CLINICAL MICROSYSTEM APPROACH-A METHOD FOR HEALTH CARE IMPROVEMENT

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1 ORIGINAL ARTICLE CLINICAL MICROSYSTEM APPROACH-A METHOD FOR HEALTH CARE IMPROVEMENT Samiei V 1, Aniza I 1, Sharifa Ezat WP 1, Alsheikh HI 1, Kari HA 1, Saleh M 1, Sengee G 1, Waruegh N 1 1 Community Health Department, UKM Medical Centre ABSTRACT The quality of the health care services has been always a big responsibility and sensitive issue. Health care delivery is complex and critical for many reasons related to management and organizational planning and development. Health system reorganization is one of the approaches that health care managers adopt to overcome dysfunction. Clinical Microsystems (CM) is believed to be a one of vital steps in providing a high quality of patient care through system reorganization. CM has the potential to drive the health care to greater success through proper understanding, process and resource planning and health outcomes continuous assessment and improvements. CM integrate patients, providers and family needs and roles to form a vision of community system that cooperate for better outcomes.the components of an effective CM are produce quality, patient safety, and cost outcomes at the front line of care. This article aims to explore the concept, characteristics models and components of these Clinical Microsystems. It also highlights the steps to initiate, plan and sustain this innovation in hospitals in a systematic manner. Key words: Clinical microsystem, health care, organization development. INTRODUCTION The health care system is plagued by widespread preventable errors, unnecessary tests and procedures, and misused and underused services. These manifestations of poor-quality care have led to unacceptably high numbers of avoidable deaths and preventable injuries. Misuse can be seen in the failure of many hospitals to adopt information technology that reduces medical errors and in various forms of inappropriate care. Under use of needed services is widespread and creates quality problems, as well. The failure of the health care system to routinely provide certain preventive, screening, and acute care services leads to illnesses, relapses, complications, and other conditions that could have been avoided altogether or caught earlier to minimize the impact on health status and on the costs of treatment. Poor-quality care not only results in unnecessary deaths and injuries, but also adds significantly to the costs of patients and the organizations that finance care 1. According to the Institute of Medicine s recent report with titled: Crossing the Quality Chasm: A New Health System for the 21st Century ; makes the point of system failure clear in which the health care today harms too frequently and routinely fails to deliver its potential benefits. During the last decade alone, more than 70 publications in leading peer-reviewed clinical journals have documented serious quality shortcomings. Therefore we can say that The current system cannot do the job. Trying harder will not work. Changing systems of care would be the best solution to propose 1. First and foremost we need to look at the current system and its components. In accordance with the true structure of the health system is composed of a few basic parts as: front-line clinical microsystems, overarching microsystems, and patient subpopulations needing care. The three fundamental assumptions about the structure of the health system states that bigger systems (macro systems) are made of smaller systems; These smaller systems (Microsystems) produce quality, patient safety, and cost outcomes at the front line of care; and ultimately the outcomes of the macro systems can be no better than the microsystems of which it is composed. In order to bring about fundamental change in the health system of the magnitude required, there will need to be systematic transformation at all levels of the system. Although many attempts have been made to change the system like focusing on individual patients, the individual physicians serving these patients, the larger provider organizations, the payment system, and other aspects of health care policy; here have been very few efforts to understand and change the front-line clinical units that actually deliver the care 2. In order to move toward a perfected system of care, the performance of each individual microsystem must be optimized and the linkages between different clinical microsystems must be

