Clinical micro system

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 After you complete this week’s readings including the Clinical Microsystem Greenbooks, describe one that relates most closely to your project topic and how this microsystem will help you develop your change project. 

1 page 

1 scholarly article 

topic:  Do nursing students who experienced combined virtual reality and traditional simulations have increased confidence in their clinical knowledge when compared with nursing students with only traditional simulation experience 

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Draft version 1.0, June 2010

Supporting Microsystems

“The Place Where Patients, Customers, Families, and
Professionals Meet”

Assessing, Diagnosing and Treating
Your

Microsystem

www.clinicalmicrosystem.org

Purpose

Processes

Professionals

Patterns

Patients/
Customers

Patients/
Customers

Request

Assignment

Process

Completed

Delivered

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Strategies for Improving “The place where patients,
customers, families and professionals meet.”

A Supporting Microsystem Self-Assessment, Diagnosis and Treatment Plan

Supporting microsystems are the units that provide support and services to clinical microsystems, including patients
and families. They are the places where patients, customers, families and professionals meet. Supporting
microsystems also include support staff, processes, technology and recurring patterns of information, behavior and
results. Central to every supporting microsystem is the customer and patient.
The supporting microsystem is the place where:

• Services are made and delivered
• Quality, safety, reliability, efficiency and innovation are made
• Staff morale and patient/customer satisfaction are made

Supporting microsystems are the building blocks that support clinical microsystems. The quality of care can be no
better than the quality produced by the small systems that come together to provide care. Here is the quality equation:

Health System Quality = Quality of Microsystem 1 + Quality of Microsystem 2 + Quality of Microsystem 3-n

All health care professionals—and we believe all front line and support staff are professionals—have 2 jobs.
Job 1 is to provide services and care. Job 2 is to improve services and care.

Finding time to improve care can be difficult, but the only way to improve and maintain quality, safety, efficiency and
flexibility is by blending analysis, change, measuring and redesigning into the regular patterns and the daily habits of
clinicians and staff. Absent the intelligent and dedicated improvement work by all staff in all units, the quality, efficiency
and pride in work will not be made nor sustained.

This workbook provides tools and methods that busy interdisciplinary supporting microsystems can use to improve the
quality and value of customer and patient care and services as well as the work-life of all staff who contribute to this
care and services. These methods can be adapted to a wide variety of settings, large and small, urban and rural,
community-based and academic.

The Path Forward

This workbook provides a guide for making a path forward towards higher performance. Just as you can assess,
diagnose and treat patients; you can assess, diagnose and treat your supporting microsystem. This workbook is
designed to guide your supporting microsystem on a journey to develop better performance. There are many good
ways to improve performance; research shows that this is one of those good ways.
You can access more examples, tools and blank forms to customize at www.clinicalmicrosystem.org

Note: We have developed this workbook with tools to give ideas to those interested in improving healthcare. “The Dartmouth Institute Microsystem
Academy and the developers of this workbook are pleased to grant use of these materials without charge, providing that recognition is given for their
development, that any alterations to the documents for local suitability and acceptance are shared in advance, and that the uses are limited to their
own use and not for re-sale.”

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© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

3

The Path Forward
A Supporting Microsystem Self-Assessment, Diagnosis and Treatment Plan
Step 1: Organize a “Lead Interdisciplinary Improvement Team”

Successful, sustainable cultural change requires the commitment and active involvement of
all members of the supporting microsystem. To keep the supporting microsystem on track
and focused, a “Lead Interdisciplinary Improvement Team” of representatives of all roles
should be formed.

Step 2: Do the Assessment

Assess your supporting microsystem using the “5Ps” as your guide. Review your current
performance metrics.

• Purpose
• Patients/Customers
• Professionals
• Processes
• Patterns
• Metrics That Matter

Step 3: Make a Diagnosis

Based on Step 2, review your assessment and Metrics That Matter to make your diagnosis.
You should select a “Theme and Aims” for improvement based on this diagnosis and your
organization strategic priorities. This process will aid you to take action based on
knowledge and data and not just experiences alone.

Step 4: Treat Your Supporting Microsystem

Use scientific improvement methods and tools. Besides the usual improvement model of
The Dartmouth Microsystem Improvement Curriculum which uses Plan-Do-Study-Act &
Standardize-Do-Study-Act (PDSA-SDSA) supporting microsystems often benefit from tools
such a LEAN and six sigma when reviewing production and standardized processes.

Step 5: Follow-up & Sustain

Design and execute monitoring processes, outcomes and results. Ensure improved and
newly designed processes are tracked over time and included in staff and improvement
meetings to ensure the new processes are sustained over time. Move to your next
improvement themes.

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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STEP 1: Organize a “Lead Interdisciplinary Improvement Team”
Assemble a “Lead Interdisciplinary Improvement Team” to represent all disciplines and roles in your supporting
microsystem. Include managers, supervisors, leads and clerical staff, customers (units, clinics, providers), patients and
families along with any other professionals who are regularly in the supporting microsystem providing a service.

Must dos:

• Lead Team should meet weekly to maintain focus, make plans and oversee improvement work
• Effective meeting skills should be used in the weekly meetings (see www.clinicalmicrosystem.org)
• Monthly ALL staff meetings should be held to engage and inform all members of the supporting microsystem
• Explore creative ways to communicate and stay engaged with all staff on all shifts and all days of the week

Use email, newsletters, listservs, paper, verbal, visual displays, communication boards and buddy systems
• Remember true innovation is achieved through active engagement of the customers, patient and family with the

Lead Team

STEP 2 Assess Your Microsystem
Complete the “5Ps” assessment. This process needs to be completed by the Lead interdisciplinary improvement team.
Building common knowledge and insight into the supporting microsystem by all members will create a sense of equal
value and ability to contribute to the improvement activities.

Start with Purpose. Why does your microsystem exist?
Raise this question to EVERYONE in your microsystem to create the best statement of purpose that everyone can
support and live.

Assess Your Patients/Customers, Professionals, Processes and Patterns using the worksheets in the “Greenbook.”
The aim is to create the “Big picture” of your system to see beyond one patient/one sample/one test at a time.
Assessing the “5Ps” and then reflecting on their connections and interdependence often reveals new improvement and
redesign opportunities.

Create a timeline for the assessment process. The whole workbook DOES NOT need to be completed within 2 weeks.
Some supporting microsystems have the capacity and resources to move quickly through the workbook in a short
period of time. Many supporting microsystems need to pace themselves through the workbook and complete the
worksheets and assessment through a longer timeline. Some supporting microsystems may need to start an important
improvement immediately while starting the assessment process. In this case, the ongoing assessment will give you
needed context and will help you make better improvements.

Remember however you choose to progress through the workbook, it MUST be done within the context of your
interdisciplinary team.

