Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis (2000)

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INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS 53 TABLE 15 Micro-System Examples of Supportiveness of the Larger System Supportiveness of the larger system Low High Larger organization’s actions Micro-system views larger perceived as “toxic” to the micro-system organization as helpful “I think that there is a barrier at the institutional “They have been very supportive in terms of wanting level. For example, the institution has launched a to do cutting edge work. The priority for the system is Clinical Consistency Program. Basically, they patient care. They identified areas where CQI teams want every place in their system to practice the were needed. That is where the Breast Care team came same way. However, this hurts us because we up. They supported us financially too. They have paid have found ways to do things efficiently here, and close attention to the results. They have identified if we have to practice like the rest of the system, breast care as an area where they want a center of ex- we feel that we’ll be practicing ‘mediocre’ care. cellence. It is a priority of the system.” Thus, there is a philosophical barrier.” “At the system level the priorities for the system “We had the commitment from top administrators— are not the same as the priorities for me in pri- the Presidents from four systems set up the task force. mary care.” 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 ad- vance 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 communi- ties, that support may not be there. I could go to medi- cal records and say this is what I need—and I need to report back to the 4 presidents. I met very little resis- tance. My organization in particular put a lot of im- portance in this and asked me to put a lot of time in it. I wasn’t just asked to work it in to my other responsi- bilities.” “The corporate policy for open access was a bar- “We can make changes quickly and are free to make rier and facilitator at the same time. The way cor- investments and commit resources to change. We re- porate defined open access wasn’t really open ac- cently created a management services division here. cess and they set incentives based on their We help other clinics and care sites to do marketing, definition. Some people had different views about quality improvement in patient flow, etc.. This is our what open access was. For us, it was ‘doing to- entrepreneurial spirit. The larger organization pro- day’s work today.’ For corporate, it was ‘if your vided us with some resources to allow us to do this.” schedule is open 75% a week out you will get a bonus’.” “It is a mixed message. The organization talks “The hospital system has shown great effort in helping about team care but then subverts their vision— us out with patient restraint protocols. Restraint man- they put in a centralized phone system with a agement has been an area where they have excelled nurse in charge of scheduling appointments. Well and this has made the ER a safe place to work. They she has no way of knowing whether Doctor X and are also helping us out in quality end-of-life issues and Y are on the same team. If a patient of Dr. X how cultural differences of people necessitate indi- cannot go to Dr. X because he is on vacation, the vidualized care.” nurse may send the patient to Dr. Z though Dr. Y is on Dr. X’s team. So instead of the patient going to Dr. Y, they go to Dr. Z.” 

54 INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS 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 fo- cus on what they 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 chil- dren, 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—for staff as well as patients. It’s easier for the staff person to just waive the $8 fee. Investment in Improvement High performing micro-systems make improvement a priority by making an invest- ment. Examples of this dimension are shown in Table 18. This investment comes in the form of resources, such as time, money, 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 in- vest 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 tradi- tionally 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. 

INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS 55 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 “What we do well is communicate the importance of original aim was that we would practice the best diabetes care—up to the senior leaders of the organi- medicine we could, understanding that we zation; across to other providers’ and out, to the com- couldn’t be as financially successful. Now some munity. We are advocates for our own work. When- of the physicians are compromising for the finan- ever I walk into a room, people think diabetes.” cial aspects. They are spending less time with pa- tients, care is not as complete.” “At the department level there are barriers. We “Our principle is that all of today’s work is done to- try to make changes across departments because day.” 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 be- fore making the change.” “I feel strongly that if we could have more time “The focus of this micro-system is improving advance with patients for coaching, behavioral changes, care planning through systems of healthcare. This is a and attitude changes we could improve diabetes joint effort of 2 healthcare systems. They assist and care. Nobody wants to do anything if it isn’t re- encourage adults to do advance care planning and imbursed. Wherever the $ goes that is where the them make sure written plans are available and fol- service goes. Now there isn’t adequate time or lowed. These 2 healthcare systems are competitors— resources for teaching patients in any setting. Pa- competing for the same patients.” tients are so sick now when they are in the hospi- tal, 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 mem- ber at home to help them.” “There are various ways that health care workers “A lot of our work is around controlling chronic ill- let patients know that we are busy—don’t tell us ness, addressing the co-mordities, maintaining quality that you are having a problem because we don’t of life. We want the patient to maintain community have time to deal with that. For a lot of nurses the residence for as long as possible. This is an HMO— reason for being a nurse was to relieve pain and we are the payor—if the patient goes to a nursing suffering. But then we send the message that we home we pay for that care and monitor the care. It don’t have time to help you.” 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 in- creased staff satisfaction and lower turnover, they acknowledged that some staff were un- comfortable working in an expanded role. As one respondent noted, “Casualties move on to other parts of the hospital.” 

56 INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS TABLE 17 Micro-System Examples of Connection to Community Connection to community Low High No clear connection to community Micro-system is a beyond current patient population resource to the community, community is a resource to the micro-system “Patient surveys are done periodically (so far we “There has been a strong consumer movement re- have only done two). We have one page exit inter- cently on creating peer support centers. These are views. We haven’t changed a lot based on these not run by our group but by consumers. We refer surveys.” 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 edu- cate 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 illness. And none of the education teaches that. The peer support centers let people with the illness teach the residents about it.” “The only way we get information about the com- “The neonatology group has a commitment of being munity is from the managed care organization.” a resource to the region. We have a commitment to the health of a population. This is crucial to our suc- cess. As a resource, we provide education and re- view the quality of care for the whole region.” “The community used to look at us as leaders. But “40 percent of our patients are self-pay. We use a the hospital was taken over by a large system. So sliding fee schedule. Our minimum fee is usually we aren’t community leaders anymore. We need the $8. Sometimes the patient asks us to waive this. In healthcare dollars to come to the community and January, Social Services started asking them to use then we decide how to take care of the community. ‘time dollars’—that’s part of our MORE (member The trustees of the hospital have no idea about organized resource exchange) time dollar exchange. healthcare or affecting change.” 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 pa- tients. 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 immuniza- tion, 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 techni- cians are caregivers. Expectations have changed. The ones that stay are good 

INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS 57 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 particu- lar. The strength of this method was that the sample selection used input from a pool of re- ognized 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 “We have a manager for staff development. She cards in their wallets. We talked about it for 10 min- works on skill building and coaches the teams in how utes or so and decided to do it. But it didn’t work. we get along. It’s important to assign the role of staff We don’t know how to implement it. We don’t know development to someone.” 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.” “Our micro-system is a prisoner of our macro- “We put together a guidance team and the idea was system. If it isn’t important for the macro-system, we that this team would tell us what to work on. But I have no incentive to do it and improvement hasn’t saw most of the good ideas coming from the front been a priority.” 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 “Remember that even when it seems you have ac- make this better . . .’ but there is so much pressure to complished something, new people come who were reduce the time we see with patients and see more not party to the original plans. Before you know it, patients every day. Now there is pressure from the you’ve fallen back. We used to think that people organization to see patients at 10 minute intervals. would learn the systems by osmosis. Now, they have They are going to start to tie incentives to that. Each a formal induction system to explain and show peo- physician will have to decide how to deal with that - ple how the systems should work.” more money, less hours, etc.” Continued