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Microsystem Management as a Promising New Methodology for Improving the Cost and Quality of Health Care
JOURNAL
ON
QUALITY IMPROVEMENT
The monthly microsystem meeting might look to the observer like a miniaturized hospitalwide performance improvement meeting or an executive committee meeting, but it has critical differences. It is part retreat and part microsystem working group. The interaction is cordial; there is a sense of connection and cooperation that requires time and trust to build. We save agenda space for patients to visit with us and share stories of what went well and what did not go well. Private attending physicians are frequently guests, also recounting what went well and what needs improvement and participating in very time-efficient ways in team improvement work. Somehow the evolution in our microsystem thinking coincided with an increasing appreciation of the value of analyzing success, as well as problems. We embed “appreciative management” into our microsystem work. For example, we subject what we call “positive outliers” to a miniaturized version of a root cause analysis, which is performed by the microsystem team and involves significant numbers of line staff. Microsystem thinking has migrated to other parts of the hospital, largely through the influence of the director of performance improvement, Tina Maund, who adapted it to what microsystem thinkers call the macrosystem level.3 For example, Tina often finds that representatives of microsystems can come together to identify ways to improve safety; there are many safety issues in which better communication at the interface of microsystems can reduce risk. Is the microsystem concept science? Can it be scientifically proven? It sounds awfully poetic! Our sense is that empiric testing of these notions will come in time. For the present, we consider microsystem thinking a kind of neopragmatism, in homage to William James’s pragmatism.4 James might have asked whether microsystem thinking helps us to align other parts of our experience into a consistent and useful model. He might then have asked what is the “cash value” of microsystem thinking in experiential terms. Does it serve as a useful map to get where we want to go? Our experience to date suggests that this is strongly the case. There is indeed a poetic nature at play here. Our use of the term self-aware microsystem or the authors’ thinking of such units as building blocks has been intellectually fresh and liberating for us. Richard Rorty, extending and borrowing the thinking of the
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literary critic Harold Bloom, might see this as the language of the “strong poet.”5,6 If that is so, microsystem vocabulary might in time come to represent a scientific principle, much as the initial strongly poetic nature of Newton’s term gravitas came in time to be represented by equations. The readers of this series have the opportunity to decide for themselves. In a most unscientific spirit, I invite the reader to enjoy the articles to follow. We have found great joy and energy in these constructs. As Bateson notes,7 if such ideas are fit for use, they will be fit to compete with other ideas and will thrive. – James Espinosa, MD, FACEP, FAAFP Medical Director, Emergency Department, Atlantic Health System/Overlook Hospital, Summit, New Jersey Quality Advisor, Atlantic Quality Institute, Atlantic Health Systems, Florham, New Jersey Member of The Joint Commission Journal on Quality Improvement’s Editorial Advisory Board and Series Editor References 1. Nelson EC, et al: Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. Jt Comm J Qual Improv 28:472–494, 2002. 2. Nelson EC, et al: Improving health care, Part 1: The Clinical Value Compass. Jt Comm J Qual Improv 22:243–258, 1996. 3. Maund T, Espinosa J, Kosnik L: Beyond rapid cycle: A one-day safety summit tool to prevent mislabeled laboratory specimens. Jt
Comm J Qual Improv 28:127–128, 2002. 4. James W: Pragmatism. Amherst, NY: Prometheus Books, 1991 (original publication, 1907). 5. Rorty R: Contingency, Irony and Solidarity. New York: Cambridge University Press, 1989. 6. Bloom H: The Anxiety of Influence. New York: Oxford University Press, 1997 7. Bateson G: Steps to an Ecology of Mind. New York: Random House, 1972.
Microsystem Management as a Promising New Methodology for Improving the Cost and Quality of Health Care Articles on how to improve health care quality and cost have often focused on “top down” or “policy” initiatives that must be implemented by the power centers of the health care structure. Most of the initiatives have failed because they did not deal with crucial information, management, and motivational elements at the point at which care itself is delivered. However, many institutions have found that by concentrating
9
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
495
THE JOINT COMMISSION on the microsystems actually delivering care, they can both improve health care quality and lower its cost by orders of magnitude. This article by Nelson et al1 serves as an introduction to an extensive series on a promising new methodology for improving the cost and quality of health care. If improved microsystem management can be accepted and disseminated widely within the profession, it could literally revolutionize the costs and practices of health care as it has done in other service industries, such as overnight package delivery and financial services. Seeking causative factors in high-performing microsystems, the authors use a stratified sample of different types of microsystems, institutions, and geographical areas. They do not attempt to isolate a single variable that will explain total consequences. Instead, they discover key variables that are highly interactive and require an integrated management approach for success. The authors’ systems approach is critical. As the Institute of Medicine’s report suggests, “The current system cannot do the job. Trying harder will not work. Changing systems of care will.”2(p 4) But which systems? How can they be best changed? What are the essential processes of change? What are the possible results? This article provides some of the answers to these critical questions. The authors point out that achieving effective change requires changes at multiple levels, some of which are within the microsystem, and others, such as leadership, practice culture, and outcomes measurement, that occur both within and outside the unit itself. The combination of systematic qualitative and quantitative observation provides useful guidelines for both current action and future studies. Most important, the authors recognize that improvement is a long-term, continuous, and interactive learning process—and cite approaches that have been found successful in their previous work and in service activities elsewhere. They recognize the health care system’s inherent complexity but offer some practical and tested steps such as focusing on superior microsystem results, using simple rules and linked metrics, integrating information systems, communicating clearly and understanding missions, and decentralizing accountability with appropriate support systems and performance measurements.
