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Tables, Figures, and Exhibits xiii Foreword xix Donald M. Berwick Preface xxiii Acknowledgments xxvii Introduction xxxi The Editors xxxix The Contributors xliii Part One: Cases And Principles 1 1 Success Characteristics of High-Performing Microsystems: Learning from the Best 3 Eugene C. Nelson, Paul B. Batalden, Thomas P. Huber, Julie K. Johnson, Marjorie M. Godfrey, Linda A. Headrick, John H. Wasson True Structure of the System, Embedded Systems, and Need to Transform Frontline Systems The Bladyka Case Research Design Results Practical Implications Conclusion 2 Developing High-Performing Microsystems 34 Eugene C. Nelson, Paul B. Batalden, William H. Edwards, Marjorie M. Godfrey, Julie K. Johnson Case Study: A Decade of Progress for an Intensive Care Nursery A Model of Development and a Curriculum to Catalyze Microsystem Growth Conclusion 3 Leading Microsystems 51 Paul B. Batalden, Eugene C. Nelson, Julie K. Johnson, Marjorie M. Godfrey, Thomas P. Huber, Linda Kosnik, Kerri Ashling Leader, Leadership, Leading Recap of Methods Three Fundamental Processes of Leading: What Clinical Microsystem Team Members Observe and Report Discussion Conclusion 4 Leading Macrosystems and Mesosystems for Microsystem Peak Performance 69 Paul B. Batalden, Eugene C. Nelson, Paul B. Gardent, Marjorie M. Godfrey Case Study: A True Story, with Names Changed to Protect the Innocent Leadership Frameworks: Some of the Best Approaches Leading Large Health Systems to Peak Performance Using Microsystem Thinking Conclusion 5 Developing Professionals and Improving Worklife 106 Thomas P. Huber, Marjorie M. Godfrey, Eugene C. Nelson, Julie K. Johnson, Christine Campbell, Paul B. Batalden Case Study: Staff Development at Massachusetts General Hospital Downtown Associates Conclusion 6 Planning Patient-Centered Services 124 Marjorie M. Godfrey, Eugene C. Nelson, John H. Wasson, Julie K. Johnson, Paul B. Batalden Planning Patient-Centered Services and the 5 P's Case Study: Planning Services for Subpopulations of Patients to Best Provide Care for Individual Patients A Developmental Journey: Beginning to Assess, Understand, and Improve a Clinical Microsystem Analysis and Improvement of Processes A Huddle in Plastic Surgery Conclusion 7 Planning Patient-Centered Care 148 John H. Wasson, Marjorie M. Godfrey, Eugene C. Nelson, Julie K. Johnson, Paul B. Batalden Planning Care Well: Exemplary Clinical Microsystems Planning Care in Any Microsystem A Low-Tech Example for Ambulatory Services: CARE Vital Signs Conclusion 8 Improving Patient Safety 165 Julie K. Johnson, Paul Barach, Joseph P. Cravero, George T. Blike, Marjorie M. Godfrey, Paul B. Batalden, Eugene C. Nelson Microsystem Patient Safety Scenario Case Study: Dartmouth-Hitchcock PainFree Program Conclusion 9 Creating a Rich Information Environment 178 Eugene C. Nelson, Paul B. Batalden, Karen Homa, Marjorie M. Godfrey, Christine Campbell, Linda A. Headrick, Thomas P. Huber, Julie K. Johnson, John H. Wasson Case Study 1: Specialty Care: Dartmouth-Hitchcock Spine Center Case Study 2: Overlook Hospital Emergency Department Case Study 3: Intermountain Health Care Shock Trauma Intensive Care Unit Tips and Principles to Foster a Rich Information Environment Discussion Conclusion Part Two: Activating the Organization And the Dartmouth Microsystem Improvement Curriculum 197 10 Overview of path forward And Introduction to part two 199 Recap of Part One and Overview of Part Two Using Real Case Studies and Practical Applications of Microsystem Thinking, Methods, and Tools Working at All Levels of a Health System Focusing on the Microsystem Level Review Questions Prework 11 Introduction to Microsystem Thinking 230 What Is a System in Health Care? How Did Clinical Microsystem Knowledge Evolve? What Is a Clinical Microsystem? Where Do Clinical Microsystems Fit in the Health Care Delivery System? What Does a Clinical Microsystem Look Like? Why Focus on the Clinical Microsystem? How Do Clinical Microsystems Link to Crossing the Quality Chasm? What Were the Findings of the Dartmouth Clinical Microsystem Research? What Does a Microsystem's Developmental Journey Look Like? Conclusion Case Studies Review Questions Between Sessions Work 12 Effective Meeting Skills I 243 What Is a Productive and Effective Meeting? Why Use Meeting Skills and Roles? What Are Effective Meeting Roles? What Are the Phases of an Effective Meeting? What Processes Are Evident in an Effective Meeting? What Is the Seven-Step Meeting Process? What Does a Meeting Agenda Template Look Like? What Are the Ground Rules for Meetings? What Are Some Tips for Getting Started with Productive Meetings? How Do You Keep a Rhythm of Improvement? Case Studies Review Questions Between Sessions Work 13 Assessing Your Microsystem with the 5 P's 258 How Does an Interdisciplinary