The Anatomy and Physiology of Primary Care
By Gregory Makoul, PhD, MS
Clearly understanding how the structure of primary care practices affect their function – what we term the anatomy and physiology of primary care – is a logical foundation for any transformation effort.
The clinical microsystems approach, developed by colleagues at The Dartmouth Institute, offers one useful approach for analyzing the anatomy and physiology of primary care. A clinical microsystem is the smallest replicable unit of care; it includes the team that provides care, the people who receive care, and the data systems that support and inform care. Any primary care practice – whether a solo practitioner, a group practice, or a large clinic – is a microsystem.
A microsystems analysis addresses five core elements, known as the 5Ps:
- Purpose - What is the goal of the microsystem? Why does it exist?
- Personnel - Who works within the microsystem? How do they function as a team?
- Patients - Who does the microsystem serve?
- Process - What work does the microsystem do?
- Patterns - What do we see when the microsystem is in action?
At CIPCI, we’ve conducted clinical microsystem analyses at 10 primary care practices, ranging from large clinics that also serve as residency training sites to very small private practices. Regardless of practice size, results have been eye-opening at each site.
Process mapping is a major part of the analysis – it gives an immediate visual sense of the steps involved in care as well as the people involved in each step. The maps are wildly different, setting the stage for asking questions, identifying issues/opportunities, and moving toward productive redesign.
At one of the largest clinics, a group of physicians, residents, nurses, medical assistants and administrators used the “current state” process map and patient feedback to create an “ideal state” process map. Both providers and patients see the streamlined map – which eliminates wasted steps and reduces wasted time – as the basis for transformation to truly patient-centered primary care.
Ideal StateRead part 2, "Thinking about Visit Time from the Patient Perspective" here.