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Howard Landa, M.D.
Chief Medical Information Officer
 Alameda County Medical Center
                    Oakland, CA
   Old tools:
    ◦ Whining, complaining, cajoling, threatening
    ◦ Incentives (Money, power, glory…Money)
      Used for ages without dramatic success
    ◦ Bad data  First 3 of the 5 Kubler-Ross stages):
      Denial, Anger, Bargaining
      Depression  acceptance requires good data!
   New tools
    ◦ Electronic Health Record
      Alerting and better data (Analytics)


                    Not much change!
   Improve primary care and non-PCP ordering
    ◦ Identifying
    ◦ Alerting        EHR!
    ◦ Ease ordering                    CMIO

   Improve cycle time
   Improve patient satisfaction with process

   Earlier detection  Improved outcome
   Kinda worked for primary care (less change)
   Not so much for others
    ◦   Doing the “right” thing isn’t always enough
    ◦   It is more work/unfunded mandate
    ◦   Knowledge deficit
    ◦   Lack of support
    ◦   Fear, Uncertainty, and Doubt (FUD)
    ◦   What else???

 That’s  why the call it
    change management!
Urologist orders mammogram
Result comes back:
 “BI-RADS 3, Probably benign”
“Doctor, what does “Probably” mean?



               Result-o-phobia
            The fear of looking stupid in not
         knowing how to interpret an abnormal
                          result
Education alone was NOT sufficient!

   Advance Practice nurse intercepts ALL results
    ◦ APN accountable for negative study communication and
      follow-up by protocol
    ◦ Communicates with Breast team non-negative
   Ordering provider gets “Courtesy” copy
    ◦ Informational, so no action is required
   Breast team becomes accountable for all
    subsequent care
    ◦ Contacts patient and arranges follow up
   Kaiser Permanente Hawaii in 2009
    ◦ Highest breast CA screening rate (42 – 69)
       ~72%  85% in 2009
    ◦ How?
        EHR can alert and facilitate
        Out-reach and In-reach
        Incentives and accountability
        Mitigation of result-o-phobia
    ◦ *Operationally supported workflow*

                                                   7
   Care standardization / Preparation for CPOE
    ◦ Electronic Order Entry with Paper Output
       Increase the number of order sets
       Reduce the # of actual paper forms
       Expedite creation
       “Test drive” order sets for CPOE
       Provide for maintenance of content
iHT2 Health IT Summit San Francisco Summit 2013 - Dr. Howard Landa, CMIO, Alameda County Medical Center - Case Study “Change Management in Health IT: The Elephant is Leaving the Room”
iHT2 Health IT Summit San Francisco Summit 2013 - Dr. Howard Landa, CMIO, Alameda County Medical Center - Case Study “Change Management in Health IT: The Elephant is Leaving the Room”
iHT2 Health IT Summit San Francisco Summit 2013 - Dr. Howard Landa, CMIO, Alameda County Medical Center - Case Study “Change Management in Health IT: The Elephant is Leaving the Room”
   Improved compliance with ordering of
    complete insulin coverage
   DVT prophylaxis compliance has increased
    from 50% to 97%
   Compliance with required orders
    ◦ E.g. Admit, Code status, Telemetry criteria,
      Resident/Attending/Service identification
   28% reduction in time from decision to
    admit to creation of inpatient orders
Lose weight, Being more productive, Quit
smoking.
So hard we don’t like to start
What about getting married or having a baby?
Not all change is hard
The question is: How desirable
(intellectually and emotionally) is the
future state and how hard is the path to
get there?
An Elephant and Rider on a path to a
             new (changed) destination


   Appeal to the intellect
    ◦ Direct the rider
   Encourage the emotions
    ◦ Motivate the Elephant
   Shape the path

                         http://www.heathbrothers.com/switch
The easy part for healthcare…
   Quality
      Safety
           Efficiency

