Introduction
Globally, healthcare services organizations have moved or are moving definitely towards EHRS (Electronic Health Record Systems). EHRS ensures data availability on demand in a standard and readily usable format to care providers as well as patients that are secure, confidential, and available 24x7. Introduction of EHRS across a variety of organizations have given numerous benefits to different care providers in different ways over a period of time. Maturity and reliability of EHRS is as good as the data. The way it is fed into the system. The primary data capture point is at nursing care on a daily basis, while providing care.
Nursing staff play a key role in accessing and using this data, while also entering data into the system. Transition between a paper-based medical record maintenance and an EHRS would mean the nursing staff, improving their computer literacy skills as well as maintaining records up-to-date in real-time. This transition is not as simple as it sounds, and the implementation of full-fledged organization-wide EHRS requires careful change management plans.
As the Chief Nursing Officer (CNO), it is the responsibility to ensure full compliance with the demands of EHRS and also ensure rigorous implementation to maintain high levels of fidelity of data captured at the care provision points. This requires careful data capture systems, which is recorded diligently into the EHRS. This paper explores the various facets of a good EHRS system as well as a robust change management plan to ensure success of EHRS implementation.
Managers, today, are implementing change and development programs in their organizations in order to keep in pace with the constantly changing external environment. When they get into problems in the course of implementing the change and development programs, they approach practitioners’ who are specialized in Organization Development to get help in solving the problems. The specialists diagnose the problems faced by the managers and suggest appropriate OD interventions as a solution to the problems. Such interventions help the organizations improve their performance and efficacy.
An organization is essentially a place where a group of people work collectively for the achievement of a common organizational goal(s). Such goals are then redefined to obtain measurable performance targets. Such measurable parameters help the management monitor employees and ensure that they are on the right track. The management also develops strategies that will help the organization meet its goals. The implementation of these strategies requires a formal structure of authority and responsibilities. A well designed organization structure facilitates coordination among the activities of employees and enables an organization to accomplish its goals and objectives.
The Proposed Plan
There are a number for of factors that impact action planning. First among them is to ensure that there is a clear cut goal or objective that is set out for the plan. Second factor is to be able to identify the key stake holders for the plan. The third factor is to ensure that each of the stake holders have sufficiently evident “what’s-in-it-for-me” built in. The fourth factor is to ensure that communication of what is the outcome of action and how it benefits each stake holder clearly. Action planning is a critical area for managerial effectiveness today. Despite any amount of knowledge or skill, if the manager today does not plan for action the resultant output of the manager’s productivity will tend to zero.
The entire EHRS implementation system kick starts with the creation of a project plan. Typical HER systems, when bought off the shelf and implemented, would need anywhere between six months to one year of time frame, implemented across all the hospital departments including pharmacies. The typical project lifecycle would consist of the following key steps:
- Procurement – The procurement is the most key step in the HER implementation process. Negotiations with prospective vendors and definition of deliverables, while moving to a new operational environment is a fairly complicated process, with complexities further added by vendor competition and various legal aspects of the contracting process. The organizational leadership might be under pressure and may not even feel comfortable in this kind of situations. An external consultant could be looked up to, for the selection of vendor(s) and a variety of systems that could become part of the proposed EHRS. A vendor must be considered more as a partner in the implementation of EHR systems and must offer excellent knowledge and commitment to EHR implementation in the organization. This must be further supported by sufficient training to all the end-users, while allowing extensive customization to the EHR systems, instead of asking for customization of processes within the organization to suit the EHR system, the newly proposed system must be customized to suit the operational process of the hospital. The vendor must be willing to acquire the existing patient data while creating suitable interfaces. While implementing an EHR system, the planning must be futuristic and must not be constrained by current operational process.
- Initiation – The EHR implementation process must begin suitably with selection of appropriate project team to manage the implementation process. The manager, within the organization, must be a person with extensive healthcare experience and also with extensive IT project, preferably formally certified in various facets of project management. The next logical step would be to identify various key stakeholders in the project and identification of internal leadership for the EHR implementation team.
