# Presentation: 463952

## 505IT Implementation, Change Management Strategy and Leadership

**Presented by:**
- Lynn Cooper, MS, RN AD/PS, Columbia, MO
- Kim Radant, MS, RN AD/PCS Indianapolis, IN
- Tina Lund, MSN, RN, CNAA, Nurse Exec, Mpls, MN

## Role of Nurse Executive

- Leadership
- Strategy
- Change management
- Fitting IT initiatives into workflow
- Managing the related changes

## Leadership Implementation Strategies

- Lynn Cooper

## Healthcare is a Team Sport

## Leading the Way with IT

- Embrace the opportunity to shape technology
- Fit nursing practice rather than adapt nursing practice to fit technology
- Facilitate research on IT applications in nursing to support evidence-based practice

## Key Issues & Trends

- Connectivity
- Electronic Medical Record
- Data Standardization
- Decision Support Systems
- Patient Safety

## Key Issues & Trends cont.

- Cost-benefit Analysis
- Privacy and Security
- Consumerism and Wellness
- Net Generation

## Where Are We in VA?

- IT Reorganization
- Health Systems Committee (NLB)
- Information and Data Management Committee (NLB)
- Technology development in all NLB committees

## Office of Nursing Service

- 2000 ONS Strategic Plan established Goal Group 2 – Technology and Systems Design
-          Components: Administrative,
-                   Clinical, BCMA
- 2001 – 2007 – Established membership on IT committees impacting nursing and patient care
- 2007 Goal Group 2 has redesigned itself to Technology Consultant Group

## VA Nursing Outcomes Database (VANOD)

- National database of clinically relevant quality indicators
- Nursing sensitive
- Support decision-making
- Benchmarking

## VANOD Indicators

- Patient falls
- Pressure ulcers
- Patient Satisfaction
- Staff Musculoskeletal Injury
- Staff Satisfaction
- Staff Mix
- Hours per patient day

## Nursing Informatics

- “a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.......to support patients, nurses, and other providers in their decision-making....using information structures, information processes and information technology”
-                                  American Nurses Association  2001

## Nursing Informatics cont.

- ANA recognition 1992
- ANA certification 1995
- Career opportunities: transforming administrative and education systems, pioneering telehealth, mobile computing, influencing public policy

## IT: A Means to Evidence Based Practice

- IT tools and how they are implemented
- Value of tools for staff and care team members

## Lessons Learned *

- Improve Patient Flow
- Improve Workflow
- Process Improvement is a Discipline
- Measure Results
- Medication Administration Drives Quality at the Bedside

## Lessons Learned (cont.)

- Smart Alerts Improve Care
- Provide Ubiquitous Access to Digital Image
- Don’t Forget OR
- Plan for the Worst
- Infrastructure is Key to Success
-                    * *Most Wired Hospitals,** **Hospital and Health Network, July 2007*
*                        *

## Nurse Executive Strategies

- Develop informatics vision and goals
- Enthusiasm re: innovation, creativity, flexibility in planning
- Guide through change, attention to the human side of practice
- Keep communication lines open
- Balance high tech with high touch

## Strategies (cont.)

- Facilitate research on IT applications in nursing to enable EB informatics practices
- Encourage tech-driven training
- Promote nursing informatics expertise in clinical practice

## Change Management

- Kim Radant

## The more things change, the more they stay the same....

## The character of nursing is changing

**Traditional roles and values are undergoing intensive scrutiny, critical reevaluation and constructive alteration.**
**Concepts, standards, and objectives of nursing care are being reviewed and revised.  **
**Long established principles of comprehensive patient care are being augmented and reinforced as the result of studies and research.  **
**The magnitude and tempo of these social and professional  trends demand continued changes in planning for nursing care.  **
**We need to be sensitive to changes, interpretative of their significance, industrious in initiating constructive action, and flexible in reevaluating our concepts and philosophy in reference to these changes.**

## Program Guide for Nursing                                                               Services, April 10, 1957

## How can we encourage early-adoption?

- Factors that influence adoption
-     - Opinion Leaders
-     - Champions
-     - Experts

**Notes:**
Opinion leaders
Champions
experts

- Why don’t people use it?
-    - Translation Science
-    - Changing Healthcare Behaviors

- Using what we know is right!

## Translation Science		

- Understanding the mechanisms by which people uptake and use knowledge.
- Testing the effect of interventions aimed at promoting the rate and extent of adoption of evidence-based practices by nurses, physicians, and other healthcare providers  (Titler and Everett, 2002).

## Translation Science (cont’d)	

- Describing organizational, unit, and individual variables that effect the use of evidence in clinical and operational decision-making
- From Bench to clinical trials
- Research findings to patient care.

## Applying research results to practice

- It takes how long?
- Why on Earth would this take so long?
- Is it the same for evidence related to IT change?

## Factors to consider

- Education alone is not enough
- How similar is this to patient education and challenges related to altering healthcare behavior?