2 seamless, timely, efficient, and carefully reliable. Although change is required at all levels of the system, the powerful new idea here is that the microsystem concept offers an opportunity to transform health care at the front line of service delivery 3. If a person were to explore his or her local health system, he or she would discover myriad clinical microsystems: a family practice, a renal dialysis team, an orthopedic practice, an in vitro fertilization centre, a cardiac surgery team, a neonatal intensive care unit, a home health care delivery team, an emergency department, an inpatient maternity unit and so on 2. WHAT IS MICROSYSTEM? Microsystems include patients, clinical people, processes, and recurring patterns cultural patterns, information flow patterns, and results patterns 3. Microsystems in health care can be defined in the following way: A clinical microsystem (CM) is a small group of people who work together on a regular basis to provide care to discrete subpopulations of patients. It has both clinical and business aims, linked processes, a shared information environment, and produces performance outcomes. Microsystems evolve over time and are often embedded in larger organizations. They are complex adaptive systems and as such they must: (a) do the primary work associated with core aims, (b) meet the needs of internal staff, and (c) maintain themselves over time as a clinical unit 3. Microsystems are the essential building blocks of the health system. They can be found everywhere and vary widely in quality, safety, and cost performance. Microsystems are the local setting in which patients, providers, support staff, information, and processes converge for the purpose of obtaining and providing care to meet health needs 4. If a person were to explore his local health system he would discover a myriad of clinical microsystems. Examples would be such as: a family practice, a renal dialysis team, an orthopedic practice, an in-vitro fertilization center, a cardiac surgery team, a neonatal intensive care unit, a home health care delivery team, an emergency department, an inpatient maternity unit and so on 4. The traditional existing system focused on the clinical process only to achieve desirable outcomes with high quality and efficiency to serve the patients needs and expectation. While the current proposed system expands the frame to include an explicit focus on the local context that is, the naturally occurring clinical units that form the front line of health care delivery. It also takes into consideration the information support system such as health management information system (HMIS) as well as high and comprehensive staff interactions in both clinical and administrative level. Mohr and Donaldson recently investigated highperforming clinical microsystems 5. The research was based on a national search for the highestquality clinical microsystem. Forty-three clinical units were identified, and leaders of those units participated in in-depth interviews and results of the interviews were analyzed to determine the characteristics that seemed to be most responsible for enabling these high-quality microsystems to be successful. The results suggested that eight dimensions were associated with high quality: Constancy of purpose; is consistent with the aim of the larger system and guides the work of the microsystem. Where constancy of purpose is high, the aim is apparent to the microsystem, and it is also communicated across the boundaries of the microsystem. Connection to the community; represents a symbiotic relationship between the microsystem and the community that extends well beyond the clinical care of a defined set of patients. Investment in improvement; it comes in the form of resources such as time, money, and training, but above all it involves creating a philosophy of improvement within the microsystem. Alignment of role and training for efficiency and staff satisfaction; suggests that there is a deliberate effort within the multidisciplinary team to match the team member s education, training, and licensure with their role. Interdependence of the care team to meet patient needs; microsystems with a high degree of interdependence are mindful of the importance of the multidisciplinary team approach to care, whereas those with a lower degree of interdependence are characterized by providers and staff working as individuals with no clear way of sharing information or communicating. Integration of information and technology into work flows; microsystems vary on how well information is integrated into its daily work and the role that technology plays in facilitating the integration. Ongoing measurement of outcomes; part of the work of the microsystem becomes the development of a set of measures that are appropriate for the goals of the microsystem. Supportiveness of the larger organization.

