Guideline Adherence andManagement System
Cognuse White Paper
October 2019 version 1.0

COGNUSE CONURSE | Guideline Adherence and Management System

INTRODUCTION
Despite the widespread adoption of quality improvement programs, adverse events continue to cause
patient harm, generate unnecessary cost and produce extra burden in hospital settings.
In recent years, checklists have become a widely advocated solution to the ongoing problem. Successfully
deployed in aviation, the expectation is for these simple tools to improve clinical task decision-making,process and memory leading to a reduction in unnecessary medical errors and unwarranted care variations.
Yet despite the hype and some positive outcomes, checklist use has been inconsistent and their efficacy
questionable . As a result, critics argue for a) more research into the factors influencing their adoption, use
and impact and b) greater consideration of their integration with clinical guidelines and workflows, especiallyfor more complicated, infrequent and context-dependent tasks.
In this white paper, we describe how the Cognuse CoNurse application helps to overcome theshortcomings of checklist-driven and -dependent care quality improvement initiatives. In it, we:oExamine briefly why harmful adverse events occur, with a particular focus on understanding thenature of medical errors and their causal factorsoDescribe the potential and adoption of checklists as a "panacea" to resolve these errorsoSummarise the factors that are limiting the adoption and usefulness of checklistsoExplain how the CoNurse solution can address these factors by improving adherence toguidelines, and the need to go beyond checklist-thinking-as-solution aloneoProvide an overview of the evolution, prototyping and experience of CoNurse across Europe

First, we go "back to basics" to explore quickly the cost, incidence and causes of patient harm and adverse
events in hospital settings.

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COGNUSE CONURSE | Guideline Adherence and Management System

THE PROBLEM EXPLORED
The burden of in-hospital adverse events
Adverse events (AEs) continue to negatively impact patient safety, the quality of care and staff morale inhospitals. Despite variations in their definition and recording, all studies confirm the significant scale of the
problem as the summary data in Figure 1 testifies.

About 10% of hospital
admissions suffer anadverse event1

All
Hospital
Admissions

Some methods record the
proportion as high as 40% whenusing a looser definition of AE
type, severity and consequence2

10% ofhospital
admissions1

About 50%
are thought to be preventable

Around 7%
result in a fatal outcome

FIGURE 1: PERCENTAGE OF IN-HOSPITAL ADMISSIONS THAT INCUR AN ADVERSE EVENT1
Notes: 1 - Recording of Adverse Events using the Harvard Method; 2 -Recording of Adverse Events using the Global Trigger Tool

In terms of cost, one respected study estimates that AEs add an additional 17.2 billion dollars of
unnecessary spend to the US healthcare system2.
Without question, AEs incur high direct and indirect costs, distract from care priorities, place burden on
patients, their families and staff, and can cause reputational damage to hospitals.
But what can and is being done to reduce them? First, we suggest we must start by better understanding
their causes.

1

Based on data in Schwendimann, René et al. (2018) The occurrence, types, consequences and preventability of in-hospital adverse
events – a scoping review. BMC Health Services Research. 18 (1) 521
2 Van Den Bos J, Rustagi K, Gray , Halford M, Ziemkiewicz E, Shreve J. The $17.1 billion problem: the annual cost of measurable medical
errors. Health Aff (Millwood). 2011;30(4):596–603© Cognuse Limited. All Rights Reserved

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COGNUSE CONURSE | Guideline Adherence and Management System

Medical errors, adverse events and causal factors
When seeking to reduce adverse events and improve patient safety, it is important to consider the causal
factors of AEs very carefully. To do so, we must make a distinction between AEs arising from standard,planned or intended care and AEs arising from medical errors of various kinds (see Figure 2).

