You are previewing Value by Design: Developing Clinical Microsystems to Achieve Organizational Excellence, Second Edition.
O'Reilly logo
Value by Design: Developing Clinical Microsystems to Achieve Organizational Excellence, Second Edition

Book Description

Value by Design is a practical guide for real-world improvement in clinical microsystems. Clinical microsystem theory, as implemented by the Institute for Healthcare Improvement and health care organizations nationally and internationally, is the foundation of high-performing front line health care teams who achieve exceptional quality and value. These authors combine theory and principles to create a strategic framework and field-tested tools to assess and improve systems of care. Their approach links patients, families, health care professionals and strategic organizational goals at all levels of the organization: micro, meso and macrosystem levels to achieve the ultimate quality and value a health care system is capable of offering

Table of Contents

  1. Copyright
  2. FOREWORD
    1. References
  3. PREFACE
    1. IMPROVEMENT AT THE FRONT LINE OF CARE
      1. The Dartmouth Institute's Clinical Microsystems Course
      2. Organization of the Microsystems Course
      3. The Clinical Microsystem Model
      4. Organization of This Book
      5. Additional Features and Online Resources
  4. 1. INTRODUCING CLINICAL MICROSYSTEMS
    1. 1.1. LEARNING OBJECTIVES
    2. 1.2. MICROSYSTEMS IN HEALTH CARE
      1. 1.2.1. The Functional Unit in Health Care
    3. 1.3. A BROADER VIEW OF SYSTEMS AND MICROSYSTEMS
      1. 1.3.1. Systems Dynamics and Embedded Systems
      2. 1.3.2. The Institute of Medicine's Chain of Effect in Health Care
      3. 1.3.3. Horizontal and Vertical Levels of the Health Care System
      4. 1.3.4. Microsystems and Their External Context
    4. 1.4. RESEARCH ON MICROSYSTEMS IN HEALTH CARE
      1. 1.4.1. Microsystem Research
      2. 1.4.2. Microsystem in Macrosystem Research
      3. 1.4.3. Emerging Microsystem Research in Sweden and the Future
      4. 1.4.4. Organizing for Quality
    5. 1.5. THREE CONCEPTUAL IMPERATIVES IN THE WORK OF VALUE IMPROVEMENT
      1. 1.5.1.
        1. 1.5.1.1. Imperative Number 1: Engage Everyone in Value Improvement
        2. 1.5.1.2. Imperative Number 2: Work the Improvement Equation
        3. 1.5.1.3. Imperative Number 3: Frame Problems and Practice Solutions as Simple, Complicated, or Complex
    6. 1.6. CONCLUSION
    7. 1.7. SUMMARY
    8. 1.8. KEY TERMS
    9. 1.9. REVIEW QUESTIONS
    10. 1.10. DISCUSSION QUESTIONS
    11. 1.11. REFERENCES
  5. Chapter One ACTION GUIDE
    1. 1.12. INTRODUCTION TO THE 5PS
    2. 1.13. THE CLINICAL MICROSYSTEM PROCESS AND STRUCTURE OF THE 5PS MODEL
    3. 1.14. EXTERNAL MAPPING TOOL
    4. 1.15. MICROSYSTEM ASSESSMENT TOOL (MAT)
      1. 1.15.1. Description and Use of MAT
      2. 1.15.2. Guidelines for Scoring with MAT
      3. 1.15.3. Interpretation of Scores
  6. 2. PARTNERING WITH PATIENTS TO DESIGN AND IMPROVE CARE
    1. 2.1. LEARNING OBJECTIVES
    2. 2.2. THE AIM OF HEALTH CARE AND THE NEED TO PARTNER WITH PATIENTS
    3. 2.3. CONCEPTUAL FRAMEWORKS FOR PARTNERING WITH PATIENTS
      1. 2.3.1. Core Concepts
      2. 2.3.2. Target Diagram and Clinical Microsystem Model
      3. 2.3.3. Kano Model of Satisfaction with Services
      4. 2.3.4. Deming Model for Organizing Services as a System of Production