3 Analysis of the above results suggests that each clinical unit from the 20 high-performing sites is indeed a complex, dynamic system with interacting elements that come together to produce best performance. No single feature or success characteristic can stand alone to produce high-quality, high-value systemic results. That being said, a common set of nine success characteristics were shared by these microsystems and interact with one another to produce highly favorable systemic outcomes. These nine success characteristics are: 1. Leadership of microsystem: Leadership maintains constancy of purpose, establishes clear goals and expectations, fosters positive culture, advocates for the microsystem in the larger organization, and provides on-the-spot leadership. 2. Culture of microsystem: There is pattern of values, beliefs, sentiments, and norms that reflect clinical mission, quality of staff work life, and respectful patterns of interpersonal relationships. 3. Macro-organizational support of microsystem: The larger organization provides recognition, information and resources to enhance and legitimize the work of microsystem. 4. Patient focus: The primary concern is to meet all patient needs like caring, listening, educating, and responding to special requests, smooth service flow, establishing the relationship with community and other resources. 5. Staff Focus: There is selective hiring of right kind of people, integrating new staff into culture and work roles, aligning daily work roles with training competencies. Expectations of staff are high regarding performance, continuing education, professional growth, and networking. 6. Interdependence of care team: The interaction of staff is characterized by trust, collaboration, willingness to help each other, appreciation of complementary roles, and a recognition that all contribute individually to a shared purpose. 7. Information and information technology: Information is key, technology smoothes the linkages between information and patient care by providing access to a rich information environment. Technology can facilitate effective communication and multiple formal and informal channels are used to keep everyone informed. Everyone s ideas are heard and they are connected to important patient care topics. 8. Process improvement: An atmosphere for learning and redesign is supported by the continuous monitoring of care, use of benchmarking, frequent tests of change, and staff that has been empowered to innovate. 9. Performance pattern: Performance focuses on patient outcomes, avoidable costs, streamlining delivery, using data feedback, promoting positive competition, and frank discussions about performance 6. These nine success characteristics interact dynamically with one another. In addition to these nine primary characteristics, three additional themes emerged from the content analysis and were frequently mentioned, although not as much as the nine cited above like patient safety, health professional education, and the external environment (for example, financial, regulatory, policy, and market environment) in which the microsystem is embedded. The topperforming clinical units were vibrant, vital, dynamic, self-aware, and small-scale clinical enterprises that were led with intelligence and staffed by skilled, caring, self-critical staff. These individual microsystems are tightly or loosely connected with one another and perform better or worse under different operating conditions. Our ability to see them as functional units is challenged by our conventions for managing human resources, information, and cost. Our commitment to professional disciplines and specialties as a prime organizing principle often creates barriers that impede the daily work of clinical microsystems. IMPORTANCE OF THE CLINICAL MICROSYSTEMS (CM) Health care is delivered within a specific context, called a microsystem 2. Examples of clinical Microsystems are outpatient clinics and inpatient wards. Individual health care professionals are often trained separately, and much of this training takes place outside the context (setting) in which patients are treated 4. Clinical microsystems are essential ever since it is associated with patients safety and life quality. Patient safety has been defined as freedom from accidental injury 7. Various organizations have accepted the call to action to make patient safety a priority. How can an organization respond to the need to meet patient safety goals? Mohr & Batalden consider a table to show the linkage of microsystem characteristics to patient safety that reveals clearly the meanings of characteristics such as leadership, organizational support, staff focus and the other factors as below 7.

4 Table 1. Linkage of microsystem characteristics to patient safety Microsystem characteristics Leadership Organisational support Staff focus Education and training Interdependence of the care team Patient focus Community and market focus Performance results Process improvement Information and information technology What this means for patient safety Define the safety vision of the organisation Identify the existing constraints within the organisation Allocate resources for plan development, implementation, and ongoing monitoring and evaluation Build in microsystems participation and input to plan development Align organisational quality and safety goals Engage the Board of Trustees in ongoing conversations about the organisational progress toward achieving safety goals Recognition for prompt truth telling about errors or hazards Certification of helpful changes to improve safety Work with clinical microsystems to identify patient safety issues and make relevant local changes Put the necessary resources and tools into the hands of individuals Assess current safety culture Identify the gap between current culture and safety vision Plan cultural interventions Conduct periodic assessments of culture Celebrate examples of desired behaviour for example, acknowledgement of an error Develop patient safety curriculum Provide training and education of key clinical and management leadership Develop a core of people with patient safety skills who can work across microsystems as a resource Build plan do study act (PDSA) into debriefings Use daily huddles to debrief and to celebrate identifying errors Establish patient and family partnerships Support disclosure and truth around medical error Analyse safety issues in community and partner with external groups to reduce risk to population Develop key safety measures Create feedback mechanisms to share results with Microsystems Identify patient safety priorities based on assessment of key safety measures Address the work that will be required at the microsystem level Enhance error reporting systems Build safety concepts into information flow (for example, checklists and reminder systems)

