‘Microsystem’ measures offer team approach to QI
November 1, 1999 4 minutes read
Microsystem’ measures offer team approach to QI
Dartmouth Hitchcock adapts business ideas
You’ve heard about performance measurement of health plans, medical groups, and individual physicians. Now there’s another level of feedback that provides useful information: the microsystem or team-based approach.
Microsystem thinking is actually a concept adapted by Dartmouth Hitchcock Health System in Lebanon, NH, from leading business theory. Quality improvement focuses on the "smallest replicable unit or the smallest groups that can be standardized and replicated," explains Marjorie Godfrey, RN, MS, director of accelerating clinical improvement at Dartmouth Hitchcock.
"The microsystem model revolves around the team and the unique contribution every member of the team makes," she says. That means data feedback and quality improvement includes everyone who supports the physicians, nurses, and medical assistants, such as receptionists, secretaries, and clerical staff. In medical groups in which physicians may see each other’s patients as needed, the microsystem might encompass the entire office.
But when there are natural segments, such as groups of physicians who take calls for each other and share support staff, the measurement could occur at that "team" level, says Paul B. Batalden, MD, director of health care improvement leadership development at Dartmouth Medical School and a pioneer in clinical care evaluation.
"It is my belief that the reality of daily care for patients is that microsystem," he says. "The reality of daily care for the usual caregiver is that microsystem. It is not until we change the design of that microsystem, measure at the level of that microsystem, and link our measures with our models and practices of care, that we’re going to see change at the macro level."
A new way of thinking about practice
A microsystem is not just a new way of presenting outcomes data. It’s a new way of thinking about medical practice. To illustrate this concept, Dartmouth Hitchcock developed a pictorial that shows how patients with myriad health needs are oriented and cared for by a medical team. Team members’ names are written at the bottom, as are team-based measurements for items such as access and patient satisfaction.
The team needs to understand the range of issues facing its patients, and patients need to be properly informed about the workings of the office, says Godfrey. "If you need a prescription renewed, this is how you do it. If you have test results, this is how you can expect us to communicate the test results. [Providing the ground rules] helps inform the patients and helps them set expectations."
One Dartmouth Hitchcock clinic site is conducting health risk assessments by phone or computer before patients arrive for office visits. In addition to learning more about needs of individual patients, physicians are gaining information on the age distribution and health status of the overall patient load.
"Most [physicians] view their practice as providing episodes of care without looking at the big picture of the continuum of care and the outcomes that go along with them," says Godfrey.
Clinics stem losses with team approach
Dartmouth Hitchcock has a strong incentive to make this team-based, microsystem change work. In the 1997-98 fiscal year, four clinics in the southern region of New Hampshire suffered a cumulative $18 million loss. The improvements are designed to improve efficiency, quality of care, and patient and staff satisfaction, as well as reduce costs.
Some of the measures taken include:
- Clinics reduced the number of appointment types and several teams adopted "open access" scheduling that leaves 60% to 70% of the schedule available for same-day appointments. Clinics expanded their hours, and some have hours seven days a week.
- Nurses standardized the advice they give to patients who call with various symptoms and conditions. In one pediatric group, physicians designed standard, age-specific physical exams based on growth and development of children, so that every physician would perform at least those processes.
- Managers used software to track referrals and urged physicians to reduce unnecessary referrals outside the health system.
Staff morale improved with the greater efficiency and the team approach that valued all members’ contributions. In one department, staff satisfaction rose from 47% to about 80% in just six months.
However, the changes also reduced the sense of autonomy for individual physicians, and some physicians left, acknowledges Godfrey. But others have adapted to a new way of thinking and have embraced the changes. "The unit of care does not rotate around [physicians]," she says. "It really rotates around the patient."
Not all the teams have been equally successful with quality improvement projects, although they all met their budget in the last fiscal year. Meanwhile, the work continues, with monthly measurement of key indicators and charts that show change over time.
"This is not just a one-time fix and move on. It’s a living system that constantly needs attention, encouragement, and measurement," says Godfrey.
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