Accelerated Solutions
Health systems house multiple constituencies with multiple points of view. As
such, some level of resistance to the change represented by clinical transformation
is inevitable. However, unless the rationale and implications of the proposed
change are clear to each constituency in language and measures that are meaningful
to them, one can expect to meet with avoidance, resistance, and delay in the project.
There are, however, ways in which acceptance and adoption can be accelerated. These techniques focus on bringing physicians, nurses, and hospital management together to create a common understanding of the benefits to clinical transformation, as well as the sacrifices and resource commitment needed to see the process through to the new way of doing things. For the effort to be successful, the right questions must be addressed, such as how care is to be rendered across the continuum. These are truly core issues for which constituents have deeply held opinions.
Accelerator tools create a forum in which new understanding can be created, opinions changed, and consensus forged. This understanding can then be followed by a collaborative design process in which there is minimal risk of hostility and resentment and optimal potential for collaborative innovation.
The Use of Accelerators
The most significant challenge of clinical transformation lies in the fact that success rests as much on the management and attainment of intangibles (defining a common view of the future, clinician buy-in, and establishing a culture of cross departmental decision-making and accountability), as it does on the attainment of tangibles (change in processes and procedures, implementation of technology, etc.). Both types of issues must be addressed in order to ensure acceptance and adoption.
Accelerators catalyze change by serving as forums for both design and implementation. Two specific accelerators — DesignShop® and RapidDesignSM — have particular value to clinical transformation. DesignShop incorporates collaborative learning, prototyping/testing of options, and accelerated decision making. This tool is helpful when multiple constituencies need to commit to a future state or address strategic issues in order for the organization as a whole to move forward. RapidDesign facilitates multidisciplinary groups at the department or business-unit level to make design decisions on operational and technology issues. DesignShop promotes creation of breakthrough change solutions, whereas RapidDesign addresses specific process design issues or system requirements.
Accelerators can provide significant value to an organization, such as:
- Support efficient use of organizational resources: Accelerators maximize
the use of valuable time by engaging participants in productive two- to three-day
work sessions where decisions are made with stakeholders' commitment. This
is different from the more traditional approach where a limited number of
stakeholders meet periodically every few weeks and do not consistently resolve
key decisions. Typically, three to seven months are saved.
- Address complex problems in a structured environment: Accelerators provide
an environment to assemble stakeholders from separate organizations or departments,
with different systems, processes, and bureaucracies to agree on and commit
to clinical policies, practices, and system decisions.
- Facilitate the right decisions: Accelerators provide a process for up to
hundreds of clinicians and operational executives and managers to apply their
expertise and make the right decisions in a compressed time frame. Importantly,
these decisions are fact-based. Often organizations attempt to make decisions
with limited stakeholder involvement and end up making decisions that have
to be revisited later because they lacked input from the right people the
first time.
- Bring down silos: An added benefit of accelerators is that this approach helps bring down organizational silos and creates a culture of interdepartmental decision-making.
DesignShop
In the DesignShop process, diverse groups of 35 to 100 constituents come together for one to four days. They develop a common understanding of how the organization will operate in an improved future state. To ensure a deep understanding of options and group commitment, a 3-step process is used. The Decision by Design® methodology is presented in Figure 1.
This approach starts with a series of group exercises designed to draw out ideas about the desired state from the participants. At this point, anything and everything is up for consideration. These ideas are subsequently combined with objective facts and informed opinion about what currently works and what doesn't to iterate different scenarios. Options that will work are developed, while options that will not work are discarded. With 60 percent of the work completed in small teams of eight or nine people, specific options are explored and stress-tested. At this point, the collective group can endorse, support, and commit to the options that provide breakthrough solutions.
The group then develops solutions in detail and establishes a high-level action plan to move the developed initiatives forward. Concrete decisions regarding activities to be conducted, assignment of responsibilities for follow-through, and specific timeframes position the group to maintain momentum in the days and months following the session.
DesignShop works as a very effective accelerator because it incorporates the following characteristics:
- Co-designs the right purpose: Event executive sponsors develop and
agree upon event objectives, "hard" deliverables, "soft" outcomes, the specific
work to be completed, who should attend, and the information needed to complete
the assigned work.
- Uses a creative work environment: Unique to DesignShop is the use
of a creative workspace configured to inspire group genius. This space is
technology-enabled and promotes out-of-the-box thinking, exploration of new
ideas, testing of assumptions, and development of breakthrough change solutions.
Thousands of square feet of white board are available for participants to
capture big, bold ideas.
- Establishes trust: Participants generate iterative solutions as they
flow between facilitated large group sessions and small break-out groups.
By successfully completing work on a time-boxed basis, participants build
rapport, understanding, decision-making skills, mutually defensible agreements,
and ultimately trust.
- Creates a coalition for change: Given the time to work in a creative
way, DesignShop participants identify root-cause problems, design and test
break-through solutions, create action plans, and make decisions on how to
move and sustain change in the organization. Leadership of the required change
is expanded beyond formal operational and clinical leaders.
- Manages participants' creative work: A facilitation team is used. Comprised of trained knowledge workers, the team manages the creative environment, facilitates participants' work during the event, and documents the knowledge and solutions created by participants.
Where to Use the DesignShop Accelerator in Clinical Transformation
Health systems face struggles in clinical transformation that lend themselves to the use of DesignShops. For example, there is need for a common and shared view of how the health system will operate after the clinical system has been implemented, as well as the implications of these changes for physicians, clinicians, and operational leaders. Giving the stakeholders who will be directly affected the means to resolve these particular issues is critical for establishing buy-in and sustaining change.
