334

ORGANISATIONAL MATTERS

Using a Malcolm Baldrige framework to understand high-

performing clinical microsystems
Tina C Foster, Julie K Johnson, Eugene C Nelson, Paul B Batalden
...................................................................................................................................

Qual Saf Health Care 2007;16:334–341. doi: 10.1136/qshc.2006.020685

Background, objectives and method: The Malcolm Baldrige National Quality Award (MBNQA) provides a
set of criteria for organisational quality assessment and improvement that has been used by thousands of
business, healthcare and educational organisations for more than a decade. The criteria can be used as a tool
for self-evaluation, and are widely recognised as a robust framework for design and evaluation of healthcare
systems. The clinical microsystem, as an organisational construct, is a systems approach for providing clinical
care based on theories from organisational development, leadership and improvement. This study compared
the MBNQA criteria for healthcare and the success factors of high-performing clinical microsystems to (1)
determine whether microsystem success characteristics cover the same range of issues addressed by the
Baldrige criteria and (2) examine whether this comparison might better inform our understanding of either
See end of article for framework.
authors’ affiliations
........................ Results and conclusions: Both Baldrige criteria and microsystem success characteristics cover a wide range of
areas crucial to high performance. Those particularly called out by this analysis are organisational
Correspondence to: leadership, work systems and service processes from a Baldrige standpoint, and leadership, performance
Dr Julie K Johnson,
University of Chicago, results, process improvement, and information and information technology from the microsystem success
Chicago, Illinois 60637, characteristics view. Although in many cases the relationship between Baldrige criteria and microsystem
USA; jjohnso2@medicine. success characteristics are obvious, in others the analysis points to ways in which the Baldrige criteria might
bsd.uchicago.edu
be better understood and worked with by a microsystem through the design of work systems and a deep
Accepted 30 April 2007 understanding of processes. Several tools are available for those who wish to engage in self-assessment
........................ based on MBNQA criteria and microsystem characteristics.

T
he Malcolm Baldrige National Quality Award provides a set challenge of using a system-based approach to improve the
of criteria for organisational quality assessment and quality and safety of care provided to their patient populations.
improvement and has been used by thousands of business,
healthcare and educational organisations for more than a OVERVIEW OF THE MALCOLM BALDRIGE NATIONAL
decade. The criteria can be used as a tool for self-evaluation, QUALITY AWARD
and are widely recognised as a robust framework for design and The Malcolm Baldrige National Quality Improvement Act,
evaluation of healthcare systems. As described by Batalden, signed into US law in August 1987, led to the creation of the
Nelson and colleagues, a clinical microsystem can be defined as Malcolm Baldrige National Quality Award in 1988. The purpose
‘‘the small, functional front-line unit that provides health of this competitive award programme is to improve quality and
care.’’1 2 In 2005, the Malcolm Baldrige Award took a specific productivity in the USA by establishing guidelines and criteria
interest in the clinical microsystem concepts, as they could that can be used by organisations to evaluate their own quality
operationalise the Baldrige criteria and bring them into improvement efforts.3 The Baldrige Award is given by the US
mainstream efforts to improve the performance of large and President to businesses (manufacturing as well as service) and
small healthcare organisations. Towards this end, a focus on to education and healthcare organisations that apply and are
clinical microsystem thinking was included in the case study judged to be outstanding in seven areas: (1) leadership,
written for the 2006 annual examiner training. Following (2) strategic planning, (3) customer and market focus,
examiner training, the case study was made available to the (4) measurement, analysis and knowledge management,
public as a resource that is illustrative of an award application (5) human resource focus, (6) process management and
(available online at http://baldrige.nist.gov/Arroyo.htm). (7) results.4
The purpose of this paper is to explore the insights that can The Baldrige Award is designed and managed by the
be gained from considering the Malcolm Baldrige criteria for National Institute of Standards and Technology (NIST), a
healthcare in the context of high-performing clinical micro- non-regulatory agency of the Commerce Department’s
systems. Specifically, we discuss whether the microsystem Technology Administration. NIST develops and promotes
success characteristics, identified in prior research,1 cover the measurements, standards and technology to enhance produc-
same range of issues addressed by the Baldrige criteria; tivity, facilitate trade and improve the quality of life. NIST was
examine whether this comparison might better inform our selected by the US Congress to design and manage the award
understanding of either framework; and investigate what we programme because of its role in helping American organisa-
might learn about high-performing microsystems by looking at tions compete, its world-renowned expertise in quality control
them through ‘‘Baldrige lenses’’. Finally, we discuss the tools and assurance, and its reputation as an impartial third party.
that are available for those wishing to engage in self- The American Society for Quality assists NIST with the
assessment based on the Baldrige Award criteria and micro- application review process, preparation of award documents,
system characteristics. These are summarised and presented as publicity and information transfer.4 Awards were made to
recommendations for organisations ready to accept the business applicants beginning in 1989. Criteria for healthcare

