Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Lecture 8A
Similar to Lecture 8A (20)
More from CMDLMS
More from CMDLMS (20)
Recently uploaded
Recently uploaded (20)
Lecture 8A
- 1. Quality Improvement HIT Implementation Planning for Quality and Safety Lecture a This material (Comp 12 Unit 8) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award Number 90WT0005.. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 2. HIT Implementation Planning for Quality and Safety Learning Objectives — Lecture a • Critique an implementation team and the roles they play in ensuring quality and safety of patient care during implementation. • Analyze effective implementation planning. 2
- 3. Transition • “It isn’t the changes that do you in, it’s the transitions.” – William Bridges, 2009. 3
- 4. Effective Implementation Teams 8.01 Figure. 4
- 5. Effective Implementation Teams: Team Characteristics — 1 • “Contact is not enough”(Sargeant et al., 2008). • Effective teamwork requires: – Communication. – Understanding and respecting team member roles. – Understanding the clinical practice setting. – Having practical “know-how.” – Recognizing that teamwork requires work. 5
- 6. Effective Implementation Teams: Team Characteristics — 2 • “Contact is not enough”(Sargeant et al., 2008). • Effective teamwork requires: – Communication. – Understanding and respecting team member roles. – Understanding the clinical practice setting. – Having practical “know-how.” – Recognizing that teamwork requires work. 6
- 7. Effective Implementation Teams: Team Characteristics — 3 • “Contact is not enough”(Sargeant et al., 2008). • Effective teamwork requires: – Communication. – Understanding and respecting team member roles. – Understanding the clinical practice setting. – Having practical “know-how.” – Recognizing that teamwork requires work. 7
- 8. Effective Implementation Teams: Team Characteristics — 4 • “Contact is not enough”(Sargeant et al., 2008). • Effective teamwork requires: – Communication. – Understanding and respecting team member roles. – Understanding the clinical practice setting. – Having practical “know-how.” – Recognizing that teamwork requires work. 8
- 9. Effective Implementation Teams: Team Characteristics — 5 • “Contact is not enough”(Sargeant et al., 2008). • Effective teamwork requires: – Communication. – Understanding and respecting team member roles. – Understanding the clinical practice setting. – Having practical “know-how.” – Recognizing that teamwork requires work. 9
- 10. Effective Implementation Teams: Lessons Learned — 1 • Organizational decision making and project management: – Empower project leaders who are close to the ground. – Ensure close coordination of operations, clinicians, and IT. – Beware of scope creep. – Begin with the end in mind. – Engage “bridgers.” 10
- 11. Effective Implementation Teams: Lessons Learned — 2 • System deployment and roll out: – Don’t try for perfection…it won’t happen. – Pilot, improve, roll out, and improve. – Value the curmudgeons. – Get feedback and use it. – Look for the opportunity and the easy win. 11
- 12. Effective Implementation Teams: Lessons Learned — 3 • System deployment and roll out: – Training never ends. – Implementation never ends. – Users are beta testers. – Be nimble, be quick. – Patient care comes first. – Consider data capture workflows that have “downstream” impact on secondary use of data for clinical quality measures (CQM). 12
- 13. HIT Implementation Strategies 8.02 Figure. 13
- 14. HIT Implementation Strategies: Single Vendor — 1 • Strategy used most often by smaller hospitals and provider practice settings. • Enterprise architectures avoid the need to develop and maintain complex bi- directional interfaces between disparate applications. • Accountable care organization delivery model requires ability to capture and share data across all care modalities. 14
- 15. HIT Implementation Strategies: Single Vendor — 2 • Benefits: – Contract management. – Financial management. – Competency development. – Software maintenance. • Limitations: – Often necessitates radical change. – Professional resistance. – Failure: significant financial losses. – Curtails future ability to change to another vendor. 15
- 16. HIT Implementation Strategies: Best of Breed — 1 • May have different vendors for the acute care EHR, ED, ambulatory EHR, and surgery environments. • Usually found in academic medical centers. • Requires interfaces for exchanging data between these disparate systems, creating additional capital and operating costs to upgrade and maintain. 16
- 17. HIT Implementation Strategies: Best of Breed — 2 • Benefits: – Avoids massive business process reengineering. – Closely aligned with service-specific requirements. – Higher quality. – Competitive advantage. • Limitations: – Fragmentation. – Requires wide range of skills to manage multiple applications. – Compliance risk with financial implications. 17
