Organisational risk specialist, Humber Mental Health Teaching NHS Trust
Gray, M. (2007) Using clinical microsystems and mesosystems in mental health. www.nursingtimes.net
VOL: 103, ISSUE: 31, PAGE NO: 30-31
Mike Gray, MBA, RMN, DipHSM, LSMS
This article discusses the service improvement work undertaken by Mike Gray and Mike Gill, Modernisation Team, Humber Mental Health Teaching NHS Trust, June 2006.
We argue that clinical microsystems have proven to be an effective method for working with frontline teams in mental health. We believe the mesosystem acts as a vital mediator between clinical microsystems and the strategic imperatives of the wider NHS. This relationship can be positive or negative. We argue that an understanding of both can be obtained by working through a clinical microsystems approach at both levels. This can lead to greater harmony and more effective working.
We argue that clinical microsystems can be applied to mental health service teams and our hypothesis is that it has similarities with brief therapy.
Working with clinical microsystems in mental health service teams appears to show that the main problem at the frontline level is a lack of purpose and clarity. We argue that the clinical microsystem approach appeals to frontline workers because it is patient-centred. We further argue that the same approach can be taken at what might be called the mesosystem level, replacing patient-centeredness with patron-centeredness. This may prove a useful way of resolving the tensions between the micro- and meso- levels of NHS mental health services.
Clinical microsystems are different in nature from mesosystems and this leads to tensions between the two which need to be resolved if effectiveness is to be achieved.
Since the formulation of the Humber Mental Health Modernisation Team in September 2003, we were influenced by the five simple rules as outlined by the director of the Modernisation Agency, David Fillingham (2002). Over time they have proved to be the backbone of all our work:
- See things through a patient’s eyes;
- Find better ways of doing things;
- Look at the whole picture;
- Give frontline staff the time and tools to tackle problems;
- Take small steps as well as big leaps (Fillingham, 2002).
Like all other areas of the NHS, mental health services can be divided into smaller groups of people within a specific geographical area or who have clinical expertise that sets them slightly apart from others. In the simplest form, this is a clinical microsystem. The use of clinical microsystems as a framework for service improvement has been developed at DartmouthHitchcockMedicalSchool in the US. Ian Golton, national lead for clinical microsystems in the UK, described clinical microsystems as:
‘the small, functional, frontline units that provide most healthcare to most people. They are the essential building blocks of the health system. They are the place where patients and healthcare staff meet. The quality and value of care produced by a large health system can be no better than the services generated by the small systems of which it is composed.’
Teams differ in make-up and in clinical strengths. As in a family, there are different component parts that all affect the smooth running of a household. Gill Gorell Barnes explained it as follows: ‘Family patterns are made up of interpersonal relationships involving people with individually specific constitutions and past histories, living in a particular social network in a particular culture’ (Gorell Barnes, 1984).
Clinical microsystem service improvement work helps to get the very best from what you have. It sometimes states the obvious and does not appear at times to be complex, which can be very appealing to health staff who want to make changes to their working environment but are busy.
The strength of a workplace can be assessed according to Buckingham and Coffman (1999) using their measuring stick (Box 1). They drew up 12 questions which have been refined from many thousands of questionnaires. Much of the power lies in the extremes of the questions designed to invoke a response. The questions are not surprising in their content but surprising in their simplicity.
Box1. Measuring stick
1. Do I know what is expected of me at work?
2. Do I have the materials and equipment I need to do my work properly?
3. At work, do I have the opportunity to do what I do best every day?
4. In the last seven days, have I received recognition or praise for good work?
5. Does my supervisor, or someone at work, seem to care about me as a person?
6. Is there someone at work who encourages my development?
7. At work, do my opinions seem to count?
8. Does the mission/purpose of my company make me feel like my work is important?
9. Are my co-workers committed to doing high-quality work?
10. Do I have a best friend at work?
11. In the last six months, have I talked with someone about my progress?
12. This last year, have I had opportunities to learn and grow?
(Buckingham and Coffman, 1999)
Paul Batalden, professor and director, and Marjorie Godfrey, director of clinical practice improvement, both at the Dartmouth Hitchcock Medical School, have developed with others a way of taking the best of the measuring stick and applying it to a team. Some of the best practices are contained in Clinical Microsystem Action Guide (Godfrey et al, 2002). The clinical microsystem has to have a shared identity or purpose in some way which defines it as a microsystem, and Godfrey et al’sfive P model can help with the focus and identification (Box 2).
