Once again, Eugene Nelson, Paul Batalden, Julie Mohr, and Stephen Plume are enlightening us with a view of the future healthcare improvement model. Long recognized as the leaders in process-level measurement, the experiences they share from the front lines of Dartmouth-Hitchcock have enabled many of us to reduce drastically deployment cycle times and the learning curves of our organizations. Here they share a practical healthcare application-new to me, at least-of Quinn's replicable unit concept (Quinn 1992). As presented, this approach, called the microunit approach, calls for the widespread deployment of strategic teams at the core process level; in the example presented, the team focuses on management of a managed care population. Facilitators aid the team in creating a master deployment plan, consisting of creation of an aim for the management of population, system map creation, strategic measurement tracking, selection of high-leverage subprocesses to improve, and deployment of its process improvement methodology. This concept is immediately appealing because it meets three of the most critical success factors proven to be present in successful strategic initiatives: rapid implementation cycles, strategic measures, and intense involvement of process owners as a team. Kaiser reported results using a similar approach to clinical guideline improvement in 1995 (Caldwell 1998). I have some significant experience with this approach: When I was CEO of West Paces Medical Center in Atlanta from 1986 through 1993, multidisciplinary disease-state teams were deployed using spider diagrams to track their strategic initiatives (Caldwell 1995). Nelson and Batalden were instrumental in helping to establish the core process boundaries, strategic spider diagrams, deployment of the FOCUS-PDCA process improvement model, and ongoing mentoring of team leadership. While beyond the scope of this commentary, our analysis revealed that many were enormously successful and others not so successful. What can we glean from the experiences of the authors in the deployment of microunit teams? Success Criteria for Microunit Team Deployment Importance of Replication as an Organizational Core Competency As Nelson et al. explain Quinn's concept, microunit teams are described as small, replicable units. A lesson I recall from Blan Godfrey, chairman of the Juran Institute, amplifies this point. During a review of strategic achievements at a global petroleum company, the president of one of the offshore subsidiaries proudly presented the results of an improvement project, which saved millions for the parent corporation. In his commentary to the team and senior leadership, Blan lamented with the proud president that he must be anguishing over his unit's success; the president, obviously shaken, simply looked on. Blan went on to explain that the burden on the offshore president to transfer and teach his colleagues around the globe so that the entire organization might save billions instead of just millions must be an overwhelming burden. The point is applicable here, as well. While the achievement of microunit rapid cycle improvements alone might help an organization outdistance its competition in both quality and cost, ultimate success of the organizations also rests on its ability to rapidly transfer and implement breakthroughs of each microunit team to all other teams in very short implementation cycles. The success of small replicable units could be said to be dependent on both factors. Multiunit Team Strategic Measures The authors highlight the importance of a unified, organizationwide set of external quality characteristics to measure success of microunit teams. They suggest price, choice, service quality, and outcomes quality. I choose to highlight these here because frequent, focused measurement is one of the cornerstones of every successful initiative I have observed. Nelson et al. have been pioneers in this area for years, and readers would benefit from reviewing and re-reviewing their past writings. …
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