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BMJ Quality & Safety: Ten years of improvement innovation in cystic fibrosis care

A decade of healthcare improvement in cystic fibrosis: lessons for other chronic diseases

From 2002 to 2012, the median predicted survival age for people with cystic fibrosis (CF) increased nearly 10 years— from 31.3 years to 41.1 years.1 2 Strategic efforts to improve care for CF marked this remarkable era. These efforts were supported by expert leadership among CF healthcare improvement professionals and resources from the CF Foundation. While process outcomes improved substantially— for example, more timely clinic visits, increased influenza immunisation rates, and more effective screening for associated problems such as depression and diabetes, clinical outcomes improved even more dramatically— notably, pulmonary function, nutritional status and predicted survival.

This supplement, Ten Years of Improvement Innovation in Cystic Fibrosis Care, captures the larger perspective of this comprehensive improvement initiative and reports representative CF care centre-level examples. It also identifies strategies to widen the circle of improvement professionals who successfully publish their innovative work in scholarly journals.

Improving chronic care delivery and outcomes: the impact of the cystic fibrosis Care Center Network

Cystic fibrosis (CF) is a multisystem, lifeshortening genetic disease that requires complex care. To facilitate this expert, multidisciplinary care, the CF Foundation established a Care Center Network and accredited the first care centres in 1961. This model of care brings
together physicians and specialists from other disciplines to provide care, facilitate basic and clinical research, and educate the next generation of providers. Although the Care Center Network has been invaluable in achieving substantial gains in survival and quality of life, additional opportunities for improvements in CF care exist. In 1999, analysis of data from the CF Foundation’s Patient Registry detected variation in care practices and outcomes across centres, identifying opportunities for improvement. In 2002, the CF Foundation launched a comprehensive quality improvement (QI) initiative to enhance care by assembling national experts to develop a strategic plan to disseminate QI training and processes throughout the Care Center Network. The QI strategies included developing leadership (nationally and within each care centre), identifying best CF care practices, and incorporating people with CF and their families into improvement efforts. The goal was to improve the care for every person with CF in the USA. Multiple tactics were undertaken to implement the strategic plan and disseminate QI training and tools throughout the Care Center
Network. In addition, strategies to foster collaboration between care centre staff and individuals with CF and their families became a cornerstone of QI efforts. Today it is clear that the application of QI principles within the CF Care Center Network has improved adherence to clinical guidelines and achievement of important health outcomes.

The Cystic Fibrosis Foundation Patient Registry as a tool for use in quality improvement

The US Cystic Fibrosis Foundation (CFF) began in 1955 with a mission to support the development of new drugs to fight the disease, improve the quality of life for those with cystic fibrosis (CF), and ultimately to find a cure for this disease. The CFF does this by supporting basic science and clinical research in CF, supporting the
care of CF patients through accredited CF centres nationwide and advocating for CF patients at the state and national level.

Recognising the critical role of data collection and measurement of outcomes to better understand the natural history of CF, the CFF created a patient registry in 1966, the CFF Patient Registry (CFFPR). The CFFPR has evolved over the years from a few demographic variables including vital status to a comprehensive database that gives healthcare providers, researchers, policy makers and change agents data to support epidemiological and clinical research as well as efforts to improve quality of care.

The specific purpose of this commentary is to describe the CFFPR and primarily to focus on how the CFFPR and its associated tools are being used for quality improvement (QI) activities, with the hope that it may help CF healthcare teams in the USA who are not familiar with the registry’s capabilities, CF providers outside the USA with registries at various stages of development, and others interested in how a patient registry has been used to improve care.

Key findings of the US Cystic Fibrosis Foundation’s clinical practice benchmarking project

Benchmarking is the process of using outcome data to identify high-performing centres and determine practices associated with their outstanding performance. The US Cystic Fibrosis Foundation (CFF) Patient Registry contains centre-specific outcomes data for all CFF-certified paediatric and adult cystic fibrosis (CF) care programmes in the USA. The CFF benchmarking project analysed these registry data, adjusting for differences in patient case mix known to influence outcomes, and identified the top-performing US paediatric and adult CF care programmes for pulmonary and nutritional outcomes. Separate multidisciplinary paediatric and adult benchmarking teams each visited 10 CF care programmes, five in the top quintile for pulmonary outcomes and five in the top quintile for nutritional outcomes. Key practice patterns and approaches present in both paediatric and adult programmes with outstanding clinical outcomes were identified and could be summarised as systems, attitudes, practices, patient/family empowerment and projects. These included: (1) the presence of strong leadership and a well-functioning care team working with a systematic approach to providing consistent care; (2) high expectations for outcomes among providers and families; (3) early and aggressive management of clinical declines, avoiding reliance on ‘rescues’; and (4) patients/families that were engaged, empowered and well informed on disease management and its rationale. In summary, assessment of practice patterns at CF care centres with top-quintile pulmonary and nutritional outcomes provides insight into characteristic practices that may aid in optimising patient outcomes.

