Eight themes emerged that became a framework for thinking about characteristics of high performing micro-systems. Because the framework emerged during the analysis, it was necessary to return to the data and search each interview again and again to ensure that each interview was correctly coded.

RESULTS

Leaders of 43 micro-systems responded to questions grouped into five topics: level of performance, patient experience, information and information technology, improvement, and leadership. Analysis is presented in two parts. The first analysis (I) is a case-level summary of each of the five topics with samples of verbatim responses. The fifth and last topic includes, in addition, some cross-cutting issues that respondents emphasized as they described requirements for replication of their accomplishments, what we call “lessons” for replication.

The second part of the analysis (II) was a cross-case analysis based on eight themes that appeared to be associated with high performing micro-systems. Those themes are: integration of information, measurement, interdependence of care team, supportiveness of the larger system, constancy of purpose, connection to community, investment in improvement, and alignment of roles and training.

I. Case-Level Summaries by Topic

Level of Performance

To determine the level of performance of the micro-system, the first part of the interview asked respondents what their micro-system does very well and how they know this; that is, what data are being collected about performance. The majority of micro-systems (70 percent) identified taking care of specific types of patients (e.g., the frail elderly) or providing a specific type of care (e.g., women's reproductive care or diabetes care) as what they do especially well. Other areas that were identified are working as a team (14 percent), using information technology (12 percent), conducting research (7 percent), educating and training providers and staff (5 percent), improving access to care (5 percent), and communicating (1 percent).

The connection between what the micro-system does very well and how micro-systems knew they did was so not so clear. Forty-nine percent of the micro-systems interviewed mentioned measuring their success by looking at clinical outcomes or some defined set of measures that includes clinical, functional, and financial indicators. Seven percent of the micro-systems cited measuring their micro-system performance against guidelines or protocols. For example, one micro-system tracks which protocols are being used, by how many physicians, and what percent of time. Forty-four percent of the micro-systems mentioned measuring patient satisfaction, and seven percent of the micro-systems identified provider satisfaction as an important indicator.

Nine percent of the micro-systems identified benchmarking as a specific method for comparing their outcomes to others. However, one micro-system leader viewed benchmarking as potentially problematic:



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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis Eight themes emerged that became a framework for thinking about characteristics of high performing micro-systems. Because the framework emerged during the analysis, it was necessary to return to the data and search each interview again and again to ensure that each interview was correctly coded. RESULTS Leaders of 43 micro-systems responded to questions grouped into five topics: level of performance, patient experience, information and information technology, improvement, and leadership. Analysis is presented in two parts. The first analysis (I) is a case-level summary of each of the five topics with samples of verbatim responses. The fifth and last topic includes, in addition, some cross-cutting issues that respondents emphasized as they described requirements for replication of their accomplishments, what we call “lessons” for replication. The second part of the analysis (II) was a cross-case analysis based on eight themes that appeared to be associated with high performing micro-systems. Those themes are: integration of information, measurement, interdependence of care team, supportiveness of the larger system, constancy of purpose, connection to community, investment in improvement, and alignment of roles and training. I. Case-Level Summaries by Topic Level of Performance To determine the level of performance of the micro-system, the first part of the interview asked respondents what their micro-system does very well and how they know this; that is, what data are being collected about performance. The majority of micro-systems (70 percent) identified taking care of specific types of patients (e.g., the frail elderly) or providing a specific type of care (e.g., women's reproductive care or diabetes care) as what they do especially well. Other areas that were identified are working as a team (14 percent), using information technology (12 percent), conducting research (7 percent), educating and training providers and staff (5 percent), improving access to care (5 percent), and communicating (1 percent). The connection between what the micro-system does very well and how micro-systems knew they did was so not so clear. Forty-nine percent of the micro-systems interviewed mentioned measuring their success by looking at clinical outcomes or some defined set of measures that includes clinical, functional, and financial indicators. Seven percent of the micro-systems cited measuring their micro-system performance against guidelines or protocols. For example, one micro-system tracks which protocols are being used, by how many physicians, and what percent of time. Forty-four percent of the micro-systems mentioned measuring patient satisfaction, and seven percent of the micro-systems identified provider satisfaction as an important indicator. Nine percent of the micro-systems identified benchmarking as a specific method for comparing their outcomes to others. However, one micro-system leader viewed benchmarking as potentially problematic:

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis We measure success against ourselves. We try very hard not to measure against benchmarks. Benchmarks can limit you. Sometimes the benchmarking in and of itself becomes the goal. We do 1400 hearts a year. We should be the benchmark. Success to us is any incremental thing that makes us better than yesterday. . . . It is a mistake to benchmark pieces of your process against multiple other pieces of process. . . . Just keep working on little projects to improve what you are doing. Finally, nine percent of the micro-systems interviewed acknowledged that measuring and collecting data is difficult work. Other people use surveys and other ways to benchmark. We just do it seat-of-the-pants. We figure that we will get feedback. We don't use any modern techniques to measure anything. It's very expensive. We don't have extra capital to invest in recreational data collection to prove how we are doing to someone else when we know how we are doing. When thinking about the micro-system concept, a common question is, “How do we recognize a micro-system? Is it just another word for a team?” In consideration of these questions, respondents were asked to describe how a patient would experience care differently in their micro-system. Similarly, respondents were asked how a clinician would experience the micro-system differently from another micro-system that treats similar patients. Respondents reported most frequently that patients would perceive care differently because of the level of information that the micro-system gives the patient. Respondents mentioned, for example, making welcome calls to new enrollees, sending information about the services provided, and making sure the patient has a copy of the physician's notes at the conclusion of the appointment. One respondent noted that there are “no barriers to information.” Data on the measures we are monitoring are displayed on a wall—patients can see what the micro-system is working on. The level of information may include an increased use of information technology. Some micro-systems are communicating with patients by e-mail and referring patients to web sites for patient education. Other differences in the patient experience were a team approach to care and the focus on building a relationship with the patient and family. When asked how clinicians would experience the micro-system differently, one respondent said, “the clinical part is not that different—it's the technology and the teams.” Other respondents indicated that technology has an increasingly significant role. However, one person articulated the importance of not confusing information with information technology: Frankly, all this stuff about how information systems are what has been holding us back—that's [nonsense]. Everyone is just waiting for some kind of cure-all information technology system instead of figuring out how to track things themselves.

