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Service Delivery Innovation Profile

Clinical Microsystem Improvements in Children's Hospital Lead to Fewer Codes and More Timely Delivery of Essential Care

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Cincinnati Children's Hospital Medical Center uses a clinical "microsystem" approach to improve patient safety and quality; clinical microsystems are subcultures of clinicians, equipment, and processes within a hospital that provide care to specific subpopulations of patients.1 Under this approach, strategic and microsystem-based teams worked on 16 inpatient units to design and implement system changes to improve specific outcomes. For example, a general pediatric unit developed and implemented the following: an early warning system and decision algorithm to prevent codes, guidelines to promote routine use of evidence-based care, a standardized admission process focused on improving timeliness of care, a medical response team, proactive encouragement of families to voice concerns, leadership walkarounds, and leadership-led investigation of adverse events. Pre- and post-implementation comparisons show that the changes led to a significant reduction in codes and more timely administration of care.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the number of days without a code and the provision of care within 75 minutes of arrival on the unit.
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Developing Organizations

Cincinnati Children's Hospital Medical Center
Cincinnati, OHend dobegin pp

Patient Population

Vulnerable Populations > Childrenend pp

Problem Addressed

Failure to adhere to evidence-based care, develop and follow standardized care processes, and include patients and families in care often jeopardizes the safety and quality of patient care in the United States. Cincinnati Children's Hospital Medical Center experienced many of these failures and realized that an immature improvement infrastructure was preventing them from transforming their care delivery system.
  • Failure to adhere to evidence-based practice: Failure to provide evidence-based care has led to significant harm2 and death3 that could have been avoided. Much of this failure can be attributed to the lack of practical tools and strategies that help translate the research for use in everyday clinical practice.4 Although lengthy clinical guidelines are available, few have been summarized, translated into standardized care processes, and/or integrated into practical point-of-care tools that make them easy to use by busy frontline clinicians.
  • Failure to include patients and families in safety: Recognizing that patients and families are often not included in care, The Joint Commission in 2007 added patient involvement as a National Patient Safety Goal, calling on health care organizations to devise a mechanism for patients and families to report safety concerns.5
  • Immature improvement infrastructure: The Institute of Medicine stated that hospitals need to change systems of care to improve safety and quality of patient care.6 At Cincinnati Children's and many hospitals across the United States, there is limited organizational infrastructure to undertake improvement efforts.

What They Did

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Description of the Innovative Activity

Cincinnati Children's Hospital Medical Center used strategic and clinical microsystem teams on 16 units to design and implement initiatives to improve patient safety and quality. In this program, a clinical microsystem is defined as an inpatient unit and includes clinicians, nonclinicians, equipment, and processes providing care to specific subpopulations of patients. For example, a general pediatric unit developed and implemented the following: an early warning system and decision algorithm to prevent codes, guidelines to promote routine use of evidence-based care, a standardized admission process focused on improving timeliness of care, a medical response team, proactive encouragement of families to voice concerns, leadership walkarounds, and leadership-led investigation of adverse events. Key elements of the changes made by this unit appear below; see the Planning and Development section for more information on the formation and operation of the teams and the processes they use to improve care.
  • Pediatric early warning system and decision algorithm: Clinicians use a scoring system to proactively identify patients who are deteriorating clinically and post a corresponding color card (green, yellow, orange, or red) at the bedside to ensure the patient's status becomes transparent to all staff. A decision algorithm provides standardized processes that clinicians follow, depending on the patient's state of deterioration, to improve their medical status and thus avoid a code.
  • Guidelines to encourage consistent use of evidence-based care: The Cincinnati Children's Hospital Medical Center develops its own guidelines based on the most widely used pediatric guidelines in the United States; these guidelines are available at Nurses proactively identify and reduce any barriers that prevent adherence to these guidelines.
  • Standard admission process: A faculty physician and nurse manager initiate a conference call to clarify the plan of care for each admission, and enter orders in an electronic system before the patient arrives to ensure timeliness of required treatment. An evening shift nurse takes over this responsibility when the physician and nurse manager are not working. The goal of this new process is to provide all recommended care within 75 minutes of arrival on the unit.
  • Medical response team: A medical response team answers all calls to address unresolved concerns made by nurses, physicians, and families (see below for more information on family involvement). The team includes an intensive care unit fellow, nurse, respiratory therapist, hospital nurse manager, and senior resident. The team receives roughly 10 calls each month; about half the patients who are the subject of such calls stay on the unit, with the rest being transferred to a higher level of care.
  • Encouraging families to voice concerns: Family members can call the medical response team at any time if they perceive a worsening in their child's medical condition or have a safety concern. Staff also ask parents several times a day if they have a concern. If so, two staff members must address and resolve the problem before moving forward with medical treatment.
  • Unit walkarounds: Approximately once a week, leaders perform unit walkarounds where they discuss improvement goals and strategies for reaching them with frontline staff, listen to staff concerns, and give positive feedback on successes.
  • Real-time analysis of adverse events: Whenever a significant adverse event occurs, leaders assemble the staff and physicians involved, as close to the time of the event as possible, to conduct a near real-time analysis of the event and decide what can be done to prevent a recurrence.

