Quality by Design E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
The latest edition of the bestselling text on quality improvement in health care, providing powerful theoretical frameworks and principles, valuable tools and techniques, and a proven action-learning program
Now in its second edition, Quality By Design contains an evidence and practice based strategy for teaching and practicing the clinical microsystem approach across all levels of health care organizations. Overall, the microsystem approach continues to evolve and adapt to meet the changing needs of healthcare organizations. Ongoing research, the development of updated models, and innovative applications across diverse settings demonstrate the approach’s potential to transform healthcare delivery and improve outcomes for patients and staff alike.
This innovative volume provides research and practical results based on the original high-performing clinical microsystems research conducted at The Dartmouth Institute for Health Policy and Clinical Practice. Quality By Design, Second Edition, advances clinical microsystem theory and practice with new material and updates:
New in the Second Edition:
- Global Impact: The microsystem approach has gained traction internationally, with healthcare organizations and universities in various countries successfully adapting and implementing the approach in specific healthcare cultural and contextual nuances. Real-world case studies showcase the microsystem approach’s success across diverse healthcare settings.
- Patient-Centered Care: Emphasis on coproduction of care, where patients and families are active partners in improvement
- Meeting Standards: Guidance on using the microsystem framework including effective meeting skills to ensure productivity and value of meetings.
- Team Coaching: Team Coaching case studies demonstrate its effectiveness in empowering frontline teams and improving their capabilities. Simultaneously, insights into multi-level leadership guide horizontal and vertical integration efforts for organizational success.
- Workforce Development and Well-being: Updated strategies for interprofessional education and development early in a career and throughout a career to learn to provide care and improve care is included
- System-Wide Improvement: New models and insights underscores the importance of integrating micro, meso, and macro systems to create a cohesive and efficient healthcare system. This involves aligning goals, processes, and communication across different levels of the organization.
- Data-Driven Decision Making: Strategies for building information-rich environments and leveraging data at all levels including key measurement and change management techniques.
- Patient Safety and Reliability: A personal case study offers a fresh perspective on error prevention and improving reliability
- Action Guide: An updated guide to accelerating improvement in clinical mesosystems.
- Remember: Successful implementation of the microsystem approach requires a long-term commitment to continuous learning, collaboration, and adaptation. By fostering a culture of improvement and empowering staff at all levels, organizations can harness the power of microsystems to achieve their quality and safety goals.
This expanded edition solidifies Quality by Design as an indispensable resource for anyone committed to transforming healthcare through the power of microsystems.
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Veröffentlichungsjahr: 2025
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Table of Contents
COVER
TABLE OF CONTENTS
TITLE PAGE
COPYRIGHT
TABLES, FIGURES, AND EXHIBITS
FOREWORD
PREFACE
ACKNOWLEDGMENTS
THE EDITORS
THE CONTRIBUTORS
INTRODUCTION
CHAPTER ONE: CLINICAL MICROSYSTEMS
AIM
LEARNING OBJECTIVES
Introduction
True Structure of the System, Embedded Systems, and the Need to Transform Frontline Systems
Success Characteristics of High‐Performing Sites
Case Study: International Research on Clinical Microsystems
Conclusion
Mesosystem Considerations
Summary
Review Questions
Discussion Questions
Additional Activities
References
Additional Resources
Key Words/Terms
CHAPTER TWO: DEVELOPING HIGH‐PERFORMING MICROSYSTEMS
AIM
LEARNING OBJECTIVES
Introduction
Case Study: Maintaining Fidelity in the Face of Complexity – Using Microsystem Improvement to Structure Change in Cystic Fibrosis Care
A Model of Development and a Curriculum to Catalyze Microsystem Growth
Conclusion
Mesosystem Considerations
Summary
Review Questions
Discussion Questions
Additional Activities
References
Additional Resources
Key Words/Terms
CHAPTER THREE: LEADING IMPROVEMENT OF HEALTHCARE SERVICE SYSTEMS: MICROSYSTEMS, MESOSYSTEMS, AND MACROSYSTEMS
AIM
LEARNING OBJECTIVES
Introduction
Case Study: Leadership
Leading Clinical Micro‐, Meso‐, and Macrosystems
Some Current Priorities for Leading the Improvement of Health and Health Care
Focus on Basics
Relentlessly Reduce Waste and Add Value
Enable Continual Inquiry into the “Unchanged Present” and Offer the Social Support that Fosters It
Co‐creating Health Through Relationships that Align Micro‐, Meso‐, and Macrosystems
Conclusion
Summary
Review Questions
Discussion Questions
Additional Activities
References
Additional Resources
Key Words/Terms
CHAPTER FOUR: DEVELOPING PROFESSIONALS AND IMPROVING WORK LIFE
AIM
LEARNING OBJECTIVES
Introduction
Case Study One: Dartmouth‐Hitchcock Frontline Clinical Manager Development
Case Study Two: Exploring a Reflective Team Coaching Model as a Leadership Strategy to Cultivate Frontline Quality and Safety Improvement Capability
Helpful Resources and Methods
Conclusion
Mesosystem Considerations
Review Questions
Discussion Questions
Additional Activities
References
Additional Resources
Key Words/Terms
CHAPTER FIVE: TRANSFORMING A PRIMARY CARE CLINIC TO AN NCQA-CERTIFIED PATIENT-CENTERED MEDICAL HOME
AIM
LEARNING OBJECTIVES
Introduction
Case Study: Transforming from a Primary Care Clinic to an NCQA‐Certified Patient‐Centered Medical Home
A Developmental Journey: Beginning to Assess, Understand, and Improve a Clinical Microsystem
Getting Started: Using the 5Ps to Explore Systems
Putting it all Together: Co‐Designing and Planning Services
Conclusion
Mesosystem Considerations
Summary
Review Questions
Discussion Questions
Additional Activities
References
Additional Resources
Key Words/Terms
CHAPTER SIX: PARTNERSHIP WITHIN THE CLINICAL MICROSYSTEM'S FRAMEWORK: COPRODUCING GOOD OUTCOMES WITH PATIENTS AND FAMILIES
AIM
LEARNING OBJECTIVES
Introduction
Improvement Science and Relationship‐Centered Care
A Framework for Patient‐Professional Partnership
Methods for Partnering with Patients and Families
Case Study: Example from Cambridge Health Alliance
Conclusion
Mesosystem Considerations
Summary
Review Questions
Discussion Questions
Additional Activities
References
Additional Resources
Key Words/Terms
CHAPTER SEVEN: IMPROVING PATIENT SAFETY AND RELIABILITY
AIM
LEARNING OBJECTIVES
Introduction
Safety, Medical Errors, and Patient Harm
Case Study: Noah
Learning from Errors and Adverse Events
Diagnostic Errors
Role of Risk Management and Patient Disclosure
Conclusion
Mesosystem Considerations
Summary
Review Questions
Discussion Questions
Additional Activities
References
Additional Resources
Key Words/Terms
CHAPTER EIGHT: CREATING AN ACTIONABLE HEALTHCARE INFORMATION ENVIRONMENT TO INFORM INTELLIGENT ACTION
AIM
LEARNING OBJECTIVES
Introduction
Rich Information Environments
Case Study One: Evolution of the Learning Healthcare Microsystem: From Historic Beginnings in the Dartmouth Spine Center to National Adoption by the Swedish Rheumatology Quality Register (SRQ)
Case Study Two: Using Data from Multiple Microsystems to Create a Mesosystem‐Level Information Environment: The
Dallas
OneCF
Center
Pediatric to Adult CF Care Mesosystem Measurement Journey
Case Study Three: Cascading Data from the Macrosystem Level to Inform Performance and Improvement: Examples of Data Registry Applications from Sweden and the United States
Case Study Four: The Role of Clinical Informatics: Using Data from an Electronic Health Record (EHR) to Improve Health Maintenance Outcomes in the MaineHealth System
Creating a Rich Information Environment
Designing Information Flow to Support Systems:
Feed Forward/Feedback
,
Feed Up/Feed Down
, and
Feed In/Feed Out
Approaches
Leveraging Clinical Informatics to Optimize the Information Environment
Tips and Principles to Foster an Actionable Information Environment
Conclusion
Mesosystem Considerations
Summary
Review Questions
Discussion Questions
Additional Activities
References
Additional Resources
Key Words/Terms
CHAPTER NINE: INTERPROFESSIONAL EDUCATION AND THE CLINICAL MICROSYSTEM
AIM
LEARNING OBJECTIVES
Introduction
Case Studies – New Models for Enhancing Interprofessional Education and Practice in Microsystems
Case Study One: Using “Educational Microsystems” to Develop a “Clinician‐Leader‐Improver” Curriculum
Case Study Two: The Social Field Model of Collaborative Care
Case Study Three: The Clinical Nurse Leader Role – Two Stories of Clinical Microsystem Transformation
Conclusion: A New Future Waiting
Mesosystem Considerations
Summary
Review Questions
Discussion Questions
Additional Activities
References
Additional Resources
Key Words/Terms
CHAPTER TEN: THE NEW FRONTIER OF SYSTEM IMPROVEMENT – MESOSYSTEMS
AIM
LEARNING OBJECTIVES
Introduction
Two Case Studies
Case Example One: Acute Care Flow of Frail Older Patients
A Mesosystem Improvement Journey
Case Example Two: Improving the Cystic Fibrosis Lung Transplant Mesosystem
Discussion
Guiding Principles from the Two Case Examples
Conclusion
References
Key Words/Terms
AFTERWORD
APPENDIX: ACCELERATING IMPROVEMENT IN CLINICAL MESOSYSTEMS: Action Guide
GLOSSARY
NAME INDEX
SUBJECT INDEX
END USER LICENSE AGREEMENT
List of Tables
Chapter 1
TABLE 1.1 SCOPE OF PRIMARY SUCCESS CHARACTERISTICS AND ILLUSTRATIVE UNDERLY...