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Understanding high-performing clinical microsystems 335

and education were available beginning in 1999 and the first healthcare criteria, which are built on the following set of
healthcare award was made in 2002. By the conclusion of the inter-related core values and concepts:
2005 application cycle, a total of 116 healthcare organisations
had submitted applications and five healthcare organisations N Visionary leadership
had received the prestigious award, recognising their commit- N Patient-focused excellence
ment to the values and concepts espoused by the programme.5
The Baldrige criteria have been successfully used by the Veterans
N Organisational and personal learning

Health Administration as a framework for the its Kizer Quality N Valuing staff and partners
Achievement Recognition Grant. Similarly, 37 states in the USA N Agility
offer quality awards based on Baldrige criteria.5 N Focus on the future
Table 1 summarises the Malcolm Baldrige Criteria for N Managing for innovation
Performance Excellence and the specific items for healthcare
that are based on those criteria. Similar to the criteria designed
N Management by fact
specifically for business and education, the healthcare criteria N Social responsibility and community health
reflect some of the unique issues facing healthcare organisa- N Focus on results and creating value
tions. Figure 1 illustrates the relationship of the seven N Systems perspective

Table 1 Malcolm Baldrige performance excellence criteria and specific items for healthcare4
Criteria Definition Specific items for healthcare*

Leadership Examines how senior executives guide the 1.1 Organisational How do senior leaders guide your organisation, including how they
organisation and how the organisation deals leadership review organisational performance?
with its responsibilities to the public and 1.2 Public responsibility How does your organisation address its responsibilities to the public,
practises good citizenship and citizenship practise good citizenship, and contribute to the health of its
community?
Strategic Examines how the organisation sets strategic 2.1 Strategy How does your organisation establish its strategic objectives, including
planning directions and how it determines key action development enhancing its performance relative to other organisations providing
plans similar healthcare services and its overall performance as a healthcare
provider?
2.2 Strategy How does your organisation convert its strategic objectives into action
deployment plans? Summarise your organisation’s action plans and related key
performance measures/indicators. Project your organisation’s future
performance on these key performance measures/indicators
Customer and Examines how the organisation determines 3.1 Patient/customer How does your organisation determine requirements, expectations,
market focus requirements and expectations of customers and healthcare market and preferences of patients, other customers, and markets to ensure the
and markets; builds relationships with customers; knowledge continuing relevance of your healthcare services and to develop new
and acquires, satisfies and retains customers healthcare service opportunities?
3.2 Patient/customer How does your organisation build relationships to acquire, satisfy, and
relationships and retain patients/customers and to develop new healthcare service
satisfaction opportunities? How does your organisation determine patient/
customer satisfaction?
Measurement, Examines the management, effective use, analysis, 4.1 Measurement and How does your organisation provide effective performance
analysis and and improvement of data and information to analysis of management systems for measuring, analysing, aligning and
knowledge support key organisation processes and the organisational improving performance as a healthcare provider at all levels and in all
management organisation’s performance management system performance parts of your organisation?
4.2 Information How does your organisation ensure the quality and availability of
management needed data and information for staff, suppliers/partners, and
patients/customers?
Human resource Examines how the organisation enables its 5.1 Work systems How do your organisation’s work and jobs, compensation, career
focus workforce to develop its full potential and how progression, and related workforce practices motivate and enable all
the workforce is aligned with the organisation’s staff and the organisation to achieve high performance?
objectives 5.2 Staff education, How does your organisation’s education and training support the
training and achievement of your overall objectives, including building staff
development knowledge, skills, and capabilities and contributing to high
performance?
5.3 Staff wellbeing How does your organisation maintain a work environment and staff
and satisfaction support climate that contribute to the wellbeing, satisfaction and
motivation of all staff?
Process Examines aspects of how key production/ 6.1 Healthcare service How does your organisation manage key processes for healthcare
management delivery and support processes are designed, processes service design and delivery?
managed and improved 6.2 Business processes How does your organisation manage its key processes that lead to
business growth and success?
6.3 Support processes How does your organisation manage its key processes that support
your daily operations and your staff in delivering healthcare services?
Business results Examines the organisation’s performance and
improvement in its key business areas: customer
satisfaction; financial and marketplace
performance; human resources, supplier and
partner performance; operational performance;
and governance and social responsibility. The
category also examines how the organisation
performs relative to competitors

*These were the specific items for healthcare at the time of the analysis. Please visit http://baldrige.nist.gov/ for current healthcare items.

