Quality By Design: A Clinical Microsystems Approach

Tables, Figures, and Exhibits xiii

Foreword xix
Donald M. Berwick

Preface xxiii

Acknowledgments xxvii

Introduction xxxi

The Editors xxxix

The Contributors xliii

Part One: Cases And Principles 1

1 Success Characteristics of High-Performing Microsystems: Learning from the Best 3
Eugene C. Nelson, Paul B. Batalden, Thomas P. Huber, Julie K. Johnson, Marjorie M. Godfrey, Linda A. Headrick, John H. Wasson

True Structure of the System, Embedded Systems, and Need to Transform Frontline Systems

The Bladyka Case

Research Design

Results

Practical Implications

Conclusion

2 Developing High-Performing Microsystems 34
Eugene C. Nelson, Paul B. Batalden, William H. Edwards, Marjorie M. Godfrey, Julie K. Johnson

Case Study: A Decade of Progress for an Intensive Care Nursery

A Model of Development and a Curriculum to Catalyze Microsystem Growth

Conclusion

3 Leading Microsystems 51
Paul B. Batalden, Eugene C. Nelson, Julie K. Johnson, Marjorie M. Godfrey, Thomas P. Huber, Linda Kosnik, Kerri Ashling

Leader, Leadership, Leading

Recap of Methods

Three Fundamental Processes of Leading: What Clinical Microsystem Team Members Observe and Report

Discussion

Conclusion

4 Leading Macrosystems and Mesosystems for Microsystem Peak Performance 69
Paul B. Batalden, Eugene C. Nelson, Paul B. Gardent, Marjorie M. Godfrey

Case Study: A True Story, with Names Changed to Protect the Innocent

Leadership Frameworks: Some of the Best Approaches

Leading Large Health Systems to Peak Performance Using Microsystem Thinking

Conclusion

5 Developing Professionals and Improving Worklife 106
Thomas P. Huber, Marjorie M. Godfrey, Eugene C. Nelson, Julie K. Johnson, Christine Campbell, Paul B. Batalden

Case Study: Staff Development at Massachusetts General Hospital Downtown Associates

Conclusion

6 Planning Patient-Centered Services 124
Marjorie M. Godfrey, Eugene C. Nelson, John H. Wasson, Julie K. Johnson, Paul B. Batalden

Planning Patient-Centered Services and the 5 P’s

Case Study: Planning Services for Subpopulations of Patients to Best Provide Care for Individual Patients

A Developmental Journey: Beginning to Assess, Understand, and Improve a Clinical Microsystem

Analysis and Improvement of Processes

A Huddle in Plastic Surgery

Conclusion

7 Planning Patient-Centered Care 148
John H. Wasson, Marjorie M. Godfrey, Eugene C. Nelson, Julie K. Johnson, Paul B. Batalden

Planning Care Well: Exemplary Clinical Microsystems

Planning Care in Any Microsystem

A Low-Tech Example for Ambulatory Services: CARE Vital Signs

Conclusion

8 Improving Patient Safety 165
Julie K. Johnson, Paul Barach, Joseph P. Cravero, George T. Blike, Marjorie M. Godfrey, Paul B. Batalden, Eugene C. Nelson

Microsystem Patient Safety Scenario

Case Study: Dartmouth-Hitchcock PainFree Program

Conclusion

9 Creating a Rich Information Environment 178
Eugene C. Nelson, Paul B. Batalden, Karen Homa, Marjorie M. Godfrey, Christine Campbell, Linda A. Headrick, Thomas P. Huber, Julie K. Johnson, John H. Wasson

Case Study 1: Specialty Care: Dartmouth-Hitchcock Spine Center

Case Study 2: Overlook Hospital Emergency Department

Case Study 3: Intermountain Health Care Shock Trauma Intensive Care Unit

Tips and Principles to Foster a Rich Information Environment

Discussion

Conclusion

Part Two: Activating the Organization And the Dartmouth Microsystem Improvement Curriculum 197

10 Overview of path forward And Introduction to part two 199

Recap of Part One and Overview of Part Two

Using Real Case Studies and Practical Applications of Microsystem Thinking, Methods, and Tools

Working at All Levels of a Health System

Focusing on the Microsystem Level

Review Questions

Prework

11 Introduction to Microsystem Thinking 230

What Is a System in Health Care?

How Did Clinical Microsystem Knowledge Evolve?

What Is a Clinical Microsystem?

Where Do Clinical Microsystems Fit in the Health Care Delivery System?

What Does a Clinical Microsystem Look Like?

Why Focus on the Clinical Microsystem?

How Do Clinical Microsystems Link to Crossing the Quality Chasm?

What Were the Findings of the Dartmouth Clinical Microsystem Research?

What Does a Microsystem’s Developmental Journey Look Like?

Conclusion

Case Studies

Review Questions

Between Sessions Work

12 Effective Meeting Skills I 243

What Is a Productive and Effective Meeting?

Why Use Meeting Skills and Roles?

What Are Effective Meeting Roles?

What Are the Phases of an Effective Meeting?

What Processes Are Evident in an Effective Meeting?

What Is the Seven-Step Meeting Process?

What Does a Meeting Agenda Template Look Like?

What Are the Ground Rules for Meetings?

What Are Some Tips for Getting Started with Productive Meetings?

How Do You Keep a Rhythm of Improvement?

