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What system?

world—not to claim bragging rights, but to provide the best care possible. That meeting was, in effect, a tipping point, setting in motion an ongoing quest for excellence in the ICN.

Shortly thereafter, Edwards formed an interdisciplinary team of about seven ICN staff members. The team met regularly for six months to think through their mission and goals. They identified critical clinical outcomes for their tiny patients—such as whether an infant developed infections, hemorrhages, or various kinds of impairment—as well as the primary drivers of costs both for patients' families and for the ICN. The team then identified changes that had a strong potential to create better outcomes.

The first change they focused on was reducing noise levels in the ICN. Research suggested that noise can affect the physiology of low-birthweight babies and even cause serious damage. Batalden, Nelson, Edwards, and others wrote about this initiative in the November 2003 Journal on Quality and Safety of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO): "The next steps involved assessing the sources of loud noises (people and equipment), gathering baseline data on noise levels, and planning tests of change using the scientific method . . . The first set of changes focused on noise produced by staff, family, and visitors." Using a clever twist on a standard phrase —"Quiet Pleases"—the team posted signs throughout the unit. "The second set of changes targeted equipment noise produced by myriad alarms—'buzzers, bells, and whistles'—that were constantly erupting to signal possible danger."

The team's efforts proved successful. Before the changes, noise in the ICN exceeded 60 decibels (about the volume of a normal conversation) 55% of the time. Afterward, noise exceeded 60 decibels only 33% of the time. Even more powerful than the noise reduction was the fact that the project gave everyone in the ICN—physicians, nurses, nursing assistants, and administrative staff—a chance to work together and learn the principles of microsystem quality improvement.

"It generated a visible, short-term 'win,' " Batalden and his colleagues wrote in the JCAHO journal. In addition, this initial project reinforced understanding within the unit of how to achieve improvement, reinforced the importance of using data and the scientific method in the process of doing so, and, perhaps most

"The inspiration for microsystem thinking was in 1992 when Brian Quinn wrote the book Intelligent Enterprise." Quinn, an emeritus professor at Dartmouth's business school, "was studying the best service organizations in the world," such as Federal Express and Sony.

importantly, "fostered respectful interdependence and shared leadership patterns, all of which built a solid foundation for continuing on the path toward excellence and transformation." That foundation was a launching pad for even more dramatic changes.

From 1994 to 1997, the ICN used the microsystem approach to improve discharge planning, management of apnea and related conditions, and infants' transition to oral feeding. They also focused on reducing unnecessary diagnostic tests and changing antibiotic prescribing patterns. All told, the changes led to a recurring savings of $1.3 million per year for patients and insurers and a measurable drop in the average length of stay. But these changes weren't just about cost-cutting. During the same time period, the DHMC nursery reduced its hospital-acquired infection rate by about 70%; decreased the mean number of days that infants needed mechanical ventilation; and, as part of a collaboration with 10 other ICNs, increased family involvement by including parents in daily rounds and making them members of the care team.

Most recently, DHMC's ICN has applied the microsystem approach to reducing intravenous-related bloodstream infections in babies who weigh less than three pounds or were born more than 10 weeks early. Previously, the average

period without such an infection had been 10 to 15 days. A few months into the project, the ICN experienced infection-free runs of 30 to 40 days. And between May 2005 and mid-December 2005, the nursery went more than 200 consecutive days without a single infection in target babies. "Our results have far exceeded my expectations," Edwards said recently.

As illustrated by the ICN example, a microsystem approach to improvement requires the involvement and investment of all frontline players, including patients and families. It also requires observation, data collection, intervention, measurement, and analysis.

The ICN is not the only unit at DHMC that has used the microsystem approach to create change. Others include the Comprehensive Breast Program—which coordinates all aspects of breast cancer diagnosis, treatment, and support for patients; and the Spine Center—internationally known for its approach to back care, in which the biases of surgeons and other specialists are removed from the decision-making process.

J. Brian Quinn, an emeritus professor at Dartmouth's Amos Tuck School of Business Administration, wrote an essay about his care at DHMC's Spine Center for Dartmouth Medicine's Fall 2000 issue. When he began to have back pain, he said, "Everyone has advice. . . . I do it all. But nevertheless—slowly but inexorably—the pain gets worse. Advice and results conflict more and more. I am confused. Can't sit, can't walk, can't see any way through the pain.

"Then comes the Spine Center," he continued. Founded in 1998, it was designed from the ground up as a microsystem. "It is a health-delivery innovation that has given me back my active life," wrote Quinn. "At its heart are people—an orthopaedist, a neurosurgeon, an anesthesiologist, and a physical therapist. All are very human and friendly. They focus on me, on my problem, not on their particular skill and how to sell it. All look at the same MRI, the same history, the same charts, simultaneously. They exchange views, give me confidence." Quinn concluded by calling Dartmouth's Spine Center "a true jewel."

As it happens, although Quinn wrote that essay from the perspective of a patient, not an academic, the concept he benefited from in 2000 had its origins in his own scholarly work.

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