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58 INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS TABLE 18 Micro-System Examples of Investment in ImprovementâContinued Investment in improvement Low High Training, resources not available Resources made available for improvement (training, $$, time) âWe started looking at the data because we had a âIn a given week we are spending about 100 person- high rate of wound infection after CABG. We hours on teams. People are being paid to spend their brought together all the different people and looked time doing this, not just during their lunch hour. at all the different issues over 2 years. We found that Someone said, âYou have to assume youâll be around there is a strong correlation between diabetes and here 5 years from now. Do you want to be doing infection, which the national data shows too. We things the same way?â Most of us donât. This re- decided that we should work on managing blood quires a new attitude that results in understanding sugars before, during, and after surgery. As it turns that industries must invest in change in these micro- out, there are so many primary care providers refer- systems. You have to tolerate pulling people off-line ring patientsâwe couldnât agree on a way to work to work. This is a radically new way of thinking in on blood sugars before surgery and they didnât want medicine which traditionally views any sort of to invest the resources that would be necessary to do meeting as a waste of time. Traditionally, the view is this. We couldnât get any primary care providers to that the only useful time is spent seeing patients. I work with us on this because working on improve- think that unless you spend time considering how to ment impacts their productivity, which impacts how deliver care better, much of that time seeing patients much they are paid. Even though it was clear what is wasted.â needed to be done, they chose the easier way and started working on just the peri-operative phase. Two years later we found that the staff wouldnât make the changes because they wouldnât buy into what we wanted to do. And the leaders had forgotten why they ever bought into it to begin with. As it turned out, some of the physicians were offended because we came to them with these changes and they werenât involved with planning the changes. But they had forgotten that when we started all this they didnât want to be involved because they didnât have the time to do it. I am sick and tired of hearing that people are too busy to work on this. When I was younger and less experienced I believed it, but I donât wonât to hear that anymore.â study were high performing or successful micro-systems, and probes were included in the interview to assess what evidence micro-systems might offer to validate statements about their level of performance. We did not, however, seek validation from documents or other written materials. Although the intent of the sampling strategy was to study high performing micro-systems, a very small number of apparently negative cases were useful for compari- son. More importantly, as expected, each site had some areas of very strong performance and other areas that were undistinguished, and they formed a natural cross-case comparison group. Although the sites were selected because of expert opinion, the database is limited by being self report. It is possible that the leaders of the micro-systems had an interest in making their micro-system appear to be better than it is, and we did not have any independent verifi- cation of their assertions. For this reason, we did not make any judgments about the validity of respondentsâ assertions and have limited the analysis to descriptive summaries and themes based on the respondentsâ own words.
INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS 59 TABLE 19 Micro-System Examples of Alignment of Role and Training Alignment of role and training Low High Health professionals not expected to Health professionals expected work within the limits of their education, certification to work at the limits of education, training (overqualified) âThe system wants me to simply be a âbroker.â They âThe receptionist talks them through the systems of want me to just do my CHF part and then make refer- the office. They are trained to follow through spe- rals. I want to be more involved in the care process.â cific areas of care such as screening, childhood im- munization, and antenatal care, so they have one person to contact. They have become expert in their areas.â âWe emphasize training medical assistants to a much higher level than most expect, use 2 NPs ex- tensively. MAs trained in using technology, stan- dardized triage functions, training patients in self- management. As a group they stay with the practice for long periods. We are trying to âpush the enve- lopeâ and rely less on credentialing and more on continually developing new skills.â âThe system can be an advocate. It can be a re- minder that a mammogram needs to be done, that there is a system in place to make sure it happens, that things go well. A system can empower the medical assistant to insist that a patient be seen, even if it means clashing with a provider.â âIf the Respiratory Therapist notes an abnormal lab value, she is comfortable not just taking a blood sample and reporting it, but managing it. The tech- nicians are caregivers. Expectations have changed. The ones that stay are good a adjusting therapy to within physiological parameters are cross trained so that they can take on nursing tasks, starting IVs when needed. When fully trained and confident they may tell an admitting doc that a patient is not ready to have a ventilator tube removed.â A second limitation of this study was that the interviews were not tape-recorded to provide a raw data âgold standardâ for later reference. For this reason, we went to consider- able effort to ensure the quality of note taking as described in the methods section, and we obtained respondentsâ consent to follow-up with them to clarify notes. Follow-up was neces- sary in only a few instances. The notes were voluminous and rich in detail. A third limitation is that for most of the interviews, one respondent represented each of the forty-three micro-systems. A more comprehensive assessment would include inter- views with at least one person from each of the key roles within the micro-system, including patients. Such tradeoffs in qualitative analysis between breadth and depth are inevitable,31 but
60 INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS given that this was an exploratory study, we decided to include as many micro-systems as possible with follow-up in later studies. Research currently underway will expand on this work by taking a more comprehen- sive look at individual micro-systems and the outcomes of care provided to determine if high performing micro-systems achieve superior results for patients. Directions for Further Research This research has been exploratory in that it is the first systematic look at health care micro-systems. The power of the research is that it gave a voice to individual micro-systems and provided a way to explore them while creating constructs that may be generalizable to other micro-systems. It has begun the work of defining and characterizing health care micro- systems. The greater value of this analysis will be to go beyond the findings of this research to develop tools to help existing micro-systems improve and to replicate and extend the achievements of these micro-systems. The basic concept of health care micro-systemsâsmall, organized groups of provid- ers and staff caring for a defined population of patientsâis not new. The key components of micro-systems (patients, populations, providers, activities, and information technology) exist in every health care setting. However, current methods for organizing and delivering health care, preparing future health professionals, conducting health services research, and formu- lating policy have made it difficult to recognize the interdependence and function of the mi- cro-system. Further analysis of the database would likely yield additional themes. All can be the basis of hypothesis testing for continued work. For example, further work might establish criteria of effectiveness and test whether the features identified as the eight themes are pre- dictive of effectiveness. More refined or additional questions might clarify aspects of the general themes that are critical. More intensive data gathering, for example, of multiple members of the micro-system, including patients could validate results and expand our un- derstanding of these micro-systems. Two questions were central as we undertook this study: (1) would the term micro- system be meaningful to clinicians in the field? (2) Would they participate and give us detailed enough information to draw inferences? The answers to both questions were clearly: Yes. Overall, we discovered that the idea of a micro-system was very readily understood by all we interviewed. They had no difficulty in identifying and describing their own micro- systems and, when appropriate because they directed several (such as several intensive care units), differentiating among them in terms of their characteristics. The study was assisted in its work by an extremely able and distinguished steering group and Subcommittee whose reputations in the field unquestionably enabled us to secure the participation of nearly all who were invited despite our requesting an hour and a half of a busy clinicianâs time. Many of those interviewed willingly went on for a longer than the al-