Microsystems: Using the building blocks’ of quality improvement
Proponents say they hold the key to improving patient care
The Institute of Medicine (IOM) has expressed great interest in them. The Institute for Healthcare Improvement (IHI) refers to them as if they were an integral part of the quality improvement process. They’re called microsystems, and they already exist in your institution — even if you don’t know it.
"Microsystems are the building blocks that form the health system, the fundamental organizing unit around which patients, physicians, and providers meet — the sharp edge of the delivery system," says Eugene C. Nelson, DSc, MPH, professor of community and family medicine at Dartmouth Medical School, and director of quality education, measurement, and research at Dartmouth-Hitchcock Clinic in Hanover, NH.
"The essential notion is that the microsystem is the smallest fractal unit that emulates the larger system, the smallest unit of an organization that still maintains the properties of the larger whole," adds James Espinosa, MD, FACEP, FAAFP, chairman of the emergency department at Overlook Hospital in Summit, NJ.
"Microsystems are where patients and the competency of health care meet," asserts 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 and, along with Nelson, one of the leading authorities on microsystems and co-author of several studies.
Already a fact of life
One of the most fascinating aspects of microsystem theory is that you don’t create microsystems or even discover them; they simply exist. "It’s not just a way of looking at things; the microsystem already exists in the world," Espinosa says. He personally defines a microsystem as the smallest unit within a health care organization that could spawn a Baldrige application — referring to the Malcolm Baldrige National Quality Award — if it were allowed to. "This entails such things as leadership, strategic planning, results, human resources, and a focus on the patient," he explains.
For nearly 80 years, Espinosa notes, hospital organizational charts and procedures have reflected a military perspective, complete with departments, units, orders, and so on. "But if you look at it from a patient’s point of view, they are relatively uninterested in peoples’ departmental lines," he says. "You look for function; what you realize when you are in the [emergency department (ED)] world, is that it has its own culture."
But microsystems are not necessarily the same as departments; in fact, often they are not. "If you actually wish to improve in quality or safety, you have to recognize the real structure of the system," Nelson notes. "It may involve a series of closely coupled microsystems, such as the operating room and post-acute care unit, or loosely coupled ones, such as the nutrition department and behavioral medicine. Sometimes, you might want nutrition and behavior to join hands for treatment. Referring physicians are loosely linked to inpatient services. With this approach, you start to recognize the true structure of the delivery system.
"Oftentimes, we are organized along profession lines, like the department of medicine or the physical therapy department, yet when physicians in the department of medicine are actually in the process of providing care, they no longer are in their department," he continues. "They are generally meeting face to face with patients in a setting [that] often has an interdisciplinary team and support staff around them. In other words, traditional organization doesn’t often coincide with the actual small systems of care."
"If we don’t understand microsystems, we are held hostage to the old dynamics," Batalden asserts. "With microsystems, patients, providers, and information technology are all part of the same system, but we rarely make change that way. The myths of professional autonomy have become the way in which we have customarily led; since that disregards the facts, it makes it very tricky to facilitate improvement."
Opening new vistas
Recognizing the existence of microsystems, and more importantly, recognizing your own microsystem, is a powerful force for change, Espinosa observes. "This involves recognizing what I feel to be an organic reality, becoming a self-aware microsystem," he says. "If you are a microsystem and don’t know it, it does not mean you are not one, but it means you are merely functioning as a department."
If you become a self-aware microsystem, you have the capacity to think differently, he continues. "We blew up departmental meetings and developed a microsystem meeting once a month," he says. "This reconfigures everything, and the spirit of the meeting is different."
Recognizing microsystems helps you "keep your eye on the ball" — the patients and the needs of the patients, and doing the right thing for them, Nelson says. "If you wanted to improve care for community-acquired pneumonia, a traditional approach might say, Search the evidence, bring guidelines off the web, develop a pathway, and let people know about it,’" he observes. "But they mostly sit on the shelf. They’re not adopted into the real flow of the real work. There are people already fully engaged in the real work, but absent the recognition of an inside-out understanding of the nature and feel of the delivery system, you have little hope of finding best practices.’"
One of Nelson’s Dartmouth students addressed such a problem. "Remembering that the bouncing ball is the patient, he started to map the trajectory of certain patients to see where they were landing and how they flowed through systems. This way, you could see the common pathways of care they are taking," he relates.
"If we wish to improve, what it means in this particular hospital is that we’ve really got to develop an effective program of care within the ED and handoff to four inpatient nursing units, and we have to involve the medical staff associated with the patient most often. It really becomes a case of optimizing care and the handoff of care within small systems," Nelson adds.
Under a more traditional approach, two departmental nurses probably would develop a guideline and believe that should be enough, he says.
"They know feedback is important, so they throw in a little guideline compliance and show mortality trends. But the cell must take it up and float it around — they are the receptor sites for the new process — literally in the microsystem," Nelson says. "That means staff, patients, and information systems."
One of the major advantages of the microsystem is its ability to respond quickly, Espinosa says. "If a complaint emerges at 3 p.m., the best people to address it are found at the microsystem level. He recalls a specific instance at Overlook where the ED was running low on a particular medication because of supplier delay. "We talked about it in microsystem, and then I was able to go to the pharmacy and talk with them directly. The problem was solved in two hours, and a procedure was instituted to prevent this from happening in the future."
Some things can be done effectively only at the microsystem level, Espinosa asserts. "If the health department gives marching orders that we must be safer with needlestick, they flip it down to the next logical system: the hospital," he hypothesizes. "The hospital can get a team together, or form a committee, but once you get down to the granularity of many safety concerns, you’re talking about microsystems."
