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Effective Strategies for Change [1 ed.]
 9781938904707, 9780429055010, 9780429619755, 9780429617607, 9780429621901

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Effective Strategies for CHANGE™

Claire McCarthy, MA, FHIMSS Douglas Eastman, PhD David E. Garets, FHIMSS

First published 2014 by HIMSS Published 2018 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN 52 Vanderbilt Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business

Copyright© 2014 by the Healthcare Information and Management Systems Society. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. ISBN 13: 978-1-938904-70-7 (pbk)

About the Authors

Claire McCarthy, MA, FHIMSS, is a recognized change management/ technology adoption strategist with extensive experience supporting people through transitions driven by software implementations and other large-scale changes. Her healthcare career includes change lead­ ership positions at Providence Health & Services, Kaiser Permanente, Group Health Cooperative of Puget Sound, Premera Blue Cross and Premier, Inc. Ms. McCarthy’s focus is developing individual and organizational readiness for change. Through alignment of cross-functional work in change management, training, communication, operations and work­ force planning, clinical and business users are prepared to assume new roles and responsibilities in support of organizational objectives. Ms. McCarthy works with healthcare providers and staff at all levels, understanding that developing willingness and ability in people is what makes change successful and produces lasting results. With 25 years of healthcare industry technology adoption experi­ ence, Ms. McCarthy has designed and led the human side of technical implementations for a wide variety of software deployments, includ­ ing EMRs, practice management, material management/supply chain, client relationship management, e-commerce, and ICD-10 conver­ sion. She speaks internationally on the topic of technology adoption, encouraging healthcare leaders to set the stage for benefit realization by investing in the people side of implementation. Ms. McCarthy is a certified William Bridges Organizational Change practitioner and is accredited in Accelerating Implementation Methodology from Imple­ mentation Management Associates, Inc. She holds a masters degree in sociology from the University of Montana and a bachelor s degree in sociology from California State University. She can be reached at [email protected]

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Douglas Eastman, PhD, is an organizational development executive with extensive experience managing large-scale change initiatives. With more than 20 years of consulting experience, Dr. Eastmans focus is to help organizations grow and manage change by unleashing human potential. His specialties are organizational transformation; technology adoption and optimization; process redesign; large-scale change management; strategic planning; program and tools develop­ ment; and facilitation. As the Executive Director of Usability and Technology Adoption within the Kaiser Permanente Information Technology Care Delivery Business Information Office, Dr. Eastman currently advises senior operational and project executives on the country’s largest public EMR system implementation and myriad other large change initiatives. Dr. Eastman leverages best practices from across the program and devel­ ops implementation readiness tools and methodologies, as well as pio­ neering several best practice post go-live optimization strategies and programs aimed to ensure end-users are building the requisite level of system skill proficiency. Prior to joining Kaiser Permanente, Dr. Eastmans consulting career includes positions with Andersen Consulting (now Accenture), Watson Wyatt Worldwide, and a boutique employee relations consult­ ing firm. He was also vice president of operations for a technology ser­ vices firm, at which he was responsible for the company’s restructuring and repositioning in its marketplace that grew 200% during his tenure. Dr. Eastman served on the board of directors for the Childhood Anxiety Network. He holds a PhD in organizational psychology from the California School of Professional Psychology, a master’s degree in psychology from Pepperdine University, and a bachelor’s degree from Ohio State University. He can be reached at [email protected] David E. Garets, FHIMSS, is a semi-retired advisor to corporations and health systems. Mr. Garets is a Principal at Mountain Summit Advisors, providing M&A, recapitalization/financing, and consulting services to private healthcare IT firms. He’s also an advisor and chair of the Executive Advisory Board for SCI Solutions, as well as a Senior Advisor for Next Wave Connect.

About the Authors

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Previously, he served as President and CEO of HIMSS Analytics and Executive Vice President of HIMSS. He has held executive posi­ tions at Healthlink and Gartner and is an experienced healthcare CIO. Mr. Garets served as HIMSS board chair in 2004. He sits on the gov­ erning boards of Health Care DataWorks and the PeaceHealth North­ west Network. He served on the faculties of the CHIME Information Man­ agement Executive courses for 11 years and was a charter member of CHIME. He is an internationally known author and speaker on healthcare information strategies and technologies and in 2011 was elected to the HIMSS 50-in-50, the 50 most memorable contributors to healthcare IT in the last 50 years. Mr. Garets is the co-creator of the HIMSS Analytics EMR Adoption Model, the international de facto standard for measuring the progress toward a full electronic medical record. Mr. Garets earned a bachelor s of business administration in marketing from Texas Tech University. He can be reached at [email protected] garets.com. We welcome your comments and questions. We can be reached as indicated above.

Acknowledgments The authors would like to thank the following individuals for sharing their expertise and experiences for this book: Safaa Al-Haddad, MD Internal Medicine University Hospitals Cleveland, Ohio

Paul Cohen Deputy CEO Barwon Health Geelong, VIC Australia

Ronnie D. Bower, Jr., MA Director of Applied Clinical Informatics Tenet Healthcare Corporation Dallas, TX

Vicki Davis, PMP Former Epic Training Director Providence Health & Services Renton, WA

Marc Chasin, MD, MMM, CPE, CHCIO System Vice President, CMIO and CIO St Lukes Health System Boise, ID Nabil Chehade, MD, MSBS, CBC Former Director, Medical Informatics Regional Chief of Urology KP HealthConnect Regional Physician Lead Kaiser Permanente Medical Group Cleveland, OH

Adrienne Edens, CHCIO, FCHIME Vice President & Regional CIO Sutter Health East Bay Region Oakland, CA Mary Carroll Ford, MBA Senior Vice President and CIO Lakeland Regional Medical Center Lakeland, FL Michael Geist, MD, FACP Medical Director for Informatics PeaceHealth Medical Group Bellingham, WA

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viii Kenneth Goodman, MD Associate Director, Center for Continuing Medical Education Department of Family Medicine Cleveland Clinic Marie Hamilton, RN Kaiser Permanente Oregon Federation of Nurses and Health Professionals Healthcare Information Technology Committee, AFT Healthcare Portland, OR Lindsey P. Jarrell, FACHE Former Senior Vice President & CIO BayCare Health System Tampa, FL

Effective Strategies for CH AN GE™

J. Scott Joslyn Senior Vice President and CIO MemorialCare Long Beach, CA Margaret M. Rudolph, PhD Consultant, BC, Canada Tom Smith CIO (retired) NorthShore University HealthSystem Evanston, IL

Contents

Foreword by David E. Garets, FHIMSS.................................................. xi Introduction to the Revised Edition: What’s New?.............................. xv Chapter 1: The Business Case for Change Management...................1

Section 1: Leadership—Establishing a Foundation for Change.... 21 Chapter 2: Vision................................................................................. 23 Chapter 3: Sponsorship........................................................................37 Chapter 4: Organizational Readiness Team..................................... 55

Section 2: Willingness—Building Commitment.............................. 77 Chapter 5: Stakeholder Management................................................ 79 Chapter 6: Communication................................................................ 95

Section 3: Ability—Developing Requisite Skill................................109 Chapter 7: Training Strategy.............................................................I l l Chapter 8: Reinforcement..................................................................127 Chapter 9: Implementation Readiness.............................................137

Section 4: Summary............................................................................177 Chapter 10: The Journey....................................................................179 Chapter 11: Lessons from the Trenches...........................................189 References and Additional Suggested Resources............................... 213 Index........................................................................................................ 215