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336 Foster, Johnson, Nelson, et al

STUDY OF HIGH-PERFORMING MICROSYSTEMS

In the late 1990s, Mohr and Donaldson conducted a national
study of high-performing clinical microsystems. They identified
43 clinical units by using a theoretical sampling methodology.
Semistructured interviews were conducted with leaders from
each of the microsystems.15 16 Additional research, described
below, built on the Mohr and Donaldson study and conducted
20 case studies of high performing microsystems. This study
included on-site interviews with representative members of the
microsystems and analysis of individual microsystem perfor-
mance data.1 17–24
In the 2000–2002 study, funded by the Robert Wood Johnson
Foundation, Nelson et al sought to identify success character-
istics present in microsystems that provide high-quality, cost-
efficient care. Using site visits, detailed interviews, direct
observations, and reviews of medical records and financial
information, a common set of 10 success characteristics was
identified.1 17–21 These characteristics have been described in
detail and are summarised in table 2. As we considered these
high-performing microsystems and the success characteristics,
we felt it would be important to compare them to the Baldrige
Figure 1 Inter-relatedness of the Baldrige criteria for healthcare criteria, which is a widely recognised and established frame-
organisations. work.

Methods
OVERVIEW OF THE CLINICAL MICROSYSTEM We created a database of fully transcribed interviews with
CONCEPT members of 20 high-performing microsystems. This consisted
The conceptual underpinnings of our clinical microsystem work of 223 documents linked to qualitative data analysis software,
are based on ideas developed by Deming, Senge, Wheatley and ATLAS.ti (version 4.1 for Windows). Two researchers coded the
others, who have applied systems thinking to organisational database using success characteristics, as described in detail
development, leadership and improvement.6–8 The seminal idea elsewhere.1
for the clinical microsystem stems from the work of James Of the 20 high-performing microsystems in the Robert Wood
Brian Quinn.9 Quinn’s work is based on analysing the world’s Johnson Foundation database, we selected 10 for additional
best-of-best service organisations, such as FedEx, Mary Kay analysis using the Baldrige framework. These 10 were felt to be
Cosmetics, McDonald’s, Scandinavian Airlines and Nordstroms. the best performers in terms of quality and cost, based on
He focused on determining what these extraordinary organisa- reviews of the information gathered at site visits and on overall
tions were doing to achieve high quality, explosive growth, high impressions of the team leaders. The transcripts from these 10
margins and wonderful reputations with customers. He found sites (a total of 110 documents) were then coded by two
that they organised around, and continually engineered, the researchers using the Baldrige criteria in effect at that time
frontline relationships that connected the needs of customers (table 1).
with the organisation’s core competency. Quinn called this Note that the transcribed interviews do not constitute a
frontline activity that embedded the service delivery process the Baldrige assessment. While some questions posed by the
‘‘smallest replicable unit’’ or the ‘‘minimum replicable unit’’. interviewers were similar to those asked by Baldrige, many
This smallest replicable unit, what we call the microsystem, is areas were not explicitly addressed in the conversations. Sites
the key to implementing effective strategy, information did not undertake the extensive self-assessment that Baldrige
technology and other key aspects of intelligent enterprise. requires, and data to support results were not formally
A healthcare clinical microsystem can be defined as the presented in the interviews. However, we felt that given the
combination of a small group of people who work together in a wide-ranging nature of the interviews and the focus on high
defined setting on a regular basis—or as needed—to provide performance, many areas covered in Baldrige would probably
care and the individuals who receive that care (who can also be also be addressed during the site visits. The coders thus
recognised as part of a discrete subpopulation of patients). As a reviewed the transcripts for ‘‘answers’’ to the Baldrige ‘‘ques-
functioning unit, it has clinical and business aims, linked tions’’ in categories 1–6. In effect, researchers coded the
processes, a shared information and technology environment and transcripts based on which, if any, Baldrige criteria (‘‘codes’’)
produces services and care which can be measured as were invoked by each individual statement. Category 7 (results)
performance outcomes. These systems evolve over time and are was not coded, as actual results data were not presented in the
(often) embedded in larger systems/organisations. transcript. Only material pertaining to the microsystem itself
As any living complex adaptive system, the microsystem was coded with the Baldrige codes; comments about the larger
must: (1) do the work, (2) meet member needs and (3) organisation, or its relation to the microsystem, were coded as
maintain itself as a functioning clinical unit. As we continue to ‘‘macro’’.
move beyond conceptual theory and research to application in For all of the documents in the Baldrige sample, one
clinical settings, the emerging fields of chaos theory, complexity researcher coded the even numbered documents and the other
science, complex adaptive systems and lean production have coded odd numbered documents. Together, the researchers
influenced how these concepts have been applied to improving read interviews from all 10 sites, for a total of 110 documents.
microsystems.10–13 This is evident in the work to bring together Forty-three of these documents were detailed verbatim notes
microsystems from around the world to learn and share best taken in the field; the remaining 67 were direct transcriptions
practices (updates on these efforts are available at http:// of recorded interviews. A total of 3404 text quotations were
clinicalmicrosystem.org14). selected for coding, with the Baldrige ‘‘codes’’ applied 4043