- 18. HIT Implementation Strategies: Best of Suite — 1 • Organization selects an EHR vendor to provide the core clinical IT support for delivery care across all modalities beyond the acute care setting. • Usually found in large urban hospitals and especially in integrated delivery systems. 18
- 19. HIT Implementation Strategies: Best of Suite — 2 • Benefits: – Retain/integrate legacy clinical applications. – Reduce need for disruptive work process redesign. – Decrease professional resistance. • Limitations: – Vendors have strong bargaining positions with respect to future contracting rates and customization flexibility. 19
- 20. HIT Implementation: Clinical Workflow • Process description: – How tasks are done. – By whom. – In what order. – How quickly. • Set of relationships between all activities, from start to finish. • Movement of information across organization. 20
- 21. HIT Implementation: One Size Does Not Fit All — Primary Care • Key factors: – Expectations of EHRs. – Time and training required to implement and adopt the EHR. – Emergence of an EHR champion or problem- solver. – Providers’ readiness to accept the system. 21
- 22. HIT Implementation: Small Ambulatory Practices • Barriers: – Cost. – Lack of standardization/ designed for large practices. – Technical support. – Productivity reductions. – Resistance to change. – No perceived benefits for providers. • Steps for success: – Build in flexibility. – Secure buy-in (local ownership of project and change process). – Create an actionable vision for change. – Tailor each phase to the individual practice. – Monitor goal achievement. 22
- 23. HIT Implementation: Vendor Selection in Ambulatory Practice 8.03 Figure. 23
- 24. HIT Implementation: Critical Access Hospitals — 1 • Critical Access status requires: – Not-for-profit. – In a non-metropolitan statistical area. – At least 35 miles (mountainous areas: 15 miles) from a short-term general hospital. – 25 or fewer acute-care beds. • Improves financial ability to invest in HIT. 24
- 25. HIT Implementation: Critical Access Hospitals — 2 • Number of IT staff: – 34 percent have none. – 50 percent have 1–2. • Use of external IT consultants: – 91 percent use external consultants. – 50 percent to a large or great extent. 25
- 26. HIT Implementation: Critical Access Hospitals — 3 • Outsourcing for IT services: – 85 percent outsource, mostly for highly technical work. • Application service providers (ASPs): – 38 percent use ASPs, but only 9 percent to a great extent. 26
- 27. HIT Implementation: Critical Access Hospitals — 4 • Organization has clear strategies, objectives, and plans. • Management discusses ways to link IT agenda to organization’s strategies. • Organization holds itself accountable for its performance. • Efficient/effective IT governance is in place. • Organization determines processes that require IT-enabled improvement/measures performance. 27
- 28. HIT Implementation: Hospitals • Multiple supporting initiatives are incorporated. • Multidisciplinary teams are used. • Organization understands the complicated nature of the EHR value proposition. • Clinicians are continually engaged in improving systems and related workflows. • Investment in infrastructure is supported. • Organization invests in modest, thoughtful IT experimentation. 28
- 29. HIT Implementation Planning for Quality and Safety Summary — Lecture a • Characteristics of effective implementation teams include organizational structure, team processes, and individual contributions. • Six key drivers of implementation effectiveness include: purpose, goals, leadership, cohesion, communication, and mutual respect. • Contact is not enough. • Organizations can use single vendor, best of breed, or best of suite strategies. • There is no single right way to implement HIT. • HIT professionals can assist each organization to design an implementation plan that meets its unique needs. 29
- 30. HIT Implementation Planning for Quality and Safety References — Lecture a — 1 References Bridges, W., & Bridges, S. (2009). Managing transitions. Making the most of change. 3rd edition. Philadelphia, PA: DaCapo Press. Chin, H. L. (2004). The reality of EMR implementation: Lessons from the field. Permanente Journal, 8(4), 1–7. Retrieved May 31, 2016, from: https://www.thepermanentejournal.org/files/Fall2004/reality.pdf Dave, M., & Garets, D. (2010 July 9). Vendors with mature enterprise architectures lead the market. Washington, DC: The Advisory Board Company. Ford, E. W., Menachemi, N., Huerta, T. R., & Yu, F. (2010). Hospital IT adoption strategies associated with implementation success: Implications for achieving meaningful use. Journal of Healthcare Management, 55(3), 175–189. Glaser, J. (2009). Implementing electronic health records: 10 factors for success. Healthcare Financial Management, 63(1), 50-2, 54. Retrieved May 31, 2016 from http://search.proquest.com/docview/196389711?accountid=11752 Mickan, S., & Rodger, S. (2000). Characteristics of effective teams: A literature review. Australian Health Review, 23(3), 201–208. Mickan, S. M., & Rodger, S.A. (2005). Effective health care teams: A model of six characteristics developed form shared perceptions. Journal of Interprofessional Care, 19(4), 358–370. 30