Baseball, Apple pie and Chevrolet
   FOLLOW THE BRIGHT SPOTS.
    ◦ Investigate what’s working and clone it.
   SCRIPT THE CRITICAL MOVES.
    ◦ Don’t think big picture, think specific
      behaviors.
   POINT TO THE DESTINATION.
    ◦ Change is easier when you know where you’re
      going and why it’s worth it
   FOLLOW THE BRIGHT SPOTS.
    ◦ Who had the best screening rates?
    ◦ What orders were written most reliably
   SCRIPT THE CRITICAL MOVES.
    ◦ Use ancillary staff to support providers
    ◦ Default safe/reliable orders
   POINT TO THE DESTINATION.
    ◦ Improved screening metrics
    ◦ Core measure improvement, less calls
   FIND THE FEELING.
    ◦   Knowing something isn’t enough to cause change.
    ◦   Make people feel something.
    ◦   Does it pass the champagne test?
    ◦   Connect the team to the outcome/(+) Peer pressure
   SHRINK THE CHANGE.
    ◦ Break down change till it no longer evokes fear
    ◦ Make it feel do-able
   GROW YOUR PEOPLE.
    ◦ Cultivate a sense of identity
    ◦ Instill the growth mindset.
   FIND THE FEELING.
    ◦ You want your loved one to be screened?
    ◦ Highest quality/Safest care?
    ◦ Aren’t both something worth bragging about?
   SHRINK THE CHANGE.
    ◦ Order one mammogram at a time
      and we will take care of the rest
    ◦ Orders based on current paper tools,
      Limit paper output and limited scope
   GROW YOUR PEOPLE.
    ◦ Be proud of what you and your organization can do
   TWEAK THE ENVIRONMENT.
    ◦ When the situation changes, the behavior changes,
      So change the situation.
    ◦ Make the right thing the easy thing
      Shrink the change
      Look for quick wins
      Perfection is the enemy of good enough
   BUILD HABITS.
    ◦ When behavior is habitual, it’s “free”
   RALLY THE HERD.
    ◦ Behaviors are contagious, help it spread.
   TWEAK THE ENVIRONMENT.
    ◦ Anyone can place a mammogram order
      Everyone will be asking about it
    ◦ Every computer has the program on the desktop
    ◦ Here is a number to call if you have a problem
   BUILD HABITS.
    ◦ Ordering mammograms becomes routine workflow
    ◦ Using the Order entry system becomes routine workflow
    ◦ Rapid PDCA cycles
   RALLY THE HERD.
      Everyone uses the ordering software and expects the output
   Months of gradually increasing unrest
   Issue identification
   First consequence
   Threats of additional consequences
   Decisive action
   FUD (Fear Uncertainty Doubt)
   Direct the Rider
    ◦ Bright spots
      Honesty and directness
      Validation (directs the Rider and Elephant)
      Acknowledge errors and spot-lighters
    ◦ Point to the destination
      Understand the “Why” and turn it into
       actionable response
    ◦ Craft the critical moves
      Layout a course
   Find the feeling
       Safe environment to ask questions
    ◦ Validation
       Acknowledge pain and suffering
   Shrink the change
    ◦ Mitigate the fear moving forward
   Grow your people
    ◦ FUD (Frankness Unanimity Deescalate)
   TWEAK THE ENVIRONMENT.
    ◦ Open communications
    ◦ Demonstrate a culture of safety
   BUILD HABITS
    ◦ Ensure against recurrences
    ◦ Seek out concerns
   RALLY THE HERD
    ◦ Story telling within reason
    ◦ Mutual support
   Just because you build it does NOT mean they
    will come!
   Managing the change is as critical as the
    change itself.
   The road to hell is paved with good
    intentions…and (in Healthcare information
    technology) bad implementations

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iHT2 Health IT Summit San Francisco Summit 2013 - Dr. Howard Landa, CMIO, Alameda County Medical Center - Case Study “Change Management in Health IT: The Elephant is Leaving the Room”