FIGURE 2: MEDICAL ERROR-RELATED ADVERSE EVENTS AS A SUBSET OF ALL ADVERSE EVENTSUnfortunately, distinguishing adverse events that arise from warranted and/or standard care and those that
occur due to medical error is not easy. This lack of distinction has important implications when designinginterventions to prevent AEs and reduce patient harm. It is particularly relevant when thinking about thepotential of checklists as a quality improvement tool, as we shall describe later.
Next, we look at the actual evidence of medical error-related adverse events.

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COGNUSE CONURSE | Guideline Adherence and Management System

Medical errors and common adverse events
In a major study of medical errors in the US (using insurance claims data, seen as a reliable method), theauthors were able to identify and rank specific medical errors (see Table 1). They found that pressure ulcers
were the most common AE caused by medical error, followed by postoperative infections and postlaminectomy syndrome. Together, they calculate that ten errors account for 69 percent of the total medical
cost for measurable medical errors. Postoperative infections were the costliest error, followed by pressure
ulcers.
TABLE 1: MOST COMMON IN-HOSPITAL PREVENTABLE MEDICAL ERRORS, US 2008
Range of probability of error (%)
Error

10

20

30

40

50

60

70

80

90

100

Pressure ulcer
Postoperative infection
Accidental puncture or laceration during a procedure
Hemorrhage complicating a procedure
Hematoma complicating a procedure
Post-laminectomy syndrome
Mechanical complication of noncardiac device, implant, or graft
Mechanical complication of cardiac device, implant, or graft
Ventral (abdominal) hernia without mention of obstruction or
gangrene
Unspecified adverse effect of drug or medicinal or biologicalsubstance
Source: Shreve J, Van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. The economic measurement of medical errors [Internet].
Denver (CO): Society of Actuaries; 2010 Jun [cited 2011 Mar 2]. Available from: http://www.soa.org/files/pdf/research-econmeasurement.pdf. NOTES Pressure ulcer is a Medicare “never event,” explained in the text. Postlaminectomy syndrome is pain following
back surgery. A Hemorrhage complicating a procedure could be hemorrhage that occurs during (intraoperative) the surgical procedure due
to inadvertent laceration of an organ or vessel or bleeding that occurs or becomes evident after the surgical procedure is completed(postoperative). The latter (postoperative) may be due to inadequate hemostatis during surgery (intraoperative) as the result of overlooked
bleeding vessels or failure to appropriately suture or cauterize bleeding vessels.

What may be the cause of medical errors leading to the above adverse events? In the next section, we
explore their underlying factors.

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COGNUSE CONURSE | Guideline Adherence and Management System

CONTEXTS AND CAUSESIn a recent meta-review of studies of preventable medical errors, the authors concluded that,“the most frequent errors result from rather common medical services for which cost-cutting
efforts compromise patient safety. That is, the majority of medical errors leading to inhospital AEs are not caused by poorly performing physicians, nurses, or other clinicians.
More commonly, they arise from care delivery problems that result from conditions at thelevel of the individual patient or staff member, the task or the health care team. They may
even be rooted in the overall work environment.”3
Such care delivery and task, workflow or environment-related problems include those shown in Figure 3.

High workload that
reduces practitioner
attention

More complex
patients withcomplicating
multiple conditions

Shortages of staff
and equipment

High staff
turnover

Cultural issues intranslation andinterpretation ofprocedures

Distractions andinterruptions in thecare environment

Causes of Medical Error
leading to Adverse Events
Out-of-date or more
complextechnologies suchas devices

Unclear andchanging guidelines

Communication
challenges
especially at
handover

Knowing when to
perform a standard
or to modify acertain procedure

A lack of patient
data and difficulty ofintegrating data intoa care routine

Delays in receipt ofvital test results

FIGURE 3: CAUSES OF MEDICAL ERRORS LEADING TO ADVERSE EVENTS

They denote a wider set of socio-technical causal factors that surround and influence clinical tasks andprocedures in any given hospital setting, and which can lead to medical error.
These include:oStaff (experience, shortages, turnover, workload)

3 Schwendimann, René et al. (2018) The occurrence, types, consequences and preventability of in-hospital adverse events – a scoping
review. BMC Health Services Research. 18 (1) 521© Cognuse Limited. All Rights Reserved

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COGNUSE CONURSE | Guideline Adherence and Management SystemoMaterial resource (quality, availability, cost, performance)oInteraction (culture, communications, interruptions, information sharing, departmental)oWorkflow and guidelines (adherence, relevance, recency, ease) and last but not least,oPatient factors (status, changes in status, complexity, involvement in care).

