All readers beware! This is the antidote and NOT the answer.
I want to explore efforts I’ve participated in to turn poor implementation results into a highly successful change effort.
When confronted with the continued reality of not having dedicated change management resources (read: zero) for a large implementation effort, the team I led decided to learn from the mistakes of prior efforts and take on the work that ordinarily would be orchestrated by someone focusing on the change component. Fortunately, I understand enough about how to build change into a project and was able to steer the training plan into one that included enough components of change methodology to improve upon what was learned in prior efforts.
This manifested through a project to bring clinicians and nursing staff from the ambulatory surgery center onto the system-wide electronic medical record. The implementation took on the highly challenging task of moving staff from never using computers and documenting all their work in a paper chart to fully utilizing a the electronic medical record.
The team I led was primarily a training team, but one that understood the dangers of going into training without prepared students.
Key changes were made in the approach to implementation. Some of the most important changes were:
1. Preparing end users for the change
A series of three “in-services” were organized in the months leading up to the implementation. During these scheduled in-services, trainers prepared end users (primarily nursing staff) for using the computer during their patient time. The hour long preparatory meetings helped nurses feel more comfortable with the planned changes, and gave them hands on exposure to the system and how it was being configured. This strategy went a long way toward reducing resistance and fears, and nurses were told after each in-service that they had to begin using the computers to look up patient chart information.
2. Training the end users
Through negotiations with key business leaders within the organization, a training plan was developed that mixed didactic knowledge sharing strategies with hands-on practice time. In all, nurses attended two 8 hour classes spread a week apart, and were able to learn the system through exposure and practice.
3. The Sandbox
Critical to the success of the project was the development of a “sandbox environment” that matched the production environment nurses and doctors would eventually use to document patient care. With the support of management and project leadership, the training team set up a series of opportunities for users to practice real-life scenarios in the sandbox environment. With the help of trained facilitators who were their colleagues, nurses flowed through the sandbox training room and began their process of mastering the skills needed to be effective on day one of go-live.
3. Assessment and support:
The skills of clinicians and nursing staff were assessed after the training and sandbox practice time to determine what they had retained and to prepare for the next level of intervention: end user support.
Clinicians assessed their own confidence in using the new system at the end of class. When the system was turned on and a clinician was scheduled to perform a surgery, a support person used that assessment to quickly connect with the clinician and help bridge the learning gaps that s/he still had. Targeting offered support based on what those areas not fully understood was an effective strategy in moving clinicians to proficiency.
Nurses, who have significantly more documentation in the electronic record than do doctors, received a hands on assessment by a nurse educator or a skilled colleague. The results of that assessment were given to designated support staff who at implementation connected individually with nurses to review areas that presented as skill gaps. With this focus, nurses quickly brought their documentation skills up to a level of proficiency.
Within three days of implementation, these change strategies resulted in productivity levels rising to normal (i.e. prior to implementation of the new system) and in some areas productivity showed increases. Within two weeks, the surgery center was surpassing prior productivity standards, and patients were getting better quality care.
What did we learn?
Using assessments to gauge staff preparedness set forth a new dynamic. End users knowing that their understanding and budding skills were going to be assessed contributed to their increased ability to learn the new system.
This contrasted with past efforts when messaging about the change implicitly was interpreted by users as more a choice to learn, as there were no built-in accountabilities. The classroom time, then, acted more as an “exposure” to the system as there were no clear expectations to learn it.
In the case of the surgery center, effectively preparing new users for the movement to the electronic medical record paid significant dividends. As management set clear expectations, change efforts introduced the new world with enough time for end users to get beyond the denial and anger stages. Combined with effective post-training support, the effort culminated with the most successful implementation the team had ever experienced.
So what were the lessons learned?
1. Prepare end users by early engagement in learning opportunities.
2. Set clear expectations about learning, backed by means to assess progress
3. Provide ample opportunity to practice skills with real life scenarios in a structured, facilitated environment.
4. Utilize assessment to target areas where users did not get fully prepared through training and pro-actively reach out to them to provide “on the job” training.
The implementation of an electronic medical record can be daunting from a number of perspectives, but with proven methodology, the challenge of moving medical staff from traditional documentation methods to electronic formats can be highly successful.
Making this happen in such an environment is possible. But can such experience by transferred into the larger social context to bring about social change? That’s the question this site is dedicated to explore. What do you think?
