Quality By Design: A Clinical Microsystems Approach

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Product Description

Quality by Design reflects the research and applied training conducted at Dartmouth Medical School under the leadership of Gene Nelson, Paul Batalden, and Marjorie Godfrey. The book includes the research results of high-performing clinical microsystems, illustrative case studies that highlight individual clinical programs, guiding principles that are easily applied, and tools, techniques, and methods that can be adapted by clinical practices and interdisciplinary clinical teams. The authors

• describe how to develop microsystems that can attain peak performance through active engagement of interdisciplinary teams in learning and applying improvement science and measurement;
• explore the essence of leadership for clinical Microsystems;
• show what mid-level leaders can do to enable peak performance at the front lines of care;
• outline the design and redesign of services and planning care to match patient needs with services offered;
• examine the issue of safety;
• describe the vital role of data in creating a rich and useful information environment;
• provide a core curriculum that can build microsystems� capability, provide excellent care, promote a positive work environment, and contribute to the larger organization.

Ancillary materials for use in classroom teaching, training, or coaching are available at http://clinicalmicrosystem.org/materials/

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Quality By Design: A Clinical Microsystems Approach Review

A Book Review
Quality by Design - A Clinical Microsystems Approach
Edited by Eugene C. Nelson, Paul B. Batalden and Marjorie M. Godfrey
First Edition, 459 pp., illustrated. Jossey-Bass 2007. ISBN: 978-0-7879-7898-3 (pbk)

Today most practicing clinicians know very little about quality improvement in health care and very few know how to do it the right way, partly because there are few publications serving as a "How-to Guide Book".

This Book "Quality By Design - A Clinical Microsystem Approach" published in 2007 by Jossey-Bass comes in handy for practicing physicians, academic or non academic. Now that the evidence of quality improvement work is a requirement for renewing the Specialty Board in Pediatrics, I believe that other specialties will follow suit soon.
The three authors are from the Center for the Evaluative Clinical Sciences at Dartmouth. They are the nation's leaders in developing and using measures of health care delivery system performance for the improvement of health care. They have written, published and taught extensively in the subject of quality improvement. Their series of 9 articles entitled "Microsystems in Health Care published in Joint Commission Journal on Quality and Safety" (2002-2003) was a landmark publication in health care literature.

What is different and unique in this book is its emphasis on quality improvement through the microsystem approach. To put it simply, the small system (microsystem like NICU) produced quality, safety and cost outcome at the front line of care. The outcome of a macrosystem (like hospital) can be no better than the outcomes of microsystems of which it is composed. Thus a microsytem is the most important building block of a health care system.

We were fortunate enough to be introduced to their microsystem approach to health care improvement through participation in A National Evidence-Based Quality Improvement Collaborative for Neonatology of Vermont Oxford Network (VON). VON adopted the Dartmouth microsystem improvement curriculum on quality improvement as an educational tool for VON's special project called "Your Ideal NICU" in 2005.
Twelve NICU centers were selected among VON network centers and the NICU staff received a 2 year intensive training in Quality Improvement using the microsystem approach. The 2 year curriculum included lectures by 3 authors of the books, on-site (in hospital) private coaching, monthly conference calls, tasks, assignments, poster presentations, post lecture exercises on improvement tools etc, etc. After being put through 2 years of exhausting hard work and thoughtful coaching, we for the first time realized what true Quality Improvement is about. We have learned new ways of thinking, doing, acting and unlearning old behaviors and sentiments. As a result of the multiple improvement projects we have conducted, we have made measurable progresses and continue to build improvement efforts into all of our daily work in order to sustain the gain.

This book is divided into two parts. In part one the authors provided case studies of high performing Microsystems and demonstrated their success characteristics. Through these they provide guidelines on how to develop high performing Microsystems. A 5-stage model of development and curriculum to catalyze microsystem growth is clearly delineated. In part two of the book, readers are given a step-by-step guide for getting started along the path to improving care as part of everyone's daily work. This part is the most practical and most useful for the beginners. It contained 14 chapters. It started by introduction to microsystem thinking, assembling of a lead improvement team and putting the team to work through effective meeting skills. I enjoyed this part very much because it made me feel painfully sure that most of our previous meetings were ineffective and unproductive. A productive meeting is without question a key to success. Once getting started the book gives you an ADT tool (assessment, diagnosis and treatment) to assess your current status, diagnose your strengths and weaknesses and come up with treatment. This process took us quite a few months to complete, but it is a very worthwhile endeavor, without which one will not be able to go any further. Once weaknesses are identified, the authors provide you with tools for improvement such as PDSA-SDSA and a guide to establish processes for improvement one at a time.

The major strength of this book is its emphasis on measurement and monitoring of your improvement process. This book provides you with an abundance of tools to access, evaluate, measure, monitor, analyze, standardize and follow through on improvement.
What is unique in this book is Dr. Nelson's invention of the measurement of quality and value of care called Value Compass (for patients) and Balance Score Card (for the unit). These measurement tools make you focus on improvement processes, clinical outcomes, patient satisfaction and cost of care evaluation. We have learned to use this method and witnessed unquestionably that quality improvement improves patient outcomes, increases parents' satisfaction and reduces the cost of care.

We have now accumulated 3 years of experience in QI through microsystem approach. We have made significant improvements in our unit. I would like to strongly recommend this book for all health care personnel and I believe this is a must read book for all my neonatal colleagues.

Shyan Sun, M.D., D.C.H.
Saint Barnabas Medical Center
Livingston, New Jersey

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