Foreword By David E. Garets, FH IM SS CHANGE™ deployments are not about technology. They are about equipping organizations to reach critical business objectives by pro­ viding people with technical capabilities that make new things possi­ ble, and by engaging people in changing their behavior to effectively use the new capabilities to generate results. Since we first wrote Change Management Strategies for an Effective EMR Implementation in 2009, a lot has changed in healthcare. Many organizations have made significant progress implementing EMRs, preparation for ICD-10 is well underway, business intelligence (BI)/ analytics is increasingly important and, of course, as healthcare reform continues, we are faced with complex and interrelated changes that will take years to fully understand. Mistakes will be made along the way, but we believe that organizations that invest in their people will have an easier time navigating the morass. Another change since 2009 is the adoption of the “electronic health record” moniker by most of the industry in preference to “elec­ tronic medical record.” You 11 notice we haven’t changed the acronym were using. The reason for that is that what were talking about are the information systems being installed in hospitals and physician offices to capture the data that will supply the “electronic health record.” Our use of “EMR” is intentional to differentiate the computer hardware and software that captures full medical data in a particular care site from the superset of data contained in a patient s “electronic health record.” Since 2009 significant changes have also taken place in the world of change management. Most importantly the change management discipline emerged on a global scale. The Association of Change Management Professionals (ACMP), a global professional society for change management practitioners, was established and professional certification is being developed. At the same time, interesting find-

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ings are coming out of the neurosciences world, and as they shed light on how our brains work, they help explain human behavior during change. Additionally, much has been written in the last few years about emotional intelligence and the role it plays in the work place. These factors, and others, are accelerating demand for change management practitioners across industries. Another significant change worth mentioning is the increasingly pervasive use of technology in all aspects of life. In general, people are much more comfortable with technology now than they were a few years ago. Personal devices are common. And with that advance comes a change in user expectations. “My iPhone is so easy, why cant the EMR be like that?” This is an important shift. Ten years ago careful attention had to be paid to whether doctors could type; now you are far more likely to have an issue with clinicians wanting to use their personal devices in their day-to-day work. The environment in which change initiatives are taking place is very different. And all the changes mentioned above have led to another change— the evolution of the CIO role from one of predominately “owning all things IT,” including being responsible for the business value received from the investment in IT, to that of owning the infrastructure but act­ ing in the roles of facilitator and coach to the business unit peers who are now tasked with “ownership” of the “business initiative with an IT component” and who are accountable for the business value achieve­ ment. We talk more about that in the Sponsorship chapter (Chapter 3). The goal of this book is to equip you to create an environment for success in your organization that not only ensures your EMR or ICD -10 or clinical integration efforts are successful, but that your orga­ nization builds change capacity and flexibility in the process. This new nimbleness will serve you well in our world of continual change. We believe that the concepts and methodologies we share in the book are applicable to large and small healthcare organizations alike. While the book isn’t exactly a “do-it-yourself guide,” its close! This means that small organizations with limited resources will get as much value from reading it as large organizations will. Defining change management is as important as understand­ ing what change management is not. It isn’t project management or solely process improvement. Rather, it is a set of specific disciplines,

Foreword

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described in detail in this book that, when coordinated and integrated, make the difference between tossing money into a CHANGE™ pit (similar to the ones that we boaters throw our money into!) or getting the sought-after results in your organization. The bottom line reason we stress the importance of supporting users through change is that when users are successful, the healthcare organization and its patients benefit. Our advice is to invest in your human capital—its your great­ est asset. CHANGE™ is an experience, not just a set of tasks—which is why CHANGE™ is about culture, environment and relationships, not just a project plan. Chapter 2 on Vision is especially important. In it, we explain how leadership paints the picture of what is expected from the implemen­ tation of a CHANGE™ initiative. I would argue that for most major change initiatives, visioning is a process that involves not only rep­ resentatives of the front line, their managers and the senior execu­ tive team, but also the board. A CHANGE™ initiative, like an EMR implementation, done right—meaning the technology works, was implemented on time and within budget, and the people modify their behavior and processes to achieve commensurate value for the invest­ ment—is more transformative than anything else a healthcare organi­ zation can do. It needs to be driven from the board down. That way the right people, e.g., the CEO and executive management team, are held accountable for the success of this crucial business initiative with an information technology component. And, from what I can tell, there wont be many major change initiatives going forward that DON’T have an IT component. This book should be required reading for every member of the executive team in every healthcare organization that is planning to implement a CHANGE™ in the next few years (that would be all of them!). I was happy to be asked to edit the original book and to write the foreword, and it wasn’t for the fame and fortune. It was because I would then have to read the material and I’m glad I did. I learned an incredible amount about a topic that most of us in the technology and management worlds do not understand well—dealing with people issues. Claire and Doug nailed it, and I guarantee you’ll be thankful to have the knowledge they’ve shared.

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I got “promoted” to co-author for this revised edition and led the effort to broaden the book beyond change management related to EMR implementations to change management as it relates to any initiative that seeks to change the scope of healthcare delivery and financing (ACOs, medical home, and clinical integration to name a few) or seeks to keep the lights on (ICD-10 remediation or new revenue cycle applica­ tions to support new reimbursement mechanisms). The principles are the same, and the seeming lack of attention by many healthcare execu­ tives to behavior change to get maximum value from the CHANGE™ is the same, too. We re trying to fix that with this revised edition of the book.

Introduction to the Revised Edition: What’s New? First and most importantly, in this revised edition we introduce CHANGE™. Its not only a logo that were trademarking for use in future writing and consulting well do, but also a shortcut for our effort to broaden the scope of this book beyond just EMR implementations. Well be inserting it throughout the book to mean:

“Any major business initiative, with or without an IT component (but don’t try doing an Accountable Care Organization [ACO] without one, for example), including, but not limited to, electronic medical record implementation and optimization, ICD-10 conver­ sion and clinical documentation improvement, ERP implementations, the change in business processes that healthcare organizations (HCOs) have to implement to become an ACO, partnerships with your physicians to establish a clinical integration initiative to measurably improve quality of care, ongoing change processes, such as centralizing call centers, creating large multi-specialty group practice medical offices, moving volume to outpa­ tient venues, developing competitive capabilities such as imaging centers and reference labs that once only lived in the hospital, standardizing and centralizing back office functions including revenue cycle, supply chain, HIM, finance, and HR into a central business center, and the process of partnering to create or offer an insurance product.*” Aren t you glad we came up with the CHANGE™ shortcut? * Thanks to Adrienne Edens, Regional CIO at Sutter Health East Bay Region, for suggesting several of these components.

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Its not that EMR implementations are passe. There are still numer­ ous health systems working to implement the technology and trying to get Meaningful Use money. There are even more in the “optimi­ zation” phase, trying to get full adoption, transforming the way care is delivered, reducing medical errors, increasing internal efficiencies for clinical and administrative users, improving revenue capture, and providing a host of other critical benefits. Its that reimbursement reform, rampant mergers and acquisitions, softening of inpatient demand, implementation of ACA, movement to bundled payments and medical home and clinical integration and ICD-10 have put enormous downward pressure on revenues of health systems and forced what heretofore would have been considered rad­ ical actions to sustain the health systems. HCO management is con­ solidating and centralizing support services, executing reductions in force and struggling to make their cultures more nimble. In such an unstable environment, change management isn’t a “nice to have,” but rather an absolute necessity to bring your people through the turmoil and set them up to succeed in the new world of healthcare delivery and financing. The primary audience of this book is everyone who leads or is directly involved in the people-focused change management/tech­ nology adoption efforts of a CHANGE™ initiative. As we described CHANGE™ on the previous page, that would be any healthcare change management, organizational effectiveness or organizational develop­ ment person and their management team. Our secondary audience is everyone else who has a stake in the users willingness and ability to change behavior so the potential of the technology and the success of the business initiative can be realized. That would be any member of the management team of an HCO, consultants and suppliers who support those initiatives, and governing board members. So whether you are actively engaged in change management/technology adoption work or your support and advocacy of change management/technol­ ogy adoption is needed—this book is for you. Regardless of your specific role (executive, middle-management, front-line supervisor, physician, nurse, medical assistant, IT profes­ sional, consultant, or other stakeholder in the success of a CHANGE™ initiative), our hope is that you will gain an appreciation for the impor-

Introduction to the Revised Edition: What’s New?