To address the cause and burden of preventable and identifiable medical errors leading to AEs, research
into the above factors, their relations and influence continues. Checklists are increasingly viewed as one
important solution, and form one major strand of such an effort.
In the next section, we review these tools and explore their limitations. Specifically, we ask the question:
Are checklists really the panacea to the AE problem?

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COGNUSE CONURSE | Guideline Adherence and Management System

CHECKLISTS AS PANACEA?
Checklists are regarded as a relatively simple solution to address in-hospital AEs. Advocates, including theWorld Health Organisation, have developed and hope to implement checklists at a wider scale. In 2008,
The Surgical Safety Checklist (SSC), introduced by WHO together with Atul Gawande (MD), a pioneer ofthe checklist movement, has been introduced in many hospitals around the world4,5. In 2015, WHOintroduced The Safe Childbirth Checklist (SCC) and embarked on a major program to implement it aroundthe world6,7.
Without question, checklists can help by improving or modifying a healthcare practitioner’s cognitive
capacities when planning or performing a particular healthcare task (see Figure 4).
Plan a specific task
Improve control of a task, avoid variation, error and duplication
Ensure that standards are followed
Aid decision-making when faced with uncertainty
Help with memory when planning and keeping track of task progress (and dealing with interruptions)
Perform routine tasks in the most appropriate sequence
Overcome planning and working memory constraints
Enable task recording and documentation
Streamline and speed-up tasks or slow them down when needed
Fill in practitioner knowledge gaps
Increase the predictability, performance and reliability of patient outcomes

FIGURE 4: COGNITIVE CAPACITIES OF CHECKLISTS

4 Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K,

Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a
global population. The New England Journal of Medicine. 2009; 360(5): 491–99.
5 Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklists in Ontario, Canada. The New
England Journal of Medicine. 2014; 370(11): 1029–38.
6 Amaya AAC, Cortés Díaz ML, Gomez LM, Eslava-Schmalbach J. Effectiveness of three intervention programs designed to implement WHO
Safe Childbirth Checklist in Colombia. International Journal for Quality in Health Care. 2016; 28(1): 47–48.
7 Semrau KE, Hirschhorn LR, Delaney MM, Singh VP, Saurastri R, Sharma N, Tuller DE, Firestone R, Lipsitz S, Dhingra-Kumar N, Kodkany
BS, Kumar V, Gawande AA. Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India. The New England Journal of
Medicine. 2017; 377(24): 2313-24.
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COGNUSE CONURSE | Guideline Adherence and Management System

While early checklist introduction and use resulted in many positive and evidenced outcomes including adecreased amount of infection rates8,9, reduction in the rates of death and readmissions10, and less inpatient complications due to surgical procedures11, not all checklist implementations have been successful.
This variation in performance has led to some disappointment and increased questioning of the assumptionof effectiveness in improving patient safety. For example, one study12 re-examined the impact of theimplementation of surgical safety checklists across a large number of acute care hospitals in Canada. It
found that none of the targeted surgical outcomes improved; a finding in stark contrast to an earlier study
that reported reductions in morbidity and mortality following checklist implementation.
Due to the inconsistency of results from checklist deployment, there is some concern that many are ‘‘neither
clinically helpful nor widely used”13. Even though the use of checklists has increased substantially,
resistance to their use continues. Next, we ask why is that and offer an explanation.

