Quality of locally designed surveys in a quality improvement collaborative: review of survey validity and identification of common errors.

OBJECTIVE: Surveys are a commonly used tool in quality improvement (QI) projects, but little is known about the standards to which they are designed and applied. We aimed to investigate the quality of surveys used within a QI collaborative, and to characterise the common errors made in survey design. METHODS: Five reviewers (two research methodology and QI, three clinical and QI experts) independently assessed 20 surveys, comprising 250 survey items, that were developed in a North American cystic fibrosis lung transplant transition collaborative. Content Validity Index (CVI) scores were calculated for each survey. Reviewer consensus discussions decided an overall quality assessment for each survey and survey item (analysed using descriptive statistics) and explored the rationale for scoring (using qualitative thematic analysis). RESULTS: 3/20 surveys scored as high quality (CVI >80%). 19% (n=47) of survey items were recommended by the reviewers, with 35% (n=87) requiring improvements, and 46% (n=116) not recommended. Quality assessment criteria were agreed upon. Types of common errors identified included the ethics and appropriateness of questions and survey format; usefulness of survey items to inform learning or lead to action, and methodological issues with survey questions, survey response options; and overall survey design. CONCLUSION: Survey development is a task that requires careful consideration, time and expertise. QI teams should consider whether a survey is the most appropriate form for capturing information during the improvement process. There is a need to educate and support QI teams to adhere to good practice and avoid common errors, thereby increasing the value of surveys for evaluation and QI. The methodology, quality assessment criteria and common errors described in this paper can provide a useful resource for this purpose.

Virtual Learning Collaborative Compared to Technical Assistance as a Strategy for Implementing Health Promotion in Routine Mental Health Settings: A Hybrid Type 3 Cluster Randomized Trial.

BACKGROUND: Despite widespread use of learning collaboratives, few randomized trials have evaluated their effectiveness as a strategy for implementing evidence based practices. This randomized trial evaluated the effectiveness of a virtual learning collaborative (VLC) in the implementation of a health promotion program for persons with serious mental illness (SMI) aimed at reducing cardiovascular risk reduction in routine mental health settings, compared to routine technical assistance (TA). METHODS: Fifty-five mental health provider organizations were recruited to participate in a Hybrid Type 3 cluster randomized implementation-effectiveness trial of the InSHAPE health promotion program for persons with SMI. Sites were stratified by size and randomized prior to implementation to an 18-month group-based VLC with monthly learning sessions or individual site TA with four scheduled conference calls over 18 months. Primary implementation and service outcomes were InSHAPE program fidelity, participation, and reach. Primary clinical outcomes were weight loss, cardiorespiratory fitness, and cardiovascular risk reduction (≥ 5% weight loss or > 50 m increase on the 6-Minute Walk Test). Program fidelity was assessed at 6, 12, and 24 months; program participation and participant-level outcomes were assessed at 3, 6, 9, and 12 months. RESULTS: VLC (N = 27) and TA (N = 28) sites were similar in organizational characteristics (all p > 0.05). At 12-month follow-up mean program fidelity score was higher in VLC compared to TA (90.5 vs. 79.1; p = 0.002), with over double the proportion with good fidelity (VLC = 73.9% vs. TA = 34.8%; p = 0.009). Over half of individuals in both VLC and TA achieved cardiovascular risk-reduction at 6-month follow-up (VLC: 51.0%; TA: 53.5%; p = 0.517) and at 12-month follow-up (62% VLC and TA; p = 0.912). At 12-month follow-up VLC compared to TA was associated with greater participation (VLC 69.5% vs. TA 56.4% attending at least 50% of sessions, p = 0.002); larger caseloads (VLC = 16 vs. TA = 11; p = 0.024); greater reach consisting of 45% greater number of participants receiving InSHAPE (VLC = 368 vs. TA = 253), and 58% greater number of participants achieving cardiovascular risk reduction (VLC = 150 vs. TA = 95). CONCLUSION: Virtual learning collaboratives compared to routine technical assistance as an implementation strategy for evidence-based health promotion promote greater intervention fidelity, greater levels of intervention participation, greater reach, and a greater number of participants achieving clinically significant risk reduction outcomes, while achieving similarly high levels of intervention effectiveness for participants who completed at least 6 months of the program.

