Implementation Approaches
New Technologies, Same Old Problems
The traditional systems implementation, even of cutting-edge clinical technology, tends to automate how things are currently done rather than how they might be done to drive best practices and leverage the functionality of the new technology. Frequently, traditional implementations have been accused of hard-coding the current state so that making future changes is, in fact, more difficult. In the end, operations are not optimized and financial performance suffers. Taking this approach, an organization may end up with exactly what it doesn't want: automating suboptimal (and costly) care.
There are certain predictable issues that plague traditional systems implementations. When dealing with clinical information systems areas, the issues can be compounded. These issues include:
- Lengthy and costly investment streams with distant (and elusive) benefit
streams.
- Failure of target users to adopt new technology.
- Failure to attain full desired functionality of the technology due to over-reliance on single vendor solutions.
Health systems can avoid these quagmires by adopting specific implementation strategies.
Implementation Strategies That Create Value
An organization's implementation approach impacts the results it can achieve. A clinical transformation approach is comprised of three major phases:
- Discovery: Creating a common, tangible understanding of how the organization
can be improved through the use of new clinical technologies, how it will
function once new technologies are brought online, and how operations must
change to achieve the improvements.
- Implementation planning: Focusing on the selection of software vendor(s)
or modules that support the desired changes for the organization, and planning
for the implementation of both process changes and technology.
- Implementation of transformation initiatives: Establishing the "new order" through the implementation of both new care processes and technology in such a way that the organization begins to realize the stream of benefits prior to the technology going live.
Strategies that impact success can be built into the approach at a number of critical junctures. Within discovery, an initial triage can be undertaken to ascertain where to focus energy and resources most productively. Within implementation planning, collaborative planning efforts can take place to customize clinical workflow in support of the broadest level of user support possible. Within implementation of transformation initiatives, a multi-sited organization can establish a model of operation that can then be rolled out to the multiple locations in a more efficient and effective manner. Each of these strategies will be examined in detail.
First Things First
Given that clinical transformation involves the entire organization, it is fair to ask, "Where is the best place to start?" The answer depends on the goals of the organization and where the opportunities for improvement lie. It will also be influenced by IT-specific issues such as a need to replace aging software, pending termination of vendor contracts, or other issues that may influence priorities.
It is important to begin with a brief period of discovery during which current operational processes, clinical practices, patient outcomes, financial performance, technology, and related initiatives under way are identified and evaluated against leading practices. Additionally, physician readiness to undertake such a process is assessed. Specific to clinical transformation, the following processes should be evaluated:
- Physician clinical practice
- Patient access
- Departmental/support services
- Pharmacy/medications safety
- Care management
- Clinical documentation
- Health information management
Figure 1 illustrates how clinical and operational processes are interrelated with specific software modules, and how the integration of best practices can yield significant improvements.
Figure 1: Integrating Leading Practices for Clinical and Operational Processes
This discovery yields an in-depth understanding of where in the organization areas of improvement potential lie. The organization is then in a position to establish priorities based on an objective quantification of benefits associated with possible initiatives. The slate of actions that are selected — termed below as the "improvement portfolio" — becomes the focus of all subsequent technology and process redesign efforts. An example of such an improvement portfolio can be found in Figure 2.
(See Larger Image)
Figure 2: Sample Business Improvement Portfolio
From an IT perspective, the business imperative must be blended with information technology imperatives, which are often not visible to the organization beyond the applications level. While the business imperative gives significant insight into strategic and operational requirements, some IT-specific considerations will need to be included:
- Strategic IT plan and capital requirements
- Infrastructure requirements
- Applications portfolio
- Status of current vendor systems and contracts
- Requirements for additional or upgraded systems or applications
As the lead time for acquisition of new systems or applications can vary widely depending on the status of current systems, the ultimate implementation plan must blend realistic IT delivery timeframes with requirements for process changes to create an integrated approach. For example, if a two-year lead time is anticipated for acquisition and implementation of new clinical systems, that two-year period can be used to make certain initial process changes which are then incorporated into the ultimate information system design.
Collaborative Design
Physicians and nurses have tremendous, often competing, demands for their time and attention. These demands and other stresses associated with clinical practice create "one chance challenges" where clinicians will generally have sufficient endurance for a major clinical system installation — but only once. And since systems such as those encompassed by clinical transformation impact how clinicians go about completing their work and how they receive and provide information, the risk of alienating physicians is compounded. To avoid alienation, structured collaborative design is a proven implementation strategy.
Key to collaborative design is the organizational structure to facilitate clinician involvement in the design of clinical processes and systems functionalities. Strong internal individual physician leadership supported with a core physician oversight group will be essential to establishing principles, making key design and implementation decisions or recommendations, and garnering broader medical community support for the project. Other elements of collaborative design include focus groups to assess preferences, resistance, and must-dos for successful transformation.
It is equally important to organize and track design decisions and recommendations. This keeps meetings action-oriented and focuses their work. It also serves as a guide to their progress and an objective way to track success, monitor lack of consensus, and foreshadow the future work that they will address. During actual implementation, users need to be heard and shown that issues that arise are being addressed in a timely fashion so that they will continue to invest their time and intellectual energy into the work at hand.