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis Other differences that respondents pointed out as being different for clinicians in their micro-systems were standardization cross training of staff, and the infusion of improvement into daily work. To understand the culture of the micro-system, we asked respondents to describe the day-to-day work environment of their micro-system. Most comments discussed the impact of a team approach to care. There has been a radical change since we introduced teams. You can see it even where they hang out. Before the docs were together, the nurses together, etc. But now the team hangs out with the team. At the morning meetings, you may see the medical assistants providing the leadership. The medical director calls it the “fast break”—three people on the floor and anybody can finish the play. Other aspects of the culture mentioned by micro-system leaders were the freedom to make decisions regarding own work, an increased level of communication, and a commitment to improve. Respondents were asked whether their micro-system had made specific efforts to support professional ethics, encourage peer feedback or develop the skills of its members. Answers range from micro-systems that admitted “we haven't done much” to one micro-system that has a full-time person who is responsible for organizing and leading sessions on the issues involved in working in teams. Other sites acknowledged the importance of this type of training, but lacked a systematic way of doing it, We try to do this through the course of our activities. But we don 't do it conscientiously. It's kind of on-the-job training. The final (optional) question in the “level of performance” section asked how long the micro-system had been working the way the respondent described it. Answers ranged from one year to “since 1945.” Of the respondents who were asked this question (n = 22), three sites reported more than ten years (16 years, 22 years, and 55 years). All the others reported less than ten years. Patient Experience In the second section of the interview, respondents were asked to describe the patient's experience in the micro-system. Specific questions asked about a new patient's experience, scheduling, risk assessment, referral, waits and delays, and patient education. These questions were designed to elicit information about innovations in delivery of care. Six of the sites have moved to an “open access” model, where patients are given an appointment to be seen the same day they call if they wish to come in that day. We assure that a patient can be seen that day if they can be seen by five; otherwise, the next day. That is not a big problem because phone calls to be seen

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis that day drop way off in the afternoon. The primary focus has to be: “We are here for you.” Another comment from a micro-system with open access shows that they feel they have developed an approach that works well. In the old system, variation in quality was caused when patients went elsewhere to be seen (for example, an urgent care center) or when they gave up trying to be seen. Now the variation in quality is based on the doctors. In the first generation of open access people carve out slots based on predicted urgent care demand. But you need to move beyond this and dispel the myth of “needs vs. wants where wants are seen as unjustified demands. . . . The way to manage demand is over time, not with a call to a nurse. Other sites continue to carve out slots for urgent, same-day appointments but otherwise schedule future appointments. This does not appear to eliminate barriers to access and, as the following comment suggests, may not be the best solution for providers, patients, or the health care system in general. We have quick access, but not open access. We take care of anyone who just walks in, but we don't advertise that. We try to triage based on urgency. Next available appointment slots may be a month out. The extenders have more open slots. The older, established MDs have a longer wait time for next available appointment. We maintain 10 percent open slots for same day appointments. Other innovations in organizing and delivering care include building time into the daily work for teams to communicate, present cases, and learn from each other. Building in mechanisms for communication seems to be key to managing referrals, as well, and information technology can facilitate this communication. We started as a multi-specialty group. If I pick up a phone I can connect directly to a specialist. This makes the transfer of care smooth. The Epic system generates referrals for non-urgent referrals. My notes go with the referral. It's the same method for getting information back to me. We are also connected via e-mail, and we do a fair amount of communicating this way. Many micro-system have specifically addressed the need to reduce waiting time and delays. They described improvements such as standard stocking of rooms, pulling up information about the patient before the visit, and adding a patient-flow facilitator to the team. We asked respondents how their patients get information about their health condition. Predominately, they reported that patient education is conveyed during one-on-one interaction with providers, via printed materials, videos, and classes. There appears to be an increasing level of comfort with technology and the integration of technology into patient education. Everett Rogers's framework for studying the adoption of innovation can be applied to this phenomenon. 27 Rogers's findings from decades of research in the diffusion of innovation

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis demonstrate that the rate of adoption over time follows an S-shaped curve. During the early stages of an innovation, such as use of computer technology in providing patient education, there are relatively few adopters, but eventually more and more groups adopt it. Figure 1 shows Rogers's model for diffusion of innovation overlaid with three examples from the micro-system interviews regarding the current use of e-mail for patient education in these micro-systems. Respondents were also asked about incentives that reward management and staff for meeting and exceeding patient expectations. Responses fall into three categories, (1) no incentives, (2) incentives, and (3) misaligned incentives. The first is no incentive: The only reward is the knowledge that you are providing good personal care for each patient. Another micro-system discussed an Independent Development Plan (IDP) that recognizes successful efforts to improve with a raise in salary. We just started this year. Next year it will be mandatory to meet your IDP to get a raise. For example, one group wanted to improve patient satisfaction in their team. One team wanted to decrease supply costs. They cut supply costs by 28 percent. Two respondents mentioned incentives that appear to be misaligned; that is, the incentives do not promote the functioning of the micro-system either because the incentive is not connected to the work of the micro-system or because the incentive is not given to all the people working in the micro-system. There are only incentives for high-level administrators to meet HEDIS measures. Nothing filters down. If at the end of a quarter, there are savings from the unit, the money is split one third to the facility, one third to the health plan, and one third to the physicians. The final question in the patient experience section asked respondents how the micro-system seeks input from the community or keeps the community aware of what the micro-system is doing. The micro-systems responded that they interact with the community at two levels—acting as a resource for the patient population and acting as a resource for other clinicians and health care providers by providing education and setting the standard of care in the community. Information and Information Technology Forty-nine percent of the sites included in this study indicated that patient records are paper based; 39 percent indicated that patient records and financial systems are computer based but separate; and 12 percent indicated that patient records and financial systems are to