Use the Data Review sheet to help outline and track which data and information will be retrieved in current systems and
which data/info will be measured through a worksheet. Review the worksheets of the Assess, Diagnose and Treat Your
Supporting Microsystem Practice workbook. Determine which worksheets you will copy and use to collect new data
and information. Which worksheets will you NOT use because you have data systems that can provide useful, timely
data for you without a special effort? What new data and information do you discover outside of this workbook that will
help your improvement efforts?

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Microsystem Assessment of Data Sources and Data Collection Actions

• With your interdisciplinary team, review the Assess, Diagnose and Treat workbook-“The Greenbook”. Use this
form to determine which measures you can obtain from your organization and therefore, don’t need to use the
worksheets. Be sure the data is current and not months old.

• Determine which worksheets will be used. Plan who, when and how the worksheets will be completed.
• Decide who oversees the compilation of each worksheet or alternative data source.

Page/Type of Data Data Source/Data Collection Action Date/Owner
Page 6 B Know Your Patients/Products

B1. Estimated number of customers
B2. Mix of services
B3. List Your Top Requested Services
B4. Top Sources of work requests
B5. Volume of work from top 10

customers/units

B6. Work request method/process
B7. Data Management System
B8. Frequent high volume customers
B9. Customer Satisfaction Scores
B11. Through the Eyes of the Customer

Page 6 C Know Your Professionals

C1. Current Staff
Float Pool
On-Call
Per Diem Staff

C2. Days of Operation
C3. Hours of Operation
C7. Staff Satisfaction Scores

Personal Skills Assessment
Activity Survey

Page 6 D Know Your Processes

D1. Create Flow Charts of Routine
Processes

D2. Cycle Time Tool
D3. Core and Supporting Processes
D4. High Level Flow Charts
D5. Use of Data management software

D6. Work Flow: Spaghetti Diagrams

Page 6 E Know Your Patterns

E1. Most Significant Pattern
E2. Successful Change
E3. Most Proud of
E4. Patterns of Errors
Unplanned Activity Tracking Card

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Supporting Microsystem Profile
A. Purpose: Why does your microsystem exist?

Name of Service: Site Contact: Date:
Service Manager: Service Lead:
B. Know Your Customers: Take a close look into your microsystem; create a “high-level” picture of the Customers that you serve. Who are they? What resources

do they use/request? How do customers view the services they receive?
Est. Distribution of
workload % List Your Top 10

Work type requests
Top requesting
Customers Customer Satisfaction Scores %

Excellent

Source- 1. 6. Experience via phone
Source- 2. 7. Length of time to get complete work
Source- 3. 8. Accuracy of work
Source- 4. 9. Satisfaction with personal manner
Source- 5. 10. Satisfaction with work product

Customers who are frequent
users of your service and
their reasons for interacting
with your microsystem

Other services you interact
with regularly as part of your
normal work processes.

Work load distribution: Do these
numbers change by season? (Y/N) # Y/N

Est. # of work
requests in last
month

Work load in a day
Work load in last week

Work load in last month

Top Payors Other

.

*Complete “Through the Eyes of Your Customer

C. Know Your Professionals: Use the following template to create a comprehensive picture of your microsystem. Who does what and when? Is the right person doing the
right activity? Are roles being optimized? Are all roles who contribute to the patient experience listed? What hours are you open for business? What is the morale of
your staff?

Current Staff FTEs Role/Function Days of Operation Hours of Operation

Enter names below totals (Use separate sheet if needed) Monday |
Tuesday |

Microsystem Total Wednesday |
Thursday |
Title: Friday |
Saturday |
Title: Sunday |
Which activities are you involved in? Check all that apply.
Title:  Electronic Work Request  E-Mail (with customers)
 Data Management  Website
Title:  Certification  Other-

 Regularly attend clinical
microsystem meetings you are
supporting

 Other-

Title:
 Leadership meets regularly with
clinical microsystems being
supported

Managers

Other:

Work Type Cycle Time Comment
Do you use a Float Pool?  Yes  No
Do you use On-Call?  Yes  No
Staff Satisfaction Scores % Do you use Per Diems?  Yes  No
How stressful is this microsystem? % Very stressed
Would you recommend it as a good place to work? % Strongly Agree

*Each staff member should complete the Personal Skills Assessment and “The Activity Survey”
D. Know Your Processes: How do things get done in the microsystem? Who does what? What are the step-by-step processes? How long

does it take to complete the work here, are the delays? What are the “between” microsystems hand-offs? Have you discussed a shared purpose
with clinical microsystems and other supporting microsystems?

1. Track cycle time from work requested, work assigned, work completed, final product sent to customer.
2. Complete the Core and Supporting Process Assessment Tool
E. Know Your Patterns: What patterns are present but not acknowledged in your microsystem? What is the leadership and social pattern? How often does the

microsystem meet to discuss processes? Are customers involved? What are your results and outcomes?
• Does every member of the microsystem meet • Do the members of the microsystem regularly review • What have you successfully changed?

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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regularly as a team? and discuss errors, safety and reliability issues? • What are you most proud of?
• How frequently? • What is your financial picture?
• What is the most significant pattern of variation? *Complete “Metrics that Matter”

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INSERTDDE

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Customers
• Customers have valuable insight into the quality of the work we provide. Real time feedback can pave the way for

rapid responses and quick tests of change. This “Point of Service” Survey can be completed at the time of the
encounter to give real time measurement of satisfaction.

• Use the Microsystem to review “Know Your Customers.” Determine if there is information you need to collect or if
you can obtain this data within your organization. Remember the aim is to collect and review data and information
about your patients and customers that might lead to a new design of process and services.

• Conduct the Customer Satisfaction Survey for 2 weeks with your customers.

Customer Satisfaction
“Point of Service”

Date:

Think about this encounter.

1. How would you rate your satisfaction with getting through by phone?

 Excellent  Very Good  Good  Fair  Poor

2. How would you rate your satisfaction with the length of time before receiving the service

requested?

 Excellent  Very Good  Good  Fair  Poor

3. How would you rate the quality of the product or service provided?

 Excellent  Very Good  Good  Fair  Poor

4. How would you rate your satisfaction with the personal manner of the person you dealt with?

(courtesy, respect, sensitivity, friendliness)?

 Excellent  Very Good  Good  Fair  Poor

5. How would you rate your overall satisfaction with the product or service requested?

 Excellent  Very Good  Good  Fair  Poor

Comments:

Thank You For Completing This Survey

Patients/Customers

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Supporting Microsystem Patient/Staff Viewpoint Survey

Please rate the following questions about this supporting microsystem.
Excellent Very

Good Good Fair Poor

1. The time from request to completion by supporting microsystem.
2. Convenience of the location of this supporting microsystem.
3. Getting through to the microsystem by phone.
4. Length of time waiting at the microsystem (if applicable).
5. Satisfaction with the person you interact with.
6. Explanation of what was done.
7. The technical skills (thoroughness, carefulness, competence) of the person you saw.
8. The personal manner (courtesy, respect, sensitivity, friendliness) of the person you saw.
9. The staff sensitivity to your special needs or concerns.
10. Your satisfaction with getting your questions answered.
11. Your feeling about the overall quality of the staff interaction.