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Understanding high-performing clinical microsystems 337

Table 2 Microsystem characteristics identified by Nelson et al in the 2000–2002 study

Characteristic Definition

Leadership The role of leaders is to balance setting and reaching collective goals, and to empower
individual autonomy and accountability, through building knowledge, respectful action,
reviewing and reflecting
Organisational support The larger organisation looks for ways to support the work of the microsystem and
coordinate the hand-offs between microsystems
Staff focus There is selective hiring of the right kind of people. The orientation process is designed to
fully integrate new staff into culture and work roles. Expectations of staff are high regarding
performance, continuing education, professional growth and networking
Education and training All clinical microsystems have responsibility for the ongoing education and training of staff
and for aligning daily work roles with training competencies. Academic clinical
microsystems have the additional responsibility of training students
Interdependence The interaction of staff is characterised by trust, collaboration, willingness to help each
other, appreciation of complementary roles, respect and recognition that all contribute
individually to a shared purpose
Patient focus The primary concern is to meet all patient needs—caring, listening, educating and
responding to special requests, innovating to meet patient needs, and smooth service flow
Community and market The microsystem is a resource for the community; the community is a resource to the
focus microsystem; the microsystem establishes excellent and innovative relationships with the
community
Performance results Performance focuses on patient outcomes, avoidable costs, streamlining delivery, using
data feedback, promoting positive competition, and frank discussions about performance
Process improvement An atmosphere for learning and redesign is supported by the continuous monitoring of
care, use of benchmarking, frequent tests of change, and a staff that has been empowered
to innovate
Information and Information is the connector—staff to patients, staff to staff, needs with actions to meet
information technology needs. Technology facilitates effective communication and multiple formal and informal
channels are used to keep everyone informed all the time, listen to everyone’s ideas and
ensure that everyone is connected on important topics