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tance of behavior change and the effort required to ensure operational success. This book emphasizes effective ways to plan and implement change. The content is based on decades of combined experience man­ aging the people side of CHANGE™ initiatives in healthcare. It is important to point out, however, that this book is not meant to be a course on change management/technology adoption. Our intent is not to review existing research or current academic models and the­ ories but rather to share the insights and lessons we have learned over the years in delivering sustainable results and healthy organizational change. For technically oriented project leads, the success of an EMR implementation, or any other business initiative with an IT compo­ nent, tends to focus too heavily on “screwing in the system” on time and on budget. But, as important as it is, getting the technology up and running should not be the primary focus. Equal emphasis must be placed on how the new technology will be embraced, utilized, and leveraged to realize a return on this significant investment. Flipping the switch and turning the technology on is merely half of the game. We believe the promise of an effectively implemented EMR or a successful accountable care organization is great, with potentially sig­ nificant returns for the patient, user, organization, and the industry as a whole. When we hear words such as automated, it sounds as if life will be made easier and become more organized and efficient. How­ ever, healthcare organizations do not always think about the critical steps involved in making these hopes a reality. This is due in large part because managing the people side of an initiative, and developing and installing major technology require different skills sets. Neither side of the coin is necessarily more important, but they both must be seen as equally significant. The role in managing the people side of an implementation rarely fits neatly into how technically focused projects have historically been measured, and this creates a scenario in which the people side is often misunderstood, discounted and, worst case, ignored altogether. Consider the difference between what it takes to install the system (a technology focus) and what it takes to get the desired outcomes (a focus on people doing things differently). The management of ambiguity, resistance, and user motivation is admittedly hard to measure and unfortunately involves methods that

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are not always easily checked off a list. The process is more fluid and organic than linear. At times it is unpredictable, requiring rethink­ ing and course corrections. After all, we are dealing with people. Not everything is clear cut. Don t believe anyone who tells you it is! People come with different backgrounds, frames of reference, experience with technology, comfort with change or ambiguity, trust in leadership, and so forth. Whatever the mix of scenarios, individuals never start from the same place—and they move through the change process at different speeds, meaning they continue to be in different places throughout the project. The good news is that people do grow and develop over the course of the project, and many eventually accept things they wouldn’t agree to at first. But they require understanding— their fears, needs, hopes, and their reactions to the challenges that impact their ability to perform. A sound, comprehensive people strat­ egy that creates an environment in which they can succeed is essential. If the goal of your CHANGE™ initiative is to achieve sustainable results, growth, or organizational transformation, then a substantial investment in people must be central to your overall implementation strategy. The better prepared people are for the change and the less they see it as threatening, the faster they will deliver value.

“Man is still the most extraordinary computer of all.” - John F. Kennedy

HOW THE BOOK IS STRUCTURED Preparing an organization for a successful CHANGE™ implemen­ tation involves a big-picture approach that takes into account all the factors that influence behavior change. The idea is to establish an orga­ nizational context—a culture in which desired behavior is supported and reinforced through a variety of methods—creating a learning organization that grows to achieve its vision, priorities, and goals. In

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this book, we present an Implementation Readiness Model and discuss each factor involved in ensuring the organization and users are fully prepared to realize the potential of the new technology. This book is organized in a simple fashion. First, we make the busi­ ness argument for change management/technology adoption, explain­ ing why technology implementations will not deliver benefits without a significant focus on users. Next, we discuss two critical success fac­ tors in any large-scale change management effort—a clear vision and effective leadership. Then we argue for the development of a cross-functional team of representatives from key areas within the organization—the Organi­ zational Readiness Team (ORT)—and introduce a pragmatic model that outlines the scope of complexity and work that the ORT manages throughout the project lifecycle. This establishes a foundation for sub­ sequent chapters in which each provides further detail about the inter­ relationship of work involved to effectively drive sustainable change. These chapters dig deeper into lessons learned and successful practices related to stakeholder management, communication, training strategy, and reinforcement, as all must be aligned to successfully satisfy the end goal of a meaningful implementation. The Implementation Readiness chapter shows how the prior chap­ ters serve as building blocks to formulate a comprehensive and power­ ful Implementation Readiness Program aimed at securing ready users who are engaged and prepared for the transitional changes ahead. We wrap up with a discussion of our key lessons learned and insights regarding the overall journey. Pay particular attention to some of the larger challenges related to a CHANGE™ implementation in settings both large and small, as these scenarios have proven to have a signif­ icant impact on an organizations speed and ability to position itself for benefit realization. The book ends with a collection of comments from veterans seasoned in implementation of technology-related CHANGE™ in healthcare. We hope their insights will convince you that paying attention to the human side of CHANGE™ is essential. It is important to stress that focusing on just one factor of imple­ mentation readiness is not sufficient to drive organizational change and sustainable results. Each chapter describes an individual factor in detail and provides lessons and useful examples, tools, and other bits of

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information intended to help you succeed in preparing your organiza­ tion for a successful CHANGE™ implementation. But the real purpose of the book is to raise awareness of how all factors work in concert to influence desired change associated with a CHANGE™ initiative. The factors work best as an integrated whole, overlapping and reinforcing each other. They typically have separate leadership but, whether for­ mally integrated or not, they are pieces of one picture. Like other books, you can jump to any chapter of interest at any point. However, we strongly encourage you to read this book cover to cover first to gain an understanding of the end-to-end process and how each factor contributes to overall success. A strategy that accounts for all factors is more effective than just one intervention or multiple disconnected interventions. In this case, the sum is definitely greater than its individual parts.

“Experience is a hard teacher because she gives the test first, the lessons afterwards.” - Vernon Law

We speak to you in a conversational and straightforward man­ ner to make this rather difficult side of a CHANGE™ initiative more approachable. We hope you will find our insights valuable and will leverage this book as your change management reference guide. It will further your cause if all stakeholders accountable for a successful launch of any major initiative in your organization have a common framework for approaching the collective end goal. We certainly wish wed had a book like this years ago to guide us through the minefield of culture change enabled by software implementations! Finally, we hope you enjoy the process of supporting people through the transition to the new world. There is something very rewarding about seeing people who were fearful and resistant, even in tears and thinking seriously of quitting their jobs, feel the pride of accomplishment when they succeed. Each person who stays the course

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and becomes a contributing member of the electronically enabled organization represents untold cost avoidance. Knowledge and talent stay in the organization, replacement costs are avoided, relationships are preserved and critical staff shortages are reduced. Technology adoption is truly a contribution to the bottom line. In the words of one of our grandfathers, “People change when they’re damned good and ready, and not before.” Were here to help you get them ready!