TABLE 1.2 SPECIFIC EXAMPLES OF THE PRIMARY SUCCESS CHARACTERISTICS.
TABLE 1.3 ILLUSTRATIVE BEST PRACTICES USED BY HIGH‐PERFORMING CLINICAL MICR...
TABLE 1.4 NATIONAL AND INTERNATIONAL RESEARCH AND IMPROVEMENT PROGRAMS.
APPENDIX 1.1 THE TWENTY SITES EXAMINED IN THE CLINICAL MICROSYSTEM STUDY
Chapter 3
TABLE 3.1 HYPERTENSION IMPROVEMENT MATRIX.
TABLE 3.2 BEST PRACTICE IMPROVEMENT TOOLKIT FOR HYPERTENSION.
TABLE 3.3 SUMMARY OF CHANGES.
TABLE 3.4 IMPROVEMENT TRAINING METHODS.
TABLE 3.5 BEHAVIORS, ACTIONS, AND APPROACHES THAT LEADERS USE TO “BUILD KNO...
TABLE 3.6 ATTRIBUTES, CONCRETE STEPS, AND BEHAVIORS ASSOCIATED WITH LEADERS...
TABLE 3.7 HOW LEADERS REVIEW AND REFLECT.
TABLE 3.8 NEEDS IDENTIFIED BY MESOSYSTEM LEADERS.
TABLE 3.9 HELPFUL KNOWLEDGE AND SKILLS FOR CLINICAL MESOSYSTEM LEADERS.
TABLE 3.10 SIX COMMONLY RECOGNIZED NEEDS.
TABLE 3.11 POSITIVE WORK‐LIFE CONTEXT STATEMENTS.
TABLE 3.12 SUPPORTIVE INFORMATION INFRASTRUCTURE QUESTIONS.
TABLE 3.13 FACTORS THAT INFLUENCE OUR THINKING.
TABLE 3.14 TIME ESTIMATES TO DO THE WORK.
Chapter 4
TABLE 4.1 CHANGES OVER TIME.
TABLE 4.2 SELF‐EVALUATION WITH COACHING INTERDISCIPLINARY PROFESSIONAL....
TABLE 4.3 FOUR LEVELS OF RELATIONSHIPS.
APPENDIX 4.1 STAFF SATISFACTION SURVEY.
APPENDIX 4.2 STAFF PERSONAL SKILLS ASSESSMENT.
TABLE 4.4 EXAMPLES OF SKILLS ADDRESSED IN A PERSONAL SKILLS ASSESSMENT.
TABLE 4.5 FIVE THEMES MANAGERS SHOULD INCLUDE IN THEIR LEADERSHIP AND DEVEL...
Chapter 5
TABLE 5.1 PCMH SUCCESS ELEMENTS AND THEIR LINKS TO THE 5PS.
TABLE 5.2 KNOW THE PS FOR CLINICAL MICROSYSTEMS ACROSS THE HEALTH CONTINUUM...
TABLE 5.3 PRACTICE CORE AND SUPPORTING PROCESSES ASSESSMENT.
TABLE 5.4 ASSESSING YOUR PRACTICE DISCOVERIES AND ACTIONS: THE PS.
TABLE 5.5 ASSESSING YOUR PRACTICE DISCOVERIES AND ACTIONS: COMMON OVERSIGHT...
TABLE 5.6 CHALLENGES ON MEDICAL SERVICES BY MICROSYSTEM DOMAIN.
Chapter 6
TABLE 6.1 A FRAMEWORK FOR PATIENT–PROFESSIONAL PARTNERSHIP.
TABLE 6.2 THE 5PS CLINICAL MICROSYSTEM FRAMEWORK AUGMENTED WITH A COPRODUCT...
TABLE 6.3 CHANGE CONCEPTS FOR COPRODUCTION.
Chapter 7
TABLE 7.1 CLASSIFICATION OF PATIENT SAFETY EVENTS.
TABLE 7.2 CONDITIONS THAT CONTRIBUTE TO ERRORS AND ADVERSE EVENTS AS SEEN T...
TABLE 7.3 LINKAGE BETWEEN MICROSYSTEM CHARACTERISTICS AND PATIENT SAFETY.
Chapter 8
TABLE 8.1 DALLAS ONECF CENTER POPULATION MEASURES.
TABLE 8.2 DALLAS ONECF CENTER OUTCOME MEASURES.
TABLE 8.3 DALLAS ONECF CENTER PROCESS MEASURES.
TABLE 8.4 PERCENTAGE OF HEALTH MAINTENANCE ACTIVITIES COMPLETED (FEBRUARY 2...
TABLE 8.5 PERCENTAGE OF HEALTH MAINTENANCE ACTIVITIES COMPLETED (IMPROVEMEN...
TABLE 8.6 TIPS FOR DEVELOPING AND SUSTAINING AN ACTIONABLE RICH INFORMATION...
TABLE 8.7 FUNDAMENTAL AND INTERMEDIATE IMPROVEMENT MEASUREMENT SKILLS EDUCA...
Chapter 9
TABLE 9.1 KEY CONSTRAINTS CREATING BARRIERS TO QUALITY AND SAFETY INTEGRATI...
TABLE 9.2 SUMMARY OF SCHOOL OF NURSING QUALITY IMPROVEMENT TASK FORCES AND ...
TABLE 9.3 SUMMARY OF PATIENT AND TEAM SELF‐PERCEPTION.
Chapter 10
TABLE 10.1 QUALITY IMPROVEMENT ASSESSMENT (QIA) CATEGORIES.
TABLE 10.2 RELATIONAL COORDINATION SURVEY DIMENSIONS.