General Questions
Please answer the general questions about your satisfaction with this microsystem.
12. If you could go anywhere to have your needs met, would you choose this center or would you prefer to go someplace else?
Would choose this center Might prefer someplace else Not sure
13. I am delighted with everything about this support microsystem because my expectations for service and quality of care are

exceeded.
Agree Disagree Not sure

14. In the last 12 months, how many times have you depended on this microsystem?
None One time Two times Three or more times

15. Is there anything the microsystem can do to improve the care and services for you?
No, I’m satisfied with

everything
Yes, some things can be

improved
Yes, many things can be

improved

Please specify improvement:
16. Did you have any good or bad surprises with this microsystem?
Good Bad No surprises

Please describe:

Sources: Medical Outcomes Study (MOS) Visit-Specific Questionnaire (VSQ), 1993
Patient Utilization Questions, Dartmouth Medical School

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Patients/Customers
• Gain insight into how your patients/customers experience your service delivery. One simple way to understand

the patient/customer experience is to experience the process. Members of the staff should do a “Walk Through”
in your department. Try to make this experience as real as possible. This form can be used to document the
experience. You can also capture the customer experience by making an audio or videotape.

Through the Eyes of Your Patients/Customers
Tips for making the “Walk Through” most productive:
1. Determine with your staff where the starting point and

ending points should be, taking into consideration
obtaining the work request, assignment of work and
completion.

2. Two members of the staff should role play with each
playing a role: requesting person, receiving person.

3. Other members of the staff could follow the work
request through all the steps.

4. Set aside a reasonable amount of time to experience
the customer/work journey. Consider doing multiple
experiences along the customer journey at different
times.

5. Make it real. Include time from work request to work assignment to
final completion.

6. During the experience note both positive and negative experiences,
as well as any surprises. What was frustrating? What was
gratifying? What was confusing? Again, an audio or video tape can
be helpful.

7. Debrief your staff on what you did and what you learned.

Date: Staff Members:

Walk Through Begins When: Ends When:

Positives Negatives Surprises Frustrating/Confusing Gratifying

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Professionals
• Development of each member is a key to success for staff and the supporting microsystem. The Personal Skills

Assessment tool helps determine the education and training needs of staff. All staff members complete this
survey and then discuss the action plan with leadership and other staff. A plan is developed to help members
achieve goals so they can become the best they can be.

• This tool provides guidance for individual development plans along with assessing the “group” needs to plan
larger learning and training sessions.

Personal Skills Assessment

Name: Unit:

Role: Date:

Competencies:

Please create your list of competencies and evaluate. Want to
Learn Never Use Occasionally Frequently

 1 2 3 4 5 6 7 8 9 10

Data Base/Information/Computer System Used:

What features and functions do you use? Enter
them in each row below then evaluate.

Want to
Learn Never Use Occasionally Frequently

 1 2 3 4 5 6 7 8 9 10
 1 2 3 4 5 6 7 8 9 10
 1 2 3 4 5 6 7 8 9 10
 1 2 3 4 5 6 7 8 9 10
 1 2 3 4 5 6 7 8 9 10

 1 2 3 4 5 6 7 8 9 10
 1 2 3 4 5 6 7 8 9 10
 1 2 3 4 5 6 7 8 9 10
 1 2 3 4 5 6 7 8 9 10

 1 2 3 4 5 6 7 8 9 10
 1 2 3 4 5 6 7 8 9 10
 1 2 3 4 5 6 7 8 9 10

Technical Skills:

Please rate the following on how often you use them. Want to
Learn Never Use Occasionally Frequently

Data Base/Computer System  1 2 3 4 5 6 7 8 9 10
E-mail  1 2 3 4 5 6 7 8 9 10
PDA (i.e. Smart phone)  1 2 3 4 5 6 7 8 9 10
Other:  1 2 3 4 5 6 7 8 9 10

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Personal Skills Assessment page 2
Name: Unit:

Technical Skills cont’d:

Please rate the following on how often you use them. Want to
Learn Never Use Occasionally Frequently

Word Processing (e.g. Word)  1 2 3 4 5 6 7 8 9 10
Spreadsheet (e.g. Excel)  1 2 3 4 5 6 7 8 9 10
Presentation (e.g. Power Point)  1 2 3 4 5 6 7 8 9 10
Database (e.g. Access or File Maker Pro)  1 2 3 4 5 6 7 8 9 10
Database/Statistics  1 2 3 4 5 6 7 8 9 10
Internet/Intranet  1 2 3 4 5 6 7 8 9 10
Printer Access  1 2 3 4 5 6 7 8 9 10
Fax  1 2 3 4 5 6 7 8 9 10
Copier  1 2 3 4 5 6 7 8 9 10
Telephone System  1 2 3 4 5 6 7 8 9 10
Voice Mail  1 2 3 4 5 6 7 8 9 10
Pagers  1 2 3 4 5 6 7 8 9 10

Meeting & Interpersonal Skills: Want to
Learn Never Use Occasionally Frequently

What skills do you currently use?  1 2 3 4 5 6 7 8 9 10
Effective Meeting Skills (brainstorm/multi-vote)  1 2 3 4 5 6 7 8 9 10
Timed Agendas  1 2 3 4 5 6 7 8 9 10
Role Assignments During Meetings  1 2 3 4 5 6 7 8 9 10
Delegation  1 2 3 4 5 6 7 8 9 10
Problem Solving  1 2 3 4 5 6 7 8 9 10
Patient Advocacy Process  1 2 3 4 5 6 7 8 9 10
Open and Effective Communication  1 2 3 4 5 6 7 8 9 10
Feedback – provide and receive  1 2 3 4 5 6 7 8 9 10
Managing Conflict/Negotiation  1 2 3 4 5 6 7 8 9 10
Emotional/Spiritual Support  1 2 3 4 5 6 7 8 9 10

Improvement Skills and Knowledge: Want to
Learn Never Use Occasionally Frequently

What improvement tools do you currently use?

Flowcharts/Process Mapping  1 2 3 4 5 6 7 8 9 10
Trend Charts  1 2 3 4 5 6 7 8 9 10
Control Charts  1 2 3 4 5 6 7 8 9 10
Plan/Do/Study/Act (PDSA) Improvement Model  1 2 3 4 5 6 7 8 9 10
Aim Statements  1 2 3 4 5 6 7 8 9 10
Fishbones  1 2 3 4 5 6 7 8 9 10
Measurement and Monitoring  1 2 3 4 5 6 7 8 9 10
Surveys- Customers and Staff  1 2 3 4 5 6 7 8 9 10
StAR Relationship Mapping  1 2 3 4 5 6 7 8 9 10

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Professionals
• What do you spend YOUR time doing? What is your best estimation of how much time you spend doing it?