A virtual learning collaborative to implement health promotion in routine mental health settings: Protocol for a cluster randomized trial.

BACKGROUND: Despite widespread use of learning collaboratives in health care, few randomized trials have evaluated their effectiveness. The primary aim of this cluster randomized implementation trial is to evaluate the effectiveness of a virtual learning collaborative (VLC) in the implementation of a lifestyle intervention for persons with serious mental illness (SMI) in routine mental health settings, compared to standard individual technical assistance. METHODS: Forty-eight mental health provider organizations from across the United States will be recruited to participate in the trial. The evidence-based practice to be implemented is the InSHAPE health promotion intervention for persons with SMI. Sites will be stratified by size and randomized to receive an 18-month intensive group-based VLC with monthly learning sessions or individual technical assistance with four scheduled conference calls over 18 months. Sites will be enrolled in three blocks of 16 sites each. The primary outcomes are InSHAPE program participation and fidelity, and participant weight loss; secondary outcomes are program operation, program uptake, participant health behaviors of physical activity and nutrition, organizational change, and program sustainment. Implementation outcomes are measured at 3, 6, 12, 18, and 24 months after the program start-up. Participant-level outcomes are measured at fixed intervals every 3 months after each participant enrolls in the study. DISCUSSION: This study will determine whether VLCs are an effective implementation strategy among resource-limited providers when the new practice necessitates a shift in mission, scope of practice, type of services delivered, and new financing. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03891368 Registered 25 March 2019, retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT03891368?term=NCT03891368&rank=1.

Comparing Three Methods for Reducing Psychotropic Use in Older Demented Spanish Care Home Residents.

BACKGROUND/OBJECTIVE: In nursing homes across the world, and particularly in Spain, there are concerns that psychotropic medications are being overused. For older Spanish nursing home residents who had dementia, we sought to evaluate the association between applying interventions designed to reduce inappropriate psychotropic medication use and subsequent psychotropic use. DESIGN: Retrospective, propensity score-matched, controlled, patient-level observational analysis. SETTING: A total of 45 nursing homes in Spain. PARTICIPANTS: A total of 1653 nursing home residents, aged 70 to 99 years, who had dementia and were prescribed an antipsychotic, anxiolytic, or antidepressant medication, 606 of whom received an intervention; the remainder served as propensity score-matched controls. INTERVENTION: Team Rounds, Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria, or a Patient Decision Aid. MEASUREMENTS: At 2 and 4 weeks following intervention: change from baseline drug class-specific milligram-equivalent daily dose (MEDD); at 2 weeks: patient falls and restraint use. RESULTS: Within each intervention/drug-class cohort, intervention patients and matched controls had similar baseline demographic characteristics, Charlson scores, lengths of admission, and drug class-specific MEDDs. Compared to controls, patients exposed to Team Rounds experienced a 23.3% (95% confidence interval [CI] = 13.9%-32.8%) reduction in antipsychotic and a 23.1% (95% CI = 18.3%-28.0%) reduction in anxiolytic MEDDs; those exposed to Patient Decision Aids had a 24.8% (95% CI = 15.6%-33.9%) reduction in antipsychotic and a 31.8% (95% CI = 25.5%-38.2%) reduction in anxiolytic MEDDs; and those exposed to STOPP/START application had a 27.7% (95% CI = 22.4%-33.0%) reduction in antipsychotic and a 39.5% (95% CI = 35.5%-43.5%) reduction in anxiolytic MEDDs. Intervention-associated antidepressant MEDD reductions were statistically significant but less dramatic. Interventions were associated with higher rates of medication discontinuation, but not higher rates of deaths, patient falls, or physical restraints. CONCLUSION: We found strong evidence that the interventions we studied were associated with reduced psychotropic use without commensurate harms, suggesting that such interventions should be incorporated into Spanish nursing home care models. Public reporting of psychotropic medication use in Spanish care homes may encourage care homes to regularly monitor psychotropic medication use and implement such instruments. J Am Geriatr Soc, 2019.

