1 Presentation Johan Ensing The Spaarne ... - World of Health IT

Presentation Johan Ensing
The Spaarne Hospital is a medium sized, top clinical hospital situated in the Western part of
the Netherlands.
The Spaarne Hospital has always had more than an average interest and ambition of using
automation to improve quality of care and efficiency and is known as a hospital that paves
the digital way for other hospitals. As a result of this ambition, in 2003 Spaarne Hospital
became the first hospital in the Netherlands to introduce the EMR- hospital-wide- for
physicians and nurses. To maintain the organization’s position as a leader in optimal use of
information technology, the board decided in 2007 to introduce an integrated EMR; EpicCare
from Epic.
Within two and half years we implemented 80% of all EPIC applications in all relevant
departments The second phase of implementation in May 2009 can be remembered as the
Big Bang Go Live.
This Big Bang implementation was complicated because Spaarne Hospital was the first in
Europe to implement Epic. As well, a change of the entire Board of Directors, 50% of higher
management and the program manager took place in 2008. These factors and the immense
scale of the project occasionally caused concern that the project would get stuck.
In this presentation I will describe successes and challenges of this significant milestone for
our organization ass well as the main conditions required to implement a hospital wide,
integrated EMR in a relatively small hospital within a period of two and half years time.
In the years working with EpicCare we did a lot of things correctly and we have made a lot of
mistakes. This presentation benefits from both.
Team selection
An EMR project is a major and complex process of change within both the organization and
its employees. The implementation approach and the employees should therefore
seamlessly try to connect to this complexity. A blueprint doesn’t exist and a standard
technocratic approach doesn’t work.
Why is this so
We have learned that unpredictable behavior in such a major change process is the rule
rather than the exception. The impact on daily work routines, procedures and cooperation is
immediate and huge while care providers and management are hardly able to imagine in
advance that impact as well as the opportunities and improbabilities of an EMR as EpicCare.
At that time, many physicians saw the implementation of our former EMR as an exchange of
their pen for a keyboard and they actually wanted to continue the same work process.
In this non-integrated EMR, mentioned by one of our physicians as a My-record, the status
quo in work process was largely facilitated. Partly based on those experiences many
physicians demanded before and during the implementation that there should not be any
changes in their work routines.
In contrast with this demand, EpicCare enables the end-users to reorganize their work
processes and bring them in line with hospital goals. Also, many physicians demand that the
new EMR should not take more time. But in contrast the physician must invest more time in
filling out the EMR properly. The problem we experienced is that physicians aren’t always
able to realize that a small investment at the start of the care process can save a great
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amount of time for themselves and other care providers further on in the chain of patient
care.
These advantages arise from the integrated nature and chain orientation of the Epic system;
this is the main strength of a We-record. In addition, task reallocation provides opportunities
to decrease the workload for physicians.
Altogether these variations of requirements mean that simple solutions aren’t sufficient;
people and behavior are key, meaning that management and implementation should not be
bureaucratic and distant.
Strong involvement and flexibility serve as the basis. Learning is essential for both the user
and the project team. This places high demands on the employees in the projectteam.
After signing the contract with Epic, one of the first steps was the formation of the project
team. Based on competence profiles, the former Board of Directors chose the best
employees from the hospital to support the Epic project, including highly skilled and
experienced department managers and experts on work processes in the OR, the ER,
nursing departments etc. You will understand that this didn’t lead to applause from the
remaining line management and employees.
To prepare the projectteam as much as possible for their roles in this project, each team
member was intensively trained on Epic applications and the Epic administer toolkit. This
training was mainly followed in the US. The former department managers were also trained
in project management and they had to take on the role of project manager.
What are the success factors and lessons learned for Spaarne Hospital
Trust is crucial for the success of the project. The projectteam should consist of
employees who have the knowledge of the organization, work and care processes, speak
the language of the physicians and other care providers and are used to dealing with
resistance. Make sure the project team works together at a central location to exchange
knowledge and information and to give mutual support.
Make sure the project members can take the point of view of the end-user so that they
can understand what drives them and how they can find their WIIFM, sometimes solving
minor issues for the end user will help them to attain their objective.
Invest in the education of the projectteam concerning the EMR, project management,
change management and process management.
Big Bang Go Live
Spaarne Hospital has chosen to implement 80% of the EMR in three short successive
stages.
Which considerations have played a part in this strategy
A well-known phenomenon in change management is the reality of resistance. Resistance
comes from the fact that people can and will change but they don’t want to be changed.
The resistance that arises fluctuates in the various stages as they occur, such as
bereavement as once described by Dr. Elisabeth Kübler-Ross.
Imposed changes and giving up familiar working routine creates the feeling of losing control.
The greater the autonomy, the stronger the emotions in the different stages can be
experienced.
To illustrate a short story in a number of statements from our physicians:
Denial What’s the first thing they do They think the new EMR will disappear!
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‘No seriously, this system will not last for 3 months!’
