I have learned earlier on in my nursing career that, in order to lead my patient toward wellness, I have to apply the nursing process as a method of problem solving which enables a nurse to organize and deliver nursing care.  It is an element of critical thinking that allows nurses to make decisions and intervene based on reason.  The nursing process is used to diagnose and treat human responses to health and illness by utilizing five steps:  assessment, diagnosis, planning, implementation, and evaluation (ADPIE).  ADPIE provides a blueprint for critical thinking which allows the nurse to individualize care and respond to a client’s need in a timely and reasonable manner therefore improving or maintaining the client’s level of health. The purpose of the nursing process is to identify the client’s health care needs (assessment), determine priorities (diagnosis), establish goals and expected outcomes of care, establish and communicate a client-centered plan of care (planning), provide nursing interventions designed to meet client needs (implementation), and appraise the effectiveness of nursing care in achieving expected client outcomes and goals (evaluation).  As laid out, these principles can easily be applied in parallel to project management.

     Project Management according to Lewis (2007, Chapter 1) is, “a temporary endeavor undertaken to produce a unique product, service, or result.” Similarly, project management follows the same basic tenets as the nursing process of ADPIE.  Every project manager needs to define the project (assessment), develop solution options (diagnosis), plan the project (planning), execute the plan (implementation) and finally monitor, control progress and close out the project accordingly (evaluation).  Just as a nurse ensures that the patients transitions from health to wellness, Lewis (2007, Chapter 2) quips, “the primary responsibility of the project manger is to ensure that all work is completed on time, within budget and scope, and the correct performance level.”  A project manager will develop a work breakdown structure, (WBS) to pictorial represent to team members and stakeholders all the components that are necessary to deliver the project.  The nurse in return has a similar tool the equivalent of a WBS called the Care Plan, which is the documentation of a plan identified by a nurse as all the necessities required to assist a patient (a nurses project), move from illness to wellness. Just as every project team member utilizes the WBS to gain a big picture perspective, all nurses involved in patients treatment regimen will look to the care plan.

     With healthcare reform currently at the center of our nation’s political debate, what has been overshadowed is The Health Information Technology for Economic and Clinical Health Act (HITECH) enacted into law by President Obama in February of 2009 with the basic premise of providing healthcare organizations with stimulus dollars and emphasizing on quality and efficiency and utilizing information technology to affect changes the healthcare industry desperately needs.  In a struggling economy it was only natural for the organization I work for then, a not for profit, faith based community hospital, to strategically align itself to realize the full profit potential the stimulus funding can provide.  In our usual annual fashion my Chief Nursing Officer (CNO) provided me with a report on projects approved by the organization’s Executive Team.  In reviewing these approved projects, it became apparent to me that the strategic plan for the year will be without complications.  Utilizing the process of ADPIE I quickly realized that my organization was asking me to do the equivalent of building a roof without the basic structure a home needs to support it.   In order for our organization to sustain the yearly requirements for stimulus funding, certain prerequisite projects were needed to scale our system to the desired end point.  Furthermore, I knew building the system without the prerequisite architecture would fragment data and therefore ultimately affect how the clinicians provide patient care and, subsequently affect patient outcomes.  As a health care provider I became quickly cognizant of the demands that have been overlooked, but I also knew I could not merely respond by saying it cannot be done.  I then embarked on a process of analysis, using ADPIE as my basic framework, to foresee how I could continue with the approved projects and at the same time reinstate the previously dismissed projects and build a business case that still aligned itself with the organization’s strategic plan for the year.  Apparently, I was organically utilizing project management principles in the process as well.  With a business plan the equivalent of a work breakdown structure (WBS) and risk analysis in place, I then engaged my CNO in a crucial conversation in which I asked her to re consider reinstating the previously dismissed projects.  Following a principle provided by Verzuh (2008, Chapter 11), “the best way to communicate difficulties to customers and managers is simply to present them the facts.”  I went on to articulate crucial components of a plan, in essence the critical path, which included reallocation of funding and resources to support the end goal.  The plan had a slight caveat, the need for additional funding with an amount that I felt was reasonable and minimal in quantity considering the funding and returns on investment that would be realized.   Clear and transparent communication being the key, my CNO was in agreement that certain items may have been overlooked by the Executive Team, and felt I had equipped her with enough information to confidently go back to the leadership team and request additional funding.   Approval was ultimately obtained and I came to the realization that in the process I had learned to advocate for the needs of the healthcare consumer as well as our healthcare providers.