Chapter 1

The Business Case for Change Management “Were not in Kansas anymore..

EMR and other large scale CHANGE™ initiatives with a big IT compo­ nent have been justifiably compared to a tornado that whips through an organization, turning life upside down and throwing users into a world filled with new ways of doing things and seeking ways to recap­ ture some sense of balance and control. CHANGE™ initiatives disrupt the status quo, and along with the many opportunities they promise, they also bring a whirlwind of seemingly never-ending changes; these changes can have an entirely different effect on different people. While even an initiative that is effectively managed brings these challenges, a poorly managed one can be disastrous and will cost the organization much more time, energy, and money to get things back on track. Its a case of pay up front or pay more later; either way there is a price, but it costs less if done right in the first place. CHANGE™ initiatives don’t have to be nightmarish for organi­ zations, but there certainly will be obstacles and challenges along the way. The key is to help the people in the organization through the roadblocks and enable them to experience a positive journey. This pro­ cess is always easier when people know what they are getting into, feel supported, and are prepared for what lies ahead—both good and bad. This is the role of change management.

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CHANGE MANAGEMENT DEFINED Its important to understand why you should make an investment in the people side of your initiative. Joining an accountable care organi­ zation (ACO), standing up for a clinical integration initiative or imple­ menting the best technology possible doesn’t mean anything unless your employees/users are comfortable and proficient with it. The truth is just because you build it doesn't mean they will come. Let’s start by answering the two questions we are most often asked, “What is change management anyway? What is it change managers do?” To avoid confusion, we’ll say up front we are not talking about change management as it relates to technical issues, such as version or change control. We also want to be clear that change management is not project management. What we are talking about is the human side of CHANGE™ initiatives, the human-focused work of engaging and preparing people to succeed in the new world created by CHANGE™. A word about project management: while good project manage­ ment facilitates change management, the two disciplines are not the same. Project management is more linear and task focused, whereas change management deals with the complexities of human behavior. But a good project plan creates a structure and a foundation in which the change management process occurs. The two disciplines, though different, complement and support each other. A word of caution: do not confuse the project plan with the end result. The plan is necessary, and it guides you throughout the process. The plan is proactive; it’s the order in the chaos. But technology adop­ tion is kind of like herding cats—it’s unpredictable, and you need to maintain flexibility to respond as things evolve. This is a more reactive process than what may be expressed in a plan. In our experience, a CHANGE™ initiative requires both structure and flexibility. There is a saying in change management circles: When one door closes another one opens, but sometimes its hell in the hallway. Change management deals mostly with the hallway situation, facilitating the human transition from the present to the future. These days, change is ongoing and requires focused leadership if it is to be as fast and pain­ less as possible. One of the great benefits of doing change manage­ ment well is that the process creates increased change capacity in the

C h a pter 1: The Business Case for Change Management

3

organization—meaning that subsequent changes occur in an environ­ ment that is more change enabled. key trip Our assumption is that the software you are implementing works. If the software doesn’t work, you have another kind of problem— one that even the best change management won’t resolve.

The four legs of the project or business initiative stool represent the critical components of an implementation (see Figure 1-1)—Peo­ ple, Process, Technology and Data. The people are the most important! When technology projects fail, it is primarily due to a lack of use, not failure of the software. The focus of change management is people and the objective is to change behavior. Change management is not about fluff—being nice or placing an emphasis on feelings. Its about perfor­ mance and results. This is good for business because it accelerates the change process so benefits are achieved faster.

Figure 1-1: The Four-legged Stool

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As shown in Figure 1-1, the leg of the stool representing data is an addition to what was once referred to as the three-legged stool because of the significance data plays in the overall picture. Now that many HCOs have implemented their EMRs and are accumulating vast amounts of structured and hopefully standardized data, there’s a hype-filled rush to “big data,” business intelligence (BI), and analytics to turn that data into information and knowledge. That, in turn, will reshape and accelerate the transformation of healthcare delivery and provide a more global and strategic impact on how we must approach CHANGE™. If you search the literature, you will find a variety of definitions of human-focused change management. They all cover similar concepts, sometimes using different terminology. The simplest explanation of change management is to say, “Its all about the people!” But for the purposes of this book, we expand on that concept and use the follow­ ing definition of change management: • A structured process designed to deal directly and intentionally with the human factors involved in not just planning and imple­ menting a CHANGE™ initiative but through behavior change, achieving the anticipated benefits that justified the initiative in the first place. • Desired behavior change is achieved by helping people understand and internalize change and by preparing them to be successful contributors in the future state. In the case of EMR implementa­ tions, effective change management delivers users who are willing and able to use an EMR in a way that satisfies the requirements of the job, the needs of the patient, and the health of the organization. Well-designed, integrated, people-focused work builds logically over time in a way that makes sense to the user. It brings users along, guiding and supporting them so they arrive where you want them to be. This is about willingness and ability, hearts and minds. You must have both. The overarching purpose of change management is to accelerate

the speed at which people move successfully through the change process so that anticipated benefits are achieved faster. And there are additional benefits to change management. Through optimizing the efficiency and efficacy of users, an effective change management program will also:

C h a pter 1: The Business Case for Change Management

5

• Improve organizational outcomes and performance. Effective use of a new system or process generates value to patients and the organization. • Enhance employee satisfaction, morale, and engagement. When people learn new skills, meet performance expectations, and con­ tribute to a greater good they feel pride in their accomplishments. • Improve service quality. Users feel valued and supported by an organization that makes an investment in them; this positively impacts how they treat patients. • Help achieve hoped-for benefits benefits that include CHANGE™ value realization, reduction of errors, return on investment, etc. • Create higher levels of openness, trust, involvement, and teamwork (develop an engaged workforce). • Build change capability and capacity in the organization, resulting in improved ability to respond quickly and effectively to new situa­ tions (create organizational nimbleness through embedded change management knowledge, structure, and process). In other words, it really is all about the people. Intentionally man­ aging the cultural, behavioral, and organizational changes that need to take place to make the desired CHANGE™ future not only a reality but a sustainable reality pays off on many levels in that it also facili­ tates organizational transformation. Building on individual capability and organizational capacity, change management results in a changecapable culture—a huge advantage in todays competitive and fast­ changing world.

Change Management, Technology Adoption— What’s the Difference? There are a number of terms that people use to refer to the work involved in managing the people side of a change effort. We think of change management as the mother ship, that is, the umbrella term that embraces all specialties within the field. Similar to the various special­ ties or domains of service within a healthcare system, change man­ agement professionals may choose specific areas of focus. Technology adoption, specifically information technology (IT), is one such area, and it involves the application of change management principles to the implementation of IT.

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Effective Strategies for CH AN GE™

Effective technology adoption professionals align themselves with the operational/business side of the organization and tailor solutions that drive behavioral change and tangible outcomes. They participate in CHANGE™ initiative projects from the beginning, driving the peo­ ple side of change throughout and continuing to add value post-live as the CHANGE™ becomes part of the central nervous system of the organization.

