at adjusting therapy to within physiological parameters. They are cross-trained so that they can take on nursing tasks, for example, starting IVs when needed. When fully trained and confident, they may tell an admitting doc that a patient is not ready to have a ventilator tube removed.

CONCLUSIONS AND DIRECTIONS FOR FURTHER RESEARCH AND POLICY

Limitations of This Research

There are limitations to all sampling strategies and to qualitative research, in particular. The strength of this method was that the sample selection used input from a pool of reognized experts in the organization, delivery, and improvement of health care. Even with a pool of recognized experts, it is reasonable to expect that some high performing micro-systems were overlooked. It was also possible that less than high performing micro-systems were included. In fact, a concern was how to ensure that the micro-systems included in the

TABLE 18 Micro-System Examples of Investment in Improvement

Investment in improvement

Low

High

Training, resources not available

Resources made available for improvement (training, $$, time)

“One change was to get people to carry medication cards in their wallets. We talked about it for 10 minutes or so and decided to do it. But it didn't work. We don't know how to implement it. We don't know how to flowchart. We don't know how to improve the system. We have closets full of good ideas but don't know how to implement them.”

“We have a manager for staff development. She works on skill building and coaches the teams in how we get along. It's important to assign the role of staff development to someone.”

“Our micro-system is a prisoner of our macro-system. If it isn't important for the macro-system, we have no incentive to do it and improvement hasn't been a priority.”

“We put together a guidance team and the idea was that this team would tell us what to work on. But I saw most of the good ideas coming from the front lines. The front line needed to be empowered to make the changes. So, now the guidance team will become the quality council. It will have membership from each of the three teams. Changes that teams want to work on will be presented to the Quality Council—‘this is what we want to do, we want to use this method.' The Council's goal will be to provide guidance and facilitation. ‘Yes, that project meets our overall goals, what resources do you need?'”

“We look at the data and say, ‘what can we do to make this better . . .' but there is so much pressure to reduce the time we see with patients and see more patients every day. Now there is pressure from the organization to see patients at 10 minute intervals. They are going to start to tie incentives to that. Each physician will have to decide how to deal with that more money, less hours, etc.”

“Remember that even when it seems you have accomplished something, new people come who were not party to the original plans. Before you know it, you've fallen back. We used to think that people would learn the systems by osmosis. Now, they have a formal induction system to explain and show people how the systems should work.”



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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis at adjusting therapy to within physiological parameters. They are cross-trained so that they can take on nursing tasks, for example, starting IVs when needed. When fully trained and confident, they may tell an admitting doc that a patient is not ready to have a ventilator tube removed. CONCLUSIONS AND DIRECTIONS FOR FURTHER RESEARCH AND POLICY Limitations of This Research There are limitations to all sampling strategies and to qualitative research, in particular. The strength of this method was that the sample selection used input from a pool of reognized experts in the organization, delivery, and improvement of health care. Even with a pool of recognized experts, it is reasonable to expect that some high performing micro-systems were overlooked. It was also possible that less than high performing micro-systems were included. In fact, a concern was how to ensure that the micro-systems included in the TABLE 18 Micro-System Examples of Investment in Improvement Investment in improvement Low High Training, resources not available Resources made available for improvement (training, $$, time) “One change was to get people to carry medication cards in their wallets. We talked about it for 10 minutes or so and decided to do it. But it didn't work. We don't know how to implement it. We don't know how to flowchart. We don't know how to improve the system. We have closets full of good ideas but don't know how to implement them.” “We have a manager for staff development. She works on skill building and coaches the teams in how we get along. It's important to assign the role of staff development to someone.” “Our micro-system is a prisoner of our macro-system. If it isn't important for the macro-system, we have no incentive to do it and improvement hasn't been a priority.” “We put together a guidance team and the idea was that this team would tell us what to work on. But I saw most of the good ideas coming from the front lines. The front line needed to be empowered to make the changes. So, now the guidance team will become the quality council. It will have membership from each of the three teams. Changes that teams want to work on will be presented to the Quality Council—‘this is what we want to do, we want to use this method.' The Council's goal will be to provide guidance and facilitation. ‘Yes, that project meets our overall goals, what resources do you need?'” “We look at the data and say, ‘what can we do to make this better . . .' but there is so much pressure to reduce the time we see with patients and see more patients every day. Now there is pressure from the organization to see patients at 10 minute intervals. They are going to start to tie incentives to that. Each physician will have to decide how to deal with that more money, less hours, etc.” “Remember that even when it seems you have accomplished something, new people come who were not party to the original plans. Before you know it, you've fallen back. We used to think that people would learn the systems by osmosis. Now, they have a formal induction system to explain and show people how the systems should work.”