The goal is to have the right person doing the right thing at the right time. The group can discuss which
activities are or are not appropriate for the individual’s level of education, training, and licensure.

• You can start with one group of professionals such as Medical Technologist, Medical Technicians or clerical
staff, assessing their activities using the Activity Survey. This estimate of who does what is intended to reveal,
at a high level, where there might be mismatches between education, training, licensure and actual activities. It
is good to eventually have all roles and functions complete this survey for review and consideration. Be sure to
create the same categories for each functional role. Some groups may hesitate to make time estimates; if this
happens, just ask them to list their activities for the first review.

Practice Activity Survey Sheet Example

Position: Medical Technologist % of Time Position: Laboratory Clerk % of Time
Activity: Perform Laboratory Tests

30%

Activity: Answering Phone

15% Specific Items Involved: • List Categories of questions
• Pulling patient test list •
• Receiving Specimens •
• Setting up testing procedures Activity: Specimen Receipt

3% Activity: Run Quality Controls 9% Specific Items Involved:
Activity: Resolve Control Issues 2% • Accessioning
Activity: Perform Test

10%
Activity: Direct Patient Care

30%
Specific Items Involved: • See patients in clinic
• Manual or Automated testing • Injections
Activity: Resulting of Tests

25%

• Assist provider with patients
Specific Items Involved: •
• Evaluating Test Results Activity: Follow-up Phone Calls

22% • Reporting abnormal test results Specific Items Involved:
Activity: Critical Value Reporting

5%


Specific Items Involved: Activity: Review and Notify Patients of Lab Results

5% • Pathology Review Specific Items Involved:
• Contacting Ordering provider/Documenting • Normal with follow-up
Activity: Making Reagents

5%
• Drug adjustments

Specific Items Involved: Activity: Complete Forms

18% • Making Stock/Working Reagents Specific Items Involved:
Activity: Stocking of Supplies/Reagents 5% • Referrals
Activity: Test/Quality Control Correlations

5%
• Camp/school physicals

Specific Items Involved: Activity: Call in Prescriptions
5% • Review results and determine next actions Specific Items Involved:

Activity: Student Teaching 2% •
Activity: Miscellaneous

2%
Activity: Miscellaneous

2% Specific Items Involved: Specific Items Involved:
• CME; attend seminars; attend meetings • CME; attend seminars; attend meetings

Total 100% Total 100%

Activity Occurrence Example:
What’s the next step? Insert the activities from the Activity Survey Here.
Activities are combined by role from the data collected above. This creates a master list of activities by role. Fill-in THE NUMBER OF TIMES PER
SESSION (AM and PM) THAT YOU PERFORM THE ACTIVITY. Make a mark by the activity each time it happens, per session. Use one sheet for
each day of the week. Once the frequency of activities is collected, the practice should review the volumes and variations by session, day of week,
and month of year. This evaluation increases knowledge of predictable variation and supports improved matching of resources based on demand.
Role: Pharmacist Date: Day of Week:
Visit Activities AM PM Total
Triage Patient Concerns 14
Family/Patient Education 11
Direct Patient Care 42
Non-Visit Activities
Follow-up Phone Calls 26
Complete Forms 19
Call in Prescriptions 16
Miscellaneous 15

Total 63 65 128

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Processes

• Beginning to have all staff understand the processes and services is a key to developing a common
understanding and focus for improvement. Start with the high level process and use the Cycle Time tool.
You can assign someone to track all work requests for a week to get a sample, or the cycle time tool can
be initiated for all requests in a one week period with many people contributing to the collection and
completion of this worksheet.

• Typically, other processes will be uncovered to measure and you can create time tracking worksheets like
this template to measure other cycle times.

Cycle Time
Day: Date:

Work Request Arrived: Fax Electronic In Person Phone

Time

1. Time Request Arrived.

2.___________________

3.___________________

4.___________________

5. __________________

6. Total Time

Comments:

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Processes
• Review, adapt and distribute the Core and Supporting Processes evaluation form to ALL staff. Be sure the list

is accurate for your microsystem and then ask staff to evaluate the CURRENT state of these processes. Rate
each process by putting a tally mark under the heading which most closely matches your understanding of the
process. Also mark if the process is a source of customer complaints.
Tally the results to give the Lead Team an idea as to where to begin to focus improvement from the staff
perspective.

• Steps for Improvement: Explore improvements for each process based on the outcomes of this assessment
tool. Each of the processes below should be flowcharted in its’ current state. Once you have flowcharted the
current state of your processes and determined your Change Ideas, use the PDSA Cycle Worksheet to run
tests of change and to measure.

Microsystem Know Your Processes

Core and Supporting Processes

Processes Works
Well

Not a
Problem

Small
Problem

Somewhat
a Problem

Totally
Broken

Cannot
Rate

We’re
Working

On It

Source of
Patient/

Customer
Complaint

Answering Phones

Assigning Work Roles

Receiving requests

Processing requests

Delivering request
products/services

Scheduling Requests

Interacting with Clinical and
Supporting Microsystems

Email communication

Tracking performance
measures specific to cycle
time

Tracking errors in processing

Add specifics to supporting
microsystem:

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Processes
• Deming has said, “If you can’t draw a picture of your process you can’t improve anything.” He is referring to

the improvement tool of process mapping. With your interdisciplinary team, create a high level flow chart of
the appointment process or the entire treatment experience. Start with just ONE flow chart. Eventually you
will wish to create flowcharts for many different processes in-and-between your practice. Keep the symbols
simple!

• Review the flowchart to identify unnecessary rework, delays and opportunities to streamline and improve.

Microsystem High Level Flowchart

Request for products/Services

Symbol Key: Process beginning
or end
Activity step

Decision points

Waits and delays

Process flow direction

Connector (e.g. off page)

Assignment Processing Completion Delivered Evaluate
Processes

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Patterns
• Collect total data using this worksheet to see the patterns and volumes of prescriptions hourly and daily.
• Use one worksheet per shift.

Workload Tracking
AM PM Date:

TOTAL

7:00 – 8:00

8:00 – 9:00

9:00 – 10:00

10:00 – 11:00

11:00 – 12:00

12:00 – 1:00

1:00 – 2:00

2:00 – 3:00

3:00 – 4:00

4:00 – 5:00

5:00 – 6:00

6:00 – 7:00

TOTAL

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

19

Professionals
• What do you spend YOUR time doing? What is your best estimation of how much time you spend doing it? The goal is to have the right

person doing the right thing at the right time. The group can discuss which activities are or are not appropriate for the individual’s level of
education, training, and licensure.

