Microsystem? What's that?

The confusing concept of a "microsystem" is central to the Institute of Medicine's recommendations for improving hospital-based health care, as presented in Crossing the Quality Chasm. What do they mean by that term? Where do we have to stand so that it becomes as obvious to us as it is to them that microsystems are important?

In this post I want to try to address those questions.
Here's two links to the IOM report:

IOM's "Executive summary

Entire IOM "Crossing the Quality Chasm" book (readable on-line)
http://www.nap.edu/catalog/10027.html#toc

First, 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' Report
by 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 embodies two more very critical, dramatic, and profound concepts:

#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".

and

#2) 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 Leaders
Microsystems in Health Care
Robert Wood Johnson Foundation
Dartmouth

Third, 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? Very little. In fact, the primary intervention required is simply to provide them 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:
Microsystems in Health Care, part 2:
Creating a Rich Information Environment
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 focuses on "technology-mediated collaboration."

Fourth, 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 other posts, such as the Capstone presentation below, I discuss why empowering teams of patients, or the patient and the patient's family or "posse", is equally important for dealing with chronic care for such diseases as diabetes or obesity, in which the patient is the locus of control.
That need increasingly will be met by RHIO's and Personal Health Records, although, for reasons I discuss elsewhere, I think PHR's will be far more able to cover this gap than RHIOs because they are so much less risk-averse and more able to experiment, adapt, and fill small niches.

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 is not a familiar role to IT, and so far has been embraced more by the School of Information at the University of Michigan ("technology-mediated collaboration") than by health systems in the USA.

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.