- 31. HIT Implementation Planning for Quality and Safety References — Lecture a — 2 References Sargeant, J., Loney ,E., & Murphy, G. (2008). Effective interprofessional teams: “Contact is not enough” to build teams. Journal of Continuing Education in the Health Professions, 28(4), 228–234. Terry, A., Thorpe, C. F., Giles, G., et al. (2008). Implementing electronic health records: Key factors in primary care. Canadian Family Physician, 54(7), 730–736. Whittenburg, L. (2010). Analysis of nursing workflow documentation in the electronic health record. Journal of Healthcare Information Management, 24(3), 71–75. Charts, Tables, Figures 8.01 Figure: Effective Implementation Teams. Adapted from Mickan and Rodger by Dr. Anna Maria Izquierdo-Porrera. 8.02 Figure: HIT Implementation Strategies. Dr. Anna Maria Izquierdo-Porrera. 8.03 Figure: HIT Implementation Vendor Selection in Primary Care. Dr. Anna Maria Izquierdo-Porrera. 31
- 32. Quality Improvement HIT Implementation Planning for Quality and Safety Lecture a This material (Comp 12 Unit 8) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award Number 90WT0005. 32
Editor's Notes
- Welcome to Quality Improvement: HIT Implementation Planning for Quality and Safety. This is Lecture a. In this lecture, we will explore HIT implementation planning to maximize quality and safety. The first segment is on the implementation team and the steps for effective planning.
- The objectives for HIT Implementation Planning for Quality and Safety are to: Critique an implementation team and the role it plays in ensuring quality and safety of patient care during implementation. Analyze effective implementation planning.
- William Bridges, in his national bestseller, Managing Transitions: Making the Most of Change, writes, “It isn’t the changes that do you in, it’s the transitions.” Change is situational. For example, implementing a new EHR represents a change. Transition is the psychological process clinicians come to terms with when adjusting to the new EHR and any redesigned workflow that results from this change. This distinction is critical for effective implementation teams to understand. When putting together an EHR implementation team, we need to ensure that the composition of the implementation team is reflective of the characteristics that will ensure both effective change and effective transition.
- Mickan and Rodger described effective teams to include four major domains: Team environment, Team structure, Team process, And individual contribution. They proposed that only six team characteristics actually drive effectiveness. The six drivers include: Having a shared purpose that clearly demonstrates shared ownership, Establishing goals that link the teams’ purpose with the desired outcomes, Having team leaders who set and maintain structures for decision making and conflict management, Establishing regular patterns of communication, where all members share ideas and information with each other, Developing group cohesion through camaraderie and involvement that develops over time, And exhibiting a high degree of mutual respect, with acceptance of diversity and professional contribution.
- In writing on interprofessional team building in primary care settings, Sargeant and her colleagues caution that contact is not enough. Just having professionals working side by side is not enough to effect change and manage transition. The level of interdependence and collaboration required for effective implementation teams demands the highest level of communication. For example, team members need to be continually open with each other and communicate on a regular basis. To do this effectively, team members need to have access to each other and need to have effective communication skills. In addition to regularly scheduled meetings, effective implementation teams often use web-based communication tools that facilitate collaboration and implementation management. Communication is one of the most important aspects of effective implementations. Communication is important not only within the core implementation team but with the bigger organization undergoing the transition. Although a comprehensive communication strategy may initially slow the progress of the implementation, it will eventually ensure a successful effort.