      5. 2.3.5. Wagner's Chronic Care Model and Lorig's Self-Management Model
      6. 2.3.6. Amy's Experience in Clinical Microsystems
        1. 2.3.6.1. Reflections on Amy's experience
    4. 2.4. TACTICS FOR PARTNERING WITH PATIENTS
      1. 2.4.1. Feed Forward Health Status Assessment
      2. 2.4.2. Motivational Interviewing, Patient Contracting, and Goal Setting
      3. 2.4.3. Shared Decision Making and Shared Medical Appointments
      4. 2.4.4. Health Coaching and Information Prescriptions
    5. 2.5. PATIENTS AS INFORMANTS AND ADVISORS
      1. 2.5.1. Using Direct Observations to Improve Care
      2. 2.5.2. Interviews and Surveys
      3. 2.5.3. Value Stream Mapping
      4. 2.5.4. Patients and Families as Committee Members and Advisors
    6. 2.6. CONCLUSION
    7. 2.7. SUMMARY
    8. 2.8. KEY TERMS
    9. 2.9. REVIEW QUESTIONS
    10. 2.10. DISCUSSION QUESTIONS
    11. 2.11. REFERENCES
  7. Chapter Two ACTION GUIDE
    1. 2.12. GAINING CUSTOMER KNOWLEDGE
      1. 2.12.1. Observational Skills and Ethnography
      2. 2.12.2. Tips for Writing Survey Items
      3. 2.12.3. Different Types of Survey Questions
        1. 2.12.3.1. Ratings
        2. 2.12.3.2. Opinions
        3. 2.12.3.3. Reports
        4. 2.12.3.4. Verbatim
      4. 2.12.4. Steps for Conducting a Written Survey
        1. 2.12.4.1. Structure of a Written Survey
    2. 2.13. INSTITUTE FOR PATIENT AND FAMILY-CENTERED CARE MATRIX
    3. 2.14. VALUE STREAM MAPPING
    4. 2.15. DEFINITIONS OF SELECTED VALUE STREAM MAPPING TERMS
  8. 3. IMPROVING SAFETY AND ANTICIPATING HAZARDS IN CLINICAL MICROSYSTEMS
    1. 3.1. LEARNING OBJECTIVES
    2. 3.2. CASE STUDY OF ORGANIZATIONAL FACTORS TO PROMOTE A CULTURE OF SAFETY
      1. 3.2.1. Prevention of Nosocomial Infections
    3. 3.3. DISCUSSION
    4. 3.4. DEFINITIONS
    5. 3.5. IDENTIFICATION OF MEDICAL ERRORS AND ADVERSE EVENTS
    6. 3.6. FREQUENCY OF ADVERSE EVENTS AND MEDICAL ERRORS
      1. 3.6.1. Causation of Medical Errors
      2. 3.6.2. The Swiss Cheese Model
      3. 3.6.3. Diagnostic Errors
      4. 3.6.4. Prevention of Medical Errors to Ensure Patient Safety
      5. 3.6.5. Proactive Identification and Mitigation of Error Risks
      6. 3.6.6. Implementation and Monitoring of Safety Practices
      7. 3.6.7. Learning from Errors
        1. 3.6.7.1. Work Conditions
        2. 3.6.7.2. Human Conditions
        3. 3.6.7.3. Organizational Conditions
      8. 3.6.8. Valuing a Culture of Safety
      9. 3.6.9. Responding to Medical Errors
      10. 3.6.10. Communicating with the Patient and the Patient's Family After an Error
      11. 3.6.11. Care of Involved Health Professionals
    7. 3.7. CONCLUSION
    8. 3.8. SUMMARY
    9. 3.9. KEY TERMS
    10. 3.10. REVIEW QUESTIONS
    11. 3.11. DISCUSSION QUESTIONS
    12. 3.12. REFERENCES
  9. Chapter Three ACTION GUIDE
    1. 3.13. 5S METHOD
      1. 3.13.1. Sort/Seiri (Organization)
      2. 3.13.2. Straighten/Seiton (Orderliness)
      3. 3.13.3. Shine/Seiso (Cleanliness)
      4. 3.13.4. Standardize/Seiketsu (Adherence)
      5. 3.13.5. Sustain/Shitsuke (Self-Discipline)
    2. 3.14. CHECKLISTS
      1. 3.14.1. How to Make a Checklist
    3. 3.15. FAILURE MODE AND EFFECTS ANALYSIS
      1. 3.15.1. How to Conduct the FMEA Process
    4. 3.16. REHEARSALS OR SIMULATIONS
    5. 3.17. DESIGNING PATIENT SAFETY INTO THE MICROSYSTEM
      1. 3.17.1.
