Improving midwifery practice: the American College of Nurse-Midwives' benchmarking project.

Quality management in clinical practice involves the use of numerous techniques that monitor the quality of care clinicians provide. Quality improvement is an approach to quality management that emphasizes system and processes, rather than a focus on individual performance. Quality improvement examines objective data to improve these processes, even when high standards of performance appear to have been met. Benchmarking measures one's processes and outcomes against "best in class" and is a part of a quality improvement program. By using benchmarking to provide goals for realistic process improvement and identification of the most efficient and effective methods of meeting all of their customer's needs, health care providers can document their effectiveness in terms of cost, quality, and satisfaction. This article details the American College of Nurse-Midwives' benchmarking project and presents benchmarks for obstetric practice from the year 2004.

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.

Integrating improvement competencies into residency education: a pilot project from a pediatric continuity clinic.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) requires residents to attain 6 core competencies. This article describes a model for integrating 2 of these competencies (practice-based learning and improvement and systems-based practice) into residency education and assesses the clinical outcomes achieved for patients. STUDY DESIGN: An observational study with before-after comparisons. INTERVENTION: Pediatric faculty facilitated multidisciplinary improvement team meetings (which included 8 residents) and implemented an established improvement model to improve the selected clinical condition (immunizations). MAIN OUTCOME MEASURES: The proportion of consecutive children who were up-to-date on DTP, polio, MMR, HIB, and hepatitis B vaccines by 24 months of age. RESULTS: The residents' improvement team successfully implemented 5 changes in the clinic process, which coincided with an increase in immunization rates for 2-year-olds during the 1-year study period. Clinic immunization rates increased from 60% at baseline to 86% at follow-up (P =.04). CONCLUSION: This study suggests that it is feasible to integrate practice-based learning and improvement and systems-based practice into residency education while providing a valuable learning experience for residents and improving patient outcomes.

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.

Creating effective leadership for improving patient safety.

Leadership has emerged as a key theme in the rapidly growing movement to improve patient safety. Leading an organization that is committed to providing safer care requires overcoming the common traps in thinking about error, such as blaming individuals, ignoring the underlying systems factors, and blaming the bureaucracy of the organization. Leaders must address the system issues that are at work within their organizations to allow individual and organizational learning to occur.

Microsystems in health care: Part 1. Learning from high-performing front-line clinical units.

BACKGROUND: Clinical microsystems are the small, functional, front-line units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients and providers meet. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed. METHODS: A wide net was cast to identify and study a sampling of the best-quality, best-value small clinical units in North America. Twenty microsystems, representing different component parts of the health system, were examined from December 2000 through June 2001, using qualitative methods supplemented by medical record and finance reviews. RESULTS: The study of the 20 high-performing sites generated many best practice ideas (processes and methods) that microsystems use to accomplish their goals. Nine success characteristics were related to high performance: leadership, culture, macro-organizational support of microsystems, patient focus, staff focus, interdependence of care team, information and information technology, process improvement, and performance patterns. These success factors were interrelated and together contributed to the microsystem's ability to provide superior, cost-effective care and at the same time create a positive and attractive working environment. CONCLUSIONS: A seamless, patient-centered, high-quality, safe, and efficient health system cannot be realized without the transformation of the essential building blocks that combine to form the care continuum.