- It is also essential that there is a clear understanding and respect for the unique roles of each team member. If team members are not aware of each other’s roles, they’ll not be able to effectively work together as a team. They may try to delegate functions that are not appropriate to the particular role of a team member. For example, they may assume that a member has a particular power base, whereas that individual may not have the desired sphere of influence needed for the task allocated.
- Effective implementation teams ensure that all team members have a clear understanding of the unique principles that guide the particular practice setting in which they are implementing the EHR. This includes knowledge of the purpose and mission of that setting, the services provided and the populations served, roles and responsibilities of health care and supportive personnel, and how daily operations are carried out. It is for this reason that it is imperative to include all appropriate clinicians on the implementation team.
- Effective implementation teams have representation of individuals with both technical and clinical know-how. Having practical know-how of EHR implementation is also a critical component of effective implementation teams. IT professionals are skilled and experienced in implementation team planning, addressing hardware needs — including mobile device requirements — and planning for IT activation support needs. Clinical team members are skilled and experienced in managing complex patient care activities during times of transition, understanding and applying organizational clinical care policies, clinician workflow, and making decisions as to the most appropriate timing of activation, as well as the specifics of pre-activation strategies, such as chart-building activities.
- Finally, experienced implementation teams tell us that success is the result of active and ongoing effort. This requires focused attention, time, and a considerable amount of work. Effective teamwork doesn’t just happen. Team members work to make it happen.
- Kaiser Permanente, which has a wealth of experience in implementation of integrated electronic health records, provides us with lessons learned over the years. For teams to be effective, with respect to organizational decision making and project management during the implementation phase, they need to empower project leaders who have a close link to people who are affected by the decisions. There needs to be close coordination of operations for project management expertise, and the clinical community for clinical expertise, and IT for technical expertise. It is important to start with the objective in mind and to think through all steps necessary to achieve that objective. It is also very helpful to have people who can bridge the gap and the “cultural divide” between the developers, EHR vendors, and the end users of the EHR.
- For teams to be effective, with respect to system deployment and roll out during the implementation phase, they need to remember that implementation is still an art rather than a science, and that the perfect recipe does not exist. Later in this unit we will explore methods that hold promise, but implementation strategies are not a one-size-fits-all endeavor. Make sure that you pilot the system first, as there will always be improvements that can be made and you really need to identify significant issues early on so that these issues can be fixed. Listen to and carefully evaluate feedback from critics. Solicit feedback from all stakeholders early on and frequently. If you come across an opportunity in which tweaking the system will result in significant benefit, do it.
- Remember that training never ends. Initial training gives users enough to get by, but generally, they only remember about 50 percent of what is taught. Reinforcement of training is critical, as well as ongoing evaluation, education, and training. By the same token, implementation never ends, since health IT systems are constantly changing. Application software, hardware, mobile devices, and clinical knowledge all change at a rapid pace, resulting in ongoing enhancements, upgrades, and other changes that make implementation an ongoing activity. Understand that users are beta testers. It is extremely difficult to replicate the production database in a test environment. It is usually impossible to test every aspect of the system before an initial “go live” or a significant upgrade, although it’s a good idea to try to do so. Frequently, many issues and problems surface soon after “go live,” and implementation teams need to ensure that users have an immediate feedback loop and quick problem resolution, especially for problems that affect patient safety. Remember that patient care comes first, and this includes all aspects of quality, including clinical efficiency and effectiveness. “Downstream” impact of data capture on secondary uses for quality measurement should be addressed during implementation and workflow design/redesign.
- Three strategies have been identified, with respect to implementation of EHR systems. These include single vendor, best of breed, and best of suite approaches. All of these strategies are in use today, and each strategy has specific strengths and limitations. It is important to understand these characteristics when planning for effective implementations.