TABLE 10.3 CF LTT LLC RELATIONAL COORDINATION INTERVENTIONS – EXAMPLES....
TABLE 10.4 COMPARISON OF TWO CASE STUDIES
List of Illustrations
Chapter 1
FIGURE 1.1 CHAIN OF EFFECT IN IMPROVING HEALTHCARE QUALITY.
FIGURE 1.2 NETWORK OF CARE.
FIGURE 1.3 ANATOMY OF A CLINICAL MICROSYSTEM.
FIGURE 1.4 RESEARCH DESIGN FOR STUDY OF 20 CLINICAL MICROSYSTEMS.
FIGURE 1.5 SUCCESS CHARACTERISTICS OF HIGH‐PERFORMING CLINICAL MICROSYSTEMS....
FIGURE 1.6 A MODEL OF KNOWLEDGE CREATION THROUGH INTERACTIVE RESEARCH.
Chapter 2
FIGURE 2.1 SUCCESS CHARACTERISTICS OF HIGH‐PERFORMING CLINICAL MICROSYSTEMS....
FIGURE 2.2 MAP OF AREA AROUND SHEFFIELD UK.
FIGURE 2.3 TEAM COACHING MODEL.
FIGURE 2.4 THE IMPROVEMENT RAMP.
FIGURE 2.5 I DROPPED MY QUARTER.
FIGURE 2.6 LAMPPOST FIGURE – SPC CHART OF ADHERENCE DATA.
FIGURE 2.7 BEGINNING THE IMPROVEMENT JOURNEY: THE STAR INDICATES THE THEME O...
FIGURE 2.8 THE CF CLINIC FLOWCHART.
FIGURE 2.9 CAUSE AND EFFECT FOR PATIENT WAITING IN CF CLINIC.
FIGURE 2.10 CF CLINIC REDESIGN PROCESS FLOWCHART.
FIGURE 2.11 SPC CHART OF WAITING TIMES IN THE CF CLINIC.
FIGURE 2.12 OVERVIEW OF CF IMPROVEMENT ACTIVITIES.
FIGURE 2.13 ADAPTED COM‐B BEHAVIOR CHANGE MODEL.
FIGURE 2.14 A MODEL FOR A MICROSYSTEMS DEVELOPMENTAL JOURNEY.
FIGURE 2.15 MIXED UP IMPROVEMENT RAMP.
Chapter 3
FIGURE 3.1 A VIEW OF THE MULTILAYERED HEALTH SYSTEM.
FIGURE 3.2 EXAMPLE OF LOCAL AREAS OF AUTONOMY COMPARED TO SERVICE LINES: CAR...
FIGURE 3.3 FINAL HYPERTENSION WORK FLOW – PRIMARY CARE.
FIGURE 3.4 FINAL HYPERTENSION WORK FLOW – SPECIALTY CARE.
FIGURE 3.5 TEAM‐BASED CARE MODEL OF SERVICE LINE RESOURCES.
FIGURE 3.6 TEAM‐BASED CARE MODEL: HORIZONTAL ALIGNMENT ACROSS MICROSYSTEMS....
FIGURE 3.7 HYPERTENSION IMPROVEMENT OVER TIME.
FIGURE 3.8 MICROSYSTEM PREVENTATIVE, ACUTE, CHRONIC, AND PALLIATIVE SUBPOPUL...
FIGURE 3.9 THE HEALTHCARE SYSTEM AS AN INVERTED PYRAMID.
Chapter 4
FIGURE 4.1 PARTICIPANT CONFIDENCE WITH CONFLICT MANAGEMENT AND RELATIONSHIPS...
FIGURE 4.2 COACHES‐IN‐TRAINING CONFIDENCE IN COACHING SKILLS.
FIGURE 4.3 CLINICAL MICROSYSTEM STAFF SHORT SURVEY.
Chapter 5
FIGURE 5.1 THE ORIGINAL IMPROVEMENT FORMULA.
FIGURE 5.2 THE UPDATED IMPROVEMENT FORMULA.
FIGURE 5.3 TWO SYSTEM LEVELS OF ACTION TO PLAN FOCUSED AND DISCIPLINED IMPRO...
FIGURE 5.4 MEDICAL HOME ACTIVITY SURVEY.
FIGURE 5.5 MEDICAL HOME GANTT CHART.
FIGURE 5.6 PATIENT VIEWPOINT SURVEY.
FIGURE 5.7 RC MAP.
FIGURE 5.8 HIGH‐LEVEL VIEW OF A PRIMARY CARE CLINICAL MICROSYSTEM. ...
FIGURE 5.9 CF LUNG TRANSPLANT MESOSYSTEM 5PS.
Chapter 6
FIGURE 6.1 THE PHASES OF PROJECT EXECUTION/SYSTEM DEVELOPMENT LIFE CYCLE.
FIGURE 6.2 COPRODUCTION CONTINUUM: HEALTH PROFESSIONALS AND PATIENTS.
FIGURE 6.3 PATIENT–PROFESSIONAL PARTNERSHIP ALONG THE IMPROVEMENT RAMP....
Chapter 7
FIGURE 7.1 HADDON MATRIX ANALYZING AN AUTO ACCIDENT.
FIGURE 7.2 SAFETY MATRIX FOR ANALYZING PATIENT SAFETY EVENT.
Chapter 8
FIGURE 8.1 DARTMOUTH SPINE CENTER DASHBOARD.
FIGURE 8.2 SRQ DASHBOARD FOR A RHEUMATOID ARTHRITIS PATIENT.
FIGURE 8.3 LONGITUDINAL OUTCOMES FOR RHEUMATOID ARTHRITIS PATIENTS IN SWEDEN...
FIGURE 8.4 DALLAS ONECF CENTER MODIFIED SCORECARD.
FIGURE 8.5 DUMMY DASHBOARD STRUCTURE.
FIGURE 8.6 DALLAS ONECF CENTER POPULATED DUMMY DASHBOARD.
FIGURE 8.7 DALLAS ONECF CENTER INITIAL DASHBOARD.
FIGURE 8.8 DALLAS ONECF CENTER SPC DASHBOARD
FIGURE 8.9 CASCADING MEASURES.
FIGURE 8.10 COLORECTAL SCREENING STRATIFIED BAR CHART.
FIGURE 8.11 DEPRESSION SCREENING RUN CHART.
FIGURE 8.12 CLINICAL VALUE COMPASS.
FIGURE 8.13 BALANCED SCORECARD.
FIGURE 8.14 BASIC IMPROVEMENT MEASUREMENT PROCESS.
FIGURE 8.15 LINKING SHORT‐ AND LONG‐TERM MEASURES.
FIGURE 8.16 CASCADING MEASURES ACROSS SYSTEM LEVELS.
FIGURE 8.17 INFORMATION FLOW SYSTEMS (“FEED SYSTEMS”).
FIGURE 8.18 STRATIFIED BAR CHART.
FIGURE 8.19 STRATIFIED TIME PLOT.
Chapter 9
FIGURE 9.1 PERCEIVED KNOWLEDGE OUTCOMES AND STUDENT EXPERIENCE OUTCOMES FROM...
FIGURE 9.2 KNOWLEDGE OUTCOMES FROM A SCHOOL OF NURSING COURSE EMBEDDED WITHI...
FIGURE 9.3 SCHOOL OF NURSING CURRICULUM THREAD FOR QUALITY AND SAFETY INTEGR...
FIGURE 9.4 SHORT‐TERM PROCESS AND OUTCOMES PERFORMANCE RESULTS.
FIGURE 9.5 STATISTICAL PROCESS CONTROL (SPC) CHART OF PASS RATE PERFORMANCE ...
FIGURE 9.6 BEFORE AND AFTER THE DEVELOPMENT OF A SOCIAL FIELD.
FIGURE 9.7 DIFFERENCES BETWEEN TRADITIONAL AND SOCIAL FIELD APPROACH TO CARE...
