July 2002

Grant Results

SUMMARY

From 1999 to 2000, National Academy of Sciences - Institute of Medicine (IOM) conducted a study of high-performing micro-systems — small, organized patient care units with a specific clinical purpose, set of patients and practitioners — within health care institutions or systems.

The study was part of a larger IOM initiative on the Quality of Health Care in America, the goal of which was to develop recommendations for improving the overall US health care system.

The study was based on interviews with the leaders of 43 micro-systems.

Key Findings
In their report, entitled Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross Case Analysis, the investigators identified six factors that may be key to replicating a high-performing micro-system:

  • Senior executives and management support innovation and improvement efforts.
  • Clinical leadership is strong, focused and sustained.
  • Multi-disciplinary teams collaborate both for clinical care and for improvement efforts.
  • Explicit attention is paid to the development of systems of care.
  • Good information systems make measurement of performance possible.
  • The focus is on the needs of patients.

They also identified eight themes that typify high-performing micro-systems:

  • Information from a variety of sources is integrated into the daily work.
  • Performance measures have been developed and are used to modify patient care.
  • Key players work as a collaborative multidisciplinary team.
  • The aims of the micro-system are consistent with those of the larger system.
  • Clear aims guide work and are communicated across micro-system boundaries.
  • The micro-system is a resource for the community and vice versa.
  • Training, money and time are available for making improvements.
  • There is high alignment between health professionals' roles and qualifications.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $235,959.

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THE PROBLEM

Most efforts to identify exemplary health care institutions, systems, or programs have focused on large units of analysis (for example, health plans, integrated delivery systems, hospitals). However, high-performing, non-health companies such as McDonalds, Wal-Mart, and AT&T have found that concentrating on improvements in the smallest unit (the interface between the customer and the company) has been the key to better service and financial success.

In the late 1990s, an IOM Committee on the Quality of Health Care in America (QHCA) began to look at such micro-systems in health care for clues to providing recommendations for improving the overall US health care system. Health care micro-systems generally include a core team of health professionals, a defined group of patients, and the supporting staff, equipment, and office environment. Examples include cardiac care units, breast care centers, and individual physicians' practice sites. (The IOM is part of the National Academy of Sciences, which advises the federal government on science, engineering, and technology issues.)

The IOM appointed a QHCA subcommittee on Building the 21st Century Health System. The subcommittee's interest in the micro-system concept was based on several notions, including:

  1. Micro-systems provide an organizational structure that is meaningful to patients.
  2. Micro-systems are a more stable unit of analysis than are larger systems.
  3. Micro-systems have a more longitudinal focus on patient care.
  4. Micro-systems represent the key to maximizing quality, since they are the venue where care is provided.

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THE PROJECT

The grant supported an IOM study of high-performing micro-systems within health care institutions or systems. The goal was to provide a possible blueprint for managed care organizations, health care professionals, researchers, and administrators to improve the quality of health care delivered in the United States.

A recognized expert on micro-systems, Paul B. Batalden, M.D., of the Center for the Evaluative Clinical Sciences at Dartmouth Medical School in Hanover, N.H., served as a project consultant and as a member of the Study Steering Group, which was a subset of members from the QHCA subcommittee (see the Appendix for a roster of members).

Project staff also collaborated with the Institute for Health Care Improvement, a Boston, Mass., nonprofit organization that, at the time, was working to develop and implement a series of organizational design principles that would lead to improvements in clinical practice at 42 office sites throughout the country.

To carry out the project, researchers:

  • Conducted a literature review to describe the characteristics of various micro-systems.
  • Developed a definition of health care micro-systems as "small, organized patient care units with a specific clinical purpose, set of patients, technologies, and practitioners who work directly with these patients."
  • Identified 100 high-performing micro-systems to include in the study through suggestions from QHCA committee members and other experts in the field. "High-performing" micro-systems were defined as organizations that had a reputation for employing innovative models of health care delivery; innovative use of technology; and a high level of performance or investment in quality improvement activities.
  • Conducted structured telephone interviews with leaders of 43 high-performing, health care micro-systems. The 43 micro-systems that agreed to participate in the study included hospital units (cardiac care, newborn intensive care), primary care and other ambulatory settings, chronic disease management programs, hospices, and a hospital specializing in a single procedure.

    The interviews covered five general topics:
    1. The level of performance and the concept, model, or map of the micro-system.
    2. Patient experience, control, and involvement.
    3. Information and information technology.
    4. Investment in improvement.
    5. Leadership and management, and improving care delivery.
  • Analyzed the data from the interviews.

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FINDINGS

Researchers published the following findings in Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross Case Analysis, 2000.