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis “We started looking at the data because we had a high rate of wound infection after CABG. We brought together all the different people and looked at all the different issues over 2 years. We found that there is a strong correlation between diabetes and infection, which the national data shows too. We decided that we should work on managing blood sugars before, during, and after surgery. As it turns out, there are so many primary care providers referring patients—we couldn 't agree on a way to work on blood sugars before surgery and they didn't want to invest the resources that would be necessary to do this. We couldn't get any primary care providers to work with us on this because working on improvement impacts their productivity, which impacts how much they are paid. Even though it was clear what needed to be done, they chose the easier way and started working on just the peri-operative phase. Two years later we found that the staff wouldn't make the changes because they wouldn't buy into what we wanted to do. And the leaders had forgotten why they ever bought into it to begin with. As it turned out, some of the physicians were offended because we came to them with these changes and they weren't involved with planning the changes. But they had forgotten that when we started all this they didn't want to be involved because they didn't have the time to do it. I am sick and tired of hearing that people are too busy to work on this. When I was younger and less experienced I believed it, but I don't won't to hear that anymore.” “In a given week we are spending about 100 personhours 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 5 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 off-line 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 view 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.” study were high performing or successful micro-systems, and probes were included in the interview to assess what evidence micro-systems might offer to validate statements about their level of performance. We did not, however, seek validation from documents or other written materials. Although the intent of the sampling strategy was to study high performing micro-systems, a very small number of apparently negative cases were useful for comparison. More importantly, as expected, each site had some areas of very strong performance and other areas that were undistinguished, and they formed a natural cross-case comparison group. Although the sites were selected because of expert opinion, the database is limited by being self report. It is possible that the leaders of the micro-systems had an interest in making their micro-system appear to be better than it is, and we did not have any independent verification of their assertions. For this reason, we did not make any judgments about the validity of respondents' assertions and have limited the analysis to descriptive summaries and themes based on the respondents' own words.

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis TABLE 19 Micro-System Examples of Alignment of Role and Training 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 limits of education, training “The system wants me to simply be a ‘broker.' They want me to just do my CHF part and then make referrals. I want to be more involved in the care process.” “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.” “We emphasize training medical assistants to a much higher level than most expect, use 2 NPs extensively. MAs trained in using technology, standardized triage functions, training patients in self-management. As a group they stay with the practice for long periods. We are trying to ‘push the envelope' and rely less on credentialing and more on continually developing new skills.” “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 empower the medical assistant to insist that a patient be seen, even if it means clashing with a provider.” “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 a adjusting therapy to within physiological parameters are cross trained so that they can take on nursing tasks, starting IVs when needed. When fully trained and confident they may tell an admitting doc that a patient is not ready to have a ventilator tube removed.” A second limitation of this study was that the interviews were not tape-recorded to provide a raw data “gold standard” for later reference. For this reason, we went to considerable effort to ensure the quality of note taking as described in the methods section, and we obtained respondents ' consent to follow-up with them to clarify notes. Follow-up was necessary in only a few instances. The notes were voluminous and rich in detail. A third limitation is that for most of the interviews, one respondent represented each of the forty-three micro-systems. A more comprehensive assessment would include interviews with at least one person from each of the key roles within the micro-system, including patients. Such tradeoffs in qualitative analysis between breadth and depth are inevitable, 31 but

