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The nuts and bolts of microsystems

For over a decade, Paul Batalden, M.D., and members of his quality improvement team—Eugene Nelson, D.Sc., M.P.H., and Marjorie Godfrey, M.S., R.N.—have been singing the praises of "clinical microsystems," the building blocks of every health-care system. About six months ago, they released a "toolkit" titled Clinical Microsystems: A Path to Healthcare Excellence. Intended to help others understand the microsystem concept, it was featured at the Institute for Healthcare Improvement's national forum in December 2005 in Orlando, Fla.

The toolkit includes a choice of a video or a DVD describing the characteristics of high-performing clinical microsystems; two workbooks, including an exercise to help users see health care through patients' eyes; and a tutorial on adapting the workbooks to individual microsystems.

Following is an edited transcript of interviews conducted by Dartmouth Medicine's associate editor, Laura Stephenson Carter, with Batalden, Nelson, and Godfrey. Batalden is the director of health-care improvement leadership development at DMS. Nelson is the director of quality education, measurement, and research at DHMC. And Godfrey is the director of clinical practice improvement at DHMC.

DM: Where did the microsystems idea come from?
Nelson: The spark was in 1992, when Brian Quinn [now an emeritus professor at Dartmouth's Tuck School of Business and a longtime DHMC Trustee] wrote the book Intelligent Enterprise. He discovered that the best service organizations in the world were focused on what was happening between the customer and the frontline service provider, such that customers get what they want and need. We realized how far away we are in health care from focusing attention on what happens to the patient.
Batalden: As I read that book, I wondered

The microsystem approach is also being applied in England, Sweden, France the Netherlands, Germany, Kosova, and elsewhere. The microsystems toolkit developed at Dartmouth has been translated into several languages.

what the analogue was in health care. I thought back to my own practice as a pediatrician. Another pediatrician and I, a nurse practitioner, a nurse, and a secretary all worked in the same hallway. We had a group of patients that we shared. Bingo—there it was, a microsystem.

DM: What do you mean by a "microsystem"?
Godfrey: It's the place where patients, families, and care teams meet. It's frontline care, and it includes the support staff, processes, technology, and recurring patterns of information and behavior and results. The patient is central to every clinical microsystem.

DM: Why is it important to look at microsystems?
Batalden: What microsystems are about is understanding what you are trying to change or improve. You can't do quality improvement that's going to last unless

you understand the work and how people interact.

DM: How do you know what a good microsystem is?
Nelson: We visited 20 of the best performing clinical microsystems in North America. We chose them by evaluating published results, award winners, and organizations that had done best in Institute for Healthcare Improvement (IHI) assessments; by talking to people in the know; and then by asking the selected organizations to identify their best microsystems. Some were inpatient units; some were ambulatory units; some were home health; some were nursing homes.
Then we observed what they did, what made each microsystem so good on quality, on efficiency, a place you'd like to work in. Our work was supported by a Robert Wood Johnson Foundation grant—$300,000 for three years—and after we did the work we published a nine-part series in the Joint Commission Journal on Quality Improvement. We learned a lot of lessons.

DM: What sort of lessons did you learn?
Nelson: That it was a blend of five things that made these units so great. First, they were very focused on the patient. Second, they were very focused on staff. The staff felt like they were important and that their work was valued, no matter if they were the newest hire, the most senior person, or the housekeeper. A third was excellent leadership. There were always two leaders—be it a nurse and a doctor, or a doctor and an administrator. The leaders reinforced the idea that patients were at the center and that staff contributions were valued.
Fourth was the emphasis on providing good care—on outcomes and on the processes that produce those outcomes. They were always trying to figure out how to get better results, because that's what delivered the health benefit to the patients. Fifth was innovative and/or easily usable information technology, as well as effective communication—staff to

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