through 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, product 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, automatable 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 experimentation. 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 predecessors; 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. Organizations 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 coworkers 6 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 complex 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 technologies they use. Nelson and his colleagues 7 have described the essential elements of a micro-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.

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