Transcript What is a Microsystem and 5Ps slides

clinicalmicrosystem.org
What is a clinical microsystem?
How did this idea get
started and how is it
being used?
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Assumptions
clinicalmicrosystem.org
• Many have heard of the idea and has
various notions of what it means
• We all have more experience living in,
working in, and using them; than we
have studying, changing, and leading
them
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Understanding Health Care
as a System
clinicalmicrosystem.org
How we improve
what we make
What society
needs
How we create,
make health care
3
Which system is the unit of practice, intervention, measurement, policy?
Self-care
system
Market /
Geopolitical
clinicalmicrosystem.org
system
Macrosystem
Individual
care-giver
& patient
system
Mesosystem
Microsystem
4
Dartmouth Study 2002
clinicalmicrosystem.org
Eugene C. Nelson, DSc, MPH
Paul B. Batalden, MD
Thomas P. Huber, MS
Julie J. Mohr, MSPH, PhD
Marjorie M. Godfrey, MS, RN
Linda A. Headrick, MD, MS
John H. Wasson, MD
5
High Performing Clinical Microsystems
clinicalmicrosystem.org
Leadership
Staff
• Leadership
• Organizational
support
• Staff focus
• Education &
Training
• Interdependence
of care team
Information
&
Information
Technology
Performance
Patients
• Performance
results
• Process
improvement
• Patient Focus
• Community &
Market Focus
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Definition
clinicalmicrosystem.org
A health care clinical microsystem can be defined as the combination of a
small group of people who work together on a regular basis—or as
needed—to provide care and the individuals who receive that care
(who can also be recognized as members of a discrete subpopulation of
patients.)
It has clinical and business aims, linked processes, a shared information
environment and produces services and care which can be measured as
performance outcomes. These systems evolve over time and are (often)
embedded in larger systems/organizations.
As any living adaptive system, the microsystem must: (1) do the work, (2)
meet staff needs, (3) maintain themselves as a clinical unit.
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A Picture of Embedded
Systems
clinicalmicrosystem.org
The Anatomy
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Patients
Building a Team to Manage A Panel of Primary Care Patients
MIssion: The Dartmouth-Hitchcock Clinic exists to serve the health care needs of our patients.
Purpose
People with
healthcare
needs
People with
4
Healthy
P
A
C
Prevention
Acute
Chronic
healthcare
clinicalmicrosystem.org
needs met
E
Educate
Chronic
PACE
Very High Risk
Very High Risk +++
1
Healthy
Very High Risk
Assign to
PCP
2
3
Orient to
Team
Assess &
Plan Care
Functional
& Risks
Biological
Functional
& Risks
ACPPE
Palliative
Expectations
Costs
Biological
Satisfaction
Costs
PACPPE
Chronic ++
Healthy
Chronic
PACE
Processes
Healthy
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6
7
8
9
10
11
12
13
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Info Systems
& Data
Phone,
Nurse First
Scheduling
Medical
Records
Laboratory
Radiology
Pharmacy
Referrals
Billing
Physical
Space
Department
Division and Community
Professionals
TEAM MEMBERS:
Nashua Internal Medicine
Measuring Team Performance & Patient Outcomes and Costs
Sherman Baker, MD
Missy, RN
Amy, Secretary
Measure
Leslie Cook, MD
Diane, RN
Buffy, Secretary
Panel Size Adj.
Joe Karpicz, MD
Katie, RN
Mary Ellen, Secretary
Deb Urquart, NP
Bonnie, LPN
Kristy, Secretary
Carole, LPN
Charlene, Secretary
Ron Carson, PA
Erica, RN
Nancy, LPN
Laura, RN
Mary Beth, MA
Maggi, RN
Lynn, MA
Skill Mix: MDs _2.8_ RNs _6.8_ NP/PAs __2__ MA _4.8 LPN _____ SECs __4_
Patterns
Southern Region
Hitchcock Clinic System
Current
Direct Pt. Care Hours:
MD/Assoc.