     Project Management however goes beyond the day to day managing of task and deliverables.  If projects were that easy, then we would not see a failure rate of 83%, which basically suggest that a project is bound for failure the minute it is started (Lewis, 2007).  There is a crucial component to project management which I like to call the people management. These include the managing of the project team and the crucial conversations that must take place between the project team and the project stakeholders.  As a project manager, assumptions can be a dangerous thing, even detrimental.  As a people manager, a project manager has the difficult job of ensuring all parties are moving towards the ultimate goal, which is the successful implementation and completion of a project.  It is not just completing the project that determines success.  It is doing so in such a way that meets your stakeholder’s original intent, along with being on time and on budget.  Clearly there are three major moving parts; people, timeline and budget that ultimately will define if a project is indeed a success.  Lewis (2007, Chapter 10) explained the difficult task of a project manager the best when he stated, “a manager should try to satisfy the needs of the organization, while simultaneously helping individuals satisfy their own needs through participation in the project.” 

     In my years working in Healthcare Information Technology I have leveraged the use of the nursing process not realizing I have also been utilizing project management concepts.  Both of these principles have been an objective tool that has been so ingrained in me that I have used it often.  In the almost seven years that I have been in a managerial role, managing the electronic medical record implementation for hospitals, what has enabled me to thrive and manage such a complex implementation with multiple moving parts and sometimes conflicting priorities, is my very own knowledge and utilization of the project management process which has allowed me to achieve, and has been instrumental in, realizing my managerial potential.  Clearly whether it is patient care, or project oversight, structure and proper methodology is needed in order to be successful.  The process of ADPIE is such a universal concept that it can be an instrumental tool versatile enough that it can be used in business practices as well as in life decision making processes.  By using this blue print one can prioritize and approach critical situations with ease and confidence.

References

Lewis J P 2007 Fundamentals of project managementLewis, J. P. (2007). Fundamentals of project management (3rd ed.). New York, NY: AMACOM.

Verzuh, E. (2008). The fast forward mba in project managment (3rd ed.). Hoboken, NJ: John Wiley & Sons, Inc. 

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     Embarking on a journey of implementing a Computerized Provider Order Entry (CPOE) has been of recent a strategic goal for many health care organizations looking to take advantage of stimulus funding made available by the American Recovery and Reinvestment Act (ARRA).    The impetus to adopt such a technology stems from a November 1999 Institute of Medicine Report (IOM) that found 98,000 Americans die every year from preventable medical errors in hospitals (http://www.iom.edu).  Consequently the health care industry has focused on a new technology CPOE as the messiah that can provide organizations the tool needed to prevent all of these unwarranted errors and subsequently improving patient safety.  Unfortunately, “use of CPOE is not widespread.  Presumably, implementation lags because CPOE, by reputation, is hard to implement, expensive and difficult to coax clinicians (Physicians) to use (Ash, Stavri & Kuperman, 2003).”  Recent legislature however provided health care organization with the proverbial iceberg that was desperately needed or that sense of urgency to propel a CPOE change effort from a nice to have to a must have.  President Obama’s American Recovery and Reinvestment Act (ARRA), includes a provision “to improve American health care delivery and patient care through an unprecedented investment in health information technology (HIT)…the Act focuses primarily on promoting the wide deployment and use of electronic health care records (EHR) among health care administrators and providers across the country (http://recovery.gov).”  This act has laid out an aggressive incentive program to assist organizations move towards HIT, but also penalties for those slow to adopt.  This review will chronicle how the book, Our Iceberg Is Melting has masterfully outlined the steps necessary for a successful change transformation effort.  Specifically, how crucial it is to have a sense of urgency and identifying the appropriate team to be the ambassadors of change.   In the process a parallel analysis will be exemplified by looking at the dynamics experienced in the Penguin colony and similarly to organizations who implement CPOE.