THE IMPORTANCE OF THE PEOPLE SIDE OF A CHANGE™ INITIATIVE There are many references in the literature to failed change efforts and the IT implementations that support them. Estimates are that only a third of these projects achieve success, which means two thirds fail to meet expectations. The good news is that failure is optional, as much has been learned about why some change efforts fail and others suc­ ceed. The irony is that though much has been learned, there is not a lot of evidence to show increasing success with change. Our belief is that this is due, at least in part, to the way change is handled. It is still mostly episodic, one project or initiative at a time. What is needed is the development of change-enabled culture so that future changes take place in an environment that nurtures change rather than resisting it at every turn. The environment in which the change occurs is important because while the change itself is an external event—the EMR implementation, clinical integration, a reorganization, proposed outsourcing, a promo­ tion, etc.—the transition from old to new that those who are impacted experience is a psychological and emotional process. It is this transi­ tion that is difficult, even when a change is self-imposed or considered positive. So to the extent that the environment enables change, the psy­ chological process that people go through is made easier. In the words of William Bridges, a key thought leader in manage­ ment of transitions, “It isn’t the changes that do you in, its the transi­ tion after the change that does!”1 For an implementation team, part of the problem encountered during transition is that change is messy: people start where they are, not where we want them to be. And when considering the personnel within a typical hospital, people can be all over the place in terms of

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7

comfort with computers, stage in life, commitment to the organiza­ tion, fear of change, etc. Add to this the fact that for change to be suc­ cessful three things must occur. People must: • Let go of their current reality; have an ending. • Go through a confused period in-between (hell in the hallway). • Accept a new beginning.1 To take this a step further, consider the case of change initiatives that have large IT components: while IT vendors and staff want to install the system and make enhancements, the users will ultimately determine how the system is used. This use is affected by human, not technical, factors: • Different frames of reference, backgrounds, experience with technology. • Organizational history and experience with other large-scale change projects. • Levels of resistance, fear, ability to deal with ambiguity. • Degree of alignment of “Whats in it for me?” for the various stake­ holder groups. • Inefficiencies uncovered because the system creates transparency. • Workarounds that become quickly entrenched. • Pressure to get through the day can override doing what is right. • User/work-life balance issues that come into play from the very beginning. • Organizational attitude toward employees—are they considered an important asset or a bunch of whiners? All of these factors create problems for implementation teams that just want to install technology or set up the separate ACO entity or build a big multispecialty group practice. How do you effectively address the people issues? Is it easier to just install the technology or set up the ACO or group practice and assume that people will follow because they have to? Some on the implementation team may falsely assume that users of an EMR system, for example, will snap into place over time and do what is right for the organization. This thinking is a fools paradise. In the foreword to this book, Dave Garets made the point that CHANGE™ deployments are not about technology but about equip­ ping organizations to reach critical business objectives by providing

8

Effective Strategies for CH AN GE™

employees with technical capabilities that make new things possible, and by engaging employees in changing their behavior to effectively use the new capabilities to generate desired results. With all due respect to the technical side of a CHANGE™ ini­ tiative, installing the technology is only half the battle. This is not to degrade the importance of the technology. The fact that we spend a lot of money researching technology, acquiring it, configuring it, install­ ing it, and supporting it speaks to its importance. If we weren’t imple­ menting CHANGE™, we wouldn’t even be having a discussion about CHANGE™-related change management. I

CIO Perspective

During my master's program I took an Organization Development (OD) class that really opened my eyes to peoples’ needs during large-scale change. Since the OD class I have been very interested in what makes people tick and why people react in different ways to the same environment. No matter how good of an idea a large-scale technology implementation is, we will always have early adopters, average adopters and laggards. As leaders within large organizations, we have a responsibility to plan for, and respect, all types of technology adopters. Ultimately the people who work within in our organizations want a positive human experience when they are at work. Utilizing a change management methodology enables the implementation and leadership teams to provide a positive experience during the period of significant change. By utilizing a solid change management methodology the organization promotes team communication, a safer environment for the patient, a work environment that promotes trust and an environment where people are allowed to talk about the fear of change. All of this promotes a better human experience and a much stronger work force. ... An effective change management program has meant the difference between good go-lives and great go-lives at our 10 hospitals. Lindsey P. Jarrell, FACHE Former SVP & CIO BayCare Health System Clearwater, FL

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But implementation of the technology is just a first, and very nec­ essary, step—because in and of itself the technology does not generate value. The technology is necessary but not sufficient for benefit reali­ zation to occur. To create value requires people, and this is why change management is so important. Too much of a focus on technology, even in the early stages, will create issues downstream. And even with the best technology, if not used efficiently, hoped-for benefits will be tough to achieve. CIO Perspective I’ve been In healthcare IT a long time and I now realize it’s all about change management. What was considered soft is now hard. We know so much more about how to install technology— it’s the people part we don’t know well yet, and so it’s hard. J. Scott Joslyn CIO MemorialCare Long Beach, CA

Remember that change is a personal experience. It is also local and it is individual. And its hard—even when its self-imposed and pos­ itive. There are no shortcuts. People have to go through the process of change in much the same way that we move through the stages of grief.2 This cant be avoided or skipped. You can measure twice and cut once, or you can cut now and then do costly remediation later. Either way, you cant avoid the expense or time required for real change to occur.

“No man can think clearly when his fists are clenched.” - George Jean Nathan

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Effective Strategies for CH AN GE™

SYSTEMS PERSPECTIVE Experienced technology adoption professionals embrace a systems perspective when given the assignment to drive performance, man­ age perceptions, and increase the utilization of new and existing tech­ nology. A systems approach is the ability to see the big picture and address the interrelationships among the variables within the fabric of the organization and influence the combined impact these variables have on organizational effectiveness. As each variable has the power to influence the outcome of any intervention, behavior change is often not sustainable because variables tend to work against one another. Effective technology adoption strategies account for this interrelationship/interdependency and aim to bring these variables into alignment as a means for driving sustainable results. Figure 1-2 introduces the Organizational Fabric Model, which highlights the six primary threads (or variables) that are interwoven in the fabric (or culture) of an organization. The model suggests that all six threads must work in concert to successfully shape the organi­ zational fabric. A well-woven technology adoption plan strategically manipulates these threads to influence desired change. A poorly woven plan, in which a thread or combination of threads is not accounted for, leads to disaster, or by way of analogy, will hit a snag down the road. Depending on the flexibility and durability of this fabric, a snag can result in a huge hole that detracts from the overall strength of the intervention. The intent of the Organizational Fabric Model is to stress how important it is to understand the future state, recognize how each variable or combination of variables will come into play, and develop a sound technology adoption program that appropriately influences this set of variables to reshape the fabric or culture, so desired change can actually take place.

Key Point | Fundamentally, culture is “the way we do things around here.”

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11

Figure 1-2: Organizational Fabric Model

The Organizational Fabric Model will be revisited in subsequent chapters as each thread or variable is explored in further detail. For now, we reiterate that technology adoption strategies must not rely on only one or two threads to drive behavior change. Sustainable out­ comes result from an organizations ability to leverage the combination of all six threads, working in concert, to create an environment for success.

CREATING AN ENVIRONMENT FOR SUCCESS Technology adoption is about creating a context, an environment, in which change can be achieved and sustained over the long term. This involves two levels—organizational and individual. With a CHANGE™ initiative, the organization must create the supporting environment, provide needed training and resources, articulate a clear direction coupled with clear expectations, engage its people, include them in the process, and reinforce desired new behav­ iors. This is not about checking things off a list, but rather about find­ ing synergy among impacted groups, giving them what they need, and coordinating efforts to meet the end goal. Its an ongoing effort.

