The Clinical Microsystem:friend of the future of

professional education…even a future with limited

duty hours?

Paul Batalden, M.D.

AAMC, San Francisco

November 10, 2002

Aim

• Open the idea of the design andfunctioning—quality,safety,value—ofclinical microsystems in academicmedical centers.

• Consider together what it might take toexplicitly design health professionaldevelopment into the functioning of youracademic medical center clinicalmicrosystems—at a time like this.

Appreciation• David Stevens

• Gene Nelson

• Julie Mohr

• Margie Godfrey

• Martha Regan-Smith

• Dartmouth Hitchcock &Center for EvaluativeClinical Sciences(CECS) Faculty, StaffColleagues

• Linda Headrick

• Sue Hassmiller &RWJ Foundation

• David Leach

• Dozens of sites inUS, elsewhere

• Hundreds of CECSmasters degreestudents

Assumptions

• To thrive in the period ahead, healthprofessionals will need to be able to– Improve service for patients and

families

– Redesign care so that• Outcomes (balanced measures) improve

• Value increases by taking out cost yearafter year

• Professional pride and joy in workincreases

“Ancient Greeks thought the futurecomes upon us…from our backs as thepast recedes away before our eyes…the past dominating everything in oursight.” [emphasis added]

Postscript Zen and the Art of

Motorcycle MaintenanceRobert Pirsig

At our backs, creating the future…• Mismatch between societal expectations and

daily performance.• Hidden differences in the care we give which

cannot be scientifically supported.• Growth of empirical basis for care.• Loss of provider sovereignty.• Mismatch (excess?, skills?) of care-giving

capacity & need for the same.• Profound process, system illiteracy.• Integration, customization of information &

communication technologies.• Designer drugs.• Unrelenting cost reduction pressures.

Agenda

• The actual way we offer, make healthcare today.

• What we do well, what we couldimprove.

• Implications for education,professional development.

More assumptions• We all know the current realities of caring for

patients in today’s organizational settings forhealth care…and of trying to promote learningthere.

• Learning and patient care are part of the samesystem in academic medical centers…thoughsometimes not treated that way.

• We share the intention to improve the care forpatients and to take cost out.

• We share the desire to link learning of “thehead, the hand and the heart” as we work toform tomorrow’s trusted health professionals.

Agenda

• The actual way we offer, make healthcare today.

• What we do well, what we couldimprove, what we shouldn’t lose.

• Implications for education,professional development.

Chief InfoChief NurseChief Doctor

Chief Chief

A common health care organization

But, actually…

The way we work to “make” health care

Community,Market,

Social PolicySystem

Macro-organization

System

ClinicalMicrosystem

Individualcare-giver& patientSystem

Self-care

System

Isn’t “clinical microsystem”just a different name for

what others have called, thehealth care “team”?

• No, the clinical microsystem includes thesmall population of patients as part of thesame system as the providers.

• No, it includes information & informationtechnology as a “full” participant.

What is a “clinicalmicrosystem?”

• Small group of doctors, nurses, otherclinicians

• Some administrative support

• Some information, information technology

• A small population of patients

• Interdependent for a common aim, purpose

Physician,Care-giver

Mid-levelPractitioner

ClinicalSupport

AdministrativeSupport

InformationTechnology

Need, aim

CareFew OtherPhysicians

Who is the clinical microsystem?

Mid-levelPractitioner

ClinicalSupport

AdministrativeSupport

InformationTechnology

Need, aim

Few OtherPhysicians

Our doctor “sees” us

Physician,Care-giverCare

The context

Physician,Care-giver

Mid-levelPractitioner

ClinicalSupport

AdministrativeSupport

InformationTechnology

Need, aim

CareFew OtherPhysicians

Some Dartmouth HitchcockChild Health Care Examples

Physician,Care-giver

Mid-levelPractitioner

ClinicalSupport

AdministrativeSupport

InformationTechnology

Need, aim

CareFew OtherPhysicians

Who is the neonatal intensive clinical microsystem?

Patient

Nurse

Discharge Nurse using electronic and paper information

Neonatologist

Rounding team, including parents

Parent and Doctors

Receptionist

Information technology (monitors)

Physician,Care-giver

Mid-levelPractitioner

ClinicalSupport Administrative

Support

InformationTechnology

Need, aim

CareFew OtherPhysicians

Who is the general medical clinical microsystem?

