У нас теперь есть приложения для Android и iOS: The tragic story of the frontline village Zaitsevo is told by a famous News Front team of documentalists Maksim Fadeev and Sergey Belous. It is a story of several local citizens who stayed in the semi-destroyed place. 📌Android: https://play.google.com/store/apps/details?id=info.newsfront&utm_source=Viber&utm_medium=Chat&utm_campaign=Private 📌App Store: https://appsto.re/ru/fgCpeb.i Обязательно подпишитесь на нас в соц.сетях: http://www.vk.com/newsfront_tv http://www.ok.ru/news.front https://twitter.com/News_Front_info https://www.facebook.com/NewsFront.info/ https://plus.google.com/+News-Frontinfo Информационное агентство NewsFront – новый проект информационного центра «Юго-Восточный фронт». Информационный центр «Юго-Восточный фронт» начал свою деятельность в марте 2014 года. Сегодня мы расширяемся и растём, растут и объёмы информации, что потребовало запуска нового интернет-ресурса – сайта www.news-front.info News Front («Новостной фронт») – информационное агентство, цель которого – объективное и правдивое освещение событий в Новороссии, России, Сербии, Болгарии, Молдове, Украине и во всём мире. NewsFront видит своей целью защиту интересов русской цивилизации, показ истинного лица противников русского мира. Мы надеемся донести до общественности истину о совершённых преступлениях против человечности и помочь своим читателям и зрителям разобраться в нарастающем потоке циничной лжи западных средств массовой информации.
Genesee & Wyoming (GWR) benefits from strong freight demand and efforts to reward shareholders in the form of buybacks. However, rise in operating expenses are concerns.
CAPTION TEXT HERE/Getty Images A core challenge of management is to ensure that the organization’s priorities, strategies, and metrics are consistently embraced and that any impediments are identified and addressed quickly. At Salt Lake City-based Intermountain Healthcare, ensuring the alignment of all these things to provide extraordinary care requires a constant regimented focus across our 23 hospitals, 170 clinics, and 850,000-member health insurance plan. To achieve that, we have implemented a model of daily huddles on an extensive scale. In this article, I’d like to share the insights we’ve gleaned from the model’s first full year of operation, which hopefully organizations in health care and many other industries will find useful. The model has been used in other industries and has parallels to the “teams of teams” approach in the agile method of operating that has become so popular. But the scale at Intermountain Healthcare, where more than 2,500 huddles occur every morning, makes it especially illuminating and instructive. At Intermountain, the 15-minute huddle is the key. It enables knowledge from activities throughout the organization in the previous 24 hours to escalate up to executive leadership — Tier VI in our model — and be addressed. Using that 15 minutes effectively requires structure: Each huddle has a leader; the participants are designated, as is the recorder of the data; the huddle is scheduled; and the categories of reported information are captured on a prepared chart. We have four fundamentals of extraordinary care that are covered in our daily huddles: safety, quality, access, and stewardship of resources so they are used to provide the best possible care. Across those fundamentals, eight key topics are reported every day. They include potential serious safety events that could have harmed a patient, caregiver injuries, and reported downtimes (of equipment, elevators, systems or processes, for example). The information that escalates up falls into two categories: Issues that cannot be resolved at a given tier Metrics that are reported daily, such as “units at capacity.” Information flowing back down includes follow-up reports on previous action items. Every action that emerges, including those at Tier VI, is tracked, and the outcome is communicated back through all tiers, so participants know what has transpired and understand the value of their input. After each Tier VI huddle, for instance, the recorder sends an e-mail to the person who owns each action and follows up to ensure that resulting outcomes are communicated. An item is not removed from the action register until follow-up is completed and conveyed. Interestingly, despite the number of huddles, the number of action items has never overwhelmed the system. Beginning at 8:45 AM, care teams and managers in our hospitals and clinics gather in more than 1,500 Tier I huddles. At 9 AM, their reporting is considered in about 170 Tier II huddles, consisting primarily of directors of hospitals and clinics. By 9:15 AM, the reports of those directors are considered in Tier III huddles by hospital administrators and geographical clinic groups. Their findings and needs are, in turn, considered 15 minutes later in Tier IV huddles of affinity hospital groups such as trauma hospitals, rural hospitals, home care, and the Medical Group. Their reports escalate further to Tier V, consisting of major organizational areas such as all hospitals and community-based care. By 10 AM, vital information has risen to the executive leadership, which includes the CEO and his direct reports plus other assigned functional executives. The entire