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis FIGURE 1 The Diffusion of Innovation and the Use of E-Mail for Patient Education. some extent or entirely integrated. Computer-based records tended to be concentrated in hospital units. The majority (58 percent) of the sites interviewed were either linked or had access to patient data from other units, such as laboratories, pharmacies, or the emergency department. Some micro-systems used computer-based information systems to generate reports about their practice (n = 15), to support real-time patient care (n = 12), or to support clinical decisions (n = 6). Only one micro-system indicated that the clinical information system includes direct data input by patients (patients use a touch pad to answer relevant questions and report on their health status), You would be given a touchpad computer when you come in for your visit for filling out all the intake information. Your picture would be taken digitally. All this would happen, and the doctor would see it, before you see the doctor. The doctor would explain your responses—e.g., what the SF-36 score means. Improvement The micro-systems provided rich examples of improvement projects. Respondents commented about what they had done to redesign services and to improve the quality of care and how they knew that these efforts were successful. Projects range from improving clinical

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis care (such as improving diabetes or asthma care), to improving administrative or service aspects of care (such as scheduling or reducing delays). When asked about the context for quality improvement efforts, respondents frequently cited time and financial constraints and lack of organizational support for improvement. The amount of change in staff is huge. Staff changes are as frequent as every month. Second, building our team and dealing with the administration that deals with 20 physicians has also been tough. . . . One hand, they say “work as a team,” and on the other hand, they don't let the team meet or work together. . . . The last barrier is still having a paper-based medical record. This is the primary source of information. There is definitely a lag time before all the information is there. One site noted the need for improvement teams to be anchored in the micro-system. We did something wrong the first time. We created an ad hoc team to lower infection rates. They brought the [suggestions for] change back to the unit. The unit didn't want to make the changes. The improvement team was “offline.”. . . Our goal is to make a unit that creates improvements. Respondents were asked if the micro-system uses any guidelines, protocols, or expert systems to help clinicians get up-to-date information. Most micro-systems have guidelines and protocols in place and cited many instances of their adaptation, use, and development. However, most reported difficulty in integrating the guidelines and protocols into the daily work of the micro-system. There are a lot of guidelines in most institutions, but the way they are implemented destroys their usefulness. For example, the diabetes guidelines are 40 pages. As a physician, I look at them and decide on the two to three most important things that should be done, and I work on getting those done consistently. Work on the others later. Even this is very hard to implement consistently. A few of the respondents mentioned formal benchmarking arrangements with other organizations. Overall, among the sites interviewed, there appears to be a lack of a formal mechanism for learning about best practices and for sharing new information. Patient Safety. With the recent publication of the Institute of Medicine's report, To Err is Human, 28 national attention has been focused on medical errors and patient safety. One part of the micro-systems interview asked participants to describe what happens in their micro-system when someone makes an error. It also asked about the major sources of error or harm, the extent to which there is a blame free culture, and procedures that had been implemented to improve patient safety. Medication errors and follow-up of abnormal lab results were the most frequently mentioned sources of error. Several respondents described formal mecha-

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis nisms that were in place. For those without a formal mechanism, talking about errors appeared to be more difficult. It's hard to talk about “error” because it is culturally not acceptable for fear of litigation. But we try. Several respondents recognize the importance of a systems approach to reducing errors. If something bad happens, it seems to me then the system has set the person up for failure. When you gather the data, it almost never is what it seems to be. We had a patient who wasn't doing well. The physician ordered lidocaine. The nurse gave the patient a whole amp of epinephrine. We all thought “how stupid.” But when we started looking at the medications they were beside each other in almost identical boxes. Still, she shouldn't have made the mistake, but you could see how it could happen the way we had things set up. The system can be an advocate. It can be a reminder that a mammogram needs to be done, that there is a system in place to make sure it happens, that things go well. A system can also empower the medical assistant to insist that a patient be seen, even if it means clashing with a provider. Leadership and Management: Lessons for Replication The last section of the interview was a set of questions related to leadership and replication, including: the role of the macro-system, financial structures for payment and rewards that would be ideal for improving the quality of care, key factors to success—the key lessons for others who would like to replicate what had been done, the major barriers to replicating this elsewhere, and how barriers had been overcome. Most micro-systems function within a larger system, or “macro-system.” It is possible that micro-systems are successful only in certain organizational environments. On the other hand, a micro-system could fail because of its organizational environment. Respondents were asked to provide examples of helpful and toxic ways the macro-system affected the care they provided. Respondents provided examples of supportive macro-systems—that is, supportive in providing resources or in creating the environment or culture for the micro-system's work. However, the tension between the micro- and macro-system was evident in other responses. They have been very supportive in terms of wanting to do cutting edge work. The priority for the system is patient care. They identified areas where CQI teams were needed. They supported us financially too. They have paid close attention to the results. They have identified __ care as an area where they want a center of excellence. It is a priority of the system. The administration is a barrier. Sometimes I wish that they would just open the door and get out of the way. Respondents were asked to comment on what they would consider to be an ideal financial structure for improving the quality of care. Among the respondents asked this ques-