- Single vendor is usually the strategy used by standalone hospitals and in provider practice settings. Enterprise architectures (defined as a consistent architecture across revenue cycle management, electronic health record, and specialty clinical departments) have the distinct advantage of avoiding the need to develop and maintain complex bi-directional interfaces between disparate applications. Many organizations are also moving to accountable care delivery models. These models require the ability to capture and share data across all care modalities.
- We know that the single vendor strategy is used by most U.S. hospitals, and that this market share is growing. There are four main benefits to this approach: the organization contracts with a single certified vendor to help meet federal regulations; there is a single contract to manage initial capital outlays and ongoing operating costs; HIT staff can build competency in a single product; and centralized maintenance and updating of software decreases complexity. Collectively, these benefits reduce operational complexity and enables conformance to a single standard once the system is fully implemented. Limitations to this approach include the fact that such a system often necessitates radical change in business policies and operating procedures across the organization; key stakeholders may resist changing to suit an HIT application rather than having the HIT application designed to suit current workflows; if the system fails, there could be significant financial losses; and investing in a single vendor system significantly curtails the organization’s future ability to change to other vendors.
- With a best of breed strategy, the organization may select different vendors for the acute care, emergency department, ambulatory, and operating room EHRs. The best-of-breed approach has been found most frequently in academic medical centers. This approach requires interfaces for exchanging data between these disparate systems, adding additional financial burden.
- The best of breed strategy has the benefit of avoiding the massive business process reengineering that often accompanies single vendor solutions. By integrating components of software from multiple vendors, and, in many cases, customizing components developed within the organization, proponents of best of breed systems feel that the systems are more closely aligned with the requirements of each clinical area. They believe that they can put together, in a deliberate fashion, a system that ensures the highest quality and creates a competitive advantage. Limitations of the best of breed strategy include the technical and organizational fragmentation of multiple systems that require a wide range of technical skills to manage. There is also concern that these systems pose a compliance risk and have financial implications, with respect to meaningful use incentives.
- The third approach is the best of suite approach. This approach represents a hybrid strategy in which organizations use one application package as the basis for integrating all other applications. The organization selects a vendor that will provide the clinical IT support for delivery across all modalities, to include ED, ambulatory, and operating room settings. Within the last 10 years, the best of suite approach is mostly seen in large urban hospitals and integrated delivery systems.
- There are three main benefits to this approach: the organization can retain and integrate legacy clinical applications into a single backbone application; there is reduced need for disruptive work process redesign; and, therefore, decreased resistance on the part of the professional staff. The major limitation of this strategy is that multiple vendors have strong bargaining positions, with respect to future contracting rates and customization flexibility. As a future HIT professional, you will find that each of these aforementioned strategies is prevalent in health care organizations today. There is no one-size-fits-all strategy, and you should be aware of the strengths and limitations of each strategy.
- Luann Whittenburg has described the importance of attention to nursing workflow in the EHR implementation process. Such attention is critical for all types of clinical workflow, not just the workflow attributable to nurses. Implementation teams should ensure careful process descriptions (how clinical tasks are done, by whom they are done, who documents them, in what order they are performed and documented, and how quickly they are done and entered in the health record). In addition, the sets of relationships between and among all activities, from start to finish, are critical to success. For example, the ability of the nurse to plan for and administer medications is dependent on the prescriber entering the order in CPOE (Computerized Physician Order Entry) and the pharmacist reviewing the order before it is released to the electronic medication administration record. Also, movement of information around the organizations — for purposes such as sign-off and evaluation — must be taken into consideration.
- In EHR implementations, one size clearly does not fit all. Primary care settings have very different needs than academic centers or small community hospitals or even federally qualified health centers. Amanda Terry and her team synthesized the findings of three studies examining adoption of electronic health records in primary care settings in Canada. They found four key factors for implementation success. These factors include the user’s expectations of the system and what is needed to use the software, how much prior knowledge of computers potential users have and the time and training they will need to implement the system, the level of commitment to implementation and adoption of the EHRs and the availability of a provider willing to take a leadership or champion role, and providers’ readiness to adopt the system.
