A clinical microsystem is a group of clinicians and staff working together with a shared clinical purpose to provide care for a population of patients.^1–3 The clinical purpose and its setting defines the essential components of the microsystem. These include the clinicians and support staff, information and technology, the specific care processes, and the behaviours that are required to provide care to its patients. Microsystems evolve over time, responding to the needs of their patients, providers, and external pressures. They coexist with other microsystems within a larger (macro) organisation. Examples of clinical microsystems include a cardiovascular surgical care team, a community based outpatient care centre, or a neonatal intensive care unit. Each example has in common core elements: a focused type of care, clinicians and staff with the skills and training needed to engage in the required care processes, a defined patient population, and a certain level of information and technology to support their work. The core elements are consistent across these examples. What often differs across microsystems is the ability of individual caregivers to recognise their efforts as part of a microsystem as well as the microsystem’s level of functioning.

The purpose of this paper is to provide an overview of the clinical microsystem and the relationship between the macrosystem and microsystem, to address how the microsystem concepts can enhance the quality and safety of care on the frontlines, and to discuss how to facilitate learning and collaboration across microsystems.

OVERVIEW OF CLINICAL MICROSYSTEMS

The conceptual theory of the clinical microsystem is based on ideas developed by Deming, Senge, Wheatley, and others who applied systems thinking to organisational development, leadership, and improvement.^4–6 The seminal idea for the clinical microsystem stems from the work of Quinn, based on analysing the world’s best of best service organisations, such as FedEx, Mary Kay Cosmetics, McDonald’s, and Nordstrom.⁷ He focused on determining what these extraordinary organisations were doing to achieve high quality, explosive growth, high margins, and excellent customer reputation. He found that these leading service organisations organised around, and continually engineered, the frontline relationships that connected the needs of customers to the organisation’s core competency. Quinn called this frontline activity that embedded the service delivery process the smallest replicable unit or the minimum replicable unit. The smallest replicable unit, or the microsystem, is the key to implementing effective strategy, information technology, and other key aspects of intelligent enterprise.

In the late 1990s, Mohr and Donaldson investigated high performing clinical microsystems.^2,8 Their research was based on a national search for the highest quality microsystems in health care. Forty three clinical units were identified using theoretical sampling and their leaders were interviewed using a semi-structured interview protocol. The results of the interviews were analysed to determine the characteristics that seemed most responsible for enabling these microsystems to be effective. The results suggested that eight dimensions were associated with high quality of care (see box 1). Further research on clinical microsystems provided more indepth case studies of 20 high performing microsystems and included on site interviews with every member of these microsystems and an analysis of the individual microsystem’s performance data.^9–17 A microsystem assessment tool, based on these eight dimensions, was developed to translate this research into practice, by giving clinicians and staff a way to gauge the level of functioning of their microsystem and then to help identify areas for improvement.¹⁸

Systems, in general, often bring up images of well oiled machines. In actuality, much of what we know and have experienced in health care does not match this description. Healthcare systems are cumbersome, unwieldy, unfriendly, and opaque to the users and the patients. Healthcare systems are better described as complex adaptive systems. As such, they are a collection of individual healthcare professionals who are free to act in ways that are not totally predictable; the organisational boundaries are fuzzy, in that membership changes and providers can simultaneously be members of other systems. Furthermore, given the complexity of these systems, the actions of individuals are interconnected so that the actions of one provider changes the context for all of the other providers.^19,20

As we continue to move beyond conceptual theory and research to clinical applications, the emerging fields of chaos theory, complexity science, and complex adaptive systems have influenced how we have applied these concepts to improving microsystems.^19–22 This is evident in the work to bring together microsystems from around the world to learn and share best practices (see http://clinicalmicrosystem.org).

Microsystem v macrosystem

Healthcare organisations are composed of multiple, differentiated, autonomous microsystems. Several assumptions are made about the relationship between the microsystem and the macrosystem⁹:

• Bigger systems (macrosystems) are made of smaller systems

• These smaller systems (microsystems) produce quality, safety, and cost outcomes at the frontline of care

• Ultimately the outcomes of the macrosystems can be no better than the microsystems on which they are formed

• The loyalty of most microsystem providers is first and foremost to their patients and to the microsystem and rarely to the larger macrosystem.

This requires interventions within all microsystems in the organisation if the organisation as a whole wants to improve. However, this doesn’t mean that the microsystem functions independently from the other microsystems it regularly works with, or its macrosystem—indeed the microsystems within the macro-organisation are interconnected. The role of leadership is to set the general tone of the organisation, to facilitate the interconnections between the microsystems, and to cultivate learning disciplines in the organisation. Finally, senior leaders can pay careful attention to the questions they ask to hold the microsystems accountable for their performance to provide safer care (see box 2). They must realise the unintended consequences of mandating new rules and regulations but not respecting the ecology of the microsystem.²³

Improving safety within the clinical microsystem

Patient safety has been defined as freedom from accidental injury.²⁴ Accidental injury can be due to error that includes the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.^24,25 Various organisations have accepted the call to action to make patient safety a priority. For example, in the United States the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has developed programme specific patient safety goals.²⁶ As we go indepth in one specific area, the recently released 2005 JCAHO goals for hospitals include improving the accuracy of patient identification, the effectiveness of communication among caregivers, the safety of using medications and infusion pumps, and reducing the risk of healthcare associated infections.²⁶ How can an organisation respond to the need to meet patient safety goals?