8 Bion J, Richardson A, Hibbert P. 'Matching Michigan': a 2-year stepped interventional programme to minimize central venous catheter-

bloodstream infections in intensive care units in England. BMJ Quality Safety. 2013; 22: 110–23.
9 Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel
C. An intervention to decrease catheter-related bloodstream infections in the ICU. The New England Journal of Medicine. 2006; 355:
2725–32.
10 McCarroll ML, ZulloG MD, Roulette D, Mendise TM, Ferris E, Zolton J, Andrews SJ, Gruenigen VE. Development and implementation
results of an interactive computerized surgical checklist for robotic-assisted gynecologic surgery. Journal of Robotic Surgery. 2014; 9(1):11–18.
11 Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy
K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality
in a global population. The New England Journal of Medicine. 2009; 360(5): 491–99.
12 D.R. Urbach et al., Introduction of surgical safety checklists in Ontario, Canada, N. Engl. J. Med. 370 (11) (2014) 1029–1038.
13 G.D. Schiff, D.W. Bates, Can electronic clinical documentation help prevent diagnostic errors?, N Engl. J. Med. 362 (12) (2010) 1066–
1069.
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COGNUSE CONURSE | Guideline Adherence and Management System

THE LIMITATIONS OF CHECKLISTSAt Cognuse, we believe that checklists (and their advocates) take an overly narrow view of the cause andnature of medical errors leading to adverse events. Then, when checklists are implemented, their use andefficacy is too often constrained by the many complicated, unplanned and unknown contextual factors andinfluences present in diverse in-hospital environments.

Task
Integration

Patient
Variation

Workflow
Integration

Purpose and
DesignPractitioner
Variation

ChecklistsasPanacea?

Evidence ofEfficacy

FIGURE 5: CHECKLISTS AS PANACEA? FACTORS INFLUENCING CHECKLIST USE AND EFFICACY

In short, we identify that the provision, compliance and usefulness of checklists in hospitals is often
compromised by a number of influencing factors. These relate closely to the diverse, inter-related causesof medical errors described above. At Cognuse, we identify six categories of the factors that limit the use
and efficacy of checklists. These are shown in Figure 5 and are listed in Table 2.

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COGNUSE CONURSE | Guideline Adherence and Management System

TABLE 2: FACTORS DIMINISHING THE USE AND EFFICACY OF CHECKLISTS IN HEALTHCARE

Factor of Use andEfficacy

Issue

Lack of effective and standardised guidelines for checklist design and use
Guidelines cannot always be reduced to a linear task flow
Not all tasks are routine, or tasks may need to diverge from routine
Uncertain purpose: Planning, memory, decision-aid or flowchart?
When is a checklist a checklist? A guideline guide or a single task?

PURPOSE AND
DESIGNooooo

WORKFLOWINTEGRATIONo Lack of proper consideration and integration with all components of theclinical / non-clinical work systemo Resources required to use checklists may reduce other resources
available to perform other taskso Lack of effective and standardised methodologies for checklist
implementationo May require organisational changes, e.g., staff roles

TASK INTEGRATIONo May reduce staff communication when performing task (assumes a 1:1
clinician-task relationship)o Format and content may misalign with task ergonomics, e.g., manual
dexterity, cognitive difficulty, vital data capture, patient documentation andrecording, task recommendation, etc.
o Difficulties when using more than one checklist (integration, sequence)o Cumbersome paper-based checklist designs

PATIENT CONTEXTo Complicating patient situation and factors may require a non-standard
procedure; may force unnecessary standardisationo Can detract from need for patient dialogue interactiono May create a false sense of patient safety and reduce the need to look at
the holistic picture of the whole patient

PRACTITIONERCONTEXTo Resistance to use based on familiarity, ego and/or experienceo Competes with individual routines of habit and familiarity, cognitive bias orclinical judgemento Reliance on intuition when to use or not use a checklist
o Risk of checklist fatigue

EVIDENCE OF VALUEo Lack of consistent measures and standards for checklist evaluationo Uncertainty as to what is being measured? Adherence to procedure? Orclinical outcomes? Not performing care at all? Not using a checklist whereit should be used, or an error arising when using a checklist?

