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3 Implementation Challenges that EHR Vendors Should Address Now

EHR projects are challenging for any healthcare organization, but especially so for LTPAC providers, who typically lack IT resources, capital infrastructure, and the staff stability that is crucial to implementing any large technological and process change. The result of this is many providers struggle with poorly implemented, un-optimized systems that don’t deliver the full transformative power of the technology. On top of the internal and systemic challenges facing providers, EHR vendors have been slow to develop workflow-based EHR solutions, adopt adult-learning-based implementation models, and truly partner to help solve the most challenging quality and service-related issues in the industry.

As they push forward the technology of their systems, EHR vendors would be wise to look at three key pitfalls in current implementation approaches:

1) Training content cannot be delivered effectively through multi-hour webinars. These webinars are nearly a complete waste of staff time and training resources, yet are still the most common method for delivering implementation training. The most efficient and effective approach to training staff is to combine lecture and live-practice at the same time. The more you separate these two integrated activities, the less staff will retain (and the more resources you’ll waste in additional training and practice). In addition, the training schedule should match the clinical workflow, rather than teaching modules in an architecture-based way. What does this mean? Don’t train based on how the EHR has divided up the work in modules (orders, events, progress notes, ADT, etc.)– train based on the user’s workflow; the quicker the training matches known work, the quicker staff will be able to apply the learning to their own internal reference points. And yes, this means training should be customized by facility and by role– a cookie-cutter approach

Most vendors have begun offering a variety of webinar-based, interactive web-based, pre-recorded content and user help guides. These items are an improvement over materials of the past, but are still nowhere near an optimized learning suite. The biggest barrier? Implementation and training costs are billed out to providers as a separate cost, and there is little incentive for vendors to optimize this process. In addition, vendors have little incentive to ensure systems are actually adopted, as the replacement cost for an EHR is beyond what most providers will consider.

2) Sandboxes are confusing as much as they are helpful. I’ll be honest– this has been one of the most surprising learnings I’ve had myself. A sandbox allows the learner to practice working in the EHR environment by utilizing a test facility with made-up residents. This model works really well for conceptual learners (such as myself)– but is challenging for those who are not (such as many, if not most, nursing home staff). Instead of being helpful, by and large, nursing home staff are confused by the sandbox approach and struggle initially to apply the conceptual lessons (adding an order to Susie the test case, for instance) to their own future workflow (adding an order to Susie the resident). In addition, sandboxes often become littered with examples of every variable possible within the EHR– but in places you typically wouldn’t find them. On a recent installation, for example, the sandbox contained a PRN order for NovoLog that required charting on pain level and blood pressure. The order was used to demonstrate a PRN order, and show how you could require certain charting to be completed before administering the medication. The trainees, however, struggled to get beyond the fact that you would never chart for pain level and blood pressure before administering NovoLog (an insulin).

Sandboxes serve a purpose– letting users practice outside of the actual medical records– but they should be crafted to match the implementing facility as much as possible. Once the initial data entry (or a portion, even) is completed, vendors should replicate the database to use as the sandbox. Using familiar residents, assessments, and orders can significantly improve the retention of training.

3) Listen to users, but don’t rely on self-reported user suggestions and improvements as the whole story. When EHRs first came to the market, they presented a variety of solutions that barely resembled long-term care workflows. This is understandable, since they were primarily designed to automate MDS data collection and submission (an entirely different and problematic topic). Over time, as providers shared frustrations and challenges with the software, vendors responded not only by making improvements to the software, but also creating user groups and councils to directly solicit feedback from users. This is a great step forward, and in line with many of the vendors’ switch towards agile-style development.