process, which involved 652,080 huddles in the first year, is monitored by Intermountain Healthcare’s Continuous Improvement Team, and the categories of information collected are reviewed quarterly. The Continuous Improvement Team consists of about 50 caregivers who are spread geographically across the system. Team members have varied experience from industrial engineers to nurses and physicians, and a physician has responsibility for the team. Their focus is culture-based, not project-based, since we believe that real change and improvement come from a culture of continuous improvement aligned with strategy and a daily management system. At every tier, needs that can be addressed at that level are resolved, while remaining ones, along with accumulating data, escalate up. The process provides three key qualities — clarity, alignment and accountability — for patients and caregivers alike. The reporting lets executive leadership know precisely what is happening and unlocks frontline wisdom. It ensures alignment of goals, resources, and people. It pushes out responsibility and accountability to the frontline and enables executive leadership to intervene to remove barriers and release resources. It connects to the organization’s overall strategy and performance goals. Throughout the first year of operation of this model, which began in full in April 2017, the range and breadth of issues addressed was extensive. At the Tier VI level alone, 365 unique issues were tackled, resulting in 22 systemwide safety alerts to our caregivers, organizational awareness of 15 pharmaceutical and supply shortages, rapid communication for potential formulary alternatives when supplies become limited, and better facilitation of patient transfers within the system. We also recognized and closed gaps in training on new equipment, replacement parts, new products, and instructional manuals, allowing the system to implement swift training for our caregivers. An example of an important success of the escalation huddles is the ability to identify potential exposures to infectious diseases and quickly move to prevent the spread of diseases like pertussis, hepatitis, and chicken pox. Earlier this year, for instance, a community-wide outbreak of hepatitis b occurred. Our clinics reported the early development of the disease in huddles. That enabled Intermountain to prepare guidance for all clinics and ensure that staffing levels were appropriate and that increased dosages of needed drugs were on hand. Another example is how the huddles allowed us to better track caregiver injuries and patient safety issues. These successes are vital within a health care system devoted to the safety and wellness of our patients and caregivers. On the business side, the escalation process has provided improved visibility into operations. For instance, we have been able to track the increase in extended hours of access (beyond Monday to Friday; 8 AM to 5 PM) for our Medical Group clinics, including phone access and appointment availability, from 49% to 90% of clinics. We have pinpointed opportunities for improving staffing procedures and reducing interruption of services. On a national level, we have been able to work with two large vendors to improve their international shipping processes for replacement parts for imaging equipment, benefiting not only our organization but also many other customers of those companies. Here are some lessons we have learned about how to make the huddles approach work. It’s important to focus on trends and continually add and address issues being tracked. Every quarter we analyze what has escalated up and align it with key performance metrics. We often see significant quarterly differences — both because new needs arise and because previous efforts have improved metrics. We look at trends and how to address them, which may require adding new things to be tracked. In October, for instance, we added a new topic: errors in imaging, so that we can better understand any errors and how they occur. In reviewing trends, we have refined further the most vital metrics for executive leadership. We have also implemented a series of weekly reports in key system areas. Accountability is vital to the efficiency of the process. Every action taken is tracked, a time frame assigned, and the resulting resolution reported back through the tiers. That accountability demonstrates the value of the process to all participants. It reveals rapid results. It shows that executive leadership is engaged daily in responding to frontline needs. Perhaps most importantly, it underscores, in practical daily terms, the organization’s commitment to continuous improvement, providing a constant reminder and tangible evidence that the commitment is real and ongoing at the highest level of management. The entire process — from top to bottom — must be tied to the organization’s overall strategy and performance goals. That’s why Intermountain Healthcare’s four fundamentals of extraordinary care and eight key topics are covered in every day’s huddles. The eight topics are then tracked constantly and tie back to specific organizational goals. Continuous improvement is a constant quest. Escalation huddles offer enormous potential and striking results in that pursuit — both in health care and beyond.
