staff, or staff to family or patient.
Godfrey:We also learned that every clinical microsystem is unique.

DM: Are there other theories of quality improvement?
Batalden: There are some who believe that what you need to do is to get the financial incentives right—that if you pay people correctly they will magically do the right thing.

DM: It doesn't sound like you agree with that approach.
Batalden: The incentive is extrinsic to the needs of production. You can believe if we put the financial incentives in place, then the magic will happen. Or if doctors write the correct order, the magic will happen. Or if we get the right people there, the magic will happen. What we're trying to do is deconstruct the magic, actually try to understand how people interact.

DM: And you feel this is more effective than a top-down approach?
Batalden: Well, the top down can make things happen. But you know how happy you'd be if you got precise instructions about how to write an article. You could do it, but it wouldn't be a source of joy. And the effects most likely wouldn't be sustainable.

DM: What are the high-performing microsystems at DHMC?
Godfrey: The Spine Center is one. Its creators came to our 10-week course at Dartmouth and learned how to create a high-performing microsystem. Another really good unit is the Intensive Care Nursery, which is part of a national collaborative using microsystems thinking. Plastic Surgery has been working for about two years using microsystems thinking. There's also the Comprehensive Breast Program and Dermatology.

It's essential to have a basic understanding of how a given system works. If you don't understand the way things work and you try to change them, it won't be sustainable change. . . . And to create a high-performing organization, you have to have high-performing small systems within it.

DM: How did the toolkit come about?
Godfrey: The American Hospital Association (AHA) called us about 18 months ago and said, "We'd like to put a publication out with you. What do you think?" We developed it with the help of the Geisinger Health System, the AHA, the Institute for Healthcare Improvement, Premier, and VHA, Inc. It was exciting, and it also helped formalize our materials.

DM: Can you describe how the toolkit works?
Godfrey: It will help interdisciplinary frontline units assess themselves and identify the five Ps—purpose, patients, people, processes, and patterns. For instance, in assessing the third P, the people—the professionals—we consider questions like these: Do we know when they're available? Do we have mismatches in volume and need? Are there roles we haven't included? One

group realized that most of their population was over 50 years old and had primarily musculoskeletal complaints. The fifth P is patterns, such as outcome patterns: What does our data show us as far as productivity or social patterns? How often does an interdisciplinary team talk about the process of care or safety?

DM: Can people order the toolkit and use it on their own?
Godfrey: Premier, VHA, and AHA are distributing these toolkits all over the country right now. Institutions can order them directly from us, too. We will also be offering orientations via web seminars and interactive videos, as well as opportunities for face-to-face learning.

DM: How long does it take for a particular unit to become a high-performing microsystem?
Godfrey: We usually find that it takes 18 to 24 months. By then the new ways of working have become habit.

DM: Where else is the microsystem approach being applied?
Godfrey: In England, Sweden, France, the Netherlands, Germany, Kosova, and elsewhere. The toolkit has been translated into several languages.

DM: How much interest has there been in the toolkit?
Godfrey: Our phones have been ringing off the hook since we introduced the toolkit in Orlando.

DM: Do you have any final words about microsystems?
Batalden: It's essential to have a basic understanding of how a given system works. If you don't understand the way things work and you try to change them, it won't be sustainable change.
Nelson: To create a high-performing organization, you have to have high-performing small systems within it.