% Panel Seeing Own
PCP:
Total PMPM Adj.
PMPM-Team
Micro-System Approach 6/17/98
Revised: 1/27/00
Target
Measure
Current
Target
External Referral Adj.
PMPM-Team
Patient Satisfaction
Access Satisfaction
Staff Satisfaction
c
Eugene C. Nelson, DSc, MPH
Paul B. Batalden, MD
Dartmouth-Hitchcock Clinic, June 1998
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A Picture of a
Microsystem
clinicalmicrosystem.org
The Physiology
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A “Generic” Clinical Microsystem Model
Satisfaction of need, monitoring, assessment of outputs
clinicalmicrosystem.org
Acute care
Entry,
Assignment
Orientation
Initial
Work-up,
Plan for care
Chronic care
Preventive care
Palliative care
Disenrollment
Beneficiary knowledge, including knowledge of life
while not in direct contact with the health care system
Functional
Biological
Expectations
Costs
Functional
Biological
Satisfaction
Costs
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So, why focus on the
“clinical microsystem?”
clinicalmicrosystem.org
• Basic “building block”
of health care as a
system
• Unit of clinical policy-inuse
• Locus of most
workplace “motivators”
and many “hygiene”
factors
• Most variables relevant
to patient satisfaction
controlled here
• Where “good value” and
“safe” care is made
• Where most health
professional “formation”
occurs after initial
preparation
It’s where everything happens with, for and to the patient and family
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The Clinical Microsystem
Need, aim
clinicalmicrosystem.org
NP, RN
Care
Physician,
Care-giver
Clinical
Support
Information
Technology
Few Other
Physicians
Administrative
Support
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Family Practice
clinicalmicrosystem.org
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3 Thread Tactic
clinicalmicrosystem.org
• Finding ways to do better at meeting
each patient’s needs
• Making the work experience for every
staff person meaningful & joyous
• Increasing each staff person’s ability
to improve his/her own work &
contribute to betterment of system
15
clinicalmicrosystem.org
To do things differently, we must see
things differently. When we see things we
haven’t noticed before, we can ask
questions we didn’t know to ask before.
John Kelsch, Xerox
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As An Interdisciplinary Group…
clinicalmicrosystem.org
• What do we really know about our patients and families?
(or patients/customers if a supporting microsystem)
• What do we know about our work?
– How do we get things done?
• What do we know about our context?
• What are the patterns we may talk about but we do not
study to learn more deeply?
• How do we know what the results of our efforts are?
• What should we be looking for?
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Assess & Diagnose Your
Clinical Microsystem
clinicalmicrosystem.org
• Main Idea …
Build Capacity from Inside Out
• The 5 “Ps”
Use the Clinical Microsystems Workbook to continue to
diagnose the strengths of your microsystem and to
start identifying improvement opportunities
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DMIC and The “Ramp”
Global
Aim
3
Dartmouth
Microsystem
Improvement
Curriculum
2
1
SDSA
3
2
1
PDSA
Fishbones
clinicalmicrosystem.org
A P
S D
A P
S D
A P
S D
Measures
Change Ideas
Specific Aim
Global Aim
Theme
Assessment
Flowcharts
Meeting Skills/Group Dynamics
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So, how might you improve
your own microsystem?
clinicalmicrosystem.org
• It’s just like patient care
– To improve a patient’s health status … You
assess, diagnose, treat, and follow-up based
on biomedical and care science
– To improve a microsystem’s “health” status
… You assess, diagnose, treat, and follow-up
based on improvement science and the
science of clinical practice
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Patients
Building a Team to Manage A P anel of P rim ary Care P atients
MIssion: The Dartmouth-Hitchcock Clinic exists to serve the health care needs of our patients.
