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Healthcare Quality at the Organization and Microsystem Level

Healthcare Quality at the Organization and Microsystem Level

Systems Thinking

“…A view of reality that emphasizes the relationships and interactions of each part of the system to all the other parts” (McLaughlin & Olson 2012, 23).

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McLaughlin, D.B., & J.R. Olson. 2012. Healthcare Operations Management, 2nd ed. Chicago, Health Administration Press.


A systems thinking approach to quality management

The interconnected system model

The three core process model

The Baldrige performance excellence program framework

Socioecological framework


Interconnected system level

Divided into four levels:

Environment level

Organization level: is a critical level of change in the health care system because it can provide an overall climate and culture for change.

Microsystem level

Patient level


Three core process model

Clinical, Medical, and Technical process: are critical process because they are the main reason why clients seek health care assistance.

Operational or patient flow process (registering patient, scheduling): enable clients to gain access.

Administrative process (decision making, communication, resource allocation, and performance evaluation)

The improvement in any one of these process has the potential to increase the value of the service provided.


Three Core Process Model


Clinical outcomes



Functional status


Clinical/Medical/Technical Processes

Operational/Patient & Client Flow Processes

Administrative Decision-Making Processes

Administrative Decision-Making Processes




Source: Kelly, D. L. 2017. Applying Quality Management in Healthcare, 4th Edition. Chicago: Health Administration Press.

Baldrige Performance Excellence Program Framework (BPEP)

The model describes essential elements of organizational effectiveness

The model shows the importance of alignment in the organization





Source: www.baldrige.gov.

Socioecological Framework

A transdisciplinary systems perspective on promoting health and wellness that uses and reflects theory from multiple fields; medicine, public health, behavior and social science.

Emphasis on multilevel and recognition of the complexity of human environment

Provide a more expansive view of the nature of health and wellness

Help to understand interventions designed to improve the quality and safety of services.

Maybe used to better understand smoking behavior and drinking



Socioecological Framework: Determinants, Interventions, Evaluation


Systems Models: Lessons for Managers

Interconnected System Model Three Core Process Model Baldrige Performance Excellence Program Framework Socioecological Framework
Places the patient at the center of healthcare delivery Fosters feed back mechanisms that reinforce or balance system performance Encourages awareness of linkages between major elements affecting patient care Illustrates the wave effect of changes in the environment Encourages concurrent improvement of inter-dependent processes Aligns processes around patient/client/customer needs Values all provider/ employee groups Views administrative role as a process not a function Shows how the components of organizational effectiveness are related Recognizes the context in which the organization operates Promotes alignment of all organizational activities, including performance measurement Illustrates essential links in the system Broadens and expands the manager’s view Addresses community and policy influences on health outcomes Illustrates the interrelationships among multiple levels involved in improving health outcomes Encourages interrelated, multilevel interventions

Source: Kelly, D. L. 2006. Applying Quality Management in Healthcare, 2nd Edition. Chicago: Health Administration Press. Reprinted with permission.




Where do data on health care quality come from?


Administrative data

Medical records

Qualitative data

Disease registries

Data availability and validity are key elements to consider when selecting appropriate quality and resource use measures.


How are quality measures used?

Public reporting: CMS provides quality performance data for hospitals in the Medicare program on its Hospital Compare website, also, data for the Medicare program on nursing homes, home health agencies, and Medicare Advantage plans.

Provider incentive programs: For example, rather than paying providers for the volume of care they deliver, payers can link all or part of a payment to the quality of care that is delivered. (ACOs) use quality measurement as a critical method of allocating payments to participating providers.

Accreditation and certification: ACA requires all qualified health plans to be accredited.

Discussion Questions

Identify 1-2 activities a manager in St. David’s HealthCare did to advance organizational excellence in each of the following Baldrige framework categories:






Quality measurements can be grouped into four categories: 1. clinical quality including process and outcomes, 2. financial performance, 3. patient, physician, staff satisfaction, 4. functional status.

System models help managers identify the elements and connections between those elements in their organizations and the environments in which they functions.

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