FIGURE 9.8 GROWTH OF RELIABILITY AND RESILIENCE IN CARE TEAMS.
FIGURE 9.9 OBSERVABLE DIFFERENCES BETWEEN TRADITIONAL AND COLLABORATIVE CARE...
FIGURE 9.10 EXAMPLES OF CARE OUTCOME IMPROVEMENTS – SOCIAL FIELD MODEL OF CO...
FIGURE 9.11 UNIVERSITY HOSPITALIST TEACHING SERVICE PREPARING TO IMPLEMENT C...
Chapter 10
FIGURE 10.1 FLOWCHART OF KEN BLADYKA’S JOURNEY THROUGH MULTIPLE MESOSYSTEMS ...
FIGURE 10.2 THE “BIG ROOM” TRANSLATED FROM TOYOTA OBEYA.
FIGURE 10.3 A DISPLAY BOARD IN THE “BIG ROOM.”
FIGURE 10.4 GSM BED OCCUPANCY FROM JANUARY 1, 2012.
FIGURE 10.5 CURRENT DESIGN – ASSESS TO DISCHARGE AND FLIPPED TEST. ...
FIGURE 10.6 PILOT WARD MEAN SPELL LENGTH OF STAY FOR ALL DISCHARGES FROM JAN...
FIGURE 10.7 MEAN DELAY FROM REFERRAL TO ASSESSMENT FOR ALL AR – BY WEEK....
FIGURE 10.8 CF LUNG TRANSPLANT LEARNING AND LEADERSHIP TIMELINE OF ACTIVITIE...
FIGURE 10.9 30,000‐FOOT VIEW – THE EIGHT PHASES OF CF LUNG TRANSPLANT AND TR...
Guide
COVER
TABLE OF CONTENTS
TITLE PAGE
COPYRIGHT
TABLES, FIGURES, AND EXHIBITS
FOREWORD
PREFACE
ACKNOWLEDGMENTS
THE EDITORS
THE CONTRIBUTORS
INTRODUCTION
BEGIN READING
AFTERWORD
APPENDIX: ACCELERATING IMPROVEMENT IN CLINICAL MESOSYSTEMS
GLOSSARY
NAME INDEX
SUBJECT INDEX
END USER LICENSE AGREEMENT
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QUALITY BY DESIGN
A Clinical Microsystems Approach
Second Edition
Edited by
Marjorie M. Godfrey
Tina C. Foster
Julie K. Johnson
Eugene C. Nelson
Paul B. Batalden
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
Published simultaneously in Canada.
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10 9 8 7 6 5 4 3 2 1
We dedicate this book to
Our teachers –we are grateful to have learned from the pioneers/luminaries in the fields of improvement and learning.
We have been fortunate to learn directly from several of these thought leaders: James Brian Quinn, the “father” of micro‐meso‐macrosystem thinking, Parker Palmer, Karl Weick, Don Berwick, Staffan Lindblad, Maureen Bisognano, Atul Gawande, Brenda Zimmerman, Trish Greenhalgh, Jody Hoffer Gittell, and Edgar Schein. Through their writings, we have benefited from other thought leaders such as W. Edwards Deming, Florence Nightingale, Avedis Donabedian, and Donald Schön.
We are also grateful to the members of the clinical microsystem, including members of the communities who coproduce care and help us co‐design systems that will provide the right care, at the right time, at the right place, every time.
Our families Our loved ones who support our passion and pursuit for excellence in health care.
TABLES, FIGURES, AND EXHIBITS
Tables
1.1 Scope of Primary Success Characteristics and Illustrative Underlying Principles 15
1.2 Specific Examples of the Primary Success Characteristics 17
1.3 Illustrative Best Practices Used by High‐Performing Clinical Microsystems 20
1.4 National and International Research and Improvement Programs 23
3.1 Hypertension Improvement Matrix 76
3.2 Best Practice Improvement Toolkit for Hypertension 77
3.3 Summary of Changes 82
3.4 Improvement Training Methods 83
3.5 Behaviors, Actions, and Approaches that Leaders Use to “Build Knowledge” 89
3.6 Attributes, Concrete Steps, and Behaviors Associated with Leaders in High‐Performing Clinical Microsystems 91
3.7 How Leaders Review and Reflect 93
3.8 Needs Identified by Mesosystem Leaders 94
3.9 Helpful Knowledge and Skills for Clinical Mesosystem Leaders 95
3.10 Six Commonly Recognized Needs 95
3.11 Positive Work‐Life Context Statements 97
3.12 Supportive Information Infrastructure Questions 97
3.13 Factors that Influence Our Thinking 98
3.14 Time Estimates to do the Work 98
4.1 Changes Over Time 122
4.2 Self‐Evaluation with Coaching Interdisciplinary Professional 124
4.3 Four Levels of Relationships 128
4.4 Examples of Skills Addressed in a Personal Skills Assessment 134
4.5 Five themes Managers Should Include in Their Leadership and Development 136
5.1 PCMH Success Elements and Their Links to the 5Ps 151
5.2 Know the Ps for Clinical Microsystems Across the Health Continuum 158
5.3 Practice Core and Supporting Processes Assessment 166
5.4 Assessing Your Practice Discoveries and Actions: the Ps 174
5.5 Assessing Your Practice Discoveries and Actions: Common Oversights and Wastes 177
5.6 Challenges on Medical Services by Microsystem Domain 180
6.1 A Framework for Patient–Professional Partnership 193
6.2 The 5Ps Clinical Microsystem Framework Augmented with a Coproduction Lens 202
6.3 Change Concepts for Coproduction 207
7.1 Classification of Patient Safety Events 223
7.2 Conditions That Contribute to Errors and Adverse Events as seen through the Who Framework 224
7.3 Linkage Between Microsystem Characteristics and Patient Safety 239
8.1 Dallas OneCF Center Population Measures 259
8.2 Dallas OneCF Center Outcome Measures 259
8.3 Dallas OneCF Center Process Measures 260
8.4 Percentage of Health Maintenance Activities Completed (February 2016) 268
8.5 Percentage of Health Maintenance Activities Completed (Improvement Phase) 270
8.6 Tips for Developing and Sustaining an Actionable Rich Information Environment 286
8.7 Fundamental and Intermediate Improvement Measurement Skills Education in Dartmouth Microsystem Academy Programs 289
9.1 Key Constraints Creating Barriers to Quality and Safety Integration 304
9.2 Summary of School of Nursing Quality Improvement Task Forces and Pdsa Cycles 310
9.3 Summary of Patient and Team Self‐Perception 321
10.1 Quality Improvement Assessment (Qia) Categories 352
10.2 Relational Coordination Survey Dimensions 352
10.3 CF Ltt Llc Relational Coordination Interventions – Examples 355
10.4 Comparison of Two Case Studies 357
A.1.1 The Twenty Sites Examined in the Clinical Microsystem Study 35
A.4.1 Staff Satisfaction Survey 130
A.4.2 Staff Personal Skills Assessment 132
Figures
1.1 Chain of Effect in Improving Healthcare Quality 4
1.2 Network of Care 5
1.3 Anatomy of a Clinical Microsystem 7
1.4 Research Design for Study of 20 Clinical Microsystems 11
1.5 Success Characteristics of High‐Performing Clinical Microsystems 13
1.6 A Model of Knowledge Creation Through Interactive Research 25
2.1 Success Characteristics of High‐Performing Clinical Microsystems 38
2.2 Map of Area Around Sheffield Uk 40
2.3 Team Coaching Model 41
2.4 The Improvement Ramp 42
2.5 I Dropped My Quarter 44
2.6 Lamppost Figure – SPC Chart of Adherence Data 45
2.7 Beginning the Improvement Journey: the Star Indicates the Theme of Improvement 47
2.8 The CF Clinic Flowchart 48
2.9 Cause and Effect for Patient Waiting in CF Clinic 49
2.10 CF Clinic Redesign Process Flowchart 49
2.11 SPC Chart of Waiting Times in the CF Clinic 51
2.12 Overview of CF Improvement Activities 52
2.13 Adapted COM‐B Behavior Change Model 54
2.14 A Model for a Microsystems Developmental Journey 57
2.15 Mixed Up Improvement Ramp 60
3.1 A View of the Multilayered Health System 72
3.2 Example of Local Areas of Autonomy Compared to Service Lines: Cardiovascular Care 75
3.3 Final Hypertension Work Flow – Primary Care 79
3.4 Final Hypertension Work Flow – Specialty Care 80
3.5 Team‐Based Care Model of Service Line Resources 81
3.6 Team‐Based Care Model: Horizontal Alignment Across Microsystems 82