The causes are numerous and complex, but it is the scale and the age of those involved that alarms adults on the frontlineWith a metallic creak, the door to one of Birmingham’s “weapons surrender bins” opened to reveal a plethora of blades, from kitchen knives to karambits, claw-shaped knives commonly used in south-east Asian martial arts which have lately featured in some computer games.It was a collection that had been building in the windswept car park of a church in the Hockley area of the city before being unlocked last week. Continue reading...
PlayStation 4, Xbox One, PC; EA/DiceThis technical tour de force throws you into realistic second world war battles – shame it felt only 70-80% finished at launchWith the advent of battle royale games like PUBG and Fortnite, there’s plenty of evidence that modern tastes in first-person shooters are changing and fragmenting, but Dice’s long-running Battlefield series has always catered for shooter enthusiasts who like to feel that they are participating in a realistic facsimile of a war. The good news is that Battlefield V takes that experience to new heights. It’s a technical tour de force, taking in second world war settings that vary from North African deserts and French villages to a Rotterdam reduced to rubble, with totally convincing looks, sound design and weapon-feel. Related: Beyond the frontlines: how Battlefield V found fresh WWII battles to fight Continue reading...
Manchester’s mayor says the city’s firefighters do not need to apologize for the delayed response to the suicide bombing at the Manchester Arena.
MirageC/Getty Images After a blizzard of hype surrounding the electronic health record (EHR), health professionals are now in full backlash mode against this complex new tool. They are rightly seen as a major cause of professional burnout among physicians and nurses: Clinicians are spending almost half their professional time typing, clicking, and checking boxes on electronic records. They can and must be made into useful, easy-to-use tools that liberate, rather than oppress, clinicians. Performing several tasks, badly. The EHR is a lot more than merely an electronic version of the patient’s chart. It has also become the control panel for managing the clinical encounter through clinician order entry. Moreover, through billing and regulatory compliance, it has also become a focal point of quality-improvement efforts. While some of these efforts actually have improved quality and patient safety, many others served merely to “buff up the note” to make the clinician look good on “process” measures, and simply maximize billing. Mashing up all these functions — charting, clinical ordering, billing/compliance and quality improvement — inside the EHR has been a disaster for the clinical user, in large part because the billing/compliance function has dominated. The pressure from angry physician users has produced a medieval solution: Hospital and clinics have hired tens of thousands of scribes literally to follow clinicians around and record their notes and orders into the EHR. Only in health care, it seems, could we find a way to “automate” that ended up adding staff and costs! Insight Center Health Care’s New Frontier Sponsored by Optum How technology is changing the design and delivery of care. As bad as the regulatory and documentation requirements are, they are not the largest problem. The electronic systems hospitals have adopted at huge expense are fronted by user interfaces out of the mid-1990s: Windows 95-style screens and dropdown menus, data input by typing and navigation by point and click. These antiquated user interfaces are astonishingly difficult to navigate. Clinical information vital for care decisions is sometimes entombed dozens of clicks beneath the user-facing pages of the patient’s chart. Paint a picture of the patient. For EHRs to become truly useful tools and liberate clinicians from the busywork, a revolution in usability is required. Care of the patient must become the EHR’s central function. At its center should be a portrait of the patient’s medical situation at the moment, including the diagnosis, major clinical risks and trajectory, and the specific problems the clinical team must resolve. This “uber-assessment” should be written in plain English and have a discrete character limit like those imposed by Twitter, forcing clinicians to tighten their assessment. The patient portrait should be updated frequently, such as at a change in clinical shifts. Decision rules determining precisely who has responsibility for painting this portrait will be essential. In the inpatient setting, the main author may be a hospitalist, primary surgeon, or senior resident. In the outpatient setting, it’s likely to be the primary care physician or non-physician provider. While one individual should take the lead, this assessment should be curated collaboratively, a la Wikipedia. This clinical portrait must become the rallying point of the team caring for the patient. To accomplish this, the EHR needs to become “groupware” for the clinical team, enabling continuous communication among team members. The patient portrait should function as the “wall” on which team members add their own observations of changes in the patient’s condition, actions they have taken, and questions they are trying to address. This group effort should convey an accurate picture (portrait plus updates) for new clinicians starting their shifts or joining the team as consultants. The tests, medications or procedures ordered, and test results and monitoring system readings should all be added (automatically) to the patient’s chart. But here, too, major redesign is needed. In reimagining the patient’s chart, we