Trans-Atlantic collaboration: applying lessons learned from the US CF Foundation quality improvement initiative.

BACKGROUND: Between 2002 and 2006 France launched a national cystic fibrois (CF) newborn screening program; organized a network of specialized CF care centers; and issued CF diagnostic and treatment standards. To continue to build on this success in 2007 the Cystic Fibrosis Center of Expertise for Rare Diseases (CF CERD) of Nantes-Roscoff in partnership with the French CF Society, the French CF Association (Vaincre la Mucoviscidose), and all CF center leaders from across the country agreed to pursue center-level improvement in medical outcomes for people with CF by adapting the U.S. Cystic Fibrosis Foundation's (US CFF) national initiative, Accelerating the Rate of Improvement in CF Care. To launch the Program to Improve Results and Expertise in CF (le Programme d'Amélioration des Résultats et de l'Expertise en Mucoviscidose - PHARE-M), French leaders pursued mentorship and guidance from leaders at the US CFF, the Dartmouth Institute (TDI), and clinical care teams at CF centers across the U.S. METHODS: The following activities enabled the Nantes-Roscoff CF CERD team members and a parent, involved with the French CF Association board and a quality engineer by training, to gain the leadership and quality improvement knowledge and skills necessary to implement the PHARE-M program: 1) regularly attending national meetings, tracking publications, and leveraging existing partnerships; 2) completing two sabbaticals to visit U.S. CF centers and enrolling in academic and professional training courses; and, 3) inviting US CFF and TDI leaders to France to meet key opinion leaders and frontline teams. CONCLUSIONS: The Nantes-Roscoff CF CERD team successfully adapted the US CFF's initiative to accelerate improvement in CF care by establishing a partnership with U.S. leaders to communicate and exchange strategies and lessons learned; intentionally studying and adapting the Clinical Microsystems approach to quality improvement; and learning directly from the experience of frontline teams in the U.S. They continue to partner with U.S. leaders and are seeking to collaborate with European colleagues to continue to improve care for individuals with CF and their families across Europe.

Accelerating the rate of improvement in cystic fibrosis care: contributions and insights of the learning and leadership collaborative.

INTRODUCTION: The Learning and Leadership Collaborative (LLC) supports cystic fibrosis (CF) centres' responses to the variation in CF outcomes in the USA. Between 2002 and 2013, the Cystic Fibrosis Foundation (CFF) designed, tested and modified the LLC to guide front line staff efforts in these efforts. This paper describes the CFF LLC evolution and essential elements that have facilitated increased improvement capability of CF centres and improved CF outcomes. METHODS: CF centre improvement teams across the USA have participated in 11 LLCs of 12 months' duration since 2002. Based on the Dartmouth Microsystem Improvement Curriculum, the original LLC included face to face meetings, an email listserv, conference calls and completion of between learning session task books. The LLCs evolved over time to include internet based learning, an electronic repository of improvement resources and examples, change ideas driven by evidence based clinical practice guidelines, benchmarking site visits, an applied QI measurement curriculum and team coaching. RESULTS: Over 90% of the CF centres in the USA have participated in the LLCs and have increased their improvement capabilities. Ten essential elements were identified as contributors to the successful LLCs: LLC national leadership and coordination, local leadership, people with CF and families involvement, registry data transparency, standardised improvement curriculum with evidence based change ideas, internet resources with reminders, team coaching, regular progress reporting and tracking, benchmarking site visits and applied improvement measurement. CONCLUSIONS: The LLCs have contributed to improved medical and process outcomes over the past 10 years. Ten essential elements of the LLCs may benefit improvement efforts in other chronic care populations and health systems.

Coaching interprofessional health care improvement teams: the coachee, the coach and the leader perspectives.