After a typical session, the executives, physicians, and clinical and departmental directors have often gone through a process where they have struggled and then triumphed to develop a common understanding and commitment to the initiative. They begin to appreciate the benefits to patient care as well as the compromises and unpopular decisions that may be required across departments. This up-front commitment is critical, since the transformation will require these same leaders to make and support difficult decisions that will be tested and challenged throughout the initiative.
Multi-entity systems face special needs. In many cases, the member organizations for these systems are starting from very different places regarding the use of evidence-based medicine, clinical information systems, and other enabling technology. DesignShop gives stakeholders with very different vantage points the opportunity to candidly debate differences, raise the right questions, create new options, and come to agreement on what will work within their system.
Health system leaders have responsibility for communicating the rationale for undertaking clinical transformation to multiple constituencies. Research has found that the most influential communication occurs between people who share knowledge of the same world. DesignShop provides the forum for the rationale to be explored, created, understood, and agreed to by a large group of stakeholders. This effort supports consistency of message while recognizing the need for variation in form for different audiences.
RapidDesign
RapidDesign facilitates business decisions across departments or business units. Figure 2 summarizes the types of decisions that are addressed in a series of RapidDesign sessions for a clinical transformation.
During RapidDesign, multiple teams work in parallel on design decisions. The number of teams is dependent on the decisions that are required to make the best use of the enabling technology. The number of participants in each session depends on the number of departments affected by the process to be redesigned. Typically, three sessions occur over the course of three to four months and involve anywhere from 120 to 300 participants.
The first session focuses on defining future state processes (including patient care processes, ambulatory work flow, and integration of rules and alerts). The second session focuses on the data and content that populate a system (nomenclature, system parameters, and screen design). The third session focuses on policies and procedures, security, and reports.
At one multi-hospital system, RapidDesign was used to create a common system design across all facilities. The approach enabled the completion of design activities within a five-month period, involved more than 400 participants (including 75 physicians), and resulted in 75,000 design decisions, including approval of 151 process flows, 976 screen designs, and 97 policies and procedures.
RapidDesign works as an effective accelerator because it integrates the following characteristics into the process:
- Uses a whole systems approach: Stakeholders representing the entire
process are physically together in one location working collaboratively
on tailoring decisions. This process assures that the appropriate knowledge
and expertise are available during the design process and that the stakeholders
commit to the decisions.
- Integrates strawcase solutions: The process leverages prepared straw
models that reflect leading industry practices and the unique needs of
the organization. These straw models ensure that the participants use
their time tailoring the future state of their institutions, instead of
doing clean-slate design and re-creating the wheel.
- Undertakes concurrent decision-making: Different teams work in parallel on separate sets of tailoring decisions to accelerate the process. No two teams work on the same set of decisions.
An Example of RapidDesign as an Accelerator in Clinical Transformation
In addition to the larger RapidDesign sessions discussed above, smaller, more focused sessions can be used throughout the course of the transformation project to address specific topics or issues. The results of these RapidDesign sessions can be significant. While reviewing care processes for surgical services, the design group at a major health system discovered major problems with the registration and scheduling process. The physician office staffs were spending a tremendous amount of time trying to connect with registration and scheduling personnel and running down patients who fell between the cracks or whose preparations for procedures were incorrectly addressed. On the health system side, the difficulty of getting all the pertinent patient information from the physicians' offices had resulted in lost revenue and incorrect billing.
As a result of the collaborative efforts during a RapidDesign session, physicians and operational managers redesigned the registration and scheduling process. It included a single electronic form by which all scheduling and information sharing for an individual patient would occur. Routine scheduling requests were batched at the physicians' offices and sent electronically to registrars and schedulers near the end of the day. The hours of the registrars and schedulers were modified to permit them to work into the evening when patients were available at home for information verification. The electronic format of these requests permitted the schedulers to create reports on the requests. This improved their productivity and assured that patients did not fall through the cracks. Once the process redesign was complete, appropriate technology was brought in to support the new process.
As a result of the redesign, physicians experienced a drop in cancellation or postponement of procedures due to incomplete patient information. Patients who had scheduled time off work for procedures were no longer inconvenienced by cancellations, and the health system increased its revenue capture. The consensus of participants was that such a redesign would have taken months to accomplish in a more traditional meeting format. Using the RapidDesign accelerator, the process was completed in three sessions over the course of two weeks.
RapidDesign is also an effective tool to help develop order sets for computerized physician order entry. In a series of three-hour sessions, varied groups of physicians and other clinicians can produce order sets to facilitate order entry and support leading practice and reduction in practice variation.
Summary
For clinical transformation to be successful, a health system must be prepared to deal with tangible changes such as selection and migration to new technology and the creation of new clinical care and operational processes. The organization must also be able to deal with the intangible aspects such as clinicians and other users accepting and endorsing changes, and establishing a new culture that embraces cross-departmental decision-making and evaluates performance based on outcome measures.
Accelerators support both tangible and intangible benefits by creating environments for decision-making in which the right people are present to generate enterprise-wide commitment, a time-tested approach to creative design and decision-making is employed, and the structures for implementation and project management follow-up are created. The result can reduce the overall time requirements for the transformation significantly and improve the realization of benefits.