times, as some statements were responsive to more than one of Results

the Baldrige codes. A grand total of 4359 codes were applied All 14 possible Baldrige codes (one for each of the healthcare
when the ‘‘macro’’ code is included. specific items in categories 1–6 shown in table 1) were used; co-
To ensure that researchers were coding the interviews in a occurrences with all of the success characteristics were identified.
similar fashion, we checked 10% of the documents for This suggests that the two different frameworks cover similar
reliability, based on a consultation with Research Talk, Inc. conceptual territory, and supports the idea that the microsystem
(Bohemia, NY, USA), a consulting company specialising in success characteristics that emerged from the original analysis are
qualitative analysis. This meant that both researchers coded comprehensive. One area specifically addressed by the success
10% of the documents. These documents were selected at characteristics is organisational support, which allows investiga-
regular intervals throughout the coding process. The other 90% tion of the relationship between the microsystem and the larger
of the documents were coded by one or the other researcher organisations that encompasses it, which we refer to as the
alone. mesosystem and the macrosystem which ‘‘surround’’ the micro-
system. This relationship is not necessarily called out by the
Analysis Baldrige system, which is designed more to look at an entire
In addition to analysis of the Baldrige coding, we also merged organisation than at the discrete and complementary subsystems
the Baldrige-coded database with the success characteristics- that come together to form the whole enterprise. In our coding,
coded database. Multiple methods of analysis were used, this issue regarding the relationship of the microsystem to the
including discussion among researchers about their thoughts larger organisation, was captured using the ‘‘macro’’ code (short
and experiences coding, and discussion about the definitions of for macrosystem or the larger organisation in which the
the Baldrige and success characteristics codes. The ATLAS.ti microsystem was embedded), which occurred frequently (316
query and supercode tools were used to examine co-occurrences times). Both positive and negative comments about the larger
of the success characteristics and Baldrige codes. organisation were coded as ‘‘macro’’.
For comparison of the success characteristics and Baldrige Analysis of which success characteristics co-occur with the
codes, co-occurrences were tabulated. For example, to compare Baldrige codes and which Baldrige codes co-occur with the
the Baldrige criterion 1.1 (organisational leadership) with the success characteristics is informative. Table 3 presents the most
success characteristics, all instances that had been coded as 1.1 common co-occurrences for each of the 14 criteria. Looking
were identified, and the database queried regarding which from the standpoint of the microsystem success characteristics,
success characteristics occurred in those same segments of text. leadership, staff focus, patient focus, performance results,
The reverse comparison was also performed, taking a given process improvement, and information and information tech-
success characteristic and seeing which Baldrige criteria had nology have the greatest number of co-occurrences. In many
been coded for the same material. This highlighted areas of cases, the relationships seem quite obvious: 1.1 (organisational
correspondence and difference between the success character- leadership) with leadership, 5.3 (staff wellbeing and satisfac-
istics and Baldrige codes. The overall distribution of the tion) with staff focus, and so on. In other cases, examination of
Baldrige codes was also tabulated. the success characteristics co-occurrences indicates ways in

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338 Foster, Johnson, Nelson, et al

Table 3 Co-occurrences (%) of Baldrige and success characteristics*

Microsystem success characteristics

Information
Community and
Organisational Staff Education and Patient and market Performance Process information
Baldrige criteria Leadership support focus training Interdependence focus focus results improvement technology

Organisational 51/22 –/10 30/13 –/9 –/10 –/5 –/11 30/11

leadership (1.1)
Public 48/7 25/– 22/–
responsibility and
citizenship (1.2)
Strategy 32/– 22/– 21/– 50/–
development (2.1)
Strategy 28/– 31/– 26/– 29/– 49/–
deployment (2.2)
Patient/customer 47/– 39/– 25/–
and healthcare
market knowledge
(3.1)
Patient/customer 58/12 27/– 19/– 18/–
relationships and
satisfaction (3.2)
Measurement and 68/18 35/– 26/–
analysis of –/7
organisational
performance (4.1)
Information 37/12 29/– 64/26
management (4.2)
Work systems 21/15 –/8 41/23 –/19 30/27 20/13 –/10 23/13 25/17
(5.1)
Staff education, 24/8 34/– 54/31 26/–
training and
development (5.2)
Staff wellbeing 23/– 68/12 23/– 25/–
and satisfaction
(5.3)
Healthcare service –/9 –/8 32/15 23/11 35/15 25/14
processes (6.1)
Business process 19/– –/6 54/15 23/–
(6.2)
Support process 23/– 23/– 36/– 38/–
(6.3)

*In each pair of numbers, the first represents the percentage of times that text coded for a given Baldrige item was also coded for a particular success characteristic. For
example, text coded as referring to Baldrige item 1.1 (organisational leadership) was also coded as referring to the success characteristic of leadership 51% of the time.
The second number represents the reverse comparison: 22% of text coded for leadership was also coded for Baldrige item 1.1.