## John K. GalbraithProfessor of economics at Harvard University 

- “Faced with the choice between changing one’s mind and proving that there is no need to do so, almost everybody gets busy on the proof.”
- 	_[http://www.biographybase.com/biography/Galbraith_John_Kenneth.html](http://www.biographybase.com/biography/Galbraith_John_Kenneth.html)_

- “Behavior change happens mostly by speaking to people’s feelings.  This is true even in organizations that are very focused on analysis and quantitative measurement, even among people who think of themselves as smart in an MBA sense.  In highly successful change efforts, people find ways to help others see the problems or solutions in ways that influence emotions, not just thought.”

**Quote by: ****Dr. John Kotter****	*****Harvard Business School***

## How do we make it easier and encourage early adoption??

## The Basics

- Appropriateness of equipment
- Workflow—No layering
- Small Trials/Large Trials

## Changing health habits/translating evidence to practice ...Yin and Yang?

- It is important to identify, achieve and celebrate some quick, positive results for the vital emotional lifts that they provide.

## Dr. John Kotter:  Short-term wins are important.  Victories that nourish faith in the change effort, emotionally reward the hard workers, keep the critics at bay, and build momentum.  Without sufficient wins that are visible, timely, unambiguous, and meaningful to others, changes efforts invariably run into serious problems.

- Changing health habits/translating evidence to practice ...Yin and Yang? (Cont’d)

## What’s a Nurse Exec to do?

- Charting the course/setting the Vision
- Emotional Persuasion:  Convey passion
- Figure out the appeal/why should I do this?
- Look for early adopters and opinion leaders
- Dr. Dean Ornish:  Facts are important but not always sufficient.  Radical, sweeping comprehensive changes are often easier for people than small, incremental ones?
- 		_[http://www.fastcompany.com/magazine/94/open_change-or-die.html](http://www.fastcompany.com/magazine/94/open_change-or-die.html)_
- Dr. John Kotter:  Go for small successes?
- Rewarding the Successes

## Leadership Case Study

- Tina Lund

## Expansion/Replacement Project

- ICU Clinical Information System
- (CIS)

## Role of Nurse Executive

- Senior driver for the project vision
- Co-author of the Management Definition guide (MDG)
- Commitment of project resources
- Consider implications of change

- Assure integrated implementation across service lines
- Assure commitment of education and staff time dedicated to training
- Communication to all key stakeholders

## Background

- Increased use of Clinical Information Systems in ICU
- _[http://www.picis.com/](http://www.picis.com/)_
- _[http://www.medical.philips.com/](http://www.medical.philips.com/)_
- CIS will/must enhance workflow

## MVAMC CIS History

- 1990 - CareVue implemented in ICUs
- FY03 – Chief Biomed approached Nurse Executive regarding replacement project
- Team meetings began 10/24/02
- Vendor brainstorming inquiry 1/03
- MDG completed 3/03
- Funding request submitted 12/03
- Funding received 6/04
- Site visit to Mayo 2/05
- V21 site visits to SF & Palo Alto 4/05
- Vendor review onsite 6/05

## CIS Upgrade/ReplacementMANAGEMENT DEFINITION GUIDE

**Purpose:**
**Project Description:**
- The existing... product in ICUs and... 3K will be outdated and “unfixable”... vendor support to the software/equipment ends 12/2002.
- To replace/upgrade the current CIS/Carevue documentation system ....
- To implement the “new” system in ... ED, OR/PACU.
- Implementation of a documentation system that has ...interaction with VistA/CPRS and the capacity for data repository .....
**Cost of the Status Quo:**
- System and equipment failures... more frequently...until... unrepairable.
- Failure to implement ... will result in return to a paper documentation system...negatively impact the efficiency of nurses, physicians,  ...
- Quality of documentation will be affected, ....ramifications for JCAHO and other accrediting standards and regulations.
- The use of electronic documentation is a “State of the Art” recruitment tool ....cease.
- Patient Safety and decision-making may be adversely impacted as the current system builds in decision making and safety flags
- The current system provides a comprehensive visual display of patient information that is readily accessible to multiple clinicians and this would not be possible in a paper format.

## MANAGEMENT DEFINITION GUIDE (MDG) Cont’d

**Vision and Objectives:**
**Vision:**
- Electronically provide documentation of complete patient information at the point of care.
- To implement an electronic system for clinical staff that is portable to the VA Midwest Healthcare Network
**Objectives:**
- Enhance patient outcomes by delivering reliable, up-to-date patient information at the point of care
- Maintain quality of care through use of standardized documentation process and guided clinical decision-making tools
- Enhance patient safety/prevention of adverse events through the provision an integrated clinical database that provides ongoing up-to-date assessment, treatment, medication and clinical information at the point of care.
**Continuous Quality Improvement Measures:**
- Documentation audits to measure completeness of the electronic Medical Record
- Same level of assessment and data capture in intensive care settings to meet same standards of care.

