Figures and Tables xi Foreword Elliott S. Fisher xvii Preface: Improvement at the Front Line of Care xxi Acknowledgments xxix The Editors xxxiii The Contributors xxxv 1 Introducing Clinical Microsystems 1 Learning Objectives 1 Microsystems in Health Care 1 A Broader View of Systems and Microsystems 6 Research on Microsystems in Health Care 11 Three Conceptual Imperatives in the Work of Value Improvement 20 Conclusion 24 Summary 25 Key Terms 25 Review Questions 26 Discussion Questions 26 References 26 Chapter One Action Guide 29 Introduction to the 5PS 29 The Clinical Microsystem Process and Structure of the 5Ps Model 29 External Mapping Tool 35 Microsystem Assessment Tool (MAT) 40 2 Partnering with Patients to Design and Improve Care 47 Learning Objectives 47 The Aim of Health Care and the Need to Partner with Patients 48 Conceptual Frameworks for Partnering with Patients 51 Tactics for Partnering with Patients 61 Patients as Informants and Advisors 65 Conclusion 67 Summary 67 Key Terms 67 Review Questions 68 Discussion Questions 68 References 68 Chapter Two Action Guide 71 Gaining Customer Knowledge 71 Institute for Patient and Family-Centered Care Matrix 82 Value Stream Mapping 83 Definitions of Selected Value Stream Mapping Terms 84 3 Improving Safety and Anticipating Hazards in Clinical Microsystems 87 Learning Objectives 87 Case Study of Organizational Factors to Promote a Culture of Safety 88 Discussion 92 Definitions 93 Identification of Medical Errors and Adverse Events 94 Frequency of Adverse Events and Medical Errors 95 Conclusion 107 Summary 107 Key Terms 108 Review Questions 108 Discussion Questions 109 References 109 Chapter Three Action Guide 113 5S Method 113 Checklists 116 Failure Mode and Effects Analysis 118 Rehearsals or Simulations 120 Designing Patient Safety into the Microsystem 122 The Link Between Safety, the Microsystem, and Mindfulness 123 Conclusion 129 References 130 4 Using Measurement to Improve Health Care Value 131 Learning Objectives 131 Measuring What Matters at All Levels of the System 132 Tips and Principles to Foster a Rich Information Environment 138 Designing Information Flow to Support High-Value Care 140 Conclusion 150 Summary 151 Key Terms 152 Review Questions 152 Discussion Questions 152 References 153 Chapter Four Action Guide 155 Patient Value Compass 155 Balanced Scorecard 156 Measure What Matters Worksheet 157 Examples of Data Walls 159 References 160 5 Starting the Patient's Care in Clinical Microsystems 161 Learning Objectives 161 The Entry Functions of Clinical Microsystems 162 Conclusion 182 Summary 183 Key Terms 183 Review Questions 183 Discussion Questions 184 References 184 Chapter Five Action Guide 187 Process Mapping with Flowcharts 187 Access Measures and Tools 190 CARE Vital Signs 192 Reference 195 6 Designing Preventive Care to Improve Health 197 Learning Objectives 197 The Work of Preventive Health Care 198 An Action-Based Taxonomy of Preventive Health Services 202 Conclusion 213 Summary 213 Key Terms 213 Review Questions 214 Discussion Questions 214 References 214 Chapter Six Action Guide 217 Radiology Microsystem Preventive Activity of Mammography and VAP Bundles in Critical Care 217 7 Planning for Responsive and Reliable Acute Care 221 Learning Objectives 221 Anticipating the Needs of Acutely Ill Patients 222 Defining Acute Care Needs of Patients and Families 222 An Overview of Design Requirements for Acute Care 225 Advanced Access and Effective Care Transitions 233 Conclusion 235 Summary 236 Key Terms 236 Review Questions 236 Discussion Questions 237 References 237 Chapter Seven Action Guide 239 Microsystem Transitions and Handoffs 240 8 Engaging Complexity in Chronic Illness Care 241 Learning Objectives 241 An Invitation to Complexity 242 The Experience of Chronic Illness 244 The Burden of Chronic Illness 245 The Goals of Chronic Illness Care 248 Clinical Complexity in Chronic Illness Care 250 Designing for Complexity Through Alignment of Problems and Practice Solutions 252 The Nature of Complex Adaptive Systems 254 The Chronic Care Model 255 Care Coordinaton and Transitions 260 Patient Self-Management 262 Conclusion 265 Summary 266 Key Terms 266 Review Questions 267 Discussion Questions 267 References 267 Chapter Eight Action Guide 271 STAR Generative Relationships 271 Reference 273 9 Supporting Patients and Families Through Palliative Care 277 Learning Objectives 277 The Need for Palliative Care in Modern America 278 End-of-Life Experience Yesterday and Today 279 Principles of Palliative Care 281 Reducing Variation in End-of-Life Care 283 Core Processes in Palliative Care 285 Care Coordination Near the End of Life 287 Formal Palliative Care and Hospice Programs 289 Planning for Both Life and Death with Advance Directives 291 Conclusion 293 Summary 295 Key Terms 295 Review Questions 295 Discussion Questions 296 References 296 Chapter Nine Action Guide 297 Mental Models 297 Using the Ladder of Inference to Explore Mental Models 297 Reference 301 10 Designing Health Systems to Improve Value 303 Learning Objectives 303 From Parts to Whole 304 New Vision of Integrated Systems to Produce High Value 305 The Execution Triangle 313 Leading Change at All Levels 315 Changing Local Culture 318 The Path Forward for Making High-Value Health Systems 323 Summary 326 Key Terms 326 Review Questions 326 Discussion Questions 327 References 327 Chapter Ten Action Guide 331 Micro-, Meso-, and Macrosystem Matrix 331 Index 335
Eugene C. Nelson, DSc, MPH, is director of Population Health and Measurement for the Dartmouth-Hitchcock Medical Center and professor of Community and Family Medicine at Dartmouth Medical School and the Dartmouth Institute for Health Policy and Clinical Practice. He is the recipient of the Joint Commission on Accreditation of Healthcare Organizations' Ernest A. Codman award for his work on outcomes measurement in health care. Paul B. Batalden, MD, is professor of Pediatrics and of Community and Family Medicine at Dartmouth Medical School. He is the associate director of the Dartmouth-Hitchcock Leadership Preventive Medicine Residency, and teaches at the Dartmouth Institute for Health Policy and Clinical Practice, the Institute for Healthcare Improvement and in the Jonkoping Academy for the Improvement of Health and Welfare in Sweden. Marjorie M. Godfrey, MS, RN, is codirector of the Microsystem Academy, instructor for the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, and a recognized national and international leader in health care improvement with interdisciplinary professionals. Joel S. Lazar, MD, MPH, is assistant professor of Community and Family Medicine at the Dartmouth Institute for Health Policy and Clinical Practice and section chief and medical director of Family Medicine at Dartmouth-Hitchcock Medical Center, where he also serves as director of quality improvement.