need to modify today’s importing function, which encourages users indiscriminately to overwhelm the clinical narrative with mountains of extraneous data. The minute-by-minute team comments on the wall should erase within a day or two, like images in SnapChat, and not enter and complicate the permanent record. Typing and point and click must go. Voice and gesture-based interfaces must replace the unsanitary and clunky keyboard and mouse as the method of building and interacting with the record. Both documenting the clinical encounter and ordering should be done by voice command, confirmed by screen touch. Orders should display both the major risks and cost of the tests or procedures ordered before the order can be confirmed. Several companies, including Google and Microsoft, are already piloting “digital” scribes that convert the core conversation between doctor and patient into a digital clinical note. Moreover, interactive data visualization must replace the time-wasting click storm presently required to unearth patient data. Results of voice searches of the patient’s record should be available for display in the nursing station and the physicians’ ready room. It should also be presentable to patients on interactive white boards in patient rooms. Physicians should be able to say things like: “Show me Jeff’s glucose and creatinine values graphed back to the beginning of this hospital stay” or “Show me all of Bob’s abdominal CT scans performed pre- and postoperatively.” The physician should also be able to prescribe by voice command everything from a new medication to a programmed reminder to be delivered to the patient’s iPhone at regular intervals. Population health data and research findings should also be available by voice command. For example, a doctor should be able to say: “Show me all the published data on the side-effect risks associated with use of pembrolizumab in lung cancer patients, ranked from highest to lowest,” or “Show me the prevalence of postoperative complications by type of complication in the past thousand patients who have had knee replacements in our health system, stratified by patient age.” AI must make the clinical system smarter. EHRs already have rudimentary artificial intelligence (AI) systems to help with billing, coding, and regulatory compliance. But the primitive state of AI in EHRs is a major barrier to efficient care. Clinical record systems must become a lot smarter if clinical care is to predominate, in particular by reducing needless and duplicative documentation requirements. Revisiting Medicare payment policy, beginning with the absurdly detailed data requirements for Evaluation and Management visits (E&M), would be a great place to start. The patient’s role should also be enhanced by the EHR and associated tools. Patients should be able to enter their history, medications, and family history remotely, reducing demands on the care team and its supporting cast. Patient data should also flow automatically from clinical laboratories, as well as data from instrumentation attached to the patient, directly to the record, without the need for human data entry. Of course, a new clinical workflow will be needed to curate all of this patient-generated data and respond accordingly. It cannot be permitted to clutter the wall or be “mainlined” to the primary clinical team; rather, it must be prioritized according to patient risk/benefit and delivered via a workflow designed expressly for this purpose. AI algorithms must also be used to scrape from the EHR the information needed to assign acuity scores and suggest diagnoses that accurately reflect the patient’s current state. Given how today’s clinical alert systems inundate frontline caregivers, it is unsurprising that most alerts are ignored. It is crucial that the EHR be able to prioritize alerts that address only immediate threats to the patient’s health in real time. Health care can learn a lot from the sensible rigor and discipline of the alert process in the airline cockpit. Clinical alerts should be presented in an easy-to-read, hard-to-ignore color-coded format. Similarly, hard stops — system-driven halts in medication or other therapies — must be intelligent; that is, they must be related to the present reality of the patient’s condition and limited to clinical actions that truly threaten the health or life of the patient. From prisoners to advocates. The failure of EHRs thus far to achieve the goals of improving health care productivity, outcomes, and clinician satisfaction is the result both of immature technology and the failure of their architects to fully respect the complexity of converting the massive health care system from one way of doing work to another. Today, one can see a path to turning the EHR into a well-designed and useful partner to clinicians and patients in the care process. To do this, we must use AI, vastly improved data visualization, and modern interface design to improve usability. When this has been accomplished, we believe that clinicians will be converted from surly prisoners of poorly realized technology to advocates of the systems themselves and enthusiastic leaders of efforts to further improve them.
Risk-averse culture to blame for fire chiefs barring deployment until two hours after bomb blastFrontline firefighters in Manchester who turned up two hours late to the Manchester Arena bomb last year have nothing to apologise for, according to Andy Burnham, the mayor of Greater Manchester.Some firefighters asked for forgiveness after an independent review into the arena terror attack criticised the fire service for playing “no meaningful role” in the aftermath of the bombing on 22 May last year. Continue reading...
