key: cord-1009296-mapmeugl authors: Vilcahuamán, Luis; Rivas, Rossana title: Improvement Healthcare Projects: Meeting Healthcare and Technology Challenges date: 2017-07-21 journal: Healthcare Technology Management Systems DOI: 10.1016/b978-0-12-811431-5.00008-4 sha: 916d81f510b97b4344f521edbc196bca0257b7e7 doc_id: 1009296 cord_uid: mapmeugl The complexity of the healthcare environment and the one related to the healthcare organization itself are some challenges of today’s healthcare, these challenges determine a relevant change in the way we understand health systems and determine approaches to improve the results of healthcare projects. In the same regard, the management of emerging technologies requires transformational changes to face effectively the trends in healthcare. The chapter introduces to Systems Engineering it involves thinking holistically and work with transdisciplinary teams to develop solutions. These challenges determine a relevant change in the way we understand health systems, Fig. 8 .1 illustrates some obstacles in the case of the biodefense role of public health for example; in this regard Salinsky [1] states, "A transformed public health system is needed to address the demands of emergency preparedness and health protection. . . .The future public health system cannot afford to be dictated by outmoded tools, unworkable structures, and outdated staffing models." Mega Trends are global, sustained, and macro-economic forces of development that impact business, economy, society, cultures, and personal lives thereby defining our future world and its increasing pace of change. On the top of the "Top 10 Mega Trends to 2020," eight have significant emerging technology components. Emerging technologies will be the dominant driver of disruptive change for the future [2] . Healthcare systems despite the level of their economic sector should be aligned to the change. See Fig. 8 .2A, B: The Mega Trend number 8: "Health, Wellness & Wellbeing" facilitates the understanding about (1) the increasing level of complexity of the health organization; and (2) the value of the multidisciplinary workforce (physicians, nurses, engineers, managers, biologists, chemists, etc.) capacity to work as a team to be aligned to the current and expected challenges. See Fig. 8 .3. The Healthcare trends experimented by developed and developing countries define a relevant change for health systems. An interesting contribution from The consideration of the enablers contributes to the understanding that the management of technology from an effective and consistent perspective dismisses the link of health technology exclusively with operational and/or technician areas. Systems Engineering (SE) is a systems approach which focuses on developing solutions aligned to (1) economics; (2) technology; (3) social dynamics; and (4) healthcare policy. This perspective is consistent to high, medium, or small levels of economy. A systems approach involves thinking holistically and work with transdisciplinary teams to develop solutions [3] . The Institute of Medicine-IOM [4] and the National Academy of Engineering-NAE [5] recommended and advocated the widespread application of SE tools to improve healthcare delivery [6] . Despite the differences between the levels of the economic sector, healthcare environments have in common: management, project planning, inventory, logistics, facilities design, process flow analysis, resource synchronization, etc. This framework aims on improving the analysis and results expected. Kopach-Konrad [7] emphasizes that the application of SE requires medical professionals and managers understand and appreciate the power that SE concepts and tools can bring to (1) redesigning, and (2) improving healthcare environments and practices. SE focuses on the design, control, and orchestration of system activities to meet performance objectives. A System is a set of possibly diverse entities (patients, nurses, physicians, etc.), each performing some set of functions. The interaction of these entities as they perform their various functions gives rise to a global System Behavior. Fig. 8 .5 illustrates the steps oriented to manage a healthcare improvement project according to SE model [7] . SE approach is pertinent to the growth, operation, and synchronization of many information-rich and technologically complex economic sectors, as described above health related to developed and developing countries is certainly an interesting sector to SE's application. The following is one of the examples: Applied Physics Laboratory-APL and Johns Hopkins Medicine-JHM [8] applied successfully SE to achieve effectiveness and efficiency objectives in the intensive care unit-ICU (Project funded by the Johns Hopkins University Whiting School of Engineering Systems Institute-WSE-SI to study integration and interoperability opportunities and challenges in the ICU, emphasizing the role of the patient and family in their own care within the ICU, USA, 2011À2012.). The objective was on identifying where and how integration and interoperability could improve clinical situational awareness and command and control. The new ICU system has an information display system based on a common Integrated Clinical Picture-ICP user interface. ICP is designed for rapid, intuitive information integration, assimilation, and sense-making. The ICU system also provides the ability to control the state of clinical systems (infusion pumps, ventilators, and other medical devices) and nonclinical systems (lighting, heating, ventilation, television controls, etc.). The process included the development of measures of effectiveness and measures of performance that quantitatively and qualitatively provided guideposts to improve safety and quality in healthcare delivery. Below the "V-model," sequence of system development, test & evaluation, and fielding utilized by the team, see Fig. 8 .7. By using V-model health workforce team adheres to