According to recent IOM reports, The Future of Nursing, Nurses can play a key role in the healthcare transformation process. Organizations such as the American Nurses Credentialing Center, the American Nurses Association and Magnet programs have supported and strengthened the mission to improve the nursing profession through education, advanced degrees and certifications. Central to the transformation process is self-regulation and accountability for clinical practice (Code of Ethics, ANA). The Peer Review process affirms the nurse's duty to being accountable for professional practice, competence in skills and knowledge in evidence-based care delivery. Thus, peer feedback promotes patient safety, reduces the likelihood of errors, and addresses the human factor element in patient care delivery to improve patient outcomes.

1. 0 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
Aligning Clinical Practice & Process
Improvement in Healthcare Delivery
. . . help close gaps in care
Abstract This proposal
advocates an alternative approach to
reduce clinical variability in patient care
delivery by integrating a collaborative
learning model with continuous
professional development, quality
improvement, and real-time health
information management.
Failure to adopt best practices and care
coordination contributed approximately
$125 billion dollars in excess spending to
the US healthcare system.1,2

2. 1 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
Copyright© 2013 clinicalMessage Inc.
All rights reserved.
CloseCareGap is trademark of closecaregap LLC and clinicalMessage is
trademark of clinicalMessage Inc. All other brand, company, and product
names are used for identification purposes only and may be trademarks that
are the sole property of their respective owners.
Aligning Education and Process Improvement in Healthcare Delivery
....help close gaps in care
Document No. 2013-01-011
Published by CloseCareGap and clinicalMessage 2013
Any comments relating to the material contained in this document may be
submitted to:
• 761 West Sproul Road, Suite #301 Springfield, PA 19064 USA

3. 2 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
Context and Opportunity Statement
The Healthcare system is undergoing unprecedented change.
Patients, providers and policy leaders are coming together to re-
design care delivery, expand services, improve patient safety,
reduce errors, and decrease total cost of care.3
At the same time,
professional associations and regulatory agencies are striving to
close gaps in care by adopting new technologies, building creative
care models, and developing collaborative learning programs. 2,3,4,6
According to recent IOM reports, The Future of Nursing,7,8
nurses can play a key role in the healthcare transformation
process. Organizations such as the American Nurses Credentialing
Center,9,10
the American Nurses Association11
and Magnet
programs have supported and strengthened the mission to
improve the nursing profession through education, advanced
degrees and certifications. Central to the transformation process is
self-regulation and accountability for clinical practice (Code of
Ethics, ANA 12
). The Peer Review process affirms the nurse's duty
to being accountable for professional practice, competence in skills
and knowledge in evidence-based care delivery.13
The Continuous Improvement
Methodology
In this proposal, we embrace “Peer Assessment” methodology
since it creates a non-punitive culture and supports experimental
and shared learning. A Peer review provides a healthy means for
obtaining critical feedback and compliance measures for clinical
performance in care delivery.13
A robust Peer Review Process (PRP)
is achieved through direct, real-time clinical observations or
through retrospective chart review. Peer-to-Peer observations
measure the current practice against industry standards and
reduce care variability. Continuous performance improvement
fosters the refinement of knowledge, skills, and clinical decision-
Silent Leaders of
Change
When I was asked to
improve the health and
safety performance of a
car manufacturing plant
twenty- five years ago,
the change leaders were
not the CEO, or the Plant
Manager; the true
leaders were the people
on the shop floor. They
were the unsung heroes
who implemented and
drove real change not
because somebody asked
them to do so but due to
the fact that change had a
positive impact to their
work life and organization
leadership freed them to
realize this needed
change.
Similarly, if we want to
improve quality and
safety of patient care in
hospitals, we need to tap
our silent leaders –
Nurses; let’s free them to
do their job.
Read the Blog

