Kevin Shea -- Process Collaboration

How NOT to implement EMR or other hospital applications

This from a hospital sales consultant .... and consistent with the alternative approach offered here  - scroll to bottom of post

"What ever EMR you implement, you need to customize it to be user friendly. Not user friendly for an IT person but user friendly for clinical staff. I just did a demo in NY and the CIO didn't seem to care about getting feedback from any of the nursing staff (who will use the system on a daily basis) and that will be his downfall with his implementation in my opinion." 

An “evolutionary” approach to EHR/EMR implementation.

 

This post relates to a previous post of Why EHR implementations fail and is offered to "bridge the difficult gap that exists between business units and IT". See What people say about what I do in the left column.

This suggested approach provides the business (those who perform the work) with a means to manage and control process execution while slowly moving towards implementation of an EHR/EMR. This approach seeks to drive technology selection from a basis of a well-informed staff using a well-developed, proven process improvement methodology.

1. Interview staff (preferred anonymously) and determine current problems related to patient care and safety. Rank the problems
2. During interviews ask participants how they would address the problems. Use suggestions as input to a process/performance improvement effort.
3. Develop a running list and note if EHR or functions of an EHR are among the needs defined in the interviews.
4. As part of the interview, ask how they rank EHR as part of a solution suite. Ask staff to list the 5 most important elements of what an EHR/EMR application must provide in order to be “useful”.
5. Subsequently, determine if current issues can be addressed with process/methods changes or introduction of “easy to use”/simple tools
6. Create a collaborative framework or system architecture within which people, processes and technology can be “mixed and matched” and applied to problem solving.
7. Solve a few problems to demonstrate how process changes can provide benefits to staff. Continually determine if solutions are providing the intended benefits.
8. If EHR does not show up well in rankings (item 3), but is envisioned to be necessary in the long run, develop a multi-year roadmap that addresses immediate needs, but points the organization toward this goal.
9. Gain the support of staff by demonstrating consistent ability to deliver solutions (people, process or technology) and by integrating staff into decision-making.  Educate staff about process, process change, utility of technology to support change, etc.
10. Demonstrate how individual functions of EHR fit into the framework, how these functions extend the benefits of previous process changes, how the tools supports the needs in Item 4, and how these functions decrease workload.
11. Conduct a series of informational efforts, demonstrations of EHR/EMR, team conversations, etc, to vet potential applications.
12. After staff becomes familiar with all aspects of EHR, how it will work in their environment, how they will benefit by its use, a team creates a requirements document that forms the basis for selecting a tool.
13. Begin implementation following a well-developed plan managed and controlled by user organizations.

 

The alternative:

Management, feeling pressure from external sources, tells IT to find an EHR application that is not too expensive. IT asks a few staff members what might be good, and buys an EHR application from a salesman who assures them that it is easy to use, has already been implemented in many different locations, and is the most cost effective application among many competitors.  IT selects application A since XYZ hospital bought it and “they must know what they are doing”.

 

More problems with "disintegration" of information in healthcare

The following article is from Jan 31, 2010 Boston Globe 

Ref: my related experience and blog post on the same topic Systems integrator

 

MY WORK as a doctor only partly prepared me for my 84-year-old mother’s recent brush with death. During her illness, “job one’’ became helping her navigate the shoals of our health care system so that she could survive her medical conditions. If she hadn’t survived, her death certificate would have listed a heart attack and a diabetic emergency as the causes. The sad truth is the actual cause would have been a lack of communication between her doctors. The antidote to this all-too-common scenario lies in the state’s plan to switch from fee-for-service payments to more coordinated treatment, and in our much-maligned national health reform law, which contains a critical mechanism to improve communication and care.

The usual experience of a sick older person today is similar to that of an American traveling in a foreign country with no passport, no ability to speak or read the language, and no tour guide, all while deathly ill, often hungry and thirsty, exhausted, confused, and frightened. During my mother’s illness, my sister (a lawyer) and I were her “health care navigators,’’ and together we managed the treacherous voyage.

In the hospital, after her heart attack, my mother’s diabetes doctors weren’t allowed to prescribe her medications or diet because she was on a cardiology unit. Despite good intentions, the hospital almost killed her by giving her 32 ounces of apple juice one day, causing her blood sugar to rise to a dangerous level. To compensate, they had to give her a lot of extra insulin, which caused her blood sugar to drop precipitously. At one point they had to resuscitate her because her blood sugar went so low. This happened because the diabetes doctors had almost no real-time way to communicate with the cardiology doctors. They needed a navigator — a knowledgeable intermediary — to make sense of the overall picture and connect the doctors to each other.