We believe that the first step is the realisation that safety is a property of the clinical microsystem that can be achieved only through a systematic application of a broad array of process, equipment, organisation, supervision, training, and teamwork changes. The clinical microsystem—as a unit of research, analysis, and practice—is an important level at which to focus patient safety interventions. It is at this systems level that most patients and caregivers meet, and it is at this level that real changes in the patient care usually given can (and must) be made. Errors occur within the microsystem and ultimately it is the functioning microsystem that can stop, prevent, or mitigate errors from causing patient harm. Many methods are available to explore the causal system at work^27–31 including probability analysis²⁹ and near miss analysis.³² These all suggest the importance of analysing the entire causal system, not just seeking a root cause.

Table 1 builds on the research of high performing microsystems and provides specific actions that can be further explored. This list provides an organising framework to apply safety concepts to the microsystem.

PROMOTING SYSTEM RESILIENCE ACROSS AND BETWEEN THE MICROSYSTEMS

Microsystems usually coexist with multiple other microsystems within the organisation. Patients are aware of the gaps and hand offs between microsystems as they navigate the healthcare system, for example as they transfer from inpatient care back into the community. These cross-microsystem relationships will be essential to improving hand offs but also to providing opportunities for learning about systemic problems within the institution and interventions to improve quality and safety. We might learn something useful about how to facilitate the interaction of different microsystems by examining the factors that lead to success in other types of collaborative relationships, such as community health partnerships.

An effective collaborative relationship is based on the underlying assumption that collaboration is a more effective approach to achieve a goal than multiple individual efforts. Weick suggests that leaders today need to develop groups that are respectful of the interactions that hold the group together.^33,34 Resilient groups have respectful interactions that are founded on three major elements³⁵:

• Trust—a willingness to base beliefs and actions on the reports of others

• Honesty—reporting so that others may use your observations in developing and enhancing their own beliefs

• Self-respect—integrating one’s perceptions and beliefs with the reports of others without depreciating them or yourself.

Kaluzny³⁶ discusses the conditions that must be present for relationships across organisations to develop. For voluntary interactions—which may be quite different than those mandated by an external power—several conditions must be met. There must be an internal need for resources, a commitment to an external problem, and the opportunity to change. In addition, there must be a consensus on the external problem(s) facing the organisations as well as a consensus on the specific goals and services for developing a joint effort. The 1999 Institute of Medicine report To err is human, for example, brought patient safety to the forefront of the agenda as well as set the stage for discussing specific goals and strategies for achieving those goals.³⁷

Mitchell and Shortell provide a synthesis of the literature on success of community health partnerships to suggest factors that influence the success of interorganisational relations (box 3).

The Center for the Advancement of Collaborative Strategies in Health (CACSH) at The New York Academy of Medicine focused on strengthening the ability of partnerships to assess and achieve the unique advantage of collaboration—what they term partnership synergy. CACSH conducted a study to create and operationalise a framework for assessing partnership synergy and for identifying its likely determinants (box 4).³⁸

According to CACSH, effective leadership facilitates productive interactions among partners by bridging diverse cultures, performing boundary spanning functions, and revealing as well as challenging assumptions that limit thinking and action.

Partnership efficiency refers to making good use of partners’ time, in-kind resources, and financial resources. The effectiveness of a partnership’s administration and management also has an impact on partnership synergy, although this effect was not statistically significant. Administration and management activities, such as coordination of communication among partners and partnership activities, and the preparation of materials that inform partners, are the glue that makes it possible for multiple independent people and organisations to work together. Analysis results indicate that the sufficiency of non-financial resources influences, although non-significantly, partnership synergy. Non-financial resources such as skills and expertise, information, and connectivity to target populations play a unique role; synergy is largely built from these resources, and it is only by combining them in novel ways that partners can potentially create something that enables them to accomplish more than they could on their own.

CONCLUSIONS

The microsystem concepts have evolved from systems theory and primary research on characteristics of high performing clinical units. Specific interventions can be made to embed quality and safety into the microsystem. Although we offer several suggestions related to each of the microsystem characteristics, this list should only serve as a guiding framework to adapt to individual microsystems. Leaders should set the stage for making safety a priority for the organisation, but they should allow individual microsystems to create innovative strategies for improvement. Successful examples of improving safety and quality in microsystems will help to harvest the experiences in cross microsystem colloboratives. Healthcare organisations are not monolithic, but composed of smaller microsystems, so interventions need to be expressed at the microsystem level. This requires attention to detail in redesign of health care. Fostering collaborative relationships among microsystems should be an important goal of organisations. Microsystems can help to organise and design resilience into the communications, work processes, and clinical environments of complex healthcare organisations.