Clinical Microsystems

In this article, we’re going to take a look at clinical microsystems: what they are, what they consist of, what they do and their value to healthcare, and - more specifically - their value within Quality Improvement (QI).

Introduction to Clinical Microsystems

The clinical microsystem is a Quality Improvement (QI) approach. You may be familiar with clinical microsystems from your own organisation, but if not, the Institute for Healthcare Improvement (IHI) describe a clinical microsystem as a ‘small, interdependent group of people who work together regularly to provide care for specific groups of patients.’

A clinical microsystem is often part of a larger organisation and often has a specific focus or purpose around a certain area of care. Also described by Nelson et al as a ‘small-scale team and its local environment: a small group of people (including health professionals and care receiving patients and their families) who work together in a defined setting on a regular basis (or as needed) to create care for discrete subpopulations of patients’.

So, clinical microsystems can be made up of clinicians, patients, carers - with information and IT important parts of the process.

The Clinical Microsystems approach

The clinical microsystems approach is used to encourage sustainable improvements in healthcare and the methodology was originally developed by the Dartmouth Institute in the USA: ‘Clinical microsystems are the building blocks of organisations such as hospitals and can be characterised as the small units where care happens with a group of patients, for example wards, outpatient clinics and diagnostic departments.’

Godfrey et al describe the clinical microsystems approach as identifying a problem and then ‘developing a systematic approach to address it using a ‘toolkit’ of activities and a workbook to lead the team through a process.’

If you are thinking of designing a clinical microsystem in your own organisation, you would first need to think about evaluating the ‘four P's’, which are:

• Patient subpopulations that are served by the microsystem,
• People who work together in the microsystem,
• Processes the microsystem uses to provide services, and
• Patterns that characterize the microsystem's functioning.’

Godfrey et al again set out the five steps to take in order to organise your clinical microsystem:

‘Step 1: Organise a ‘lead team’
Assemble a ‘lead team’ to represent all disciplines and roles in the practice (professional and clerical), and patients. Employ effective meeting skills, including assigning individual roles/tasks. Meets weekly to maintain focus, plan and oversee improvement work

Step 2: Do the 5Ps assessment
Complete the ‘5Ps’ assessment of Purpose, Patients, Professionals, Processes and Patterns using practice data and the microsystems workbook with templates. For example, fishbone diagram (cause and effect analysis) and data wall (metrics related to problem being addressed). Aims to create an overview of the system under review and identify improvement opportunities

Step 3: Make a diagnosis

Review the data (including strengths and weaknesses of the system) and select an issue to address. Create an overall theme, or global aim statement to maintain motivation and focus

Step 4: Treat the microsystem
This begins with making a specific aim statement using numerical goals, specific dates and specific measures. Uses Plan-Do-Study-Act (PDSA) as the model for improvement. Address sustainability issues using Standardize-Do-Study-Act (SDSA). Daily huddle whereby the team reviews the coming day/week to plan actions based on patient need and available resources, and contingency planning

Step 5: Follow-up
Monitor the new patterns of results and select new themes for improvement. Embed new habits into daily work using daily huddles, weekly lead team meetings, monthly all team meetings, data walls and storyboards’

The clinical microsystem approach can be used in all areas of healthcare. For example, The 2019 report ‘An evaluation of the clinical microsystems approach in general practice quality improvement’ looks at how clinical microsystems can be used in primary care, while the the abstract ‘Microsystems in health care: Developing small clinical units to attain peak performance’ takes a look at how using the microsystem approach can really help in clinical units.

Improving quality in the microsystem

Once you have decided to design a clinical microsystem, it’s really important maintain quality within it. In the study ‘Redesigning systems to improve teamwork and quality for hospitalized patients (RESET): study protocol evaluating the effect of mentored implementation to redesign clinical microsystems,’ the authors look at the challenges for clinicians in doing just that.

The study sets out the five characteristics that make up successful microsystems, which include: local leadership, focus on the needs of staff, emphasis on the needs of patients, attention to performance, and a rich information environment.

They go on to explore the challenges for clinicians and their objective for the study was to ‘implement a set of evidence-based complementary interventions across a range of clinical microsystems, identify factors and strategies associated with successful implementation, and evaluate the impact on quality.’

They used the Advanced and Integrated MicroSystems (AIMS) interventions to test the following: 'The AIMS interventions consist of 1) Unit-based Physician Teams, 2) Unit Nurse-Physician Co-leadership, 3) Enhanced Interprofessional Rounds, 4) Unit-level Performance Reports, and 5) Patient Engagement Activities'.

In the study ‘Learning from a clinical microsystems quality improvement initiative to promote integrated care across a falls care pathway,' the team use the clinical microsystem approach to explore developing a more integrated service for the falls care pathway across community and hospital care in Sheffield.

Using a three phase clinical microsystems quality improvement approach, the team were successful in changing key areas of the pathway, as well as engaging staff from different areas of the pathway. They took the approach of viewing the pathway as a ‘series of interrelated CMS enabled stakeholders to understand the complex nature of the pathway and to target key areas for change.’

Their conclusion was thus: ‘CMS quality improvement methodology may be a useful approach to promoting integration across a care pathway. Using a CMS approach contributed towards clinical and professional integration of some aspects of the service. Recognition of the pathway operating at meso- and macrosystem levels fostered wider stakeholder engagement with the potential of improving integration of care across a range of health and care providers involved in the pathway.’

In this blog, we’ve seen lots of great examples of clinical microsystems can be valuable across different areas of healthcare.

Let’s finish with the words of Richard Bohmer in the piece ‘Instrumental value of medical leadership, Engaging doctors in improving services’.

He concludes: ‘Frontline medical leaders, even those not in a formal unit or divisional leadership role, must operate at multiple levels: the individual patient and a population of patients, and the microsystem that supports their care.

These two levels – the patient and the population – are typically cast as conflicting; a doctor cannot care for an individual and consider the system at the same time. However, in practice, medical leaders need to focus on both, if only because the performance of the latter shapes the experience of, and outcomes from, the former.’