        1. 3.17.1.1. Background
    6. 3.18. THE LINK BETWEEN SAFETY, THE MICROSYSTEM, AND MINDFULNESS
      1. 3.18.1. Principle 1. Humans Are Error-Prone by Nature and so Errors Will Occur
      2. 3.18.2. Principle 2. The Microsystem Is the Unit of Analysis and Training
      3. 3.18.3. Principle 3. Design Systems to Identify, Prevent, Absorb, and Mitigate Errors
      4. 3.18.4. Principle 4. Create a Culture of Safety
      5. 3.18.5. Principle 5. Talk to and Listen to Patients
      6. 3.18.6. Principle 6. Integrate Practices from Human Factors Engineering into Microsystem Functioning
    7. 3.19. CONCLUSION
    8. 3.20. REFERENCES
  10. 4. USING MEASUREMENT TO IMPROVE HEALTH CARE VALUE
    1. 4.1. LEARNING OBJECTIVES
    2. 4.2. MEASURING WHAT MATTERS AT ALL LEVELS OF THE SYSTEM
    3. 4.3. TIPS AND PRINCIPLES TO FOSTER A RICH INFORMATION ENVIRONMENT
      1. 4.3.1. Principle 1: Design It—Provide Access to a Rich Information Environment
      2. 4.3.2. Principle 2: Connect with It—Use Information to Connect Patients to Staff and Staff to Staff
      3. 4.3.3. Principle 3: Measure It—Develop Performance Goals and Linked Measures That Reflect Primary Values and Core Competencies Essential for Providing Needed Patient Services
      4. 4.3.4. Principle 4: Use It for Betterment—Measure Processes and Outcomes, Collect Feedback Data, and Redesign Continuously Based on Data
    4. 4.4. DESIGNING INFORMATION FLOW TO SUPPORT HIGH-VALUE CARE
      1. 4.4.1. Framework 1: Feed Forward and Feedback
      2. 4.4.2. Framework 2: Patient Value Compass
      3. 4.4.3. Framework 3: Balanced Scorecard—Can We Use Data to Measure and Improve?
      4. 4.4.4. Comparing the Compass and the Scorecard
      5. 4.4.5. The Dashboard Metaphor
      6. 4.4.6. Using the Cascades Metaphor to Measure at Different Levels of a System
        1. 4.4.6.1. Measure What Matters Worksheet
    5. 4.5. CONCLUSION
    6. 4.6. SUMMARY
    7. 4.7. KEY TERMS
    8. 4.8. REVIEW QUESTIONS
    9. 4.9. DISCUSSION QUESTIONS
    10. 4.10. REFERENCES
  11. Chapter Four ACTION GUIDE
    1. 4.11. PATIENT VALUE COMPASS
    2. 4.12. BALANCED SCORECARD
    3. 4.13. MEASURE WHAT MATTERS WORKSHEET
    4. 4.14. EXAMPLES OF DATA WALLS
    5. 4.15. REFERENCES
  12. 5. STARTING THE PATIENT'S CARE IN CLINICAL MICROSYSTEMS
    1. 5.1. LEARNING OBJECTIVES
    2. 5.2. THE ENTRY FUNCTIONS OF CLINICAL MICROSYSTEMS
      1. 5.2.1. Access and Handoffs
        1. 5.2.1.1. Access to Care and Services
        2. 5.2.1.2. Systematically Improving Access to Care
        3. 5.2.1.3. Methods to Increase Access and Improve Flow
        4. 5.2.1.4. Evaluating Successful Access to Care
      2. 5.2.2. Outpatient
      3. 5.2.3. Inpatient
      4. 5.2.4. Transitions and Handoffs
        1. 5.2.4.1. Principles of Effective Transitions and Handoffs
        2. 5.2.4.2. Methods
        3. 5.2.4.3. Evaluating Successful Care Transitions
      5. 5.2.5. Direct Assessment and Monitoring of Transition Metrics
      6. 5.2.6. Indirect Assessment and Monitoring of Downstream Outcomes
      7. 5.2.7. Orienting Patients to Navigate Care
        1. 5.2.7.1. Principles for Orienting Patients to Microsystems
        2. 5.2.7.2. Methods of Improving the Orientation Process
        3. 5.2.7.3. Evaluating Success of the Orientation Process