AIM: To investigate health care improvement team coaching activities from the perspectives of coachees, coaches and unit leaders in two national improvement collaboratives. BACKGROUND: Despite numerous methods to improve health care, inconsistencies in success have been attributed to factors that include unengaged staff, absence of supportive improvement resources and organisational inertia. METHODS: Mixed methods sequential exploratory study design, including quantitative and qualitative data from interprofessional improvement teams who received team coaching. The coachees (n = 382), coaches (n = 9) and leaders (n = 30) completed three different data collection tools identifying coaching actions perceived to support improvement activities. RESULTS: Coachees, coaches and unit leaders in both collaboratives reported generally positive perceptions about team coaching. Four categories of coaching actions were perceived to support improvement work: context, relationships, helping and technical support. CONCLUSIONS: All participants agreed that regardless of who the coach is, emphasis should include the four categories of team coaching actions. IMPLICATIONS FOR NURSING MANAGEMENT: Leaders should reflect on their efforts to support improvement teams and consider the four categories of team coaching actions. A structured team coaching model that offers needed encouragement to keep the team energized, seems to support health care improvement.

Clinical microsystems, Part 4. Building innovative population-specific mesosystems.

BACKGROUND: In 2005, the Geisinger Health System (Danville, Pennsylvania) developed ProvenCare, first applied to coronary artery bypass graft (CABG), as an innovative provider-driven quality improvement program to promote reliable delivery of evidence-based best practices. A new mesosystem is created for each ProvenCare model, integrating the care delivery process between contributing microsystems and defining new mesosystem leadership. The approach has been expanded to many patient populations, including percutaneous coronary intervention (PCI). A NEW PCI MESOSYSTEM: In 2007 clinical microsystem thinking was applied to PCI: understanding the current processes and patterns, assembling the frontline professionals to redesign the processes, and using a beta-test phase to measure the changes and adjust accordingly, until the best process was established. A new mesosystem team was created to ensure that the right care is delivered at the tight time. REFINING IMPLEMENTATION: In the course of developing the CABG initiative, Geisinger established role definitions to keep teams on track; a comprehensive plan from design through execution and follow-up; and guiding principles established for the teams engaged in designing, developing, and implementing ProvenCare programs. PRELIMINARY EXPERIENCE: For the 40 measurable process elements in the PCI mesosystem pathway, as of month seven (July 2008) of the beta-test phase, 55% of the patients received 100% of the identified process elements. CONCLUSION: Geisinger Health System has joined different microsystems to form an innovative mesosystem capable of producing reliable, evidence-based care for patient subpopulations. This approach to embedding evidence-based care into routine care delivery can be adapted by others.

Clinical microsystems, Part 3. Transformation of two hospitals using microsystem, mesosystem, and macrosystem strategies.

BACKGROUND: Two hospitals-a large, urban academic medical center and a rural, community hospital-have each chosen a similar microsystem-based approach to improvement, customizing the engagement of the micro-, meso-, and macrosystems and the improvement targets on the basis of an understanding of the local context. CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER (CCHMC): Since 2004, strategic changes have been developed to support microsystems and their leaders through (1) ongoing improvement training for all macro-, meso-, and microsystem leaders; (2) financial support for physicians who are serving as co-leaders of clinical microsystems; (3) increased emphasis on aligning academic pursuits with improvement work at the clinical front lines; (4) microsystem leaders' continuous access to unit-level data through the organization's intranet; and (5) encouragement of unit leaders to share outcomes data with families. COOLEY DICKINSON HOSPITAL (CDH): CDH has moved from near closure to a survival-turnaround focus, significant engagement in quality and finally, a complete reframing of a quality focus in 2004. Since then, it has deployed the clinical microsystems approach in one pilot care unit (West 2, a medical surgery unit), broadened it to two, then six more, and is now spreading it organizationwide. In "2+2 Charters," interdisciplinary teams address two strategic goals set by senior leadership and two goals set by frontline microsystem leaders and staff DISCUSSION: CCHMC and CDH have had a clear focus on developing alignment, capability, and accountability to fuse together the work at all levels of the hospital, unifying the macrosystem with the mesosystem and microsystem. Their improvement experience suggests tips and actions at all levels of the organization that could be adapted with specific context knowledge by others.

