconsin) referred to a collection of these standard processes as a “platform” for a clinic or an inpatient unit. At HealthPartners, standardization of processes in clinics and office practices takes place within a platform that is called the “Care Model Process” and includes processes before, during, and after an office visit by a patient.
Of course in health care many microsystems are the direct providers of care and are under time and productivity pressures. An executive seeking to develop these microsystems must support their work and provide encouragement. Without this support, expectations become exhortations. The support will include some time for front-line staff to test changes using PDSA cycles. Some measurement support may also be needed. Many microsystem leaders will need coaching in how to adapt existing meetings, management structures, and communication vehicles so that they include a focus on improvement. Encouragement and appreciation are vital to keep the members of the microsystems motivated for continual improvement. Executives skilled at this type of leadership schedule frequent visits to the locations of care to understand the needs of front-line care givers. In addition to expressing appreciation, they look for barriers to improvement and quality of work life that they could remove.
The combination of performance measures and the intrinsic motivation of clinicians and other health care workers can be a powerful source of energy within a microsystem. David Pryor, MD, Senior Vice President, Clinical Excellence, Ascension Health, emphasized the use of a small set of shared measures across hospitals, called Health Ministries, and patient care units within those Health Ministries to drive learning and change. Ascension Health, like other organizations, used internal collaborative projects to support the efforts of the local Health Ministries. Health Ministries in Ascension Health with a common goal for the year — for example, improving perinatal safety, eliminating pressure ulcers, eliminating nosocomial infections, reducing mortality, eliminating surgical complications, or reducing falls and fall injuries — can voluntarily join a collaborative effort called an Affinity Group and receive support from system resources of Ascension Health. Some of the multi-national industrial organizations that we interviewed used these collaborative initiatives to provide support for improvement across national boundaries. One organization referred to them as "worldwide initiatives."
Executives and Human Resource professionals have many options at their disposal for assembling a development plan for leaders of microsystems. Some of these options are described below. (For more, see www.clinicalmicrosystem.org/workforce.htm)
Some Components of a Development Plan for Leaders of Microsystems
1. Lead an improvement initiative within the microsystem
Improvement is concerned with testing and implementing changes. This can best be done in the actual microsystem setting. The individual learning and development comes from frequent reflections on the experience of leading this work, with help from a capable colleague or improvement advisor.
2. Attend seminars and conferences
These options seem most useful after a person has had some experience with leading or at least participating in improvement efforts within the local setting. A very worthwhile conference called the Dartmouth Clinical Microsystem Fall Invitational is held every October. The IHI National Forum is also a yearly opportunity for leadership development.
3. Lead a workshop for members of the microsystem
A microsystem leader who is in the mid-range of capability could further develop his or her skills by teaching other members of the microsystem, perhaps with some coaching from a skilled advisor. These teaching opportunities could be integrated into existing management, supervision, or educational systems.
4. Rotate for an extended period into a central improvement group
Many organizations have some type of central improvement group that provides resources and knowledge for improvement work throughout the organization. Several persons that we interviewed mentioned that their organization used one- to three-year assignments in these groups as a development option for those to acquire advanced skills.
Organizations that have intentionally developed pervasive improvement capability in their microsystems have an efficient and effective means of meeting the increasing expectations that regulators and society have of our health care system. Consider the matrix in Figure 3 describing the contributions and interrelations among inpatient units — microsystems — to the safety initiative at Cincinnati Children’s Hospital (Cincinnati, Ohio). Bellin Health System uses a similar approach to highlight the contributions of individual microsystems and to ensure that no one unit is overburdened with improvement requirements that were generated external to their microsystem. Each microsystem is expected to contribute to the organization’s improvement goals, but microsystem leaders are expected to raise a concern when more than five of these externally generated initiatives substantially impact the microsystem.
Figure 3. Contributions of Inpatient Microsystems to Improving Patient Safety at Cincinnati Children's Hospital (Click for larger image)
Execution for system-level results requires a system of execution. One such system is described in the Framework for Execution shown in Figure 1. Pervasive high-performing microsystems complement large-scale projects that impact the structural elements of the organization and aim to produce breakthrough results for patients and families. High-performing microsystems are vital to ensure that these breakthrough results are sustained, that the structural changes are supported by local processes, and that front-line health care providers maintain the quality of work life and vitality necessary for excellent patient care.
Related stories in this series:
Part 1: Organizational Approaches to Execution — Inside and Outside of Health Care
Part 2: Achieving Breakthrough Performance: Setting Goals and Developing a Portfolio of Projects
Part 3: Achieving Breakthrough Performance: Deploying Resources and Providing Oversight
03/13/2007
