Closing the Loop by Operationalizing Systems Engineering and Design (CLOSED)
Motivation:
Specific Aims :
Aim 1:​Use systems engineering and patient engagement to design, develop, and refine a highly reliable “closed loop” system for diagnostic tests and referrals that ensures diagnostic orders and follow-up occur reliably within clinically- and patient-important time-frames.
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Aim 2: Use systems engineering and patient engagement to design, develop, and refine a highly reliable “closed loop” system for symptoms that ensures clinicians receive and act on feedback about evolving symptoms and physical findings of concern to patients or clinicians.
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Aim 3: Design for generalizability across health systems more broadly so that the processes created in Aims 1 and 2 are effective in (1) a practice in an underserved community, (2) a large tele-medicine system, and (3) a representative range of simulated other health system settings and populations.
Partners:
Sunday, June 2, 2019
Sunday, June 2, 2019
Approach:
Sunday, June 2, 2019
Results to Date:
Improvements to Root Cause Analysis of Patient Safety Events
About
Patient safety and adverse events are a major problem across the healthcare continuum, generating substantial costs and negative health implications. Although there has been significant focus towards their improvement over the course of the last 30 years, progress has been slow and limited.
The objective of this project was to understand inter-rater reliability of selected safety analysis methods and study the relative advantages and disadvantages of these methods compared to Root Cause Analysis RCA.
Results
Training materials were developed and used to prep undergraduate and graduate students for going to the VA National Center for Patient Safety (NCPS) in Ann Arbor. A VA site visit was conducted and a team of researchers were then based at the VA in Ann Arbor, MI to assess local patient safety and adverse event data. It was identified that FRAM, a safety assessment method, could be an alternative to RCA since FRAM evaluates safety events from a nonlinear systems approach.
Project Team
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Lindsay Baldo
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Nicholas Fasano
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Ali Hobbs
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Karen Chen
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Saytan Chari