Воруженная группировка «Джейш аль-Ислам» готовится к обороне населенного пункта Дума, расположенного в пригороде Дамаска Восточная Гута. Об этом сообщает организация Syrian Rebel Observatory (SRO) со ссылкой на собственные источники
The sad state of frontline tech support raises the question of whether AI bots could take it all over and we could fix any problem with a few words to our smartphone, making summoning technical support as easy as asking for the latest hit song on our Alexa or Google Home.
Via MauldinEconomics.com, Last month, Bain & Company issued a magnum opus report called “Labor 2030: The Collision of Demographics, Automation and Inequality.” The bad news is that Bain thinks automation will eliminate up to 25% of US jobs by 2030, with the lower-wage tiers getting hit the hardest and earliest. That will be devastating, and it’s not that far away. On a positive note, Bain predicts that the manpower needed to build out the technology will keep us all working until 2030. The Bain team is way more optimistic than I am. But they have their reasons. Why Is This Happening? The answer is demographics and automation. Employers increasingly turn to automation as they can’t find enough workers with the skills they need. The Baby Boom generation is leaving the workforce - although many Boomers are putting off their retirement as long as they can. The additional labor that came from one-time factors like China’s opening up has mostly run its course. At the same time, technology is getting better and less expensive. Source: Bain Macro Trends Group Much of the job automation so far has been mild. It has mostly replaced dangerous factory work or other repetitive, unpleasant manual labor. Often, automation makes human workers more productive instead of replacing them. But that’s about to change as artificial intelligence technology improves. Machines will be able to perform cognitive tasks that once required highly trained, experienced humans. Automation Will Hurt Everyone This trend might look like a good thing to employers. Invest in machines, lay off people, mint more profits. But that’s short-sighted because someone has to buy your products. The laid-off workers won’t spend as much unless they get new jobs. In theory, automation will enable lower prices, which will raise demand and create more jobs. Bain does not think it will happen that way. They foresee up to 40 million permanent job losses in the US. Source: Bain Macro Trends Group Projected Data Implies an Unemployment Rate of 25% In the next 10–12 years, the US economy will swing from a labor shortage to a huge labor surplus. With the labor force presently around 160 million, this implies an unemployment rate around 25%. I find it hard to see how we could call that an economic boom. Bain’s report also points out that wages will go down long before workers get replaced by machines. The mere existence of the new technologies will cap wages as the price of automating vs. employing humans falls. This will increase inequality and curb consumption. The best case is that reduced demand will result in decades of flat or mild growth. The worst? Economic dislocation and inequality lead to social breakdown and more calls for government intervention, higher taxes on the wealthy, and more generous welfare programs. None of those outcomes would be good, but it’s not clear to me how we’ll avoid them. Wealth Tax Is Coming There is a 50-50 chance that a left-wing populist movement will arise in the coming decade. And those odds mean higher taxes. And larger government and more government controls. And a wealth tax. Not an income tax, mind you, but a tax on all your wealth. Now imagine having to “donate” 1% or 2% of your net worth to the IRS every year. It could happen, and if it does, it will make it that much harder to keep your assets growing against other headwinds. I know that many of us think this outcome would be a terrible thing for the country. But it is quite possible that many more voters in this country will disagree with us, and things will change. Remember that the significant majority of Millennials, who will be voting in greater numbers, think that socialism is superior to free-market capitalism. For investors, a wealth tax would mean that merely keeping your wealth, let alone growing it, may get a lot harder in the next decade. * * * Join hundreds of thousands of other readers of Thoughts from the Frontline Sharp macroeconomic analysis, big market calls, and shrewd predictions are all in a week’s work for visionary thinker and acclaimed financial expert John Mauldin. Since 2001, investors have turned to his Thoughts from the Frontline to be informed about what’s really going on in the economy. Join hundreds of thousands of readers, and get it free in your inbox every week.
On the face of it, veteran virologist Robert Redfield seems like a good pick to lead the agency, but decades-old disputes are shadowing his appointment.
Seattle Genetics' (SGEN) cancer drug, Adcetris, gets FDA approval to include fifth indication, frontline treatment of advanced classical Hodgkin lymphoma, in its label.
