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)

Avg

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LCL

Target

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20%

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40%

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90%

100%

May-05 Jun-05 Jul-05 Aug-05 Nov-05 Jan-06 May-06 Jul-06 Sep-06 Oct-06 Jan-07 Mar-07 Jun-07 Jul-07 Sep-07 Nov-07 Jan-08 Mar-08 May-08

Date

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BP

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

Community, Market,

Social Policy System

Macro -

organization System

MicrosystemSystem

Individual care - giver & patient

Self -

care System

Mesosystem

What is the appropriate unit of measurement and intervention in health care?

“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?

PLAN

DOSTUDY

ACT

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. Brainstorming

2. Ishikawa/fishbone diagram

3. Flow chart

4. 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 1Use 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 2Use 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.

PolicyPeople

Methods Materials

Fishbone Diagram, Part 3Use 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.

PolicyPeople

Methods Materials

Many new clinicians who are not familiar

with the system

Clerks check in patients for drop-in, continuity clinic, and

specialty clinic

No defined way for patients to access the clinic

Administrators expect patients to have drop-in

clinic access

Exam rooms are not fully stocked each day

Computer scheduling system does not keep track

of drop-in appointments

Clinician schedules are variable. Difficult to know

how many clinicians will be present in clinic.

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 cause-effect 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?

PLAN

DOSTUDY

ACT

Langley et al. , The Improvement Guide, 1996

Door to Balloon TimeCase 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 PerformanceImprovement

Batalden, 2003

Evidence-based Improvement

Generalizable Scientific Evidence + Particular

Context

Measured PerformanceImprovement

Batalden, 2003

Evidence-based Improvement

Generalizable Scientific evidence + Particular

Context

Measured PerformanceImprovement

• control for context• generalize across contexts• experimental design• statistics

• understand system “particularities”

• learn structures, processes, patterns

• culture and context of changes

• balanced measures• clinical• functional• satisfaction• costs

Batalden, 2003

choosing best plan

executing locally

Evidence-based Improvement

Generalizable Scientific Evidence + Particular

Context

Measured PerformanceImprovement

Patients with acute MI should be in cath

lab with balloon inflated within 90

minutes of entering your facility

Much variation in meeting this goal

“Longer door-to-balloon time was associated with increased in-hospital 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)

Avg

UCL

LCL-50

0

50

100

150

200

250

300

350

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Patient Number

Time,

minu

tes

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 ChartPatient has urgent medical care need

Calls telephone triage for advice

Patient arrives at drop-in clinic

Patient needs to be seen today?

Checks-in at front desk with clerk

Arrange for appropriate follow-up

Triaged by nurse

Emergent issue?

Patient waits in drop-in clinic waiting area

Evaluated by clinician

Blood work or xraysneeded?

Visit completed

Prescription ordered?

Wait in pharmacy waiting area

YN

Send to ED for evaluation

Y

Y

N

N

Pick-up medications

Y

N

Visit completed

Patient has urgent medical care need

Calls telephone triage for advice

Patient arrives at drop-in clinic

Patient needs to be seen today?

Checks-in at front desk with clerk

Arrange for appropriate follow-up

Triaged by nurse

Emergent issue?

Patient waits in drop-in clinic waiting area

Evaluated by clinician

Blood work or xraysneeded?

Visit completed

Prescription ordered?

Wait in pharmacy waiting area

YN

Send to ED for evaluation

Y

Y

N

N

Pick-up medications

Y

N

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 ChartCheck-in ClerkNurse Clinician Change opportunities?Possible Measures

Patient calls for advice

Patient arrives at drop-in clinic

Patient needs to be seen today?

Checks-in at front desk

Triaged by nurse

Emergent issue?

Evaluated by clinician

Blood work or xraysneeded?

Prescription ordered?

Y

N

Send to ED for evaluation

Y

Y

N

N

Pick-up medications

Y

N

Visit completed

Arrange for follow-up

Waits in waiting room

• # calls per day• # pts referred for drop-in clinic

• waiting time from check-in to completion of visit• waiting time from triage to evaluiationby clinician

• # and type of diagnoses in drop-in clinic• # lab and xraysstudies from drop-in per day

• patient satisfaction• staff satisfaction

• improve the waiting room area so patients have options to stay busy and engaged while waiting (e.g., internet access to health sites)

• increase number of clinician in drop-in• eliminate drop-in so that patients see their own provider always for urgent needs

• create appointments

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

Person #1 Change opportunities?Possible Measures Person #2 Person #3 Person #4

Start or stop of the process

A step in the process

Decision point

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?

PLAN

DOSTUDY

ACT

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