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

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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

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

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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

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Clinical Microsystem

•Use of information is key to the microsystem’s ability to function

•Information technology facilitates collecting, assessing, and sharing information

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Microsystems Exist Within Other Systems

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Self-care System

Individual caregiver, team &

patient SystemClinical

Microsystem

MacroOrganization

System

Community, Market, Social Policy System

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

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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

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Aren’t You Just Talking About “Teams”?

Team and Teamwork

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What are the characteristics of a good team experience?

•collaborative•better result•efficient•effective•fun•clear roles •shared responsibilities •dedication •sense of team work

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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

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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

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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

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Bertalanffy, 1968

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

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An Example of A Microsystem

•A Neonatal Intensive Care Unit at an Academic Medical Center

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Where Can You Find a Microsystem?•Everywhere!

▫A community based general pediatric practice

▫A cardiac surgery team ▫A spinal cord injury care team

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A Common View of an Organization

Chief of Chiefs

Chief of Doctors Chief of Nurses Chief of Information

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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

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Explore the link between microsystems and improvement

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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.

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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

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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.

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

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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

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The Haddon Matrix

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HumanHuman VehicleVehicle EnvironmentEnvironment

Pre-eventPre-event

EventEvent

Post-eventPost-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

HemorrhageRapidity of energy dissipation

Emergency medical response

Haddon Matrix adapted to Patient Safety in the Microsystem

Patient/Patient/FamilyFamily

Health Health Care Care

ProfessionProfessionalal

Systems/Systems/

EnvironmeEnvironmentnt

Pre-eventPre-event

EventEvent

Post-eventPost-event

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Debriefing

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Patient/Patient/FamilyFamily

Health Care Health Care ProfessionalProfessional

Systems/Systems/

EnvironmentEnvironment

Pre-Pre-eventevent

Orientation to Orientation to the processthe process

Probablistic Risk Probablistic Risk Assessment (PRA)Assessment (PRA)

Scenario BuildingScenario Building

Hazard AnalysisHazard Analysis

ChecklistsChecklists

Failure Modes Failure Modes Effects Analysis Effects Analysis (FMEA)(FMEA)

Human Factors Human Factors EngineeringEngineering

EventEventInterviewInterview Crew Resource Crew Resource

Management (CRM)Management (CRM)

ChecklistsChecklists

Root Cause Root Cause Analysis (RCA)Analysis (RCA)

Post-Post-eventevent

Interview, Interview,

Focus Group Focus Group InterviewsInterviews

Microsystem Microsystem Analysis Morbidity Analysis Morbidity and Mortality and Mortality Conference (M&M)Conference (M&M)

Root Cause Root Cause Analysis (RCA)Analysis (RCA)

Discuss strategies for translating research into practice

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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

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Information&

Information Technology

Staff• Staff focus• Education & Training • Interdependence of care team

Patients• Patient Focus• Community & Market Focus

Performance• Performance results• Process improvement

Leadership• Leadership• Organizational

support

Assess, Diagnose and TreatYour Microsystem

• PATIENTS …▫ Assess▫ Diagnose▫ Treat

Involving the patient & family in the process

• MICROSYSTEMS …▫ Assess▫ Diagnose▫ Treat

Involving the microsystem players in the process

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Know YOUR 5 Ps

•Purpose•Patients•Professionals•Processes•Patterns

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