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Exploring Innovation and Quality Improvement in Health Care Micro-Systems A Cross-Case Analysis A Technical Report for the Institute of Medicine Committee on the Quality of Health Care in America by Molla S. Donaldson, Dr.P.H., M.S., and Julie J. Mohr, Ph.D., M.S.P.H. Submitted to the Robert Wood Johnson Foundation November 3, 2000 RWJF Grant Number 36222 INSTITUTE OF MEDICINE Washington, D.C.
INSTITUTE OF MEDICINE â¢ 2101 Constitution Avenue, N.W. â¢ Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. Support for this project was provided by The Robert Wood Johnson Foundation. The views pre- sented in this report are those of the authors and are not necessarily those of the funding agency. The full text of this report is available on line at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2000 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. Cover Art: Interdisciplinary morning rounds at The George Washington University Hospital In- tensive Care Unit.
âKnowing is not enough; we must apply. Willing is not enough; we must do. âGoethe INSTITUTE OF MEDICINE Shaping the Future for Health
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of dis- tinguished scholars engaged in scientific and engineering research, dedicated to the further- ance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the Na- tional Academy of Sciences the responsibility for advising the federal government. The Na- tional Academy of Engineering also sponsors engineering programs aimed at meeting na- tional needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibil- ity given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, re- search, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academyâs pur- poses of furthering knowledge and advising the federal government. Functioning in accor- dance with general policies determined by the Academy, the Council has become the princi- pal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and en- gineering communities. The Council is administered jointly by both Academies and the In- stitute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.
ABSTRACT Objective. To identify key characteristics that enable health care micro-systems to continu- ously improve the quality of care. Micro-systems are small, organized patient care units with a specific clinical purpose, set of patients, technologies and practitioners who work directly with these patients. Data Sources. Structured interviews were used to collect primary data (summer, 1999) from 43 micro-systems providing primary and specialty care, hospice, emergency, and critical care. Study Design. Qualitative methods, specifically cross-case analyses, were used to understand how micro-systems function, what they know about their level of performance, how they im- prove care, the leadership needed, the barriers they have encountered, and how they have dealt with these barriers. Principal Findings. Responses to each interview topic are summarized, including key les- sons identified by respondents that may point the way toward replication. A framework for thinking about health care micro-systems emerged from a cross-case analysis of the inter- views. Eight themesâintegration of information, measurement, interdependence of the care team, supportiveness of the larger system, constancy of purpose, connection to community, investment in improvement, and alignment of role and trainingâwere present in the micro- systems to varying degrees. It is possible that the most effective micro-systems will demon- strate a high level of performance in each of these themes. We identify directions for further research that could contribute to designing and redesigning delivery systems, improving care, preparing future health professionals, and formulating health policy. Key Words. Micro-system, systems of care, quality improvement, health care delivery v
Acknowledgments We are appreciative of the many individuals and groups who made this project possible and who assisted our work. The support of the Robert Wood Johnson Foundation, and the assistance of the Project Officer, Susan B. Hassmiller, Ph.D., were critical to our undertaking this work, and we are grateful for Dr. Hassmillerâs encouragement and advice during the study process. Second, we wish to thank the individuals at all the sites that participated and gave their time to provide us with extensive information about their groups. We hope this report accu- rately reflects their extraordinary achievements and that it will provide them with useful in- formation as their work advances. Two groups provided invaluable guidance in the study design and identification of sites. The first was a Steering Group that included Paul B. Batalden, M.D.; Donald M. Berwick, M.D.; Eugene C. Nelson, Sc.D.; Thomas Nolan, Ph.D.; and Stephen M. Shortell, Ph.D. The second was the Institute of Medicine Subcommittee on Building the 21st Century Health Sys- tem. Its members were Donald M. Berwick, M.D., M.P.P. (Chair); Christine K. Cassel, M.D.; Rodney Dueck, M.D.; Jerome H. Grossman, M.D.; John E. Kelsch; Risa Lavizzo-Mourey, M.D.; Arthur Levin, M.P.H.; Eugene C. Nelson, D.Sc., M.P.H.; Thomas Nolan, Ph.D.; Gail J. Povar, M.D., M.P.H.; James L. Reinertsen, M.D.; Joseph E. Scherger, M.D., M.P.H.; Stephen M. Shortell, Ph.D.; Mary Wakefield, R.N., Ph.D.; and Kevin Weiss, M.D., M.P.H. In addition, Andrew Balas, M.D., Ph.D., organized a telephone conference to help us formulate questions and identify sites for our section on information technology. Participants included Paul Clayton, Ph.D., Columbia University; Patricia Flatley Brennan, University of Wisconsin; Jerome Grossman, M.D., Liongate Corp; David Kindig, University of Wisconsin; and Clement McDonald, M.D., Regenstrief Institute. Connie Davis, M.N., A.R.N.P., helped us to identify sites that had innovative chronic disease management programs, and Joanne Lynn, M.D., helped us to identify sites with innovative programs addressing care at the end vii
viii ACKNOWLEDGMENTS of life. Charles M. Kilo, M.D., M.P.H., and the staff of the Institute for Health Care Im- provement graciously included one of us (MSD) at a meeting of the prototype sites for the Idealized Design of Office Design project. Finally, we would like to express our gratitude to the IOM staff who facilitated the proj- ect. We are grateful for the overall direction provided by Janet Corrigan, Ph.D., director of the Division of Health Care Services and project director of the Committee on the Quality of Health Care in America; the advice of Linda T. Kohn, Ph.D., on the design of and protocol for the study, program assistance by Kelly Pike and Shari K. Maguire, research assistance by An- and Parekh and Tracy McKay; assistance in the report review process from Claudia Carl and Clyde Behney in the IOMâs Office of Reports and Communication; the editorial assistance of Mike Edington; and help in financial management by Kay Harris and Jennifer Cangco.
REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Councilâs Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that the report meets institutional standards for ob- jectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report: MARY C. CORLEY, Associate Professor, Department of Integrative Systems, School of Nursing, Virginia Commonwealth University KATE GOONAN, Vice President, Clinical Quality Service, University of Massachusetts Memorial Healthcare, Marlborough ARNOLD KALUZNY, Professor of Health Policy and Administration, School of Public Health, University of North Carolina at Chapel Hill BRUCE VAN CLEAVE, Vice President, Clinical Affairs, Trinity Health System, Farmington Hills, MI Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Paul Cleary, Professor, Department of Health Care Policy, Harvard Medical School, ap- pointed by the Institute of Medicine, who was responsible for making certain that an inde- pendent examination of this report was carried out in accordance with institutional proce- dures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authors and the institution. ix