Children

Parent

Pediatrician

Receptionist, Scheduler

Electronic and paper information

Nurse

Telephone Nurse

Physician,Care-giver

Mid-levelPractitioner

ClinicalSupport

AdministrativeSupport

InformationTechnology

Need, aim

CareFew OtherPhysicians

Who is the medical home clinical microsystem?

Pediatric Care coordinator

Doctor and Patient

Electronic and paper information

Office visit scheduler

Parent to Parent Representative

Patient and mom

Another patient

Parents, care coordinator, physician conference

How have we responded?

Chief Doctor

Chief Nurse

Chief Info

Chief InfoChief NurseChief Doctor

Chief Chief

Does this “anatomy” make it easy to do the“physiology” of our work for patients &those others who benefit?

Whose fingers are in the “holes” when our organizational systems fail?

“Physiology” of general health care clinical microsystem

RWJF study of high performingclinical microsystems

• Twenty sites:In-patient, Ambulatoryspecialty, Ambulatory primary,Nursing home, Home health.

• Surveys, on-site data collection,interviews.

Batalden, Nelson, Mohr, Huber, Headrick, Wasson, Godfrey

High performing clinical microsystems

Information&

Information Technology

Staff• Staff focus• Education & Training

• Interdependence of care team

Patients• Patient Focus• Community & Market Focus

Performance• Performance results• Process improvement

Leadership• Leadership• Organizational

support

Why this focus?• Basic building block of health care.

• Unit of clinical policy-in-use (vs. “espoused”.)

• Good value & safe care “made” here.

• Patient satisfaction variables largely controlledhere.

• Work practice “dissatisfiers” are controlled hereand “genuine motivators” are present here—making real joy, pride in health professional workpossible.

• Setting for life-long professional “formation.”

• Living adaptive health care system “laboratory”with structure, pattern & process.

From our work with ~120 clinical microsystems in five countries

Chief InfoChief NurseChief Doctor

Chief Chief

Answer: It doesn’tmake the work easier +

it adds duty hours

Write down the names, purpose of theclinical microsystem you know best

• Small group of doctors, nurses, other clinicians

• Some students

• Some administrative support

• Some information, information technology

• A small population of patients

• Interdependent for a common aim, purpose

Agenda

• The actual way we offer, make healthcare today.

• What we do well, what we couldimprove, what we shouldn’t lose.

• Implications for education,professional development.

Three levels of “current reality”

1

1

12

2 2

3

Professional educationalpreparation and the designof the clinical microsystem

Pick one of the three levels and workwith a neighbor.

• What do we currently do well as we educateand prepare professionals for their work atthis level?

• What could we do better…where might we beable to reduce some duty hours that are nowof relatively low value for education &learning?

• What must we take care not to lose?

Health professionalpreparation for Level 1-within

the clinical microsystem• Do well • Do better

• Don’t lose

Health professional preparationfor Level 2-across and between

clinical microsystems• Do well • Do better

• Don’t lose

Health professionalpreparation for Level 3-the

work of macro-systems• Do well • Do better

• Don’t lose

Agenda

• The actual way we offer, make healthcare today.

• What we do well, what we couldimprove, what we shouldn’t lose.

• Implications for education,professional development.

Weick’s action path

• Notice

• Make sense

• Take action

Some abilities that might help...

• To recognize these clinical microsystems—and theircontexts.

• To understand and monitor their work—for individualpatients and populations.

• To develop and test changes for the improvement of thequality, safety and value of health care in them.

• To identify the “general competencies” in the daily work/ life in them.

• To have some fun doing this and to attract others to thesame work, discovery and leadership.

“It is uncommon to find ayoung man with practical

wisdom.”Aristotle

Aristotle’s Intellectual Virtues• Episteme. Scientific knowledge. Universal,

invariable, context-independent. Based on generalanalytical rationality.

• Techne. Craft/art. Pragmatic, variable, context-dependent. Oriented toward production. Based onpractical instrumental rationality governed by aconscious goal.

• Phronesis. Ethics. Deliberation about values withreference to praxis. Pragmatic, variable, context-dependent. Prudence. Oriented toward action. Basedon practical value-rationality. (The original concept has noanalogous contemporary term.)

After Flyvbjerg

It’s integrating these that’s such a challenge!

1

Dreyfus model

• Stages in human skill acquisition.

• Based on studies of airplane pilots,chess players, automobile drivers &adult learners of a second language.

2

Novice

Dreyfus model progressions

• abstract principles

• situations areequallyrelevant bits

• detached observer

• past concreteexperiences

• situations arewholes with certainrelevant parts

• involved participant

Expert

3

Dreyfus model

• novice

• advanced beginner

• competent

• proficient

• expert

4

Lifelong professional development

• Explorer

• Novice

• Advanced beginner

• Competent

• Proficient

• Expert

• Master

5

Exploring the Dreyfus model...• Explorer--what is the role all about?