496
In summary, this article reports on a very important project and provides an insightful piece of the mosaic in the developing literature for what is probably the most profound change in health care practice on the current horizon (if it can be properly implemented)—that is, introducing change at the front-line microsystem level. – James Brian Quinn, PhD Buchanan Professor of Management, Emeritus, Amos Tuck School, Dartmouth College, Hanover, New Hampshire References 1. Nelson EC, et al: Microsystems in Health Care: Part 1. Learning from high-performing front-line clinical units. Jt Comm J Qual Improv 28: 472–494, 2002.
2. Institute of Medicine Committee on Quality of Health Care in America: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
Senior Leaders’ Role in Improving the Performance of the Front-Line Delivery Units A growing number of senior leaders in health care are focusing on the importance of continually improving the performance of the front-line delivery units. The focus, however, often falls critically short of getting results. What is needed is exactly what this article1 and the forthcoming articles in the series provide. The ongoing efforts by Nelson et al to expand the body of knowledge of the microsystem concept, capture useful insights from high-performing clinical units, articulate leadership imperatives, and outline practical steps with useful tools should help leaders achieve the microsystem excellence they seek. It is noteworthy, as Nelson et al discuss, that unlike our counterparts outside health care, senior leaders in health care “did not make the attainment of microsystem excellence a basic pillar of their management strategy.”1(p 486) It is not surprising then, although it is disturbing, that organizational support was the factor mentioned least frequently by microsystem members as contributing to their success. We know firsthand that organizational support of the microsystem is critical. We cannot
SEPTEMBER 2002 JOURNAL Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
ON
QUALITY IMPROVEMENT
The monthly microsystem meeting might look to the observer like a miniaturized hospitalwide performance improvement meeting or an executive committee meeting, but it has critical differences. It is part retreat and part microsystem working group. The interaction is cordial; there is a sense of connection and cooperation that requires time and trust to build. We save agenda space for patients to visit with us and share stories of what went well and what did not go well. Private attending physicians are frequently guests, also recounting what went well and what needs improvement and participating in very time-efficient ways in team improvement work. Somehow the evolution in our microsystem thinking coincided with an increasing appreciation of the value of analyzing success, as well as problems. We embed “appreciative management” into our microsystem work. For example, we subject what we call “positive outliers” to a miniaturized version of a root cause analysis, which is performed by the microsystem team and involves significant numbers of line staff. Microsystem thinking has migrated to other parts of the hospital, largely through the influence of the director of performance improvement, Tina Maund, who adapted it to what microsystem thinkers call the macrosystem level.3 For example, Tina often finds that representatives of microsystems can come together to identify ways to improve safety; there are many safety issues in which better communication at the interface of microsystems can reduce risk. Is the microsystem concept science? Can it be scientifically proven? It sounds awfully poetic! Our sense is that empiric testing of these notions will come in time. For the present, we consider microsystem thinking a kind of neopragmatism, in homage to William James’s pragmatism.4 James might have asked whether microsystem thinking helps us to align other parts of our experience into a consistent and useful model. He might then have asked what is the “cash value” of microsystem thinking in experiential terms. Does it serve as a useful map to get where we want to go? Our experience to date suggests that this is strongly the case. There is indeed a poetic nature at play here. Our use of the term self-aware microsystem or the authors’ thinking of such units as building blocks has been intellectually fresh and liberating for us. Richard Rorty, extending and borrowing the thinking of the
VOLUME
28
NUMBER
literary critic Harold Bloom, might see this as the language of the “strong poet.”5,6 If that is so, microsystem vocabulary might in time come to represent a scientific principle, much as the initial strongly poetic nature of Newton’s term gravitas came in time to be represented by equations. The readers of this series have the opportunity to decide for themselves. In a most unscientific spirit, I invite the reader to enjoy the articles to follow. We have found great joy and energy in these constructs. As Bateson notes,7 if such ideas are fit for use, they will be fit to compete with other ideas and will thrive. – James Espinosa, MD, FACEP, FAAFP Medical Director, Emergency Department, Atlantic Health System/Overlook Hospital, Summit, New Jersey Quality Advisor, Atlantic Quality Institute, Atlantic Health Systems, Florham, New Jersey Member of The Joint Commission Journal on Quality Improvement’s Editorial Advisory Board and Series Editor References 1. Nelson EC, et al: Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. Jt Comm J Qual Improv 28:472–494, 2002. 2. Nelson EC, et al: Improving health care, Part 1: The Clinical Value Compass. Jt Comm J Qual Improv 22:243–258, 1996. 3. Maund T, Espinosa J, Kosnik L: Beyond rapid cycle: A one-day safety summit tool to prevent mislabeled laboratory specimens. Jt
Comm J Qual Improv 28:127–128, 2002. 4. James W: Pragmatism. Amherst, NY: Prometheus Books, 1991 (original publication, 1907). 5. Rorty R: Contingency, Irony and Solidarity. New York: Cambridge University Press, 1989. 6. Bloom H: The Anxiety of Influence. New York: Oxford University Press, 1997 7. Bateson G: Steps to an Ecology of Mind. New York: Random House, 1972.