Anger When I have a flat tire Epic is to blame! One of our physicians actually experienced
this… this was a challenge for the helpdesk
Bargaining Realizing you have to work with the system. You must reduce production otherwise I
really can’t work with it.
Depression Oh my God, what should I do I’ll quit and work somewhere else where they’re working
with paper files.
Acceptance Ok. It stays. Actually it’s a fine system. No, are you crazy, I wouldn’t go back to the old
EMR.
A common problem is that people get stuck in one phase. Thus a person may become stuck
in anger, never moving on from the position of not accepting the inevitable future.
When we just zoom in on the chart of Maxwell, we see in front a small group of innovators, a
large middle group and at the back a small group of so called laggards, these employees will
find themselves on the right behind and that’s where they will stay no matter what. Stop
putting your energy into these employees but put your effort into the larger middle group
where the potential to move to the forefront is most possible.
A Big Bang should not only prevent a decline in the ‘mourning period’ within each new
implementation, which can result in change fatigue; but it should also lead to quick and wide
spread advantages of an integrated EMR such as digital ordering, using order sets, direct
24/7 availability of all documented information throughout the whole chain of patient care,
decision support, immediate availability of results etc.
Another aspect, in which this decision played a role, was the strategy to make it impossible
or as unattractive as possible to return to the old system or paperwork and to prevent
working in several parallel systems.
Finally we wanted to decline the frequency for training for more than 1,500 employees. We
know from experience how difficult it is to get 1,500 employees out of their daily work for
training activities.
What are the conditions for a Big Bang GoLlive to be successful
Formulate a clear vision of how the EMR will contribute to achieving the hospital goals.
Get a good fit analysis
Get an adequate framework for all implementation roles.
Make clear in advance for the EMR to take time in one segment in order to save time at
another location in the chain of operations. Also look actively for opportunities for task
reallocation to reduce time spent for physicians
Make clear in advance that work processes should and will change. Improvement has to
be in line with hospital objectives.
Use a sample configuration of the supplier.
Get a proven implementation method so that the focus can be on unpredictable issues
and not wasting time and energy on subjects that should be routine matters.
Keep a good overview of the risks by applying a Go Live readiness assessment.
Keep in mind that during ‘the renovation, sales continue.’ Adjust your support to this.
Communicate loud and clear that optimal organizing of an EMR is impossible without
actual experience. Learning and optimization is a continuous process that starts after the
implementation and needs a special effort from all end users and project team members.
Contribution of the board
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At the launch of the EMR project in 2008 many physicians lacked a sense of urgency. They
had access to a digital file, which was perfectly adapted to the details and needs of the
individual physician.
There were also too few doctors who were able to look ahead and take their expectations
from their individual perspective (the Me file) and exchange this for the over-all objectives of
the Spaarne Hospital. In this perspective, the patient is seen as the owner of the file and the
physician is seen as a temporary administrator serving in the interest of the patient (the WE
file).
When there is no urgency, the leading role at the top of the hospital administration becomes
more important.
What is effective And what roles has the director completed in the Spaarne hospital
As a leader the director sets the vision and goals; and puts the focus on the story on the
future on how care will change and not on the clicks.
As a figure head/sponsor the director inspires and motivates employees by expressing great
personal commitment.
As chairman of the program-board, the director made sure the lines of decision-making were
short and transparent.
In these roles there are some special topics regarding the group of physicians:
Make sure the unpredictable behavior of the laggards is limited as much as possible by
keeping a very close eye on them and, as a director, sometimes literally sitting next to them
during their consultation hours.
Let the director act as a lightning conductor when the pressure reaches high level so that the
project team isn’t affected.
Be personally present at difficult moments like for example the weekend and early morning
as the team prepares for Go Live and be present during the Go Live phase on the
department floor.
Pay personal attention to key figures and put your ear to the ground.
Walking on eggs shells can’t prevent conflicts with physicians. Only the director has the
position to manage these conflicts effectively. Take full advantage of it!
Finally I want to share some General tips with you:
Ownership:
Take care of management involvement, and by management I mean the medical-and
division managers, and let them experience ownership. They’re the ones to take the initiative
for process redesign with the aid of EMR functionality. The projectteam has to work side by
side with management and needs to inspire them by showing how existing and new
functionality can solve their problems from today and tomorrow.
Learning Strategy:
Formulate a learning strategy with the credo: without effort no results!
Make training and testing mandatory! Not competent = No access to the EMR!
Optimization:
Epic is a great EMR; to use it to its full potential you need to invest and spend much time for
optimization. As mentioned earlier, the learning process starts after implementation and
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optimization starts with the learning process. Be prepared to put the same amount of time,
energy and money in the optimization as in the implementation!! Optimization will bring you
success.
Communication:
Don’t over promise and don’t under deliver! Communicate in different ways and don’t be
disappointed when the message doesn’t come through. Use the doctors to make the doctors
like it.
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