1. QUERI Robert L Jesse, MD, PhD Chief Consultant Medical Surgical Service

3. Transforming Healthcare Transactional Quality and Management: a healthcare redesign process through which clinical practices are both enhanced and ensured by real-time insights into their systems. Quality is integrated into the workflow Data is aggregated through the process Quality and safety are driven by efficiency 3

4. Transactional Quality and Management Guiding Principle #1: If data is important enough that it is needed to manage the patient and/or the system, then it must be acquired as an integral part of the work process and not through retrospective data collection.

5. Transactional Quality and Management Guiding Principle #2: “Solutions” must make the work easier, and not impose undue burden or require re-work. – No pain for the gain – Technology must facilitate the workflow and not encumber it.

6. Transactional Quality and Management Guiding Principle #3: Real-time visibility into the system must be available, and it must be transparent across the enterprise: – Manage all patient-health system interactions location and times - waits and delays – Manage patient-staff relationships Include patient-staff transitions (handoffs) – Manage all tests and procedures in real-time From scheduling to completion Concurrent documentation

7. Transactional Quality and Management Guiding Principle #4: In order to deliver evidence-based care we must have evidence-based management. – Clinical processes support – Administrative processes support – IT support – Materials management – Equipment – Beds – Staff Management – Point of service logistical support

8. Transactional Quality and Management Guiding Principle #5: In order to ensure that we effectively manage the delivery of evidence-based care we must manage complexity Data Information Knowledge Wisdom

9. Patient Flow and Technology Management of patient flow requires real-time information: – Technology eliminates the need for manual data entry – RTLS: Real-time location systems (i.e. RFID/IR) – Bar-code scanning – Email and paging notifications – Electronic interfaces to clinical systems – Web based for easy deployment Technology is enabling, but technology is not in and of itself a solution

10. Patient Flow Visibility Key Components for the Intelligent EMR Real-time visiblity into the system must be available for the entire process and must be transparent across the enterprise – Follow all patient movements Location and length of time in any given location Forward looking to avoid delays – Map and capture all tests and procedures Minimize delays to actionable steps – Document patient-staff relationships – Document patient-staff transitions (handoffs)

11. Provide the right information → to the right people →at the right time → in the right place → in a comprehendible form Automated Bed Boards (ED and inpatient) Form Factors Mobile Computers Desktop Computers Context driven views Comprehensive management of patient flow from point of entry through to discharge Automation of all processes that impact patient flow Patient Flow Visibility Key Components for the Intelligent EMR

12. Hierarchy of Healthcare Systems Structure and Function Performance Improvement Levers VHA StrategiesGoalsCharacteristics Information Process Service Offering System Model Responsiven ess Efficiency Effectivenes s Level of Implementation Complexity Electronic Health Record Accessible Health Data VHA Systems Redesign Integrated Workflow Processing Evidence Based Management Fully Integrated Health System Value Predictive Analytics Longitudinal Health Management Distributed Healthcare Patient as node on Wide Area Health Network Optimizing Clinical Performance Clinical Decision Support Engineering Care Delivery Integrated Hospital/Clinic Efficiencies

13. Healthcare From a Systems Perspective Engineering Principles Apply – Supply must always exceed demand Erlang’s law (?) Any service delay is unacceptable – Action when and where needed Just-in-time supply chain management – Multiple steps and processes are involved Map processes and pre-specify the plan Parallel process when ever possible – Complexity must be managed

14. Summary Data must be acquired as an integral part of the workflow process. Adoption is dependant on workload burden. Real-time visibility into- and transparency across the enterprise are required. Evidence-based management is needed to ensure evidence-based care. Knowledge and complexity management are crucial to moving forward.