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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis APPENDIX E Telephone Interview Interviewee: Interview Date: Site: Today's Date: Notes by: Interviewer (if different from author of these notes): What are the main issues or themes that struck you during the interview? Impressions and Surprises Are any clarifications needed? What additional questions or follow-up do you have for this site? Did this interview give you any ideas for additional/revised codes? (see general themes listed above.) Introduction (5 minutes) and recap of purpose and plan Thank you for agreeing to participate today (tonight). I am _________ (name--speak slowly and clearly), and I am working with the IOM committee. We are scheduled for an hour and a half today (tonight), but may not need all of that time. In any case, we will not ask you to go beyond that time. Let me start by telling you a little bit about the Institute of Medicine and about this study of health care micro-systems that you have agreed to participate in. The IOM is part of the National Academy of Sciences. It is a non-governmental, not-for-profit organization that was chartered by Congress to give advice on health policy.
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis We recently received funding from the Robert Wood Johnson Foundation to explore characteristics of healthcare micro-systems. This is part of a larger study of the quality of healthcare in America. Your micro-system has been nominated as one in which we might be especially interested in learning more about. By the term “micro-systems” we mean small, organized groups of clinicians and staff working together to provide care for a defined set of patients. The purpose of the study is to help us gain a better understanding of what makes micro-systems more effective. During our interview, I will be asking you about what your micro-system is particularly successful at doing. I will also be asking about: what characteristics you believe are important for us to know about, how patients may experience it differently from other systems, how you go about making improvements, what sorts of barriers you have run into, and how you have overcome them. During the interview I will be taking notes. We will summarize the findings in the committee report. We will be sending you a copy of the report when we it is available. The information you give me will be confidential. If for some reason we would like to identify a particular site by name in the report as an example, we will specifically ask your permission to do so. PAUSE FOR QUESTIONS AND COMMENTS (before I go on, do you have any questions you'd like to ask about this?) Before we start the interview, let me review information about your micro-system. As I understand it, your micro-system is: Is that right? If no: ALSO CLARIFY ANYTHING ON PRE-SURVEY THAT IS UNCLEAR
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis I. LEVEL OF PERFORMANCE AND CONCEPT, MODEL, OR MAP OF MICRO-SYSTEM What does your micro-system do very well? How is it different from others that treat similar patients ? Can you give me some examples? What is your micro-system particularly successful at? What makes your micro-system special? How is it different from others that treat similar patients? Can you give me some examples? How do you define success in ________?(what they identified as doing well) From what I hear you saying, you define success along several dimensions . . .(repeat them for clarification) How do you know you are achieving this? What sorts of data are you collecting about (list the dimensions) If I were a patient at ________ how would I experience it differently? If I were a clinician at ________ I would I experience differently from another micro-system that cares for similar patients?
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis Working Culture--How would you describe the day-to-day work environment for those in the micro-system? What does it feel like to work at ? People sometimes says that it has become increasingly hard to be a professional nowadays. Can you point to some examples of what your micro-system has done in this area, for example, to support professional ethics, encourage peer feedback or skill development? Optional: if newly developed program or processes: How long has the micro-system been working this way? How is it different now from an earlier time?
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis II. PATIENT EXPERIENCE, CONTROL, AND INVOLVEMENT If you think about a new patient with a health problem could you walk me through a year's experience (or an episode of care) starting when they first come as a patient? FOLLOW-UP QUESTIONS Have you put in place any special patient scheduling processes, for example, some practices have gone to open access systems? How do you assess patients their needs and health risks? Are there particular surveys or other ways you have developed to do this? How do patients get information about their health condition? For example, some clinicians give patients booklets, articles, web sites, or have health education groups they send patients to. Sometimes patients have health problems such that they are referred to a number of specialists and find the information they get confusing, information is lost, or they are not sure who is in charge or where to ask questions. Are there particular ways you have addressed this coordinating issue in your micro-system? If a patient has an unusual problem that requires expertise from people in a number of disciplines outside your micro-system, do you have any ways of bringing that expertise together?