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis tion, a common response was to have some sort of capitated system, as suggested in the following comment. To encourage improvement, you need a structure that makes you responsible for a defined population—some sort of capitated system. In a couple of sections here, the payment scheme is fee-for-service—this makes people less involved in the team. The incentive is to maximize their own profits. This hurts improvement efforts. This section of the interview was of special interest to the IOM Committee on Quality of Health Care. Because it has been difficult to deploy improvements either within or across organizations, 29 , 30 we were particularly interested in what micro-system respondents would tell us about how to replicate what they were accomplishing. Many of those interviewed expressed clear ideas about how they were reorganizing practices, their principles for doing so, and their commitment to an ongoing process. Respondents described their early limited successes or outright failures. We heard what had and had not been successful, If you can have those three things in place before you start—the right team, the senior leader support, and the financial issues resolved—you can replicate what we have done. What we are doing is not undoable in other places. In many cases it's just common sense. It is helpful to have a clear sense of goals, a philosophy of the service. Line everything else up with that. Funding must be aligned somehow to make the model possible. It is helpful to have some leaders who are in the micro-system all the time working on the administrative and organizational support of the model of care. We get visitors a lot. . . . They are interested in how everyone involved understands the goal of care, the high level of communication. Productivity expectations, but paid on salaries, are helpful for improvement. Plus recognition for those working on improvements. There isn't a hierarchy of how much opinions are valued. Everyone's opinions are valued. The meetings and care plans are done for a thought out reason. It isn't by accident that this is how we got here. It would help to have supervision from someone who has done the model. Our model has been replicated. Mentoring has helped. There needs to be a connection over time—someone to talk to about difficulties and barriers as they occur. Talk it through with someone who has been there. It's hard to set up a model just by reading about it.

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis Respondent answers about requirements for replication could be grouped into six “lessons for replication”: Executive and governance-level support for innovation and improvement efforts, Strong, focused, and sustained clinical leadership, Collaboratively functioning multidisciplinary clinical teams, Explicit attention to the development of systems of care, Good information systems that made measurement of their performance possible, and A focus on the needs of patients. Sections below explain each of these factors and include tables with illustrative verbatim comments. Executive and Governance-Level Support for Innovation and Improvement Efforts. Most micro-systems function within a larger system, or “macro-system.” In this study, the macro-system was generally a hospital or health plan. Micro-system leaders repeatedly cited the support of senior executive management as a sine qua non to their ability to succeed (Table 5). Respondents cited support of their efforts at innovation as critical, whether by setting direction, demonstrating interest and attending to the results, by providing financial and administrative resources, or the “space” for innovation despite sometimes strong external financial pressure. Support included a willingness to set aside time for the micro-system leaders and members to work on improvement rather than their having to carve it out of other clinical responsibilities. In such micro-systems, the aim(s) of the micro-system are consistent with the aims of the larger “macro” system. Strong, Focused, and Sustained Clinical Leadership. A second area that emerged very clearly as leaders articulated how their work might be replicated was the need for strong clinical leadership at the micro-system level combined with a clear sense of purpose or aim that guides the work (Table 6). Respondents cited a high level of energy, focus, credibility, commitment, patience, and inclusiveness as important to success. Where aims are clear, they are communicated across micro-system boundaries, “When I walk in a room, everyone thinks, ‘diabetes.' ” Collaboratively Functioning Multidisciplinary Clinical Teams. Respondents cited the importance of collaborative work both for clinical care and for improvement efforts (Table 7). They emphasized the need for quality improvement work to be based within the team, the need to recognize the contributions that all members of the group could make, with various members taking leadership roles for specific improvement activities. They also described new or expanded roles and the need for coaching and training new members of the micro-system in their work relationships. Explicit Attention to the Development of Systems of Care. Respondents often cited their micro-system's investment in improving their systems of care, and they identified such work as being as critical to their micro-system as one-on-one patient care (Table 8). This investment

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis TABLE 5 Importance of Executive and Governance-level Support for Innovation and Improvement Efforts Type of Micro-System Comments Spine center They provided space, money, people, and a chance to make my vision a reality. Breast care center They have been very supportive of cutting edge work. They identified areas where CQI teams were needed. They supported us financially, too. They have paid close attention to the results. They have identified breast care as an area where they want a center of excellence. It is a priority of the system. Advance care planning team We had the commitment from top administrators—the presidents from four systems set up the task force. The task force was to talk about ways to collaborate to improve healthcare. We set as a goal that at least 50 percent of adults in our community would have an advance care plan before a crisis and that the program we implemented to do this would be accepted by the community. The endorsement from the administrators made the task force much easier.... I met very little resistance. My organization, in particular, put a lot of importance on this and asked me to put a lot of time in it. I wasn't just asked to work it in to my other responsibilities. Ophthalmic center We can make changes quickly and are free to make investments and commit resources to change. We recently created a management services division here. We help other clinics and care sites to do marketing, quality improvement in patient flow, etc. The larger organization provided us with some resources to allow us to do this. Endoscopy unit The top leadership support must be there—if the CEO is directly obstructing you, just pack your bags and leave. Emergency department The hospital system has shown great effort in helping us out with patient restraint protocols. Restraint management has been an area where they have excelled and this has made the ER a safe place to work. They are also helping us out in quality end-of-life issues and identifying how cultural differences necessitate individualized care. Hospital cardiac care service The VP of Medical Staff has worked with the physicians. The Chief of Staff was supportive of disease management. The 12 chiefs work closely with our department. If they are given numbers they don' t like, the VP of Medical Staff will not let them get by with that. They have to work to improve it. Newborn intensive care Someone at the leadership level has to be committed to good quality. You must keep the stimulus there to be the best. Leadership must think of ways to encourage, support change, and think of ways to change.

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis   Patients don't want to go to an urgent care clinic. When they are sick they want to see “my doctor.” The reason they needed to go to the urgent care clinic was because of the backlog of appointments which made it increasingly unlikely they would see their doctor. I call this the “urgent care death spiral.” The only way to solve this is to get rid of the backlog. We knew that the number of patients seen daily were about the same as those calling to be seen. But of those who called, some were seen the same day as an urgent visit, and those who could wait were given routine appointments. Now we adopted the principle: If you call today, we will see you. If your own doctor is here, she'll see you. We closed the urgent care clinics and distributed the urgent care doctors to the various offices. We decided it was a big mistake to divide people into the streams: well, acute, and chronic because: a) the patient doesn't see him/herself that way—they divide themselves by their doctor; b) wellness, acute illness, and chronic care are dynamic-needs. All three exist at various times and often simultaneously; c) it is a waste of time to try to get them into the right category, and we don't get it right anyway; d) it increases work in the system because all the urgent care clinic does is acute care and they have to make another appointment for chronic and wellness care; and e) it turns nurses and appointment staff into antagonists of patients who have to fit into the correct category of urgent or not be allowed to come in. In the old system, we had a steady state-constant input and output and a “lake of waiting ” in the middle. This system eliminated the “lake.” We used a carrot and stick approach: the carrot: you get to take care of your own patients. The stick: You have to take care of your own patients. The number of patient visits went down by 8 percent. Using this system all our preventive care numbers went up—pneumovax, pap smears, mammograms.