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Effective Strategies for CHANGE 1M

To give you an idea of what we are talking about, heres an exam­ ple of an individual situation occurring within a social context. Think about what happens when you want to make a significant change in your personal life—quit smoking, stop drinking, lose weight. Its one thing to talk with a doctor or another professional during an appoint­ ment about what needs to happen, but once you leave the office you then return to your social reality. If your friends and family dont want your behavior to change, you will have a tough time. All the reinforce­ ments and temptations will conspire to prevent you from making changes. But, if you can get some important people in your life to make the changes with you, or at least support you in the process, you have a much greater chance of success. The lesson is don’t send a changed

person back into an unchanged environment if you want to see sus­ tained behavior change! Engaging individuals involves arousing two key aspects—willing­ ness and ability. The organization must influence both in order to suc­ ceed. With the help of the Skill Versus Will Matrix (Figure 1-3), think about it this way: • When people want to do something but dont know how, they cant (willing/unable). • When people know how, but dont want to, they wont (able/ unwilling).

Figure 1-3: The Skill versus Will Matrix

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Can you think of examples in your own life when you have been in either of these situations? Consider the circumstance of people who know how to do some­ thing, but don’t want to do it. This is a “will” not a “skill” issue, and it is a very common technology adoption dilemma. If the amount of work and effort involved are not perceived by the user as being equal to the return or value experienced through the implementation, the user will most likely choose to reduce the effort. A goal of an effective people-focused strategy is to identify potential areas of disconnect and find ways to increase the perceived value to users. The assumption is that when the return is perceived to be greater, the effort increases. When there are no incentives to try harder, it may be difficult to drive desired behavior change. Remember, “What’s in it for me?” The point in getting users to actively support the deployment of a CHANGE™ is about a lot more than a communication plan or feature/ function training. Managing the people side of a CHANGE™ initia­ tive requires a savvy business plan and/or technology adoption plan that ties sponsorship, training, communication, workflow harmoniza­ tion, user support and reinforcement to the business priorities of the organization and effectively coordinates all of these activities with the affected stakeholder/user in mind—in an environment that reinforces desired behavior changes.

Two key questions to remember throughout the project are (1) How will this decision impact the user? (2) How might it impact patients?

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Effective Strategies for CH AN GE™

Consider this example: Key Point In native cultures, there tend to be rites of passage that serve to transition a person from childhood to adult status in the community. The child may actually leave the village for a day or two of contemplation, following a prescribed process. When the child returns he or she is redefined as an adult and assumes the consequent privileges and responsibilities. The entire community reinforces the person’s new status; the new adult is not allowed to return to being a child whenever it’s convenient, but is supported to complete the transformation to adulthood. The change to adulthood does not happen in a vacuum but is part of a carefully designed process that ensures success.*•

In this example, what are the key elements of this process that ensure success? • The picture of success, the desired outcome, is clear—it is for the child to become a functioning adult in the community. • How this happens is clearly defined in behavioral terms. There is a process that is known and understood by the entire community, including children. • Leaders at all levels in the community agree on the desired out­ come, support the entire process, and actively fulfill their roles to ensure success. Leaders include village elders and formal lead­ ers, parents of the children, informal opinion leaders, and family members. • The children who are about to become adults take an active role in their own transformation, taking responsibility for their success. They receive guidance and counsel from elders. They know and understand the transformation process and what they must do to achieve their new status. Goals and steps are clear. They also understand the consequences of not successfully transitioning to adulthood. • If there is more than one child slated to go through transformation to adulthood at the same time they are a peer group and as appro­ priate, prepare together and support each other.

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• The entire community works together to bring about the transformation. • Success results in positive reinforcement. The future of the society depends on a steady flow of new adults stepping up to their role. The cultural imperative is clear—no respon­ sible adults, no society. The environmental context is the trump card in any implemented hand. It takes a lot of work to create a suitable environment, but it is an essential ingredient in being able to drive and sustain change.

Willingness and Ability Earlier we mentioned willingness and ability as key concepts in tech­ nology adoption. Willingness and ability can also be thought of as hearts and minds, or will and skill. The point is the same regardless of the terms used. People need to be supported on both an emotional level, to commit, and on an intellectual level, to be able. The question to be answered is, “What are the conditions under which users will accept and adopt the CHANGE™?” Let s talk about willingness first. Willingness, or hearts, is the commitment to go forward. This is impacted by many things, including the following elements: • Leadership: Perceived support, or lack of support, for the change from senior executives in the company, the cascade of sponsors down through the organization and, just as importantly, from the employees direct supervisor. • Communication: Quality and frequency of verbal and written messages that describe the desired future state tell why the change needs to happen and what will happen if change isn’t made, set clear expectations, explain how the organization will prepare and support people to success, and describe local details such as time­ lines, etc. • Reinforcement: Degree of appropriateness and timeliness of rewards for demonstrating desired new behaviors and conse­ quences for sticking to the old ways. • Participation: Degree to which users are involved, every step of the way, either directly as individuals or indirectly by being effec-

16

Effective Strategies for CH AN GE™

tively represented by trusted local opinion leader peers who serve as liaisons between users and the project team. • Organizational History with Change: Previous organizational experience with change—good and bad—will influence user per­ ceptions and expectations of the next CHANGE™. Understanding the past is important in planning for the future. This all sounds logical but the reaction to it can be emotional. This is where people confront their fear of failure, of feeling stupid, of mak­ ing mistakes, etc. Remember that the change may require people to give up the very things that they believe made them successful in the past. This can be a difficult sell. Ability, or minds, is about the actual capability to successfully meet new job expectations. This is impacted by many things, including the following elements: • Training and Support: In most cases, the new CHANGE™ abil­ ities must be learned. An effective training program that is rolebased and intentionally focused on preparing people to perform new job expectations is key. Just discussing desired outcomes is not enough though; people need to know what they are expected to do, meaning behaviors. Though this requires an intellectual under­ standing of what and how; a conceptual understanding is neces­ sary but not sufficient for change to occur. Most people need to practice something new to develop competence and confidence, to get comfortable with the behaviors. Safe opportunities to practice, preferably with immediate feedback, are very important to profi­ ciency development and sustainability. Getting people to move in the direction you want is the difficultysome say the hardest part of the whole project. And if you agree that people are the foundation of success—that benefit realization is depen­ dent not on technology but on people agreeing to go through personal disruption, learn new things, change established patterns and confront their fears—then we must be proactive and courageous in addressing the human issues. This is the people side of the project. It includes an organiza­ tional readiness function and requires collaboration, coordination and sequencing of activities, information and events from all peoplefocused areas. The idea is to have all the people-focused functions

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17

working together to reach clearly defined, shared outcomes. The organi­ zational readiness plan to create individual and organizational readiness is the umbrella that connects it all—the glue that holds it together and the grease that makes it work—for the user. We will address the struc­ ture and process for doing this in more detail in subsequent chapters.

