The US has one of the biggest and inefficient health care systems in the world, which despite the high per capita expenditure, has failed to provide efficient and dependable coverage to the poorest populations (Blank, 2012, p. 416). One of the reasons for the high costs and poor coverage is the high fragmentation in the system, role duplication, and flawed performance measurement and reward systems for care providers. This is worsened by rising costs (in part due to high costs of drugs and medical equipment), unpredictability of the economy, and rising lifestyle diseases (e.g. diabetes and heart diseases) that effectively increase health care facilities utilization. The Affordable Care Act (PL 111-148) tries to address this problem, by expanding insurance coverage to the low-income population and introduce performance-based payment systems, but the system’s problems go further than it is anticipated. Other than rising costs, the system struggles with quality issues. According to Anderson & Townsend (2010), medical errors cost the country $19.5 billion in 2008 and 98,000-200,000 lives every year. To curb the cost inflation, inefficiency and improve quality, the adoption and integration of health information technology (Electronic Health Records (EHR)) remains one of the most important changes that most health care facilities in the country face.
Project Nature and Chief Nursing Officer’s Role
The Keystone hospital is a medium-sized facility with 51 acute beds, 68 operating domiciliary beds and 23 long-term care beds providing tertiary, secondary and primary care. It serves in excess of 80,000 patients annually. The hospital is acquiring VistA, an EHR system that offers integrated inpatient and outpatient health records, Computerized Provider Order Entry system, and other inbuilt tools that make for better efficiency and quality. The system integrates administrative tools (e.g. automated billing system), laboratory and radiology components, pharmacy, clinical documentation systems and decision support systems among others. The radiology module, for instance, includes medical imaging facilities, access to scanned documents, waveforms, sound and multiple other multimedia resources. It will allow medical practitioners at Keystone to capture, store, retrieve and easily share patient information generated over multiple encounters and settings, without necessarily jeopardizing their privacy.
However, EHRs are meant for use by all licensed healthcare practitioners (including nurses, physicians, pharmacists, hospital administrators, radiologists and lab technicians) working with Keystone hospital and partner facilities in the country. The full implementation of the system will involve considerable workflow disruptions, necessitate new skills acquisition and potentially alter other aspects of the organization. Even most importantly, resistance (active/passive) is expected, and the support of all the professionals that will ultimately use the system is critical to the success of the project. The chief nursing officer is expected to provide a direction and vision for the organization, but also ensure the attainment of the highest quality nursing service by meeting the systemic challenges that arise (which includes implementing EHRs to cut costs and bolster quality). Further, I am expected foster nursing human capital development, offer strategic management and ensure open and collaborative communication among nursing and other health care practitioners. Effectively, as the Chief Nursing Officer in charge of the project, I am responsible for liaising with key stakeholders to ensure support, communication, facilitate the acquisition requisite skills in the use of the technology and helping handle non-technical teething issues that may arise from new technology’s implementation.
Challenges and Opportunities
The implementation of the EHRs promises considerable benefits for the institution and the individual health care practitioners. To begin with, inbuilt decision support facilities facilitate the provision of safe and effective services. The system is convenient to patients and health care practitioners, not least because they allow fast and remote access to real-time patient charts, reports, and complete documentation. It is no longer necessary to fill out multiple duplicate forms and answer the same questions at every encounter with the health care system. Other than the incorporation of biometric identification capabilities, these systems also prevent data loss by backing up data on multiple servers. Even most importantly, patients may have limited access privileges to their information, which is central to the management of chronic diseases such as heart disease, where patient-centered management is critical in the attainment of optimal patient outcomes. Empirical evidence shows that EHRs improve patient safety, facilitate evidence-based care, avert redundant tests/procedures and role duplication, and provide preventive/medication error and other alerts.