Microsystem Management as a Promising New Methodology for Improving the Cost and Quality of Health Care Articles on how to improve health care quality and cost have often focused on “top down” or “policy” initiatives that must be implemented by the power centers of the health care structure. Most of the initiatives have failed because they did not deal with crucial information, management, and motivational elements at the point at which care itself is delivered. However, many institutions have found that by concentrating
9
Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations
495
THE JOINT COMMISSION on the microsystems actually delivering care, they can both improve health care quality and lower its cost by orders of magnitude. This article by Nelson et al1 serves as an introduction to an extensive series on a promising new methodology for improving the cost and quality of health care. If improved microsystem management can be accepted and disseminated widely within the profession, it could literally revolutionize the costs and practices of health care as it has done in other service industries, such as overnight package delivery and financial services. Seeking causative factors in high-performing microsystems, the authors use a stratified sample of different types of microsystems, institutions, and geographical areas. They do not attempt to isolate a single variable that will explain total consequences. Instead, they discover key variables that are highly interactive and require an integrated management approach for success. The authors’ systems approach is critical. As the Institute of Medicine’s report suggests, “The current system cannot do the job. Trying harder will not work. Changing systems of care will.”2(p 4) But which systems? How can they be best changed? What are the essential processes of change? What are the possible results? This article provides some of the answers to these critical questions. The authors point out that achieving effective change requires changes at multiple levels, some of which are within the microsystem, and others, such as leadership, practice culture, and outcomes measurement, that occur both within and outside the unit itself. The combination of systematic qualitative and quantitative observation provides useful guidelines for both current action and future studies. Most important, the authors recognize that improvement is a long-term, continuous, and interactive learning process—and cite approaches that have been found successful in their previous work and in service activities elsewhere. They recognize the health care system’s inherent complexity but offer some practical and tested steps such as focusing on superior microsystem results, using simple rules and linked metrics, integrating information systems, communicating clearly and understanding missions, and decentralizing accountability with appropriate support systems and performance measurements.
496
In summary, this article reports on a very important project and provides an insightful piece of the mosaic in the developing literature for what is probably the most profound change in health care practice on the current horizon (if it can be properly implemented)—that is, introducing change at the front-line microsystem level. – James Brian Quinn, PhD Buchanan Professor of Management, Emeritus, Amos Tuck School, Dartmouth College, Hanover, New Hampshire References 1. Nelson EC, et al: Microsystems in Health Care: Part 1. Learning from high-performing front-line clinical units. Jt Comm J Qual Improv 28: 472–494, 2002.
2. Institute of Medicine Committee on Quality of Health Care in America: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
Senior Leaders’ Role in Improving the Performance of the Front-Line Delivery Units A growing number of senior leaders in health care are focusing on the importance of continually improving the performance of the front-line delivery units. The focus, however, often falls critically short of getting results. What is needed is exactly what this article1 and the forthcoming articles in the series provide. The ongoing efforts by Nelson et al to expand the body of knowledge of the microsystem concept, capture useful insights from high-performing clinical units, articulate leadership imperatives, and outline practical steps with useful tools should help leaders achieve the microsystem excellence they seek. It is noteworthy, as Nelson et al discuss, that unlike our counterparts outside health care, senior leaders in health care “did not make the attainment of microsystem excellence a basic pillar of their management strategy.”1(p 486) It is not surprising then, although it is disturbing, that organizational support was the factor mentioned least frequently by microsystem members as contributing to their success. We know firsthand that organizational support of the microsystem is critical. We cannot
SEPTEMBER 2002 JOURNAL Copyright 2002 Joint Commission on Accreditation of Healthcare Organizations