4. 3 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
making processes to enhance individual competencies and
enterprise capabilities.14
Thus, peer feedback promotes patient
safety, reduces the likelihood of errors, and addresses the human
factor element in patient care delivery.13
PRP brings additional
benefits by meeting professional requirements to various
organizations such as Magnet designation, ANCC for evaluating
learning effectiveness, the employer for improved patient
outcomes, and society by making care affordable.
Solution Direction
Our mission is to identify and measure unexplained gaps in clinical
care. These critical gaps lead to unnecessary care variability and
medical errors15
. To close the gaps and incorporate evidence into
action, we advocate a clinical improvement learning platform by
leveraging lessons from proven industry leaders4,16
. Toyota and the
airline industries have revolutionized the consumer experience by
systematically simplifying, standardizing, combining and
automating processes and raising the bar to zero error defects.
Healthcare is now realizing the benefits of such EBP models16
and
incorporating checklists, bundles, Lean, Six Sigma and Crew
Resource Management to improve care delivery.17, 18
Our solution advocates a Lean approach (effective tool to tame
wicked problems) with Six Sigma tools building a Clinical Learning
Improvement Platform (CLIP). This process improvement learning
model includes two key components - peer review and real-time
process observations. The professional clinical learning platform
collects data from peers and then measures care delivery against
best practice standards. Clinical Improvement Learning Platform
(CILP) includes:
 Self-paced online learning for common nursing processes
 Instructor-led education delivered to geographically
diverse audiences
Healthcare
Transformation is a
wicked problem 19
There are some problems
that are just “wicked” in
nature. They can’t be
solved and can only be
tamed. Healthcare
Improvement is one such
wicked problem because of
a variety of factors
including:
 Social complexity: the
number of stakeholder
who are impacted by any
change
 Wickedness: the number
of stakeholders who
must agree on the
problem definition as
well as the solution
 Technology complexity:
our current technology
solutions are just not
capable of handling the
speed, agility and cost
effectiveness required in
healthcare solutions.

5. 4 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
 Ability to engage in the Peer Review process through
real time clinical process observation
 A guide to continuous improvement initiatives through
the project management life cycle
 An industry repository data bank to measure variations
in clinical care delivery
 Adoption of an agile real-time health information system
that is integrated with current EHR and delivers
pertinent patient health information at the point of care
Care Processes to Audit/Review
Our team has developed an integrated HIT capability to help reduce
variations in the clinical practice at the bedside. This platform can be
implemented incrementally with minimum disruption to your
hospital’s current operations. We have adopted the “IHI Leadership,
Support and Care Processes” listed below as critical areas to focus on
closing gaps in care using a Continuous Learning Improvement
Platform.
(Table 1: IHI Process Map)20
Support Care Processes
Communication Infection Control
Care Transitions Hand-washing
Critical Lab Reporting Isolation & Patient Transport
Daily Goal Setting/CP Standard Precautions
DC Planning Use of PPE
Documentation
Handoff
HIPAA Confidentiality
Hourly Rounds
Huddles
Multi-disciplinary Rounds
Select the Right
Projects and Do Them
Right the first time
Quality and Cost of care
will improve only when
the enterprise has the
capability to execute
these IHI outlined
processes repeatedly
with minimum variation
regardless of who, when
and where the care
processes are executed.
New information
technology such an EHR
is a tool and not a
solution.
Avoid the mistakes that
other industries have
made with their
Enterprise Resource
Planning Systems.