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis Are you able to tell how long it takes a patient to move through your micro-system to definitive diagnosis and treatment? For example, a breast care center might track how long it usually takes for a woman who has a breast lump to be scheduled for a visit, receive a definitive diagnosis and therapy. Are you able to identify the sources of delay? Optional Probe: Have you set objectives about what you is believe to be a timely process? Are there any incentives that reward management and staff for meeting and exceeding patient expectations? Optional: I would like to ask you now about the community in which the micro-system practices. 9a. Are there things you do seek input from the community about their health needs? 9b. Are there things you do to keep the community aware of your results and what you are doing?
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis III. INFORMATION/INFORMATION TECHNOLOGY This section can be used to probe responses given on the pre-interview survey. Answers will determine whether to ask additional questions. On the pre-survey interview you indicated that your information system . . . .Do I have that right? If no . . . . FOLLOW-UP QUESTIONS Is you information system home grown, vendor-supplied? Is it supported by the larger organization or is it free-standing in your micro-system?
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis IV. INVESTMENT IN IMPROVEMENT Can you tell me what sort of things your micro-system has done to redesign your services and to improve the quality of care? Can you give me some examples of specific projects to improve quality, reduce cost or waste? FOLLOW-UP QUESTIONS In what ways were they successful? Are there specific levels of performance you can point to? Are there changes over time that you have been able to document? What are the barriers to making change? How have you overcome them? (or are trying to)? Optional: How is everyone made aware of these results? For example, how do others (patients? clinicians? referring or referral physicians?) learn about your results? Optional: Do you have any internally or externally funded quality-related research or quality improvement projects underway now? What are their objectives? What has been learned? Within the micro-system have there been any specific efforts devoted to leadership training, such as creating effective teams, conflict management, change management, or the like?
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis Expert Systems, Knowledge-based medicine We hear a lot about guidelines, protocols, and expert systems to help clinicians get up-to-date information. Do you use any such systems? What do you think would be ideal in helping your own practice? Optional: How do you and others in the micro-system access and incorporate emerging clinical evidence? What triggers changes in clinical practice? (e.g., guidelines are issued, literature) Optional: How do you identify “best practice” sites and processes? Optional: How is new information shared among clinicians and incorporated into clinical practice? Error and Patient Safety I'd like to ask now about medical error and patient safety. What happens in your micro-system when someone makes an error--for example, abnormal lab results are not seen, or the wrong dose of medication is given? FOLLOW-UP QUESTIONS Examples. Try to go beyond the mechanics of dealing with the error to the culture of safety or blame Probe the extent to which there is there a blame-free culture, comfort in identifying and addressing errors, and efforts to learn from error. What would a nurse say, a technician? Optional: Have you instituted any procedures to improve patient safety (e.g., standardize, simplify, training in teams, simulation, error reporting and investigation)?
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis What do you believe are the major sources of error or harm? Optional: Do you have any information about rates of error or harm?
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis V. LEADERSHIP AND MANAGEMENT/IMPROVING CARE DELIVERY Can you give me some examples of particularly helpful ways in which (name of larger org) affects the care provided by the micro-system? toxic ways in which (name of larger org) affects the care provided by the micro-system? FOLLOW-UP QUESTIONS When you think about payment, what sorts of financial structures for payment and rewards do you believe would be ideal for improving the quality of care? For example, what mix of fee-for-service and capitation might be optimal? Finally, I'd like to ask what you think it would take to replicate what you are doing? What do you think are the key factors to your success—the key lessons for others who would like to replicate what you have done? What are the major barriers to replicating this elsewhere? What barriers have you overcome?
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Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis Clarification of any points (5 minutes) Anything that I need to clarify for my own notes? As I write-up my notes, I may need to contact you later to clarify points or ask additional questions. Is that ok with you? Closing comments and thanks (2 minutes) Thank you.
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