BACKGROUND

A primary task for the IOM Subcommittee was to settle on the level of analysis it would use to anchor its work. A number of possibilities were offered: an entire health system, an integrated delivery system, an organization that delivers a particular kind of care, such as a hospital or nursing home, and so forth. The Subcommittee chose to focus on units it calls micro-systems.

This reason for this choice requires some explanation of both the origin of the term micro-unit or micro-system and the place of systems thinking in health care. Although the term micro-system is new to health care and may, at first, seem jarring, it was chosen carefully. The prefix micro- emphasizes its focus on small systems that are often embedded in larger macro-systems. The term system emphasizes that success in achieving clinical purposes requires the conscious development of systems to guide care processes.

The committee adopted the term micro-system in contrast to more traditional terms, such as team, practice, or panel to emphasize the idea that a micro-system encompasses not just the practitioners but also the patients, technologies (including information technologies), and processes of care that are integral to their work. It also emphasizes systemness as a feature that can be purposefully advanced using regular, ongoing information about the outcomes of care that indicate how well the micro-system processes meet patients' needs.

As described by Bertalanffy and others in early work on general systems theory, a system is a set of interdependent elements interacting to achieve a common aim. 1 These elements may be both human and nonhuman, such as equipment and technologies. 2 During the period following World War II, cybernetics and information theory, which originated in the disciplines of physics and biology, began to be applied across scientific disciplines to systems engineering and operations research to understand increasingly complex levels of organization, including social systems. 3 ,4 Since that time, organizational theorists, researchers, and managers have turned to systems theory for help in improving the performance of organizations. To date, however, the application of operations research has moved ahead faster and more widely in the business community than in health care. In many ways, the clinical office of today is little changed from the 1950s. The process of care is organized around individual patient visits with little clinical information technology to assist decisionmaking and very little information about performance to guide improvement, whether concerning patient health outcomes or their experience.

Despite substantial market pressure to improve both productivity and the acceptability of services, office practices and units within larger organizations (such as within hospitals) encounter substantial barriers in making threshold changes in their performance and even greater barriers in disseminating their successes within or across organizations. At the same time, the morale of health care professionals has been severely strained by efforts to do more with fewer resources even while coping with an avalanche of new technologies and knowledge.

This study began by looking beyond health care to other industries for help in framing the investigation. A primary source for the conceptual framework came from the work of James Brian Quinn. Quinn approached a study of business performance by identifying break-



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CONTENTS xii Supportiveness of the Larger System 50 Constancy of Purpose 52 Connection to Community 54 Investment in Improvement 54 Alignment of Role and Training 55 CONCLUSIONS AND DIRECTIONS FOR FURTHER RESEARCH AND POLICY............................................................................................. 57 Limitations of This Research 57 Directions for Further Research 60 IOM Quality of Care Study 61 REFERENCES ................................................................................................................. 62 APPENDIXES A Example of Thin and Thick Description for Quantitative Analysis 65 B Letter of Invitation 67 C Rosters 69 D Pre-Interview 71 E Telephone Interview 74 TABLES METHODS Stage 2: Study Design and Data Collection TABLE 1 Range of Micro-Systems Studied 12 TABLE 2 Micro-System Descriptions 14 TABLE 3 Question Completion Rate 18 Stage 3: Data Analysis TABLE 4 Micro-System Variables 20 RESULTS I. Case-Level Summaries by Topic TABLE 5 Importance of Executive and Governance-level Support for Innovation and Improvement Efforts 31 TABLE 6 Importance of Strong, Focused, and Sustained Clinical Leadership 33 TABLE 7 Importance of Collaboratively Functioning Multidisciplinary Clinical Teams 35 TABLE 8 Importance of Explicit Attention to the Development of Systems of Care 37 TABLE 9A Importance of Good Information Systems for Individual Patient Care 40 TABLE 9B Importance of Good Information Systems for Improving Care 41 TABLE 10 Importance of a Focus on the Needs of Patients 44

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CONTENTS xiii II. Cross-Case Analysis—Themes Related to Effective Micro-System Performance TABLE 11 Summary of Micro-System Framework 48 TABLE 12 Micro-System Examples of Integration of Information 49 TABLE 13 Micro-System Examples of Measurement 51 TABLE 14 Micro-System Examples of Interdependence of Care Team 52 TABLE 15 Micro-System Examples of Supportiveness of the Larger System 53 TABLE 16 Micro-System Examples of Constancy of Purpose 55 TABLE 17 Micro-System Examples of Connection to Community 56 TABLE 18 Micro-System Examples of Investment in Improvement 57 TABLE 19 Micro-System Examples of Alignment of Role and Training 59 xiii

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis INTRODUCTION This is the final report to The Robert Wood Johnson Foundation on the study meth- ods, findings, and conclusions of grant number 36222 to the Institute of Medicine (IOM) to assist its Committee on the Quality of Health Care in America (QHCA). One objective for the IOM committee was the identification of key characteristics and factors that enable or encourage providers, health care organizations, health plans and communities to continuously improve the quality of care. To advance its work, a subcommittee of QHCA, the Subcom- mittee on Building the 21st Century Health System, used the micro-systems study as an op- portunity to use the empirical findings from structured interviews to guide its deliberations and to increase its understanding of exemplary health care delivery systems. Specifically, the tasks set out for the study and described in this report were: • to define and describe health care micro-systems; and • to analyze characteristics that enable specific micro-systems to improve the quality of care provided to their patient populations. This study reports on structured interviews used to collect primary data (summer, 1999) from 43 micro-systems providing primary and specialty care, hospice, emergency, and critical care. It summarizes responses to the interviews about how micro-systems function, what they know about their level of performance, how they improve care, the leadership needed, the barriers they have encountered, and how they have dealt with these barriers. Analysis includes, first, summary description of each interview topic, including a section on lessons for replication identified by respondents that may point the way toward replication of the work of these micro-systems. Second, the analysis includes eight themes that emerged from the cross-case analysis of the interviews. These themes provide a framework for think- ing about how health care micro-systems function. It is possible that the most effective mi- cro-systems will be able to demonstrate a high level of performance in each of these areas. The study also identifies directions for further research that could contribute to designing and redesigning delivery systems, improving care, preparing future health professionals, and formulating health policy. 1

