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.
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-