The new challenge, however, is that facility staff generally don’t understand the EHR architecture, and the vendor product owners don’t understand facility workflows and, more importantly, facility care and service goals. This lack of understanding on both ends of the development process inhibits EHRs from being transformative in practice, and instead we are getting slightly less clunky applications still driven by paper-centric thinking. To get ahead, vendors need to rethink their development process, gathering not only ideas but also goals and desired outcomes from providers. (Think of it as a root cause analysis process.) The development challenge then is to design the best, most efficient way to accomplish those outcomes and goals (instead of the current approach of simply adding functionality)—which will generally require re-engineering the workflow itself. Thus, the vendor development team should include not only software development and subject matter experts, but also workflow analysis and design experts. By doing so, they’ll develop a product that can be much more easily implemented and adopted.

 

For providers, the good news is that the intense competition in the EHR market, combined with a rapidly pivoting payment landscape, is thrusting the need for an optimized and adoptable EHR solution to the forefront. Many of the legacy vendors are committing significant resources to redevelopment and a renewed emphasis on user adoption, while a few newcomers to the space (I’m particularly intrigued by LG CNS for the integrated market and Medtelligent for the AL space) are making surprisingly strong inroads.

For those that are unhappy with their current systems, this is a great time to start looking at replacement options. For the few providers who are still relying on paper workflows, this is an ideal time to make the transition.

 

 

Considering an Electronic Health Record system for your nursing home or assisted living community? Looking to optimize a current installation? Learn how we can help with our EHR Consulting Services.

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Confusion as a Major Waste in Healthcare

Identifying and eliminating waste is a core part of Lean work. In traditional Lean literature, there are seven or eight “wastes” identified:

  • Defects
  • Overproduction
  • Waiting
  • Transportation
  • Inventory
  • Motion
  • Excess processing
  • (Non-utilized talent)

In her book A3 Problem Solving for Healthcare, Cindy Jimmerson makes an argument for confusion being a primary waste. Certainly, confusion leads to many of the other wastes, especially defects, waiting and excess processing, and in my own learning and understanding of Lean, I’ve felt more comfortable sticking with the traditional listing. This highlights one of the challenges with Lean: at its core, it’s a changing methodology and set of tools, rooted in a philosophy of respect-based continual improvement. So when we translate the principles to other settings, such as healthcare, Lean itself begs to be adapted and changed as needed. So, is there something more about the waste of confusion, especially in healthcare, that warrants an examination of its place in Lean healthcare thought? After a recent client visit, I’m more inclined to say yes.

It’s common to run across confusion in healthcare, and especially in long-term care. Policies and procedures are oftentimes outdated and impractical, notes reminding staff of one task or another riddle work areas, and it doesn’t take long before you overhear a staff member say something like, “I don’t know what’s going on around here.” In some cases, the confusion is so overwhelming, we actually turn a blind eye to this fact, and begin operating from a survival perspective where it’s assumed that no one knows what’s going on, and you merely hope to make it to the end of your shift without a significant adverse outcome occurring.

As I watched staff operate during this site visit, however, I saw a number of cases where confusion acted as a primary waste. For instance, when residents would move rooms, someone would cross out their room number (originally written with a Sharpie) and write the new room number above it (usually with a pencil). In some cases, the new room number had yet to be written on the chart, though the chart itself had been moved to the new unit. I would watch staff looking back and forth through the chart rack trying to find someone’s chart, sometimes finding it and sometimes giving up and writing a note of a piece of paper to file later.

In another case, a nurse remarked how she didn’t know what was happening on her unit because she hadn’t worked there for a week and the previous nurse had left without giving report. In response, she was just taking issues and concerns as they came, rather than addressing anything proactively.

In both cases, it’s easy to see wastes and potential for wastes present: defects, inevitably bound to occur by picking the wrong chart or missing crucial information; waiting, or, perhaps more accurately, time wasted searching; motion, for sure, as staff would walk back and forth several times trying to find the right chart; excess processing and non-utilized talent, both from doing unneeded work (but that the staff member didn’t know was unneeded) or extra work, such as writing something down and then later rewriting it in the chart.