Clinical microsystems, part 2. Learning from micro practices about providing patients the care they want and need.

BACKGROUND: Usual medical care in the United States is frequently not a satisfying experience for either patients or primary care physicians. Whether primary care can be saved and its quality improved is a subject of national concern. An increasing number of physicians are using microsystem principles to radically redesign their practices. Small, independent practices-micro practices-are often able to incorporate into a few people the frontline attributes of successful microsystems such as clear leadership, patient focus, process improvement, performance patterns, and information technology. PATIENT FOCUS, PROCESS IMPROVEMENT, AND PERFORMANCE PATTERNS: An exemplary microsystem will (1) have as its primary purpose a focus on the patient-a commitment to meet all patient needs; (2) make fundamental to its work the study, measurement, and improvement ofcare-a commitment to process improvement; and (3) routinely measure its patterns of performance, "feed back" the data, and make changes based on the data. LESSONS FROM MICRO PRACTICES: The literature and experience with micro practices suggest that they (1) constitute an important group in which to demonstrate the value of microsystem thinking; (2) can become very effective clinical microsystems; (3) can reduce their overhead costs to half that of larger freestanding practices, enabling them to spend more time working with their patients; (4) can develop new tools and approaches without going through layers of clearance; and (5) need not reinvent the wheel. CONCLUSIONS: Patient-reported data demonstrate how micro practices are using patient focus, process improvement, performance patterns, and information technology to improve performance. Pati ents should be able to report that they receive "exactly the care they want and need exactly when and how they want and need it."

Clinical microsystems, part 1. The building blocks of health systems.

BACKGROUND: Wherever, however, and whenever health care is delivered-no matter the setting or population of patients-the body of knowledge on clinical microsystems can guide and support innovation and peak performance. Many health care leaders and staff at all levels of their organizations in many countries have adapted microsystem knowledge to their local settings. CLINICAL MICROSYSTEMS: A PANORAMIC VIEW: HOW DO CLINICAL MICROSYSTEMS FIT TOGETHER? As the patient's journey of care seeking and care delivery takes place over time, he or she will move into and out of an assortment of clinical microsystems, such as a family practitioner's office, an emergency department, and an intensive care unit. This assortment of clinical microsystems-combined with the patient's own actions to improve or maintain health--can be viewed as the patient's unique health system. This patient-centric view of a health system is the foundation of second-generation development for clinical microsystems. LESSONS FROM THE FIELD: These lessons, which are not comprehensive, can be organized under the familiar commands that are used to start a race: On Your Mark, Get Set, Go! ... with a fourth category added-Reflect: Reviewing the Race. These insights are intended as guidance to organizations ready to strategically transform themselves. CONCLUSION: Beginning to master and make use of microsystem principles and methods to attain macrosystem peak performance can help us knit together care in a fragmented health system, eschew archipelago building in favor of nation-building strategies, achieve safe and efficient care with reliable handoffs, and provide the best possible care and attain the best possible health outcomes.

Quality improvement learning collaboratives.

PURPOSE: To identify and synthesize characteristics of successful data-driven Quality improvement learning collaboratives (QILCs) in the United States and Europe, and to extend previously discussed and newly identified guidelines for developing successful data-driven QILCs across health care settings and systems. METHODS: An interview guide of open-ended questions was developed and posed to 18 key informants of various disciplines involved in the development and implementation of successful QILCs across 10 organizations in 3 countries. Aspects of successful QILCs were analyzed to identify patterns emerging from structure-process interactions between complex health care systems. RESULTS: Shared patterns of successful collaboratives included cultivating trust, attendance to the human dimension, nonlinear development, attendance to organizational culture, integrated philosophy of quality improvement, and a focus on process and outcome measurement to drive change. This study extends the knowledge base through synthesis of findings from previous quality improvement research with the findings from this study to develop guidelines for establishing and developing successful QILCs. CONCLUSIONS: The core characteristics identified in this study were critical to successful collaboration when these approaches were used in the contexts identified. The intrinsic complexity of QILCs requires that effectiveness studies employ qualitative as well as quantitative methodologies.