Kyle Mizokami Security, What would you use to go to war with? The standard weapon of the Russian Ground Forces is the AK-74M. Developed in the 1970s as a replacement for the iconic AK-47, the main difference between the two weapons was the use of smaller, lighter 5.45-millimeter ammunition. The weapon, equipped with a thirty-round magazine, saw extensive use in the Soviet occupation of Afghanistan and was issued to frontline Soviet Units, particularly airborne, naval infantry and Germany-based conventional army units. The rifle has a side folding stock, 16.3-inch barrel and an overall length of thirty-seven inches. In 2015, the Russian Army adopted a number of Western-style upgrades to the AK-74M, including a skeletonized stock with adjustable cheek weld, a rail accessory mounting system similar to that on the M4 developed by Piccatinny Arsenal, foregrip and improved muzzle brake. Warfare in the post-9/11 period is primarily infantry-focused, with ground troops taking part in small-unit actions against insurgents and guerrillas. Fought on a wide variety of terrain, from arid desert regions to jungles and even cities, infantrymen have relied on their service rifles to get the mission done. Here are five of the best weapons, and how the wars of the twenty-first century changed them. M4 Carbine: Originally developed by Colt to fulfill a contract for the UAE, the M4 carbine was later accepted into U.S. Army and Marine Corps service. The M4 carbine is very similar to the M16A2 assault rifle, but features a shorter 14.5-inch barrel as opposed to the twenty-inch barrel of the M16. Like the M16A2, the M4 carbine fires the 5.56-millimeter round from a thirty-round magazine and has both semiautomatic and three-round-burst modes. Recently, as a result of battlefield experience with the M4, the U.S. Army decided to upgrade the weapons to the M4A1 standard. The -A1 carbines have thicker barrels for accuracy retention during sustained fire, an improved trigger, ambidextrous safety controls and the ability to fire on full automatic. Recommended: The Colt Python: The Best Revolver Ever Made? Read full article
Syrian President Bashar Assad was filmed driving through the recently liberated areas in the suburbs of Damascus on his way to visit frontline troops in eastern Ghouta. READ MORE: https://on.rt.com/91f6 COURTESY: RT's RUPTLY video agency, NO RE-UPLOAD, NO REUSE - FOR LICENSING, PLEASE, CONTACT http://ruptly.tv Check out http://rt.com RT LIVE http://rt.com/on-air Subscribe to RT! http://www.youtube.com/subscription_center?add_user=RussiaToday Like us on Facebook http://www.facebook.com/RTnews Follow us on Telegram https://t.me/rtintl Follow us on VK https://vk.com/rt_international Follow us on Twitter http://twitter.com/RT_com Follow us on Instagram http://instagram.com/rt Follow us on Google+ http://plus.google.com/+RT RT (Russia Today) is a global news network broadcasting from Moscow and Washington studios. RT is the first news channel to break the 1 billion YouTube views benchmark.
ilbusca/Getty Images A lot of money has been spent on information technology in health care with little to show for it. To understand why we must pay a visit to the hospital. It only takes 10 minutes of direct observation of a nurse in a hospital to understand care-delivery processes are not standardized and are dependent on individuals, not systems. This lack of reproducibility leads to errors. Since every caregiver does it his or her own way, it’s difficult to improve anything. Stable systems that are reproducible are required to deliver consistently high quality. Industrial companies figured this out 50 years ago. The writings of manufacturing gurus Imai and Shingo provide insight into how quality is built into processes. A process must first be stabilized then standardized before being improved. Because few standardized processes exist in care delivery there are many possibilities for error. That’s why simply making a poor process electronic by implementing an electronic health record (EHR) doesn’t lead to better quality or cost. When it comes to change, the technology is the easiest part. Most health systems in America have or are implementing the EHR. And the vendor processes for implementation have become very good. The hard part is to get the doctors, nurses, and administrators to agree on what is the best way to deliver the care. Since the doctors control most care decisions, the rest of the provider team follows the doctors’ lead. If the doctor wants to do things a certain way, that’s what is done. The problem is the next doctor wants it his way and so on. Eventually, we end up with a hopeless mess in which no one knows how anything should be done on any given day. And good luck to a new nurse or technician coming into the system who must learn a multitude of work processes and remember the doctor-dependent differences. Health care technology is very effective when it is used to support a well-designed care process. The design of new standard care processes need to be owned and driven by the people doing the work, not by some outside consulting firm that brings a 100-page playbook as the answer. As the frontline workers create new designs, they need certain systems that can help them deliver the improved care. Examples of these systems include electronic alerts for medication interactions and reminders to ensure all steps in the care process for the pneumonia patient