Box 2. Five Ps
Patients: Who are they? How do you know what they want from you? How do you communicate with them informally / formally?
People: Who is in your team? What skills do you have? How can you make the most of everyone?
Patterns: How do things vary? What happens when things go wrong? How could it be better?
Processes:How do things happen in the team? What systems do we have and are they right for us now?
Purpose:Is what we do clear to everyone? Are there competing demands on our service?
Dartmouth Hitchcock Medical Centre
Within our mental health service we have concentrated on the five Ps as the basis of our service improvement work. I knew that using the five Ps would be easily accepted by busy mental health professionals as they are simple and go right to the core of most staff belief systems.
With my colleague Mike Gill, and the support of our head of service, Martin Leach, we developed a service improvement course that we could facilitate with teams, based on the five Ps. We used the four Ps, including ‘purpose’ at all points of our discussions, not as a main topic item.
The main aim of the facilitation was to encourage frontline teams within mental health services to look at themselves, their patients, their processes and patterns, and to look at ways in which they could see improvements and then to action plan for the improvements.
When we were thinking about the questions to be put to the teams, it became very clear to me these were the same questions I asked individuals when I was a community psychiatric nurse. Our first eureka moment - systemic or brief therapy for teams.
Taking our thinking forward, our research led us to a book, The Solution Focus by Paul Jackson and Mark McKergow (2002). This book offers subtle yet powerful ways to bring about positive change using a solution-focused approach, building on the positive, not searching for the problem. The book details simple ways of working, allowing bespoke interactions. This work reaffirmed our system’s thinking and enriched our microsystem questions for the teams (Box 3).
Our clinical microsystem questions:
- What do you do well?
- What could be better?
- How could you make it better?
- How many times do you think you could try that before next time?
- If everything was suddenly working at its best, what would it look and feel like?
- Let’s do that and, if it is no good, we can try something else;
- Are these changes going to benefit the patient? If not, why are we doing it?
Box3. Solution-focused therapy
Professor Andrew Derrington (1999) compared solution-focused brief therapy with other therapies and said:
‘In choosing a therapy I would steer clear of experts who professed to be able to analyse my problem. It’s not that I don’t care what the problem is. It’s more that I don’t think they would know any better than I. And anyway, it’s more important to identify the solution than to understand the problem.
‘The therapy that takes exactly this view is solution-focused brief therapy. It helps clients to find solutions to their problem by using two questions. The first is called the miracle question.
‘Imagine you were to wake up tomorrow and a miracle had happened during the night: your problem had disappeared. What would be different about the way you feel? The second question, known as the scaling question, is simpler. It asks clients to put a number on how they feel where 0 is the worst [it could possibly be] and 10 is the way they would feel the morning after the miracle.
‘The sequel to the scaling question is to ask clients to imagine what they may be able to do to move themselves half a point up the happiness scale. Whenever I have a dose of the glums I ask myself this question. The thing that amazes me, and convinces me that I shall never need therapy, is that I always know the answer. Try it yourself. You will put your therapist out of business.’
Plan, do, study and act (PDSA) cycles have played a large part in clinical microsystem service improvement.
Walter A. Shewhart first discussed the concept of the predecessor cycle, PDCA (plan, do, check and act), in his 1939 book, Statistical Method from the Viewpoint of Quality Control. Shewhart’s protege W. Edwards Deming encouraged a systematic approach to problem-solving and promoted the now widely recognised four-step PDSA cycle - which was also referred to as the Shewhart process - for continual improvement. The Japanese call it the Deming Cycle and it is also referred to as the Deming Wheel.