5 It is believed that the first step is the realization that safety is a property of the clinical microsystem that can be achieved only through a systematic application of a broad array of process, equipment, organization, supervision, training, and teamwork changes. The clinical microsystem as a unit of research, analysis, and practice, is an important level at which to focus patient safety interventions. It is at this systems level that most patients and caregivers meet, and it is at this level that real changes in the patient care usually given can (and must) be made. Errors occur within the microsystem and ultimately it is the functioning microsystem that can stop, prevent, or mitigate errors from causing patient harm between microsystems as they navigate the healthcare system, for example as they transfer from inpatient care back into the community. These cross microsystem relationships will be essential to improving hand offs but also to providing opportunities for learning about systemic problems within the institution and interventions to improve quality and safety 7. An effective collaborative relationship is based on the underlying assumption that collaboration is a more effective approach to achieve a goal than multiple individual efforts. Weick suggests that leaders today need to develop groups that are respectful of the interactions that hold the group together 8. There are couple of microsystem characteristics related to patient safety for example Leadership can be employed means for patient safety many things such as quality as well as quality constrains identification resources proper management and allocation and preparedness. While organizational support plays important role in looking at the issues related to the patients safety and initiating a relevant local changes. Other characteristics that are associated to the patients safety are staff focus which aims to enhance creating and maintaining safety culture and education and training which develops patient safety curriculum. This is parallel to the patient focus intending to establish patient and family partnerships and support disclosure and truth around medical error. Other characteristics concerning patients safety focus on the community market, performance results, process improvement 9. In health care, learning to improve quality and safety needs to occur at the individual, team and organizational levels. Errors result from physiological and psychological limitations of humans based on different causes 10. Factors determining work performance reflect organizational culture and illustrate beliefs and values that affect behavior 11. A culture forms what and how to perform, including the way in which patients and relatives are treated and are influenced by the staff and the leaders of the organization. The prevention and management of adverse events is important in the work of a culture that values quality and patient safety 12. Health care is delivered within a specific context, called a microsystem 2. Examples of clinical Microsystems are outpatient clinics and inpatient wards. Individual health care professionals are often trained separately and much of this training takes place outside the context (setting) in which patients are treated 4. A method of improving organizational learning is for the health professionals working within a given clinical setting to actively reflect on and discuss the processes and outcomes of their clinical decisionmaking, and to view this within the context of the system of patient care provided by the entire clinical team. Organizational learning takes place through analysis of processes of care; it can be judged as effective when system failures that jeopardize patient safety are identified and changes instituted within the system to improve the safety of the care delivered. Errors are too often seen as individual carelessness or incompetence to be corrected by "naming, blaming and shaming", while the existence of systematic weaknesses remain hidden, and no lesson is learnt. A proper analysis of the event could be a starting point for organizational learning and improvement 9. We want to discuss about health care professionals learning process how to influence for patients safety by using one case study result. So our purpose is to show how health personnel can improve and avoid harmful errors in patient care by delivering care within the setting of a clinical team and addressing and analyzing errors through a systematic learning process. This paper will describe the learning process in detail and show how it can be applied to various clinical situations to improve patient safety. In a case: Wrong blood transfusion; two blood units were ordered for a patient undergoing surgery 13. During the operation, bleeding occurred, and the blood was controlled and transfusion prepared. However, the bleeding was stopped before transfusion had started. The unbroken blood units were put in a plastic bag and put back in the refrigerator. In the meantime, blood for another patient was placed in the same refrigerator. Later it was decided to transfuse the same patient, and another nurse collected the blood, but this time the blood was not checked against the identity of the patient, leading to transfusion of two units of unmatched blood.

