Small team feedback control in health care

• (This is a rewrite of a prior post to make it more helpful).
  
  Thoughts on the IOM and feedback to small teams (“microsystems”)
  General “white paper”
  R. Wade Schuette
  5/4/07 (original post)
  
  [ some sections of my original document were not relevant and were removed, and I added some updated links.]
  
  So, where does the IOM refer to this? Searching the full text of the IOM report doesn't even hit that word? We have to start with the main author's after-thought (reformatted for clarity below):A User's Manual for the IOM's 'Quality Chasm' Reportby Donald M. Berwick, Health Affairs, V 21 No. 3 May/June 2002, p 80-90,http://content.healthaffairs.org/cgi/reprint/21/3/80.pdf
  
  
  ABSTRACT: Fifteen months after releasing its report on patient safety (To Err Is Human), the Institute of Medicine released Crossing the Quality Chasm. Although less sensational than the patient safety report, the Quality Chasm report is more comprehensive and, in the long run, more important. It calls for improvements in six dimensions of health care performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity; and it asserts that those improvements cannot be achieved within the constraints of the existing system of care. It provides a rationale and a framework for the redesign of the U.S. health care system at four levels: patients’ experiences; the “microsystems” that actually give care; the organizations that house and support microsystems; and the environment of laws, rules, payment, accreditation, and professional training that shape organizational action.
  
  From the "Prologue" to the article:
  
  One of the architects of the [IOM] report, Donald Berwick, decided that it would be worthwhile to condense the message into a “user’s manual” for interested readers in the United States and abroad. In this paper he synthesizes the report’s structural themes and presents them, executive summary–style, as a framework that did not appear in the final report but was the basis for the months of discussion that led up to the report’s writing and dissemination.This framework comprises four levels of interest:
  
  the experience of patients (Level A),
  the functioning of small units of care delivery (or “microsystems”) (Level B);
  the functioning of the organizations that house or otherwise support microsystems (Level C);
  and the environment of policy, payment, regulation, accreditation, and other such factors (Level D) that shape the behavior, interests, and opportunities of the organizations at Level C ...
  
  As the author of more than 100 peer-reviewed papers in numerous journals,Berwick was ideal for the task. A pediatrician by training, Berwick is chief executive officer of the Institute forHealthcare Improvement (IHI).
  
  So we can see here a four-level multi-level model of patient care with a very surprising twist - namely, it seems to have skipped over the doctor, going from the patient right up to the whole small team that includes the doctor(s), nurses, and other staff who collectively deliver care within that clinic or unit.This gap is no oversight. It reflects some very profound hypotheses:1) when caught up in an institutional environment, the boundaries of individuals blur, because doctors behave differently than they would in solo practice. Their behavior is as much a function of the team they are in as it is of their own "self".and2) if we want to intervene in this 4-level health care system to improve things, the place we should intervene is at the small team level, not at the level of the individual doctor.
  

The first concept is an inevitable consequence of putting together groups of any kind of actor that is aware of and sensitive to its environment, in a social setting where collective action is the norm. It shows up in primates where there is a rule that "There is no thing as one chimpanzee," because the behavior of the "one", when isolated in a room, is so different than when the "one" is in social context.

This phenomenon shows up among interacting robots, or interacting electronic components in some device. This is a "systems" concept, and as primal as any physical law, such as conservation of energy or conservation of momentum.The second concept then, that this is the place to intervene, follows from the first. Again, experience robustly supports this in public health, where trying to change the behavior of "an individual" while not changing their peer group or family has proven to be extremly difficult, and the trend is dramatically shifting to "family-centered" interventions.

But, this is not just a theoretical model. Experience in the field shows that this does in fact appear to be universally true in institutional health care, and that interventions at the team level are, in fact, dramatically successful.This document discusses 20 different health systems in which this was found to be true.

Executive Summary for Health Care LeadersMicrosystems in Health CareRobert Wood JohnsonFoundationDartmouth

http://www.dartmouth.edu/~cecs/hcild/downloads/RWJ_MS_Exec_Summary.pdf

OK, so then the question becomes “What sort of "Intervention" is necessary to improve the performance and behavior of this team level entity and produce safer care in a more cost-effective manner?”

The surprising answer given by the IOM that very little intervention is needed.

In fact, the primary intervention required is simply to provide the team sufficient real-time feedback of how they are doing, and trust them to respond to it appropriately, without any further management intervention. This is a mix of "Theory Y" of management, and Deming's models of the behavior of employees, who, he asserted, given the tools to do their jobs, would do them.
(But note that the team remains within the context of a larger health system, and that is important too.)Here's a detailed but readable discussion of how that feedback can work:

Powerpoint: http://www.dhs.ca.gov/pcfh/cms/nqi/ppt/MicrosystemsHlthCare.ppt
and
Microsystems in Health Care
http://www.clinicalmicrosystem.org/publications.htm Joint Commission Journal of Quality and Safety

So, what does this tell us about the role of Information Technology (IT) within a health system? It seems to me that this clearly indicates crucial role for the real-time capturing of outcomes and visible feedback to the team, as well as a crucial role for interactive collaboration tools between the team members.

This is IT at the microsystem level, and is almost entirely absent in many health systems, in which IT is considered the exclusive province of levels C and D - the enterprise and national statistics. This recommendation of the IOM focuses on an area that is referred to as "technology-mediated collaboration” by the University of Michigan School of Information’s program in just such an area.
(see that program here: http://www.si.umich.edu/research/area.htm?AreaID=3 )

Note that a fully-integrated national health care system would actually provide the necessary IT support for all four levels - A,B,C and D in a coherent fashion.In conclusion, the national health information infrastructure model, as perceived by the IOM, really includes providing real-time self-managment tools as the crucial, key IT support to small teams of caregivers, whether the caregivers are "providers" in a hospital, or patients and their friends and family.This needs to be more central to the discussion of IT in a health-care environment, and it is a very different subject than simply automating medical records -- it is empowering small-team collaboration.

That, according to the IOM, is where we need to focus our energies.
The realization behind this is very simply that we have good people who will figure out on their own how to do good things if they simply have the tools to see the impact of what they are doing, in as close to real-time as possible.