Transcript Microsystems in Health Care Identifying Systems

Understanding and Identifying
Systems in Health Care
Greg Ogrinc, MD, MS
Dartmouth Medical School
25 June, 2009
Objectives
• Understand and identify clinical
microsystems in healthcare
• Use techniques that can describe the
people, structures, and functions within a
microsystem
• Connect the knowledge of the processes
in the system to the improvement of care
Agenda
1. Welcome and review agenda
2. Story time!
3. Theory burst #1: Overview of systems
and interprofessional care
4. Video case study and exercise (part 1)
5. Theory burst #2: Creating process
models
6. Video case study and exercise (part 2)
7. Summary
Storytime…
Percent Normotensive (<140/<90) (Avg=74.39, UCL=83.66, LCL=65.11 for subgroups Jun-07-May-08)
100%
90%
80%
UCL
Target
Avg
% patients with normal BP
70%
60%
LCL
50%
40%
30%
20%
10%
0%
May-05
Jun-05
Jul-05
Aug-05 Nov-05
Jan-06 May-06
Jul-06
Sep-06
Oct-06
Date
Jan-07
Mar-07
Jun-07
Jul-07
Sep-07 Nov-07 Jan-08
Mar-08 May-08
Hypertension Letter
High blood pressure can lead to heart disease and stroke if
not well controlled. We review the risks and benefits of
changing their blood pressure treatment regimen on a
regular basis. Checks of your Blood Pressure show that it
is higher than 140/90, so we need to get this under better
control to reduce your risk of heart disease and stroke.
You can do the following things to help keep your blood
pressure under control:
- Reach or maintain a normal body weight
- Eat a healthy diet without too much salt.
- Eat plenty of fruits and vegetables
- Limit the amount of caffeine
- Include regular physical activity in your schedule
- Do not drink more then 2 ounces of liquor or 2 glasses of
beer or wine in one day.
Hypertension Letter
In order to help you get better control of your blood
pressure, I recommend the following:
(1) Discontinue HYDROCHLOROTHIAZIDE.
(2) Start CHLORTHALIDONE 100MG each morning.
I have made the changes in the computer and the
meds will be mailed to you.
(3) Please come to the WHITE MOUNTAIN FIRM for
a blood pressure check in 2 weeks. You do not
need an appointment.
(4) Stop by the laboratory for blood work on the
same day you come for the blood pressure check.
Lawrence J. Henderson
“Patients and doctors are part of
the same system.”
NEJM, 1935
What is the appropriate unit of measurement
and intervention in health care? Community,
Self care
System
Market,
Social Policy
System
Macro organization
System
Mesosystem
Individual
care - giver
& patient
System
Microsystem
“The functional unit of health care
is the clinical microsystem”
- Paul Batalden
What do they look like?
How can you find them?
Ingredients of a clinical microsystem
• Small group of doctors, nurses, other
clinicians
• Some administrative support
• Some information, information technology
• A small population of patients
• Interdependent for a common aim,
purpose
Microsystem Definition
• A small group of people who work together
on a regular basis to provide care to discrete
subpopulations of patients.
• It has clinical and business aims, linked
processes, a shared information
environment, and it produces outcomes.