We doctors typically get paid only when we interact directly with patients. Due to over-interpreted privacy laws, the lack of compensation for time spent on communication, and disconnected systems, it’s difficult and costs us money to communicate with each other. Each doctor practicing in a different part of the system — hospitals, doctors’ offices, nursing homes — has information critical to the decision-making of other doctors. Yet the system works against us if we try to make that vital connection.

Under the national reform law, 11 months from now doctors and hospitals will have an opportunity to create accountable care organizations. These connected networks of providers will benefit from, rather than be sanctioned for, communicating and coordinating care. This should save both money and misery, as in the case of my mother’s resuscitation that shouldn’t have been necessary.

This missing, yet essential, communication can take many forms. “She’s not able to tell me her history,’’ was the refrain I heard so often from hospital doctors who didn’t know what to make of a well-educated, elderly lady who couldn’t remember what her near-lethal blood sugar level had been after her insulin pump failed and brought on her heart attack. She couldn’t say what her dose of insulin had been changed to during her last visit with her primary care physician. She couldn’t remember these things because she was too sick to remember.

If the hospital doctors had spoken to her primary care physician, they could have had all the information they needed to guide their decisions. But hospital doctors often don’t communicate with office doctors, leaving the patient to fend for herself, just when most vulnerable. In addition, office doctors are responsible for a patient’s care after she leaves the hospital, but frequently don’t even know that she’s been hospitalized until she returns to the office.

When my mother became stable enough to leave the ICU, she was transferred to a step-down unit only two doors away, but with a whole new medical team — doctors, nurses, aides, case managers. And every new clinician had to read the paper chart, or if unable to decipher it, “interview’’ my mother again. “She’s not able to tell me her history. . .’’ over and over again. Exasperated, my sister introduced us with, “Hi, this is my sister, she’s a doctor. And I’m a lawyer.’’

Patients should not need a doctor and a lawyer in the family in order to get appropriate medical care. My mother survived her near fatal illness because she had knowledgeable, relentless insiders to advocate and communicate for her.

The health reform law and its groundbreaking accountable care organizations are under attack. This reform deserves public support. Otherwise, next time you need care, be prepared to take a lawyer and a doctor with you

 

Top Ten Reasons why EHR/EMR implementation fail

This topic is one that came from LinkedIn.

It's really not hard to reply to this subject since EHR/EMR is simply another IT solution, and can be readily compared with any other IT implementation deployed in any other industry. The issues are basic and fundamental and do not necessary reflect uniqueness of the medical field. 

1. Proposed solution does not solve a problem that staff currently have
2. Solution providers do not listen to the needs of the staff.
3. The solution is cumbersome, awkward, and requires more administration time than current method.
4. The solution is hard to use, requires extensive training, or requires special treatment.
5. The solution providers are enamored with their application.
6. The current practice is considered serviceable, and the suggested benefits of the new solution are not apparent to the staff.
7. Solution providers are seeking a single, large-scale deployment when staff will only accept incremental, easy to swallow, step by step changes that can be adapted.
8. No efforts have been made to adapt the solution to the current or future processes that improve performance.
9. The deployment is not fully supported by a broad strategic plan that provides a long-term framework which reflects the organizations capability to change.
10. A culture of technology first, then process and lastly people exists when one of “people, process, then technology” should prevail.

 

 

How to Prepare for a JCAHO TJC compliance audit

Rather simply, .......  excel at everything that you do.

Compliance audits are required in many businesses and the best businesses simply do not worry about being audited. They are fundamentally prepared for any audit at any time since they have taken basic and fundamental steps that are necessary to run an effective operation that assures highest quality and best in class customer service.

The declared mission of JCAHO/TJC is "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value".

In comparison, ISO9000 standards were instituted in the late 80's with the intention of driving consistent practices and methods of execution throughout industrial companies. The goal was to improve quality and make national manufacturing more competitive.

But where did the ISO standards come from? .... From those practices used within successful companies. And how did those companies develop best in class practices.... they listened to their customers.

If one looks at the declared mission of ISO9000 it may read similarly to JCAHO "To continuously improve product quality, in collaboration with other stakeholders, by evaluating manufacturing organizations and inspiring them to consistently provide products and services of the highest quality and value, improve business efficiency, and increase customer satisfaction.

It isn't too far of a stretch to see that JCAHO will leverage much of the best lessons learned from ISO. One lesson learned was if an industrial firm spent more time preparing for an audit, than in running an effective operation, they failed to obtain a certification.