Accelerating the rate of improvement in cystic fibrosis care: contributions and insights of the learning and leadership collaborative

INTRODUCTION: The Learning and Leadership Collaborative (LLC) supports cystic fibrosis (CF) centres’ responses to the variation in CF outcomes in the USA. Between 2002 and 2013, the Cystic Fibrosis Foundation (CFF) designed, tested and modified the LLC to guide front line staff efforts in these efforts. This paper describes the CFF LLC evolution and essential elements that have facilitated increased improvement capability of CF centres and improved CF outcomes.

METHODS: CF centre improvement teams across the USA have participated in 11 LLCs of 12 months’ duration since 2002. Based on the Dartmouth Microsystem Improvement Curriculum, the original LLC included face to face meetings, an email listserv, conference calls and completion of between learning session task books. The LLCs evolved over time to include internet based learning, an electronic repository of improvement resources and examples, change ideas driven by evidence based clinical practice guidelines, benchmarking site visits, an applied QI measurement curriculum and team coaching.

RESULTS: Over 90% of the CF centres in the USA have participated in the LLCs and have increased their improvement capabilities. Ten essential elements were identified as contributors to the successful LLCs: LLC national leadership and coordination, local leadership, people with CF and families involvement, registry data transparency, standardised improvement curriculum with evidence based change ideas, internet resources with reminders, team coaching, regular progress reporting and tracking, benchmarking site visits and applied improvement measurement.

CONCLUSIONS: The LLCs have contributed to improved medical and process outcomes over the past 10 years. Ten essential elements of the LLCs may benefit improvement efforts in other chronic care populations and health systems.

Improving inpatient cystic fibrosis pulmonary exacerbation care: two success stories

BACKGROUND: Pulmonary exacerbations (PEx) in cystic fibrosis (CF) are a frequent cause of hospitalisations and lead to long-term decline in pulmonary function. Successful CF inpatient care requires the coordination of multiple providers and complex therapies. Children’s Hospital of Wisconsin (CHW) and Children’s Healthcare of Atlanta (CHoA) independently identified PEx inpatient care for focused improvements, with emphasis on improving care coordination and patient outcomes.

METHODS: Both centres began by forming multidisciplinary workgroups, including patient and family representatives. CHW’s specific aim was to eliminate delays in the time to initial intravenous antibiotics. A written handoff tool was developed to allow more efficient ordering. Efforts at CHoA focused on coordination and consistent care delivery. A written schedule and patient incentive programme were devised to ensure proper administration of treatments and promote patient adherence.

RESULTS: At CHW, interventions decreased the mean antibiotic order time by 59% with resultant decrease in administration time by 25%. At CHoA, improvements led to a 42% decrease in the proportion of hospitalisations unsuccessful in returning lung function back to within 90% of baseline.

CONCLUSIONS: Inpatient CF PEx care is complex and requires multiple competing activities and treatments. Consistent and timely delivery of these treatments is challenging. Our improvements used the skills and insights of providers and patients to improve, standardise and synchronise care, and to develop tools to
coordinate hand offs. With these improvements, applicable to hospital treatment of many other conditions, both centres were successfully able to deliver treatments in a more consistent and timely manner with improved outcomes.

Redesigning care to meet national recommendation of four or more yearly clinic visits in patients with cystic fibrosis

Cystic fibrosis (CF) is a chronic disease requiring patients to have frequent specialty healthcare visits to delay progression of lung disease, prevent and treat failure to thrive and initiate early interventions to prevent acute illness and complications. The CF Foundation recommends that patients have visits with the CF care team at least every 3 months. During participation in the CF Foundation Learning and Leadership Collaborative IV, the CF team at Arkansas Children’s Hospital initiated quality improvement work with the aim to increase the percentage of patients attending clinic four or more times a year from 35% in 2004 and 56% in 2005 (CF Foundation Registry data) to 90% or greater. We redesigned our scheduling system, rescheduled missed patient appointments in a timely fashion and created a process to monitor attendance. This quality improvement work led to a sustained increase in the percentage of patients attending clinic visits four or more times a year reaching our goal of 90% in 2012. Improvements were also noted in the number of patients with body mass index/weight-for-length centile of 25 or greater, which could be related to more frequent clinic attendance.

The impact of re-education of airway clearance techniques (REACT) on adherence and pulmonary function in patients with cystic fibrosis

BACKGROUND: Our centre’s median forced expiratory volume in one second (FEV1) reported in the 2005 Cystic Fibrosis (CF) Foundation Patient Registry was below the national median. The focus of our quality improvement initiative was to improve lung function through re-education of airway clearance techniques (REACT).

AIM: The global aim was to improve the median FEV1 in our patients. The specific aim was to encourage adherence to airway clearance techniques (ACT). To achieve these goals we implemented the REACT programme for patients.