     Our Iceberg Is Melting is a clever fable that helps provide readers key insight into the psyche of a penguin colony as they shift a long standing lifestyle to a nomadic one (Kotter and Rathgeber, 2005, p.  140).  The utilization of a fable is a clever approach to bring light to a topic that is typically the canonical “elephant” in the room that no one dares to discuss.  It provides simple stories to assist change agents realize that merely saying business as usual can no longer exist, but change is now necessary to compete in a continuously evolving world.  This fable truly reminds us that the word change and its inherent meaning may seem simple, but doing and making it happen and stick is where the difficulty truly lies. 

   There are numerous publications that site the obstacles organizations face when implementing CPOE.  The challenge however is not so much in the technology, but in the ability of organizations to weather through the resistance that comes with such a huge organizational overhaul.  Case in point was Yale New Haven’s three hospital system that utilized a separate CPOE software package (Birk, 2010).  In Birk’s (2010) study it was evident that Yale New Haven as an organization was able to show that CPOE will work with three different systems, and there are pros and cons to each of the products.  But it is not the products that are going to make the difference; it is the leadership support of the implementation (Birk, 2010).  As depicted in Our Iceberg Is Melting, leaders like Louis were necessary in any organization serious about making a change.  It is leaders who possess Louis’ leadership trait that can help manage the NoNo’s in every organization who claim to support the change effort, but only to later find out the support was only when it was convenient and did not affect their respective areas.  Leaders such as Louis is necessary because they have the foresight to understand and strategically hand select the right group matrix to lead the change.  Every organization will need an Alice with an unwavering personality that will help the organization stay the course and keep the transformation efforts going.  An out of the box thinker like Fred is a necessity because they have the ability to look beyond the status quo.  Of course every change effort requires factual, evidenced based best practice citations that only a Professor in the group can provide.  But as Kotter and Rothgeber (2005) suggest, change efforts is often an emotional transformation rather than a logical one and therefore you need a Buddy who has the ability to appeal to the emotions of the masses (pg.  142).  A guiding coalition such as the one identified by Louis is truly necessary in any transformation efforts that will buy in to the vision and ultimately understands why change is necessary.