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis II. Cross-Case Analysis—Themes Related to Effective Micro-System Performance Using cross-case analysis, we identified several common themes that appeared repeatedly during the interviews. Each micro-system can be arrayed on each scale along a spectrum of “low” to “high.” Table 11 lists each factor and the percentage of micro-systems for which that theme was raised during the interview. In the table, the themes are arranged from the highest to the lowest percentage of micro-systems in which they appeared. Integration of Information Micro-systems vary on how well information from a variety of sources is integrated into the daily work of the micro-system and the role that technology plays in integrating information among clinician, patients, and other members of the micro-system. Some micro-systems have developed advanced systems, but providing useful, timely, and accurate information is a huge task for micro-systems, and even in these high performing micro-systems, the potential of information technology has not, for the most part, yet been tapped. If you were a patient you would experience care differently here compared to the care you might receive elsewhere. You would be given a touchpad computer when you come in for your visit for filling out all the intake information. Your picture would be taken digitally. All this would happen, and I would see it, before you see me. I would explain what your responses mean. Most of the information is there; you have to find a way to harness it. Really all that is needed is a simple system to get back information quickly. Computers, lines, high tech come to mind but it doesn't have to be that way. Talking is a way to communicate too. Information technology doesn't have to be an elaborate system. Table 12 provides several verbatim responses from the interviews that illustrate low and high levels of integration of information. Measurement Effective micro-systems measure their own performance and use that information to modify the care of individual patients and their processes of care. Part of the work of the micro-system is the development of a set of measures that are appropriate for its own goals. Although all the micro-system are measuring some outcomes, many lack measures that are useful for their daily work. As one Table 10 respondent said, “At the local level I don't get the measures that I need and the measures that I get at the regional level aren't at the level I need.” It may be that recognition of the need and type of useful measures and finding ways to gather those data are important for high performance. Table 13 provides examples of low and high levels of measurement.

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis TABLE 11 Summary of Micro-System Framework Integration of information Low High Information free environment Information is key, technology may be very helpful “We don't have control over the information that we need.” “I can show diabetics a graph of their HgA1c and comment on how it has dropped along with their weight which is graphed on the same screen.” Measurement Low High Absence of a set of useful measures Micro-system routinely measures processes and outcomes, feeds data back to providers, makes changes based on data “We have data on demograhics and length of stay, however, we don't have data on outcomes of care.” “We have developed a radar screen that has eight simultaneous processes continuously monitored.” Interdependence of care team Low High Providers and staff function as individuals, No clear way of sharing information or communicating Care provided by a multidisciplinary team, Information is key to the relationship “Often physicians have difficulty working with non-physician providers, giving them the control.” “We developed multidisciplinary rounds—everyone involved in caring for the patient.” Supportiveness of the larger system Low High Larger organization's actions perceived as “toxic” to the micro-system Micro-system views larger organization as helpful “If we have to practice like the rest of the system, we feel that we'll be practicing ‘mediocre' care.” “They have identified breast care as an area where they want a center of excellence. It is a priority of the system.” Constancy of purpose Low High Lack of a clear, consistent aim Integration of the aim throughout the micro-system “The original aim was that we would practice the best medicine we could, understanding that we couldn't be as financially successful. Now some of the physicians are compromising for the financial aspects. ” “Those other sites saw an infection as a failure, not entitlement. All the way to the bedside the unit knew that infection was a failure. The philosophy has to permeate the organization.” Connection to community Low High No clear connection to community beyond current patient population Micro-system is a resource to the community, community is a resource to the micro-system “The only way we get information about the community is from the managed care organization.” “I invite the peer support groups that are in the community to educate the residents.” Investment in improvement Low High Training, resources not available Resources made available for improvement (training, $$, time) “We don't know how to improve the system. We have closets full of good ideas but don't know how to implement them.” “The Quality Council's goal will be to provide guidance and facilitation. ‘Yes, that project meets our overall goals, what resources do you need?'” Alignment of role and training Low High Health professionals not expected to work within the limits of their education, certification(overqualified) Health professionals expected to work at the upper limits of education, training “I want to be more involved in the care process.” “When fully trained and confident they may tell an admitting doc that a patient is not ready to have a ventilator tube removed.”