Lead Improvement Team Begin to Assess and Improve a Clinical Microsystem? What Does the 5 P's Framework Look Like? What Resources Are Available to Guide the 5 P's Assessment? What Is a Helpful Way to Introduce Your Team to the Assessment Process? What Are the 5 P's? What Should You Do with the Assessment Findings? Case Studies Review Questions Between Sessions Work 14 The Model for Improvement: PDSA ? SDSA 271 What Is the Model for Improvement? Why Use the Model for Improvement? How Does the Model Fit into the Improvement Process? What Is the PDSA Part of the Model? What Are the Benefits of Using PDSA? What Is Involved in Each of the Four Steps of Plan, Do, Study, and Act? What Is the SDSA Cycle? What Is Involved in Each of the Four Steps of Standardize, Do, Study, and Act? What Tools Can Assist Your PDSA Cycle ? SDSA Implementation? What Are Some Tips for Using the PDSA ? SDSA Method? Case Studies Review Questions Between Sessions Work 15 Selecting Themes for Improvement 284 What Is a Theme for Improvement? Why Use a Theme? What Are the Theme Selection Considerations? What Process Can You Use to Generate Theme Ideas and Select a First Theme? What Are the Next Steps? Case Studies Review Questions Between Sessions Work 16 Improvement Global Aim 291 What Is a Global Aim? Why Use a Global Aim? How Do You Write a Global Aim? What Are the Next Steps? Case Studies Review Questions Between Sessions Work 17 Process Mapping 296 What Is Process Mapping? Why Use Process Mapping? What Are the Commonly Used Flowchart Symbols? What Does a High-Level Flowchart Look Like? What Does a Detailed Flowchart Look Like? What Are Some Tips for Creating a Flowchart? What Does a Deployment Flowchart Look Like? What Are Some Tips for Creating a Deployment Flowchart? Case Studies Review Questions Between Sessions Work 18 Specific Aim 308 What Is a Specific Aim? Why Use a Specific Aim? Where Do Specific Aims Come From? Where Does the Specific Aim Fit in the Overall Improvement Process? How Do You Write a Specific Aim? What Are the Next Steps? Case Studies Review Questions Between Sessions Work 19 Cause and Effect Diagrams 313 What Is a Cause and Effect Diagram? Why Use a Fishbone Diagram? What Is the Structure of a Fishbone Diagram? What Does a Completed Fishbone Look Like? What Are Some Tips for Creating a Fishbone Diagram? Case Studies Review Questions Between Sessions Work 20 Effective Meeting Skills II: Brainstorming and Multi-Voting 321 What Is Brainstorming? What Are the Benefits of Brainstorming? What Are Some Different Types of Brainstorming? What Are Some Tips for Conducting Brainstorming? What Is Multi-Voting? Do Teams Always Multi-Vote After a Brainstorming Session? How Do You Multi-Vote? What Does a Brainstorming Session with a Multi-Voting Outcome Look Like? Case Studies Review Questions Between Sessions Work 21 Change Concepts 331 What Is a Change Concept? Why Use Change Concepts? How Can You Use Change Concepts in a Process? What Are the Next Steps? Case Studies Review Questions Between Sessions Work 22 Measurement and Monitoring 339 What Are Measures, What Makes Measures Good, and How Do They Relate to Aims? What Is a Run Chart? What Are the Benefits of Using a Run Chart? How Do Run Charts Fit in the Overall Improvement Process? What Do Run Charts Tell You About Your Performance Level and Variation? What Are Special Cause and Common Cause Variation? How Do You Make a Run Chart? How Do You Interpret Run Chart Results? What Is a Control Chart? What Is the Theory Behind Control Charts? What Are the Benefits of Using a Control Chart Instead of a Run Chart? What Are the Different Kinds of Control Charts? What Is an XmR Control Chart? How Do You Interpret Control Chart Results? When Do You Recalculate Control Chart Values? What Are Some Tips for Using Run Charts and Control Charts? Case Studies Review Questions Between Sessions Work 23 Action Plans and Gantt Charts 362 What Is an Action Plan? What Is a Gantt Chart? Why Use Action Plans and Gantt Charts? How Do You Write an Action Plan? How Do You Create a Gantt Chart? What Are the Next Steps? Case Studies Review Questions Between Sessions Work 24 Follow Through on Improvement: Storyboards, Data Walls, and Playbooks 369 What Is the Importance of Follow Through? What Can You Do to Follow Through? What Are the Fundamentals of Improvement? What Is a Data Wall? What Is a Playbook? How Is the Playbook Used? How Do You Create a Playbook? How Do You Maintain Your Playbook? What Is a Storyboard? How Do You Make a Storyboard? Discussion Case Studies Review Questions Between Sessions Work 25 Conclusion: Continuing on the Path to Excellence 380 Looking Back Looking Forward and an Invitation: Make It Personal and Make It Happen Appendix A: Primary Care Workbook 385 Name Index 433 Subject Index 437

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