Evaluating a clinical microsystems approach to achieving an integrated falls service in Sheffield

Integrated fall service

Project Plan

Sheffield Teaching Hospitals NHS Foundation Trust has received funding from The Burdett Trust for Nursing to undertake a comprehensive redesign of the city-wide falls service in Sheffield. This multi-disciplinary project will use the clinical microsystems quality improvement methodology to design and implement the changes required.  Clinical microsystems are the front-line team that provide patient care.

The two-year project commenced in September 2012. NIHR CLAHRC for South Yorkshire is a co-applicant in the proposal and has agreed to undertake an evaluation of the initiative.

Clinical microsystems are a potentially powerful tool for addressing service improvement in the NHS (Appleby, 2010).  They have the capacity to empower staff and increase engagement in service improvement (Williams et al., 2009).  While focusing on the clinical microsystem can effect change in service delivery, the meso-system (the health and social care organisation) and macro-system (the health care policy and the external context) in which they operate will provide barriers and enablers to their success (Nelson et al., 2002).

In keeping with the clinical microsystems approach, the project will divide the meso-system of the falls service in Sheffield into a number of clinical microsystems.  These are the front-line units that provide patient care – examples include Accident and Emergency, Day Rehabilitation Unit or the Falls Clinic.  Each microsystem is led by a trained coach and is made up of clinicians from the area defined by the microsystem, who work together to improve care (The Dartmouth Institute, 2011).

This evaluation will assess the impact of working in clinical microsystems on empowering healthcare professionals to make improvements in service delivery and quality of care.  It will consider the impact that the clinical microsystem has on the wider organisation.  It will review the role that the meso-system (organisation) and macro-system (wider policy context) have on the effectiveness of working with clinical microsystems for service improvement.


  • To use staff experiences to explore the impact of working in a clinical microsystem on staff empowerment and engagement in service improvement
  • To use the experiences of staff and stakeholders to explore the interactions between clinical microsystems, meso-systems and macro-systems

The evaluation will use a pluralistic stakeholder approach in order to explore the effects of working in clinical microsystems on those staff involved and on the wider community within which they work.  It will examine the extent to which those directly involved have been empowered by the process.  It will also explore the ways in which the process has impacted the approach that microsystems participants take to service improvement and examine the interactions between the clinical microsystems and the meso and macro systems in which they sit.

A mixed methods approach, combining the collection of both qualitative and quantitative data will be used.  The quantitative component, involving a validated questionnaire will allow measurement of change in empowerment, across a broad sample of staff.  The qualitative component will enable a more in-depth exploration of the experiences and views of key personnel within the project through focus group discussions with the project team, interviews with key stakeholders, and observation of clinical microsystem meetings