• You can start with each subgroup of staff, assessing their activities using the Activity Survey. This estimate of who does what is intended to
reveal, at a high level, where there might be mismatches between education, training, licensure and actual activities. It is good to
eventually have all roles and functions complete this survey for review and consideration. Be sure to create the same categories for each
functional role. Some groups may hesitate to make time estimates; if this happens, just ask them to list their activities for the first review.

Pharmacy Practice Activity Survey Sheet Example

Position: Pharmacist % of Time Position: Pharmacy Tech % of Time
Activity: Intake

30%

Activity: Interact with Patient/Customers

15% Specific Items Involved: • Phone
• • Face to Face
• • Electronic mail
• Activity: Patient/Family or Customer Education

3% Activity: Unit Based Interdisiciplinary Rounds 9% Specific Items Involved:
Activity: Transcribe Orders 2% •
Activity: Follow up Phone Calls

10%

Activity: Intake

30%

Specific Items Involved: •
• Answer patient messages and requests
• Answer provider and customer messages Activity: Inventory

Activity: Advise/Support Staff

25%

Activity: Ordering supplies/medications
Specific Items Involved: •
• Activity: Follow-up Phone Calls

22% Activity: Attend Organization wide safety meetings Specific Items Involved:
Activity: Fill Prescriptions

5%

Activity: Documentation

Specific Items Involved: Activity: Review and Notify Patients/Customers of
order completion

5% • Specific Items Involved:
• • New
Activity: Write Prescriptions

5%
• Refills

Specific Items Involved: Activity: Transcribe

18% • Specific Items Involved:
Activity: Dispense Medications 5% •
Activity: Monitor

5%

Specific Items Involved: Activity: Dispense
5% •

Activity: Review Error Reporting 2% Activity: Monitor
Activity: Miscellaneous

2%
Activity: Miscellaneous

2% Specific Items Involved: Specific Items Involved:
• CME; attend seminars; attend meetings • CME; attend seminars; attend meetings

Total 100% Total 100%

Activity Occurrence Example:
What’s the next step? Insert the activities from the Activity Survey Here.
Activities are combined by role from the data collected above. This creates a master list of activities by role. Fill-in THE NUMBER OF TIMES PER
SESSION (AM and PM) THAT YOU PERFORM THE ACTIVITY. Make a mark by the activity each time it happens, per session. Use one sheet for
each day of the week. Once the frequency of activities is collected, the practice should review the volumes and variations by session, day of week,
and month of year. This evaluation increases knowledge of predictable variation and supports improved matching of resources based on demand.
Role: Pharmacist Date: Day of Week:
Activities AM PM Total
Intake 14
Family/Patient Education 11
Direct Patient Care and Advise 42

Follow-up Phone Calls 26
Complete Forms 19
Monitor 16
Miscellaneous 15

Total 63 65 128

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

20

Patterns
WORKFLOW-Spaghetti movement diagram

Observation of usual work flow within your supporting microsystem can often reveal many
opportunities for improvement due to the amount of waste identified in movement, materials, waiting,
rework, missing information and data, inefficiency and other wasteful activities.

Identify what process to be observed, outline the physical layout where the work process is
conducted, observe the staff performing the work and notice retracing of steps, extra work. Use of
multiple colored pencils allows the tracking of each staff member. Make note of time to complete the
task. Some individuals find wearing a pedometer is helpful in measuring physical steps taken in the
current state to then compare to redesigned processes.

Example: Before After

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

21

Patterns

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

22

• Patterns can be found through tracking the volumes and types of telephone calls. Review the categories on
the telephone tracking list to ensure they reflect the general categories of calls your pharmacy receives. Ask
clerical staff to track the telephone calls over the course of a week to find the patterns of each type of call and
the volume peaks and valleys.

• Put a tally mark each time one of the phone calls is for one of the listed categories. Total the calls for each day
and then total the calls in each category for the week. Note the changes in volume by the day of the week and
am/pm.

Pharmacy Telephone Tracking Log Example

Week of Monday Tuesday Wednesday Thursday Friday Saturday Sunday Week
Total

AM PM AM PM AM PM AM PM AM PM AM PM AM PM

Total
New

Prescription

Total
Prescription

Refill

Total
Prescription

Ready

Total
Pharmacist

Advice

Total
Message for

Staff

Total

Total

Total

Total

Total

DAY TOTAL

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

23

Metrics That Matter
• Measures are essential for microsystems to make and sustain improvements and to attain high performance.

All clinical microsystems are awash with data but relatively few have rich information environments that feature
daily, weekly and monthly use of Metrics That Matter (MTM). The key to doing this is to get started in a
practical, doable way; and to build out your Metrics That Matter and their vital use over time. Some guidelines
for your consideration are listed below. Remember these are just guidelines and your microsystem should do
what makes sense in the way of collecting, displaying and using Metrics That Matter.

Supporting Microsystem Metrics That Matter
1. What? Every microsystem has vital performance characteristics, things that must happen for successful

operations. Metrics That Matter (MTMs) should reflect your supporting Pharmacy microsystem’s vital performance
characteristics.

2. Why? The reason to identify, measure and track MTMs is to ensure that you are not “flying blind.”
Safe, high quality and efficient performance will give you specific, balanced and timely metrics that show:
a. When improvements are needed
b. If improvements are successful
c. If improvements are sustained over time, and
d. The amount of variation in results over time

3. How? Here are steps you can make to take advantage of MTMs.

Work with your Lead Team to establish the need for metrics and their routine use.
Quality begins with the intention to achieve measured excellence.

Build a balanced set of metrics to provide insight into what’s working and what’s not working. Some
categories to consider are: process flow, clinical, safety, patient perceptions, staff perceptions,
operations, and finance/costs. Avoid starting with too many measures.
Every metric should have an operational definition, data owner, target value and action plan.
Strongly consider using the “national” NQF*, JCAHO* and CMS* metrics whenever they are
relevant to your supporting microsystem. Consider other “vital” metrics based on your own
experience, strategic initiatives and other “gold standard” sets such as measures from NQF* and
professional organizations.

Start small and identify a data wall owner(s) who is guided by the Lead Team.
Identify a data owner(s) for each metric. The owner will be responsible for getting this measure
and reporting it to the Lead Team. Seek sources of data from organization wide systems.
If the needed data is not available, use manual methods to measure. Strive to build data collection
in the flow of daily work.

Build a data wall and use it daily, weekly, monthly, and annually.
Gather data for each metric and display it on the “data wall” reporting:

• Current value
• Target Value
• Action Plan to improve or sustain level

Display metrics as soon as possible–daily, weekly, monthly metrics are most useful–using visual
displays such as time trend charts and bar charts.

Review your set of metrics on a regular basis—daily, weekly, monthly, quarterly, annually.
Use metrics to make needed improvements whenever possible.
Make metrics fun, useful and a lively part of your microsystem development process. Discuss
Metrics That Matter frequently and take action on them as needed.