Purpose
Peo p le with
h ealth car e
n eed s
Peo p le with
4
Hea lthy
P
A
Pr event ion
Acut e
C
Chr onic
h ealth car e
clinicalmicrosystem.org
n eed s m et
E
Educat e
Chronic
PACE
Very High Ris k
Ve ry High Risk +++
1
He a lthy
Very High Ris k
Assi g n to
PCP
2
Func tiona l
& Ris ks
3
Ori e nt to
Te a m
Asse ss &
Pl an Ca re
Biologica l
Func tiona l
& Ris k s
ACPPE
Pallia tive
Expe ctations
Cos ts
Biologic a l
Satis fa ction
Costs
PACPPE
Chronic ++
Hea lthy
Chronic
PACE
Processes
5
Info Sys te m s
& Da ta
6
Phone ,
Nurs e Firs t
7
8
M e dica l
Re c ords
Sche duling
He althy
9
10
11
12
Labora tory
Radiology
Pha rm a c y
Re fe rra ls
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Billing
Phys ic a l
Spa c e
Dep ar tm en t
Divisio n an d Co m m u n ity
Professionals
T EAM M EM BERS:
Nashua Internal Medicine
M easu r in g T eam Per fo r m an ce & Patien t Ou tco m es an d Co sts
M easu r e
Sherm an Baker, M D
M issy, RN
Am y, Secretary
Leslie Cook, M D
Diane, RN
Buffy, Secretary
Joe Karpicz, M D
Katie, RN
M ary Ellen, Secretary
Deb Urquart, NP
Bonnie, LPN
Kristy, Secretary
Carole, LPN
Charlene, Secretary
Ron Carson, PA
Erica, RN
Nancy, LPN
Laura, RN
M ary Beth, M A
M aggi, RN
Lynn, M A
Patterns
So u th er n Reg io n
Hitch co ck Clin ic System
Cu r r en t
Pa ne l Si ze Adj .
Di re ct Pt. Ca re Hou rs:
M D/Assoc.
% Pan e l Se ei ng Own
PCP:
To ta l PM PM Adj .
PM PM -Tea m
M icr o -System Ap p r o ach 6/17/98
Skill Mix: MDs _ 2.8_ RNs _6.8_ NP/PAs __2__ MA _ 4.8 LPN _____ SECs
__4_
Revised : 1/27/00
T ar g et
M easu r e
Cu r r en t
T ar g et
Exte rn a l Re fe rra l Ad j .
PM PM -Te a m
Pati e nt Sati sfactio n
Acce ss Sa ti sfa cti o n
Staff Sa ti sfa cti on
c
Eu g en e C. Ne l so n , DSc, M PH
Pa u l B. Ba ta l d e n, M D
Da rtm ou th -Hi tch co ck Cl i n i c, Ju n e 19 9 8
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clinicalmicrosystem.org
Assessing
Your
Practice
“The Green Book”
Primary Care
Specialty Care
Others
www.clinicalmicrosystem.org
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Know Your Purpose
clinicalmicrosystem.org
• Have you EVER discussed with your
interdisciplinary team WHY your
microsystem exists?
• What is the purpose of your
microsystem that everyone
understands and supports?
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clinicalmicrosystem.org
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Know Your Patients
clinicalmicrosystem.org
A. Know Your Patients:
Take a close look into your practice, create a "high-level" picture of your PATIENT POPULATION (panel) that you
serve. Who are they? What resources do they use? How do the patients view the care they receive?
