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70 INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS BUILDING THE 21ST CENTURY HEALTH SYSTEM SUBCOMMITTEE DONALD M. BERWICK (Chair), President and CEO, Institute for Healthcare Improve- ment, Boston CHRISTINE K. CASSEL, Professor and Chairman, Department of Geriatrics and Adult Development, Mount Sinai Medical Center, New York City RODNEY DUECK, HealthSystem Minnesota, Mound, MN JEROME H. GROSSMAN, Chairman and CEO, Lion Gate Management, Boston JOHN E. KELSCH, Consultant in Total Quality, Cary, NC RISA LAVIZZO-MOUREY, Director, Institute on Aging, Chief, Division of Geriatric Medicine, and Sylvan Eisman Professor of Medicine and Health Care Systems, Univer- sity of Pennsylvania, Philadelphia ARTHUR LEVIN, Director, Center for Medical Consumers, New York City EUGENE C. NELSON, Professor of Community and Family Medicine, Dartmouth Medical School and Director of Quality Education, Measurement and Research, Dartmouth- Hitchcock Medical Center, Lebanon, NH THOMAS NOLAN, Associates in Process Improvement, Silver Spring, MD GAIL J. POVAR, Cameron Medical Group (Private Practice), Silver Spring, MD JAMES L. REINERTSEN, Chief Executive Officer, CareGroup, Boston JOSEPH E. SCHERGER, Associate Dean for Clinical Affairs, University of California at Irvine College of Medicine STEPHEN M. SHORTELL, Blue Cross of California Distinguished Professor of Health Policy and Management and Professor of Organization Behavior, School of Public Health, University of California at Berkeley MARY WAKEFIELD, Director, Center for Health Policy and Ethics, George Mason Univer- sity KEVIN WEISS, Director, Center for Health Services Research, Rush Primary Care Insti- tute, Chicago
APPENDIX D Pre-Interview INSTITUTE OF MEDICINE PRE-INTERVIEW SURVEY OF MICRO-SYSTEMS Please fax both sides of this survey to Molla Donaldson, Institute of Medicine, Fax: 202-334-3862. E-mail: email@example.com. Phone 202-334-2184. If you prefer e-mail, we can send this to you as an attachment. Optional: Name of person completing this survey (please print) Phone: Title: If you would like to discuss more than one micro-system during the interview, please include a survey for each. 1. Your Micro-system What is the clinical focus of your micro-system (for example, primary care, cardiothoracic surgical care, hospice care) (Check as many as apply) _ Primary care _ Specialty care _ Condition-specific (e.g., back, OB) _ hospital unit (e.g., ICU) _ Other, please specify: Please provide a 1 to 3-sentence description of your micro-systemï£§who belongs to it, how it is organized, what does it do? Please feel free to attach a diagram. What are the number and specialty mix of physicians working in your micro-system? How many and what type of non-physician practitioners does your micro-system include (for example, PAs, NPs, nutritionists, psychologists)? What is the composition of the rest of the staff of the micro-system (for example, nurses, technicians, office staff)? Does your micro-system include medical students, residents, or other trainees? If so, please indicate what kind and how many. _ No _ Yes, please specify: How often are they present? Does your micro-system use any volunteers? _ No _ Yes, please describe how you use volunteers. How would you describe the micro-system's patient population/practice location? Please check all that apply. Primarily: _ acute care _ chronic care _ palliative care OR: _ mixture of preventive, acute, chronic, palliative Age: _ pediatric _ adolescent _ working-age adult _ elderly/geriatric Other: _ minority _ underserved _ long-term care _ safety net Practice Location: _ urban _ suburban _ rural _ frontier 71
72 INNOVATION AND QUALITY IMPROVEMENT IN MICROSYSTEMS Pre-InterviewâContinued About how many patients does your micro-system care for? / Day, week, year, etc. Is your micro-system embedded in a larger organization such as a hospital or hospital system, chain, academic medical center, staff model HMO, or integrated delivery system? _ No _ Yes, please provide the organization's name: What sort of organization is this? 2. Reimbursement Mix Please provide the approximate proportion of patients in each reimbursement category: ____ % FFS% ___ Prepaid ___ % Uninsured or self-pay (Total = 100%) ____ % Commercial ___ Medicare ___ % Medicaid ___ Uninsured or self-pay (Total = 100%) Has this reimbursement mix been changing in the last year? If so, how? Do you expect the reimbursement mix to change in the coming year? If so, how? How is compensation for the physicians in your micro-system determined? (Check as many as apply) _ FFS/fee schedule _ salary _ capitation _ bonus _ witholds Are formulas based on: _ panel size _ productivity _ patient satisfaction _ clinical performance _ financial performance _ other?, please specify: 3. Computer-based Information Technology Most offices have computer-based billing information, but we are particularly interested in this section in computer-based clinical information. Does your micro-unit have computer-based patient records? __ No, Patient records are paper-based (If No, Please skip to section 4 below) __ Yes, Patient records and financial systems are computer based, but separate __ Yes, Patient records and financial systems are to some extent or entirely integrated If you answered yes above, is the clinical information system linked to any data sources outside the micro- system, such as laboratories, pharmacies, or ER? __ No __ Yes, please specify: Does the clinical information system include direct data input by patients _ No _Yes (e.g., blood glucose levels or blood pressure measurements)? Our computer-based information system is used for: Please check all that apply _generating reports about the practice _ real-time patient care _ clinical decision support (e.g., reminders, drug-drug warnings) 4. Other Do patients interact with clinicians by e-mail? _ No _ Yes Using web-based resources? _ No _ Yes Continued
APPENDIX D 73 Pre-InterviewâContinued Who (or what organizational unit) makes information technology decisions for your micro-system? Who (or what organizational unit) makes human resource policy decisions for your micro-system (hiring, assigning support staff, etc.) ? Who would you consider to be the leader of this micro-system? Please fax both sides to Molla Donaldson, IOM: Fax: 202-334-3862, Phone: 202-224-2184
APPENDIX E Telephone Interview Interviewee: Interview Date: Site: Todayâs Date: Notes by: Interviewer (if different from author of these notes): 1. What are the main issues or themes that struck you during the interview? Verbatim comment from interview: General theme: â¢ â¢ â¢ â¢ â¢ 2. Impressions and Surprises 3. Are any clarifications needed? 4. What additional questions or follow-up do you have for this site? 5. 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. 74
APPENDIX E 75 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 âmicro-systemsâ 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: â¢ what characteristics you believe are important for us to know about, â¢ how patients may experience it differently from other systems, â¢ how you go about making improvements, â¢ what sorts of barriers you have run into, and â¢ 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
76 INNOVATION AND QUALITY IMPROVEMENT IN MICROSYSTEMS 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? 1. How do you define success in ______________?(what they identified as doing well) 2. 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) 3. If I were a patient at __________ how would I experience it differently? 4. If I were a clinician at _________ I would I experience differently from another micro-system that cares for similar patients?
APPENDIX E 77 5. 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 ? 6. 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?
78 INNOVATION AND QUALITY IMPROVEMENT IN MICROSYSTEMS 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 1. Have you put in place any special patient scheduling processes, for example, some practices have gone to open access systems? 2. How do you assess patients their needs and health risks? Are there particular surveys or other ways you have developed to do this? 3. 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. 4. 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? 5. 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?
APPENDIX E 79 6. 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? 7. Optional Probe: Have you set objectives about what you is believe to be a timely process? 8. Are there any incentives that reward management and staff for meeting and exceeding patient expectations? 9. 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?
80 INNOVATION AND QUALITY IMPROVEMENT IN MICROSYSTEMS 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 1. Is you information system home grown, vendor-supplied? Is it supported by the larger organization or is it free-standing in your micro-system?
APPENDIX E 81 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 1. 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? 2. What are the barriers to making change? How have you overcome them? (or are trying to)? 3. Optional: How is everyone made aware of these results? For example, how do others (patients? clinicians? referring or referral physicians?) learn about your results? 4. 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? 5. 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?