6 This example shows the combined effects of problems at the individual level (nurse fails to verify the identity of the compatibility of the unit of blood with the patient s blood type), the team level (inadequate transfer of information between team members) and the organizational level (lack of blood transfusion hospital policies). In order to learn from these kinds of errors, the department has instituted a process of correction in which collective contextual learning occurs. Specifically, all adverse events are to be reported to the department. Contextual learning occurs when students apply and experience what is taught referencing real problems associated with their roles and responsibilities as family members, citizens, students and workers 13. Collective contextual learning in a clinical context may then occur when health personnel learn together from real problems and adverse events in their microsystem 2. CLINICAL MICROSYTEM AT THE PROCESS LEVEL Deming states that The first step is to draw a flow diagram 14. Then everyone understands what his job is. If people do not see the process, they cannot improve it. The clinical microsystem provides a conceptual and practical framework for approaching organizational learning and delivery of care. Tensions exist between the conceptual theory and the daily practical applications of providing safe and effective care. Designing and redesigning care around the clinical microsystem is consistent with Donabedian s model of structure, process, and outcome 15. As shown in Figure 1; these three important elements are mutually related together. Donabedian says that "quality comprises those attributes of the process of care that contribute to its desired outcomes. The assessment of quality varies, therefore, depending on the outcomes sought, the valuations placed on the outcomes, and the appropriateness of the means used to attain them 16. Figure 1. Donabedian quality assurance model Research on high performing microsystems has underscored the importance of process literacy coupled with effective measurement. Furthermore, a high degree of process awareness often drives the design of the work. The Spine Center at Dartmouth Hitchcock Medical Center provides an example of designing and implementing a program based on microsystem concepts. The Spine Center was built on a detailed understanding of core and supporting processes that would be required to provide care 15. The design team emphasized that improving clinical outcomes requires appreciating the inherent link between process and results. Ultimately, results depend on process. Linking performance and outcome data to the microsystem processes provides a helpful way to

7 start identifying potential areas to focus improvement on the system that is producing the processes and outcomes of care rather than on the individual. The microsystem does not focus exclusively on outcomes; rather, it gives comparable attention to processes and structure, to the linkages among them, and to how they interact to respond to and meet the needs of the patient population 16. An essential element in system analysis and monitoring is a physical and functional system mapping 15. This mapping is based on a comprehensive cognitive analysis which takes into consideration the sub- and supra- elements that allow the microsystem to function, as shown in Figure 2. Figure 2. Graphic representation of a process analysis of the microsystem in supporting patient care and the organization 15. This systems alignment helps us understand the inter-connectedness of seemingly disparate parts of the healthcare system. For example, the hundreds of people that support the operating room team like; blood bank technicians, radiology staff, intensive care unit personnel; enable the surgical microsystem to achieve its exceptional outcomes. Task analysis is a method used to describe and analyze how an individual (surgeon, nurse, patient) interacts both with the system itself and with others within that system. Task analysis describes what an individual is required to do in terms of cognitive processes, actions, or both to achieve the system s goal. The task analysis is accomplished by observations of the process of care and interviews which carefully break down the multiple elements that are part of the microsystem. The previous figure illustrates the complex interaction between the team, the support services, and hospital providers as well as the organizational structures that support these functions. It provides the foundations for understanding the relationships and transactions within the system and with its surrounding systems 15. System mapping or designing as a part of microsystem process level has two other purposes. It serves as the blueprint upon which all changes (procedural and/or physical) are designed and analyzed before testing and implementation. It is also a marketing tool that facilitates selling the necessary changes to other teams and stakeholders. Internal