which the Baldrige criteria might be better understood and are with 1.1 (organisational leadership), 5.1 (work systems)
worked with by a microsystem. For example, 5.1 (work and 6.1 (healthcare service processes); 5.1 (work systems) was
systems) had a number of success characteristics that also the most commonly coded Baldrige item, followed by 6.1
frequently co-occurred. Although the most common was staff (healthcare service processes) and 1.1 (organisational leader-
focus, the presence of interdependence, information and ship). This suggests that the design of work systems and a deep
information technology, process improvement, leadership and understanding of processes are major contributors to success.
patient focus suggests that all these aspects of the microsystem Indeed, the high degree of process awareness often drives the
must be considered when designing the work that takes place design of the work, and the coders’ experience was that the two
there. Similarly, 6.1 (healthcare service processes) has as its were often intertwined in the transcripts. Category 2 (strategy)
major co-occurrences process improvement, patient focus, was coded infrequently, but this may not reflect a lack of
information and information technology, and performance strategic thinking in microsystems. Often, discussions about
results; the close links between process improvement, analysis strategy invoked the larger organisation, and these were
of performance, use of information and maintaining a clear deliberately not coded using the Baldrige criteria. We observed
focus on patients are shown. that many comments regarding strategy development and
When all the Baldrige codes are considered, note that process deployment currently reside in the ‘‘macro’’ code used to
improvement was among the most frequent co-occurrences demarcate material relating to the larger organisation. In
with 12 of the 14; performance results co-occured with 9 of the addition, there were relatively few questions specifically about
14. This confirms the importance of process literacy and strategy that were posed during the course of the interviews. 3.1
measurement in these high-performing microsystems. (Patient/customer and healthcare market knowledge) was also
Reading across the rows, the greatest number of co-occurrences not commonly coded. This also probably relates to the questions

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 Table 4 Clinical Microsystem Assessment Tool
Characteristic and definition Descriptions

Leadership 1. Leadership: the role of leaders is to balance setting and Leaders often tell me how to do my Leaders struggle to find the right Leaders maintain constancy of purpose, Can’t rate
reaching collective goals, and to empower individual autonomy job and leave little room for balance between reaching establish clear goals and expectations,
and accountability, through building knowledge, respectful innovation and autonomy. Overall, performance goals and supporting and foster a respectful positive culture.
action, reviewing and reflecting they don’t foster a positive culture and empowering the staff Leaders take time to build knowledge,
review and reflect, and take action about
microsystems and the larger organisation
2. Organisational support: The larger organisation looks for The larger organisation isn’t The larger organisation is inconsistent The larger organisation provides Can’t rate
ways to support the work of the microsystem and coordinate the supportive in a way that provides and unpredictable in providing the recognition, information and resources
hand-offs between microsystems recognition, information and recognition, information and resources that enhance my work and makes it easier
resources to enhance my work needed to enhance my work for me to meet the needs of patients
Staff 3. Staff focus: there is selective hiring of the right kind of people. I am not made to feel like a valued I feel like I am a valued member of I am a valued member of the microsystem Can’t rate
The orientation process is designed to fully integrate new staff into member of the microsystem. My the microsystem, but I don’t think the and what I say matters. This is evident
culture and work roles. Expectations of staff are high regarding orientation was incomplete. My microsystem is doing all that it could through staffing, education and training,
performance, continuing education, professional growth and continuing education and professional to support education and training of workload and professional growth
networking growth needs are not being met staff, workload and professional
growth
4. Education and training: all clinical microsystems have Training is accomplished in We recognise that our training could There is a team approach to training, Can’t rate
Understanding high-performing clinical microsystems