## MANAGEMENT DEFINITION GUIDE (MDG) Cont’d

**Scope:**
**Business Impact:**
- The project will change how electronic documentation is accomplished-.  If an upgrade is implemented, the impact to current users will be minimal in time for training on changes.  A “new” system will require more training time for current users.  New users will need to revise work processes surrounding documentation and participate in more intensive training.  Availability of electronic documentation additional areas will greatly improve availability of patient information house-wide.
- Nursing staff will need to learn either a new system or product upgrade/enhancement.  A combination of vendor supported classroom training and hands on training will be needed bedside.  New users will require more comprehensive and intensive training.
**Systems Impact:**
- The project will require the purchase of new hardware and software.
- The project requires review of monitored bed areas in consideration of equipment needs and staff use.

## MANAGEMENT DEFINITION GUIDE (MDG) Cont’d

**Business Assumptions:**
- The IRM Technical Services Group will assist with installation & maintenance ...
- The IRM TSG will install the enhancement and test all equipment ...
- A CIS project team ... will provide overall project oversight.
- A CIS training team ... will provide training.
- Clinical staff ... will participate in reviewing and selecting product.
- V23 IT workgroup will review/approve project.
- Finance and Capital Assets Sub-council approval for funding.
**Technical Assumptions:**
- The project will involve modifying or replacing existing systems.
- Equipment ... compatible with current workstation hardware, software.
- The project will involve work area modifications
**Workgroup Assumptions:**
- Determination of replacement/upgrade specifications
- Review data storage and retrieval for archiving data
- Ability to interface with CPRS
- Dialogue with community and/or VA electronic documentation systems ....
- Determination of V23 facilities’ interest in implementation of a similar system
- Explore contractual benefit for group purchase

## MANAGEMENT DEFINITION GUIDE (MDG) Cont’d

**Evaluate available systems for electronic documentation**
**Security Impact:**
- Current computer and access security will be maintained.
**Issues**
- Staffing must be maintained at above adequate levels to allow for staff to attend training, or to learn the enhancement.
- Education and support must be available 24 hours a day.

## MANAGEMENT DEFINITION GUIDE (MDG) Cont’d

**Sponsorship / Development Participants:**

| Role | Description | Team Member
(Names, Titles & Departments) |
| --- | --- | --- |
| Authorizing/
Initiating Sponsors  | Individual/group who has the power to initiate and legitimize the change for all of the affected targets.  | Steven Kleinglass, Medical Center Director
 |
| Sustaining Sponsors  | Individual/group who has the political, logistical and economical proximity to the targets.  | Dr. John Drucker, MD, COS
Tina Lund, Nurse Executive |
| Process Owner/
Change Agent  | Individual/group who is responsible for implementing the change. | Tina Lund, Nurse Executive
 |
| Change Target/
Participants  | Individual/group who will experience or be affected by the change.  | Staff RNs 
Physicians 
Respiratory Therapists |
| Project team | Cross-functional team that will design the system and work processes or implement the project.  | Subject Matter Experts: 
   Clinical & Technical
IRM
Partnership |

## MANAGEMENT DEFINITION GUIDE (MDG) Cont’d

**Requirements**

## MANAGEMENT DEFINITION GUIDE (MDG) Cont’d

**Estimated Investment / Resources:**

## CIS Replacement Requirements- Brainstorming Session

- Flowsheet documentation of assessments and treatments
- Progress Note Configuration
- Reports
- VistA/ CPRS Requirements
- ADT Interface
- Flowsheet configuration
- IV Drips
- Cell Management

## ROI: CIS Outcomes

- Quality Improvement
- Decision Support
- Improved compliance to standards
- Nurse Recruitment and Retention

## CIS Security Requirements

- HIPAA
- HL7
- User permission/access

## CIS and Research 

- Vast amounts of clinical data available
- Data Mining
- Relational Databases

## CIS Keys to Success

- Workflow analysis and consideration
- Super users
- Staff education
- Senior leadership support

## What happened?

- FY06
- Competing priorities for Biomedical Management Service Maintenance being managed
- Downtime
- Off tour support
- Cannibalizing parts
- Network initiative - V23 decision to implement and standardize CIS

## What’s going on?

- FY 07
- MVAMC Multidisciplinary *Implementation* Team 4/07
- V23 finalizing system requirements, combining aspects of VISN 21’s  & VISN 12’s projects.  Scope includes all V23 facilities for CIS and Anesthesia Record Keeping
- Contract to be awarded end FY07

## CIS Next Steps

- Implementation/Project plan
- Timeline
- Resources, especially staffing
- Education
- Change management
- Communication Plan

## Other projects

- Automated Vital Signs Capture w/ Welch-Allyn (local)
- Electronic Scheduling Package (VasTech)
- BCMA –Motion Computing Tablet (handheld)
- APRN – CPRS-based Peer Review Program
- GUI I&O
- Progress note templates (local)
- In-Bound Demographics: VasTech Interface

## Lessons Learned

- Managing hurdles
- Communication
- Involvement of staff at point of care is critical to success

## Summary 	

## Questions?