8 marketing of change elements and process are often overlooked. Without local championship of change, system changes often fail. CURRENT SYSTEM ASSESSMENT AND LEARNING The clinical microsystems in which care is delivered require constant assessment and improvement to minimize errors in patient care. Reason 8 proposed the concept vulnerable system syndrome (VSS) and discussed two approaches to organisational learning that occur in the process of trying to address it. VSS is defined as a cluster of organisational pathologies which render some systems more liable to cause adverse events. Four learning methods which are defined in this area are: 1. Single-loop learning is adaptive learning and maintains the status quo and sustains VSS. 2. Double-loop learning is about re-designing the systems rather than just correcting existing systems and putting them back on course. It is necessary to initiate the process of breaking out of VSS. They assert that the problem of patient injury cannot be mitigated through a focus on the individual health care worker alone. 3. triple-loop learning identified by Rushmer 15 as an additional loop of learning that describes the process of learning about learning ( metalearning ). learning about that particular change that may be useful somewhere else and more generalized learning that can apply to other learning situations in a more generic way. This process is further systematized by formulating the processes of system improvement on the basis of the best available scientific evidence, complemented by clinical expertise and patient consolation. A vision for health professional, undergraduate, graduate and continuous learning is that all health professionals should be educated to deliver patient-centered care as members of a multidisciplinary team. Evidence-based practice, quality improvement approaches and informatics should all be emphasized 1. In summary successful examples of model of improving safety and quality in Microsystems will help to harvest the experiences in cross microsystem collaborative. Microsystems can help to organize and design resilience into the communications, work processes, and clinical environments of complex healthcare organizations. Other assessment tools used to assess the performance of a clinical microsystem are form looks like check list (as below in figure 3) for different purposes such as the primary care profile, specialist care profile and inpatient care profile. Those forms contain a variety of tasks that are been performed in the specific units in order to have self control or self performance awareness and monitoring Meta-learning comprises all three loops of learning and contains two elements: specific

9 Figure 3. Sample check lists

10 TOWARDS CLINICAL MICROSYSTEMS IMPRVOMENT Integrating quality and clinical Microsystems Many professionals in healthcare today are interested in health service quality improvement. people who are concerned with the quality improvement involve healthcare professionals, patients and their families, researchers, payers, planners and educators to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development as long as this health care system integrate those stakeholders and the quality of service under the same umbrella quality and improvement must concern and benefit them all. Here comes the role of the clinical Microsystems development to obtain those outcomes and reach the best quality of health care service and delivery improvement in order to acquire best outcomes for everyone s satisfaction. Improvement usually involves change, if healthcare is going to benefit fully from the science of disease biology, we need to be sure that the changes we make systematically incorporate generalisable scientific knowledge. To guide the design of change, we need to characterize the settings in which care is actually delivered (microsystems, mesosystems and macrosystems) in sophisticated ways. Moreover, to know that change is producing improvement, we need accurate and powerful measurements of what is happening. Batalden and Davidoff propose a simple formula that illustrates the way in which these forces combine to produce improvement.the formula states the way in which knowledge systems combine to produce improvements 17. The model asserting that better health outcomes, better care delivery and better professional development are inextricably linked recognizes that mutual support and stimulation among these three domains invites both sustainability and unending creativity in their efforts. As demonstrated in the Figure 4 below. Figure 4. Linked aims of improvement Drawing everyone actively into the process of testing change, all the time, presumes that everyone will develop a basic understanding of the standards of their work, as well as the skills they need to test changes in that work. Making improvement happen also requires leadership that enables connections between the aims of changes and the design and testing of those changes; that pays serious attention to the policies and practices of reward and accountability; and unshakeable belief in the idea that everyone in healthcare really has two jobs when they come to work every day: to do their work and to improve it 16. To track and share the results; Teams establish a formal process for testing initiatives to ensure they produce measurable outcomes. For example, the patient care unit developed a system for tracking the number of and response time to patient calls before and after implementation. Team leaders share data on the team's progress