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis TABLE 12 Micro-System Examples of Integration of Information Integration of information Low High Information free environment Information is key, Technology may be helpful “We don't have control over the information that we need. We need to be able to define who our panels are—we can't do that ourselves. Control of information is a barrier. Change will be more rapid in the teams as we have more control over the information.” “I can show diabetics a graph of their HgA1-C and comment on how it has dropped along with their weight which is graphed on the same screen. I can also refer them to web sites, for example, if they are interested in alternative care, acupuncture, asthma management. One thing I have been concerned about is how to communicate using the computer without losing contact [while you put information into the computer]. By having the medical assistant enter the information, I can invite them to tell the whole story, and I can listen, so it actually increases communication.” “If you aren't going to have the same nurse working with the patient then you have to have better communication. Patients get the best care when you have health care workers who communicate very well and collaborate very well. One of the biggest problems I see is physicians not talking to each other. Also, so many nurses work part-time, varying shifts. We struggle with getting them to communicate. It's hard to get them to put equal emphasis on communicating, documenting, teaching and the physical tasks that need to be done before the end of the shift. You don't get the same negative feedback from your coworkers if you aren't teaching the patient as you do if you leave some of the physical tasks undone at the end of the shift. A nurse will prioritize and get every thing done before the end of the shift, but they don't look at the patient's care plan and do the teaching that needs to be done before discharge.” “The team that takes care of patients is a working group that meets daily for 45-60 minutes. We discuss the status of all the patients and we brainstorm treatments as well as discharge planning there. All patients are listed on this blackboard that is used to organize information on the care process for each of the patients.” “At 7 p.m. one evening a person was giving care to a patient in a hospital who was receiving cancer treatment. The patient wanted an advance directive—if my heart stops, I don't want CPR. The person told the nurse at the unit desk about this request and asked that the nurse please tell the doctor. The doctor never heard this. At 6 am the next morning, the patient had a cardiac arrest and a code was called. 20 minutes into a code the request was seen in the patient's record that the patient didn't want this to happen. We saw that there was not a clear responsibility to report the request to the nurse, to report to the MD. The physician always decides whether an order will be written or whether to go talk to the patient before writing the order. The system worked a lot of the time, but it wasn't consistent.” “Sharing information with patients is the biggest safeguard (against medical error). The electronic medical record (EMR) does drug-drug interaction alerts. When the patient leaves the office, he/she gets a printout of their medication list. Once in a while a patient will call later and say, ‘I was looking over the list, and I am not taking x anymore, but Dr. So and So has put me on y.' It takes all of us. Another safeguard is that the system we use forces me to consider all the possibilities. For example, if a patient comes in with headaches and vomiting, it has a structured sequence that makes you consider the causes, including cerebral hemorrhage.”

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis Interdependence of the Care Team Members One element of a micro-system is the key players—the practitioners and staff who work together on a daily basis, but like the other features examined, the interdependence of the care team varied across micro-systems. Table 14 provides examples of interdependence of members of the care team. In sites with a high degree of interdependence, the existence and recognition of the importance of the team approach to care was evident in the interviews. We developed multidisciplinary rounds—everyone involved in caring for the patient. The major value is having everyone communicate directly with one another. Each person knows they may be asked about the patient and has to be prepared. We believe strongly that in team care, staff satisfaction is very important. Everyone is not equal, but everyone is important and has a different responsibility. I try to make sure that the clinicians know that working here requires a balance of getting to do what you want to do and of doing things as part of a team. Supportiveness of the Larger System Supportiveness of the larger (“macro”) system overlaps with other factors. In high performing micro-systems, the aim(s) of the micro-system is consistent with the aim(s) of the larger system. The interviews made clear that the larger system demonstrates that improvement is a priority by making the necessary resources available to the micro-system. Even though there is overlap with other factors, it is important to recognize the importance of the larger system for the success of the micro-system. Table 15 provides examples of such supportiveness by the larger. We can make changes quickly and are free to make investments and commit resources to change. We recently created a management services division here. We help other clinics and care sites to do marketing, quality improvement in patient flow, etc. This is our entrepreneurial spirit. The larger organization provided us with some resources to allow us to do this. The hospital system has shown great effort in helping us out with patient restraint protocols. Restraint management has been an area where they have excelled and this has made the ER a safe place to work. They are also helping us out in quality end-of-life issues and how cultural differences of people necessitate individualized care. Lack of support and shared aims was cited even by some high-performing micro-systems as an impediment to the micro-system effectiveness. It is a mixed message. The organization talks about team care but then subverts their vision. They put in a centralized phone system with a nurse in charge of scheduling appointments. Well, she has no way of knowing whether Doctor X and Y are on the same team.

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis TABLE 13 Micro-System Examples of Measurement Measurement Low High Absence of a set of useful measures Micro-system routinely measures processes and outcomes, feeds data back to providers, makes changes based on data “I think we are deficient in measuring. We are measuring the more global outcomes.” “We have developed a radar screen that has eight simultaneous processes continuously monitored. Each process is depicted in 15 minutes cut of data for the last four hours. We know where in the process not only the patient is, but where the system is. Each process measured is summarized on the screen by graphs. All we have to do to obtain data is touch the screen. When we obtain three consecutive 15 minute intervals going in the wrong way, we realize that something needs to be done.” “When it comes to collecting raw data, we have found it to be difficult. We have data on demographics, and length of stay, however we don 't have data on outcomes of care. This will come soon in the future. ” “We use a value compass. We can query a database at any time for individual patients, but also for all patients we serve. We are also hooked up to 26 other centers. We can look at data by the point of service or longitudinally. We measure functional status, health status, work measures, treatment, who you have seen (type of provider), age, sex, height, weight, SF36, satisfaction, clinical comorbidities, smoking, cost of lost work over time.” “Other people use surveys and other ways to benchmark. We just do it seat-of-the-pants. We figure that we will get feedback. We don 't use any modern techniques to measure anything. It's very expensive. We don't have extra capital to invest in recreational data collection to prove how we are doing to someone else when we know how we are doing. ” “We track our endpoints extensively and have been able to do 3-yr follow-up of 75-85% of patients. We have an annual banquet in January and invite all former patients to come. 80% of those whose surgery was in the last 2 years come to this banquet. We book a large hotel, and they are our guests. It is social but also an opportunity to do a follow-up check. We have 15 doctors doing exams. 700-800 people generally come. There is a lot of camaraderie among patients.” “Every physician says they practice excellent medicine, but you have to look at some other parameters. We look at HEDIS and NCQA. It' s hard to look at other outcomes—no one knows how to do that.” “The development of an instrument panel of measures has been very important, then feeding this back to the staff has really stimulated our thinking.” “There was a problem with how to track it [data about meeting open access goals]. There were problems because the physicians weren' t getting feedback on time about how they were doing working down the backlog and meeting open access goals. Then the MDs wouldn't get the incentive because they hadn't met the goals.” “We can track process length through our real time ‘flight simulator' system. By touching the screen, we instantly know such things as arrival to bed, bed to nurse, arrival to doctor aggregated cycle times.”

