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”
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
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”
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 mammogram
Result 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.
10.
11.
12. 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
13. Lose weight, Being more productive, Quit
smoking.
So hard we don’t like to start
What about getting married or having a baby?
Not all change is hard
The question is: How desirable
(intellectually and emotionally) is the
future state and how hard is the path to
get there?
14. 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
15. The easy part for healthcare…
Quality
Safety
Efficiency
Baseball, Apple pie and Chevrolet
16. 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
17. 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
18. 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.
19. 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
20. 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.
21. 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
22. Months of gradually increasing unrest
Issue identification
First consequence
Threats of additional consequences
Decisive action
FUD (Fear Uncertainty Doubt)
23. 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
24. 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)
25. 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
26. 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