• Evolves over time and is embedded in larger
organizations
• Behave as complex adaptive system
– Do the primary work associated with the aims
– Meet the needs of staff
– Maintain identify as a clinical unit
Microsystems ≠ Teams, Units
• Microsystems include information
• Microsystems include both providers and
patients
• Microsystems cross organizational
boundaries
• Microsystems are concerned first with the
care and flow of the patient’s need, not
with the flow of money
Clinical microsystems offer a strong theory-base
for interprofessional education…
•
•
•
•
•
Basic building block of health care
Unit of clinical “policy-in-use” (vs. “espoused”)
Good value & safe care “made” here
Patient satisfaction controlled at this level
Work practice “dissatisfiers” are controlled here
and “genuine motivators” are present here – joy,
pride in health professional work
• Setting for life-long professional “formation”
• Living adaptive health care system “laboratory”
with structure, pattern & process
High Performing Microsystems
• Constancy of purpose
– Clear aims and outcomes expected
• Investment in improvement
– Making care better is an integral part of
delivery of care
• Ongoing measurement of outcomes
• Integration of information and technology
High Performing Microsystems
• Support from the larger organization
• Connection to the community to enhance
care and extend influence
• Alignment of role and training
– People work near their maximum of training
and competence
– People continually improve and advance
“Discipline” v. “Profession”
• Interdisciplinary(-ity)
– Overall, knowledge for care is fragmented among
many disciplines
– Artificial division between these
– Seeks to reconcile and foster cohesion
• New disciplines may emerge
• Interprofessional(ity)
– Also, fragmented discipline specific knowledge
– A profession has a scope of practice
• Delivery of services to patients/clients
– Professions work together in an integrated fashion
• Unlikely to develop new professions
D’Amour & Oandasan, 2005
Interprofessionality
• “Development of a cohesive practice
between professionals from different
disciplines”
• Combination of what occurs in practice
and in health professions education
– These are interdependent for research and
practical purposes
• Work processes are a prime component
• Improved outcomes for patients is the goal
D’Amour & Oandasan, 2005
Interim Summary
• Improvement of systems requires
knowledge of the structure of the system
• Microsystems offer a focus on the smallest
replicable unit of a system
• Interprofessional care is a necessary part
of microsystem improvement
– Providing care
– Health professional development…learning
systems and care delivery systems are linked
Improving
health care
is a
contact
sport
•
A Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
ACT
PLAN
STUDY
DO
Langley et al. , The
Improvement Guide, 1996
Process Literacy
• Why is this important?
– The glue that holds improvement together
– Often neglected, often assumed
• Process arrogance
– Provides a common picture, a shared model
– Identify measures
– Generate hypotheses for change
Process Literacy
• What is it?
– Knowledge of what actually happens, day to
day
• Often from the patient’s point of view
– Need to account for many perspectives
– Not a representation of the ideal system
• How we’d like it to work…
• How it is supposed to work…
• How it was designed to work…
Tools to model processes
1.
2.
3.
4.
Brainstorming
Ishikawa/fishbone diagram
Flow chart
Deployment flow chart (swim lane
diagram)
Case Example
• Primary care community hospital
• 18 primary care providers (many are part
time)
• Active urgent care clinic for acute primary
care needs
• Long wait times for patients
– Frustrating for nurses, front desk staff,
physicians, and patients
Fishbone Diagram, Part 1
Use four of these terms (or
others) to label the main
branches of the diagram:
• People
 Processes
 Policy
 Methods
 Materials
 Environmental Factors
Patients, staff, and
clinicians are frustrated
by long wait times in
drop-in clinic.
Fishbone Diagram, Part 2
People
Policy
Use four of these terms (or
others) to label the main
branches of the diagram:
• People
 Processes
 Policy
 Methods
 Materials
 Environmental Factors
Patients, staff, and
clinicians are frustrated
by long wait times in
drop-in clinic.
Methods
Materials
Fishbone Diagram, Part 3
People
Use four of these terms (or
others) to label the main
branches of the diagram:
• People
 Processes
 Policy
 Methods
 Materials
 Environmental Factors
Policy
Many new clinicians
who are not familiar
with the system
Administrators expect
patients to have drop-in
clinic access
Clinician schedules are
variable. Difficult to know
how many clinicians will be
present in clinic.
Clerks check in patients for
drop-in, continuity clinic, and
specialty clinic
Exam rooms are not fully
stocked each day
Computer scheduling
system does not keep track
of drop-in appointments
No defined way for patients
to access the clinic
Methods
Patients, staff, and
clinicians are frustrated
by long wait times in
drop-in clinic.