* JCAHO, Joint Commission on Accreditation of Healthcare Organizations
CMS, Centers for Medicare and Medicaid Services
NQF, National Quality Foundation

Lead
Team

Balanced
Metrics

Data
Owner

Data
Wall

Review
and Use

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

24

Metrics That Matter
• Review the currently determined “best metrics” your pharmacy should be monitoring.
• List your current performance in these metrics and what the targets are.

Pharmacy Metrics That Matter Example
Name of Measure Definition &

Data Owner
Current &

Target Values
Action Plan &

Process Owner
General Metrics
Access

Staff Morale
Staff Satisfaction ##
Voluntary Turn Over ##
Work days lost per employee per year #

Safety & Reliability
Identification of high risk patient
diagnosis & associated medications that
put patient at risk, (e.g. Coumadin,
Insulin) & related tests you must track.

Patient Satisfaction
Overall ##
Access ##

Customer Satisfaction

Finance

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

25

Metrics That Matter
Pharmacy Metrics That Matter

Name of Measure Definition &
Data Owner

Current &
Target Values

Action Plan &
Process Owner

Patient-Centered Outcome Measures *
Coronary Artery Disease (CAD)
Antiplatelet Therapy
Lipid Profile
Drug Therapy for Lowering LDL Chol.
LDL Cholesterol Level
Beta-Blocker Therapy-Prior MI
ACE Inhibitor Therapy
Blood Pressure
Heart Failure (HF)
Left Ventricular Function (LVF) Assess.
Left Ventricular Function (LVF) Testing
Patient Education
Beta-Blocker Therapy
ACE Inhibitor Therapy
Weight Measurement
Blood Pressure Screening
Warfarin Therapy for Pts with Atrial Fib
Diabetes Mellitus (DM)
HbA1c Management
Lipid Measurement
HbA1c Management Control
LDL Cholesterol Level
Blood Pressure Management
Urine Protein Testing
Eye Exam Foot Exam
Preventive Care (PC)
Influenza Vaccination
Pneumonia Vaccination
Blood Pressure Measurement
Lipid Measurement
LDL Cholesterol level
Colorectal Cancer Screening
Breast Cancer Screening
Tobacco Use
Tobacco Cessation
Hypertension (HTN)
Blood Pressure Screening
Blood Pressure Control
Plan of Care
* CMS (Center for Medicare and Medicaid Services)

American Medical Association (AMA) Physician Consortium for Performance Improvement
National Diabetes Quality Improvement Alliance (Alliance)
National Committee for Quality Assurance (NCQA)

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Step 3 Diagnose
With the Interdisciplinary Lead Team review the 5Ps assessment, Metrics That Matter, and with consideration of your
organizational strategic plan, select a first “theme,” (e.g., access, safety, flow, reliability, patient satisfaction, staff morale,
prevention, supply and demand) for improvement.

• The purpose of assessing is to make an informed and correct overall diagnosis of your supporting microsystem.
• First, identify and celebrate the strengths of your system.
• Second, identify and consider opportunities to improve your system.

o The opportunities to improve may come from your own microsystem—based on assessment, staff
suggestions and/or patient and family needs and complaints.

o The opportunities to improve may come from outside your microsystem—based on a strategic project or
external performance/quality measures.

o Look not only at the detail of each of the assessment tools, but also synthesize all of the assessments
and Metrics That Matter to “get the big picture” of the microsystem. Identify linkages within the data and
information. Consider:

 Waste and delays in the process steps. Look for processes that might be redesigned to result in
better functions for roles and better outcomes for patients.

 Patterns of variation in the microsystem. Be mindful of smoothing the variations or matching
resources with the variation in demand.

 Patterns of outcomes you wish to improve.
• It is usually smart to pick or focus on one important “theme” to improve at a time, and work with all the “players”

in your system to make a big improvement in the area selected.
• Suggestions on how to make your diagnosis and select a theme follow next.

Diagnose Your Pharmacy
Write your Theme for Improvement

Overall Theme “Global” Aim Statement
Create an aim statement that will help keep your focus clear and your work productive:

We aim to improve:
(Name the process)

In:
(Clinical location in which process is embedded)

The process begins with:
(Name where the process begins)

The process ends with:
(Name the ending point of the process)

By working on the process, we expect:
(List benefits)

It is important to work on this now because:

(List imperatives)

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

27

Step 4 Treat

Draft a clear aim statement and way to measure the aim using improvement models—PDSA (Plan-Do-Study-Act) and
SDSA (Standardize-Do-Study-Act).

• Now that you’ve made your diagnosis and selected a theme worthy of improving, you are ready to begin using
powerful Change Ideas, improvement tools, and the scientific method to change your microsystem.

• This begins with making a specific aim and using Plan-Do-Study-Act (PDSA), which is known as the “model for
improvement.”

• After you have run your tests of change and have reached your measured aim, the challenge is to maintain the
gains that you have made. This can be done using Standardize-Do-Study-Act (SDSA), which is the other half
of making improvement that has “staying power.”

• You will be smart to avoid totally reinventing the wheel by taking into consideration best known practices and
Change Ideas that other clinical teams have found to really work. A list of some of the best “Change Ideas” that
might be adapted and tested in your practice follows the aim statement worksheet.

Specific Aim Statement
Create a specific aim statement that will help keep your focus clear and your work productive.

We will  improve  increase  decrease

The  quality  number/amount of  percentage of:

(process)

By:
(percentage)

OR

From:
(baseline/state/number/amount/percentage)

To/By:
(describe the change in quality or state the number/amount/percentage)

By:
(date)

Example: We will increase the number of patients who receive Flu vaccinations from 24% to 100%
By May 1st.

\\

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

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Treat Your Pharmacy
• Once you have completed the assessment and diagnosis of your pharmacy and have a clear theme to focus

on, review current best practice and Change Ideas to consider.
• The Change Ideas will continue to develop as more field testing is done and more colleagues design

improvements.

Pharmacy Practice Change Ideas to Consider:
You will find additional support and tools at the websites listed below

Change Ideas to Improve Access to Care http://www.clinicalmicrosystem.org/access.htm
1. Shape Demand
2. Match Supply and Demand
3. Redesign the System

Change Ideas to Improve Interaction
4. Design group visits or Shared Medical Appointments http://www.clinicalmicrosystem.org/sma.htm
5. Utilize email care
6. Create a practice website
7. Optimize professional roles to subpopulation care management

Change Ideas to Improve Reliability
Change Ideas to Improve Vitality

8. Engage all staff in continuous improvement and research
9. Develop strategies to actively develop individual staff
10. Create a favorable financial status which supports investments in the practice
11. Utilize “daily huddle” process with Pharmacists, Pharmacy Techs and clerical staff to review yesterday, plan

for today, tomorrow and the coming week (pg28)

*visit www.ihi.org and www.clinicalmicrosystem.org for the latest ideas

Consider the Change Concepts on page 295 of The Improvement Guide by Langley, Nolan,
Nolan, Norman and Provost (1996). The main change categories are listed below.

