1. A Clinical Microsystem Approach to Improving the Quality and Safety of Care: From Theory to Practice 1

2. Objectives This presentation will summarize the key points of the Healthcare Microsystems module. Upon completion of this presentation, you will be able to: Describe the clinical microsystem model Explore the link between microsystems and improvement Use patient safety narratives to analyze microsystems that support frontline caregivers Discuss strategies for translating research into practice 2

3. The first part of the presentation will provide an introduction to the clinical microsystem model. 3

4. Clinical Microsystems 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 ▫Clinicians and support staff ▫Information and technology ▫Care processes 4

5. Clinical Microsystem Use of information is key to the microsystem’s ability to function Information technology facilitates collecting, assessing, and sharing information 5

6. Microsystems Exist Within Other Systems 6 Self-care System Individual caregiver, team & patient System Clinical Microsystem Macro Organization System Community, Market, Social Policy System

7. From the Eyes of the Patient Patients interact with several microsystems as they navigate the health care system The handoffs of information between microsystems can be difficult and confusing for patients 7

8. What Are the Essential Elements of a Microsystem? Core team of health professionals Defined population of patients they care for Information & information technology Support staff, equipment, environment Processes, activities specific to accomplishing the aim 8 Aren’t You Just Talking About “Teams”?

9. Team and Teamwork 9

10. What are the characteristics of a good team experience? collaborative better result efficient effective fun clear roles shared responsibilities dedication sense of team work 10

11. Team A team is “a group of people who make different contributions toward achieving a common goal”  Pritchard and Pritchard. Teamwork for Primary and Shared Care, 1994. Teams and teamwork fit within the context of the clinical microsystem 11

12. Essential Characteristics of Teamwork Members of the team share a common purpose which binds them and guides their actions Each member of the team has a clear understanding of his/her own role and functions The team pools knowledge, skills, and resources and all members share responsibility for outcome The effectiveness of the team is related to its capacity to carry out its work and to manage itself as an independent group of people  Gilmore, et al 1974 12

13. The Team, as a construct, exists within the context of a system A system is a set of interacting, interrelated, or independent elements that work together in a particular environment to perform the functions that are required to achieve a specific aim 13 Bertalanffy, 1968

14. The Team, as a construct, exists within the context of a microsystem Microsystems are different from teams because the microsystem includes ▫patients as part of the same system as the providers ▫information and information technology as a “full participant” ▫processes that are necessary to achieve the aim 14

15. An Example of A Microsystem A Neonatal Intensive Care Unit at an Academic Medical Center 15

17. Where Can You Find a Microsystem? Everywhere! ▫A community based general pediatric practice ▫A cardiac surgery team ▫A spinal cord injury care team 17

18. A Common View of an Organization 18

19. The Common View vs. The Microsystem View The traditional structure of the macrosystem often “pulls apart” the microsystem ▫Effect of human resource policies and practices, information services, etc. ▫Effect of not recognizing the role of the microsystem in training physicians 19

20. Explore the link between microsystems and improvement 20

21. What We Have Learned About Clinical Microsystems Some microsystem units function better than others, which provides us with improvement opportunities that are different from improvement of a certain clinical condition. We can be successful at running QI projects in a specific clinical condition which will improve certain indicators (satisfaction, LOS, etc.). Projects may succeed for the short run, but we often fail to hold the gains or spread the changes to other areas. 21

22. Why Is This Important? Our efforts to improve safety and quality of patient care will be more effective when our efforts are designed and implemented at the microsystem level and supported and facilitated by the larger organization 22

23. What Does the Microsystem Mean for Patient Safety? The clinical microsystem – as a unit of research, analysis, and practice – is an important level at which to focus patient safety intervention. A functioning microsystem can stop, prevent or mitigate errors from causing patient harm. Safety is a property of the clinical microsystem that can only be achieved through a systematic application of a broad array of changes – process, equipment, organization, supervision, training, simulation, and teamwork. 23

24. We will use patient safety narratives to analyze microsystems that support frontline caregivers. 24

25. One method that we have found to be useful for systematically looking at patient safety events builds on Haddon’s overarching framework on injury epidemiology 25

26. The Haddon Matrix 26 HumanVehicleEnvironment Pre-event Event Post-event Source: Haddon, W. A Logical Framework for Categorizing Highway Safety Phenomena and Activity. J. Trauma 1972; 12:197. Alcohol intoxication Braking capacity Visibility of hazards Resistance to injury insults Sharp, pointed edges and surfaces Flammable materials Hemorrhage Rapidity of energy dissipation Emergency medical response

27. Haddon Matrix adapted to Patient Safety in the Microsystem Patient/ Family Health Care Professional Systems/Environment Pre-event Event Post-event 27

28. Debriefing 28 Patient/ Family Health Care Professional Systems/Environment Pre-event Orientation to the process Probablistic Risk Assessment (PRA) Scenario Building Hazard Analysis Checklists Failure Modes Effects Analysis (FMEA) Human Factors Engineering Event Interview Crew Resource Management (CRM) Checklists Root Cause Analysis (RCA) Post- event Interview, Focus Group Interviews Microsystem Analysis Morbidity and Mortality Conference (M&M) Root Cause Analysis (RCA)

29. Discuss strategies for translating research into practice 29

31. 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 31

32. Information & Information Technology Staff Staff focus Education & Training Interdependence of care team Patients Patient Focus Community & Market Focus Performance results Process improvement Leadership Organizational support

33. Assess, Diagnose and Treat Your Microsystem PATIENTS … ▫Assess ▫Diagnose ▫Treat  Involving the patient & family in the process MICROSYSTEMS … ▫Assess ▫Diagnose ▫Treat  Involving the microsystem players in the process 33

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36. Know YOUR 5 Ps Purpose Patients Professionals Processes Patterns 36 http://cms.dartmouth.edu/greenBook.htm

37. Know Your Purpose Have you EVER discussed with your interdisciplinary team WHY your microsystem exists? What is the purpose of your microsystem that everyone understands and supports? 37

38. Know Your Patients Who are the patients your microsystem treats? What do you know about the patient population your microsystem serves? 38

39. Know Your Professionals What do you know about the people who work in your microsystem? 39

40. Know Your Core and Supporting Processes What are the processes for caring for patients in your microsystem? 40

41. Know Your Patterns What do you know about the recurring patterns in your microsystem? 41