Microsystems in health care: Part 9. Developing small clinical units to attain peak performance.

BACKGROUND: This last Microsystems in Health Care series article focuses on what it takes, in the short term and long term, for clinical microsystems--the small, functional, front-line units that provide the most health care to the most people--to attain peak performance. CASE STUDY: A case study featuring the intensive care nursery at Dartmouth-Hitchcock Medical Center illustrates the 10-year evolution of a clinical microsystem. Related evolutionary principles begin with the intention to excel, involve all the players, use measurement and feedback, and create a learning system. DISCUSSION: A microsystem's typical developmental journey toward excellence entails five stages of growth--awareness as an interdependent group with the capacity to make changes, connecting routine daily work to the high purpose of benefiting patients, responding successfully to strategic challenges, measuring the microsystem's performance as a system, and juggling improvements while taking care of patients. A MODEL CURRICULUM: Health system leaders can sponsor an action-learning program to catalyze development of clinical microsystems. A "green-belt curriculum" can help clinical staff members acquire the fundamental knowledge and skills that they will need to master if they are to increase their capacity to attain higher levels of performance; uses action-learning theory and sound education principles to provide the opportunity to learn, test, and gain some degree of mastery; and involves people in the challenging real work of improving.

Microsystems in health care: Part 8. Developing people and improving work life: what front-line staff told us.

BACKGROUND: The articles in the Microsystems in Health Care series have focused on the success characteristics of high-performing clinical microsystems. Realization is growing about the importance of attracting, selecting, developing, and engaging staff. By optimizing the work of all staff members and by promoting a culture where everyone matters, the microsystem can attain levels of performance not previously experienced. CASE STUDY: At Massachusetts General Hospital Downtown Associates (Boston), a primary care practice, the human resource processes are specified and predictable, from a candidate's initial contact through each staff member's orientation, performance management, and professional development. Early on, the new employee receives materials about the practice, including a practice overview, his or her typical responsibilities, the performance evaluation program, and continuous quality improvement. Ongoing training and education are supported with skill labs, special education nights, and cross-training. The performance evaluation program, used to evaluate the performance of all employees, is completed during the 90-day orientation and training, quarterly for one year, and annually. CONCLUSION: Some health care settings enjoy high morale, high quality, and high productivity, but all too often this is not the case. The case study offers an example of a microsystem that has motivated its staff and created a positive and dynamic workplace.

Microsystems in health care: Part 5. How leaders are leading.

BACKGROUND: Leading and leadership by formal and informal leaders goes on at all levels of microsystems--the essential building blocks of all health systems--and between them. It goes on between microsystems and other levels of the systems in health care. This series on high-performing clinical microsystems is based on interviews and site visits to 20 clinical microsystems in the United States. This fifth article in the series describes how leaders contribute to the performance of those microsystems. ANALYSIS OF INTERVIEWS: Interviews of leaders and staff members offer a rich understanding of the three core processes of leading. Building knowledge requires many behaviors of leaders and has many manifestations as leaders seek to build knowledge about the structure, processes, and patterns of work in their clinical microsystems. Taking action covers many different behaviors--making things happen, executing plans, making good on intentions. It focuses action on the way people are hired and developed and involves the way the work gets done. Reviewing and reflecting provides insight as to how the microsystem's patterns, processes, and structure enable the desired work to get done; what success looks like; and what will be next after that "success" is created. CONCLUSION: The focus on the processes of leading is intended to enable more people to develop into leaders and more people to share the roles of leading.

Microsystems in health care: Part 6. Designing patient safety into the microsystem.