Having made contact and held discussions with senior managers at the trust, we formalised our project plan, then embarked on our largest microsystem programme.
Our plan involved our working with three community mental health teams providing mental health services to adults. We had both managed community mental health teams previously and had been influenced by the work of Steve Onyett. Onyett stated that within community mental health teams, ‘Effective communication achieves innovation. (Onyett, (2003). This phrase would be proved right on many occasions.
While the three teams chosen were similar, they were different because of their history and the individuals in the teams.
We went about formulating an improvement plan that would be based on clinical microsystems, which we thought would improve team members’ concept of purpose, clearly start to define the patients served, and look at removing bottlenecks in the referral process and streamlining the talking therapies.
We also thought it would help the individual teams to identify their own areas for improvement and formulate action plans based on the areas they have defined.
Day 1: People and patients
Introduction to the modernisation team and clinical microsystems
Completion of staff survey and information regarding the patient survey
Who does the team link to?
Where are the team’s strengths?
What works well in the team, what could be better and how are we going to make it better?’
Prioritisation of work streams.
Detailed action plan 1 (what, when, to whom and by)
Day 2 (Patterns)
Action plan 1 feedback
Staff survey results
What are the big topics for the team, can we break the problem up into smaller bits and when we have the smaller bits fix them back together again in a way that works?
Patient pathway, process mapping
What works well, what could work better and where can we improve?
Detailed action plan 2 (What, when, to whom and by)
Day 3 (Processes)
Action plan 1 and 2 feedback
Feedback to the team
What could you as a team do better and how would you do it?
Plan, Do, Study and Actthinking
Follow-up half day
Revisit action plans
What has been happening?
What is going well now?
What still could be better?
Actions (what, when, to whom and by)
CMHT programme Gray and Gill, 2005
Evaluation of the community mental health teams’ service improvements
Our evaluation and feedback to the teams involves written reports with digital photographs of all flip charts of work produced during the sessions. We have found this to be a very accurate way of making sure everyone who attends can see what they did and what they agreed to take forward. We have also found this to be a very time-effective way of feeding back to managers and commissioners of our work.
Throughout the workshops with the community mental health teams, it was apparent that each team had issues with communication that had not previously been identified. The roles of the team managers, senior nurse and other senior staff became crucial in the development of action plans. Staff needed to be offered the time and tools necessary to make things happen and to ensure their actions had a lasting effect.
Within the sessions, we kept a ‘parked issues’ board which logged issues that we could not comment on or to which there were no answers. ‘We need more staff’ would be a good example. To stop these issues clouding a day or taking up time, they were ‘parked’ and given to the manager of the service to resolve at a later date. It stops one person’s particular gripe or difficultly dominating and it respects what people have said without having to deal with situations there and then.
The microsystem approaches (the teams), supported by the management group (team managers/operations managers) feels strong, resilient and the results are owned by the staff.
‘Why are we doing all this work with the microsystem when the next layer up seems to need help as well?’ was a question which we kept on asking ourselves within our personal reflection after sessions.In our evaluation we started thinking that the ripples we had created in the microsystem would have effects elsewhere. This took us back to our ‘brief therapy’ or ‘teams’ statement. If we are working with the children in this family the parents are going to be wondering what we are doing. Maybe they are adding to the problem or maybe they have the keys to improving things.
Box5. System layers
|Ecological level Microsystem Mesosystem Macrosystem||Definition A setting where people engage in face-to-face interaction The relations between two or more settings that affect patient care. Not direct patient contact Blueprints for how the other components of the system should operate||Examples Home, CMHT, day centre, inpatient unit. Relations and communication between trust management to management teams to clinical staff and reverse Ideology Direction Culture Health policy||Issues affecting care offered to service users/customers Quality of interactions Responsiveness of staff Quality of relationships Respect for each other Support for each other Collaborative decision-making Understanding idividualist or collectivist orientation Democratic or autocratic orientation How mental health is defined|
Effective microsystems need great mesosystems
It became apparent that the relationship with the management structure above the clinical microsystems was critical in the effective running of a team.