- The size of provider practices varies. Small ambulatory practices are particularly challenged. Although ambulatory practices stand to reap the benefits of EHRs, such as improved patient care and office efficiency, as well as potential financial benefits, there are known barriers. These barriers include the fact that EHRs require a major financial investment, vendor systems are not standardized, and most have been developed for larger primary practices. In addition, clinicians worry about their practice’s ability to technically support the system, disturbances in workflows and temporary productivity reductions, and the perception that EHRs benefit payers and society as a whole, rather than providers. Lorenzi and her research team propose that steps for successful EHR implementation in small ambulatory practices is all about change management. The fact that there is such wide variation in the nature and organization of small ambulatory practices requires a flexible approach to change management, with emphasis on enthusiasm, commitment, communication, and cooperation. It is critical that practice leadership create an actionable vision for change that includes mutually defined, measurable goals as well as the types of tools and technologies that each person envisions using in her daily practice. The approach to each phase of implementation — decision, selection, pre-implementation, implementation, and post-implementation — will need to be tailored to the individual practice, and stated goals monitored, to ensure achievement.
- In 2009, HIMSS conducted a survey of ambulatory EHR selections. In it, they compared institutions that had gone through a second EHR after having used a previous EHR. The stated reasons for the initial implementation were price, ease of implementation, and ease of use. However, during the second implementation, price went down the priority list to occupy a tenth place, and the three most-stated reasons were support services, vendor characteristics, and scalability and interoperability.
- Smaller hospitals have less capacity and resources to afford innovations such as HIT. Rural hospitals face considerable challenges responding to the national mandate to implement EHRs. Conversion to Critical Access status is one way that small rural hospitals have been able to improve their ability to invest in and implement HIT. The Balanced Budget Act of 1997 introduced criteria by which small rural hospitals could convert to Critical Access Hospital status. To qualify, the hospital has to be not-for-profit, located in a non-metropolitan statistical area, be situated at least 35 miles (or 15 miles, if the area is mountainous) from another short-term general hospital, and have 25 or fewer acute care beds. For hospitals that qualify, Critical Access Hospital status changes their Medicare payment methodology to one that is cost based. This change has a very favorable impact on their financial returns, improving their ability to invest in and implement HIT.
- Researchers have looked at staff resources and strategies to support IT in 70 Critical Access Hospitals in Iowa. A third of these hospitals reported having no IT professionals on staff, and only half reported employing one to two IT staff. A large majority (91 percent) stated that they use external IT consultants or subcontractors to support their use of HIT; 50 percent use these consultants to a large or great extent.
- Outsourcing for IT services, such as website/Internet services, system installation, technical support, and network operations (to name a few), was reported by 85 percent of the hospitals in this study. Most of these outsourced services were highly technical. The fewer the number of IT staff, the more frequently outsourcing was used. Another strategy that is used to support IT needs is the use of application service providers or ASPs. This is where the vendor distributes services to customers across a wide-area network from a central database. Only 38 percent reported use of ASP services of any type, and only nine percent used these to a great extent.
- John Glaser looked back on his 20 years as a member of the leadership team that has implemented EHRs at Partners Health Care. He identified 10 factors for success. First, the organization needs to have clear strategies, objectives, and plans. Next, management needs to discuss ways to link the IT agenda to the strategies of the organization. The organization needs to hold itself accountable for its performance. It needs to have efficient IT governance in place. The organization not only needs to determine what processes require IT-enabled improvement, it also needs to measure its performance.
- Multiple supporting initiatives need to be incorporated using multidisciplinary teams. The organization needs to understand the complex nature of the EHR value proposition. Clinicians need to be constantly engaged in improving systems and workflows. An investment in infrastructure must be supported. The organization must invest in modest, thoughtful IT experimentation.
- This concludes Lecture a of HIT Implementation Planning for Quality and Safety. In summary, effective teams have certain characteristics that contribute to their effectiveness: organizational structure (which includes both team environment and team structure), team processes, and individual contributions. Within these domains, six key team characteristics drive effectiveness. These characteristics include: having a clear purpose, establishing goals, having solid leadership, developing group cohesion, establishing regular patterns of communication, and exhibiting mutual respect. Mere contact is not enough to ensure success.
- No audio.
- No audio.
- No audio.