Case Studies

Review Questions

Between Sessions Work

13 Assessing Your Microsystem with the 5 P’s 258

How Does an Interdisciplinary Lead Improvement Team Begin to Assess and Improve a Clinical Microsystem?

What Does the 5 P’s Framework Look Like?

What Resources Are Available to Guide the 5 P’s Assessment?

What Is a Helpful Way to Introduce Your Team to the Assessment Process?

What Are the 5 P’s?

What Should You Do with the Assessment Findings?

Case Studies

Review Questions

Between Sessions Work

14 The Model for Improvement: PDSA ↔ SDSA 271

What Is the Model for Improvement?

Why Use the Model for Improvement?

How Does the Model Fit into the Improvement Process?

What Is the PDSA Part of the Model?

What Are the Benefits of Using PDSA?

What Is Involved in Each of the Four Steps of Plan, Do, Study, and Act?

What Is the SDSA Cycle?

What Is Involved in Each of the Four Steps of Standardize, Do, Study, and Act?

What Tools Can Assist Your PDSA Cycle ↔ SDSA Implementation?

What Are Some Tips for Using the PDSA ↔ SDSA Method?

Case Studies

Review Questions

Between Sessions Work

15 Selecting Themes for Improvement 284

What Is a Theme for Improvement?

Why Use a Theme?

What Are the Theme Selection Considerations?

What Process Can You Use to Generate Theme Ideas and Select a First Theme?

What Are the Next Steps?

Case Studies

Review Questions

Between Sessions Work

16 Improvement Global Aim 291

What Is a Global Aim?

Why Use a Global Aim?

How Do You Write a Global Aim?

What Are the Next Steps?

Case Studies

Review Questions

Between Sessions Work

17 Process Mapping 296

What Is Process Mapping?

Why Use Process Mapping?

What Are the Commonly Used Flowchart Symbols?

What Does a High-Level Flowchart Look Like?

What Does a Detailed Flowchart Look Like?

What Are Some Tips for Creating a Flowchart?

What Does a Deployment Flowchart Look Like?

What Are Some Tips for Creating a Deployment Flowchart?

Case Studies

Review Questions

Between Sessions Work

18 Specific Aim 308

What Is a Specific Aim?

Why Use a Specific Aim?

Where Do Specific Aims Come From?

Where Does the Specific Aim Fit in the Overall Improvement Process?

How Do You Write a Specific Aim?

What Are the Next Steps?

Case Studies

Review Questions

Between Sessions Work

19 Cause and Effect Diagrams 313

What Is a Cause and Effect Diagram?

Why Use a Fishbone Diagram?

What Is the Structure of a Fishbone Diagram?

What Does a Completed Fishbone Look Like?

What Are Some Tips for Creating a Fishbone Diagram?

Case Studies

Review Questions

Between Sessions Work

20 Effective Meeting Skills II: Brainstorming and Multi-Voting 321

What Is Brainstorming?

What Are the Benefits of Brainstorming?

What Are Some Different Types of Brainstorming?

What Are Some Tips for Conducting Brainstorming?

What Is Multi-Voting?

Do Teams Always Multi-Vote After a Brainstorming Session?

How Do You Multi-Vote?

What Does a Brainstorming Session with a Multi-Voting Outcome Look Like?

Case Studies

Review Questions

Between Sessions Work

21 Change Concepts 331

What Is a Change Concept?

Why Use Change Concepts?

How Can You Use Change Concepts in a Process?

What Are the Next Steps?

Case Studies

Review Questions

Between Sessions Work

22 Measurement and Monitoring 339

What Are Measures, What Makes Measures Good, and How Do They Relate to Aims?

What Is a Run Chart?

What Are the Benefits of Using a Run Chart?

How Do Run Charts Fit in the Overall Improvement Process?

What Do Run Charts Tell You About Your Performance Level and Variation?

What Are Special Cause and Common Cause Variation?

How Do You Make a Run Chart?

How Do You Interpret Run Chart Results?

What Is a Control Chart?

What Is the Theory Behind Control Charts?

What Are the Benefits of Using a Control Chart Instead of a Run Chart?

What Are the Different Kinds of Control Charts?

What Is an XmR Control Chart?

How Do You Interpret Control Chart Results?

When Do You Recalculate Control Chart Values?

What Are Some Tips for Using Run Charts and Control Charts?

Case Studies

Review Questions

Between Sessions Work

23 Action Plans and Gantt Charts 362

What Is an Action Plan?

What Is a Gantt Chart?

Why Use Action Plans and Gantt Charts?

How Do You Write an Action Plan?

How Do You Create a Gantt Chart?

What Are the Next Steps?

Case Studies

Review Questions

Between Sessions Work

24 Follow Through on Improvement: Storyboards, Data Walls, and Playbooks 369

What Is the Importance of Follow Through?

What Can You Do to Follow Through?

What Are the Fundamentals of Improvement?

What Is a Data Wall?

What Is a Playbook?

How Is the Playbook Used?

How Do You Create a Playbook?

How Do You Maintain Your Playbook?

What Is a Storyboard?

How Do You Make a Storyboard?

Discussion

Case Studies

Review Questions

Between Sessions Work

25 Conclusion: Continuing on the Path to Excellence 380

Looking Back

Looking Forward and an Invitation: Make It Personal and Make It Happen

Appendix A: Primary Care Workbook 385

Name Index 433

Subject Index 437