The Adolescent Rheumatology Clinical Microsystem Microsystem Basics

A clinical microsystem is the "place" where patients, families, and health care teams meet. This place can be the rheumatology outpatient practice or an inpatient ward. Based on years of research and field testing, Nelson et al. (4) have promoted and advanced helpful concepts to guide gaining deeper knowledge into the microsystem, which results in improvements and improved measured results for patients, families and health care professionals. The clinical microsystem is defined as "a small group of people who work together on a regular basis to provide care to a discrete subpopulation of patients. It has clinical and business aims, linked processes, and a shared information environment, and it produces performance outcomes. Microsystems evolve over time and are often embedded in larger organizations. They are complex adaptive systems, and as such they must do the primary work associated with core aims, meet the needs of their members, and maintain themselves over time as clinical units" (4). This definition provides a clear understanding of the rheumatology microsystem in the population of adolescents with rheumatic diseases being cared for by an interdisciplinary team of health care professionals.

What do we need to know about our microsystem, the adolescent rheumatology clinic?

How can we help to provide the best possible evidence based care in our microsystem for every patient, every day and how do we know how our system is performing? How can we decrease unwanted variation, improve processes and start to learn from performance and outcome measurements in a "value compass."

To have deeper understanding of the rheumatology clinical microsystem, the anatomy and physiology should be explored.

The anatomy is the structure of the clinical microsystem and includes the following elements as shown in Figure 9 (4).

The 5 Ps: Purpose, Patients, Professionals, Processes, and Patterns

The purpose of the clinical microsystem is often stated as the desired outcomes for the patient population being cared for.

The patients (and families) are defined in categories of chronic, acute, preventive, and palliative care needs. Subpopulations of patients can be defined through specific diagnostic groups. Patient satisfaction, top diagnoses, patterns in volumes of patients seen by day, week, month, and season are all explored.

The professionals include all members of the care team providing care for the patients including administrative, clerical, support staff, physical and occupational therapists, social workers, nurses and physicians. Increasing knowledge of the professionals includes staff satisfaction data and information, understanding how professionals spend their time in the microsystems and gaining insight if the Professional roles are being optimized as defined by professional education, training and licensure.

The processes are the interactions between the patients and professionals intended to meet the needs of the patients. Often these processes of care are not well known or agreed upon by the professionals in the microsystem due to lack of discussions about "how" care is delivered.

The patterns are the results of the interactions within the clinical microsystem. What is the leadership like, who talks with whom, what are the measured clinical outcomes for patients, what makes the members of the microsystem proud and how often do they meet as an interdisciplinary team to discuss quality and safety.

A helpful collection of tools for gaining deeper knowledge of the 5Ps is the Clinical Microsystems' "A Path to Healthcare Excellence" (18) (www. which provides an organized clear path forward to guide the process of deepening your knowledge of your rheumatology clinic or inpatient unit.

Once an interdisciplinary team together begins to learn about the microsystem they work in through the review of anatomy, they can then explore the physiology of their microsystem (Fig. 10) (4).

The physiology of the clinical microsystem includes a group of patients or subpopulation with a need, entering a health care setting with some

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^ Eugene C. Nelson, DSc, MPH Paul B. Batalden, MD Dartmouth-Hitchcock Clinic. June 1998

Figure 9 Clinical microsystem anatomy. Source: Adapted from Ref. 4.

A generic clinical microsystem model

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degree of orientation occurring, assessment, diagnosis and plan of care designed with and for the patient with measured result as the patient leaves the microsystem of care. An important note here is to notice in this diagram the balanced measures of the patient(s) that are assessed at the beginning of the physiology of the microsystem and then re-measured after progressing through the microsystem. The balanced measures are framed in the clinical value compass model (4).

The Clinical Value Compass is a framework to use to track measures over time for a single patient or a subpopulation of patients. The Clinical Value Compass informs us if our processes and system improvement is making a measurable improvement for patient outcomes (Fig. 6).

The use of the registry and associated technology in practice supports the clinician and the team in being able to review outcome and process data in real time during a patient encounter to immediately see and track if the plan of care is effective. The registry also provides safety features in the process of care to know medication types and doses.

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