The EHR implementation team must include representatives from the board, executive positions and more importantly nurses from all in-patient and out-patient departments including emergency and ancillary areas. There must be a clear buy-in with the EHR team.
Sufficient training must become part of the EHR implementation process. The training effort must constitute between 25-35% of the EHR implementation process. Every stakeholder including all parts of management team and staff must be committed to learning and implementing EHR and readily accept changes that need to be made to the existing set of processes within the organization.
- Planning – The EHR implementation process must have sufficient planning incorporated. The workflows must be clearly scheduled, hardware and software must be selected and installed appropriately. This becomes part of the scope of the EHR implementation committee. Clearly, nursing who encompass the delivery of patient-care services across all departments and functions become critical, and hence the Head of Nursing must take keen interest in the entire process.
- Implementation – Successful EHR implementations must consider among a variety of other factors, infrastructure preparedness and readiness, encompassing training readiness and even aggregation configuration readiness. The required software for successful implementation of EHR must be procured and be in place operationally before taking any step. There must be sufficient number of workstations, printers, wireless devices, which are envisaged to deliver the patient-care services.
Before live implementation, a detailed test plan including functional testing, integration testing, volume testing, integrity testing, among others, of all the functional aspects must be planned and kept ready. Applications must be configured to suit the workflow of the organization, rather than changing workflows to suit the configuration.
Testing must be done to suit the future requirements of the organization rather than the current and existing organizational setup. This is a key factor that must be considered while keeping in mind the needs of the future, rather than taking a blinkered approach to what is being used today. The implementation plan must include go-live parallel use and complete transition phases that would entail more work on the nursing staff. Despite the fact that, it entails more work for the nursing staff, it is important to have a clear buy-in of all the staff for the change to EHR implementation. All employees must be convinced that implementation of EHR within the organization would help each other, serve the patient better and more effectively.
- Monitoring – Even before the first implementation phase happens, clear cut monitoring and control mechanisms must be put in place, and a cost-estimate of the entire EHR implementation must be made into metrics and be readily available to the top level EHR implementation team. All aspects of EHR implementation must be effectively controlled and managed to ensure successful implementation of the EHR system.
- Closure – Once the EHR implementation goes fundamentally live and tested with parallel systems implementation, there would be sufficient time and energy to ensure greater learning, assimilation, and implementation to happen.
These key steps are essential part of any EHR process planning and must take care of the overall EHR implementation policies. And once there is a final decision made by the management team to implement EHR, there must be effective communication strategies and change management processes that must effectively handle fears as well as apprehensions of any/all team members involved in the EHR implementation. These different steps in the implementation of EHR must essentially be carried out without fail to ensure that there is a sufficient return on investment available for the dollars spent on EHR implementation across the organization.
Managing the change process
Organizational change encompasses change in the behaviour as well as working style of the staff. The change might seldom enhance the workload of employees relatively, and lays disproportionate pressure on them, eventually causing immense stress to the workforce. Under situations that result in intense stress, the employee performance comes down and this eventually impacts the overall performance of the organizational. Change is inevitable in the business world. The survival of the organizations depends on their adaptability. Organizational change implies a change in the employees’ manner of working and behaviour (Drucker, 2000 Rev Ed).
One important factor that the change process owner needs to be cognizant of while implementing the change process is the fact that however well the process is planned, there is always a likelihood of sudden and un-expected events to crop up. It is now up to the individual maturity of the person at the situation to respond or react. In all such situations it is best not to react but to effectively respond to such situations. In case these are impromptu situations, it is best to ensure that people create a buffer time situation and use that buffer to have a well thought out response.
The people responsible for managing change in the organization are called change agents. Change agents can be managers, non-managers, or outside consultants. Generally, senior executives act as change agents in the organization. But these days, in many organizations, top managers seek the help of outside consultants with specialized knowledge in change management.
