Quality By Design

Eugene C. Nelson, D.Sc., M.P.H., is director of quality administration for the Dartmouth-Hitchcock Medical Center and professor of community and family medicine at Dartmouth Medical School. Paul B. Batalden, M.D. is the director of health care improvement leadership development, Center for the Evaluative Clinical Sciences, and professor of pediatrics and of community and family medicine at Dartmouth Medical School.Marjorie M. Godfrey, M.S., R.N., is instructor for community and family medicine at and director of the Clinical Microsystem Resource Group at Dartmouth Medical School .

• Tables, Figures, and Exhibits xiiiForeword xixDonald M. BerwickPreface xxiiiAcknowledgments xxviiIntroduction xxxiThe Editors xxxixThe Contributors xliiiPart One: Cases And Principles 11 Success Characteristics of High-Performing Microsystems: Learning from the Best 3Eugene C. Nelson, Paul B. Batalden, Thomas P. Huber, Julie K. Johnson, Marjorie M. Godfrey, Linda A. Headrick, John H. WassonTrue Structure of the System, Embedded Systems, and Need to Transform Frontline SystemsThe Bladyka CaseResearch DesignResultsPractical ImplicationsConclusion2 Developing High-Performing Microsystems 34Eugene C. Nelson, Paul B. Batalden, William H. Edwards, Marjorie M. Godfrey, Julie K. JohnsonCase Study: A Decade of Progress for an Intensive Care NurseryA Model of Development and a Curriculum to Catalyze Microsystem GrowthConclusion3 Leading Microsystems 51Paul B. Batalden, Eugene C. Nelson, Julie K. Johnson, Marjorie M. Godfrey, Thomas P. Huber, Linda Kosnik, Kerri AshlingLeader, Leadership, LeadingRecap of MethodsThree Fundamental Processes of Leading: What Clinical Microsystem Team Members Observe and ReportDiscussionConclusion4 Leading Macrosystems and Mesosystems for Microsystem Peak Performance 69Paul B. Batalden, Eugene C. Nelson, Paul B. Gardent, Marjorie M. GodfreyCase Study: A True Story, with Names Changed to Protect the InnocentLeadership Frameworks: Some of the Best ApproachesLeading Large Health Systems to Peak Performance Using Microsystem ThinkingConclusion5 Developing Professionals and Improving Worklife 106Thomas P. Huber, Marjorie M. Godfrey, Eugene C. Nelson, Julie K. Johnson, Christine Campbell, Paul B. BataldenCase Study: Staff Development at Massachusetts General Hospital Downtown AssociatesConclusion6 Planning Patient-Centered Services 124Marjorie M. Godfrey, Eugene C. Nelson, John H. Wasson, Julie K. Johnson, Paul B. BataldenPlanning Patient-Centered Services and the 5 P’sCase Study: Planning Services for Subpopulations of Patients to Best Provide Care for Individual PatientsA Developmental Journey: Beginning to Assess, Understand, and Improve a Clinical MicrosystemAnalysis and Improvement of ProcessesA Huddle in Plastic SurgeryConclusion7 Planning Patient-Centered Care 148John H. Wasson, Marjorie M. Godfrey, Eugene C. Nelson, Julie K. Johnson, Paul B. BataldenPlanning Care Well: Exemplary Clinical MicrosystemsPlanning Care in Any MicrosystemA Low-Tech Example for Ambulatory Services: CARE Vital SignsConclusion8 Improving Patient Safety 165Julie K. Johnson, Paul Barach, Joseph P. Cravero, George T. Blike, Marjorie M. Godfrey, Paul B. Batalden, Eugene C. NelsonMicrosystem Patient Safety ScenarioCase Study: Dartmouth-Hitchcock PainFree ProgramConclusion9 Creating a Rich Information Environment 178Eugene C. Nelson, Paul B. Batalden, Karen Homa, Marjorie M. Godfrey, Christine Campbell, Linda A. Headrick, Thomas P. Huber, Julie K. Johnson, John H. WassonCase Study 1: Specialty Care: Dartmouth-Hitchcock Spine CenterCase Study 2: Overlook Hospital Emergency DepartmentCase Study 3: Intermountain Health Care Shock Trauma Intensive Care UnitTips and Principles to Foster a Rich Information EnvironmentDiscussionConclusionPart Two: Activating the Organization And the Dartmouth Microsystem Improvement Curriculum 19710 Overview of path forward And Introduction to part two 199Recap of Part One and Overview of Part TwoUsing Real Case Studies and Practical Applications of Microsystem Thinking, Methods, and ToolsWorking at All Levels of a Health SystemFocusing on the Microsystem LevelReview QuestionsPrework11 Introduction to Microsystem Thinking 230What Is a System in Health Care?How Did Clinical Microsystem Knowledge Evolve?What Is a Clinical Microsystem?Where Do Clinical Microsystems Fit in the Health Care Delivery System?What Does a Clinical Microsystem Look Like?Why Focus on the Clinical Microsystem?How Do Clinical Microsystems Link to Crossing the Quality Chasm?What Were the Findings of the Dartmouth Clinical Microsystem Research?What Does a Microsystem’s Developmental Journey Look Like?ConclusionCase StudiesReview QuestionsBetween Sessions Work12 Effective Meeting Skills I 243What Is a Productive and Effective Meeting?Why Use Meeting Skills and Roles?What Are Effective Meeting Roles?What Are the Phases of an Effective Meeting?What Processes Are Evident in an Effective Meeting?What Is the Seven-Step Meeting