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis TABLE 14 Micro-System Examples of Interdependence of Care Team Interdependence of care team Low High Providers and staff function as individuals No clear way of sharing information or communicating Care provided by a multidisciplinary team Information is key to the relationship “Often physicians have difficulty working with non-physician providers, giving them the control, Some physicians don't do well sharing responsibility for patient care like this.” “We developed multidisciplinary rounds—everyone involved in caring for the patient. The major value is having everyone communicate directly with one another. Each person knows they may be asked about the patients and has to be prepared.” “It's always hard when we get new clinicians. They aren't used to working with paraprofessionals in the community. We try to illustrate what works. Doctors focus on what they do in the exam room but that's not enough.” “It is impossible for one individual to take care of an elderly person. Older and frail people have many health needs that can only be met by a group of dedicated individuals.” “Finally, not all doctors like the interdisciplinary philosophy. They like to do whatever they want” “There are just the three of us. We work very well together. M. is in charge of the office, I am in charge of the patients, and Dr. D. is the physician champion. He holds the key to resources and new patients.” “We created a phone center to handle problems with phone access. We have six people answering phones. I saw it as decentralization and didn't like that idea for the micro-system concept. My phone nurse knows my patients—she knows when a patient really needs 20 minutes instead of 10. This has been borne out with the phone center and it is still hard to get through [on the phone].” “We believe strongly that in team care, staff satisfaction is very important. Everyone is not equal, but everyone is important and has a different responsibility. I try to make sure that the clinicians know that working here requires a balance of getting to do what you want to do and of doing things as part of a team.” Constancy of Purpose A theme that emerged clearly in these interviews was the importance of “constancy of purpose,” or aim that guides the work of the micro-system. As Table 16 illustrates, where aims are clear, they are communicated across micro-system boundaries. In contrast, lack of a clear consistent aim may be destructive of the micro-system and, ultimately, of patient care. One respondent discussed the change in aims that his micro-system had undergone. The thing that distinguished those places that are achieving excellence is the organizational culture. Our culture [used to be], “Of course babies get infections. They are not well to begin with.” But other sites saw an infection as a failure, not an entitlement. All the way to the bedside the unit knew that infection was a failure. That philosophy has to permeate the organization. What we do well is communicate the importance of diabetes care—up to the senior leaders of the organization; across to other providers' and out, to the community. We are advocates for our own work. Whenever I walk into a room, people think “diabetes.”

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis TABLE 15 Micro-System Examples of Supportiveness of the Larger System Supportiveness of the larger system Low High Larger organization's actions perceived as “toxic” to the micro-system Micro-system views larger organization as helpful “I think that there is a barrier at the institutional level. For example, the institution has launched a Clinical Consistency Program. Basically, they want every place in their system to practice the same way. However, this hurts us because we have found ways to do things efficiently here, and if we have to practice like the rest of the system, we feel that we'll be practicing ‘mediocre' care. Thus, there is a philosophical barrier.” “They have been very supportive in terms of wanting to do cutting edge work. The priority for the system is patient care. They identified areas where CQI teamswere needed. That is where the Breast Care team came up. They supported us financially too. They have paid close atat we do well is communicate the importance of diabetes care—up to the senior leaders of the organization; across to other providers' and out, to the community. We are advocates for our own work. Whenever I walk into a room, people think “diabetes.” "At the system level the priorities for the sysytem are not he same as the priorities for me in primary care." "We had the commitment from top administrators— the Presidents from four systems set up the task force. The task force was to talk about ways to collaborate to improve healthcare. We set as a goal that at least 50 percent of adults in our community would have an advance care plan before a crisis. and that the program we implemented to do this would be accepted by the community. The endorsement from the administrators made the task force much easier. In other communities, that support may not be there. I could go to medical records and say this is what I need—and I need to report back to the 4 presidents. I met very little resistance. My organization in particular put a lot of time in it. I wasn't just asked to work it in to my other responsibilities. "The corporate policy for open access was a barrier and facilitator at the same time. The way corporate defined open access wasen't really open access and they set incentives based on their definition. Some people had different views about what open access was. For us, it was 'doing today's work today.' For corporate, it was 'if your schedule is open 75% a week out you will get a bonus'." "We can make changes quickly and are free to make investments and commit resources to change. We recently created a management services division here. We help other clinics and care sites to do marketing, quality improvement in patient flow, etc.. This is our entrepreneurial spirit. The larget organization provided us with some resources to allow us to do this." "It is a mixed message. The organization talks about team care but then subverts their vision— they put in a centralized phone system with a nurse in charge of scheduling appointments. Well she has no way of knowing whether Doctor X and Y are on the same team. If a patient of Dr. X cannot go to Dr. X because he is on vacation, the nurse may send the patient to Dr. Z though Dr. Y is on Dr. X's team. so insted of the patient going to Dr. Y, they go to Dr. Z." "The hospital system has shown great effort in helping us out with patient restraint protocols. Restraint management has been an area where they have excelled and this has made the ER a safe place to work. they are also helping us out in quality end-of-life issues and how cultural differences of people necessitate individualized care."