The change may sometimes increase the workload of employees drastically and put undue pressure on them, leading to stress. “Organizational Development is aimed at bringing about planned change which would consequently yield in increased organizational effectiveness and capability to change itself.”The planned changed that would be eventually brought in to the organization helps in solving existing problems, gaining experience, to reframe shared perceptions, obtaining adaptability to the external environment and changes in such environment, to enhance productivity and performance and also in influencing changes for future. Planned change can be described in terms of magnitude. The magnitude of change can be large or small i.e. fast, abrupt, revolutionary or slow i.e. evolutionary. Based on magnitude, planned change can be divided into two types – first-order change and Second - order change.
The main benefit of having outsiders as change agents is that they take a more intentional view and hence are expected to offer better solutions. However, a major disadvantage in seeking suggestions from these outside consultants is that they have insufficient understanding of the history of the organization, its culture and employees and various operating procedures of the organization. This is especially so when the initiation of second order changes have negative repercussions. Due to lack of thorough knowledge they may not be able to efficiently handle the problems.
It is reasonable to infer that communication forms the crux of the entire action planning. While there is no single media or method that ensures effective and efficient communication to all sections of the audience, it is up to the process owner to identify what media would be ideal to address which segment of audience. For instance if we were to address the shop floor workers who have limited computer knowledge and limited access to computer systems, there is no point in actually using intranet to communicate with these set of people. Another good example would be if we were to use paper based communication to those people who spend good amount of time on computers, it would be a waste of paper and precious resources. It would be good to target the use of intranet for this purpose.
Integrating Change and Knowledge Management
Most organizations, at some time in their existence, face decline in performance. However, quite often it so happens that, all it may need is a change in the style of leadership rather than a complete change in leadership as whole. Leadership is like any or all other skills that can be learned with practice. Skills are a manifestation of the personality traits of a person. But, as widely accepted, human beings are exceptionally good at adapting their personality to suit the occasion. So, leadership skills being the output of personality traits, the traits can be varied to the required skills.
The upturned chain of command of knowledge is an indication to lead to a different outlook in the development of information system which would support knowledge management and executive memory. It is often conflicted that this dissimilarity may have key inferences for flexibility and renewal of knowledge management at organizations. By making use or introducing the concept of Knowledge Management, organizations can be helped to emerge as knowledge-based institutions with higher and better quality of service. The introduction of Knowledge Management into the systems helps the organizations to be even more competitive and at the same time aids in a better way of sharing the knowledge i.e. information integration. One more advantage of the introduction of Knowledge Management is that, as the sharing and integration of information and knowledge increases, the efficiency of the staff also will increase simultaneously.
For instance if a manager is to succeed in conducting an employee satisfaction survey, it is not the action and process of conducting the survey itself that matters to the employees. It is those changes being implemented as a result of this survey is what matters to the employee much more than the survey results by itself. So for the manager to be successful in this scenario the manager actually needs to plan for the changes. To consult flawlessly "requires intense concentration on two processes. (1)Being as authentic as you can be at all times with the client; (2) Attending directly, in words and actions, to the business of each stage of the consulting process."
Conclusion
Implementation of a strong and robust EHRS system has many spin-offs on different organizational dimensions. While having excellent quality data and readily available information accessible to care providers from across the world at any point of time allows the care providers to be able to take informed decisions especially in emergency kind of situations. The same information is also available to the patients who can access this information that comes from a central repository and allows them to review their progress as well as how they are responding to the prescribed treatment. This also gives them a perception of higher customer service levels and also an unintended spinoff would be increased customer satisfaction levels too.
However while implementing EHRS systems there are numerous challenges other than acquisition of hardware, appropriate software, networking, WAN, internet access etc.
There are also challenges of the people involved being trained effectively and handholding them through a process of change. The earlier paper based systems tend to get replaced fully over a short period of time and predominantly the way people are used to working needs to be changed. This involves adaptation. As in any change management initiative there are challenges and severe resistance to change. Effective communication and the way the working would change and what it would mean to the stakeholders needs to be explained and the stakeholders need to be clear on what would be their stake and how their work life gets impacted. This paper has examined the various facets of change management in a healthcare setting from a point of view of the head of nursing staff since nurses play the most important role in any health care setting.
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