In this section we plunge deeper into the challenge of creating a rich information environment by discussing the central role information plays, by clarifying a fundamental informatics design principle, and by introducing three powerful frameworks for using and displaying vital data.
As displayed in Figure 1.5 in Chapter One, information and information technology make up a feeder system that supports the four areas into which the key success characteristics are grouped—leadership, staff, patients, and performance. Information exchange is the interface that connects
• Member to member—staff to patients and staff to staff—within the microsystem
• Microsystem to microsystem
• Microsystem to mesosystem and macrosystem
Information technology facilitates effective communication. Multiple formal and informal channels are used to maintain accurate, honest, and timely dialogue among all parties.
Designing Information Flow to Support the Smallest Replicable Units of Activity
A rich information environment does not just happen, it must be designed and improved over time. It can be engineered to support the organization's ability to deliver high-quality services to patients at the level of the smallest replicable units (SRUs) of activity within a microsystem (Quinn, 1992). For example, gathering patient registration data, collecting patient health status data, arriving at a diagnosis based on the data, and assessing changes in patient outcomes over the course of treatment all represent SRUs of activity that are embedded in clinical microsystems. Each of these SRUs of activity can be supported by designing an information system—to capture, analyze, use, store, and reuse data—that fits well into the flow of work and supports doing the right work in the right way efficiently. Quinn (1992) makes the point that the leading service organizations in the world do exactly this and that to do so is a strategic advantage. To realize this advantage, however, requires (1) a fundamental understanding of the nature of frontline work and frontline processes and (2) building the information system from a core process base and capturing data in its most disaggregated form, that is, at the SRU level. This can be done, as demonstrated in each case study in this chapter, but doing so is extraordinary in today's health system. It needs to be ordinary in tomorrow's health system if we are to cross the quality chasm (Institute of Medicine. . . , 2001).
Making Progress by Building on Three Useful Frameworks
The path to the creation of a rich information environment can be made smoother and easier (though still not easy) by applying some useful frameworks:
• Feed forward and feedback
• The patient value compass
• The balanced scorecard
In the following sections we provide short introductions to each of these frameworks, using our case studies to illustrate how they can be adapted to the real world of clinical practice. When leaders apply these core ideas to specific clinical microsystems, they can create more powerful information environments.
Framework 1: Feed Forward and Feedback—Can We Use Data to Do the Right Thing Right the First Time and Every Time? Figure 9.2 portrays an information environment built by a microsystem in order to use both feed forward and feedback data to manage and improve care. The general idea involved in using feed forward is to collect data at an early stage in the process of delivering care, save it, and use it again at a later stage: that is, to manage and inform service delivery—to do the right thing, in the right way, the first time (in real time) for each patient. The general idea involved in using feedback is to gather data about what has happened to a patient, or a set of patients, and to use this information to improve care so that future patients will get the right thing, in the right way.
Both feed-forward and feedback methods are commonly used in care delivery. For example, many medical practices caring for patients with hypertension have a nurse or medical assistant measure the patient's blood pressure level and feed this information forward to the physician, who uses it to guide decision making concerning the treatment and the need for adjustments to the regimen. Likewise, many primary care practices show the level of control achieved by the panel of hypertensive patients under the care of each physician in the practice and will feed these comparative data back to identify the degree of success and to identify improvement opportunities.
The case studies presented at the beginning of this chapter offer examples of advanced uses of data feed forward:
• The Spine Center uses touch-screen computers to collect information on the patient's general and disease-specific health status; this database provides a well rounded basis for patient and clinician to engage in shared decision making to best match the patient's changing needs with the preferred treatment plan.
• The Overlook ED uses cycle time monitoring to determine if and when patient flow bottlenecks are occurring; this provides a basis for taking immediate corrective action before a slowdown degenerates into a meltdown.
• The IHC STRICU uses real-time monitoring of each patient's clinical parameters to feed forward into daily rounds; this provides full-bandwidth data for the multidisciplinary team to use to make sure the care plan matches the patient's acuity.
FIGURE 9.2. FEED FORWARD AND FEEDBACK IN A MICROSYSTEM: THE SPINE CENTER DESIGN FOR INFORMATION FLOW.
Spine Center Process
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