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis Connection to Community High performing micro-systems define the boundaries of caring for a population of patients quite broadly; that is, they are connected to the community in a way that allows the micro-system to serve as a resource for the community. An unanticipated finding of this study was that for several of the sites, the micro-systems had discovered that the community was a resource for the micro-system as well. Connection to community (as described in the examples in Table 17) represents a fruitful relationship between the micro-system and the community that extends well beyond the clinical care of a defined set of patients. It's always hard when we get new clinicians. They aren't used to working with para-professionals in the community. We try to illustrate what works. MDs focus on what do in the exam room, but that's not enough. Forty percent of our patients are self-pay. We use a sliding fee schedule. Our minimum fee is usually eight dollars. Sometimes the patient asks us to waive this. In January, Social Services started asking them to use "time dollars"— that's part of our MORE (member organized resource exchange) time dollar exchange. What are you willing to do for your neighbors? Some people don't have any ideas, so we show them a list of things people do—reading to children, etc. If they agree to pay their bill way, someone will get in touch with them to follow-up. This Has really been a shift in thinking—for staff as well as patients. It's easier for thestaff person to just waive the $8 fee. Investment in Improvement High performing micro-systems make improvement a priority by making an investment. Examples of this dimension are shown in Table 18. This investment comes in the form of resources, such as time, mpney, and training, but also as an investment in creating the culture of the micro-system. For example, a respondent from a neonatal intensive care unit said, "We charged the entire operating structure of the unit with improvement." In a given week we are spending about 100 person-hours on teams. People are being paid to spend their time doing this, not just during their lunch hour. Someone said, "You have to assume you'll be around here five years from now. Do you want to be doing things the same way?" Most of us don't. This requires a new attitude that results in understanding that industries must invest in change in these micro-systems. You have to tolerate pulling people offline to work. This is a radically new way of thinking in medicine which traditionally views any sort of meeting as a waste of time. Traditionally, the views is that the only useful time is spent seeing patients. I think that unless you spend time considering how to deliver care better, much of that time seeing patients is wasted.

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis TABLE 16 Micro-System Examples of Constancy of Purpose Constancy of purpose Low High Lack of a clear, consistent aim Integration of the aim throughout the micro-system “There is some divergence in the practice. The original aim was that we would practice the best medicine we could, understanding that we couldn't be as financially successful. Now some of the physicians are compromising for the financial aspects. They are spending less time with patients, care is not as complete.” “What we do well is communicate the importance of diabetes care—up to the senior leaders of the organization; across to other providers ' and out, to the community. We are advocates for our own work. Whenever I walk into a room, people think diabetes.” “At the department level there are barriers. We try to make changes across departments because in the community we don't want to treat patients differently because of the department they go to for care (pediatics versus internal medicine or family practice). The barrier is to get agreement for everyone to make the change after one group pilots it. Every group doesn't need to pilot it before making the change.” “Our principle is that all of today's work is done today.” “I feel strongly that if we could have more time with patients for coaching, behavioral changes, and attitude changes we could improve diabetes care. Nobody wants to do anything if it isn't reimbursed. Wherever the $ goes that is where the service goes. Now there isn 't adequate time or resources for teaching patients in any setting. Patients are so sick now when they are in the hospital, they are often too sick for any teaching. So we end up teaching the family members. God help the person who doesn't have a family member at home to help them.” “The focus of this micro-system is improving advance care planning through systems of healthcare. This is a joint effort of 2 healthcare systems. They assist and encourage adults to do advance care planning and them make sure written plans are available and followed. These 2 healthcare systems are competitors—competing for the same patients. ” “There are various ways that health care workers let patients know that we are busy—don't tell us that you are having a problem because we don't have time to deal with that. For a lot of nurses the reason for being a nurse was to relieve pain and suffering. But then we send the message that we don't have time to help you.” “A lot of our work is around controlling chronic illness, addressing the co-mordities, maintaining quality of life. We want the patient to maintain community residence for as long as possible. This is an HMO—we are the payor—if the patient goes to a nursing home we pay for that care and monitor the care. It makes sense for us, financially and philosophically, to maintain the community residence as long as possible. The best thing we can do is keep them out of the nursing home.” Alignment of Role and Training Within the multidisciplinary team, several sites mentioned an alignment of role and training. That is, they described a deliberate effort to match the team member's education, training, and licensure with their role. Although several sites reported that this led to increased staff satisfaction and lower turnover, they acknowledged that some staff were uncomfortable working in an expanded role. As one respondent noted, “Casualties move on to other parts of the hospital.”

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis TABLE 17 Micro-System Examples of Connection to Community Connection to community Low High No clear connection to community beyond current patient population Micro-system is a resource to the community, community is a resource to the micro-system “Patient surveys are done periodically (so far we have only done two). We have one page exit interviews. We haven't changed a lot based on these surveys.” “There has been a strong consumer movement recently on creating peer support centers. These are not run by our group but by consumers. We refer people to them and then we participate by providing some of the educational seminars. I invite the peer support groups in that are in the community to educate the residents. It really is an eye-opener for the residents. I think that as physicians a lot of us don't have any idea what it is like to live with a mental the residents about it.” peer support centers let people with the illness teach illness. And none of the education teaches that. The “The only way we get information about the community is from the managed care organization.” “The neonatology group has a commitment of being a resource to the region. We have a commitment to the health of a population. This is crucial to our success. As a resource, we provide education and review the quality of care for the whole region.” “The community used to look at us as leaders. But the hospital was taken over by a large system. So we aren't community leaders anymore. We need the healthcare dollars to come to the community and then we decide how to take care of the community. The trustees of the hospital have no idea about healthcare or affecting change.” “40 percent of our patients are self-pay. We use a sliding fee schedule. Our minimum fee is usually $8. Sometimes the patient asks us to waive this. In January, Social Services started asking them to use ‘time dollars'—that's part of our MORE (member organized resource exchange) time dollar exchange. What are you willing to do for your neighbors? Some people don't have any ideas, so we show them a list of things people do—reading to children, etc. If they agree to pay their bill that way, someone will get in touch with them to follow-up. This has really been a shift in thinking—staff as well as patients. It's easier for the staff person to just waive the $8 fee.” Micro-systems without a high level of alignment of role and training (60 percent of the sites) did not provide examples that indicate that this is an area they have addressed. However, micro-systems that emphasized this function, noted its potential contribution to the overall functioning of the micro-system (Table 19). The receptionist talks them through the systems of the office. They are trained to follow through specific areas of care such as screening, childhood immunization, and antenatal care, so they have one person to contact. They have become expert in their areas. If the Respiratory Therapist notes an abnormal lab value, she is comfortable not just taking a blood sample and reporting it, but managing it. The technicians are caregivers. Expectations have changed. The ones that stay are good