are followed. Insight Center Health Care’s New Frontier Sponsored by Optum How technology is changing the design and delivery of care. There are two types of improvement systems needed to create a well-designed care process. One is a improvement approach that brings members of an existing clinical team members together to improve an existing care process. They use proven improvement methods such as the principles, systems, and tools of the Toyota Production System (TPS). The second is an innovation process aimed at radically redesigning care. It’s associated with TPS and employs design thinking. In both cases, the initial effort where rapid experimentation occurs might be an ambulatory clinic or an ER. It becomes a place for others in the organization to learn. It is an inch-wide, mile-deep change in practice that incorporates new processes not only for care delivery but also management. It should result in the systems necessary for sustaining improvement over time. As the model line achieves 50% to 80% improvement over baseline performance, the learning should be spread to other parts of the organization. This new way becomes the new best-known way to deliver care. One example of a radical innovation is the attempt of HealthEast (now part of Fairview Health Services), which serves the Minneapolis-Saint Paul area, to create the clinic of the future. The leaders brought the vendors in their extended supply chain to the table to help in the design process. This included Epic, an EHR company; Herman Miller, an office furniture company; Boldt, a construction company; and HGA, an architectural firm. Together, the team began redesigning the care-delivery model. Each vendor had the opportunity to deeply understand the needs of the HealthEast providers. By the end of the design phase a new process supported by electronic records, architecture, furniture, and building was integrated to create a unique patient experience. Before HealthEast formed the model clinic, a group of 11 clinicians had over 11 preferred ways for “their” clinic assistant to do just about everything. One key process, screening the patient for health risks such as cancer and hypertension, resulted in over seven places in the EMR for the provider to look for relevant information. Not only is that time-consuming (contributing to physician burnout), but it also greatly increases the chances of missing important information. The multi-disciplinary team created a single screening process. Now, clinicians have just two places to look in the EMR for information on whether patients have had screens like mammograms and colonoscopies for cancer, staff can remind patients about what screening tests they need, and leaders are able to support the development of standardized clinical processes. The leader’s standard work is to audit the process and monitor the data. If the process stops being followed or the data shows deteriorating results, leaders will know that immediately. In the first three months after its introduction, the redesigned process reduced provider search time per patient by 23 minutes. The overall screening rate went from 60% compliance to 72% compliance, meaning over 500 more individuals were appropriately screened over baseline. Perhaps more telling are the changes in patient comments. They went from comments such as “I do not feel my medication list was reviewed,” to “My doctor and medical assistant are always timely, thorough, and reassuring.” These results would not have happened unless all parties were working to build a better process. Technology now exists to support disruptive innovation in health care. It is an important enabler, but the process must precede the technology. For example, Hospital at Home is an innovation that may well cut the cost of care significantly by reducing the need for inpatient beds. It couldn’t happen without the technology, which allows 24-hour monitoring of patients, real-time electronic communication between providers, and complex equipment to be rapidly set up in the patient home. But it still requires a nurse and a doctor. What that nurse and doctor do and how they do it are still what will determine successful outcomes of care. Building the care process through careful understanding of what each process step delivers is critical. The medical team can then leverage the technology for data and communication and other needs that support the steps in the process. Again, this requires standardized work. Every nurse and doctor does not get to do it his or her own way. Standards are established about how the work is performed, and those standards are followed by all until a better way is determined collectively by the team. New innovative care models such as Hospital at Home are based on clear and reproducible standards and will obsolete the old ways of the non-standardized care delivered in most hospitals. *** It takes more design time to create a care model that builds in quality and efficiency, but without that work upfront, the technology doesn’t matter and, in fact, only increases costs. This thinking is not new. Many industries from aviation to automotive to nuclear power have been applying this concept of “process before technology” for a long time. The safety and quality results in those industries is second to none. It’s about time health care catches up. Our lives may depend on it.
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