responsibility for the ongoing education and training of staff and disciplinary silos—eg, nurses train be different to reflect the needs of whether we are training staff, nurses or
for aligning daily work roles with training competencies. Academic nurses, physicians train residents, our microsystem, but we haven’t students. Education and patient care are
clinical microsystems have the additional responsibility of training etc. The educational efforts are not made many changes yet. Some integrated into the flow of work in a way
students. aligned with the flow of patient care, continuing education is available to that benefits both from the available
so that education becomes an everyone resources. Continuing education for all
‘‘add-on’’ to what we do staff is recognised as vital to our
continued success.
5. Interdependence: interaction of staff is characterised by trust, I work independently and I am The care approach is interdisciplinary, Care is provided by a interdisciplinary Can’t rate
collaboration, willingness to help each other, appreciation of responsible for my own part of the but we are not always able to work team characterised by trust, collaboration,
complementary roles, respect and recognition that all contribute work. There is a lack of collaboration together as an effective team appreciation of complementary roles,
individually to a shared purpose and a lack of appreciation for the and a recognition that all contribute
importance of complementary roles individually to a shared purpose
Patients 6. Patient focus: the primary concern is to meet all patient Most of us, including our patients, We are actively working to provide We are effective in learning about and Can’t rate
needs—caring, listening, educating, and responding to special would agree that we do not always patient-centred care and we are meeting patient needs—caring, listening,
requests, innovating to meet patient needs, and smooth service provide patient-centred care. We are making progress toward more educating, responding to special requests
flow. not always clear about what patients effectively and consistently learning and smooth service flow
want and need. about and meeting patient needs
7. Community and market focus: the microsystem is a resource We focus on the patients who come to We have tried a few outreach We are doing everything we can to Can’t rate
for the community; the community is a resource to the our unit. We haven’t implemented any programmes and have had some understand our community. We actively
microsystem; the microsystem establishes excellent and innovative outreach programmes in our success, but it is not the norm for us employ resources to help us work with the
relationships with the community community. Patients and their families to go out into the community or community. We add to the community and
often make their own connections to actively connect patients to the we draw on resources from the community
the community resources they need community resources that are to meet patient needs
available to them
Performance 8. Performance results: performance focuses on patient outcomes, We don’t routinely collect data on the We often collect data on the Outcomes (clinical, satisfaction, financial, Can’t rate
avoidable costs, streamlining delivery, using data feedback, process or outcomes of the care we outcomes of the care we provide technical, safety) are routinely measured,
promoting positive competition and frank discussions about provide. and on some processes of care we feed data back to staff and we make
performance changes based on data
9. Process improvement: an atmosphere for learning and redesign The resources required (in the form of Some resources are available to There are ample resources to support Can’t rate
is supported by the continuous monitoring of care, use of training, financial support, and time) support improvement work, but we continual improvement work. Studying,
benchmarking, frequent tests of change, and staff who have are rarely available to support don’t use them as often as we could. measuring and improving care in a
been empowered to innovate improvement work. Any improvement Change ideas are implemented scientific way are essential parts of our
activities we do are in addition to our without much discipline. daily work.
daily work.
339

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340 Foster, Johnson, Nelson, et al

asked during the interviews, rather than reflecting a lack of

Instructions: Each of the ‘‘success’’ characteristics (e.g., leadership) is followed by a series of three descriptions. For each characteristic, please check the description that best describes your current microsystem and the care it delivers OR
customer knowledge in these microsystems.

Can’t rate

Can’t rate

Can’t rate
DISCUSSION
Patients have a variety of ways to get the Our use of the Baldrige criteria to code transcripts from 10
high-performing microsystems was informative on several
learning styles. We routinely ask patients

between information and patient care by

The information I need to do my work is
for feedback about how to improve the

Technology facilitates a smooth linkage

levels. First, the Baldrige system is robust; this is supported

providing timely, effective access to a

information they need and it can be

designed to support the work of the

customised to meet their individual

information environment has been

by the fact that, even in conversations not specifically designed

rich information environment. The

to address the criteria, all were invoked. The frequency with
which certain criteria (work systems, healthcare service
information we give them

available when I need it processes, and organisational leadership) were coded under-
scores the importance of these areas in the work of the
microsystem. The design of work and a deep understanding of
process are crucial to outstanding performance, as is leadership.

clinical unit
The co-occurrences of the success characteristics and Baldrige
codes can provide insights for microsystems seeking to improve
their performance (or to understand their current level of
performance). For example, an organisation seeking to better
patients. We’ve started to think about

understand work systems (5.1) in the Baldrige system might

how to improve the information they

to use and seems to be cumbersome

are given to better meet their needs.

I have access to technology that will

enhance my work, but it is not easy
essential information is missing and
information I need, but sometimes
information that is available to all

find it helpful to know that while the most common co-

Patients have access to standard

occurrence with the success characteristics was with staff focus,

Most of the time I have the

there were also frequent co-occurrences with interdependence,

I have to track it down.

information and information technology, process improvement,

and time consuming

leadership and patient focus. This helps to clarify aspects of the

microsystem that must be addressed when designing its work.
For measurement and analysis of organisational performance
(4.1), performance results was the most frequent co-occurrence
as one might expect, but process improvement and information
and information technology were also frequently coded,
suggesting the importance of technology in measurement and
Patients have access to some standard

The technology I need to facilitate and

available to me or it is available but

analysis, as well as the need to understand processes to

information I need to do my work
information that is available to all

currently have does not make my

measure and analyse performance effectively. Interestingly,

not effective. The technology we
I am always tracking down the

enhance my work is either not

certain Baldrige codes frequently co-occurred with almost all of

the success characteristics. That 5.1 (work systems) is among
the most frequent co-occurrences for 9 of the 10 categories
highlights that collaborative work models and an under-
standing of what motivates staff are important in all domains.
Descriptions