  • 1. Howard Landa, M.D. Chief Medical Information Officer Alameda County Medical Center Oakland, CA
  • 2. Old tools: ◦ Whining, complaining, cajoling, threatening ◦ Incentives (Money, power, glory…Money)  Used for ages without dramatic success ◦ Bad data  First 3 of the 5 Kubler-Ross stages):  Denial, Anger, Bargaining  Depression  acceptance requires good data!  New tools ◦ Electronic Health Record  Alerting and better data (Analytics) Not much change!
  • 3. Improve primary care and non-PCP ordering ◦ Identifying ◦ Alerting EHR! ◦ Ease ordering CMIO  Improve cycle time  Improve patient satisfaction with process  Earlier detection  Improved outcome
  • 4. Kinda worked for primary care (less change)  Not so much for others ◦ Doing the “right” thing isn’t always enough ◦ It is more work/unfunded mandate ◦ Knowledge deficit ◦ Lack of support ◦ Fear, Uncertainty, and Doubt (FUD) ◦ What else???  That’s why the call it change management!
  • 5. Urologist orders mammogram Result comes back: “BI-RADS 3, Probably benign” “Doctor, what does “Probably” mean? Result-o-phobia The fear of looking stupid in not knowing how to interpret an abnormal result
  • 6. Education alone was NOT sufficient!  Advance Practice nurse intercepts ALL results ◦ APN accountable for negative study communication and follow-up by protocol ◦ Communicates with Breast team non-negative  Ordering provider gets “Courtesy” copy ◦ Informational, so no action is required  Breast team becomes accountable for all subsequent care ◦ Contacts patient and arranges follow up
  • 7. Kaiser Permanente Hawaii in 2009 ◦ Highest breast CA screening rate (42 – 69) ~72%  85% in 2009 ◦ How?  EHR can alert and facilitate  Out-reach and In-reach  Incentives and accountability  Mitigation of result-o-phobia ◦ *Operationally supported workflow* 7
  • 8. Care standardization / Preparation for CPOE ◦ Electronic Order Entry with Paper Output  Increase the number of order sets  Reduce the # of actual paper forms  Expedite creation  “Test drive” order sets for CPOE  Provide for maintenance of content
  • 12. Improved compliance with ordering of complete insulin coverage  DVT prophylaxis compliance has increased from 50% to 97%  Compliance with required orders ◦ E.g. Admit, Code status, Telemetry criteria, Resident/Attending/Service identification  28% reduction in time from decision to admit to creation of inpatient orders
  • 13. Lose weight, Being more productive, Quit smoking. So hard we don’t like to start What about getting married or having a baby? Not all change is hard The question is: How desirable (intellectually and emotionally) is the future state and how hard is the path to get there?
  • 14. An Elephant and Rider on a path to a new (changed) destination  Appeal to the intellect ◦ Direct the rider  Encourage the emotions ◦ Motivate the Elephant  Shape the path http://www.heathbrothers.com/switch
  • 15. The easy part for healthcare… Quality Safety Efficiency Baseball, Apple pie and Chevrolet
  • 16. FOLLOW THE BRIGHT SPOTS. ◦ Investigate what’s working and clone it.  SCRIPT THE CRITICAL MOVES. ◦ Don’t think big picture, think specific behaviors.  POINT TO THE DESTINATION. ◦ Change is easier when you know where you’re going and why it’s worth it
  • 17. FOLLOW THE BRIGHT SPOTS. ◦ Who had the best screening rates? ◦ What orders were written most reliably  SCRIPT THE CRITICAL MOVES. ◦ Use ancillary staff to support providers ◦ Default safe/reliable orders  POINT TO THE DESTINATION. ◦ Improved screening metrics ◦ Core measure improvement, less calls
  • 18. FIND THE FEELING. ◦ Knowing something isn’t enough to cause change. ◦ Make people feel something. ◦ Does it pass the champagne test? ◦ Connect the team to the outcome/(+) Peer pressure  SHRINK THE CHANGE. ◦ Break down change till it no longer evokes fear ◦ Make it feel do-able  GROW YOUR PEOPLE. ◦ Cultivate a sense of identity ◦ Instill the growth mindset.
  • 19. FIND THE FEELING. ◦ You want your loved one to be screened? ◦ Highest quality/Safest care? ◦ Aren’t both something worth bragging about?  SHRINK THE CHANGE. ◦ Order one mammogram at a time  and we will take care of the rest ◦ Orders based on current paper tools,  Limit paper output and limited scope  GROW YOUR PEOPLE. ◦ Be proud of what you and your organization can do
  • 20. TWEAK THE ENVIRONMENT. ◦ When the situation changes, the behavior changes, So change the situation. ◦ Make the right thing the easy thing  Shrink the change  Look for quick wins  Perfection is the enemy of good enough  BUILD HABITS. ◦ When behavior is habitual, it’s “free”  RALLY THE HERD. ◦ Behaviors are contagious, help it spread.
  • 21. TWEAK THE ENVIRONMENT. ◦ Anyone can place a mammogram order  Everyone will be asking about it ◦ Every computer has the program on the desktop ◦ Here is a number to call if you have a problem  BUILD HABITS. ◦ Ordering mammograms becomes routine workflow ◦ Using the Order entry system becomes routine workflow ◦ Rapid PDCA cycles  RALLY THE HERD.  Everyone uses the ordering software and expects the output
  • 22. Months of gradually increasing unrest  Issue identification  First consequence  Threats of additional consequences  Decisive action  FUD (Fear Uncertainty Doubt)
  • 23. Direct the Rider ◦ Bright spots  Honesty and directness  Validation (directs the Rider and Elephant)  Acknowledge errors and spot-lighters ◦ Point to the destination  Understand the “Why” and turn it into actionable response ◦ Craft the critical moves  Layout a course
  • 24. Find the feeling  Safe environment to ask questions ◦ Validation  Acknowledge pain and suffering  Shrink the change ◦ Mitigate the fear moving forward  Grow your people ◦ FUD (Frankness Unanimity Deescalate)
  • 25. TWEAK THE ENVIRONMENT. ◦ Open communications ◦ Demonstrate a culture of safety  BUILD HABITS ◦ Ensure against recurrences ◦ Seek out concerns  RALLY THE HERD ◦ Story telling within reason ◦ Mutual support
  • 26. Just because you build it does NOT mean they will come!  Managing the change is as critical as the change itself.  The road to hell is paved with good intentions…and (in Healthcare information technology) bad implementations