with team members and other staff within the microsystem. For example, a leader might mount poster-sized paper or dryerase boards on a centrally located wall with updated information about trends in program impact and project refinements 18. Planning and development process Planning and development process is the next stage of establishing a microsystem 18. Key elements of the planning and development process included the following steps: Forming initial microsystem: The chief executive officer invites one patient care unit to adopt the clinical microsystems approach as part of a project. Adding second microsystem: Based on the success achieved by the first microsystem, a second one forms. Hiring consultant to lead staff education: It can be a faculty member to serve as a consultant and educator. The consultant creates and leads a series of six monthly 4-hour education sessions for subsequent clinical microsystem teams. Sessions teach participants about the clinical microsystem framework and process and offered practical assistance on developing goals, examining care processes, developing tests of change, and designing and implementing outcomes measurement systems. Expanding the program: The hospital initiates additional microsystems, with different teams now meeting on a regular basis. Resources used and skills needed Staffing: The adoption of the clinical microsystems approach required no new

11 additional staff. However, the hospital had previously built up an eight-member quality improvement department as part of its overall commitment to quality. These staff members serve as facilitators on all microsystems teams until experienced team members express interest and are prepared to become facilitators of new teams. Costs: The costs of this initiative cannot be estimated. Major development costs include training the facilitators on quality processes and hiring the outside consultant. Ongoing costs include additional labor costs associated with ensuring patient care coverage when team members take time away from their daily responsibilities to participate in microsystems meetings and training. Getting started with this innovation Build a culture of front-line staff involvement: Front-line staff members represent the true experts on quality improvement and are optimally positioned to design improvements in work processes. Giving them the tools and authority to design and implement changes will increase the likelihood of success. Promote rapid cycle improvements: Quick tests and adjustments of new initiatives and processes can yields results that are just as meaningful and sustainable as those achieved through lengthier quality improvement processes. Cultivate cross-unit microsystems: Because patient care delivery in one unit can affect care offered in another unit, many projects require individuals from different areas of the hospital to work together 18. Sustaining this innovation Share best practices across teams: Although teams work in different clinical areas and may have different goals, they can improve performance by learning how other teams approach quality improvement. This is facilitated through reporting results of individual teams in front of past and current microsystem team members. Track performance over time: Maintaining improvements in one area can be difficult after the team moves on to a new one. Tracking and sharing data can keep staff focused, thus helping to prevent slippage. Include individuals from outside organizations as necessary: For example, Cooley Dickinson's newly formed team focusing on methicillinresistant Staphylococcus aureus infections will include representatives from other institutions, because many patients have already contracted methicillin-resistant Staphylococcus aureus before hospital admission 18. The outcomes of the clinical microsystems improvements At Cooley Dickinson, 16 microsystems teams have improved care processes, service quality, and efficiency; examples include significant reductions in call bell volume (by nearly 75 percent), OR turnover (45 percent), and patient room turnover time (50 percent) 19. Fewer patient calls: Between January and July 2008, one unit reduced the number of patient call bells from more than 220 to 60 per a 24-hour period (a nearly 75 percent reduction), despite an increase in patient census over the same time frame. With fewer call bells to deal with, staff improved average response time to a patient's call (quantitative data unavailable). Faster OR turnover, leading to more satisfied surgeons and less overtime: OR turnover time fell from 34 minutes to 18 minutes over a 3- month period; currently, turnover time ranges from 18 to 23 minutes. As a result, surgeon satisfaction has increased from roughly 85 percent before the team-initiated changes to 95 percent today. The hospital has also experienced a significant reduction in staff overtime hours (quantitative data unavailable), as quicker room turnover ameliorates the need for staff to stay beyond their 8-hour shift. Reduced overtime has led to cost savings (quantitative data unavailable). Quicker patient room turnover: The environmental services staff reduced the average time between patient discharge and room readiness from 70 minutes to 30 minutes between April and July