G ood News on Two Fronts 1. This is a social science! There is a body of work, research and sub­ sequent publications about the human experience with change. There are proven change management strategies, tools, and tech­ niques. This isn’t folklore, hooey, or black magic. The transition process is known and predictable. There is a change curve that describes the steps (Chapter 5, Stakeholder Management). And though there is no silver bullet, it isn’t rocket science. Senior healthcare executives must take the emerging profession of change management/technology adoption seriously. Not understanding it is no excuse for ignoring it. That is far too expensive an option. Since the first edition of this book was published, ongoing research into neuroscience and human behavior has produced advanced knowledge on emotional intelligence and how the brain works. We are fortunate to live in an age when this kind of informa­ tion is readily available. The task is to use it to achieve results. Quote “Not everything that can be counted counts, and not everything that counts can be counted.” - Albert Einstein

2. All people go through transition when change—good or bad— happens, in both their personal and professional life. You can’t avoid it. The wonderful thing is if you learn about change and tran­ sition at work, it will improve your personal life. This is one of the times when you should try it at home! We’re all human—at work and at home. So treat your people as the humans they are, and avoid some predictable expense and difficulty. Lead your organiza-

18

Effective Strategies for CH AN GE™

tion to a successful outcom e, and speed up the process by treating your staff as custom ers first. D on’t m ake the m istake o f glossin g over the critical hum an aspects o f change. Hire experts and find the em otionally intelligent people in your organization who want to participate. A nd rem em ber, you can install technology w ithout your people, but you c an t fully im plem ent

Consciously choose to move from fear and resistance to trust and adoption. Its a case and achieve return on investm ent w ithout them .

o f pay now or pay later. If you wait until later, it will always cost m ore. Technology adoption is expensive but not as expensive as trying to gloss it over and then having to undo the dam age. W hen failure h a p ­ pens, it takes a long tim e for people to re-engage. A nd in to d a y s world, this presents real problem s for healthcare organizations faced with big overlapping C H A N G E ™ initiatives and sh ortages in m any professions. There is a huge risk o f alienating and potentially losin g needed staff or in causin g long delays. We can do better.

Not so long agOy it wasn't conventional wisdom that clinical application rollouts are not IT projects. More frequently than not, these were consid­ ered technical projects in which the point of celebration was when con­ nection from workstation to central processor was reliable and wireless access actually worked. The classic IT People-Process-Technology triangle never got much past Technology to the real hard work on the People-Pro­ cess axis. That has all changed in the 21st century; system initiatives that are both successful and valuable have had people and process on thefront burner. And now Data has been added to the mix. When MemorialCare embarked on a five-hospital rollout of an EMR in 2002, it had several things in its favor: • The technology the organization ultimately acquired was robust and reliable; it worked. • It had 15 years' experience with CPOE (computerized provider order entry). Therefore, although unevenly adopted, it was not new territory.

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• It had had the experience of a system-wide rollout and standard­ ization on a general finance, human resources, and materials man­ agement system. When all was said and done, users had not been sufficiently involved, standardization fell short because involvement was low, business leadership was diffuse, and IT ownership was too high. It was judged successful overall, but the organization continues to move slowly forward with an underutilized set of applications. With this experience and the insights of others, MemorialCare pri­ oritized engagement of physicians, nurses, pharmacists, and other staff. Well before financial commitment to a new system was obtained, Memo­ rialCare hired a “Care Planning Executive,” a person whose full-time activities were devoted to the project, first to help understand the drivers of a new system, scope out the territory to be covered, gain the com­ mitment of senior leaders as well as governance, and outline the case for change. At my insistence, the Care Planning Executive, a registered nurse and former hospital chief operating officer, joined the organization, reporting to the system-wide CEO, as a peer and partner of the CIO, not a staff member, and a peer to the CEOs of each medical center campus. That dedication alone made clear the commitment, intentions, and over­ allpriority of the company. Among several other critical success factors—and the outcome was a success—was the overall employee engagement program that the Care Planning Executive established. In summary, it was an education, mar­ keting, and training program dedicated to equipping the affected staff with the knowledge and tools to embrace unavoidable change. Staff com­ munication was clear that it wasn't change for changes sake but a major move forward in the paperless way care would be delivered and workflows would be streamlined. Of course, at the time, no one could have foreseen later moves by government to push everyone in this direction (with the American Recovery and Reconstruction Act o f2009). Because of our early efforts, were now very well positioned.

J. Scott Joslyn Senior Vice President and CIO MemorialCare Long Beach, CA

Section I

Leadership— Establishing a Foundation for Change

21

Chapter 2

Vision “If you don’t know where you are going, any road will take you there!’ - The Cheshire Cat, A lices Adventures in W onderland, by Lewis Carroll

Establishing and clearly communicating a compelling vision is a criti­ cal success factor in creating an effective context for change.

VISION DEFINED The vision is the picture of the desired future state. It is the rallying point for your CHANGE™ initiative—the reason for embarking on the journey. The future state defines the overall target. Its where you re going, the context in which the initiative will take place. The more complex the change the more important it is to reach agreement on the future state—and EMR implementations are clearly complex under­ takings, as are initiatives with clinical integration, ICD-10, BI/analytics, ACOs and so on. A clear vision motivates and helps focus decisions during the natural stresses of a large, involved project. Without a clear vision its hard to tell where you might end up. Common mistakes with future state vision include: • Not developing a clear future state vision. • Developing the vision as merely a small group exercise for senior executives. • Creating the vision but never cascading the message to the front line. • Developing a vision, but when not all of the organizations leader­ ship commits to the end state the nonalignment is tolerated.

23

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Effective Strategies for CHANGE™

• Not using development of the vision as a process to engage the entire organization, including patients and the board. • Not sharing the vision broadly and continuously. • Failing to use the vision as a yardstick of progressive accomplishment. • Not understanding that a vision is a creative exercise, not a finan­ cial planning process. • Burdening the vision—too long, too much data, attached spread­ sheets and the like. • Stopping short in the visioning process—taking a technical per­ spective and confusing installed, functional software with the real objective (improved patient safety, for example). Does any of this sound familiar? The last bullet in the list above happens far too often in health­ care organizations. Some leaders confuse the activity of installing more software with achieving the organizations vision. The pitfall is that adding more and more technology does not necessarily help the organization get any closer to achieving the vision; it may just result in an organization that has a lot of technology. Screwing in more systems is not a guarantee the organization will work more efficiently, be more profitable or achieve better outcomes. Technology enables these objec­ tives but reaching them requires people to do things differently.

Developing the Vision In a good visioning process leaders take the time to truly think about where the organization is heading. To help create space for this, ask people to suspend disbelief for the time being, let go of current reality and think about what might be possible as opposed to what is. Some leaders have difficulty doing this because it requires stepping out of their current role. These individuals try to operationalize every idea that surfaces to test if the idea is feasible, but this only considers a future state with current state resources, context and thinking. Don t test the ideas right away; just let them flow. Set a future state date far enough out that people don’t get distracted by worrying about the short term. A visioning session should be held off site to limit distractions and should be planned and led by people experienced in vision devel­ opment. The process should be driven by the CEO and the senior

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C h a pter 2: Vision

executive team. The board must be involved as their engagement and commitment are required for a project of this magnitude. Other key participants include representatives from key stakeholder groups. It is important to get ideas from people up and down the organization, as well as from outside stakeholders such as patients and referring phy­ sicians. A wide variety of input will allow you to craft a vision that represents many groups. And since involvement generates engage­ ment, people who participate feel ownership of the vision and will advocate for it within their constituencies which helps generate broad acceptance. Remember, a good vision helps keep organizations from falling into reactive mode, provides focus and aides decision making as the CHANGE™ initiative moves forward. It should serve as a guide that helps people prioritize and sequence. Given the importance of clearly defining the future state, its sur­ prising how many organizations either don’t develop one or neglect to take full advantage of a clear and compelling vision once they have created one.

WHY CREATING A VISION IS IMPORTANT Creating a vision is all about starting your transformational journey with the end in mind. Its a bit like planning a road trip. Knowing where you’re trying to go matters just as much as knowing your start­ ing place. These two points identify the gap that your proposed route will fill. Add the objective of your trip and you are ready to plan a route that meets your requirements. Key Tip |

Begin with the end in mind.*•

What is your road trip objective? • To get from point A to point B as quickly as possible? • To do it the most fuel efficient way? • To stop at as many museums as possible?