• Novice--what are the rules that can help me?

• Advanced beginner--what do I need to rememberabout the setting / context for care…and theexperience of making the connections?

• Competent--what goes into a good plan for the care ofthis patient…and the experience of planning?

• Proficient--how can I get some of the waste out of mylife?…and what do I remember about the experience?

• Expert--what complex cases do you have forme?…and the experience of considering them?

• Master--what can I learn from the surprise that justhappened to me?…and the experience of thatsurprise?

Back to our current reality: someresident comments overheard--1

• “I’m afraid to leave thepatient—the care reallydepends on us beingthere.”

• “If I really want someoneto get a medication, I knowit is best to get it and giveit myself.”

• “Every rotation in thesame place does the samestuff differently—I meanthe daily routines aboutorders & follow-ups,equipment location, the IVpump types, etc.”

• “Tucking in” rounds are onlybecause they call in the middleof the night for trivial things--Ionly wish it wouldn’t take me 2-3hours.”

• “Some days I think our primaryjob is to help manage theanxiety of the staff trying tomanage the access to ourservice.”

• “I can’t stand seeing patientswho wanted to see the staff MDand couldn’t and was shunted tome instead. I got nothing out ofit and neither did the patient.”

Back to our current reality: someresident comments overheard--2

• “Arranging for disposition/ authorization took methree hours last night…it’slike no one recognizes theflawed system.”

• “You can’t rely ontransport systems to movethe procedure-relatedspecimens to thelaboratory and you can’tbe sure that the lab will getaccurate information intotheir system. They nevercall if they have aquestion.”

• “When they finally gotaround to offering teachingabout teaching for ourSenior Residents, aboutone-third couldn’t make itbecause they scheduled itin conflict with completionof ward rounds.”

• “When we try to point outproblems with the call /coverage / clinic schedules,they say, ‘we can’t figure itout--you try it.’”

Patient care design implicationsWork with 2 or 3 around you. Explore what working

on these small systems might offer and mightrequire in your own setting(s).

• What might someone be able to “notice” in theclinical microsystem’s work for good patient carethat does not add value to the education/learningfor the developing health professional?

• How could we make sense of improving thatsituation? Can we build on what we currently dowell in the clinical microsystem to help take“wasted” duty hours out? What would thatinvolve?

• What are the consequences of proceeding / notproceeding?

Educational design implicationsStay with the same 2 or 3 around you. Explore what

learning in an improved academic clinical microsystemworld might enable in your own setting(s).

• Pick a Dreyfus level: Novice, Competent or Expert.

• Connect what might be done to improve thefunctioning of the clinical microsystem to the learningof a Novice, Competent or Expert-level learner.– What might the learner, learning contribute to the work of the

academic clinical microsystem?

– What benefits might accrue to the learner? To the academicmedical center?

• What are the consequences of proceeding / notproceeding?

What arose in yourconversations?

• About making academic clinicalmicrosystems work better? (Notice,make sense, take action)

• About connecting them to thelearning of the Novice, Competentand Expert-level learner? (Notice,make sense, take action)

“I was just too busy trying tocut wood with this darn dullsaw to stop and sharpen it.”

Exhausted Wood-cutter

Framing problems

Simple Complicated Complex

Glouberman and Zimmerman

Framing the questions

Batalden, Leach, Rice after Glouberman and Zimmerman

Complicated problem Complex problem What are the structures that we need to make health professional education sustainable?

How do we build on formal and informal networks to stabilize and enhance professional education?

Can we afford reducing work hours and redesigning our approach to professional education?

How can we reduce work hours and redesign our approach to make everyone feel that we are creating an educational path that is attractive to the best minds, safer for patients and contributory to lifelong learning?

What do we have to give up to make these changes?

How can we help Academic Medical Centers enhance their educational efforts and integrate them with the best they are doing?

How much will this cost? How can professional education with its enormous existing resources contribute even more to the identity of academic medical centers?

So what?…if this makessense

• What must we do?

• What must we foster?

• What must we resist?

• What must we celebrate?

• What must we share?

One closing thought…

Osler taught us that the care of the patientand learning about that involved the twinsciences of disease biology and clinical

practice.

Academic medical centers have led in thedevelopment of the science of disease biology,it seems propitious for them to strengthen theirefforts in the science of clinical practice.