Challenges to the implementation of the project are equally formidable. To begin with, a hospital-wide implementation of EHRs requires the input of external technology providers and numerous organizational level factors (including structure, finances, human capital, coordination and technical capability). Further, a hospital setting is different from regular business settings because of the very nature of medical data and the fact that any significant disruptions/mistakes can cost lives. This is further complicated by the variety of professionals working in hospitals (physicians, nutritionists, administrative staff) that are highly qualified, powerful and autonomous. According to Blavin, Ramos, Shah, & Devers (2013), the success of EHR implementation depends on three factors i.e. the management of the actual change process, the content or actual areas of transformation and the organization’s internal and external contexts. Organizational factors may cause resistance, in the same way that poor change management may. Further, while the acquisition of the technology would lead to considerable efficiency and quality gains, it requires the radical redesign of the workflow, which can lead to catastrophic disruptions and resistance. The staff will have to spend a considerable amount of time updating and entering data into the system, undergoing training and other issues that may result in revenue losses and reduced care quality.
Timeline
The implementation plan for the EHRs is based on Kotter’s eight-step change management model. This model was preferred because it is in tandem with multiple change management models. For instance, Roger’s innovation diffusion model asserts that for innovation to be successful, the stakeholders must perceive it to supersede other ideas (economic advantage, satisfaction, social prestige, satisfaction, and convenience, etc.). It must also be compatible with the predominant experiences, norms, practices, needs and values of the adopters. Further, the innovation should be simple and easy to use, be triable and have observable results. Kotter’s model allows for the demonstration of these aspects, and thus facilitates the successful implementation. The implementation plan will take at least 30 weeks.
Leadership Strategies
Different leadership styles may be helpful in facilitating the successful implementation of the changes. One of the most important strategies is effective and efficient communication, with all the stakeholders about the project and its progress, coupled with the incorporation of their feedback into the project. Formal and informal communication channels will be used to ensure that all stakeholders are informed and meaningfully involved in the project. According to Giltinane (2013), a leader’s responsibility is to ensure effective performance from others. It involves influencing and leading the creation/development of common vision, expectations and values to bolster their organization’s planned objectives and effectiveness. Above all, successful leaders must cultivate emotional intelligence through the enhancement of self-management, self-awareness, social skills and social awareness. Emotional intelligence refers to the ability to control the effect of one’s emotions on their respective relationships with other parties. Even with extensive leadership training, it is difficult to make an effective leader without empotional intelligence. This ability allows a leader to understand the follower’s motivations, needs and abilities, necessary to build excellent relationships, which can then be leveraged to achieve specific organizational goals. I have over the years cultivated good relationships with my colleagues, which makes them trust my intuition and decisions, and thus it would be relatively easier to ensure the changes are implemented successfully.
Most importantly, however, the organizational environment that characterized most health care entities require transformational leadership strategies. Transformational leaders realize their followers’ potential, and actively work to satisfy them while at once inspiring followers to go beyond the call of duty. Such leaders serve as visible role models, empowering followers also to become leaders. Followers who are empowered have higher organizational loyalty, motivation, job satisfaction, reduced sickness leaves and contribute to a positive work environment. This is not least because transformational leaders create clear and compelling visions for the future, inspire followers intellectually, identify individual differences, and build on their respective strengths. Transformational leaders inspire and motivate and inspire to invigorate colleagues so that they follow the organization or team’s vision. In this way, the team will not feel as if the EHRs project is being imposed on them, but they will feel a sense of ownership for the same, effectively pulling together to ensure that success (Rogers, 2003; Giltinane, 2013).
Actual and Potential Barriers
Resistance to change - According to Blavin, Ramos, Shah, & Devers (2013) and Hughes (2010), resistance to the implementation of EHRs may stem from poor communication, alienation and/or inadequate involvement of key stakeholders, uncertainty about the effects of the project. The best way to deal with resistance is stakeholder communication and engagement. According to Roger’s innovation diffusion theory, it is critical that all parties understand the potential benefits of the project and why the implementation is better than the manual system that the hospital is used to. This can be achieved through seminars, brochures, formal and informal communication channels. Further, the organizational members need to understand that EHRs are no different from physical patient charts and reports, with enhanced communication and decision support systems. It is also possible to use manual systems and EHRs concurrently for some time for the staff to appreciate the differences while also learn the new system, before finally switching to EHRs. This way, they will appreciate the technology’s compatibility with the existent technology. Resistance can also be broken by demonstrating the benefits through phased implementation (ensuring triability) and lastly, it is critical to show real benefits.