BACKGROUND: This article explores patient safety from a microsystems perspective and from an injury epidemiological perspective and shows how to embed safety into a microsystem's operations. MICROSYSTEMS PATIENT SAFETY SCENARIO: Allison, a 5-year-old preschooler with a history of "wheezy colds," and her mother interacted with several microsystems as they navigated the health care system. At various points, the system failed to address Allison's needs. The Haddon matrix provides a useful framework for analyzing medical failures in patient safety, setting the stage for developing countermeasures. CASE STUDY: The case study shows the types of failures that can occur in complex medical care settings such as those associated with pediatric procedural sedation. Six patient safety principles, such as "design systems to identify, prevent, absorb, and mitigate errors," can be applied in a clinical setting. In response to this particular case, its subsequent analysis, and the application of microsystems thinking, the anesthesiology department of the Children's Hospital at Dartmouth developed the PainFree Program to provide optimal safety for sedated patients. CONCLUSION: Safety is a property of a microsystem and it can be achieved only through thoughtful and systematic application of a broad array of process, equipment, organization, supervision, training, simulation, and team-work changes.

Microsystems in health care: Part 4. Planning patient-centered care.

BACKGROUND: Clinical microsystems are the essential building blocks of all health systems. At the heart of an effective microsystem is a productive interaction between an informed, activated patient and a prepared, proactive practice staff. Support, which increases the patient's ability for self-management, is an essential result of a productive interaction. This series on high-performing clinical microsystems is based on interviews and site visits to 20 clinical microsystems in the United States. This fourth article in the series describes how high-performing microsystems design and plan patient-centered care. PLANNING PATIENT-CENTERED CARE: Well-planned, patient-centered care results in improved practice efficiency and better patient outcomes. However, planning this care is not an easy task. Excellent planned care requires that the microsystem have services that match what really matters to a patient and family and protected time to reflect and plan. Patient self-management support, clinical decision support, delivery system design, and clinical information systems must be planned to be effective, timely, and efficient for each individual patient and for all patients. CONCLUSION: Excellent planned services and planned care are attainable today in microsystems that understand what really matters to a patient and family and have the capacity to provide services to meet the patient's needs.

Microsystems in health care: Part 3. Planning patient-centered services.

BACKGROUND: Strategic focus on the clinical microsystems--the small, functional, frontline units that provide most health care to most people--is essential to designing the most efficient, population-based services. The starting place for designing or redesigning of clinical microsystems is to evaluate the four P's: the patient subpopulations that are served by the microsystem, the people who work together in the microsystem, the processes the microsystem uses to provide services, and the patterns that characterize the microsystem's functioning. GETTING STARTED: DIAGNOSING AND TREATING A CLINICAL MICROSYSTEM: Methods and tools have been developed for microsystem leaders and staff to use to evaluate the four P's--to assess their microsystem and design tests of change for improvement and innovation. PUTTING IT ALL TOGETHER: Based on its assessment--or diagnosis--a microsystem can help itself improve the things that need to be done better. Planning services is designed to decrease unnecessary variation, facilitate informed decision making, promote efficiency by continuously removing waste and rework, create processes and systems that support staff, and design smooth, effective, and safe patient care services that lead to measurably improved patient outcomes. CONCLUSION: The design of services leads to critical analysis of the resources needed for the right person to deliver the right care, in the right way, at the right time.

Microsystems in health care: Part 2. Creating a rich information environment.

BACKGROUND: A rich information environment supports the functioning of the small, functional, frontline units--the microsystems--that provide most health care to most people. Three settings represent case examples of how clinical microsystems use data in everyday practice to provide high-quality and cost-effective care. CASES: At The Spine Center at Dartmouth, Lebanon, New Hampshire, a patient value compass, a one-page health status report, is used to determine if the provided care and services are meeting the patient's needs. In Summit, New Jersey, Overlook Hospital's emergency department (ED) uses uses real-time process monitoring on patient care cycle times, quality and productivity indicator tracking, and patient and customer satisfaction tracking. These data streams create an information pool that is actively used in this ED icrosystem--minute by minute, hourly, daily, weekly, and annually--to analyze performance patterns and spot flaws that require action. The Shock Trauma Intensive Care Unit (STRICU), Intermountain Health Care, Salt Lake City, uses a data system to monitor the "wired" patient remotely and share information at any time in real time. Staff can complete shift reports in 10 minutes. DISCUSSION: Information exchange is the interface that connects staff to patients and staff to staff within the microsystem; microsystem to microsystem; and microsystem to macro-organization.