6. 5 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
Support Care Processes
Patient Education
Team Collaboration
Our award winning clinicalMessage solution helps operationalize
these evidence based practices and lets you measure their impact
on patient care outcomes and staff satisfaction.
Through partnerships with QRS (www.qrs3e.com) and Jefferson
School of Population health
(http://www.jefferson.edu/population_health.html),
clinicalMessage has developed a comprehensive education, training
and consulting program to help you develop your healthcare
transformation capability. We can help you with:
• Management of HIT Change Program Complexity: A two-day
hands-on education and strategy development program
• Business Transformation as an Enterprise Capability; an eBook
Leadership Process
Strategy and Leadership Execution and Leadership
Set Direction and Focus Alignment and Coordination
Operating Values Build capability for Execution &
Improvement
Governance and Improvement Measure, oversee and communicate
Engage Patients and Families Connect Leaders to the Frontline
Portfolio and Project
Management
Innovation and Knowledge
Management
Generate Ideas
Controlled Execution
Our Teams
We work with your
staff to help develop
their capabilities to
improve
• Support Care
Processes
• Leadership
Processes
• Patient Care
Processes
Internally we foster
collaborative and
learning culture to
share our passion and
expertise with our
customers

7. 6 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
• theBTcloud; a SaaS solution to help you improve quality,
reduce risk and cost of your transformation programs
Patient Care Processes
Assessment Checklist/Bundle Medication Prevention Safety
Admission Central Line Bundle Anticoagulation
Management
Aspiration Bed Alarms
Cardiac/Skin/G
I/ Respiratory
Foley Care Bundle Antibiotic
Timeliness
CAUTI CR Alarms
Early Warning
System
Sepsis Management Blood Product
Admin
Central Line
Care
Patient Falls
High Frequency
Observations
Sepsis Resuscitation G-J Tube Feeds Glycemic
Control
Patient
Identification
Neuro/Neurova
scular
Surgical Checklist Medication
Admin
Pressure
Ulcer
Patient
Restraints
Pain
Management
Universal Protocol Medication
Ordering
Sepsis
Detection
Pump Alarms
Pre-Op
Assessment
VAP Bundle Medication
Reconciliation
Venous
Thrombosis
Rapid Response
System
TPN
Administration
To help improve Patient Care processes, we provide a robust real-time
audit and continuous improvement platform. Your team can leverage
these tools and become part of close care gap PSO.
Summary
Our mission is simple – to use clinical process observation and
professional accountability tools to identify and measure unexplained gaps
in clinical care. These critical gaps in care delivery lead to escalating
healthcare costs, increased rates of infection, poor patient satisfaction,
delays in care and medical error. By identifying gaps in clinical practice,
we can develop specific action plans to improve patient outcomes, support

8. 7 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
quality improvement, and build transparency in the health care system to
support the IHI Triple Aim measures. We bring over twenty five years of
process improvement experience from many industries and cultures.

9. 8 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
References
1. Berwick, D. Hackbarth, A. Waste in Healthcare. JAMA. 2012;307(14):1513-1516. Website:
http://www.hta.hca.wa.gov/documents/Waste_in_Healthcare_JAMA_2012.pdf
Accessed April 20, 2013.
2. Report of the Lucian Leape Institute Roundtable. Order from Chaos: Accelerating Care Coordination
(2012) Website: http://www.npsf.org/wp-content/uploads/2012/10/Order_from_Chaos_final_web.pdf
Accessed April 20, 2013.
3. Department of Health and Human Services. Report to Congress (2012) National Strategy for Quality
Improvement in Healthcare. Website: http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf
Accessed April 20, 2013.
4. IOM Consensus Report (2012). Better Healthcare at Lower Cost: The Path to Continuously Learning
in Healthcare in America. Website: http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-
Path-to-Continuously-Learning-Health-Care-in-America.aspx Accessed April 20, 2013.
5. Stiegel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and
Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for
Healthcare Improvement; 2012.
http://www.ihi.org/knowledge/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspx Accessed
April 20, 2013.
6. IOM Core Metric for Better Care, Lower Cost and Better Health (2012). Website
http://www.iom.edu/Activities/Quality/VSRT/2012-DEC-05.aspx Accessed April 20, 2013.
7. IOM Report Brief. The Future of Nursing, Leading Change Advancing Health (2010).
http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-
Nursing/Future%20of%20Nursing%202010%20Report%20Brief.pdf
Accessed April 20, 2013.
8. IOM Consensus Report. The Future of Nursing, Leading Change Advancing Health (2011).
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
Accessed April 20, 2013.
9. American Nurses Credentialing Center’s Commission on Accreditation (2012). The Value of
Accreditation for Continuing Nursing Education: Quality Education Contributing to Quality Outcomes.
Silver Spring, MD: American Nurses Credentialing Center.
http://www.nursecredentialing.org/Accreditation/ResourcesServices/Accreditation-
WhitePaper2012.pdf Accessed April 20, 2013.
10. American Nurses Credentialing Center’s Commission on Accreditation. ANCC Primary Accreditation
Application Manual (2013) http://www.nursecredentialing.org/Accreditation/2013-
PrimaryAccreditationManual.html Accessed April 20, 2013.
11. American Nurses Association. ANA Scope and Standards of Practice Nursing, 2nd edition (2010).
http://library.brcn.edu/upload/docs/BRCN/Library/ANA/eBk_SL%20Nursing%20Scope%20%20Standards
%202e%202010.pdf Accessed April 20, 2013.
12. Nursing World. ANA, Code of Ethics with Interpretive Statements (2010).
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-
Ethics.pdf Accessed April 20, 2013.