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis given that this was an exploratory study, we decided to include as many micro-systems as possible with follow-up in later studies. Research currently underway will expand on this work by taking a more comprehensive look at individual micro-systems and the outcomes of care provided to determine if high performing micro-systems achieve superior results for patients. Directions for Further Research This research has been exploratory in that it is the first systematic look at health care micro-systems. The power of the research is that it gave a voice to individual micro-systems and provided a way to explore them while creating constructs that may be generalizable to other micro-systems. It has begun the work of defining and characterizing health care micro-systems. The greater value of this analysis will be to go beyond the findings of this research to develop tools to help existing micro-systems improve and to replicate and extend the achievements of these micro-systems. The basic concept of health care micro-systems—small, organized groups of providers and staff caring for a defined population of patients—is not new. The key components of micro-systems (patients, populations, providers, activities, and information technology) exist in every health care setting. However, current methods for organizing and delivering health care, preparing future health professionals, conducting health services research, and formulating policy have made it difficult to recognize the interdependence and function of the micro-system. Further analysis of the database would likely yield additional themes. All can be the basis of hypothesis testing for continued work. For example, further work might establish criteria of effectiveness and test whether the features identified as the eight themes are predictive of effectiveness. More refined or additional questions might clarify aspects of the general themes that are critical. More intensive data gathering, for example, of multiple members of the micro-system, including patients could validate results and expand our understanding of these micro-systems. Two questions were central as we undertook this study: (1) would the term micro-system be meaningful to clinicians in the field? (2) Would they participate and give us detailed enough information to draw inferences? The answers to both questions were clearly: Yes. Overall, we discovered that the idea of a micro-system was very readily understood by all we interviewed. They had no difficulty in identifying and describing their own micro-systems and, when appropriate because they directed several (such as several intensive care units), differentiating among them in terms of their characteristics. The study was assisted in its work by an extremely able and distinguished steering group and Subcommittee whose reputations in the field unquestionably enabled us to secure the participation of nearly all who were invited despite our requesting an hour and a half of a busy clinician's time. Many of those interviewed willingly went on for a longer than the al-

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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis lotted 90 minutes and sent us additional materials. Some who were interrupted by urgent clinical business rescheduled time to complete the interviews. Although this was a selected—not a randomly sampled—group, and there was clearly great enthusiasm and of innovative work going on at the grass-roots level. 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 as they tried to disseminate their practices throughout their organizations. We believe there is much that could profitably learned and shared beyond the individual sites that has not been yet been pulled together by a unifying conceptual framework or effective mechanism for deploying what is being learned. We were struck by two findings in particular: First, the importance of leadership at the macro-system as well as clinical level; and second, the general lack of information infrastructure in these practices. Micro-system leaders repeatedly stressed the importance of executive and governance-level support. This support was singled out repeatedly as a sine qua non to their ability to succeed. It was also apparent that although some steps have been taken to incorporate the explosion of information technologies that are being deployed for managing patient information, free-standing practices as well as much of clinical practice within hospitals have only begun to integrate data systems, use them for real-time clinical practice, or as information tools for improving the quality of care for a patient population. The potential is enormous, but as yet, almost untapped. They appear to be at a threshold of incorporating information technologies into daily practice. The potential created by the development of knowledge servers, decision support tools, consumer informatics 32 continuous electronic patient-clinician communication, and computer-based electronic health records puts most of these micro-systems almost at “time zero” for what will likely be dramatic changes in the integration of information for real-time patient care and a strong baseline for future comparison. As research on micro-systems moves forward, it will be important to transfer what has been learned from research on teams and organizations to new research that will be conducted on micro-systems. For example, research that will be helpful includes information about the different stages of development and maturity of the organization, creating the organizational environment to support teams, socializing new members (clinicians and staff) to the team, environments that support micro-systems, the characteristics of effective leadership, and how micro-systems can build linkages that result in well-coordinated care within and across organizational boundaries. IOM Quality of Care Study This study was intended to provide more than a database for research, however. It was undertaken to provide an evidence base for the IOM Committee on the Quality of Health Care in America in formulating its conclusions and recommendations. Because that committee was charged with the formulation of recommendations about changes that can lead to threshold improvement in the quality of care in this country, its members believed that it was extremely important to draw not only on their expertise and the literature but also on the best evidence it could find of excellent performance and to do so in a systematic way as exempli-