October 8-10, 2009 Day One, October 8 th Marjorie M Godfrey, MS, RN Kathleen Iaanacchino, MS, RN

1. Coach the Coach The Art of Coaching and Improving Quality October 8-10, 2009 Day One, October 8th Marjorie M Godfrey, MS, RN Kathleen Iaanacchino, MS, RN Lake Morey Resort Fairlee, Vermont www.clinicalmicrosystem.org

2. VA Clinical Teams 1:00-5:00pmThursday 1pm

3. Welcome! Day One VA Clinical Teams Inpatient Psychiatric Unit GIM- Diabetes 1pm Margie and Jason

4. Aim of Our Time Dual purposed • Support “coaches in training” • Support your early microsystem development journey • Maybe some new tools and processes will help new possibilities emerge • Experience a “tasting party” of the microsystem journey. You will try out a lot today and tomorrow to then go back to your setting and work more deeply on what you are learning.

5. Introductions & Why We are Here Introductions (Include coaches) You have specific improvements New possibilities may emerge from looking at your practice in a different way Name of Practice and Team Members 1 Thing that … Patients really love about our practice is drives some patients nuts is

6. Why We are Here Learn about our practice Improve our practice Improve our work life Studio course for Dartmouth Microsystem Improvement Curriculum You are in a “fishbowl” We have “new” coaches with invisibility cloaks on.

7. “Every system is perfectly designed to get the results it gets” - Paul B. Batalden, MD Co-founder Institute for Healthcare Improvement Founding Director Center for Healthcare Improvement and Leadership The Dartmouth Institute

8. 3 2 SDSA 3 Global Aim 1 Improvement Ramp A P S D A P D S Measures A P Change Ideas S D 1 PDSA Specific Aim Global Aim Theme Assessment Dartmouth Microsystem Improvement Curriculum 2 Cause & Effect Flowchart

9. Introduction to Microsystem Thinking “Every system is perfectly designed to get the results it gets.” Your practice is a small system A complex adaptive system Biological with adaptive capabilities A clinical microsystem 1:20 Margie

10. Six Challenges from the IOM – Crossing the Quality Chasm Safety Effectiveness Patient-centeredness Timeliness Efficiency Equity www.iom.edu

11. Institute of Medicine Old / New Rules Old rule New Rule 1. Care based on 1. Care based on visits continuous healing relationships 2. Professional 2. Care customized based on patient need & values autonomy drives variability 3. Professionals 3. Patient is source of control care. control 4. Information is a 4. Knowledge is shared record and information flows freely 5. Decision making 5. Decision making is based on training evidence based & experience

12. Institute of Medicine Old / New Rules 6. Do no harm is 6. Safety is a system individual property responsibility 7. Secrecy is 7. Transparency is necessary necessary 8. System reacts to 8. Needs are needs anticipated 9. Cost reduction is 9. Waste is sought continuously decreased 10. Preference 10. Cooperation is given to professional roles among clinicians over the system is a priority

13. Lawrence J. Henderson “[Health professionals] and patients are part of the same system.” LJ Henderson NEJM, 1936

14. What is a clinical microsystem? How did this idea get started and how is it being used?

15. Aim Offer a clear, concise introduction to the idea and its formation Survey the use(s) of the idea Introduce some helpful resources for working with the idea

16. Assumptions Everyone has 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

17. Understanding Health Care as a System What society needs How we improve what we make How we create, make health care

18. Which system is the unit of practice, intervention, measurement, policy? Market / Geopolitical system Self-care system Macrosystem Individual care-giver & patient system Mesosystem Microsystem

19. www.clinicalmicrosystem.org 10 Success Characteristics Evolution of “Clinical Microsystems” European Clinical Microsystem Network 8 Success Characteristics Fall Invitational J. Brian Quinn, PhD Future • mid-90’s • CECS course on Micro-units • HFHS “panels” of patients 1998 Hierarchy of Systems 2001 IOM 21st Century 2001 Robert W. Johnson Foundation Study 2001 Website Formed 2006 Microsystem Textbook 2002-3 JQI Articles 2003 2005 AHA Microsystem Toolkits 2000 IOM and Julie Mohr and Molla Donaldson 1992 late 1970’s & 1980’s • World-wide research and study of best-of-best service organizations • Batalden, Nelson Research and Knowledge Development • Deming • Caring for Pts & Populations • Clinical Value Compass

20. Dartmouth Study 2002 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

21. High Performing Clinical Microsystems • Staff • Staff focus • Education & • Training • Interdependence • of care team • Leadership • Leadership • Organizational support Information & Information Technology • Performance • Performance • results • Process • improvement • Patients • Patient Focus • Community & • Market Focus

22. Definition A health care clinical microsystem can be defined as the combination of asmall groupof 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 ofpatients.) It has clinical and businessaims,linked processes,asharedinformation environment and produces services and care which can be measured as performanceoutcomes.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.

23. A Picture of EmbeddedSystems The Anatomy

24. Patients Purpose Processes Professionals Patterns

25. A Picture of a Microsystem The Physiology

26. A “Generic” Clinical Microsystem Model Satisfaction of need, monitoring, assessment of outputs Acute care Chronic care Initial Work-up, Plan for care Entry, Assignment Orientation Preventive care Palliative care Disenrollment Beneficiary knowledge, including knowledge of life while not in direct contact with the health care system Functional Functional Biological Biological Satisfaction Expectations Costs Costs

27. So, why focus on the “clinical microsystem?” Basic “building block” of health care as a system Unit of clinical policy-in-use 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

28. System Levels Microsystem Mesosystem Macrosystem Example Frontline Patient Units Nursing Divisions Nursing Services Source: Henriks, Bojestig, Jonkoping CC Sweden

29. What is 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

30. The Clinical Microsystem Need, aim NP, RN Information Technology Few Other Physicians Physician, Care-giver Care Clinical Support Administrative Support

31. Who is the neonatal ICU clinical microsystem? The clinical microsystem Need, aim NP, RN Information Technology Few Other Physicians Physician, Care-giver Care Clinical Support Administrative Support

32. Patient

33. Nurse

34. Discharge Nurse using electronic and paper information

35. Neonatologist

36. Parent and Doctors

37. Rounding Team, including Parents

38. Receptionist

39. Information Technology (monitors)

41. 3 Thread Tactic 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

42. 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