The most effective way for a hospital to prepare for an audit is to consistently outperform all other hospitals and thus become the standard for all others to follow. Rather than focus on what an audit might require, focus on quality, customers, error reduction, consistent outcomes, repeatable high performance execution, singular methodologies of work, removal of barriers, integrated teams, document and data management, systems thinking, structured methods, checklists, and more. 

Regardless of specific activities, assure that these focus points become basic and fundamental in the operation at your hospital, since they are what will form the basis for most all specific standards.

Worried that the standards are ill-defined and changing? Expect that to continue. Concerned that you will need to comply with a moving target? You need not worry if you focus on those basic principles upon which the specific standard will rely.

• Focus on excellence and don't worry about audits.

• In simple terms: if you are doing it right, showing it is easy.

• If you are running an inefficient practice, the audit will be onerous, difficult and costly.

• If you want a guide to implementing a compliance plan, benchmark ISO9000 and implement many of the basic elements contained therein.

• If you want a specific approach, create an "Evidence Book". An evidence book is the collection of all materials (documents, results, changes, etc.) that are relevant to a department, division, project or individual task. The evidence book can be structured as a systemic representation of the workflow and can, when required, be used to demonstrate the efforts made in response to a particular activity.

If you implement an effective evidence book methodology, you will be prepared for an audit at any time. 

Questions for Hospitals involved in Performance and Process Improvement

• Do you have a comprehensive plan that integrates strategic intentions and tactical execution?
• Are your projects linked to a Quality Operating System?
• Have you conducted a Voice of the Customer?
• Do you envision your hospital as World Class or providing Best in Class care? If not, why not?
• Do you provide a focus on interdepartmental integration?
• Is your focus high performance execution or fixing process problems?
• How are you addressing the need to change culture and behavior?
• Does your process and transaction management link to cost containment?
• Is your performance improvement plan supported by an economic model?
• Have you taken a pulse of your staff? Do you rely on staff to identify process changes?
• Have you benchmarked your hospital against others hospitals? or compared your operation to any other industries? 
• Have you established a collaborative environment? 
• Have you established a program to drive infections to zero? yes, zero.
• Are readmissions considered a demonstration of lack of quality service? Do you have a program to drive readmissions to zero? Do you charge patients for work done on readmission?
• Have you successfully created a process improvement plan that benefits both patients AND staff members?
• Do your IT solutions service the process execution needs of staff or do the staff service the data input requirements of IT?
• Have you reduced management initiatives and eliminated conflicting requirements?
• Does meeting undefined standards (JHACO/TJC/HL7) conflict with efforts in performance improvement? Are you prepared for an audit?

What's next? -- Lean Management

The most significant item missing in lean operations is "lean management". 

In order to have truly efficient operation, lean must be established across an entire operation. It is well established that in order to have effective lean manufacturing you must have lean engineering. But, in order to have lean engineering, or lean HR, or lean finance, you must have lean management.

Companies must begin to examine management processes and management methods and apply similar waste reduction standards, process optimization and efficiency measures to assure that management activities do not contribute to lowering productivity.

Examples which lean management might include:

• Does a staff member receive different instructions from two bosses?

• Does one corporate initiative or program counteract another leave staff and process participants confused and misdirected?

• Does an arcane budgeting process cause delays in product development cycles?

 

What's next? -- Thinking INSIDE the box

"Thinking outside the box" has been fashionable for quite some time, and it seems to have lead to some interesting advancements in many industries. It may have been necessary and may still be necessary when business operations become stagnant or products lose appeal. "TOTB" is often called on to provide support to change management, process improvement, and related activities. Thinking differently than "normal" is considered valuable when vision changes are necessary.

One assessment of the current situation suggests that change management has become "all things to all people". Now, change management is being offered as the cure-all to any corporate issue and has become a commodity service offered by anyone who may have taken a Six Sigma course.

Yet, there are firms that have well established and effective change management programs. These businesses are beginning to look for more ways to create value within their operation. They are beginning to see some diminishing returns in continuous improvement, as they begin to gain control over the macro events and processes that are needed to run their business. In these companies, there is less need to be looking for vision changes, but still a need to execute at optimal levels.

In many firms, it may no longer be about changing processes, but assuring that processes are followed and each step in the process is maximized for efficiency. 

If the process is "the box", firms must begin to consider how to think inside the box and use that focus to assure every small bit of waste is removed and all transactions that occur within the box are optimized. 

This new focus on thinking inside the box will require that all process participants begin efforts at self-directed micro management or individual transaction management. Every transaction that occurs within the process and which is influenced by the participant, must be evaluated by the participant and determined to have value. 