     Lacking that sense of urgency is truly the reason why many organizations fail in their transformation efforts (Kotter and Rothgeber, 2005).  A CPOE implementation is no different in that not having enough urgency will not propel an organization to be convinced that change is necessary.  A firsthand account of this dynamic was evident at a non-profit health care organization that decided to implement CPOE, but did not evoke a strong enough sense of urgency.  Despite a Chief Information Officers (CIO) plea to the organization to understand the ARRA requirements are looming, not enough in the hospital leadership was converted to the idea that a CPOE implementation was a high priority.  This was evident at project launching and the Chief Executive Officer (CEO) in the process was practically non-existent.  The CIO created a CPOE Leadership Committee where in leaders can strategically collaborate on the implementation effort, but the CEO was never in attendance.  In defense of the CEO, he did provide the project the lip service it needed, publishing his full support in monthly publications to all staff.  Communication of this support even went to the extent of publishing its importance in a quarterly newsletter that was typically addressed to the organizations Board of Directors and Medical Executive Committee.  However, the project lacked the outward display of support it needed from the CEO.  CPOE projects require the needed tangible support that one would typically see evident in actual face to face meetings, rather, the support was displayed in the safe confines of printed memos and newsletters where it was harmless and practically did not provide a venue to challenge any of his statements.  The CEO in this case did not have the conviction of a Louis who can withstand the grumblings of the colony.  The CEO did not provide the CPOE project what Ash et al. (2003) call the commitment that is unwavering and visible.  In order for CPOE implementation to be successful, the organization must have adequate finances, technical infrastructure, project management expertise and staff readiness for CPOE, this has to be coupled with real and visible commitment of the CEO (Ash et al.  2003).  The lack of CEO support was clearly evident when decision time came to strategically identify if CPOE was going to be mandated or voluntary.  The other clinicians (i.e. Nurses, Pharmacist and Respiratory Therapist) who would be affected by this change made it clear to the CPOE Leadership Committee that mandating CPOE would be the less risky route, because the source of orders would be less ambiguous which could lead to medication errors.  The CPOE Leadership committee with a strong recommendation from the CEO, afraid at the potential turmoil a mandatory physician CPOE requirement would illicit decided against it and made the use voluntary instead.  This was truly an example of a lack of shared vision regarding the purpose of CPOE and why, “the current state is suboptimal and change is needed (Ash et al.  2003).  Because the CEO did not have the same conviction of a Louis, the organization did not have the type of leader that was needed that would say, “Yes, this is hard work. Yes, the physicians will resist, but it is the right thing to do.”

     Although very clear that a sense of urgency along with a strong guiding coalition is necessary to push any transformation efforts, the fable however due to its simplicity fails to underline the tremendous challenge that comes with injecting an organization with the right amount of urgency.  Clearly, the non-profit organization due to the lack of leadership did not have the foresight to see a CPOE project as a quality initiative for the entire hospital (Birk, 2010).  Despite having a clear and present “iceberg” which in this case even involves the Federal government providing the necessary pressure, logic is defied by emotions.  Unfortunately in the case of the non-profit organization, it may take a failed project coupled with financial penalties to be the strong force that will convince leadership to provide the CPOE project its much needed recognition and support to be successful. 

References

American Recovery and Reinvestment Act.  (2010).  Health IT grant funded by recovery [Data file].  Retrieved from

http://www.recovery.gov/News/featured/Pages/HealthcareIT.aspx

Ash, J.S., Stavri, P.Z., & Kuperman, G.J. (2003).  A consensus statement on consideration for a successful cpoe implementation. Journal of the American Medical Informatics Association. 10(3), 229-234.

Birk, S. (2010, May/June). CPOE physcican adoption.  Healthcare Executives, 24-30.

Institute of Medicine.  (1999). To err is human [Data file]. Retrieved from http://iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf 

Kotter, J., & Rathgeber, H. (2005), Our iceberg is melting: Changing and succeeding under any conditions. New York, NY: St. Martin’s Press. 

A qualified super user is experienced within their healthcare specialty, knowledgeable about their unit and is recognized as an expert resource that will prove invaluable in helping others to understanding the work processes of the unit (Hunt, et al).  In an optimum situation, the super user should have a deep interest in the project.  Unfortunately at our organization, due to labor shortages of nurses, the default super user becomes, whoever is drafted by the department manager.  The unintended consequence is now the SIT is working with an unwilling participant that is not interested with doing the task at hand and provides minimal effort at best.  In some situations, you may get a very willing participant, but they are typically the younger clinicians, who may not have enough tenure to overcome resistance from a more seasoned staff.    Compound the problem with an organizational goal to deploy a super user ratio based on project scope size and proven published methodologies (McNeive, 2009).  The other intent with the super user deployment was for these identified staff to maintain their post after activation, with each department managers assessing the needs of users to maintain super users support model.  Again, due to labor shortages department management were forced to pull the plug on the proposed super user model prematurely due to pressures to meet patient care demands.  Therefore, there was a leveling off in the engagement of our super users to a point they have dwindled off from the department’s workflow.  There was now a perception issue that super users are no longer needed and that they were super users only when it was convenient for the identified super users.  The SIT team now faces the challenge of having a user base with varying degree of experience with the application.  Boudreau (2003) studied a state institution’s successful implementation of an enterprise system and found some employees who became functional, experienced users while other employees were struggling with using the new system – with some just able to perform their job responsibilities and lacking an understanding of the systems capabilities. Consequently our current help desk model, which is staffed by analyst type, that is essentially equipped to handle day to day software issue such as password resets and security issues and not the very specific workflow processes that patient care entails.  The help desk model did not prepare for this unintended consequence due to the original strategy to rely on departmental super users to field these types of issues.  Because the super users are practically non existent, in review of the help desk tracking system, there has been a significant increase in training request.  On average the organization receives approximately 250 help desk request a month for our application.  Findings further indicate that 60% of these were training related that should a good super user model been established one can conclude would make this issue nonexistent.