As I watched the staff working though, I wondered if recognizing confusion as a primary waste would be more helpful in understanding the root causes and, ultimately, being able to address them. After all, I think most of the staff innately understood how confusing their workplace was, and how much effort they wasted because information wasn’t clear, available or accessible. While most staff can understand how defects, waiting, inventory, ect. can apply in the healthcare setting, it usually takes some explanation and translation. It’s also worth considering how Toyota originally identified primary wastes, as the language is very much rooted in a manufacturing mindset. This isn’t to say Toyota’s vocabulary isn’t applicable anywhere else– it is– but rather is there a better way– a Leaner way– to better target and resolve the waste present in healthcare.

So, should confusion be considered a primary waste? Should we talk about nine primary wastes, or reduce one as Cindy proposed? This is certainly a topic worth more consideration and discussion as healthcare continues to adapt and refine Lean applications.

 

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Leader Standardized Work

Standardized work is not only designed to guide line staff; it works equally well—and is equally important—for leaders, too. Standardized work for leaders consists of developing routines for rounding with purpose (going to the gemba) and other activities where you check in on the status of current tactical and strategic goals.

A purposeful, daily stand-up meeting is a good start to standardized work. It should consist of sharing census changes, resident concerns, staffing issues, safety incidents, future events and successes to be celebrated. Once you have started building a culture of continuous improvement, consider adding a minute of reflection. Ask the team, “How did yesterday go?” and “What can we do better today?” The idea of building upon each day keeps work from being routine and helps staff to engage in the process of making small improvements all the time. A stand-up meeting should start on time consistently and last no more than 10 or 15 minutes. For issues that require more than a minute or two of discussion, have a smaller group break off afterwards to discuss rather than occupying everyone’s time.

Developing a daily checklist that incorporates current goals is another way to standardize oversight and accountability. A daily checklist helps to reinforce priorities, communicate the intended direction of the organization, and connect to the drivers that will lead to the desired goals. The questions need to be customized to your current goals and priorities to be effective. Generally, improving resident quality and experience are top concerns of most organizations, as are employee staffing and performance issues. If there is significant construction, reorganization or major initiatives rolling out, these items should be integrated into the daily checklist.

Here are two examples of daily check sheets for an administrator and DON:

Administrator Daily Check List

 

DON

 

Sometimes, questions may seem formulaic or unnatural. Don’t worry. If staff know that they can count on a response, they will be happy to share struggles and challenges. Also, by asking questions like, “Have there been any falls in the last 24 hours?” or “Are all assessments up to date?” staff will understand the importance of these items to your work and to the organization’s overall success. Questions should change over time as priorities and goals do. The important thing is to develop a daily routine that can help keep your organization on track.

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The Basics of Lean: The PDSA Cycle

One of the most basic foundations of Lean is the PDSA cycle, which guides virtually all improvement approaches. Dr. Edwards Deming is credited with developing the Plan-Do-Study-Act (PDSA) cycle of continuous quality improvement based on his learning from Walter Shewhart at Bell Labs. The cycle is also know as Plan-Do-Check-Act (PDCA), the Shewhart cycle, or the Deming Wheel. It’s based on the scientific method:

1)  Form a question
2) Make a hypothesis
3) Predict the outcome
4)Conduct a test or experiment
5) Analysis the results
(Repeat steps 2-5 as needed)

The PDSA cycle begins with an opportunity for process improvement (OPI). This is a problem, an error, or an area you’ve identified as needing improvement.

PDSA_opiPLAN

In the planning phase, clearly identify the problem, develop an understanding of what the future state should look like (once the problem has been removed), and conduct a root cause analysis to determine the likely cause or causes of the problem.

Once the likely root cause or causes have been identified, identify solutions or countermeasures that can be tested. (Lean prefers the term “countermeasure” over “solution” because most systems and processes are complex enough that there is rarely a solution; instead, countermeasures to likely causes of problems are put in place to bring about success. In addition, thinking about countermeasures as opposed to solutions encourages a mindset of continuous improvements to a process rather than a goal to reach and then forget about.)