METHODS: Educational sessions introduced the concept of improving clinical outcomes and the importance of airway clearance in achieving optimal lung function. The REACT programme utilised an anonymous survey, in-clinic questionnaire and ACT demonstration to assess knowledge, practices and barriers to ACT. Patients were then categorised as non-adherent or adherent with correct or incorrect technique. Improper techniques were corrected. All patients were re-educated on the rationale for ACT.

RESULTS: Our surveys revealed that 43%of patients had barriers to ACT and 53% were non-adherent. Following implementation of REACT, median FEV1 increased from 84% to 92%(national median 91–94%) from 2005 to 2010 for patients aged 6–17. For patients 18 and older, median FEV1 increased from 56% to 64%(national median 62–65%) from 2005 to 2010.

CONCLUSIONS: By introducing a programme focused on technique and adherence, we were able to improve median FEV1 in patients with CF. Sustained improvement of FEV1 was accomplished by continued use of the REACT programme.

The impact of transforming healthcare delivery on cystic fibrosis outcomes: a decade of quality improvement at Cincinnati Children’s Hospital

BACKGROUND: In 2001, Cincinnati Children’s Hospital embarked on a journey to improve healthcare delivery to patients with cystic fibrosis (CF). Data from the Cystic Fibrosis Foundation National Patient Registry revealed our below-average clinical outcomes, prompting us to initiate improvement interventions.

OBJECTIVE: To improve clinical outcomes for patients with CF through a comprehensive quality-improvement approach directed at
increasing patient centredness and improving healthcare delivery.

INTERVENTIONS: In 2001, we shared our below-average outcomes with patients, families and care providers. We instituted a quality-improvement steering committee with parental and hospital leadership, and our data-management support was restructured to provide real-time clinical data to monitor our progress. In 2002, our weekly chart conference changed to a prospective planning session and individualised daily schedules were created for inpatients. In 2003, an influenza vaccination campaign was initiated and our infection-control practices were redesigned. In 2005, best-practice guidelines were developed for airway-clearance therapy. In 2007, evidence-based clinical algorithms were designed and implemented and key care-team members were added.

MEASUREMENTS: Primary outcome measures were median forced expiratory volume in 1 s per cent predicted (age range 6–17 years) and median body mass index percentile (age range 2–20 years).

RESULTS: From 2000 to 2010, median forced expiratory volume in 1 s increased from 81.7% to 100.1% predicted and median body mass index increased from the 35th to the 55th centile.

DISCUSSION: By focusing on specific outcomes, empowering families and patients, effectively using data, and standardising care processes, we transformed the culture and delivery of care for our patients with CF and learned valuable lessons potentially translatable to other chronic-care providers.

Improving transition from paediatric to adult cystic fibrosis care: programme implementation and evaluation

BACKGROUND: The paradigm of cystic fibrosis (CF) care has changed as effective therapies extend the lives of patients well into adulthood. Preparing for and maintaining high quality CF care into the adult healthcare setting is critical for prolonged survival. Unfortunately, this transfer process from the paediatric to the adult
CF centre is met with a variety of challenges.

OBJECTIVE AND METHODS: The objective of this quality improvement (QI) project was to develop, implement and evaluate a theory-based programme for transition from paediatric to adult CF care. In a multi-phase process, the paediatric and adult programmes developed a transition curriculum, addressed care standards and standardised patient transfer protocols. We evaluated the impact of this process through staff surveys, review of field notes from QI meetings, tracking transfers and responses of
patients to the Transition Readiness Assessment Questionnaire (TRAQ) at the start of the programme and 18 months after initiation.

RESULTS: The collaboration between the paediatric and adult teams continued through quarterly meetings over the past 4 years. This has provided a forum that sustained our transition programme, harmonised care across CF centres and addressed other needs of our CF centre. Discussion of transition with families in the paediatric centre increased twofold (35% to 73% p<0.001), and resulted in a trend towards improved patient TRAQ self-advocacy scores and decreased in-hospital transfer.

CONCLUSIONS: We successfully created a curriculum and process for transition from paediatric to adult CF care at our centres. This collaboration shapes the communication between our paediatric and adult CF care teams and enables ongoing feedback among patients, families and providers. The impact of our transition programme on long-term patient morbidity will require future evaluation.

Improved patient safety through reduced airway infection rates in a paediatric cystic fibrosis programme after a quality improvement effort to enhance infection prevention and control measures

OBJECTIVE: To reduce the risk of pathogen transmission between patients with cystic fibrosis (CF) and decrease the rate of acquisition of new CF pathogens in our patients.

DESIGN: Using the Model for Improvement, we developed a new process for infection prevention and control in our outpatient CF clinics.

SETTING: Paediatric CF programme at Ann & Robert H. Lurie Children’s Hospital of Chicago; approximately 180 paediatric patients aged birth to 21 years.