Technical and compatibility problems – there are many EHR vendors and these systems are not compatible with each other. Vendors also offer upgrades, maintenance and licenses for the use of varied products, and these need to be taken into consideration in the choice of the vendor. Frequent changes necessitate frequent staff retraining, but the lack of the same renders the system vulnerable to different risks. In extreme cases, it may become necessary to change the vendor completely, which is prohibitively costly. To avoid these issues, the choice of the EHR vendor must take into consideration the supplier’s capacity to meet the hospital’s future technical needs and the costs for future technical support. These will be built into the contract.
Prohibitive Costs – the EHR equipment and software are prohibitively expensive. It is estimated that only 8% of all hospitals in the US have fully implemented CPOE systems for example and the full implementation of the CPOE alone costs close to $1.9 million coupled by in excess of $0.5 million annually for maintenance, licensing and upgrades. The full implementation of EHR systems costs even more, and this can be a challenge in justifying the project and its financial feasibility if the hospital does not have the financial resources. Other than choosing a friendly cost supplier, contracts should explore options for phased payment plans depending on the implementation stage.
Leadership Strategies Amidst Failure
When the implementation of the project fails to go according to plan, the most important thing is to ensure that the organizational confidence in the project and in my leadership does not wane. Effectively, communication and transparency are important. By making the implementation process transparent, all stakeholders can understand the reasons for failure, to avoid apportionment of blame. Communication alleviates uncertainty, enhances engagement and cooperation, and ensures that stakeholders to contribute to solving the problem. Further, it is important to ensure that I earn their support using transformational leadership. I intend to connect at a personal level with as many stakeholders as possible, and once I earn their trust and I can then use this to prop up the project. Lastly, I will create a collaborative/democratic decision-making environment especially when failures occur. This ensures that all stakeholders assume a sense of ownership for the decisions made, and own the failure too, and thus they will be more driven to ensure that workable solutions to the emergent problems are found and are successful.
Requisite Resources
Financial resources – the cost of procuring the equipment and software, provision of training to all users, communication
Technical support (Human capital) – the staff need training in a range of areas, including basic computer literacy, interoperability of the EHRs, data security, HIPAA regulations and product-specific information. For this, the vendor, external consultants and internal superusers (early adopters) are absolutely critical to the success of the project. In addition, to ensure impartiality, external evaluation of the implementation may be necessary.
Time – there needs to be ample time to plan, acquire the equipment and software, train staff and roll out the project, before switching over
Additional staff to mitigate workflow disruptions – While some staff would be undergoing training, it is important that the additional burdens are not imposed on those on duty, or the quality of care is affected. Similarly, mistakes during the learning stage can be harmful if employees are worked under pressure. As such, temporary staff will be required to meet the increased burden.
External consultants – EHR implementation is complex, and it may require outside consultants to help smooth over the process through experience, train staff, evaluate the system’s effectiveness and remedial actions, etc.
Training resources e.g. conference rooms, demonstration stations and sponsorship of some employees to obtain requisite certifications
Conclusion
The implementation of HER systems is complex and potentially disruptive to the organization, which could prove to the detriment of both the project and organization’s intention to cut costs and improve the quality of care. Like any systemic organizational change, problems (including active resistance) are expected, and the implementation plan must include ways to tackle these problems. As a chief nurse officer, I will see that I give all the staff members individualized attention, leading by example and creating a democratic environment within which all members freely contribute towards attaining the set goals. However, not all members may be willing to participate, and since it is critical that all members are on board, I will also use my coercive powers and transactional leadership strategies to require compliance.
References
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Blank, R. (2012). Transformation of the us healthcare system: Why is change so difficult? Current Sociology, 60(4), 415-426.
Blavin, F., Ramos, C., Shah, A., & Devers, K. (2013). Lessons from the Literature on Electronic Health Record Implementation. Washington, DC: U.S. Department of Health and Human Services.
Giltinane, C. L. (2013). Leadership styles and theories. Nursing Standard 27 (41), 35-39.
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Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.