      8. 5.2.8. Initial Assessment and Plan of Care
        1. 5.2.8.1. Characteristics of Effective Care Plans
        2. 5.2.8.2. The Wagner Care Model
        3. 5.2.8.3. Evaluating Care Plan Success
    3. 5.3. CONCLUSION
    4. 5.4. SUMMARY
    5. 5.5. KEY TERMS
    6. 5.6. REVIEW QUESTIONS
    7. 5.7. DISCUSSION QUESTIONS
    8. 5.8. REFERENCES
  13. Chapter Five ACTION GUIDE
    1. 5.9. PROCESS MAPPING WITH FLOWCHARTS
      1. 5.9.1. Deployment Charts
    2. 5.10. ACCESS MEASURES AND TOOLS
    3. 5.11. CARE VITAL SIGNS
    4. 5.12. REFERENCE
  14. 6. DESIGNING PREVENTIVE CARE TO IMPROVE HEALTH
    1. 6.1. LEARNING OBJECTIVES
    2. 6.2. THE WORK OF PREVENTIVE HEALTH CARE
    3. 6.3. AN ACTION-BASED TAXONOMY OF PREVENTIVE HEALTH SERVICES
      1. 6.3.1. Principles for Designing and Improving Preventive Health Care in Clinical Microsystems
      2. 6.3.2. The Clinical Improvement Equation
      3. 6.3.3. Specific Questions to Support the Design and Improvement of Preventive Care
        1. 6.3.3.1. In Our Microsystem, What Diseases or Hazards Pose a Risk to Our Patients, and What Evidence-Based Interventions Can Mitigate These Risks?
        2. 6.3.3.2. In Our Microsystem, What Patient and Practice Characteristics Support or Impede Risk Reduction?
        3. 6.3.3.3. In Our Microsystem, How do We Maximize the Likelihood That Risk-Reducing Interventions Are Performed ?
        4. 6.3.3.4. In Our Microsystem, How Do We Monitor Our Performance?
    4. 6.4. CONCLUSION
    5. 6.5. SUMMARY
    6. 6.6. KEY TERMS
    7. 6.7. REVIEW QUESTIONS
    8. 6.8. DISCUSSION QUESTIONS
    9. 6.9. REFERENCES
  15. Chapter Six ACTION GUIDE
    1. 6.10. RADIOLOGY MICROSYSTEM PREVENTIVE ACTIVITY OF MAMMOGRAPHY AND VAP BUNDLES IN CRITICAL CARE
  16. 7. PLANNING FOR RESPONSIVE AND RELIABLE ACUTE CARE
    1. 7.1. LEARNING OBJECTIVES
    2. 7.2. ANTICIPATING THE NEEDS OF ACUTELY ILL PATIENTS
    3. 7.3. DEFINING ACUTE CARE NEEDS OF PATIENTS AND FAMILIES
    4. 7.4. AN OVERVIEW OF DESIGN REQUIREMENTS FOR ACUTE CARE
      1. 7.4.1. Time Is in the Foreground
      2. 7.4.2. Evidence-Based Algorithms and Structured Decision Making
      3. 7.4.3. Well-Defined (but Flexible) Roles Within the Clinical Microsystem
      4. 7.4.4. Unique Role of Patient and Family
      5. 7.4.5. Planning for the Expected Surprise
    5. 7.5. ADVANCED ACCESS AND EFFECTIVE CARE TRANSITIONS
      1. 7.5.1. Effective Care Transitions
    6. 7.6. CONCLUSION
    7. 7.7. SUMMARY
    8. 7.8. KEY TERMS
    9. 7.9. REVIEW QUESTIONS
    10. 7.10. DISCUSSION QUESTIONS
    11. 7.11. REFERENCES
  17. Chapter Seven ACTION GUIDE
  18. 8. ENGAGING COMPLEXITY IN CHRONIC ILLNESS CARE
    1. 8.1. LEARNING OBJECTIVES
    2. 8.2. AN INVITATION TO COMPLEXITY
    3. 8.3. THE EXPERIENCE OF CHRONIC ILLNESS
    4. 8.4. THE BURDEN OF CHRONIC ILLNESS
    5. 8.5. THE GOALS OF CHRONIC ILLNESS CARE
    6. 8.6. CLINICAL COMPLEXITY IN CHRONIC ILLNESS CARE
    7. 8.7. DESIGNING FOR COMPLEXITY THROUGH ALIGNMENT OF PROBLEMS AND PRACTICE SOLUTIONS
    8. 8.8. THE NATURE OF COMPLEX ADAPTIVE SYSTEMS
    9. 8.9. THE CHRONIC CARE MODEL
      1. 8.9.1. Self-Management Support
      2. 8.9.2. Delivery System Design
      3. 8.9.3. Decision Support
      4. 8.9.4. Clinical Information Systems
        1. 8.9.4.1. Is the Chronic Care Model Effective?