PARTICIPANTS: All paediatric patients enrolled in the Cystic Fibrosis Foundation Patient Data Registry at this institution.

INTERVENTIONS: Implemented contact precautions with all patients, regardless of respiratory tract culture results.

MEASUREMENT: Respiratory tract culture rates of specific pathogens by quarter were compared prior to and after implementation.

RESULTS: Our percentage of patients with a positive respiratory tract culture for Pseudomonas aeruginosa dropped from 30%to 21% (p<0.0001) and for methicillin-resistant Staphylococcus aureus (MRSA) dropped from 10.8%to 8.7% (p=0.008).

CONCLUSIONS: Use of contact precautions by all care providers, for all patients, regardless of respiratory tract culture results resulted in
decreased P aeruginosa and MRSA infection rates.

Sustained improvement in nutritional outcomes at two paediatric cystic fibrosis centres after quality improvement collaboratives

OBJECTIVE: To describe the characteristics of sustained improved nutritional outcomes through the use of quality improvement (QI) methodology.

DESIGN: Retrospective analysis of a QI intervention in two institutions, implemented as part of larger national collaboratives.

SETTING: Paediatric cystic fibrosis (CF) programmes in academic centres in Alabama and Illinois.

PARTICIPANTS: All paediatric patients enrolled in the CF Foundation (CFF) Patient Data Registry were included.

INTERVENTIONS: Improved and sustained nutrition outcomes occurred through implementation of the CFF practice guidelines for CF nutrition management via care delivery processes, nutritional interventions, team engagement and data display.

MEASUREMENT: Mean body mass index (BMI) percentile, percentage of patients less than 50th percentile and percentage less than 10th percentile for all patients aged 2–20 years were tracked through run charts and statistical process control charts. Mann–Whitney U and χ2 tests were used to determine significance between each centre and national outcomes.

RESULTS: Each centre achieved rapid improvement in mean BMI percentile in patients, one centre rising from the 40th percentile in 2001 to the 49th percentile in 2003, the other rising from the 37th percentile in 2003 to the 45th percentile in 2004. These centres have also maintained improved nutritional outcomes, so that they were at the 60th and 55th percentiles, respectively, in 2011. Sustained improvement was accomplished through QI methodology, use of data as a driver for improvement and a change in culture.

CONCLUSIONS: Participation in collaboratives led to improved nutrition outcomes while a strong culture of QI facilitated sustained

The interdependent roles of patients, families and professionals in cystic fibrosis: a system for the coproduction of healthcare and its improvement

A quality healthcare system is coproduced by patients, families and healthcare professionals working interdependently to cocreate and
codeliver care. Cystic fibrosis (CF) patients and families rely on healthcare professionals to provide the best possible care and timely, accurate information. They know that the care at home and in clinical settings needs to be seamless, using shared information and decisions. A parent’s journey of better care begins with her son’s diagnosis and moves to her involvement to improve the systems and processes of care for others. She reflects on this
work and identifies five elements that contributed to the coproduction of improved care: (1) mental and emotional readiness to engage; (2) curiosity and the search for insight; (3) reframe challenges into opportunities for improvement; (4) listen and learn from everyone, bringing home what is relevant; and (5) personal participation. Joined with the reflections of an improvement scientist, they note that chronic care relies on informed, activated patients and prepared, proactive healthcare professionals working together and that it is more than ‘patient-centric’. They propose a model for the coimprovement of systems of care.

Accelerating implementation of biomedical research advances: critical elements of a successful 10 year Cystic Fibrosis Foundation healthcare delivery improvement initiative

CONTEXT: SCIENTIFIC AND THERAPEUTIC ADVANCES: Remarkable biomedical research advances have led to innovative and increasingly effective therapies. We highlight several scientific milestones in elucidating the pathophysiology of cystic fibrosis (CF) and review the therapies that have become available over the past 20 years.

IMPACT OF THE QUALITY IMPROVEMENT INITIATIVE: In 2002, the CF Foundation launched a multifaceted quality improvement initiative to accelerate improvement in CF care. We present evidence of substantial improvement in process measures, such as more consistent outpatient follow-up, and key medical outcomes, including survival, pulmonary function and nutritional status.

CRITICAL SUCCESS FACTORS: We offer our perspective on factors critical to the success of the quality improvement initiative, including a compelling strategic plan and the commitment of the CF Foundation to its implementation; the investment in building improvement capacity at CF care centres; the engagement of people with CF and their families as partners; and the integration of quality improvement into the existing CF care

DIRECTIONS FOR THE NEXT DECADE: In addition to a continued investment in building and sustaining improvement capacity at CF care centres, and deeper patient engagement, we will address the oppressive treatment burden. We will also complement the measurement of clinical outcomes with patient reported outcomes and healthcare costs for a balanced assessment of the quality and value of care.