DO

In the do phase of the cycle, test out the proposed countermeasures. It’s usually best to try solutions in a limited area, such as one neighborhood or department, so you can make modifications or adjustments before rolling it out to the whole community.

STUDY

After implementing countermeasures, collect data and analyze the results of the pilot tests. Were the countermeasures effective? Is the problem better? Worse? The same? Different changes can require different timelines for checking on their effectiveness, but generally 30, 60 and 90 day marks provide a good place to check on the status of countermeasures.

ACT

If countermeasures were found to be effective, incorporate any improvements or learning from the pilot and roll out the countermeasures to other appropriate areas. If the pilot didn’t produce the desired result, begin the cycle again. Perhaps a root cause was incorrect or missing? The implementation wasn’t complete? Area staff weren’t involved effectively?

The key to the PDSA cycle is to work methodically through challenges, experiment with and evaluate changes, and act on the results.

PDSA is the basis for A3 thinking, a tool that grounds the improvement cycle in an easier to understand and follow process. By working through problems and their causes in a scientific, methodical way, we can develop effective countermeasures and build on prior success.

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Four Keys to Lean Problem Solving

Oftentimes, we see organizations struggle to sustain improvements in key areas of performance. Despite frequent training and supervision of staff, outcomes are difficult to obtain and continue over time, whether related to census and occupancy or incident investigation and prevention. The challenging piece is that staff almost always want to do good work, but, unfortunately, systems and processes get in the way. Lean is really about a systematized way of applying a philosophy and a set of tools to overcome barriers and produce lasting results. Here are four keys:

1) Go to the floor. (In Lean terms, we call this “the gemba,” or the place where work happens.)

You can’t solve problems by sitting in an office or a conference room. Yet, stubbornly, many quality improvement discussions occur in these places isolated from where the work actually occurs. Instead of falling into this common trap, go to the site of the issue. Be respectful of the workplace– don’t interrupt staff during busy times and let them know clearly why you are there. Use their wisdom to learn about the true nature of the work and to uncover both visible and buried barriers to the work.

2) Look across departments and focus on the resident experience (the “value stream”).

Most issues are rarely isolated to one department. Instead, we need to reach across department lines, gather diverse interdisciplinary teams, and look at challenges from the resident’s perspective. Look for ways to simplify processes, reduce barriers and deliver the right service to the right resident at the right time.

Process mapping, value stream mapping, critical to quality trees, and voice of the customer assessments are all helpful tools during this phase.

3) Find the root cause of problems and enact countermeasures.

Use the five whys, A3 problem solving, and other interactive methods to drill down to the root causes of issues. Too often, providers try to solve surface issues or apply band-aids, which wastes both staff efforts and morale. Sometimes, “solutions” even serve to further  hide problems, which leads to less value for residents. Resist the urge to come to simple conclusions.

When you do identify root causes, brainstorm countermeasures and then test them. Follow up after 30, 60 and 90 days. If the countermeasures fail, be sure to acknowledge the failure with staff and return to the problem solving process. Don’t blame staff for failures! If a countermeasure wasn’t implemented completely, analyze why and adjust the countermeasure as needed. Remember, most staff want to do good work!

4) Sustain results through standardized work.

Once you identify countermeasures, be sure that standardized work is created, staff are well trained, and there is clear and visible documentation. It shouldn’t be difficult for staff to find answers to common questions, and new staff shouldn’t be “thrown to the wolves” when they arrive on the floor. All too often, providers rely on decades-old policies and procedures (and update P&Ps constantly but fail to match them to actual work) and wonder why staff aren’t able to follow through.

Remember, standardized work is the current best practice for accomplishing work. When you know better, do better– but make sure you update the standardized work and ensure that staff are knowledgeable and trained!

Ready to get started? So are we!