3.7 Hypertension Improvement Over Time 85
3.8 Microsystem Preventative, Acute, Chronic, and Palliative Subpopulations 85
3.9 The Healthcare System as an Inverted Pyramid 87
4.1 Participant Confidence with Conflict Management and Relationships 118
4.2 Coaches‐In‐Training Confidence in Coaching Skills 119
4.3 Clinical Microsystem Staff Short Survey 129
5.1 The Original Improvement Formula 147
5.2 The Updated Improvement Formula 147
5.3 Two System Levels of Action to Plan Focused and Disciplined Improvement Strategy to Meet Pcmh Standards 153
5.4 Medical Home Activity Survey 154
5.5 Medical Home Gantt Chart 155
5.6 Patient Viewpoint Survey 163
5.7 RC Map 169
5.8 High‐Level View of a Primary Care Clinical Microsystem 171
5.9 CF Lung Transplant Mesosystem 5Ps 181
6.1 The Phases of Project Execution/System Development Life Cycle 195
6.2 Coproduction Continuum: Health Professionals and Patients 200
6.3 Patient–Professional Partnership along the Improvement Ramp 204
7.1 Haddon Matrix Analyzing an Auto Accident 226
7.2 Safety Matrix for Analyzing Patient Safety Event 227
8.1 Dartmouth Spine Center Dashboard 254
8.2 SRQ Dashboard for a Rheumatoid Arthritis Patient 255
8.3 Longitudinal Outcomes for Rheumatoid Arthritis Patients in Sweden 256
8.4 Dallas Onecf Center Modified Scorecard 258
8.5 Dummy Dashboard Structure 261
8.6 Dallas Onecf Center Populated Dummy Dashboard 262
8.7 Dallas Onecf Center Initial Dashboard 263
8.8 Dallas Onecf Center Spc Dashboard 264
8.9 Cascading Measures 265
8.10 Colorectal Screening Stratified Bar Chart 269
8.11 Depression Screening Run Chart 271
8.12 Clinical Value Compass 273
8.13 Balanced Scorecard 274
8.14 Basic Improvement Measurement Process 275
8.15 Linking Short‐ and Long‐Term Measures 278
8.16 Cascading Measures Across System Levels 279
8.17 Information Flow Systems (“Feed Systems”) 280
8.18 Stratified Bar Chart 282
8.19 Stratified Time Plot 283
9.1 Perceived Knowledge Outcomes and Student Experience Outcomes from a School of Nursing Course in which Students Used the Microsystems Assessment Tool (Mat) 307
9.2 Knowledge Outcomes from a School of Nursing Course Embedded within an Online Learning Environment 308
9.3 School of Nursing Curriculum Thread for Quality and Safety Integration Across Programs 309
9.4 Short‐Term Process and Outcomes Performance Results 312
9.5 Statistical Process Control (SPC) Chart of Pass Rate Performance Outcomes (P Chart) 313
9.6 Before and After the Development of a Social Field 316
9.7 Differences Between Traditional and Social Field Approach to Care Transformation 318
9.8 Growth of Reliability and Resilience in Care Teams 319
9.9 Observable Differences Between Traditional and Collaborative Care 320
9.10 Examples of Care Outcome Improvements – Social Field Model of Collaborative Care 322
9.11 University Hospitalist Teaching Service Preparing To Implement Collaborative Care 323
10.1 Flowchart of Ken Bladyka’s Journey Through Multiple Mesosystems of Care in Two Macrosystems 337
10.2 The “Big Room” Translated From Toyota Obeya 340
10.3 A Display Board in the “Big Room.” 341
10.4 GSM Bed Occupancy From January 1, 2012 342
10.5 Current Design – Assess to Discharge and Flipped Test 343
10.6 Pilot Ward Mean Spell Length of Stay for all Discharges from January 2013 345
10.7 Mean Delay from Referral to Assessment for All Ar – by Week 346
10.8 CF Lung Transplant Learning and Leadership Timeline of Activities 349
10.9 30,000‐Foot View – the Eight Phases of CF Lung Transplant and Transition Mesosystem 351
Exhibits
4.1 Kotter’s Eight‐Step Process for Leading Change 114
4.2 eCoach‐the‐Coach Program 116
5.1 The Improvement Formula (Batalden and Davidoff, 2007) 147
5.2 Moving from Satisfaction to Patient and Family Experience of Care 164
5.3 Analysis and Improvement of Processes 167
5.4 Relational Coordination 168
5.5 Redesigning the Microsystem to Improve Quality of Care for Hospitalized Patients 172
FOREWORD
Paul B. Batalden, MD; Eugene C. Nelson, DSc, MPH
Introduction
The meeting was about making real change in U.S. healthcare services. Professor Diane Meier, Director of the Center to Advance Palliative care and expert on palliative medicine, presented the story of the development of palliative care. As she reflected on the progress made in the quality of health care, she identified at least seven contributing levers for change:
The “business” case
The “quality” case
Social marketing to create specific audience awareness
Clinician training
Payment
Regulation, accreditation, certification
Policy change
Quality by Design, second edition, helps with each of these levers. It offers insights that can help you build the “quality” case, and it offers the basic information that can form necessary clinician education and training. It indirectly contributes to each of the other levers by bringing the basic unit where professionals and individual patients, families and communities meet (the clinical microsystem) into sharp focus.
Context and Importance of Clinical Microsystems
This book describes how the real work of healthcare services gets done and how that work can be improved. It begins with the recognition that healthcare service today is not “soloist” work. Clinical microsystems are groups of professionals and patients who regularly use information and technology to help them work together to realize shared aims. Effective clinical microsystems are based on trust and communication that builds a positive patient‐professional relationship. Together, the microsystem groups can work to help patients flourish and minimize the burden of illness. Microsystems form the basic building blocks for modern healthcare service.
When the first edition of this book was written, we had the deep belief that healthcare service professionals actually have two jobs: to do their work and to improve their work. The addition of practical improvement “know‐how” ensures that the healthcare professionals of today and tomorrow will be ready to lead the changes needed. We believe that this second edition has benefitted significantly from the reflections and experiences of hundreds of people and can help practitioners learn and master the basics of improvement as they put them to use for the benefit of the patients they serve.
The Clinical Microsystem: A Perspective and an Approach to Improvement
Clinical microsystems do not need to be “installed” or “implemented” – they already exist. However, their performance and functional effectiveness vary substantially. The first edition of this book suggested several ways that clinical microsystems might be recognized and improved. Since that book, many have engaged in the job of improving these small systems, and much has been written and spoken about their efforts. New insights, new frames, and new data have emerged. This version brings together these new insights and combines them with the introductions found in the first edition. This book provides today's healthcare leaders, practicing clinicians, and clinical learners with what they need to get started on the road to measurably improve healthcare services in a way that can be sustained and further improved upon.