CONCLUSIONS: Major advances in basic science and therapeutic development coupled with improvements in healthcare delivery have resulted in striking gains in medical outcomes for people with CF.

Healthcare improvement is incomplete until it is published: the cystic fibrosis initiative to support scholarly publication

OBJECTIVE: Preparation of this supplement, Ten years of improvement innovation in cystic fibrosis care, tested a strategy to support writing and scholarly publication by cystic fibrosis (CF) healthcare improvement professionals.

INTERVENTION: Critical elements of the writing initiative included: a request for abstracts that was distributed to over 2000 professionals in the Cystic Fibrosis Foundation-supported improvement community to identify promising work; continuous peer review of manuscripts by co-authors and writing tutors; three webinars and a 2-day face-to-face writing retreat that addressed the challenges of successful scholarly healthcare improvement writing and publication; and finally, journal submission and formal external peer review. The SQUIRE Publication Guidelines provided content framework for manuscripts.

RESULTS: 47 abstracts were submitted from which reviewers selected nine for participation. The 28 co-authors of these abstracts took part in the writing initiative. Authors’ self-assessment showed that half had previously published fewer than five papers, while 80% considered themselves insufficiently prepared to write for the scholarly improvement literature. Eventually all of the nine abstracts led to full manuscripts, which were submitted to the journal for formal peer review. Of these, seven were accepted for publication and are included in this supplement.

CONCLUSIONS: A formal initiative to develop and support scholarly writing—while resource-intensive—offers opportunities for wider publication by healthcare improvement professionals.

Clinical Microsystems 4 Part Series: The Joint Commission Journal on Quality and Patient Safety 2008

Part 1
The Building Blocks of Health Systems

BACKGROUND: Wherever, however, and whenever health care is delivered no matter the setting or population of patients—the body of knowledge on clinical microsystems can guide and support innovation and peak performance. Many health care leaders and staff at all levels of their organizations in many countries have adapted microsystem knowledge to their local settings.

CLINICAL MICROSYSTEMS: A PANORAMIC VIEW: HOW DO CLINICAL MICROSYSTEMS FIT TOGETHER? As the patient’s journey of care seeking and care delivery takes place over time, he or she will move into and out of an assortment of clinical microsystems, such as a family practitioner’s office, an emergency department, and an intensive care unit. This assortment of clinical microsystems—combined with the patient’s own actions to improve or maintain health—can be viewed as the patient’s unique health system. This patient-centric view of a health system is the foundation of second-generation development for clinical microsystems.

LESSONS FROM THE FIELD: These lessons, which are not comprehensive, can be organized under the familiar commands that are used to start a race: On Your Mark, Get Set, Go! . . . with a fourth category added—Reflect: Reviewing the Race. These insights are intended as guidance to organizations ready to strategically transform themselves.

CONCLUSION: Beginning to master and make use of microsystem principles and methods to attain macrosystem peak performance can help us knit together care in a fragmented health system, eschew archipelago building in favor of nation-building strategies, achieve safe and efficient care with reliable handoffs, and provide the best possible care and attain the best possible health outcomes.

Part 2
Learning from Micro Practices about Providing Patients the Care They Want and Need

BACKGROUND: Usual medical care in the United States is frequently not a satisfying experience for either patients or primary care physicians. Whether primary care can be saved and its quality improved is a subject of national concern. An increasing number of physicians are using microsystem principles to radically redesign their practices. Small, independent practices—micro practices—are often able to incorporate into a few people the frontline attributes of successful microsystems such as clear leadership, patient focus, process improvement, performance patterns, and information technology.

PATIENT FOCUS, PROCESS IMPROVEMENT AND PERFORMANCE PATTERNS: An exemplary microsystem will (1) have as its primary purpose a focus on the patient—a commitment to meet all patient needs; (2) make fundamental to its work the study, measurement, and improvement of care—a commitment to process improvement; and (3) routinely measure its patterns of performance, “feed back” the data, and make changes based on the data.

LESSONS FROM MICRO PRACTICES: The literature and experience with micro practices suggest that they (1) constitute an important group in which to demonstrate the value of microsystem thinking; (2) can become very effective clinical microsystems; (3) can reduce their overhead costs to half that of larger freestanding practices, enabling them to spend more time working with their patients; (4) can develop new tools and approaches without going through layers of clearance; and (5) need not reinvent the wheel.

CONCLUSIONS: Patient-reported data demonstrate how micro practices are using patient focus, process improvement, performance patterns, and information technology to improve performance. Patients should be able to report that they receive “exactly the care they want and need exactly when and how they want and need it.”

Part 3
Transformation of Two Hospitals Using Microsystem, Mesosystem, and Macrosystem Strategies

BACKGROUND: Two hospitals—a large, urban academic medical center and a rural, community hospital—have each chosen a similar microsystem-based approach to improvement, customizing the engagement of the micro-, meso-, and macrosystems and the improvement targets on the basis of an understanding of the local context.

CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER (CCHMC): Since 2004, strategic changes have been developed to support microsystems and their leaders through (1) ongoing improvement training for all macro-, meso-, and microsystem leaders; (2) financial support for physicians who are serving as co-leaders of clinical microsystems; (3) increased emphasis on aligning academic pursuits with improvement work at the clinical front lines; (4) microsystem leaders’ continuous access to unit-level data through the organization’s intranet; and (5) encouragement of unit leaders to share outcomes data with families.

COOLEY DICKINSON HOSPITAL (CDH): CDH has moved from near closure to a survival-turnaround focus, significant engagement in quality and finally, a complete reframing of a quality focus in 2004. Since then, it has deployed the clinical microsystems approach in one pilot care unit (West 2, a medical surgery unit), broadened it to two, then six more,and is now spreading it organizationwide. In “2+2 Charters,” interdisciplinary teams address two strategic goals set by senior leadership and two goals set by frontline microsystem leaders and staff.

DISCUSSION: CCHMC and CDH have had a clear focus on developing alignment, capability, and accountability to fuse together the work at all levels of the hospital, unifying the macrosystem with the mesosystem and microsystem. Their improvement experience suggests tips and actions at all levels of the organization that could be adapted with specific context knowledge by others.

Part 4
Building Innovative Population-Specific Mesosystems

BACKGROUND: In 2005, the Geisinger Health System (Danville, Pennsylvania) developed ProvenCare, first applied to coronary artery bypass graft (CABG), as an innovative provider-driven quality improvement program to promote reliable delivery of evidence-based best practices. A new mesosystem is created for each ProvenCare model, integrating the care delivery process between contributing microsystems and defining new mesosystem leadership. The approach has been expanded to many patient populations, including percutaneous coronary intervention (PCI).

A NEW PCI MESOSYSTEM: In 2007 clinical microsystem thinking was applied to PCI: understanding the current processes and patterns, assembling the frontline professionals to redesign the processes, and using a beta-test phase to measure the changes and adjust accordingly, until the best process was established. A new mesosystem team was created to ensure that the right care is delivered at the right time.

REFINING IMPLEMENTATION: In the course of developing the CABG initiative, Geisinger established role definitions to keep teams on track; a comprehensive plan from design through execution and follow-up; and guiding principles established for the teams engaged in designing, developing, and implementing ProvenCare programs.

PRELIMINARY EXPERIENCE: For the 40 measurable process elements in the PCI mesosystem pathway, as of month seven (July 2008) of the beta-test phase, 55% of the patients received 100% of the identified process elements.

CONCLUSION: Geisinger Health System has joined different microsystems to form an innovative mesosystem capable of producing reliable, evidence-based care for patient subpopulations. This approach to embedding evidence-based care into routine care delivery can be adapted by others.

Microsystems in Health Care 9 Part Series: The Joint Commission Journal of Quality and Safety 2002

Part 1
Learning from High-Performing Front-Line Clinical Units

BACKGROUND: Clinical microsystems are the small, functional, front-line units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients and providers meet. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed.

METHODS: A wide net was cast to identify and study a sampling of the best-quality, best-value small clinical units in North America. Twenty microsystems, representing different component parts of the health system, were examined from December 2000 through June 2001, using qualitative methods supplemented by medical record and finance reviews.

RESULTS: The study of the 20 high-performing sites generated many best practice ideas (processes and methods) that microsystems use to accomplish their goals. Nine success characteristics were related to high performance: leadership, culture, macro-organizational support of microsystems, patient focus, staff focus, interdependence of care team, information and information technology, process improvement, and performance patterns. These success factors were interrelated and together contributed to the microsystem’s ability to provide superior, cost-effective care and at the same time create a positive and attractive working environment.

CONCLUSIONS: A seamless, patient-centered, high-quality, safe, and efficient health system cannot be realized without the transformation of the essential building blocks that combine to form the care continuum.

Part 2
Creating a Rich Information Environment

BACKGROUND: A rich information environment supports the functioning of the small, functional, frontline units—the microsystems—that provide most health care to most people. Three settings represent case examples of how clinical microsystems use data in everyday practice to provide high-quality and cost-effective care.

CASES: At The Spine Center at Dartmouth, Lebanon, New Hampshire, a patient value compass, a one-page health status report, is used to determine if the provided care and services are meeting the patient’s needs. In Summit, New Jersey, Overlook Hospital’s emergency department (ED) uses uses real-time process monitoring on patient care cycle times, quality and productivity indicator tracking, and patient and customer satisfaction tracking. These data streams create an information pool that is actively used in this ED microsystem—minute by minute, hourly, daily, weekly, and annually—to analyze performance patterns and spot flaws that require action. The Shock Trauma Intensive Care Unit (STRICU), Intermountain Health Care, Salt Lake City, uses a data sytstem to monitor the “wired” patient remotely and share information at any time in real time. Staff can complete shift reports in 10 minutes.