SE's best practice of maintaining a comprehensive set of technology, documents, execution of reviews and analyses. V-model that enables the system requirements may be traced through the design and evaluation phases, ensuring delivery of a system that meets stated objectives. Government, Regulations, and policies influence the Test and Evaluation activities. V-model is useful in healthcare for device and system development efforts, development of new clinical protocols, the integration of devices, protocols, etc. IOM defines Quality of Care as: "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" [9] . Some reasons for low quality in health services are inadequate provision of care, limited resources, and the rising costs by inappropriate care. In this regard, a relevant number of evidences around the world, developed and developing economies included, indicate the value and need of including a Management perspective in the elaboration of solutions, the alignment is not achieved as expected yet [10] . Healthcare quality improvement nowadays requires the expansion from the traditional interpretation of structure to include broader perspectives from (1) the organizational framework; and (2) clinical/biomedical engineering (BME), healthcare technology planning and management. The achievement of quality care results is increasable complex in 2001 IOM report, "Crossing the Quality Chasm," concluded that fundamental changes in the healthcare sector are needed to ensure high quality of care for patients with chronic conditions and recommends evidence-based planned care and re-organization of practices with the goal to become organizations that meet patients' needs, since then there is a remarkable progress at the same time the goals still required to be achieved [11] . Although over the last years healthcare quality has improved, the adverse events occurred around the world are one of the evidences about the need to improve quality in healthcare. Patients can be harmed by transfusion errors, adverse drug events, wrong-site surgery, surgical injuries, treatment-related infections, falls, wrong utilization of healthcare technology, lack of knowledge/training related to clinical guidelines, etc. A study of Classen et al. ("Global trigger tool" shows that adverse events in hospitals may be ten times greater than previously measured. Health affairs 2011;30(4):581À9.) determined that in US healthcare system, adverse events occurred in one-third of hospital admissions, even in hospitals that had instituted advanced patient safety programs. According to the WHO (http://www. who.int/patientsafety/en/), based on the incidence of adverse events worldwide, the chance of being harmed in healthcare is 1 in 10; 43 million of patient safety incidents occurred around the world; the risk is distinctively higher in developing countries. Additionally, although the Evidence-based Clinical Practice Guidelines are aimed to improve quality of care for specific clinical cases, the adherence from the physicians is still insufficient [12] ; the situation has a relevant impact in the quality of service in countries like United States [13] and is one of the factors which drive the low quality of healthcare in developing countries [14] . Aligned to the perspective of linking Evidence-based Medicine to Evidencebased Management to improve quality of care, Frolich [15] states a model on which the quality of care is defined according to the level in the healthcare system at which it is assessed. The author presents Determinants of Quality of Care as features developed to improve quality of care, see Fig. 8 Some of the limitations of the management perspective are: the quality determinants at high-performing sites depend on the context; the mechanism of operation and the effect on quality of care of financial and disclosure incentives are complex and depend on shape, content, and design of the incentive. The definition of the dimensions requires analyzing the health organization considering the strategic and operational aspects; certainly this framework contributes to the quality of the healthcare project. Healthcare technology requires a systems approach as medical devices become connected to the Information Technology-IT network for interchanging data with the Electronic Health Records-EHR and other medical devices. In United States there is limited amount of appropriate curriculum and hands-on laboratory resources among the 87 US university-based BME programs to manage medical device interoperability [16] . Sloane [17] remarks that for the past decade, few medical devices were designed to operate in a vacuum. Most have one or more embedded computer and communication chips/modules that allow the devices to connect to other devices, hospital information systems-HIS, and/or specialized systems like Laboratory Information Systems-LIS and Radiology Information System-RIS. Medical devices, HIS, LIS, and RIS products are now being designed to allow or even promote device-system integration and interoperability as the author states, as a consequence the devices must be safely and reliably perform their primary design function(s), but they also now send and receive data and patient information to other devices and the HIS. This context stablishes the need of an appropriate education, training, and credentials (http://www. who.int/ehealth/en/). Figs. 8.10 and 8.11 show the recommendations for Education and Training on Skills in Management and Leadership according to Sloane. The System approach applied to Healthcare contributes to better understand and even to predict health needs also improve the elaboration of solutions. In the case of the increasing emerging Health-related technologies we observe an opportunity to improve patient outcomes; it is recommended though to consider the investment on several factors as education and training to be aligned to the requirements. 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