The first part of the book offers a panoramic and refreshed view of quality improvement and includes useful theoretical frameworks, important principles, practical tools, and powerful techniques, often in the context of real‐world cases. It covers fundamentals such as patient‐centered care, patient safety, and quality measurement, and introduces emerging issues such as the co‐production of health and healthcare services, integration of care across different levels of the system, and building rich information environments enabled by information technology.
The second part of the book provides specific guidance and a “path‐forward” curriculum. Of particular note is the advancement of clinical microsystems to mesosystems of care since people usually receive care in more than one microsystem during episodes of care. Leaders at all levels of the healthcare system can use it to successfully integrate quality improvement into the daily work of clinical professionals and support staff who serve all kinds of patients with all kinds of health‐related needs.
Editors and Authors
This second edition of Quality by Design was directed by three editors who are known for leading, teaching, and writing about quality improvement in the frontlines of care. Marjorie M. Godfrey (PhD, MS, BSN, FAAN) and Tina C. Foster (MD, MPH, MS) began working in the 1990s as quality improvement leaders and teachers at Dartmouth, which continues to be their professional home. Julie K. Johnson (MSPH, PhD) received her doctorate degree from Dartmouth and enjoys a distinguished career in quality and safety working as a professor and researcher. She is currently based at the Feinberg School of Medicine in Chicago, Illinois. We have had the privilege of working very closely with the editors and believe they have produced a wonderful book.
They have enlisted the aid of a diverse group of authors with wide‐ranging, real‐world experience and strong credentials in healthcare service improvement and innovation. The authors have brought their firsthand knowledge and worldwide experience about healthcare service and its improvement into each of the book's chapters.
Conclusion
Today, we recognize the need to build quality improvement “know‐how” into the education of tomorrow's healthcare professionals – the doctors and nurses and allied health professionals of the future. We also recognize the need to build this same quality improvement “know‐how” into the work of busy clinicians. This work and the knowledge of clinical microsystems make it possible for everyday medical practices and clinical units to be improved from “the inside out.” Those are the improvements likely to last. Go for it.
PREFACE
Marjorie M. Godfrey, PhD, MS, BSN, FAAN; Tina C. Foster, MD, MPH, MS; Julie K. Johnson, MSPH, PhD
This second edition of Quality by Design is about both clinical microsystems – the place where patients, families, and care teams meet – and other systems in health care, primarily mesosystems, which comprise multiple microsystems that (ideally) work together for a common aim. It is about what leaders at all levels need to know and do to create the conditions for excellent care at the front line. Is the care correct? Timely? Caring? Desired? Efficient? Is the care coproduced with patients and families in a way all parties can support? These questions are answered millions of times a day as real patients and families interact with real teams in real clinical microsystems and mesosystems. The experience by people in these interactions can range from “perfect” to “dreadful” (and everything in between).
In reading and using this book, we hope you will make discoveries about microsystems and mesosystems. We sincerely hope you will use the tools and processes and apply the lessons in your actual care settings; discuss the concepts with colleagues, patients, and families; and learn from your experiments.
What is a Clinical Microsystem?
A clinical microsystem is many things serving many purposes to many people.
A locus of professional formation: The place where people learn how to become competent healthcare professionals who work together and continue to develop over time. At the heart of the development of the caring and competent healthcare professional is the integration of the learning of “the head, the hands, and the heart” with the ability to take action to values.
A living system laboratory: A place to test changes in care design and delivery and to observe and work with complexity. Clinical micro‐ and mesosystems are living, complex adaptive systems that have simple rules, autonomous but interdependent agents, patterns of ordered relationships, and processes. Micro‐ and mesosystems offer opportunities to understand the work of small delivery systems in their natural context. While some problems they face are simple, many are complicated and complex.
A source of workforce motivation or alienation: The place where pride in work flourishes or flounders. Clinical microsystems are the locus of most workforce dissatisfiers and many genuine motivators for pride and joy in work. The hygiene factors in work, identified long ago by Herzberg (1987), such as work policy, administration, supervision, interpersonal relations, and working conditions, are often mandated by the macrosystem, yet are largely made manifest in the microsystems. So too are the motivating factors, such as the work itself, responsibility, recognition, and sense of achievement.
A building block of health care: The place that connects with other microsystems to form a continuum of care (mesosystem). In primary, secondary, and tertiary care settings, these small systems connect the core competencies of health professionals to the needs of patients, families, and communities. In isolation or in concert with other microsystems, the clinical microsystem makes it easy or difficult to do the right thing. Microsystems exist – not because we have installed them – but because they are where real healthcare work gets done. The idea that patients and providers are members of the same system is not new. In the 1930s, the famed physiological biochemist L. J. Henderson noted that patients and their caregivers were best thought of as members of the same system (Henderson, 1935).
The home of clinical policy in use: The place where policies are enacted and used in actual care. Much has been made of formal guidance for caregivers from the aphorisms of Hippocrates to today's guidelines, protocols, pathways, and evidence syntheses. Often, however, this formal guidance is the guidance we espouse but do not practice. Clinical microsystems have policies in use about access, about the use of information and telecommunication technologies to offer care, about the daily use of science and evidence, about staffing and the continuing development of people, and more. Sometimes a policy‐in‐use is written, sometimes not. Debates often rage about the espoused policies, whereas the policies in use often remain misunderstood and unexamined.
A maker of healthcare value and safety: The place where costs are incurred and reliability and safety succeed or fail. Clinical microsystems, like other systems, can make it easy to do the right thing. Microsystems that work as high‐reliability organizations, similar to those described by Weick and colleagues, are “mindful” of their interdependent interactions (Weick, 2002; Weick and Sutcliffe, 2001).
The facilitator of patient satisfaction: The place where patients and families coproduce care with staff and experience that care as meeting or not meeting their needs. Clinical microsystems are the locus of control for many, if not most, of the variables that account for patient satisfaction with health care. Ensuring that patients get access when they want and need it should be a goal of the scheduling processes of the microsystem. Making needed information readily available should be a priority of the microsystem. A culture that reflects genuine respect for the patient and careful listening to what patients have to say results in social learning for the microsystem. The patterns of staff behavior that the patients perceive and interpret as meeting their unique needs (or not) are generated at the level of the microsystem (Schein, 1999).
Microsystems and mesosystems are critically important to patients, families, healthcare professionals, and the communities they serve. However, they are often not recognized in daily practice and improvement, and we felt it was therefore imperative to write a second edition of this book, updating it with new considerations about mesosystems and ways of working together. In doing so, we hope that the reality and the power of systems thinking in general – and clinical microsystem thinking in particular – can be unleashed and popularized, so that outcomes and value can be improved continuously (from the inside out and from the bottom up) and health professionals at all organizational levels will have a better chance of having their everyday work in sync with their core values and their strong desire to do the right thing well.
REFERENCES
Henderson, L. J. “Physician and Patient as a Social System.”
New England Journal of Medicine
,
1935, 212, 819‐823.
Herzberg, F. “
One More Time: How Do You Motivate Employees?
”
Harvard Business Review
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September–October 1987, p. 109‐120.
Schein, E. H.
The Corporate Culture Survival Guide: Sense and Nonsense About Culture Change
. San Francisco: Jossey‐Bass, 1999.
Weick, K. E. “The Reduction of Medical Errors Through Mindful Interdependence.” In M. M. Rosenthal and K. M. Sutcliffe (eds),
Medical Error: What Do We Know? What Do We Do?
San Francisco: Jossey‐Bass, 2002, 177‐199.
Weick, K. E., and Sutcliffe, K. M.
Managing the Unexpected: Assuring High Performance in an Age of Complexity
. San Francisco: Jossey‐Bass, 2001.
ACKNOWLEDGMENTS
We are indebted to many wonderful people and outstanding organizations in the United States and around the world who helped make the original book and this second edition possible. Although it is impossible to recognize everyone who contributed to this endeavor, we would like to mention some individuals and organizations that merit special attention, and we ask forgiveness from those whom we should have mentioned and somehow overlooked.
