1. Creating Value and Joy in the Clinical Microsystem
Australian Institute of Health Innovation
Julie K. Johnson, MSPH, PhD
Associate Professor and Deputy Director
Centre for Clinical Governance Research
Australian Institute of Health Innovation
University of New South Wales
Sydney, Australia
29 August 2013

2. Overview of Today’s Session
How do we define value in healthcare?
Value models and the implications for our work
Creating value and joy in the clinical microsystem

3. Value in Healthcare
“Achieving high value for patients must become the overarching goal of healthcare delivery”
“Rigorous, disciplined measurement and improvement of value is the best way to drive system progress”
Porter, M. N ENGL J MED 363: Dec 2010

4. What is value in healthcare?
Hint: it’s not just about cutting costs and improving productivity
Value is defined as the health outcomes achieved per dollar spent
Value should always be defined around the patient’s needs
Porter, M. N ENGL J MED 363: Dec 2010

5. How do we measure value?
How do we assess whether value is improving over time?

6. A story about creating value and joy in healthcare
Christian Farman
diagnosed with renal failure at age 25
An athletic man in good shape
“It was a big shock for me to get into dialysis.”
Farman received a kidney transplant, but in 2005 he was back on dialysis in the Ryhov County Hospital hemodialysis clinic in Jönköping, Sweden
He researched self dialysis and became convinced that if he could manage his own treatment, the side effects would disappear
He spoke with Britt-Mari Banck, a nurse in the clinic. Farman said to her, “You have to help me treat myself – I need to have control in my life.”   
Source: IHI Annual Report 2012, ihi.org

7. A story about creating value and joy in healthcare
Britt-Mari showed Farman how to use the dialysis machine, read and interpret lab results, and document his care in his chart
Within five weeks, Farman was managing his dialysis independently. The side effects decreased.
Others wanted to learn to manage their own treatment . . .

8. A story about creating value and joy in healthcare
Infection rates fell
“We were a community, and we didn’t feel we were sick anymore, because the treatment was so good”
Today, nearly 60 percent of the hospital’s dialysis patients are managing their own treatments. The hospital aims to increase that number to 75 percent.
Banck says, “It’s a very joyful thing.”

9. Value Models Value Chain Value Shop Value Network Delineates a process
Providing effective treatment
Value Shop
Creates solutions to problems
Making the diagnosis
Value Network
Facilitates connections
Linking patients, healthcare professionals, processes, and the care giving environment
Nelson, et al, Value by Design, 2011
Stabell and Fjeldstad, Strategic Management Journal, 1998

10. Value Models Chain Shop Network Type of Firm Manufacturing Consultant
Telecommunication
Value Elements
Components
Competencies
Connectors
Delivers
Product
Solution
Connectivity

11. Value is defined differently in each model
Value chains
The process works reliably every time
Professionals prepared to adhere to the process
Produce the service in a timely way (efficiency)
Value (solution) shop
Intensive application of customised knowledge
Value network
Creating and facilitating networks
Christenson et al, The Innovator’s Prescription, 2009

12. How is value illustrated in Christian’s story?
Christian’s story, and Rhyhov Hospital’s story, illustrates a “value network”
What is important in this model?
How would you measure value?
What would you improve?

13. Value models applied to healthcare
The delivery of healthcare is often organised as a “shop”
Our current methods of improvement rely on redesigning the process or the “chain”
Perhaps the most potential for improvement is to focus on the “network”

14. Lingering questions How do we design for value?
How do we evaluate value?
Is their a link between value and joy in work?

15. What brings us joy?
Study of 41 primary care teams from 37 academic health centres participating in a chronic care improvement collaborative
Collaborative team members asked to describe experiences caring for people with chronic illness and the effect of the improvement collaborative on teams and teamwork
1145 narrative entries submitted
Members of teams that achieved highest performance on Collaborative indicators demonstrated an enthusiasm resulting from the work, environment, and interactions which we termed “Joy in Work”
Team members from teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” and awareness of “system failures”
Johnson et al, Joys and Challenges in Improving Chronic Illness Care. Jgen Intern Med. Vol 25 (Suppl 4), 2010.

16. Joy in Work Our data suggest
Improving specific clinical measures is meaningful for both the healthcare professional and the patient
A patient that we have been calling weekly to titrate insulin came today with perfect sugars. She was happy and so were we. We called the nurses in to look at her logbook! It takes a village to take care of a patient. [Physician]

17. Joy in Work
Improved communication among team members and the recognition of non-physician team members contributing to the care of the patient also contribute to joy in work
I am responsible for scheduling our diabetic patients for our Chronic Disease Management Visit Clinic... this is such an important task and a lot of our success hinges upon what I do. [Administrative Staff]

18. What next?
There are certain experiences that increase professional satisfaction and bring joy in work
The stories our healthcare professionals tell provide a platform for thinking about design and redesign or care
How do we feed these stories back into the improvement process to further enhance professional satisfaction and continue to improve outcomes for our patients?

19. Link Between Value and Joy
Improvement in value requires
measuring what is important to the patient,
teamwork
Sharing accountability for performance
Cooperation among providers
All hard to achieve when we work in departmental silos . . .

20. Clinical Microsystem
Small group of clinicians and staff working together with a shared clinical purpose to provide care for a defined set of patients
The clinical purpose defines the essential parts of the microsystem
Core team of healthcare professionals and support staff
Defined population of patients they care for
Information & information technology
Care processes
Equipment, environment
Processes, activities specific to accomplishing the aim

21. Systems within Systems . . .
Self-care System
Individual caregiver & patient System
Clinical Microsystem
Macro
Organization System
Community, Market, Social Policy System

22. Where Can You Find a Microsystem?
Everywhere!
A community based general practice
A cardiac surgery team
A dialysis clinic . . .

23. Microsystems are everywhere; however, some function better than others

24. What Are The Characteristics of High Performing Microsystems?
Leadership
Organizational Support
Staff Focus
Education and Training
Interdependence
Patient Focus
Community and Market Focus
Performance Results
Process Improvement
Information and Information Technology

25. Why is This Important?
The overwhelming amount of the daily work of providing care within a microsystem
The organisational boundaries of the microsystem reflect the appropriate level for measuring and improving value

26. Intersection of Value and Joy in the Clinical Microsystem
How do we design for, and evaluate, value and joy?
Value should always be defined around the patient’s needs
Patients, carers, and family members will have unique insights into the patient experience – we need to ask them
We need to elicit the stories, assumptions, and beliefs that people have about their illness, treatment of their illness, and living with their illness
We can’t create value without first creating a partnership

27. Thank you