A. Eliminate Waste
B. Improve Workflow
C. Optimize Inventory
D. Change the Work Environment
E. Enhance the Producer/Customer Relationship
F. Manage Time
G. Manage Variation
H. Design Systems to Avoid Mistakes

I. Focus on the Product or Service

Langley G, Nolan K, Nolan T, Norman T, Provost L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 1st
ed. The Jossey-Bass Business & Management Series. San Francisco, CA: Jossey-Bass Publishers; 1996: xxix, 370.

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

29

Huddle Sheet
• What can we proactively anticipate and plan for in our work day/week? At the beginning of the day, hold a review

of the day, review of the coming week and review of the next week. Frequency of daily review is dependent on the
situation, but a mid-day review is also helpful.

• This worksheet can be modified to add more detail to the content and purpose of the huddles.

Huddle Sheet
Practice: Date:

Aim: Enable the Supporting Microsystem to proactively anticipate and plan actions based on

patient/customer need and available resources, and contingency planning.

Follow-ups from Yesterday

“Heads up” for Today: (include special patient needs, sick calls, staff flexibility, contingency plans)
Meetings:

Review of Tomorrow and Proactive Planning
Meetings:

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

30

Treat Your Supporting Microsystem
Plan-Do-Study-Act PDSA
Complete the Plan-Do-Study-Act worksheet to execute the Change Idea in a disciplined measured manner, to reach
the specific aim.

Plan How shall we PLAN the pilot? Who? Does what? When? With what tools? What baseline data will be

collected?
Tasks to be completed to run test of change Who When Tools Needed Measures

Do What are we learning as we DO the pilot? What happened when we ran the test? Any problems
encountered? Any surprises?

Study As we study what happened, what have we learned? What do the measures show?

Act As we ACT to hold the gains or abandon our pilot efforts, what needs to be done? Will we modify the
change? Make a PLAN for the next cycle of change.

The Lead Team should continue to meet weekly to review progress in the design of the PDSA and then during the
execution of the test of change in a pilot format to observe and learn about the Change Idea implementation.
Remember to always test Change Ideas in small pilots to learn what adaptations and adjustments need to be made
before implementing on a larger scale. Data collection and review during the testing is important to answer the
question: How will we know if the Change Idea is an improvement?

Once the PDSA cycle is completed and the Lead Team reviews the data and qualitative findings, the plan should be
revised or expanded to run another cycle of testing until the aim is achieved.

When the Change Idea has been tested and adapted to the context of the clinical microsystem and the data
demonstrates that the Change Idea makes an improvement, the Lead Team should design the Standardize-Do-Study-
Act (SDSA) process to ensure the process is performed as designed. During this process it is important to continually
learn and improve by monitoring the steps and data to identify new opportunities for further improvement. You will
realize you will move from “PDSA” to “SDSA” and back to “PDSA” in your continuous improvement environment. New
methods, tools, technology or best practice will often signal the need to return to PDSA to achieve the next level of high
performance. You want to be able to go from “PDSA” to “SDSA” and back to “PDSA” as needed. The Scientific
method is a two-way street that uses both experimentation (i.e., PDSA) as well as standardization (i.e., SDSA).

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

31

Standardizing Current Best Process and Holding the Gains
Standardize-Do-Study-Act SDSA
Standardize the process (specify what roles do what activities in what sequence with what information flow). A good
way to track and standardize process is through the creation of a Pharmacy Practice Playbook. The Playbook is the
collection of process maps to provide care and services that all staff are aware of and accountable for. The Playbook
can be used to orient new staff, document current processes and contribute to performance appraisals.
Do the work to integrate the standard process into daily work routines to ensure reliability and repeatability.
Study at regular intervals. Consider if the process is being “adhered” to and what “adjustments” are being made.
Review the process when new innovations, technology or roles are being considered. Review what the measures of
the process are showing.
Act based on the above, maintain or “tweak” the standard process and continue doing this until the next “wave” of
improvements/innovations takes place with a new series of PDSA cycles.
STANDARDIZE How shall we STANDARDIZE the process and embed it into daily practice? Who? Does

what? When? With what tools? What needs to be “unlearned” to allow this new habit?
What data will inform us if this is being standardized daily?

Tasks to be completed to run test of change Who When Tools Needed Measures

*Playbook-Create standard process map to be inserted in your Playbook.

DO What are we learning as we DO the standardization? Any problems encountered? Any surprises? Any
new insights to lead to another PDSA cycle?

STUDY As we STUDY the standardization, what have we learned? What do the measures show? Are
there identified needs for change or new information or “tested” best practice to adapt?

ACT As we ACT to hold the gains or modify the standardization efforts, what needs to be done? Will we
modify the standardization? What is the Change Idea? Who will oversee the new PDSA? Design a
new PDSA cycle. Make a PLAN for the next cycle of change. Go to PDSA Worksheet.

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

32

Step 5 Follow-Up
• Monitor the new patterns of results and select new themes for improvement.
• Embed new habits into daily work: daily huddles, weekly Lead Team meetings, monthly “town hall” meetings,

datawalls, and storyboards.

Follow-Up

Improvement in health care is a continuous journey.

The new patterns need to be monitored to ensure the improvements are sustained. Embedding new habits into daily
work with the use of “huddles” to review and remind staff, as well as weekly Lead Team meetings keeps everyone
focused on improvements and results that can lead to sustained and continuous improvements.

Datawalls, storyboards and monthly all-staff meetings are methods to embed new habits and thinking for improvement.

The Lead Team should repeat the process for newly recognized themes and improvements that are identified in the
assessment and Metrics That Matter.

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

33

Assessing Your Practice Discoveries and Actions
Know Your

Patients Discoveries Actions Taken

1. Age Distribution 1. 30% of our patients > 65 years old
1. Designated special group visits to review specific

needs of this age group including physical
limitations, dietary considerations.

2. Disease Identification 2. We do not know what percent our patients have diabetes. 2. Staff reviewed coding/ billing data to determine
approximate numbers of patients with diabetes.

3. Health Outcomes
3. We do not know what the range of HgA1C is for out patients

with diabetes of if they are receiving appropriate ADA
recommended care in a timely fashion.

3. Staff conducted a chart audit with 50 charts during
a lunch hour. Using a toll designed to track
outcomes; each member of the staff reviewed 5
charts and noted their findings on the audit tool.

4. Most Frequent
Diagnosis

4. We learned we had a large number of patients with stable
hypertension and diabetes, seeing the physician frequently.
We also learned that during certain season we had huge
volumes of acute diseases such as URI, Pharyngitis and
poison ivy.

4. Designed and tested a new model of care delivery
for stable hypertension and diabetes optimizing the
RN role in the practice using agreed upon
guidelines, protocols and tools.