To solve this inequality with the super user engagement, and the increasing help desk request for additional training on software features and functionality, what I would propose as a solution is what I call a “shared staffing model.” The key difference in this model would be the fact that the staff reports to the Software Implementation Team.  The shared staff is carefully hand selected to ensure proper fit, as opposed to hand selected by department managers who may not know what the right qualities a super user should possess.  By nature of the shared staff reporting to the SIT, there is now a much better control and a more directed approach at the distribution of the resource.  With the shared staffing model, the SIT can concentrate their efforts on future development projects and not be slowed down fielding an increasing need for more education on how to properly utilize the application.  The new model would also employ a day and night shift personnel which is a deviation from standard SIT working hours of day shift only.  To be fiscally responsible, the ideal candidate for the position is a clinician that has part time status.  Since most hospital employees work 12 hour shift (3 shifts a week for full time designation and 2 shifts a week for part time designation), the ideal candidate would be a part time staff, who can continue to work their typical 2 shifts a week, but will now pick up an additional 2 days / 8 hour shift working with the SIT not to exceed 40 hours a week.  This will be a win-win situation for both parties, organizationally not incurring any overtime and the staff being given the opportunity to work extra hours and be introduced to a growing specialty – Healthcare Information Technology.

As a status update to date, this model has been proposed and escalated up to the executive level of the organization for approval.  The original proposal was to hire 6 shared staff (3 for days and 3 for nights) but the leadership decided to take a more conservative route to pilot this new model for effectiveness first, and approved the hiring of 2 shared staff (1 for day and 1 for night).  There will be a formal review in 6 months to evaluate effectiveness at which point it will be decided if this model will continue.  In further review of the same benchmarks used to propose this new model, in 1 month since implementing this new shared staffing model, there has been a significant decrease in training request from 60% down to 48%.   

 References

Hunt, E., Sproat, S., & Kitzmiller, R. (2004). The Nursing Informatics Implementation Guide. New York, NY: Springer-Verlag

McNeive, J. E. (2009). "Super users  have great value in your organization." CIN: Computers, Informatics, Nursing 27(3): 136-9.

Boudreau, M.-C. and Seligman, L. (2003) A Learning-based model of quality of use: Insights from a case study of ERP implementation, Pre-ICIS DIGIT Workshop, Available at http://mis.uah.edu/sigadit/workshops/files/DIGIT_2003_Boudreau.pdf.

While I am unaware of specific laws to reference that are against capitalizing generic drug names, although they may exist.   I do believe however, it is a community standard not to do so.  That is, I believe it is a community standard to use lower case to indicate generic compounds, and capitalization to indicate the Brand or Proprietary names for those compounds.    It’s use is ubiquitous.  Training books for healthcare workers from transcriptionists to pharmacy techs reference this practice.    I have personally never seem an Electronic Medical Record (EMR) or CPOE portion of the system; nor a Pharmacy system to be configured without using lower case for generic names and title case for brand names.   