Consider a Franchise Approach
Many health systems are multi-sited and pose unique issues for clinical transformation. One very effective strategy for handling this situation is to create a "franchise model" representing the enterprise solution for the entire system, followed by deployment of this model to various facilities. Figure 3 illustrates how this enterprise model structures implementation efforts by focusing considerable effort on solution definition up front with participation from all affected parties.
Figure 3: Franchise Model for Implementation
The purpose of a franchise model is to accelerate the implementation of clinical transformation across a multi-site system. The approach works best in organizations whose vision is to deploy one common set of information systems and best practices across the enterprise. This approach allows for economies of scale, while allowing for necessary variations in operations or clinical practice driven by site-specific needs — the 80/20 rule. Multi-entity organizations, however diverse, can optimize expensive IT resources and systems and can deploy leading-practice thinking using this method.
The franchise approach calls for one design and system build process, combined with repeatable components for deployment (such as equipment placement, end-user training, and go-live planning and support) across a staggered set of entities. During the design process, the broad requirements of all entities are considered. Decisions are made through a collaborative process, and guided by pre-established principles of how health system leadership would like the organization to function.
Design definition centers on how certain activities will be handled across the enterprise. This might include how nurses will do documentation, how patients will be registered, and how medication administration will work. One of the benefits of employing a franchise model lies in actual implementation. One central implementation-management team can be established. This team will oversee the implementation of the system in each location. In this way, the experience of the implementation team is leveraged from one location to another, reducing implementation time and minimizing errors and the need for duplication in staff. After the clinical transformation project, the ability to support systems efficiently is greatly enhanced due to the similarity in systems used across locations.
One large multi-entity health system used a franchise approach for the design of a clinical system that was required across nearly 20 entities of varying size and complexity — from academic medical centers to community hospitals and rural facilities. Using this approach (supplemented by professional facilitation and design techniques), this complex health system was able to design its complete clinical process and accompanying information systems in approximately six months.
Define Success
What does success look like? In creating a picture of success, the organization undertakes the task of defining a future-state vision. This vision focuses the organization and, more specifically, the project on the important aspects of required change. Thus, the future-state vision must reflect the strategic and operational goals of the organization, as well as guiding principles that should frame the project. For example, the degree of standardization of clinical practice must be addressed up front to frame the clinical redesign work. Enterprise-wide financial targets and the degree of collaboration expected across entities must also be conveyed.
A definition of success must ultimately go deeper, however, to create a tangible target for performance. Organizational processes are not true to departmental boundaries. Performance targets must therefore cut across departments. This is a difficult concept for some organizations. An example of this can be seen in Figure 4 related to care management.
Figure 4: Sample Redesign Goals — Care Management
When success is defined across the organization, then the specific clinical processes that must be modified to support success are clearer. Similarly, the ability to quantify the magnitude of the benefit makes the rationale for the undertaking more accessible and understandable for all constituencies.
Keys to Success
There are several definable characteristics of successful clinical transformation projects. Organizations seeking to leverage the experience of others would do well to evaluate their own processes to determine whether the following characteristics are present.
Clear Expectations
Transformation by its very nature means a change to a wholly different way of doing things. Unless affected parties can understand in advance what this looks like, and what the implications are for their own jobs and the care processes they follow, confusion and avoidance behavior are likely. It is worth the time to define and describe changes in performance (quality, operational, financial, and cultural) which will serve as beacons and guides for operational managers and affected constituencies in the middle of such change.
Executive and Clinician Ownership and Accountability
The mandate for change must come from the highest levels of the organization. Executive management must establish the challenge and follow through with strong oversight. The participation and ownership of the care process design by clinical leaders is instrumental to the success of the project. It is the single most important determinant of eventual wide-scale adoption of technology by the broader medical community.
Access to Functional, Clinical, and Technical Expertise
With the broad array of design decisions which must be made and the range of technology options available, organizations should leverage the experience and knowledge of the industry by working with facilitators that have sufficient depth and breadth of expertise to provide integrated working teams.
A Well-Designed Implementation Plan
Such a plan should include evaluation of potential benefit areas and redesign of business processes to be sure that expected benefits are realized.
Project Management Infrastructure
Strong project management and control mechanisms are critical to success. In such a complex undertaking, many parts and processes of the organization are in flux simultaneously and must be knit together in specific sequences. The ability to track critical timeframes and milestones and to undertake ongoing risk assessments are key components to the creation of success.
At-Risk Contractual Agreements
Timing is critical in the context of clinical transformation. It behooves an organization to establish at-risk financial arrangements with outside experts and vendors of technology to assure timely delivery of services and products.
Comprehensive Change Management Program
It is reasonable to expect uncertainty and resistance when people need to perform their jobs in a new way. Clinical transformation creates a new culture within the enterprise based on continuous performance-improvement. Key to widespread adoption and support of new processes is a comprehensive change-management program that guides communication of how changes will influence both enterprise-level operations and individual job responsibilities. Training to support management at all levels of the organization is also key.
As an industry, we know what we must do to improve the quality outcomes and financial performance of our health systems. Getting the job done, while challenging, is an undertaking that no organization can avoid. Carefully structured, it is an undertaking with great rewards for all parties.
