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iHT2 Health IT Summit San Francisco Summit 2013 - Dr. Howard Landa, CMIO, Alameda County Medical Center - Case Study “Change Management in Health IT: The Elephant is Leaving the Room”

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Case Study “Change Management in Health IT: The Elephant is Leaving the Room” …

Case Study “Change Management in Health IT: The Elephant is Leaving the Room”

The one true constant in the field of healthcare and HIT in particular, is change. The best technology implemented in a perfect way can fail if organizational change is not managed. And the most important part of change management is truly understanding the origin, the destination, and the obstacles. We will discuss the motivators and de-motivators of change and how to address each in order to optimize the first and mitigate the latter. The understanding of your change journey is a key factor in successful transformation.

At the end of the presentation the participant:

∙ Will have a practical framework to identify both the intellectual and the emotional drivers and barriers to change
∙ Understand how to describe mitigating the intellectual aspect of resistance to change
∙ Will be able to describe how to mitigate the emotional aspect of resistance to change
∙ Will be able to describe how to reduce resistance to the change process by understanding the environmental barriers to change

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  • 1. Howard Landa, M.D.Chief Medical Information Officer Alameda County Medical Center Oakland, CA
  • 2.  Old tools: ◦ Whining, complaining, cajoling, threatening ◦ Incentives (Money, power, glory…Money)  Used for ages without dramatic success ◦ Bad data  First 3 of the 5 Kubler-Ross stages):  Denial, Anger, Bargaining  Depression  acceptance requires good data! New tools ◦ Electronic Health Record  Alerting and better data (Analytics) Not much change!
  • 3.  Improve primary care and non-PCP ordering ◦ Identifying ◦ Alerting EHR! ◦ Ease ordering CMIO Improve cycle time Improve patient satisfaction with process Earlier detection  Improved outcome
  • 4.  Kinda worked for primary care (less change) Not so much for others ◦ Doing the “right” thing isn’t always enough ◦ It is more work/unfunded mandate ◦ Knowledge deficit ◦ Lack of support ◦ Fear, Uncertainty, and Doubt (FUD) ◦ What else??? That’s why the call it change management!
  • 5. Urologist orders mammogramResult comes back: “BI-RADS 3, Probably benign”“Doctor, what does “Probably” mean? Result-o-phobia The fear of looking stupid in not knowing how to interpret an abnormal result
  • 6. Education alone was NOT sufficient! Advance Practice nurse intercepts ALL results ◦ APN accountable for negative study communication and follow-up by protocol ◦ Communicates with Breast team non-negative Ordering provider gets “Courtesy” copy ◦ Informational, so no action is required Breast team becomes accountable for all subsequent care ◦ Contacts patient and arranges follow up
  • 7.  Kaiser Permanente Hawaii in 2009 ◦ Highest breast CA screening rate (42 – 69) ~72%  85% in 2009 ◦ How?  EHR can alert and facilitate  Out-reach and In-reach  Incentives and accountability  Mitigation of result-o-phobia ◦ *Operationally supported workflow* 7
  • 8.  Care standardization / Preparation for CPOE ◦ Electronic Order Entry with Paper Output  Increase the number of order sets  Reduce the # of actual paper forms  Expedite creation  “Test drive” order sets for CPOE  Provide for maintenance of content
  • 9.  Improved compliance with ordering of complete insulin coverage DVT prophylaxis compliance has increased from 50% to 97% Compliance with required orders ◦ E.g. Admit, Code status, Telemetry criteria, Resident/Attending/Service identification 28% reduction in time from decision to admit to creation of inpatient orders
  • 10. Lose weight, Being more productive, Quitsmoking.So hard we don’t like to startWhat about getting married or having a baby?Not all change is hardThe question is: How desirable(intellectually and emotionally) is thefuture state and how hard is the path toget there?
  • 11. An Elephant and Rider on a path to a new (changed) destination Appeal to the intellect ◦ Direct the rider Encourage the emotions ◦ Motivate the Elephant Shape the path http://www.heathbrothers.com/switch
  • 12. The easy part for healthcare… Quality Safety EfficiencyBaseball, Apple pie and Chevrolet
  • 13.  FOLLOW THE BRIGHT SPOTS. ◦ Investigate what’s working and clone it. SCRIPT THE CRITICAL MOVES. ◦ Don’t think big picture, think specific behaviors. POINT TO THE DESTINATION. ◦ Change is easier when you know where you’re going and why it’s worth it
  • 14.  FOLLOW THE BRIGHT SPOTS. ◦ Who had the best screening rates? ◦ What orders were written most reliably SCRIPT THE CRITICAL MOVES. ◦ Use ancillary staff to support providers ◦ Default safe/reliable orders POINT TO THE DESTINATION. ◦ Improved screening metrics ◦ Core measure improvement, less calls
  • 15.  FIND THE FEELING. ◦ Knowing something isn’t enough to cause change. ◦ Make people feel something. ◦ Does it pass the champagne test? ◦ Connect the team to the outcome/(+) Peer pressure SHRINK THE CHANGE. ◦ Break down change till it no longer evokes fear ◦ Make it feel do-able GROW YOUR PEOPLE. ◦ Cultivate a sense of identity ◦ Instill the growth mindset.
  • 16.  FIND THE FEELING. ◦ You want your loved one to be screened? ◦ Highest quality/Safest care? ◦ Aren’t both something worth bragging about? SHRINK THE CHANGE. ◦ Order one mammogram at a time  and we will take care of the rest ◦ Orders based on current paper tools,  Limit paper output and limited scope GROW YOUR PEOPLE. ◦ Be proud of what you and your organization can do
  • 17.  TWEAK THE ENVIRONMENT. ◦ When the situation changes, the behavior changes, So change the situation. ◦ Make the right thing the easy thing  Shrink the change  Look for quick wins  Perfection is the enemy of good enough BUILD HABITS. ◦ When behavior is habitual, it’s “free” RALLY THE HERD. ◦ Behaviors are contagious, help it spread.
  • 18.  TWEAK THE ENVIRONMENT. ◦ Anyone can place a mammogram order  Everyone will be asking about it ◦ Every computer has the program on the desktop ◦ Here is a number to call if you have a problem BUILD HABITS. ◦ Ordering mammograms becomes routine workflow ◦ Using the Order entry system becomes routine workflow ◦ Rapid PDCA cycles RALLY THE HERD.  Everyone uses the ordering software and expects the output
  • 19.  Months of gradually increasing unrest Issue identification First consequence Threats of additional consequences Decisive action FUD (Fear Uncertainty Doubt)
  • 20.  Direct the Rider ◦ Bright spots  Honesty and directness  Validation (directs the Rider and Elephant)  Acknowledge errors and spot-lighters ◦ Point to the destination  Understand the “Why” and turn it into actionable response ◦ Craft the critical moves  Layout a course
  • 21.  Find the feeling  Safe environment to ask questions ◦ Validation  Acknowledge pain and suffering Shrink the change ◦ Mitigate the fear moving forward Grow your people ◦ FUD (Frankness Unanimity Deescalate)
  • 22.  TWEAK THE ENVIRONMENT. ◦ Open communications ◦ Demonstrate a culture of safety BUILD HABITS ◦ Ensure against recurrences ◦ Seek out concerns RALLY THE HERD ◦ Story telling within reason ◦ Mutual support
  • 23.  Just because you build it does NOT mean they will come! Managing the change is as critical as the change itself. The road to hell is paved with good intentions…and (in Healthcare information technology) bad implementations