Process?What Does a Meeting Agenda Template Look Like?What Are the Ground Rules for Meetings?What Are Some Tips for Getting Started with Productive Meetings?How Do You Keep a Rhythm of Improvement?Case StudiesReview QuestionsBetween Sessions Work13 Assessing Your Microsystem with the 5 P’s 258How Does an Interdisciplinary Lead Improvement Team Begin to Assess and Improve a Clinical Microsystem?What Does the 5 P’s Framework Look Like?What Resources Are Available to Guide the 5 P’s Assessment?What Is a Helpful Way to Introduce Your Team to the Assessment Process?What Are the 5 P’s?What Should You Do with the Assessment Findings?Case StudiesReview QuestionsBetween Sessions Work14 The Model for Improvement: PDSA ↔ SDSA 271What Is the Model for Improvement?Why Use the Model for Improvement?How Does the Model Fit into the Improvement Process?What Is the PDSA Part of the Model?What Are the Benefits of Using PDSA?What Is Involved in Each of the Four Steps of Plan, Do, Study, and Act?What Is the SDSA Cycle?What Is Involved in Each of the Four Steps of Standardize, Do, Study, and Act?What Tools Can Assist Your PDSA Cycle ↔ SDSA Implementation?What Are Some Tips for Using the PDSA ↔ SDSA Method?Case StudiesReview QuestionsBetween Sessions Work15 Selecting Themes for Improvement 284What Is a Theme for Improvement?Why Use a Theme?What Are the Theme Selection Considerations?What Process Can You Use to Generate Theme Ideas and Select a First Theme?What Are the Next Steps?Case StudiesReview QuestionsBetween Sessions Work16 Improvement Global Aim 291What Is a Global Aim?Why Use a Global Aim?How Do You Write a Global Aim?What Are the Next Steps?Case StudiesReview QuestionsBetween Sessions Work17 Process Mapping 296What Is Process Mapping?Why Use Process Mapping?What Are the Commonly Used Flowchart Symbols?What Does a High-Level Flowchart Look Like?What Does a Detailed Flowchart Look Like?What Are Some Tips for Creating a Flowchart?What Does a Deployment Flowchart Look Like?What Are Some Tips for Creating a Deployment Flowchart?Case StudiesReview QuestionsBetween Sessions Work18 Specific Aim 308What Is a Specific Aim?Why Use a Specific Aim?Where Do Specific Aims Come From?Where Does the Specific Aim Fit in the Overall Improvement Process?How Do You Write a Specific Aim?What Are the Next Steps?Case StudiesReview QuestionsBetween Sessions Work19 Cause and Effect Diagrams 313What Is a Cause and Effect Diagram?Why Use a Fishbone Diagram?What Is the Structure of a Fishbone Diagram?What Does a Completed Fishbone Look Like?What Are Some Tips for Creating a Fishbone Diagram?Case StudiesReview QuestionsBetween Sessions Work20 Effective Meeting Skills II: Brainstorming and Multi-Voting 321What Is Brainstorming?What Are the Benefits of Brainstorming?What Are Some Different Types of Brainstorming?What Are Some Tips for Conducting Brainstorming?What Is Multi-Voting?Do Teams Always Multi-Vote After a Brainstorming Session?How Do You Multi-Vote?What Does a Brainstorming Session with a Multi-Voting Outcome Look Like?Case StudiesReview QuestionsBetween Sessions Work21 Change Concepts 331What Is a Change Concept?Why Use Change Concepts?How Can You Use Change Concepts in a Process?What Are the Next Steps?Case StudiesReview QuestionsBetween Sessions Work22 Measurement and Monitoring 339What Are Measures, What Makes Measures Good, and How Do They Relate to Aims?What Is a Run Chart?What Are the Benefits of Using a Run Chart?How Do Run Charts Fit in the Overall Improvement Process?What Do Run Charts Tell You About Your Performance Level and Variation?What Are Special Cause and Common Cause Variation?How Do You Make a Run Chart?How Do You Interpret Run Chart Results?What Is a Control Chart?What Is the Theory Behind Control Charts?What Are the Benefits of Using a Control Chart Instead of a Run Chart?What Are the Different Kinds of Control Charts?What Is an XmR Control Chart?How Do You Interpret Control Chart Results?When Do You Recalculate Control Chart Values?What Are Some Tips for Using Run Charts and Control Charts?Case StudiesReview QuestionsBetween Sessions Work23 Action Plans and Gantt Charts 362What Is an Action Plan?What Is a Gantt Chart?Why Use Action Plans and Gantt Charts?How Do You Write an Action Plan?How Do You Create a Gantt Chart?What Are the Next Steps?Case StudiesReview QuestionsBetween Sessions Work24 Follow Through on Improvement: Storyboards, Data Walls, and Playbooks 369What Is the Importance of Follow Through?What Can You Do to Follow Through?What Are the Fundamentals of Improvement?What Is a Data Wall?What Is a Playbook?How Is the Playbook Used?How Do You Create a Playbook?How Do You Maintain Your Playbook?What Is a Storyboard?How Do You Make a Storyboard?DiscussionCase StudiesReview QuestionsBetween Sessions Work25 Conclusion: Continuing on the Path to Excellence 380Looking BackLooking Forward and an Invitation: Make It Personal and Make It HappenAppendix A: Primary Care Workbook 385Name Index 433Subject Index 437