10. 9 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
13. Diaz, L. Nursing Peer Review: Developing a framework for patient safety. Journal of Nursing
Administration (2008) Nov. 38(11) 475-9.
14. IOM Workshop Summary . Digital Data Improvement Priorities for Continuous Learning in
Healthcare (2012). http://www.iom.edu/Reports/2012/Digital-Data-Improvement-Priorities-for-
Continuous-Learning-in-Health-and-Health-Care.aspx Accessed April 20, 2013
15. Hospital Survey on Patient Safety: 2012 User Database Comparative Report by AHRQ.
http://www.ahrq.gov/legacy/qual/hospsurvey12/hospsurv1223.pdf Accessed April 20, 2013.
16. Closing the Gap: From Evidence into Action (2012). The International Council of Nurses.
http://www.icn.ch/images/stories/documents/publications/ind/indkit2012.pdf
Accessed April 20, 2013.
17. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI
Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement;
2012. http://www.ihi.org/knowledge/Pages/IHIWhitePapers/UsingCareBundles.aspx
Accessed April 20, 2013.
18. Gawande, Atul, MD. The Checklist Manifesto: How to Get Things Right. Picador Publishing (2011)
(ISBN 10: 0312430000 / ISBN 13: 9780312430009)
19. Conklin, J. Wickedness and Social Complexity. http://cognexusgroup.com/wp-
content/uploads/2013/03/wickedproblems.pdf Accessed April 20, 2013.
20. Institute for Healthcare Improvement Gap Analysis Map, 2013. Accessed April 20, 2013.
http://www.ihi.org/offerings/Initiatives/Improvemaphospitals/Documents/IHIGapAnalysis.pdf

11. 10 | P a g e
Jason Uppal, MA, P.Eng. |Chief Architect, clinicalMessage.org
Kate Oneill, MSN, RN | VP, Clinical Services, CloseCareGap.org
About Us
 Close Care Gaps
Close Care Gaps is a healthcare management consulting firm with
expertise in care delivery processes. Close Care Gap principles bring
many years of hands on clinical, education and continuous process
improvement experience.
• Email: kate@kateoneill.org
• Telephone: 610. 505. 0996
• Web: www.kateoneill.org
 clinicalMessage
clinicalMessage is a platform designed to improve management and flow
of health related information across the entire continuum of care including
to patients and families. At the core, it is an information management
system that helps operationalize the evidence based best practices across
the entire organization and measures their impact on quality and cost of
care. clinicalMessage is a social corporation with the head office in
Philadelphia USA and presence in Toronto Canada.
Contact:
• Email: Jason.uppal@clinicalMessage.org
• Telephone: 610. 732. 8500
• Web: www.clinicalMessage.org