Title Details

The Editors

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 Jönköping 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.

Companion Web site: www.josseybass.com/go/nelson

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