DISCUSSION: Information exchange is the interface that connects staff to patients and staff to staff within the microsystem; microsystem to microsystem; and microsystem to macro-organization.

Part 3
Planning Patient-Centered Services

BACKGROUND: Strategic focus on the clinical microsystems—the small, functional, frontline units that provide most health care to most people—is essential to designing the most efficient, population-based services. The starting place for designing or redesigning of clinical microsystems is to evaluate the four P’s: the patient subpopulations that are served by the microsystem, the people who work together in the microsystem, the processes the microsystem uses to provide services, and the patterns that characterize the microsystem’s functioning.

GETTING STARTED: Diagnosing and treating a clinical microsystem: Methods and tools have been developed for microsystem leaders and staff to use to evaluate the four P’s—to assess their microsystem and design tests of change for improvement and innovation.

PUTTING IT ALL TOGETHER: Based on its assessment—or diagnosis—a microsystem can help itself improve the things that need to be done better. Planning services is designed to decrease unnecessary variation, facilitate informed decision making, promote efficiency by continuously removing waste and rework, create processes and systems that support staff, and design smooth, effective, and safe patient care services that lead to measurably improved patient outcomes.

CONCLUSION: The design of services leads to critical analysis of the resources needed for the right person to deliver the right care, in the right way, at the right time.

Part 4
Planning Patient-Centered Care

BACKGROUND: Clinical microsystems are the essential building blocks of all health systems. At the heart of an effective microsystem is a productive interaction between an informed, activated patient and a prepared, proactive practice staff. Support, which increases the patient’s ability for self-management, is an essential result of a productive interaction. This series on highperforming clinical microsystems is based on interviews and site visits to 20 clinical microsystems in the United States. This fourth article in the series describes how high-performing microsystems design and plan patient-centered care.

PLANNING PATIENT-CENTERED CARE: Well-planned, patient-centered care results in improved practice efficiency and better patient outcomes. However, planning this care is not an easy task. Excellent planned care requires that the microsystem have services that match what really matters to a patient and family and protected time to reflect and plan. Patient self-management support, clinical decision support, delivery system design, and clinical information systems must be planned to be effective, timely, and efficient for each individual patient and for all patients.

CONCLUSION: 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.

Part 5
How Leaders are Leading

BACKGROUND: Leading and leadership by formal and informal leaders goes on at all levels of microsystems—the essential building blocks of all health systems—and between them. It goes on between microsystems and other levels of the systems in health care. This series on high-performing clinical microsystems is based on interviews and site visits to 20 clinical microsystems in the United States. This fifth article in the series describes how leaders contribute to the performance of those microsystems.

ANALYSIS OF INTERVIEWS: Interviews of leaders and staff members offer a rich understanding of the three core processes of leading. Building knowledge requires many behaviors of leaders and has many manifestations as leaders seek to build knowledge about the structure, processes, and patterns of work in their clinical microsystems. Taking action covers many different behaviors—making things happen, executing plans, making good on intentions. It focuses action on the way people are hired and developed and involves the way the work gets done. Reviewing and reflecting provides insight as to how the microsystem’s patterns, processes, and structure enable the desired work to get done; what success looks like; and what will be next after that “success” is created.

CONCLUSION: The focus on the processes of leading is intended to enable more people to develop into leaders and more people to share the roles of leading.

Part 6
Designing Patient Safety into the Microsystem

BACKGROUND: This article explores patient safety from a microsystems perspective and from an injury epidemiological perspective and shows how to embed safety into a microsystem’s operations. Microsystems patient safety scenario: Allison, a 5-year-old preschooler with a history of “wheezy colds,” and her mother interacted with several microsystems as they navigated the health care system. At various points, the system failed to address Allison’s needs. The Haddon matrix provides a useful framework for analyzing medical failures in patient safety, setting the stage for developing countermeasures.

CASE STUDY: The case study shows the types of failures that can occur in complex medical care settings such as those associated with pediatric procedural sedation. Six patient safety principles, such as “design systems to identify, prevent, absorb, and mitigate errors,” can be applied in a clinical setting. In response to this particular case, its subsequent analysis, and the application of microsystems thinking, the anesthesiology department of the Children’s Hospital at Dartmouth developed the PainFree Program to provide optimal safety for sedated patients.

CONCLUSION: Safety is a property of a microsystem and it can be achieved only through thoughtful and systematic application of a broad array of process, equipment, organization, supervision, training, simulation, and teamwork changes.

Part 7
The Microsystem as a Platform for Merging Strategic Planning and Operations

BACKGROUND: The microsystem, as agent for change, plays a critical and essential role in developing and deploying the macrosystem’s strategic plan.