First, we acknowledge and thank our mentors, Paul B. Batalden, Gene Nelson, and Edgar H. Schein, who have guided our individual and collective learning experiences in the world of healthcare improvement. We are fortunate to have had the opportunity to stand on the shoulders of these giants.
We offer a reminder that this book was inspired by the groundbreaking scholarship of James Brian Quinn, Professor Emeritus at Dartmouth's Tuck School of Business Administration. His friendship and insights were incredibly supportive and encouraged our own studies. The original 20 clinical microsystems that we studied taught us much about the possibilities to provide superior care to patients and communities and inspire our continued efforts.
We acknowledge the support of The Dartmouth Institute for Health Policy and Clinical Practice for the original research and the work of translating research into practice. A primary partner in the translation to practice has been the Cystic Fibrosis Foundation. Bruce Marshall, executive vice president and chief medical officer, has provided never‐ending support and encouragement to adapt microsystem thinking to improve care systems for people with cystic fibrosis. We are grateful for this practice laboratory for the advancement of testing and knowledge to improve care and develop frontline interprofessional staff.
Quality by Design, second edition, is the product of decades of work and applied research nationally and globally. We are grateful to the Jönköping Academy (JA), Jönköping University, and Qulturum at Region Jönköping County, Jönköping, Sweden, for showing us how interactive research and practice coexist to cocreate learning health systems with the people they serve. Their vision of “live a good life in a good place” serves as a reminder that the health system does not work alone and that multiple systems must work together in support of communities to achieve the ultimate goal of health. Dozens of graduate and doctoral students research a variety of topics on microsystems in health care to advance the field of knowledge. JA offers a clinical microsystem graduate‐level course based on The Dartmouth Institute graduate course. Qulturum provides guidance and support to regional, national, and international leaders and interprofessional colleagues to improve care guided by clinical microsystem principles. We want to thank Göran Henriks and his team at Qulturum for hosting the annual International Clinical Microsystem Festival during the last week of February. Since its beginnings in 2003, the festival has grown to include participants from 20 countries who have created a learning network, adapting and learning about the microsystem approach from each other at the festival and throughout the year. Of special note are the Region Jönköping County leaders who include microsystem principles in their work and support the festival and our ongoing collaboration. We offer deep appreciation and admiration to Mats Boestig, chief medical officer and director of health care, Region Jönköping County, and Anette Nilsson, development strategist. Boel Andersson‐Gäre, professor at Jönköping Academy for Improvement of Health and Welfare, has inspired us with the leadership, research, and academic rigor that she provides in continued knowledge development in clinical microsystems.
We are grateful that Agneta Jansmyr, chief executive officer, Region Jönköping County, always encouraged and supported our collaboration. Her passing in March 2020 left us reflecting on the memory of her as an exemplar of reflective practice with clear, yet gentle leadership.
We gratefully acknowledge the first Microsystem Coaching Academy (MCA) established outside of Dartmouth at Sheffield Teaching Hospitals in Sheffield, UK. The MCA partnership under the leadership of Tom Downes, clinical lead for quality improvement at Sheffield Teaching Hospitals, and Steve Harrison, deputy director of organizational development at Sheffield Teaching Hospitals NHS Foundation Trust, has provided a new context to explore adaptation of these materials in the UK, Scotland, and Ireland. This generative relationship has resulted in advancement of practice in the approach of clinical microsystems and new learning and sharing opportunities. The MCA has graciously hosted the annual Microsystem Academy EXPO each June since 2015 to connect colleagues from the UK and around the world who are adapting and learning about the microsystem approach.
Many of our colleagues who contributed to the case examples and writing went above and beyond our expectations in storytelling and collaboration. In this respect, we wish to thank Boel Andersson‐Gäre, professor at Jönköping Academy for Improvement of Health and Welfare (Jönköping, Sweden), and Susanne Kvarnström, senior human resource officer, head of HR‐Academy (Region Östergötland, Sweden), and Department of Health, Medicine, and Caring Sciences, Linköping University (Linköping, Sweden), for the research and academic rigor they provide in continued knowledge development in clinical microsystems.
Martin J. Wildman and Steve Harrison (Sheffield, UK) provided the case example focused on cystic fibrosis care in the UK; Don Caruso, chief executive officer at Dartmouth‐Hitchcock (Keene, NH) offered a view of leadership from multiple levels of the organization; Gay L. Landstrom, system vice‐president and chief nursing officer at Trinity Health (Livonia, MI); and Joan Clifford, medical center director and chief executive officer at Edith Nourse Rogers Memorial Veterans Hospital (Bedford, MA), provided case examples of leading and helping frontline leaders and staff to be successful in creating a joyful work environment. Randy Messier, Health Care Quality Improvement Consultant (Fairfield, VT), an internationally‐known team coach on quality based in the microsystem approach, shared an example of achieving patient‐centered medical home certification while developing sustainable improvement capabilities. Maren Batalden, associate chief quality officer at Cambridge Health Alliance (Boston, MA); Cristin Lind, freelance facilitator and consultant of co‐creation and patient partnership (Stockholm, Sweden); and Helena Hvitfeldt, chief scientific officer of TioHundra AB Hospital and Health Care (Norrtälje, Sweden) – all shared their experiences in coproduction and partnership with patients and families. Paul R. Barach, clinical professor, Wayne State University School of Medicine (Chicago, IL); Gautham K. Suresh, section head and service chief, neonatology, Texas Children's Hospital (Houston, TX); and Tanya Lord, director, Patient Family Engagement at Foundation for Healthy Communities (Nashua, NH) contributed knowledge and a personal story about safety in health care to emphasize the issues to consider in micro‐ and mesosystems of care. Brant J. Oliver, improvement scientist, Dartmouth‐Hitchcock (Lebanon, NH); John N. Mecchella, assistant professor, Dartmouth‐Hitchcock (Lebanon, NH); and Ann Marie Hess, primary care redesign consultant (Portland, ME) – all demonstrated masterful application of micro‐, meso‐, and macrosystem measurement techniques and models in the case examples they offered. Paul N. Uhlig, associate professor, University of Kansas School of Medicine (Witchita, KS), joined colleagues in the professional education chapter to contribute social fields perspectives in education design. Tom Downes and Steve Harrison shared their evolving knowledge and processes of mesosystem improvement through their FLOW efforts in the UK with an emphasis on “The Big Room,” adapted from Toyota production.
We wish to express our appreciation for the extensive contributions and tireless efforts of our writing, designing, and proofing teams. We have special appreciation for Coua Early, for reviewing, proofing, and updating materials and graphics based on her knowledge and insight in the original clinical microsystem research to ensure our accuracy.
We deeply appreciate Cherie Caviness, who has tirelessly worked on this manuscript for months on end, always with an eye for accuracy and proper formatting.
We will always be grateful to the Robert Wood Johnson Foundation for its generous support of the Clinical Microsystem Research Program, RWJ Grant Number 036103, and to our project officer and colleague at the foundation, Susan Hassmiller, who has always been deeply interested in supporting and promoting this body of work.
We deeply appreciate the editorial skills and long‐time support from our publisher Jossey‐Bass, who has provided support and assisted us in important and tangible ways.
THE EDITORS
Marjorie M. Godfrey PhD, MS, BSN, FAAN is Founding Executive Director, the Institute for Excellence in Health and Social Systems, Research Professor, Department of Nursing, University of New Hampshire. Affiliate Professor Jönköping University, Jönköping, Sweden. Previously Founding Co‐Director Dartmouth Institute Microsystem Academy, Geisel School of Medicine, Dartmouth College.