Est. Age Dist. of Pts:
birth - 10 years
%
P atients who are Frequent Users of Y our
P ractice S ervices and Their Reasons for
S eeking Frequent Interactions and V isits
Other Clinical Microsystem s we
interact with regularly, as we provide
care for our patients. (eg. OR, V NA)
19 - 45 years
S aw who I wanted to s ee
46 - 64 years
Length of time to get appointment
Pt. Population: Do these numbers
change by season? (Y /N)
# Patients seen in last week
10 Most Frequent Conditions/Diagnoses
GIM Top Referrals (e.g. GI, Cardiology)
# New patients in last month
Disease S pecific Health Outcom es
# Disenrolling patients in last month
Diabetes HgA1c =
# Encounters per provider per year
Hypertension B/P =
LDL <100 =
#
# Patients seen in a day
% Females
pts. in Practice
% E xcellent
E x perienc e v ia P hone
Length of time waiting during appointment
80+ years
(unique)
Access/Pt. Satis. Scores
11 - 18 years
65 - 79 years
Est. #
2
Out of Practice Visits
Condition Sensitive Hospital Rate
Emergency Room Visit Rate
25
Y/N
Know Your Professionals
clinicalmicrosystem.org
C. Know Your P rofessionals :
C reate a comprehensive picture of your
practice . Who does what and when? Is the right pe
rson doing the
right activity? Are roles being optimized?
Are all roles who contribute to the patient experience listed? What hours are you open for business?
How many and what is the duration of your appointment types? How many exam rooms do you curr
ently have? What is the morale of your staff?
rd
3 Next
Cycle
Do you offer any of the following?
Current Staff
Days/Hours
FTEs
Available
Time
Check all that apply.
New
F/U
OR
Minor
Range
Group Visit
MD Total
M
T
W
TH
F
S
E-mail
Web site
RN Clinics
Phone Follow -up
Phone Care Management
NP/PAs Total
Registries
Protocols/Guidelines
# Exam Rooms
________
RNs Total
# Minor Rooms
________
Supporting diagnostic Depts. (e.
respiratory, lab, cardio. )
g.
LPNs Total
Appt.
Type
New Pt
Follow -up
Minor
LNA/MAs Total
Others Total
Secretaries Total
Do you use Float Pool?
Do you use On -Call?
____
____
Yes
Yes
___ _
___ _
No
No
Staff Satisfaction Scores
How stressful is the practice?
Would you reco mmend it as a good place to
work?
*Each staff member should complete the Personal Skills Assessment and “The Activity Survey”
Duration
Comment
%
% Not Satisfied
% Strongly Agree
, pgs 11 -13
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Know Your Processes
Cycle Time Tool
clinicalmicrosystem.org
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CF Initial Visit
Dartmouth Hitchcock Medical Center Pediatric Outpatient CF Clinic
Initial Visit Flowchart
Patient
Secretary
Nurse
MD
Nutritionist
:
Social Worker
clinicalmicrosystem.org
Physical
Therapist
Specialist /Other
Patient &
Family
Arrive
D oes Patient
H ave Insurance
& R eferral ?
C are
Management
Patient &
Family Wait
Arrives in Waiting R oom
,
calls Pt , Escorts Pt to
Exam R oom & Asks Pt to
R emove Shoes
Takes patient out into
hall to measure
height and w eight
R eturns Pt to Exam R oom , performs
Pulmonary Function Test
, Takes Vital
Signs , asks for list of current
medications and know n allergies
,
records in paper chart
, Plots Grow th
C hart & Tells Pt another team member
w ill be in for their portion of the visit
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clinicalmicrosystem.org
CYCLE
TIME TOOL
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Core and Supporting Processes Assessment
clinicalmicrosystem.org
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clinicalmicrosystem.org
Providence
Hospital
Anchorage
Alaska
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Know Your Patterns
clinicalmicrosystem.org
E. Know Your Patterns: What patterns are present but not acknowledged in your microsystem? What is the leadership and social pattern?
How often does the microsystem meet to discuss patient care? Are patients and families involved? What are your results and outcomes?

What have you successfully changed?

Does every member of the practice meet 
Do the members of the practice
regularly as a team?
What are you most proud of?
regularly review and discuss safety and 
reliability issues?

How frequently?

What is your financial picture?

What is the most significant pattern of variation?
*Complete “Metrics that Matter”, pg 22
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Metrics That Matter
clinicalmicrosystem.org
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clinicalmicrosystem.org
“I thought I knew my
practice…but I didn’t.
I now know and see new
things.”
- Angie Hilton, Practice Manager IM/FP UC Davis
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