  • The researchers identified six factors that may be key to replicating high-performing micro-systems (defined as organizations that had a reputation for employing innovative models of health care delivery; innovative use of technology; and a high level of performance or investment in quality improvement activities):
    • Senior executives and management support innovation and improvement efforts.
    • Clinical leadership is strong, focused, and sustained.
    • Multi-disciplinary teams function collaboratively both for clinical care and for improvement efforts.
    • Explicit attention is paid to the development of systems of care.
    • Good information systems make measurement of performance possible.
    • The focus is on the needs of patients.
  • The researchers identified eight broad themes that appear to characterize high-performing micro-systems.
    • Integration of information: Information from a variety of sources is integrated into the daily work of the micro-system and technology plays a role in integrating information among clinician, patients, and other members of the micro-system.
    • Use of Measurement: A set of measures appropriate for measuring the system's performance has been developed. The information is used to modify the care of individual patients and the processes of care.
    • Interdependence of the care team: The key players — the practitioners and staff who work together on a daily basis — work as a collaborative, multidisciplinary team with direct, clear communication.
    • Supportiveness of the larger system: The aims of the micro-system are consistent with the aims of the larger system.
    • Constancy of purpose: Clear aims guide the work of the micro-system and they are communicated across micro-system boundaries.
    • Connection to the community: Micro-systems define the boundaries of the population they serve so that the micro-system is a resource for the community and vice versa.
    • Investment in improvement: Training, money, and time are available for making improvements.
    • Alignment of role and training: Health professionals are expected to work at the limits of their education and training — i.e., there is high alignment between their role and their qualifications.

Limitations

  • The sample of high-performing micro-systems was selected, not random. Investigators reported that some high performing micro-systems might have been overlooked.
  • The qualities identified by the researchers as characteristic of "high performing" micro-systems were based on the information provided by the executives interviewed. They conducted no independent verification of the information obtained from each company about itself.

Communications

Project staff made presentations of their findings at the 2000 Annual Forum of the Institute for Health Care Improvement, the 2000 Annual Meeting of the Association for Health Services Research, and a meeting of the Association of American Medical Colleges Council of Southern Deans.

The staff completed a technical report entitled Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross Case Analysis, which was published in 2001 by IOM. Project staff distributed 150–200 copies of the report to members of the QHCA committee and subcommittees, to the micro-system leaders who were interviewed, and to others who requested copies. (The report is available online.) The IOM incorporated findings from the micro-systems study into its report on the larger QHCA initiative, entitled Crossing the Quality Chasm: A New Health System for the 21st Century (National Academy Press, 2001). (The report is available online.) After the close of the grant, project staff gave two additional presentations on the study to professional groups. (See the Bibliography for details.)

Project staffers continue to prepare articles about the project for publication.

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LESSONS LEARNED

  1. Direct observation through site visits would have provided a stronger basis for analysis than the telephone interviews conducted. Researchers also noted in their final report to RWJF that a more comprehensive assessment would have included interviews with at least one person from each of the key roles within the micro-system, including patients.

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GRANT DETAILS & CONTACT INFORMATION

Project

Research to Identify and Examine the Characteristics of Micro Systems in the Health Care Industry

Grantee

National Academy of Sciences - Institute of Medicine (Washington,  DC)

  • Amount: $ 235,959
    Dates: May 1999 to October 2000
    ID#:  036111

Contact

Janet M. Corrigan, Ph.D.
(202) 334-2165
jcorriga@nas.edu

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Study Steering Group

Paul B. Batalden
Center for the Evaluative Clinical Sciences
Dartmouth Medical School
Hanover, N.H.

Donald M. Berwick
President and CEO
Institute for Healthcare Improvement
Boston, Mass.

Eugene C. Nelson
Professor of Community and Family Medicine
Dartmouth Medical School and
Director of Quality Education
Measurement and Research
Dartmouth-Hitchcock Medical Center
Lebanon, N.H.

Thomas Nolan
Associates in Process Improvement
Silver Spring, Md.

Stephen M. Shortell
Blue Cross of California
Distinguished Professor of Health Policy and Management and
Professor of Organization Behavior
School of Public Health
University of California at Berkeley
Berkeley, Calif.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Books

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press, 2001. Includes information from the report, Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis (see Reports). Also available online.

Reports

Donaldson MS and Mohr J. Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis. Washington, D.C.: Institute of Medicine, 2000. Also available online.

Mohr JJ. Forming, Operating, and Improving Micro-systems of Health Care. Hanover, N.H.: Center for the Evaluative Clinical Sciences, Dartmouth Medical School, 2000.

Survey Instruments

"Survey of Micro-Systems." Institute of Medicine, fielded June 29, 1999 through September 3, 1999.

Presentations and Testimony

Molla S. Donaldson and Julie J. Mohr, "Are Micro-Systems the Missing Link? Part 2. Institute of Medicine Chassis Building Work," at the Annual Forum, Institute for Healthcare Improvement, December 9, 1999, Boston, Mass.

Molla S. Donaldson and Julie J. Mohr, "The IOM Quality Initiative," at the 2000 Annual Meeting of the Association for Health Services Research, June 26, 2000, Los Angeles, Calif.

Julie J. Mohr, "A Micro-Systems Approach to Reducing Medication Errors," at the American Association of Medical Colleges Council of Southern Deans, September 9, 2000, Winston-Salem, N.C.

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Report prepared by: Jan Hempel
Reviewed by: Robert Crum
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Susan B. Hassmiller