She is a practitioner‐researcher of improvement in health care who has a keen interest in helping frontline staff be the best they can be to provide the best care they can through applied clinical microsystem theory, team coaching, and leadership development. Godfrey’s primary interest is engaging interprofessional healthcare teams in learning about and improving local healthcare delivery systems with a focus on patients, professionals, and outcomes.
Dr. Godfrey has served on national panels including the McColl University/Robert Wood Johnson Foundation, the National Institutes of Health, National Cancer Institute, and the American Association of Colleges of Nursing (AACN) providing expert guidance based in system thinking, interprofessional team practice, and team coaching. Her career has included collaboration with leaders at all levels of health systems and interprofessional improvement teams to extensively coach and adapt clinical microsystem theory in the United States, Sweden, Canada, Norway, France, Switzerland, Kosovo, Tunisia, Chile, Ireland, Australia, Saudi Arabia and the United Kingdom.
In Sweden she has collaborated with senior leaders at Karolinksa Institutet, the Quality Registry Center, the Jönköping Academy, Jönköping County, and Qulturum to support innovation and transformation at all levels of their healthcare systems teaching clinical microsystem processes and team coaching frameworks to interprofessionals.
In England, Dr. Godfrey has collaborated with Dr. Tom Downes and Steve Harrison to adapt, design, implement, and evaluate the first Dartmouth Institute affiliated Microsystem Coaching Academy at Sheffield Teaching Hospitals. The formal partnership is active in the study of team coaching, research, and evaluation to advance the field of team coaching and healthcare improvement using the clinical microsystem framework.
For the past 20 years, Marjorie has provided leadership and guidance to the Cystic Fibrosis Foundation, Bethesda, Maryland to support the mission to partner with the CF community. In partnership with CF senior leaders and frontline interprofessional improvement teams including people with CF and their families in North America, she has adapted and taught clinical microsystem applied theory, leadership development, and team coaching through the improvement fundamentals and CF Lung Transplant Learning and Leadership Improvement Collaboratives
She has advised, led, and coached national programs at the American Thrombosis and Hemostasis Network, Vermont Oxford Network, Traumatic Brain Injury Foundation, Quality Improvement Organizations (QIOs), Cincinnati Children’s Hospital Medical Center, Exempla Health System, UC Davis, Maine Medical Center, University of Virginia Health System, and the Geisinger Health System. In addition, Marjorie has served as faculty member for national meetings and technical advisor to the Idealized Design of Clinical Office Practices initiative at the Institute for Healthcare Improvement.
Marjorie is a certified relational coordination facilitator and a board member of the Relational Coordination Research Collaborative led by Jody Hoffer Gittell based at The Heller School for Social Policy and Management, Brandeis University in Waltham, Massachusetts. She has partnered with the American Association of Colleges of Nursing (AACN) to integrate the clinical microsystem framework in the Clinical Nurse Leader Program and served as visiting faculty at several schools of nursing.
Dr. Godfrey is co‐author of the best‐selling textbooks, Quality by Design, 2007 and Value by Design, 2011 (Jossey‐Bass) and the lead author and architect of the Clinical Microsystems “A Path to Healthcare Excellence” series. She also created the Clinical Microsystem website, www.clinicalmicrosystem.org, which serves as a vehicle for information sharing and networking for the community of microsystem thinkers and designers. Dr. Godfrey’s PhD dissertation from Jönköping University in Sweden “Improvement Capability at the Front Lines of Healthcare: Helping through Leading and Coaching” is the culmination of a career of helping frontline teams accomplish healthcare improvement and led to the development of the Team Coaching Model.
She speaks regularly at national and international meetings to share practical application stories and provide instruction on microsystem concepts and team coaching. She is a strong advocate for young professionals and students in health care, identifying opportunities to support their professional development and their integration into healthcare systems.
Marjorie M. Godfrey has a Doctor of Philosophy in Nursing with a focus on healthcare improvement innovation and leadership from Jönköping University, School of Health Sciences, Jönköping, Sweden; an MS degree in outcomes, health policy, and healthcare improvement from the Center for the Evaluative Clinical Sciences at Dartmouth; a BSN degree from Vermont College at Norwich University; and a nursing diploma from Concord Hospital School of Nursing.
Tina C. Foster is Professor of Obstetrics and Gynecology and Community and Family Medicine at the Geisel School of Medicine at Dartmouth and The Dartmouth Institute. She practices at Dartmouth‐Hitchcock Medical Center (DHMC) in Lebanon, NH and serves as Vice‐Chair for Education in the Dept. of Ob‐Gyn. She is board certified in Ob‐Gyn and Preventive Medicine. A graduate of UC San Francisco medical school, she obtained her MPH (1998) at the Harvard School of Public Health and MS (2001) at Dartmouth’s Center for Evaluative Clinical Sciences while she was a fellow in the VA Quality Scholars national fellowship program in White River Junction, VT. She is former Program Director for the Dartmouth‐Hitchcock Leadership Preventive Medicine Residency (DHLPMR), a unique residency focused on the improvement of health and healthcare services. From 2003‐2013 she was Associate Director of Graduate Medical Education at DHMC. From 2013‐14 she served as national director for the VA Quality Scholars and Chief Resident in Quality and Safety programs. At The Dartmouth Institute (TDI), she co‐directed the Microsystems Academy with Marjorie M. Godfrey and co‐led two courses in TDI’s residential MPH program as well as the Practicum course for the online MPH program and a course in TDI’s online certificate program. She is a member of TDI’s COproduction Laboratory and active in the ongoing development of the International Coproduction of Health Network (ICoHN), focusing her work on building Communities of Practice.
Julie K. Johnson is a Professor in the Department of Surgery and the Center for Healthcare Studies at Northwestern University in Chicago, Illinois. Julie’s career interests involve building a series of collaborative relationships to improve the quality and safety of health care through teaching, research, and clinical quality improvement. She has a master’s degree in public health from the University of North Carolina and a PhD in evaluative clinical sciences from Dartmouth College in Hanover, New Hampshire. Johnson's PhD dissertation, “Forming, Operating, and Improving Microsystems of Health Care”, was an exploratory, descriptive study of clinical microsystems and helped shape early thinking of success characteristics of high performing microsystems. Since completing her PhD in 2000, Julie has focused her research on activities related to quality and safety of patient care. Regardless of the area of research that engages her time, the clinical microsystem has been the organizing framework for how she thinks about research and practice. She has extensive experience conducting qualitative research as part of implementation research studies and has used qualitative evaluation methods to study errors in ambulatory pediatric settings, to conduct observations in pediatric cardiac surgery, to observe how clinical teams function on inpatient medicine rounds, and to improve transitions of patient care. In her current role as the Associate Director of Evaluation for the Illinois Surgical Quality Improvement Collaborative (ISQIC) at Northwestern University, Julie aligns her experience and expertise in implementation science, improvement science, and qualitative research studies to evaluate a large 56‐hospital surgical improvement collaborative. Julie works with front line clinical teams at Northwestern Memorial Hospital to design, implement, and evaluate activities to improve VTE prophylaxis and Enhanced Recovery after Surgery (ERAS) protocols, to assess local QI readiness and local contextual adaptations, and to create patient and provider tools to facilitate implementation and rapid cycle learning. Furthermore, she has extensive experience evaluating learning collaboratives and coaching collaborative participants such as the Cystic Fibrosis Foundation’s Leading and Learning Collaborative on Transition to Lung Transplant. As a teacher, she has a special interest in developing and using serious games as a way to engage learners with important concepts related to understanding and improving the quality and safety of healthcare.
Paul B. Batalden is an Active Emeritus Professor of Pediatrics, Community and Family Medicine and the Dartmouth Institute for Health Policy and Clinical Practice at The Geisel School of Medicine at Dartmouth College and Guest Professor of Quality Improvement and Leadership at Jönköping University in Sweden.