One solution to address the above factors is digital checklists. Undoubtedly, the conversion from paper todigital formats can improve their use and efficacy14. Yet problems remain, especially concerning their

14 Kramer HS, Drews FA. Checking the lists: A systematic review of electronic checklist use in health care. Journal of Biomedical

Informatics. 2017; 71: 6-12.
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COGNUSE CONURSE | Guideline Adherence and Management System

integration into wider care guidelines and workflows, and their capacity to adapt to variations in patient andpractitioner context. In our view, if these critical factors are not addressed, then digital versions merely shift
the problem of use and efficacy onto a different platform.
Next, we explain how CoNurse from Cognuse addresses the above limitations.

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COGNUSE CONURSE | Guideline Adherence and Management System

THE CoNurse SOLUTION FROM COGNUSE
What is CoNurse?
CoNurse from Cognuse is a voice-guided application for improving quality and reducing avoidable medical
errors and patient harm in hospital settings. The solution is seamlessly integrated into clinical workflows to
help ensure that procedural protocols and guidelines are followed each and every time by supporting
nurses’ memory to remember over 300 protocols.
CoNurse is not a checklist creation and process tool, but rather a guidelines deployment and adherence
system enacted through voice-based technology at the point of patient interaction.
CoNurse runs on a standard smartphone (both iOS and Android are available) and is controlled through aBluetooth headset, ensuring that the user-experience is entirely hands-free, thereby aligning with hospitalhygiene and infection control measures.
Guideline management can be improved by providing pre-set templates for the quality department to adapt
and adjust regarding to the hospital’s specific needs.

How CoNurse works
The flow chart in Figure 6 summarises how CoNurse works.

User puts on theheadset and launches
the digital checklist toolfrom the smartphone

User inserts initials

User clicks on theprocedure name, voicebased launch also
possible

User has to provide ananswer (audio
command) to move onin the proceduralchecklist

The application plays
either a question or atask as a checklist item

Procedural checklist
startsBy providing thecommand ‘next’, user
confirms theimplementation of thechecklist item

After finishing theprocedure, application
provides information
about the duration of
the procedure

After finishing theprocedure, user quits
the application

FIGURE 6: HOW CONURSE WORKS© Cognuse Limited. All Rights Reserved

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COGNUSE CONURSE | Guideline Adherence and Management System

History and piloting
A digital prototype
The development of CoNurse started in a collaboration between Cognuse and North-Estonia Medical
Centre (NEMC) in March 2017. During the initiation phase, a prototype of a digital checklist tool wasdeveloped. This first prototype incorporated seven procedural nursing guidelines that were processed intoa digital sequence of actions to be usable in clinical workflows. Six different procedural guidelines werechosen from the total of 400 nursing guidelines that currently exist at NEMC. These are shown in Figure
7:

FIGURE 7: THE SIX CoNurse PROCEDURAL GUIDELINES DEVELOPED WITH NEMC

In each protocol, guidelines were split into procedural steps. The inclusion and exclusion of certain tasks
from the guidelines to be deployed in the application were discussed and agreed with the departmental
chief nurse and quality leader. The main objectives of the development of the digital prototype were to:oBring distant and therefore inaccessible guidelines closer to the clinical staffoConvert clinical guidelines to a simplified sequence of actions, making them usable and actionable
during clinical workoStandardise nursing procedures through active usage of procedural guides during clinical workoHelp mitigate problems arising from the work environment such as interruptions andcommunications challengesoImprove patient outcomes through reduction of medical errors and complications© Cognuse Limited. All Rights Reserved

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COGNUSE CONURSE | Guideline Adherence and Management System