More industries moving to lean management --- now Education

Edcuation may not be a industry in the old way of looking at things, but it seems that some in the education area are beginning to look at how to change processes, or at least make them better. 

I was recently conversing with a fellow who was involved in administration at a school system. He was aware of lean, TPS and other quality systems, but was trying to figure out how they could work in education.. in particular K-12.

We started at first principles --- who are your customers and what do they want. Have you done a Voice of the Customer? He was unsure who his customers were. After a bit, we determined his customers were colleges who recruited at his schools, local employers, parents, and fed and state governments -- but not teachers or the teachers unions ( they were the practitioners who delivered the desired "product" at the end of the students time in the "education factory")

We then talked about work cells and how each classroom was a cell and that its output was the input to the next cell (grade level), and that the work activity, work load, and output was highly dependent on the input. Thus, the K-12 process was an integrated process of value added streams that created a high valued and desired product by the time the tutelage was complete and "product" left the loading dock (graduation stage).

There was a lot of hmmmms and gees... and of course the concern, that "we are not a factory". Well, we agreed to continue to talk.

So can TPS, lean management, and other quality controls be introduced to education... sure, why not! 

Can Pharma Learn from Automotive successes in collaboration?

I’ve been looking more into health care as it relates to pharmaceutical companies and am seeing interesting opportunities for collaboration, process management, etc.

Can Pharma take advantages of collaboration lessons learned in the automotive industry? In short, the answer is yes.

Economic and business changes in Pharma are pushing firms to rethink business operations, process methods and the “way of doing business”.  End of cycle intellectual property, cost of manufacturing, and long-term sustainability are forcing pharma companies to reconsider past business models across the venture. Pressure from off shore generics and other regulatory and external factors contribute additional instability.

 Benchmark studies indicate that the domestic automotive industry was facing significant similar challenges during the later part of 1990’s. Pressure arose from Japanese car manufacturers in-sourcing plant operations in the south as well as competitive business practices following concepts of TPS (Toyota Production System). These actions, together with internal assessments of the current state of the business, forced auto companies to shift towards a lean operations model that sought to increase speed of execution, improve quality, reduce costs and, in general, do more with less. This lean operations model was applied equally across manufacturing and product development and was extended to include a reduced number of suppliers in a much tighter working relationship.

The shift in domestic automobile industry also saw migration to systems thinking, a focus in integration and process management, and increased attention towards efficient execution. These needs drove additional changes in the way business practices were conducted and supported. A notable change was the introduction of flexible, business friendly tools that could be managed at the business unit and which could make immediate impact. Hugh scale IT tools that took years to create and dozens of IT people to support, gave way to Out of the Box applications that could be configured by the business unit to support its business, its processes, its documents and its communications. A prominent tool that emerged was collaboration: both as process management and the tools to support it.

What defined the issues at the execution level?

Business units relied on email as their primary process execution tool. Documents were passed back and forth, suggestions for changes offered from multiple sources, multiple versions of documents were in play at the same time and most members of the staff were unsure which was the “right” document. In emails, people were constantly asking how to do something, since a standard process didn’t exist. Significant amount of time was spent on getting clarification about what to do, where to find something, who did what, or sending a document (often the wrong one) to a supplier, playing phone tag with suppliers, delaying necessary actions, or aggregating multiple documents into a single readable summary report.  In general, time was spent just trying to figure out how to operate within ill-defined processes.

Does that sound familiar? 

Many solution suppliers want you to believe that content management is the key to success. Were high cost and poor execution in automotive firms about inadequate document sharing or content management? Not really, it was about out of control processes, poor process management and inefficient execution. The most successful among the automobile companies focused the solution on process optimization and making people successful. And by getting the process right, the documents “just went along for the ride”.

In the end, business units conducted their business within collaboration frameworks that were structured to mimic the best process methods and to provide a familiar workspace that delivered benefits to all members of the staff.  Teams of business managers and staff create the frameworks after much thought with regard to past practices, new needs and a new attitude brought on by the realistic business condition called “the wolf is at the door”. Collaboration set people to working better in teams, developing a single process that they could all agree on, defining procedures for dealing with documents, and other activities that seemed so mundane in previous years.

Changes and pressure in the automotive industry gave rise to changes in business practices, which drove increases in execution efficiency. Collaboration around processes was a major driver. With changes forcing Pharma executives to reconsider past practices, can Pharma learn from Automotive and seek to shift to a process centric execution model supported by concepts and tools of collaboration?