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2 INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS BACKGROUND A primary task for the IOM Subcommittee was to settle on the level of analysis it would use to anchor its work. A number of possibilities were offered: an entire health sys- tem, an integrated delivery system, an organization that delivers a particular kind of care, such as a hospital or nursing home, and so forth. The Subcommittee chose to focus on units it calls micro-systems. This reason for this choice requires some explanation of both the origin of the term micro-unit or micro-system and the place of systems thinking in health care. Although the term micro-system is new to health care and may, at first, seem jarring, it was chosen care- fully. The prefix micro- emphasizes its focus on small systems that are often embedded in larger macro-systems. The term system emphasizes that success in achieving clinical pur- poses requires the conscious development of systems to guide care processes. The committee adopted the term micro-system in contrast to more traditional terms, such as team, practice, or panel to emphasize the idea that a micro-system encompasses not just the practitioners but also the patients, technologies (including information technologies), and processes of care that are integral to their work. It also emphasizes systemness as a fea- ture that can be purposefully advanced using regular, ongoing information about the out- comes of care that indicate how well the micro-system processes meet patients’ needs. As described by Bertalanffy and others in early work on general systems theory, a system is a set of interdependent elements interacting to achieve a common aim.1 These ele- ments may be both human and nonhuman, such as equipment and technologies.2 During the period following World War II, cybernetics and information theory, which originated in the disciplines of physics and biology, began to be applied across scientific disciplines to sys- tems engineering and operations research to understand increasingly complex levels of or- ganization, including social systems.3,4 Since that time, organizational theorists, researchers, and managers have turned to systems theory for help in improving the performance of or- ganizations. To date, however, the application of operations research has moved ahead faster and more widely in the business community than in health care. In many ways, the clinical office of today is little changed from the 1950s. The process of care is organized around in- dividual patient visits with little clinical information technology to assist decisionmaking and very little information about performance to guide improvement, whether concerning patient health outcomes or their experience. Despite substantial market pressure to improve both productivity and the acceptability of services, office practices and units within larger organizations (such as within hospitals) en- counter substantial barriers in making threshold changes in their performance and even greater barriers in disseminating their successes within or across organizations. At the same time, the morale of health care professionals has been severely strained by efforts to do more with fewer resources even while coping with an avalanche of new technologies and knowledge. This study began by looking beyond health care to other industries for help in framing the investigation. A primary source for the conceptual framework came from the work of James Brian Quinn. Quinn approached a study of business performance by identifying

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INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS 3 breakthrough levels of successful performance in industries worldwide and asking how they accomplished it.5 Quinn found that many of the world’s best run organizations recognized the advantage of focusing on small functioning units to improve timeliness and cycle time, prod- uct quality, service, customer and worker satisfaction, as well as to reduce production costs. He described these small units as microunits of production, meaning that they were the smallest or minimum “replicable unit,” which for this study means a unit whose processes are repeatable with small variation in response to local conditions and that have available to them all the necessary resources to do their work. Although the approach originated with routine manufacturing and rules-based, auto- matable systems, it proved to be applicable, as well, to service operations where it led to large increases in customer satisfaction. Surprisingly, the larger the organization, the greater the leverage for gains because of a larger information database and greater possibility for ex- perimentation. Using these small units as a starting place, Quinn found that highly effective service technologies were connected in a variety of new organizational forms that seemed to have some common characteristics: they had much “flatter” hierarchies than their predeces- sors; they were built around core service competencies typically consisting of special depth in some unique technologies, knowledge bases, skills, or other systems; and they interacted with customers using excellent information technologies and organizational design. Organi- zations discovered that these forms also made their workplaces more personally challenging and satisfying places to work. The micro-system study explored whether such an approach to understanding highly effective systems could be applied to professional organizations, and, in particular, to health care units—a special, form of service industry, often thought to be unique because inputs (patients) are so variable, outputs ill-defined, and the need for professional expertise so great. Health care requires a mix of rules-based action and judgment based on individual needs, and this combination seemed to defy simple notions based on manufacturing. Defining Health Care Micro-Systems Adapting Quinn’s notion of the micro-unit, Batalden and coworkers6 have described the concept of a health care micro-system that delivers the core “product” of health care— patient care. It is at this interface that patients experience care and that the quality of care is determined. Although health care is provided to patients by caregivers who work in very com- plex organizational arrangements, the overwhelming amount of their own daily work is as part of a small system consisting of people—the patients and practitioners—and the tech- nologies they use. Nelson and his colleagues7 have described the essential elements of a mi- cro-system: • a core team of health care professionals; • a defined population they care for;* *Batalden notes that the population may be an enrolled population in a prepaid, capitated system or those who are seen regularly by a given set of providers who work together at a single site.