Materials
Video Exercise, Part 1
• Gather with 2-3 others
• Watch this 8 minute video clip
– “First, Do No Harm”
– Partnership for Patient Safety (P4PS)
• Take notes about adverse events and
steps that occur
• Work as a group to complete a causeeffect diagram
A Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
ACT
PLAN
STUDY
DO
Langley et al. , The
Improvement Guide, 1996
Door to Balloon Time
Case Study - Setting
• Large academic hospital in Nashville, TN
– Medical students, residents physicians, and
subspecialty fellows
• Team charged by both cardiology and
emergency department administration to
lower door to balloon time
• Two other tertiary care hospitals close by
• Concern about the ED causing
inappropriate activation of the
catheterization lab Huang et al, J Invasiv Card, 2008, 20: 46-52
Evidence-based Improvement
Generalizable
Scientific Evidence
+
Particular
Patient
Measured
Performance
Improvement
Batalden, 2003
Evidence-based Improvement
Generalizable
Scientific Evidence
+
Particular
Context
Measured
Performance
Improvement
Batalden, 2003
Evidence-based Improvement
executing
locally
choosing
best
plan
Generalizable
Scientific evidence
• control for
context
• generalize across
contexts
• experimental
design
• statistics
+
Particular
Context
• understand system
“particularities”
• learn structures,
processes,
patterns
• culture and context
of changes
Measured
Performance
Improvement
• balanced
measures
• clinical
• functional
• satisfaction
• costs
Batalden, 2003
Evidence-based Improvement
Generalizable
Scientific Evidence
Patients with acute
MI should be in cath
lab with balloon
inflated within 90
minutes of entering
your facility
+
Particular
Context
Measured
Performance
Improvement
Much variation in
meeting this goal
“Longer door-to-balloon time was associated with increased inhospital mortality (mortality rate of 3.0%, 4.2%, 5.7%, and 7.4% for
door-to-balloon times of 90 min, 91 to 120 min, 121 to 150 min, and
>150 min, respectively; p for trend <0.01).”
McNamara et al., 2006, J Am Coll Cardiology
Door to Balloon Time (preintervention) (Avg=114, UCL=248, LCL=-20)
Time, minutes
350
300
250 UCL
200
150
100
Avg
50
0
-50 1
LCL
2
3
4
5
6
7
8
9
10
Patient Number
11
12
13
14
15
16
17
Huang et al, 2008
Huang et al, 2008
Flow Charts
• Use standard symbols to depict the flow of
a patient through a system
• Can be free-flowing and annotated
• No clear links to individual or professional
responsibilities
• Annotations may make the flow chart
cluttered
Wait Times Flow Chart
Patient has urgent
medical care need
Calls telephone
triage for advice
N
Arrange for
appropriate follow-up
Patient
needs to be
seen today?
Y
Patient arrives at
drop-in clinic
Checks-in at front
desk with clerk
Patient waits in
drop-in clinic
waiting area
Visit completed
Triaged by nurse
Y
N
N
Prescription
ordered?
N
Blood work
or xrays
needed?
Evaluated by
clinician
Emergent
issue?
Y
Y
Send to ED for
evaluation
Wait in pharmacy
waiting area
Pick-up
medications
Visit completed
Deployment Flow Chart
• Uses same standard symbols as a flow
chart
• Each step is assigned to a specific person
• Columns for measures and “change
opportunities”
• Important to vete the process model with
key stakeholders
Wait Times Deployment Flow Chart
Possible Measures
• # calls per day
• # pts referred for
drop-in clinic
Nurse
Check-in Clerk
Clinician
Patient calls for
advice
• create appointments
Patient arrives at
drop-in clinic
Patient
needs to be
seen today?
• increase number of
clinician in drop-in
• eliminate drop-in so
that patients see their
own provider always
for urgent needs
Y
N
• waiting time from
check-in to
completion of visit
• waiting time from
triage to evaluiation
by clinician
Evaluated by
clinician
Triaged by nurse
Emergent
issue?
• # and type of
diagnoses in drop-in
clinic
• # lab and xrays
studies from drop-in
per day
• patient satisfaction
• staff satisfaction
Checks-in at front
desk
Arrange for
follow-up
Change opportunities?
Y
Waits in waiting
room
Y
Blood work
or xrays
needed?
N
N
Send to ED for
evaluation
Prescription
ordered?
N
Visit completed
Y
Pick-up
medications
• improve the waiting
room area so
patients have
options to stay busy
and engaged while
waiting (e.g., internet
access to health
sites)
Video Exercise, Part 2
• Gather with 2-3 others
• Watch this video clip
• Take notes about the steps in care and the
people who deliver the care
• Work as a group to complete a
deployment flow diagram using the
template that is provided
Deployment Flow Chart - Template
Possible Measures
Person #1
Start or stop of the process
A step in the process
Decision point
Person #2
Person #3
Person #4
Change opportunities?
Putting it all together for the
improvement of care…
A Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
ACT
PLAN
STUDY
DO
Langley et al. , The
Improvement Guide, 1996
Summary
• Microsystems theory offers a useful way to
identify components of the health care
system
– Smallest replicable units to maximize impact of
changes
• Making care better at a system level requires
–
–
–
–
–
A clear aim
Process literacy and process model
Outcome and process measures
Collaborating across professions
Managing the changes that are tried