STRATEGIC PLANNING AND MICROSYSTEM THINKING: To effectively deploy a strategic plan, the organization must align the plan’s goals and objectives across all levels and to all functional units. The concepts of microsystem thinking were the foundation for the journey on which Overlook Hospital/Atlantic Health System (Summit, NJ) embarked in 1996. Six stages can be identified in the development of the relationship between macrosystems and microsystems. Five critical theme—trust making, mitigation of constraints and barriers among departments and units, creation of a common vocabulary, raising of microsystem awareness, and facilitation of reciprocal relationships—are associated with these stages.

NOTES FROM A MICROSYSTEM JOURNEY: The emergency department (ED) experienced Stage 1—The Emergence of a Self-Aware Microsystem—as it created cultural and behavioral change, which included the actualization of staff-generated ideas and an ongoing theme of trust making. In Stage 3—Unlike Microsystems (Different Units) Learn to Collaborate—the ED’s microsystems approach spread to other units in the hospital. Collaboratives addressed x-ray turnaround times, admission cycle times, and safety initiatives
.SUMMARY AND CONCLUSIONS: The microsystem—the small, functional, front-line units—is where the strategic plans become operationalized.

Part 8
Developing People and Improving Work Life: What Front-Line Staff Told Us

BACKGROUND: The articles in the Microsystems in Health Care series have focused on the success characteristics of high-performing clinical microsystems. Realization is growing about the importance of attracting, selecting, developing, and engaging staff. By optimizing the work of all staff members and by promoting a culture where everyone matters, the microsystem can attain levels of performance not previously experienced.

CASE STUDY: At Massachusetts General Hospital Downtown Associates (Boston), a primary care practice, the human resource processes are specified and predictable, from a candidate’s initial contact through each staff member’s orientation, performance management, and professional development. Early on, the new employee receives materials about the practice, including a practice overview, his or her typical responsibilities, the performance evaluation program, and continuous quality improvement. Ongoing training and education are supported with skill labs, special education nights, and cross-training. The performance evaluation program, used to evaluate the performance of all employees, is completed during the 90-day orientation and training, quarterly for one year, and annually

CONCLUSION: Some health care settings enjoy high morale, high quality, and high productivity, but all too often this is not the case. The case study offers an example of a microsystem that has motivated its staff and created a positive and dynamic workplace.

Part 9
Developing Small Clinical Units to Attain Peak Performance

BACKGROUND: This last Microsystems in Health Care series article focuses on what it takes, in the short term and long term, for clinical microsystems—the small, functional, front-line units that provide the most health care to the most people—to attain peak performance.

CASE STUDY: A case study featuring the intensive care nursery at Dartmouth-Hitchcock Medical Center illustrates the 10-year evolution of a clinical microsystem. Related evolutionary principles begin with the intention to excel, involve all the players, use measurement and feedback, and create a learning system.

DISCUSSION: A microsystem’s typical developmental journey toward excellence entails five stages of growth—awareness as an interdependent group with the capacity to make changes, connecting routine daily work to the high purpose of benefiting patients, responding successfully to strategic challenges, measuring the microsystem’s performance as a system, and juggling improvements while taking care of patients.

A MODEL CURRICULUM: Health system leaders can sponsor an action-learning program to catalyze development of clinical microsystems. A “green-belt curriculum” can help clinical staff members acquire the fundamental knowledge and skills that they will need to master if they are to increase their capacity to attain higher levels of performance; uses action-learning theory and sound education principles to provide the opportunity to learn, test, and gain some degree of mastery; and involves people in the challenging real work of improving.

Team Coaching

Structured Coaching Programs to Develop Staff

Health care environments are complex and chaotic, therein challenging patients and professionals to attain satisfaction, well-being, and exceptional outcomes. These chaotic environments increase the stress and burnout of professionals and reduce the likelihood of optimizing success in many dimensions. Coaching is evolving as a professional skill that may influence the optimization of the health care environment. This article reflects on three coaching programs: Gallup Strengths-Based Coaching, Dartmouth Microsystem Coaching, and Health and Wellness Nurse Coaching. Each approach is presented, processes and outcomes are considered, and implications for educators are offered. Continuing education departments may recognize various coaching approaches as opportunities to support staff professionals achieve not only the triple aim, but also the quadruple aim.

Interprofessional Education

Rapid Health Care Improvement Science Curriculum Integration Across Programs in a School of Nursing

This article describes the systematic efforts undertaken by a school of nursing in the Northeastern United States to foster innovation in health professions education. We present an application of modified team coaching and plan-do-study-act improvement methods in an educational context to rapidly integrate a quality and safety curriculum across programs. We discuss applications in generalist, advanced practice, doctoral, residency, and advanced fellowship programs and provide
examples of each.

Interprofessional collaborative practice and relational coordination: Improving healthcare through relationships