The Health Care Interdisciplinary Context: A Focus on the ...

1 The Health CareInterdisciplinary Context: A Focus on theMicrosystem ConceptJulie K. Johnson, MSPH, PhD2 CHAPTERLEARNING OBJECTIVESA fter completing this chapter, the reader will be able the microsystem as a conceptual model fororganizing Understand the theoretical underpinnings of the Define the essential elements of a Describe research that has identified high Describe one method for assessing the functioning of Explore the potential link between microsystems and 3/10/09 12:48 PM Page 19 Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTIONKEY TERMSC linical microsystemOrganizational constructSystems theorySystems thinkingComplex adaptive systemsLearning organizationsLeadershipINTRODUCTIONH ealth care is provided in complex environments with intricate webs ofrelationships.

2 These relationships represent the multiple interactions withpeople, information, technology, culture, and the physical environment inwhich patient care is provided. The organization of Health care can be de-scribed in many different ways, for example a clinic, a clinical departmentwithin a hospital, an inpatient ward, or an intensive care unit, among oth-ers. Of course, all these are accurate organizational descriptions and providesome insight into the types of care processes and providers in each area. An-other framework to describe how Health care is organized is the clinical mi-crosystem. The clinical microsystem, as an organizational construct, is asystems approach for providing clinical care that is based on theories fromorganizational development, leadership, and quality clinical microsystem can be defined as the combination of a smallgroup of people who work together in a defined setting on a regular basis or as needed to provide care and the individuals who receive that care (who also can be recognized as part of a discrete subpopulation of patients).

3 Based on this definition, the essential elements of the microsystem includea designated group of specific patients, clinicians and support staff, infor-mation and information technology specialists, and care processes. Theclinical purpose and its setting define the essential components of the mi-crosystem. For example, a microsystem that provides pediatric cardiovascu-lar surgical care has a very specific purpose that outlines the requiredcomponents to accomplish the purpose. The purpose of the microsystemalso identifies the patient population eligible to receive care ( , pediatricpatients with cardiovascular problems that need surgical repair) as well 3/10/09 12:48 PM Page 20 Jones and Bartlett Publishers, LLC.

4 NOT FOR SALE OR DISTRIBUTIONthe clinicians (surgeons, anesthesiologists, cardiologists, and nurses) andother service providers. This type of microsystem looks quite different froma microsystem that has the mission of providing outpatient care . Microsys-tems evolve over time as they respond to the needs of their patients andproviders as well as to external pressures such as regulatory and accredita-tion clinical microsystem is often embedded in a larger organizational con-text. For example, several microsystems may exist within an outpatient clinicand hundreds of microsystems may exist within a exist everywhere but their levels of functioning vary. Onecontributing factor is the ability of individual caregivers to recognize theirefforts as part of a microsystem.

5 Previous research on clinical microsystems(described later in this chapter) has identified 10 success factors, as sum-marized in Table 2-1 (Mohr, 2000). Every clinical microsystem possesseseach of these factors in varying degrees. A high-performing microsystem,( , a microsystem that consistently and reliably achieves the best outcomesfor its patients) would rate the highest on each of these a functioning unit, the microsystem has clinical as well as businessaims, linked processes, and a shared information and technology environ-ment. It produces services and care that can be measured as performanceoutcomes. The microsystem construct explicitly demonstrates the care giv-ing system. It builds on systems theory by recognizing that important sys-tems characteristics include the system-environment boundary, input,output, process, goal-directedness, and interaction of the elements of thesystem (Bertalanffy, 1968).

6 Systems, in general, often bring up images of well-oiled machines. However, healthcare systems are often cumbersome, unwieldy, unfriendly,and opaque to their users, who are the patients, physicians, nurses, and staffwho frequent the microsystem. Healthcare systems are best described ascomplex adaptive systems. As such, they are a collection of individuals whoare free to act in ways that are not totally predictable. Their organizationalboundaries are fuzzy ; their membership changes and their members si-multaneously can be members of other systems. Furthermore, given thecomplexity of these systems, the actions of individuals are interconnected sothat the action of one changes the context for all the others (Plsek & Green-halgh, 2001).

7 The clinical microsystem is a complex adaptive system, andas such it must: (a) do the work, (b) meet member needs, and (c) maintainitself as a functioning clinical 3/10/09 12:48 PM Page 21 Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION22 THEHEALTHCAREINTERDISCIPLINARYCONTEXTT able of High Performing MicrosystemsMicrosystem CharacteristicDefinition1. LeadershipThe role of leaders is to maintain balancewhile reaching collective goals, and to em-power individual autonomy and accountabil-ity through building knowledge, respectfulaction, reviewing, and Organizational supportThe larger organization looks for ways tosupport the work of the microsystem andcoordinate the hand-offs Staff focusThere is selective hiring of the best qualifiedemployees.

8 An orientation process is de-signed and implemented to fully integratenew staff into an organization s culture andwork roles. Expectations of staff are highregarding performance, continuing educa-tion, professional growth, collaboration, Education and trainingAll clinical microsystems are responsible forthe ongoing education and training of staffand for aligning daily work roles with trainingcompetencies. Academic clinical microsys-tems have the additional responsibility oftraining InterdependenceThe interaction of staff is characterized bytrust, collaboration, a willingness to helpeach other, appreciation of complementaryroles, respect, and recognition that eachstaffer contributes individually to a Patient focusThe primary concern is to meet all patientneeds: caring, listening, educating, respond-ing to special requests, innovating to meetpatient needs, and smooth service Community and market focusThe microsystem is a resource for the com-munity and the community is a resource forthe microsystem.

9 The microsystem estab-lishes excellent and innovative relationshipswith the community.(continues) 3/10/09 12:48 PM Page 22 Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTIONIn its Crossing the Quality Chasmreport, the Institute of Medicine iden-tified multiple layers of the healthcare system that influence the ability toimprove care (Berwick, 2002): the patients experience; the functioning of the microsystem; the functioning of the organizations that house or otherwise supportmicrosystems; and the environment ( , policy, payment, and regulation) that shapesthe behavior, interests, and opportunities of the at each of the different levels of the healthcare system patient,microsystem, macroorganization, environment and the interactions be-tween them can positively influence the ability to achieve patient safety andquality of care objectives.

10 Figure 2-1 illustrates the interactions of of High Performing Microsystems (continued)Microsystem CharacteristicDefinition8. Performance resultsPerformance focuses on improving patientoutcomes, avoiding unnecessary costs,streamlining delivery, using data feedback,promoting positive competition, and engag-ing in frank discussions about Process improvementAn atmosphere for learning and redesign issupported by the continuous monitoring ofcare, use of benchmarking, frequent tests ofchange, and a staff that has been empow-ered to Information and informationtechnologyInformation is the key connector for staff topatients, staff to staff, and needs with ac-tions to meet those needs.