Context of the Innovation

Cincinnati Children's Hospital Medical Center, a 475-bed, urban academic medical institution with 15 satellite centers, serves as the only pediatric hospital in the greater Cincinnati area. Known for its ability to diagnose and treat complex diseases, the hospital serves children and their families from across the country and world. The impetus for this program came from increasing pressures facing hospital leaders to deliver care that meets the needs of patients/families, payers, and external boards. These pressures, combined with landmark reports from the Institute of Medicine highlighting major deficits in quality and safety, prompted hospital leaders to more closely examine the organization. Realizing that outcomes were not as good as they should or could be, they developed a strategic plan to become "the leader in improving child health." To achieve this vision, they recognized the need for a transformation of the entire clinical delivery system. While participating in a global learning community called Pursuing Perfection, leaders learned about the concept of clinical microsystems from a hospital in Sweden.

Did It Work?

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Pre- and post-implementation comparisons show that the changes made on the general pediatric unit led to significantly fewer codes and more timely administration of care. These are just two examples of many improvements achieved in other clinical microsystems at Cincinnati Children's Hospital Medical Center (visit for ongoing improvement efforts).
  • Significantly fewer codes: At baseline in January 2004, the unit had gone 272 days without a code. After implementing the pediatric early warning system in March 2006, the unit went 504 days without a code, and then experienced a 550-day "code-free" period before the next code in December 2008.7
  • More timely care: At baseline, 40 percent of children received evidence-based treatments within the recommended 75 minutes of arrival to the unit. After standardizing the admission process, this figure jumped to 70 percent.7

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the number of days without a code and the provision of care within 75 minutes of arrival on the unit.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Developing strategic plan: In 2000, the chairman of the board, chief executive officer, and a physician champion developed a strategic plan to transform the clinical delivery system at the hospital, with the goal of significantly improving clinical outcomes.
  • Establishing business case for quality: The chief financial officer established the business case for quality improvement, using the prevention of hospital-acquired infections as an example of how the hospital had reduced costs by reducing infections and the patient's hospital length of stay.
  • Joining learning community: In 2001, the medical center joined a joint Institute for Healthcare Improvement–Robert Wood Johnson Foundation program known as Pursuing Perfection, a global learning community of 13 institutions that share experiences in transforming patient care and management systems.
  • Building improvement infrastructure: Over a 3-year period, 24 senior leaders with minimal improvement knowledge attended the Institute for Health Care Delivery Research Education Programs, sponsored by Intermountain Healthcare, to learn about the science of improvement. This program involved four 5-day sessions, with sessions spaced a month apart. In addition, the medical center developed an in-house course to teach intermediate-level sessions on the science of improvement to the physician, nurse, administrative, and support staff leaders doing the improvement work.6 This action-based learning course, known as the Intermediate Improvement Science Series Course, teaches health care professionals to perform improvement research.
  • Aligning improvement efforts with the organizational strategic plan: Hospital leaders at Cincinnati Children's recognize that aligning improvement efforts with the organizational strategic plan is the key to transforming the way care is organized and delivered at the front lines. Hospital leaders meet with leaders from the strategic and microsystem teams annually to negotiate improvement goals and develop plans to accomplish these goals.
  • Assembling strategic teams: Strategic teams comprised of leaders and staff from the front lines, families, and quality improvement personnel were formed to design and implement quality improvement initiatives that align with the organizational strategic plan. Teams report their progress on a monthly basis to a senior leader charged with supporting each strategic team. The medical center began with two strategic teams, which expanded to five by the end of 2002. It has progressively added several new teams during the hospital's annual strategic improvement planning process.
  • Assembling microsystem-based teams: Each strategic team works with one or more microsystem teams to improve outcomes. These interdisciplinary teams, which have been developed in all inpatient units, consist of nurses, physicians, social workers, respiratory therapists, nutritionists, physical therapists, nurse aides, and family members. Teams work to improve specific outcomes (e.g., reducing codes) by testing process changes, measuring improvements as a result of the changes, and making refinements as needed to sustain results.
  • Developing simulation center: The medical center developed a simulation center to help clinicians learn requisite medical and technical skills before they practice on patients. Housed in a closed hospital, the center has 10 full-time staff that work directly with clinicians. As a supplement to this training, microsystem teams also conduct informal simulations on the units to assess adverse events and practice improvement processes.