5. Patient Satisfaction 5. We don’t know what patients think unless they complain to us.
5. Implemented the “point of service” patient survey

that patients completed and left in a box before
leaving the practice.

Know Your
Professionals Discoveries Actions Taken

1. Provider FTE

1. We were making assumptions about provider time in the clinic
without really understanding how much time providers are
OUT of the Clinic with hospital rounds, nursing home rounds,
etc.

1. Changed our scheduling processes, utilized RNs to
provide care for certain subpopulations.

2. Schedules
2. Several providers are gone at the same time every week, so

one provider is often left and the entire staff works overtime
that day.

2. Evaluated the scheduling template to even out
each provider’s time to provide consistent coverage
of the clinic.

3. Regular Meetings 3. The doctors meet together every other week. The secretaries
meet once a month.

3. Entire practice meeting every other week on
Wednesdays.

4. Hours of Operation
4. The beginning and the end of the day are always chaotic. We

realized we are on the route for patients between home and
work and want to be seen when we are not open.

4. Opened one hour earlier and stayed open one
house later each day. The heavy demand was
managed better and overtime dropped.

5. Activity Surveys

5. All roles are not being used to their maximum. RNs only room
patients and take vital signs, medical assistants doing a great
deal of secretarial paperwork and some secretaries are giving
out medical advice.

5. Roles have been redesigned and matched to
individual education, training and licensure.

Know Your
Processes Discoveries Actions Taken

1. Cycle Time 1. Patient lengths of visits vary a great deal. There are many
delays.

1. The staff identified actions to eliminate, steps to
combine, and learned to prepare the charts for the
patient visit before the patient arrives. The staff also
holds daily “huddles” to inform everyone on the
plan of the day and any issues to consider
throughout the day.

2. Key Supporting
Processes

2. None of us could agree on how things get done in out
practice.

2. Detailed flow charting of our practice to determine
how to streamline and do in a consistent manner.

3. Indirect Patient Pulls
3. The providers are interrupted in their patient care process

frequently. The number one reason is to retrieve missing
equipment and supplies from the exam room.

3. The staff agreed on standardization of exam rooms
and minimum inventory lists that were posted inside
the cabinet doors. A process was also determined
on WHO and HOW the exam rooms would be
stocked regularly and through the use of an
assignment sheet, a person was identified and held
accountable.

Know Your
Patterns Discoveries Actions Taken

1. Demand on the
Practice

1. There are peaks and lows of the practice depending on day of
the week, session of the day or season of the year.

1. Resources and role are matched to demand
volumes. Schedules are created which match
resources to variation.

2. Communication 2. We do not communicate in a timely way, nor do we have a
standard form to communicate.

2. Every other week practice meeting to help
communication and e-mail use of all staff to
promote timely communication.

3. Cultural 3. The doctors don’t really spend time with non-doctors. 3. The staff meetings heightened awareness of
behaviors has helped improve this.

4. Outcomes 4. We really have not paid attention to our practice outcomes. 4. Began tracking and posting on a data wall to keep
us alter to outcomes.

5. Finances 5. Only the doctors and the practice managers know about the
practice money.

5. Finances are discussed at the staff meetings and
everyone is learning how we make a difference in
our financial performance.

© 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement
Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005, October 2012.

34

Assessing Your Practice Discoveries and Actions
Common High Yield

Wastes Recommended Method to Reduce Waste Traps to Avoid

1. Exam rooms not
stocked or standardized
– missing supplies or
equipment

– Create Standard Inventory supplies for all exam rooms.
– Design process for regular stocking of exam rooms with accountable

person
– Standardize and utilize all exam rooms

– Don’t assume rooms are being stocked
regularly – track and measure.

– Providers will only use “their own” rooms
– Providers cannot agree on standard

supplies; suggest “testing”
2. Too many appointment

types which create
chaos in scheduling

– Reduce appointment types to 2-4
– Utilize standard building block to create flexibility in schedule.

– Frozen schedules of certain types
– Use one time (e.g. 10-15 minute “building

blocks”)

3. Poor communication
amongst the providers
and support staff about
clinical sessions and
patient needs.

– Conduct daily morning “huddles” to provide a forum to review the
schedule, anticipate needs of patients, plan supplies/ information
needed for a highly productive interaction between patient and
provider.

– People not showing up for scheduled
huddles. Gain support of providers who are
interested, test ideas and measure results

– Huddles last longer than 15 minutes, use a
work sheet to guide huddle

– Don’t sit down

4. Missing information or
chart for patient visit.

– Review patient charts BEFORE the patient arrives – recommended
the day before to ensure information and test results are available to
support the patient.

– Avoid doing chart review when patient is
present

– If you have computerized test results, don’t
print the results

5. Confusing messaging
system

– Standardize messaging processes for all providers
– Educate/ train messaging content
– Utilize a process with prioritizing methods such as a “bin” system in

each provider office.

– Providers want their “own” way – adding to
confusion to support staff and decreases
ability for cross coverage

– Content of message can’t be agreed upon –
test something

6. High prescription
renewal request via
phone.

– Anticipate patient needs
– Create “reminder” systems in office, e.g. posters, screensavers
– Standardize information that

– Doesn’t need to be the RN – Medical
assistants can obtain this information

7. Staff frustrated in roles
and unable to see new
ways to function.

– Review current roles and functions using activity survey sheets
– Match talent, education, training, licensure to function
– Optimize every role
– Eliminate functions

– Be sure to focus on talent, training and
scope of practice not individual people.

8. Appointment schedules
have limited same day
appointment slots.

– Evaluate follow-up appointments and return visit necessity.
– Extend intervals of standard follow-up visits
– Consider RN visits
– Evaluate the use of protocols and guidelines to provide advice for

homecare- www.icsi.org
– Consider phone care

– Don’t set a certain number of same day
appointments without matching variations
throughout the year.

9. Missed disease-
specific/ preventive
interventions and
tracking.

– Utilize the flow sheets to track preventative activities and disease-
specific interventions.

– Utilize “stickers” on charts to alert staff to preventative/ disease
specific needs

– Review charts before patient visits
– Create registries to track subpopulation needs.

– Be alert to creating a system for multiple
diseases and not have many stickers and
many registries.

10. Poor communication
and interactions
between members.

– Hold weekly staff meetings to review practice outcomes, staff
concerns, improvement opportunities.

– Education and Development

– Hold weekly meetings on a regular day,
time and place

– Do not cancel – make the meeting a new
habit

11. High no-show rate – Consider improving same day access
– Reminder systems

– Automated reminder telephone calls are not
always well received by patients

12. Patient expectations of
visit not met, resulting
in phone calls and
repeat visits.

– CARE vital sign sheet- www.howsyourhealth.org
– Evaluating patient at time of visit if their needs were met

– Use reminders to question patient about
needs being met

– New habits not easily made.

© 2003, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement

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