An understanding of how work is designed, effective leadership

job easier
patients

and a focus on processes are vital to optimal performance;

improvement in any domain must be informed by work in
these areas.
Our study had several limitations. This analysis involved only
providers and staff

10 high-performing microsystems. The selection criteria were in

A. Integration of

C. Integration of
information with

information with

information with
B. Integration of

part subjective, and although attempts were made to represent

a variety of domains of high performance, others domains
technology

(such as community service) might have been relatively under-

patients

represented. Qualitative research is inherently subjective;

indeed, the coders’ immersion in the data and personal
understanding is a cornerstone of the process. The Baldrige
everyone is connected on important topics.

the use of technology in the microsystem,

assess your microsystem on the following
connector—staff to patients, staff to staff,

Given the complexity of information and

information with patients, (b) integration

coding was completed by two team members who frequently

communication and multiple formal and

everyone informed all the time, listen to

of information with providers and staff,

and (c) integration of information with
three characteristics: (a) integration of

discussed their approaches and experiences, and a formal

informal channels are used to keep

everyone’s ideas, and ensure that

needs with actions to meet needs.

process to assess reproducibility was used, but even so there

10. Information and information

use a microsystem you are MOST familiar with.

Technology facilitates effective
technology: information is the

might have been underlying systematic differences in the way

Characteristic and definition

they coded, or even understood, the Baldrige criteria. As noted

earlier, these transcripts in no way approximate a Baldrige self-
evaluation. Many areas that might be explored were not
addressed by the questions asked of respondents during the
interviews. Similarly, the category which in Baldrige carries the
technology.

greatest number of ‘‘points’’ (results) was not coded. Although

Table 4 Continued

the sites had provided information on clinical outcomes, quality

and financial performance, this was considered only in
choosing the 10 sites for the Baldrige analysis. Thus, our
Information

Information
Technology

findings are limited because, unlike a completed Baldrige

evaluation, we have no ‘‘hard evidence’’ of performance.
Although results were not the focus of this analysis, note that
and

they were assumed to reflect the high performance that led to

the initial selection.

www.qshc.com
Understanding high-performing clinical microsystems 341

RECOMMENDATIONS: TOOLS AND RESOURCES FOR wanted to ensure that the microsystem success characteristics
APPLYING BALDRIGE CRITERIA AND MICROSYSTEM that were identified based on our field research, were consistent
CONCEPTS with a well-recognised ‘‘gold standard’’ method (the Baldrige
Several tools and techniques are available for microsystems that criteria) for assessing the success of an organisation.
wish to engage in self-assessment based on the Baldrige Award Microsystems that operate within the context of a larger
criteria and microsystem characteristics. First, the Microsystem organisation face many challenges. In the ideal world,
Assessment Tool (MAT) can be used for a microsystem’s self- organisational alignment would be clear and consistent at all
assessment.25 26 The success characteristics emerged from our levels; the transcripts reveal that even these outstanding
analysis of the coded transcripts; they reflect what people performers do not live in such a world. While Baldrige
working in high-performing microsystems say about their work assessment can make those gaps clear, organisational leader-
and how they do it. Consequently, they provide the framework ship must be committed to closing them. In the case of the
for a microsystem-specific analysis of performance, and have microsystem, organisational leadership may not be accessible or
been the basis of the MAT (shown in table 4) which is designed to amenable to the changes required to achieve alignment. Thus, a
help microsystems understand how they can improve their different tool may be needed, which recognises the context and
performance. The MAT addresses the nature of the interaction suggests ways that the microsystem can work to improve
between the microsystem and the parent organisation, which is relations with the parent organisation. The success character-
not specifically called out by Baldrige. MAT is designed to be used istics explicitly consider this aspect of microsystem functioning.
quickly and easily by microsystem members to evaluate their own
.......................
frontline unit. Although it clearly does not have the depth of a
comprehensive Baldrige assessment, it offers considerable insight Authors’ affiliations
Tina C Foster, Eugene C Nelson, Paul B Batalden, Dartmouth Hitchcock
into the functioning of a microsystem. Understanding how the Medical Center, Lebanon, New Hampshire, USA
success characteristics and the Baldrige criteria relate to each Julie K Johnson, University of Chicago, Chicago, Illinois, USA
other can help in doing Baldrige self-assessment and in under-
Competing interests: None declared.
standing challenges to high performance. The success character-
istics, including principles and specific processes, could be helpful
to a microsystem working to better understand the Baldrige
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