Exploring Innovation and Quality Improvement in Health Care Micro-Systems A Cross-Case Analysis (2000) / Chapter Skim
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Results
Results
Pages 21-56
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From page 21... ...
Forty-nine percent of the micro-systems interviewed mentioned measuring their success by looking at clinical outcomes or some defined set of measures that includes clinical, functional, and financial indicators. Seven percent of the micro-systems cited measuring their micro-system performance against guidelines or protocols.
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From page 22... ...
Other differences in the patient experience were a team approach to care and the focus on building a relationship with the patient and family. When asked how clinicians would experience the micro-system differently, one respondent said, "the clinical part is not that different it's the technology and the teams." Other respondents indicated that technology has an increasingly significant role.
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Patient Experience ~ the second section of the interview, respondents were asked to descnbe the patient's experience in the micro-system. Specific questions asked about a new patient's expenence, scheduling, risk assessment, referral, waits and delays, and patient education.
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In the first generation of open access people carve out slots based on predicted urgent care demand. But you need to move beyond this an`!
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The micro-systems responded that they interact with the community at two levels acting as a resource for the patient population and acting as a resource for other clinicians and health care providers by providing education and setting the standard of care in the community. Information and Information Technology Forty-nine percent of the sites included in this study indicated that patient records are paper based; 39 percent indicated that patient records and financial systems are computer based but separate; and 12 percent indicated that patient records and financial systems are to
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, or to support clinical decisions (n = 6~. Only one micro-system indicated that the clinical infonnation system includes direct data input by patients (patients use a touch pad to answer relevant questions and report on their health status)
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Tt also asked about the major sources of error or harm, the extent to which there is a blame free culture, and procedures that had been implemented to improve patient safety. Medication errors and follow-up of abnormal lab results were the most frequently mentioned sources of error.
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However, the tension between the micro- and macro-system was evident in other responses. They have been very supportive in terns of wanting to dlo cutting edge work.
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Respondents described their early limited successes or outright failures. We heard what had and had not been successful, If you can have those three things in place before you start the right team, the senior leader support, and the financial issues resolved—you can replicate what we have done.
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Strong, focused, and sustained clinical leadership, 3. Collaboratively functioning multidisciplinary clinical teams, 4.
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Breast care center They have been very supportive of cutting edge work. They idenAdvance care planning team Ophthalmic center Endoscopy unit Emergency department Hospital cardiac care service Newborn intensive care tilled areas where CQI teams were needed.
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From page 32... ...
For example, a respondent Mom a neonatal intensive care unit said, "We charged the entire operating structure of the unit with improvement." Various approaches were described, including taking people "off-line" to focus on their processes of care, standardizing techniques and protocols and measuring their effect, hying small scale ("rapid-cycle") changes using small samples, and applying engineering concepts from other industries, such as continuous flow concepts for scheduling and care.
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health systems. We assist and encourage adults to do advance care planning and then make sure written plans are available and followed.
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Some of the people will take it and make it better, but if you aren't continuously improving it won't work. Taking care of sick babies the quality of clinical care.
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They have become expert in their areas. Intensive care unit If the Respiratory Therapist notes an abnormal lab value, she is com fortable not just taking a blood sample and reporting it, but manag ing it.
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From page 36... ...
They all claim that "my patients are sicker." I reply, "Give me your sickest patients those with congestive heart failure, the ones on coumadin, patients with diabetes, hypertension, the old, sick people, anyone who seems to require more than the average resources and time." When they ask why I would say this, I reply, "Because I will enlist help, resources—clinical pathways, care managers." We provide these resources to the practice and should never charge [or penalize] the doctors for this help.
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I think that unless you spend time considering how to deliver care better, much of that time seeing patients is wasted. Primary care for underserved, minority population Primary care Hospital endoscopy unit Behavioral health Primary care for underserved minority population The system can be an advocate.
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We are able to show through our fast track program for less urgent patients that total time from beginning to end has dropped from 92 to 47 minutes. Cycle time between the arrival of a patient to a doctor seeing that patient has dropped from 32 to IS minutes.
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Occupancy in the ER goes up, the number of new patients in the ER goes down. The number of free beds in the ER goes down, and the cycle time between arnval to a bed goes up for a patient.
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We have sum maries of patient records (problems, current medications, consult records) that can be called up on laptops for remote access.
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By touching the screen, we instantly know such things as arnval to bed, bed to nurse, arrival to doctor, aggregated cycle times. Cardiac care unit Databases are important—you have to make that investment.
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monitor and evaluate care. For each of these steps we have had to identify the roles of the care team.
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These data were collected auto matically for the national database and allowed comparisons among practices.
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A - problem isn't solved until the patient agrees that it is. Newborn intensive care The preconception of NICUs is highly technical and that families aren't (NICU)
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We graph pain on the vital sign sheet just below temperature. We have a place on the vital sign sheet to document pain and whether the pain management is effec tive.
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If your own doctor is here, she'll see you. We closed the urgent care clinics and distributed the urgent care doctors to the various offices.
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Integration of Information Micro-systems vary on how well infonnation from a variety of sources is integrated into the daily work of the micro-system and the role that technology plays in integrating information among clinician, patients, and other members of the micro-system. Some microsystems have developed advanced systems, but providing useful, timely, and accurate information is a huge task for micro-systems, and even in these high performing micro-systems, the potential of information technology has not, for the most part, yet been tapped.
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.. "We have data on demograhics and length of stay, "We have developed a radar screen that has eight sihowever, we don't have data on outcomes of care." multaneous processes continuously monitored." :: :::::: ::: : .
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From page 49... ...
You don't get the same negative feedback from your coworkers if you aren't teaching the patient as you do if you leave some of the physical tasks undone at the end of the shift. A nurse will prioritize and get every thing done before the end of the shift, but they don't look at the patient's care plan and do the teaching that needs to be done before discharge." "At 7 p.m.
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We believe strongly that in team care, staff satisfaction is very important. Everyone is not equal, but everyone is important and has a different responsibili~.
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We don't have extra capital to invest in recreational data collection to prove how we are doing to someone else when we know how we are doing." "We have developed a radar screen that has eight simultaneous processes continuously monitored. Each process is depicted in 15 minutes cut of data for the last four hours.
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He holds the key to resources and new patients." "We believe strongly that in team care, staff satisfaction is very important. Everyone is not equal, but everyone is important and has a different responsibility.
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Thus, there is a philosophical barrier." "At the system level the priorities for the system are not the same as the priorities for me in primary care." High Micro-system views larger organization as helpful "They have been very supportive in terms of wanting to do cutting edge work. The priority for the system is patient care.
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From page 54... ...
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 Tom 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.
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From page 55... ...
They assist and encourage adults to do advance care planning and them make sure written plans are available and followed. These 2 healthcare systems are competitors competing for the same patients." "A lot of our work is around controlling chronic illness, addressing the co-mordities, maintaining quality of life.
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From page 56... ...
In January, Social Services started asking them to use 'time dollars' that's part of our MORE (member organized resource exchange) time dollar exchange.
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