of 2008; current turnover time averages roughly 35 minutes. Reduction in no-show rate for outpatient behavioral health clinic visits: The no-show rate decreased from 46 percent to 5 percent after the implementation of the daily walk-in orientation session. Many patients, after meeting the clinician in person at the group session, schedule an appointment for the next day; the overall wait time for the one-on-one appointment is 3 days, down from 2 weeks before implementation of the orientation session. Staff satisfaction is also higher because, given that they are on a productivity payment system, they earn more. Many other improvements: Many other hospital-wide improvements have resulted from the clinical microsystem improvement process; selected improvements include the following: - Reduction in infections: The mean monthly number of health care associated infections (including surgical site infections, central line infections in the intensive care unit, Foley

12 catheter related urinary tract infections in the intensive care unit, and ventilator-associated pneumonia) has fallen from 4.1 in 2007 to 1.8 in 2008 and then to 1.3 in the first quarter of Decline in mortality: The mean acute care inpatient mortality rate fell from 2.47 percent in 2006 to 1.84 in 2007 and again to 1.65 percent in 2009 (as of May 2009). This decline occurred despite an increase in the case mix index from 1.18 in January 2008 to 1.28 in May The ratio of actual to expected acute care mortality fell from a high of 1.6 in September 2007 to 0.4 in December Fall in acute care readmissions: Acute care readmissions dropped from a 12-month average of 12.5 percent in 2007 to 11.8 percent in Most significantly, it dropped from an average of 12.3 percent in the first 6 months of 2008 to 11.1 percent in the last 6 months of CHALLENGES AND LIMITATIONS Challenges that microsystem thinking introduction or adaptation might have can be: Understanding the Microsystems aims and process and integrating the care in the hospital levels. In which the culture and the behavior of the individuals might resist such step consequently delay it or prevent it. Usually such problem is solved through proper promotion of the thinking and excellent planning however the promotion message and strategy it might make it even more difficult if not carefully employed. Another challenge that might be considered strength it the resources, well as mentioned earlier clinical microsystem don t look for hiring new staff but reallocate those exits to utilize them wisely. unfortunately resources are not only the staff but also the capital invested and the technology those staff use, therefore one must not neglect the fact that unskilled staff might bring a big loss in terms of time and many if not aware of the proper utilization techniques for the capital and technologies available such as information technology which in different levels and organizations have been always critical issue. With this we reach the third challenge which is mal-planning and poor management.as said failing to planning is planning to fail. There for staff, management and stakeholders must have enough experience and skills to maintain and sustain this systems.this can be through workshops, speeches, training and intersectional discussion 20. CONCLUSION Clinical microsystems are the smallest replicable units in the health system. Health system redesign can succeed only with leaders who take action to transform these small clinical units to optimize performance to meet and exceed patient needs and expectations and to perfect the linkages between the units. A seamless, patient-centered, high-quality, safe, and efficient health system cannot be realized without this transformation of the essential building blocks that combine to form the care continuum. Excellent planned services and planned care are attainable today in microsystems that understand what really matters to a patient and family and have the capacity to provide services to meet the patient s needs. The concept of microsystems and the assessment tools to assess and evaluate characteristics of a microsystem can make a great contribution to the future study and management of patient safety. We believe that most health care today is sought, created, delivered, and purchased at the level of the clinical microsystem. It is there that real gains in the quality, value, and safety of care can occur. Furthermore, we believe that efforts to increase awareness and mindfulness at the level of the clinical microsystem can contribute to the safety of patient care 20. REFRENCES 1. Institute of Medicine Committee on Quality in Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, Nelson EC, Batalden PB, Huber TP et al. Microsystems in health care: part 1. learning from high- performing front-line clinical units. Journal on Quality Improvement 2002; 28(9): Nelson, E.C., Batalden PB, Homa K et al. Microsystems in health care: Part 2. Creating a rich information environment. The Joint Commission Journal on Quality and Safety 2003; 29(1): Aron DC, Headrick LA. Educating physicians prepared to improve care and safety is no accident: it requires a systematic approach. Quality and Safety in Health Care 2002; 11:

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