At a meeting in York attended by Ian Golton (UK national lead for microsystems) and facilitated by Laura Hibbs (UK national coordinator for clinical microsystems), Ian Golton used the word ‘mesosystem’ to describe the management layer. For me, this was the second eureka moment.
We now describe the mesosystems as a semipermeable membrane between the microsystems and the macrosystem (the trust as a whole). Information and briefings have to pass through the membrane quickly without too much alteration, going in each direction. If the mesosystem can make information understandable to the microsystem and present it properly, the microsystem has a good chance of making things work.
We decided that we had to engage with some of the mesosystems at the trust. The heads of service in the nursing directorate were keen to be involved. Our approach was similar to the microsystem approach.
In the microsystem we had to encourage the team to comment and discuss issues, but the mesosystem comprised a team of talkers and thinkers. They were confident when talking strategy and working with high-level processes but appeared to be less taken up with the fine detail of day-to-day matters in which frontline staff were involved. Sometimes it seemed to us that a lack of attention to the fine detail led to progress not being made in the way it should.
The five Ps came back into play. The first P, patients, was no longer appropriate. We changed the patient P to ‘patrons’, and asked ‘who are the mesosystem’s customers?’ The mesosystem has to have the same knowledge about the microsystem as the microsystem has to know about the patients. The mesosystem has to know how the teams it manages work and what makes them tick.
Our mesosystem work showed that most members had worked in microsystems and thought they knew what made them work. However, microsystems had changed since some of the managers had been part of one. We encouraged the managers to challenge assumptions and beliefs about the microsystem. We discussed the realities of microsystems with them, which reminded many of them of issues in microsystems about which they may have forgotten. These themes have been common in all the mesosystem work we have done.
This work has resulted in action plans that include setting aside time when managers can talk to the staff in the clinical microsystems and which aim to improve the communication at all levels. Our statement ‘Effective microsystems need great mesosystems’ seems to have become our mantra.
Making things better in a short time
As a two-person team, we have now worked with more than 10 teams of staff which represent over 160 members of mental health staff. In not one instance have we found staff to be negative or ambivalent to the clinical microsystem/mesosystem approach.
We have found staff interested and very willing to see things through the patient’s eyes. Referring to the five simple steps for modernisation (Fillingham, 2002), we have seen small steps and large leaps and have seen managers thinking of how to make space so that improvements can be completed and are sustainable. In a very short space of time, we have seen staff energised and equipped to embrace change, making things better for the service users and, inadvertently, for themselves.
Our statement ‘Effective microsystems need great mesosystems’ seems more relevant than ever. Different approaches need to be adopted with the microsystem compared to the mesosystem but the aim is the same. When the two systems were seen to overlap, this was used to open doors which were perhaps before transparent but closed. The overlapping areas give teams a common starting point which is understood by all where all sides can contribute and feel involved
As facilitators of the team days, we have not had a hidden agenda with ideas for the teams or areas for improvement. It has come from the individuals in the teams and their managers.
We have been amazed by the variety and scope of the action taken on by teams and have often remarked that, had we suggested some of the actions, we felt we would have been shouted down as they may have seemed too difficult, bizarre or insignificant. Because the team owned their ideas they were prepared to run with them.
The Improving Working Lives policy appears to link to our microsystem/ mesosystem work. If a change makes being at work more attractive to staff, the staff should be in a better frame of mind to work effectively with patients. Our statement to staff groups - ‘If it’s not good for the patients, then don’t do it’ - suddenly feels broader and more meaningful than originally intended.
Henderson stated (1938): ‘Microsystems are the basic building blocks of healthcare. Connecting the work of one clinical microsystem to another is illustrative of leaders who recognise the integrity of the clinical microsystem as a functioning ‘building block’ of health care.’ Wenger (1998) stated: ‘Microsystems are the focus of control for many, if not most, of the variables that account for patient satisfaction with healthcare.’
Importantly, we have seen individuals and groups of staff within teams become more confident and more assured of their roles in providing patient-centred, excellent mental health services that all feel safe, effective and deliverable.
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