The procedures were performed randomly on patients who required the intervention and where it waspossible to use the tool. The users could choose when to use the tool. No data were captured on the control
state (procedures done without the tool), nor the baseline.
Four of the largest hospitals in Estonia piloted the solution during summer 2018. During the pilots, thesolution was tested in 14 different departments by approximately 100 nurses. Altogether, the participating
hospitals provided Cognuse with 60 different guidelines for nursing procedures. Each were processed,
instructionally designed, reviewed and then converted into corresponding checklist and voice-guided audio
formats. Besides nursing procedures, procedures for nursing assistants and caregivers were included in
the procedure package of one the hospitals.

Benefits
The following summarises the benefits of the prototype, as expressed by nurses and team leaders:oGood tool for learning purposes, with junior nurses benefiting the mostoSuitable for patients in intensive careoSupports experienced staff members while recalling the actions within a procedure or while
performing infrequent proceduresoExcellent for procedures involving preparatory steps and setting up medical devices

Challenges
The following are the challenges experienced by users of the prototype:o

Audio guidance causes issues with divided attention between the patient and guidelines, when
patient is awakeoPatients need to be better informed about the purpose of the application to avoid them forming anegative perception of the nurses’ knowledge and skill levelsoSpeech recognition has to be flawless (99% correct) to avoid drop off© Cognuse Limited. All Rights Reserved

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COGNUSE CONURSE | Guideline Adherence and Management System

Current Use Cases
Various application areas for CoNurse were validated in the pilot phase. Among them, three primaryprocedural scenarios were identified, standard, critical and infrequent.

Standard procedures
Suitable for nurses who are starting their career. The general feedback towards the tool
is that it is suitable for training purposes and/or for the nurses, that are yet unfamiliar
with hospital procedures. CoNurse supports junior nurses while learning hospitalspecific procedures in the beginning of their career. The use of CoNurse by all thenurses that start working in a specific ward ensures higher level of care standardisationand less care variation. As the content on the tool is periodically revised and therefore up-to-date, young
nurses start performing the procedures in a scientifically proven way, not in a way that experienced nurses
are used to. An added benefit is reduced stress of inexperienced or newer nursing staff, and reduced needfor senior mentoring and oversight. During night shifts especially, more junior nurses are more confident
while working.

Critical procedures
One of the most critical procedures that nurses have to perform is blood transfusion.
This is a procedure where, if a nurse makes a mistake, the patient can die. Use of
CoNurse as a support for blood transfusion helps to avoid situations where blood
product is given to a wrong patient. It also ensures that patient identification is done as
many times as stated in clinical guidelines. The latest development is addition of theblood scanner functionality to the solution.
The integration with the hospital IT system provides nurses with a powerful tool which can be used for
identifying whether a certain blood product is meant for the right patient.

Infrequent procedures
Modern working culture means that nurses often have to work in different wards
and hospitals. Some procedures might be done only a couple of times in certain
wards. CoNurse guidelines for infrequent procedures support nurses that are notfamiliar with those activities. Standardising infrequent procedures is an effective
way to reduce unwarranted care variation.

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COGNUSE CONURSE | Guideline Adherence and Management System

Pilot learning and recommendations
Depending on the particular healthcare system at hand and whether our focus is on national efforts or amore local, smaller set of hospitals, it is beneficial to include as many actors as possible in the overall
ecosystem when dealing with aspects of patient safety, centralized guidelines and overall quality of care.
Medical schools are the primary source of nursing professionals for the hospitals and often employ
simulation environments and supply digital aids to enhance the learning process. Facilitating an effective
back and forth transfer of relevant and validated nursing content is key to reducing variations incomprehension and subsequent nursing practice.
Furthermore, in national healthcare systems one also has to include in the discussions the legislative,
oversight and insurance or the payers.
In the case of CoNurse, this was achieved in Estonia with four of the largest hospitals, two medical schools
as well as the Ministry of Social Affairs, the Health Board and the national health insurance. The below
schema outlines the collaboration and embedded interests of the aforementioned parties.

