Clinical microsystems are the essential building blocks of larger organizations and of the health system. They are the place where patients, families, and care teams meet. Clinical microsystems do the real, hands-on, value-added work within an organization. They are the living units and always have a patient (person with a health need) at their center. Examples of clinical microsystems are the patient appointment seeking process, out-patients clinic processes, out-patient aClinical microsystems are the essential building blocks of larger organizations and of the health system (Figure 1).3 They are the place where patients, families, and care teams meet. Clinical microsystems do the real, hands-on, value-added work within an organization. They are the living units and always have a patient (person with a health need) at their center. Examples of clinical microsystems are the patient appointment seeking process, out-patients clinic processes, out-patient admission process, ER registration process, ER triage process, ER CPR process, ER observation room process, ER admission process, ER to other hospital referral process, ICU processes, lab processes, operation room processes, pharmacy processes, multi-disciplinary approach to patient processes, patient discharge process, primary health care processes, referral process from primary healthcare to secondary and tertiary healthcare centers and homecare processes.dmission process, ER registration process, ER triage process, ER CPR process, ER observation room process, ER admission process, ER to other hospital referral process, ICU processes, lab processes, operation room processes, pharmacy processes, multi-disciplinary approach to patient processes, patient discharge process, primary health care processes, referral process from primary healthcare to secondary and tertiary healthcare centers and homecare processes.
Mesosystem is a healthcare delivery system composed of various microsystems which are well-connected together to provide care that is seamless, timely, efficient as well as effective in terms of patient outcomes. A mesosystem more importantly ensures continuity of care starting from the community (including promotive and preventive measures) to the primary health care centre to secondary and tertiary healthcare centers, emergency care and homecare needs of the patients.
Macrosystem is a healthcare management organization such as a hospital, a group of healthcare providers (cluster), healthcare administration, corporate agency, company, or a public sector organization such as ministry. The macrosystem governs the overall system and monitors & ensures that the care is being provided as planned.
In designing the microsystems and mesosystems we must pay attention to:
Purpose: What is the objective of re-arranging the microsystem or creating the care pathway (mesosystem). The foremost objective should be to cut short the wastes (Muda or Lean management), control the inconsistent process (Mura) and deal with an over-burdened process (Muri). In addition address the six domains of quality of care which are; safe care, patient centered, timely, efficient, effective and equitable care. We could additionally aim to target the eight dimensions of patient centered care.
Patients: What is the definition of our patient population for whom we want to improve the microsystem or create a new mesosystem.
Professionals: Who are the professionals associated with the microsystem or mesosystem. What is the competency level of the professionals involved.
Processes: What is the current microsystem or mesosystem and what should be the future state. For this one needs to visit the Gemba. Gemba is a Japanese term meaning “the real place.” Talk to the frontline staff (the concept of ‘it’s your ship,’ and ‘pride of workman is in his creation,’ and perform the value stream mapping. The objective of Gemba Walk is to understand the value stream and its problems rather than review results or make superficial comments. The gemba walk, is an activity that takes management to the front lines to look for waste and opportunities to practice gemba kaizen. After value stream mapping enhance the steps what the patient values and minimize or eliminate the steps which the patient does not value. Value added steps are the ones for which the patient is willing to pay and these are the steps that enhance patient satisfaction.
Patterns: What patterns (KPI’s: key performance indicators) do we need to design and monitor in order to know as to how well the newly designed microsystem or mesosystem is performing. They should cover aspects of inputs (such as; number of critical care nurses, number of ICU beds, number of cardiac surgeons, number of ambulances) activities (such as; waiting time for category 2 patients in ER, lead time in a one-stop clinic, cycle time of blood gases in lab, turn around time of lab test order by physician in ER to result on screen), outputs(such as; volume of category 1 patients in ER, number of cardiac revascularization procedures performed, CAT scans done in ER) and outcomes (such as; % patient survival after MERS Co-V, % complications after laparoscopic cholecystectomy, % patient satisfaction, % workforce satisfaction).
The whole idea is about transforming the way we perceive healthcare, viewing the process of care through the eyes of the internal customers (the process owners) and external customers (the patients), addressing the patients unmet needs, enhancing the value added steps and eliminating or minimizing non-value added steps from the microsystems and mesosystems. We should be the catalyst for change and be on a continuous guard to sustain the change.