Must the macrosystem give permission?
Let’s say you’ve recognized that you are a microsystem and would like to begin approaching quality improvement from that perspective. Do you need permission from your hospital macrosystem to do so? Not necessarily, but it sure would help, according to the experts.
"I think we have lots of evidence that suggests people who regularly work together in microsystems come together and make tremendous improvements," says Paul Batalden, MD, professor and director of the health care improvement leadership development group at the center for the evaluative clinical sciences at Dartmouth College in Hanover, NH.
"To the degree their work together is recognized and rewarded as a microsystem, it will influence the degree to which changes will be retained and spread," he says. "People can make lots of improvements. The question is, how badly does the macrosystem want to sustain those gains and spread them?"
Do microsystems make changes within macrosystems that don’t recognize their existence? "It happens all the time," Batalden says. "But if the macrosystem does not understand, the microsystem leaders become frustrated that they can’t make it last or happen in another branch. The microsystems that do make significant improvements have an opportunity to share what made it possible for them to do that," he adds. Without the recognition of microsystems, he says, "Things are done in the name of making things better, but inadvertently centrifugal force pulls you apart from the natural systems."
For example, a hospital may want to improve care in the outpatient setting, Batalden says. "We get a group together and decide we want to work on access systems and the way we triage patients. The macrosystem decides the physicians still don’t get the message, so we create an incentive program for the doctors. Lo and behold, the group that had come together decided that if the docs were the only ones getting recognized, they didn’t have to sit in on the sessions. "And the docs who wanted to optimize their income realize if they don’t see the more complicated patients, they can see more patients and make more money," he points out.
"Currently [in many facilities], if you’re aware an action has to occur, you have to work through a circuitous route to get it done," says James Espinosa, MD, FACEP, FAAFP, chairman of the emergency department at Overlook Hospital in Summit, NJ. "If it’s a medication issue, you talk to the nurses who give meds, then maybe to a safety committee. But the voltage step-off’ for each step is severe. Paper has to be moved, and everything takes a long time. If you had an empowered microsystem, the macrosystem says if something needs to be fixed and it does not affect major hospitalwide procedures, fix it first and then tell us about it," Espinosa says.
The bottom line is this, says Eugene C. Nelson, DSc, MPH, professor, community and family medicine at Dartmouth Medical School, and director of quality education, measurement, and research, at Dartmouth-Hitchcock Clinic: "A macrosystem can be no better than its microsystems."
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