While not as formal  as law, ISMP has a set of helpful guidelines for pharmaceutical  labels formats that may apply:  http://www.ismp.org/Tools/guidelines/labelFormats/default.asp    Each of these guidelines recommends to “List all products by generic name using lower-case letters as the primary drug nomenclature (unless employing tall man letters as a safety strategy), ensuring that each matches FDA-approved nomenclature.”

Most importantly, using capitalization on generics may inhibit the effectiveness of the ISMP–recommended tall man lettering.    When applied well, the only capitalization would be found on Brand Names and those look-alike and sound-alike areas of the drug names that are accented by this practice.   In fact, the only additional thing I would recommend is for our organization to agree to at least adopt ALL the ISMP-recommended tall man recommended matches found at: http://www.ismp.org/tools/tallmanletters.pdf , and then to add more that prove to be useful here.

This issue defies logic for me.  Why would someone not want to follow a set of proven standards?  Please feel free to chime in and leave your thoughts in the comments!

Of the funds, HHS will award about $220 million as grants to 15 not-for-profit community groups or government entities representing diverse geographic areas. About $15 million of the funds will go toward technical assistance and program evaluation (Gruenwald, "Tech Daily Dose," National Journal, 12/2).

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Now I am open to any topic.  You can be a nurse from a different specialty looking to for advise on how to get in this highly completive industry.  You may be a nurse who by default have been asked by your administration to help launch and implement an Electronic Medical Record (EMR) project.  You might be in sales and want advice on how to market a product.  You may be the CIO of an organization wanting to find other ways to get better end-user adoption.  I want to be open to any topic…

Now let me give you a little bit of my background.  I am a Registered Nurse, and my nursing background has provided me a myriad of experiences.  From my humble beginnings as a Critical Care Nurse, I have done Public Health Nursing (more specifically Parish Nursing), Travel Nursing, Critical Care Transport Nursing and now Nursing informatics.  I have been working in the HIT industry for 5 years now starting in the vendor side and now on the provider side.  My implementation experience is in the inpatient arena.  I am open to discussions related to other disciplines (i.e. ambulatory, financial, ancillary, etc…) because I feel the process is the same.  I am not PMP certified, nor do I hold prestigious letters after my name from HIMSS.  I am not even Board Certified in Nursing Informatics.  All my experiences have been OJT (on the job training).  Depending on your opinion, I personally feel I am gaining the experiences based on real life situations, just like I felt I learned more during my nursing new grad program, than I did in nursing school.  Nursing School definitely gave me the fundamentals, but the critical thinking skills were developed while on the job. 

So, just as I have learned from great people on the job, together we can broaden this experiences through this great medium – The Internet. 

Looking forward to your questions…

Here I am at the gym. I just finished working out, trying to relieve some of the days stress. I just got into a situation, where in I am fixing a mess an employee of mine created for me. What it boiled down to, is the inability to communicate and pay attention to details. This was an employee who pratically begged me for a position, because he was hungry to be given an opportunity to be in a nursing informatics position. Well I took a risk, and he failed me miserably today. On a different note…he embarassed me.

I kept thinking, where did I go wrong, and where did I fail to communicate. As I thought about the situation even more, I personally deduced it to several factors:

1. When implementing an EMR, simply hiring a nurse is not the key. As a matter of fact, being involve in an implementation just highlights how bad of a nurse at the bedside a person was. If you can pay attention to little details that an EMR implementation requires of you, then you must not have been a tune to the suttle changes a patient goes through which highlights whether you were a proactive nurse or a reactive nurse.
2. How dedicated you are at producing a product the clinicians will use is a direct reflection of how good your bedside manners were.
3. Ability or inability to realize as implementers of EMR’s we are acting as care extenders. The product we produce has direct relationship to how safe our patients will be as recipients of care from clinicians who utilize the tool we provided.

These are my thoughts at least…

Your comments appreciated

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