    10. 8.10. CARE COORDINATON AND TRANSITIONS
    11. 8.11. PATIENT SELF-MANAGEMENT
    12. 8.12. CONCLUSION
    13. 8.13. SUMMARY
    14. 8.14. KEY TERMS
    15. 8.15. REVIEW QUESTIONS
    16. 8.16. DISCUSSION QUESTIONS
    17. 8.17. REFERENCES
  19. Chapter Eight ACTION GUIDE
    1. 8.18. STAR GENERATIVE RELATIONSHIPS
    2. 8.19. REFERENCE
  20. 9. SUPPORTING PATIENTS AND FAMILIES THROUGH PALLIATIVE CARE
    1. 9.1. LEARNING OBJECTIVES
    2. 9.2. THE NEED FOR PALLIATIVE CARE IN MODERN AMERICA
    3. 9.3. END-OF-LIFE EXPERIENCE YESTERDAY AND TODAY
    4. 9.4. PRINCIPLES OF PALLIATIVE CARE
    5. 9.5. REDUCING VARIATION IN END-OF-LIFE CARE
    6. 9.6. CORE PROCESSES IN PALLIATIVE CARE
      1. 9.6.1. Assessing the Full Health Status and Well-Being of Patient and Family
      2. 9.6.2. Planning for the Patient and Family
      3. 9.6.3. Providing Services to Patient and Family
    7. 9.7. CARE COORDINATION NEAR THE END OF LIFE
    8. 9.8. FORMAL PALLIATIVE CARE AND HOSPICE PROGRAMS
    9. 9.9. PLANNING FOR BOTH LIFE AND DEATH WITH ADVANCE DIRECTIVES
    10. 9.10. CONCLUSION
    11. 9.11. SUMMARY
    12. 9.12. KEY TERMS
    13. 9.13. REVIEW QUESTIONS
    14. 9.14. DISCUSSION QUESTIONS
    15. 9.15. REFERENCES
  21. Chapter Nine ACTION GUIDE
    1. 9.16. MENTAL MODELS
    2. 9.17. USING THE LADDER OF INFERENCE TO EXPLORE MENTAL MODELS
    3. 9.18. REFERENCE
  22. 10. DESIGNING HEALTH SYSTEMS TO IMPROVE VALUE
    1. 10.1. LEARNING OBJECTIVES
    2. 10.2. FROM PARTS TO WHOLE
    3. 10.3. NEW VISION OF INTEGRATED SYSTEMS TO PRODUCE HIGH VALUE
      1. 10.3.1. Create Value-Based Competition
      2. 10.3.2. Learn from Toyota to Relentlessly Reduce Waste and Continuously Add Value
      3. 10.3.3. Christensen's Use of Different Business Models to Improve Health Care Value
      4. 10.3.4. Fisher's Work to Create Accountable Care Organizations that Provide High-Value Care
      5. 10.3.5. Learn What We Need to Know
        1. 10.3.5.1. Lean Theory, Principles, and Methods
        2. 10.3.5.2. Safety Sciences and Human Factors Design
        3. 10.3.5.3. Performance Measurement Principles and Methods
        4. 10.3.5.4. Patient-Centered Design and Experience-Based Co-Design
    4. 10.4. THE EXECUTION TRIANGLE
    5. 10.5. LEADING CHANGE AT ALL LEVELS
      1. 10.5.1. The Process of Leading
    6. 10.6. CHANGING LOCAL CULTURE
      1. 10.6.1.
        1. 10.6.1.1. Edgar Schein's View on Changing Organizational Culture
        2. 10.6.1.2. Bate's Work on Organizing for Transformative Change in Health Care
    7. 10.7. THE PATH FORWARD FOR MAKING HIGH-VALUE HEALTH SYSTEMS
      1. 10.7.1. What We Need to Do
    8. 10.8. SUMMARY
    9. 10.9. KEY TERMS
    10. 10.10. REVIEW QUESTIONS
    11. 10.11. DISCUSSION QUESTIONS
    12. 10.12. REFERENCES
  23. Chapter Ten ACTION GUIDE
    1. 10.13. MICRO-, MESO-, AND MACROSYSTEM MATRIX