In order to avoid any bias when piloting a solution in a single ecosystem of 4 large hospitals in Estonia, theCognuse team took considerable efforts to provide external piloting and validation opportunities for the
CoNurse solution. Below we have outlined developments in Denmark and an EU-wide initiative curated by
EIT Health.

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COGNUSE CONURSE | Guideline Adherence and Management System

ProVaHealth (Denmark)The solution was also tested in a living lab in Denmark. CoLab Denmark is a partnership and cooperation
between the Health Innovation Centre of Southern Denmark, the hospitals and municipalities in the region
and private companies. CoLab Denmark consists of six Living Labs (so called CoLabs).
The test took place in the room with hospital settings in CoLab Plug & Play. Two nurses were testing
CoNurse one person at a time. Normally the nurses do not use audio guides. Instead they carry a booklet
in their pockets, which includes guidelines for the most common guidelines procedures. The tested
procedures were measurement of Glasgow Coma scale, blood transfusion, and respiratory rateassessment.
Both the nurses believed that an audio guide as CoNurse could be very useful for setting up new medical
devices at the unit. They suggested to expand the use of CoNurse for setting up medical devices andbelieved that the tool would be useful for training or as a working aid for inexperienced nurses.

EIT Health Bridgehead Programme (UK; Germany; Spain; Italy)
CoNurse was awarded a grant from EIT Health to explore further its clinical and commercial model
validation options across its partner sites in the EU during 2019. The CoNurse solution will be tried in two
European countries with hand-picked clinical sites that have explicitly expressed interest in working with
the Cognuse team on the following criteria:oSettings that experience care variation issues and are exploring new methods, beyond paper ordigital checklists, to mitigate themoSpecific patient safety challenges and adverse eventsoStaff burnout and turnover problemsoA desire to create a supportive work environmento

A wish to develop a continuous learning, certification and auditing framework© Cognuse Limited. All Rights Reserved

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COGNUSE CONURSE | Guideline Adherence and Management System

SUPPORTING YOUR PILOT IMPLEMENTATION
The adoption of any new digital solution by hospital staff presents several challenges. A plethora ofsolutions already exists at most hospitals and there are important barriers to overcome. Moreover, eachhospital is different. Even when part of a larger health system or network, the departmental and individual
conventions, working methods and work flows can differ considerably.
It is important to consider early all aspects of deployment that any new technology solution must address.
Especially, though centralized from the solution architecture standpoint, a solution such as CoNurse mustdeliver a personalized experience on the institutional, departmental and even individual levels when andwhere required.
Our structured implementation approach ensures CoNurse is not only introduced seamlessly into any
hospital, but also when live, can adapt to changing practices and protocols and expand to include newones.
The following are the summary steps we recommend are adopted when planning and making animplementation of CoNurse.
1. Review of past quality improvement programmes
2. Identification of influencing contexts, performance factors and patient outcome and clinical targets
3. Assessment of cost impact of meeting targets
4. Identification of critical guidelines and options for piloting CoNurse
5. Collaborative specification of key benchmark and criteria
6. Design of pilot programme
7. Execution of pilot programme
8. Audit of pilot programme© Cognuse Limited. All Rights Reserved

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Cognuse Inc is a digital health company. The company was foundedin 2014 and had offices both in the EU and the USA. Cognuseprovides software solutions for hospitals across the globe with amain focus on applications for critical care environments, patient
safety and the continuum of care for critical illness. The Cognuseteam strongly believes that patient safety can and should be
improved with digital technologies and human errors can be
minimized with the help of simple and accessible technology.
Cognuse OÜ
Telliskivi 60A/3
Tallinn 10412
Estonia
E: info@cognuse.com
W: www.cognuse.com