As another example, some problems in the ED may have many different determinative factors. "There may be transfer problems with the OR, faulty equipment, or medication delivery problems," he explains. "The ability to collect data, to make sense of it, and to implement solutions only can be done culturally at the microsystem level."
When you meet problems as a microsystem, it allows you to ask what needs you have that the hospital cannot possibly satisfy for you, he continues. "For example, we didn’t have a system that enabled us to know what the cycle time was between patient arrivals and their being seen by a nurse and doctor," he recalls. "So, we set up our own tracking system."
One of the defining factors of a high-functioning microsystem, Espinosa says, is information technology. "You need to have a software guy who can build the subsystems to do what you need."
Making the transition
Even if you accept the concept that microsystems already exist within your hospital "macro-system," it takes more than mere recognition to put them to work for you. "First, you have to draw out a picture of the microsystem you want to work with, draw a visual artifact to work on," Batalden says. (To find examples of these visual artifacts, see recommended reading at the end of this article.) "If you tell the truth about the way things actually work in your facility, you will see an enormous amount of foolishness that goes on every day," he continues. "Once you reveal the way things fail time after time, you run a little test change. It may be as simple as changing the way calls are answered. But as you start to understand the way things really work, you begin to see the things you are not so happy about, and you work on them."
Through this process, you begin to realize you are on the front lines not just for yourselves, but for the aim of relieving the illness burden. "Connect the aim and the purpose to this group of people, and suddenly it gets a lot more complicated," Batalden notes. "What are we doing here? How do we know this current design is the best we can do for people? You wrestle with having a clear set of goals and aims, and their relationship to daily functioning. This is very helpful because it opens up the possibility of redesign; people realize there are other ways to do things," he points out.
The final step involves strategic invitations to change. "People will come along and say, Let the patient decide,’" Batalden says. "You think about ways to integrate that approach, and then make modifications. You might experience some interest learnings. So people go through that process, testing strategic change, and out of that you begin to have a sense you could actually create some measures to monitor your own performance over time. Then, you create a data wall to measure what’s required."
(For a more detailed description of this process, see the Clinical Microsystem Action Guide Version 1.1. An unpublished PDF version is available on the web for free download at www.ClinicalMicrosystem.org.)
Thinking differently
The microsystems approach also puts you in a better position to conduct appreciative inquiry, a relatively new approach to change, Espinosa says. "You can go after fixing the system either by seeing where you screwed up or by asking yourself what went unexpectedly well and seeking to make that more common," he explains. "Ask yourself, What’s the best we’ve been?’ A microsystem can do this in spades."
At Overlook, he says, "We don’t just bring in the patients to tell us what went wrong, but what went unexpectedly right. This property of a good family has wide applications inside microsystems toward creating a culture of reliability. When a negative thing comes through, you have the energy to say, That’s not who we are.’"
When your microsystems adopt this approach, a tech can tell a doctor, "Excuse me, that’s not done here," Espinosa adds. "In the traditional model, certain behaviors might be reported to risk management, then to the state, and so on. But it turns out that much of safety deals with real-time recognition and reaction."
Espinosa says that microsystems may hold the key to safety improvement. "There ain’t such a thing as a whole hospital culture; it’s a whole combination of different cultures. Just because a memo goes out doesn’t mean the culture changes; it has to be bought and embraced by the microsystems. Until microsystems can talk to each other fluently and feed back to each other their concerns, there won’t be reliable safety in play," he says.
Recommended reading
• Mohr JJ, Batalden PB. Improving safety on the front lines: The role of clinical microsystems. Quality & Safety in Health Care 2002; 11:45-50.
• Blike G, Cravero J, Nelson EC. Same patients, same critical events — different systems of care, different outcomes: Description of a human factors’ approach aimed at improving the efficacy and safety of sedation/analgesia care. Quality Management in Health Care Fall 2001; 10(1):17-36.
• Weinstein JN, Brown PW, Hanscom B, et al. Designing an ambulatory clinical practice for outcomes improvement: From vision to reality — the Spine Center at Dartmouth-Hitchcock, year one. Quality Management in Health Care Winter 2000; 8(2):1-20.
• Nelson EC, Batalden PB, Mohr JJ, Plume SK. Building a quality future. Frontiers of Health Services Management Fall 1998; 15(1):3-32.
• Nelson EC, Batalden PB. "Knowledge for Improvement: Improving Quality in the Micro-systems of Care." In: Goldfield N, Nach DB, eds. Providing Quality of Care in a Cost-Focused Environment. Gaithersburg, MD: Aspen Publishers Inc.; 1999, pp. 75-88.
For more information, contact:
• Eugene C. Nelson, DSc, MPH, Professor, Community and Family Medicine, Dartmouth Medical School, 7251 Strasenburgh Hall, Room 307, Hanover, NH 03755-3863. Telephone: (603) 650-6548.
• James Espinosa, MD, FACEP, FAAFP, Chairman, Emergency Department, Overlook Hospital, 99 Beauvoir Ave., P.O. Box 220, Summit, NJ 07902-0229. Telephone: (908) 522-5310.
• Paul Batalden, MD, Director of the Healthcare Improvement Leadership Development Group, Center for the Evaluative Clinical Sciences, Dartmouth College, Hanover, NH. E-mail: [email protected].
For more information on microsystems, go to:
• Institute of Medicine, Washington, DC. Web site: www.iom.edu.
• Institute for Healthcare Improvement, Boston. Web site: www.ihi.org.
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