Resources Used and Skills Needed

  • Staffing: The program requires the support of senior hospital leaders and members of both the strategic and microsystem-based teams who incorporated this work into their current job. Staff with expertise in quality improvement, data analysis, and improvement science were hired to build a strong improvement infrastructure, and 10 new staff were hired to run the simulation center.
  • Costs: This program was a new approach to care and was incorporated in the medical center budget, which makes it difficult to estimate the cost. The primary development costs related to building the improvement infrastructure, which included hiring new staff (noted above), training programs such as the inhospital course (e.g., instructor and facility expenses), and the time taken from work for participants. While the simulation center is housed in the renovated section of a closed hospital, several million dollars have been invested in this facility. Once implemented, expenses were fairly minor, consisting primarily of financial support for physicians to colead clinical microsystem-based improvement efforts.
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Funding Sources

Cincinnati Children's Hospital Medical Center; Robert Wood Johnson Foundation
Cincinnati Children's Hospital Medical Center provided the funding to build the infrastructure and conduct the improvement work. The Robert Wood Johnson Foundation funded activities involved in the shared learning community and connection to national thought leaders.end fs

Tools and Other Resources

Quality measures and outcomes Cincinnati Children's Hospital Medical Center is working on throughout their organization. Available at:

Evidence-based pediatric care guidelines at Cincinnati Children's Hospital Medical Center. Available at:

Adoption Considerations

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Getting Started with This Innovation

  • Learn by doing: Begin the transformation process before the entire infrastructure has been built. Although building expertise and capacity in improvement science remains crucial for ultimate success, much of the learning occurs by actually engaging in improvements.
  • Start small, expect to grow: The improvement skills within the medical center and its teams began as rudimentary, but excellent mentoring helped the early teams to succeed. This accomplishment bolstered leadership's confidence in the value of investing in the science of improvement, which led to progressively larger investments in infrastructure and training.
  • Involve all levels in program design: The board of trustees, senior hospital leaders, unit leaders, frontline staff, patients, and families should be involved in strategizing and implementing the program.
  • Seek outside counsel if necessary: If internal expertise is limited, seek outside expertise to help with training of leaders and frontline workers on the science of improvement.

Sustaining This Innovation

  • Continually work to align organizational and microsystem-level strategies: Efforts undertaken at the unit level should align with the strategic priorities of the organization as a whole.
  • Maintain transparency and negotiate priorities: Be transparent about leaders' views on the most important priorities for improvement but also negotiate priorities with representatives from all levels of the organization.
  • Make improvement an ongoing responsibility: Encourage leaders and frontline staff to continuously look at new ways of improving care.
  • Hold regular meetings: Strategic teams and microsystem teams should meet regularly to discuss progress and strategies for overcoming any barriers to success.

More Information

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Contact the Innovator

Stephen Muething, MD
Assistant Vice President for Patient Safety, Health Policy & Clinical Effectiveness
Associate Professor, General & Community Pediatrics
Cincinnati Children's Hospital Medical Center
3333 Burnet Avenue
Cincinnati, OH 45229
(513) 636-4506

Innovator Disclosures

Dr. Muething has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section. 

References/Related Articles

Duncan H, Hutchison J, Parshuram CS. The pediatric early warning system score: a severity of illness score to predict urgent medical need in hospitalized children. J Crit Care. 2006;21(3):271-8. [PubMed]


1 Disch J. Clinical microsystems: the building blocks of patient safety. Creat Nurs. 2006;12(3):13-4. [PubMed]
2 Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002;137(5 Part 1):327-33. [PubMed]
3 Luria JW, Muething SE, Schoettker PJ, et al. Reliability science and patient safety. Pediatr Clin North Am. 2006;53(6):1121-33. [PubMed]
4 Lenfant C. Shattuck Lecture—clinical research to clinical practice—lost in translation? N Engl J Med. 2003;349(9):868-74. [PubMed]
5 Zanni GR. JCAHO's 2007 National Patient Safety Goals. Pharmacy Times. February 1, 2007.
6 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty-First Century. Washington: National Academies Press, 2001; p. 4.
7 Godfrey MM, Melin CN, Muething SE, et al. Clinical microsystems, Part 3. Transformation of two hospitals using microsystem, mesosystem, and macrosystem strategies. Jt Comm J Qual Patient Saf. 2008;34(10):591-603. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 17, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 10, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.