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Effective Strategies for CHANGE™

• • • • •

To stay the fewest nights on the road? To hit great local food spots? To visit friends and family? To follow an historical route? To just have a leisurely trip and make it up as you go? If you don t think through what you are trying to accomplish you are likely to miss the mark. The more you know about your objective the better equipped you are to plan in advance. The same is true for any large-scale CHANGE™. You need a map (options), a set of objec­ tives (vision), and roadside disaster gear (contingency plans) so you can plan your route. The vision gives the organization a target. If you want to harness the power of your organization there is nothing like having everyone aiming at the same thing! The parts people play in the process will differ (technical, clinical, executive, etc.) but its the vision that ties it all together. Another advantage of having a clear vision is that it helps you plan detours when the unexpected happens. To get back to our road trip analogy, if you discover that a bridge is washed out on your carefully planned route, knowing your trip objectives will help you make a good decision about which detour to take. Having Plans B and C ready means that when something goes wrong with Plan A you wont fail because you thought through alternatives beforehand. This is not an exact sci­ ence; you cant plan every detail, but acknowledging that things can and do go wrong helps enable flexible thinking when problems occur. Take the time and make the effort to develop your vision. Do this at the beginning of the project. Use the vision to inspire your people, and frame the project as a guide to decision making throughout the journey and as a measure of success. Vision is the context in which the change will occur. A great vision is the glue that keeps people partici­ pating even when theyd rather throw in the towel.

VISION ALIGNMENT These days, organizations are faced with juggling countless initiatives and priorities on a regular basis. With a clear vision, these initiatives should fall neatly into place and align with the direction of the orga­ nization. This is easier said than done, however, as it is common for

C h a pter 2: Vision

27

Figure 2-1: Vision Alignment Model

organizations to try to do everything they can to increase m arket share or advance to the next level o f transform ation. The fact is that organ i­ zations cannot successfully m an age an d execute on everything, and m ust focus effort and existing bandw idth on m atters that su pport and reinforce the desired end state. This requires disciplined prioritization an d sequen cing o f initiatives. The Vision A lignm ent M odel in Figure 2-1 reflects a view o f vari­ ous initiatives within the context o f the bigger picture. The large white arrow represents the direction o f the organization an d the several gray sm aller arrow s reflect the barrage o f initiatives an organization is try ­ ing to m anage. It is okay if initiatives are headin g in slightly differ­ ent directions as long as they are inside the scope o f the vision. A ny gray arrow that rests outside o f the larger arrow m ust be seen as an unw anted distraction and out o f scope at the present time. C om p etin g priorities and initiatives that are not aligned with the organizational direction confuse an d overw helm em ployees. For exam ple, to su pport an E M R im plem entation, create organizational

28

Effective Strategies for CHANGE™

focus by eliminating or postponing other priorities/projects that com­ pete for time, attention and resources with the EMR. Integrate related projects into the overall EMR effort. The work of prioritizing, stopping and postponing is required to focus the organization on the common goal of successfully implementing the electronic medical record sys­ tem. This is a key responsibility of executive sponsors. The completed vision must be used by a CHANGE™ project team when developing the implementation plan. This is important. Technology implementations are very involved, consisting of count­ less decisions, reviews and modifications. Project team members and users grow frustrated and skeptical when the project seems misaligned or haphazard. A great vision provides clear direction and helps keep everyone on track, even on bad days. The implementation plan must be tied to the vision as it is through the plan that the vision is con­ nected to daily activities and becomes an operationalized reality. One other suggestion: each time the vision is presented to a group is an opportunity to ask for a commitment or an action, whatever is appropriate. Think about what you most want from the group at that point so you are prepared to make your request. The way the group responds provides important information about their willingness to support the vision and surfaces reservations or concerns so you can respond to them. IT implementations are complex and involve a great deal of hard work and dedication. A clear vision helps people see the light at the end of the tunnel and makes it easier to manage through change, ambi­ guity, and potential confusion.

KEY ELEMENTS OF A GREAT FUTURE STATE VISION Defining a clear vision is key for a number of reasons. The following list describes the important elements to consider.

1. Think of the vision as a picture of the future for people to step into. To accomplish this, the vision must describe what life will be like when you reach the future state. This is a story, not a financial statement. Think of the following questions in terms of observable behaviors. • How will we work?

C ha pter 2: Vision

29

• • • • • • • •

What will the patient experience be like? How will we treat each other? What will newspaper articles say about us? What will our core values be? Why will people want to work for our organization? What is our reputation? Why will patients choose us first? What will we accomplish and contribute? It helps to use vignettes to tell stories of the future you have in mind. Make the stories personal so real people—your employees and patients—can see themselves and their families in the future state. If they cant relate it wont have an impact.

2. A clear vision defines the CHANGE™ you are embarking on and the reasons the CHANGE™ is necessary. This is where you talk about whats changing and why. Be clear about the ultimate objective of the implementation. There is a huge difference in saying that success is when • The technical solution is installed and functional, versus • Users are generating results for patients and the organization by using the CHANGE™ In the second definition, since user generation of results is depen­ dent on the system, installation becomes a first step—a milestone that is required for success, but in and of itself is not the ultimate goal. After all, it’s only when the system is installed and functional that the tech­ nology enabled changes can be made. Outcomes come from behavior change.

Be careful how you define success. Not doing this correctly is a key contributor to system implementation failures.

We recommend that you build your case for change, the WHY, into the future state vision. The case for change and the future state vision are closely connected and should not be considered separate pieces of work. Describe not only what life will be like when you reach

30

Effective Strategies for CH AN GE™

your desired future state, but what the change is and why it must be made; why this particular version of the future was chosen; what the tradeoffs were; and what will happen if you don’t make the change. People also want to know who made the decision to change (e.g., the board of directors or the senior executive team), what alternatives were considered and how the future vision links with the organiza­ tional mission. Make it easy for them to understand these important elements. Future state is what compels people to participate. Done well it gets at both intellect and emotion. If you are going to ask people to partici­ pate in the magnitude of change required by a CHANGE™ implemen­ tation, you must answer the who, what, when, where, how and why. A key benefit of defining what is changing is that this also defines what’s not changing. This can be a critical element for many people. Even if you are going for a full organizational transformation, building the transformation on the strengths of the past and current states will make the prospect less threatening. Remind people what is staying the same and help them understand what it is time to let go of. Honor the past and the collective journey that got you to where you are now. The future is built on your history, successes and failures, lessons learned and shared experience. All of that combines to create potential future options. One of our favorite ways to bring clarity to this is to use a sim­ ple tool called Starty Stop, Continue. Help people understand whats expected by defining activities or behaviors that should start, those that must stop, and those that are simply remaining the same. Ask the following questions: What is new? What is it time to let go of? What continues? People often are relieved when they are reminded of the many things that are expected to stay the same, even in a climate of transformation. Remember, even the most aggressive transformations are built on the foundation of the organizations history. Don’t throw the baby out with the bathwater. Honoring past contributions and ways of being makes it easier to let go of them, and being clear about which cultural aspects will be intentionally carried forward reaffirms them.

C h a pter 2: Vision

31

3. Make your vision compelling and behavioral. We cant stress this enough. One key purpose of a vision is to engage people. This means everyone from rank and file to the most senior executives to the board. Compelling visions trigger emotions. They are not dry or technical. They make people want the future— and the best visions make people want it so much that they commit to the transformation process. If the response to your vision is, “Wow! I understand that and I want it!” your vision is doing its job. The behavioral component is very important because it describes what it will be like in the future. This is early expectation setting and helps to draw a line of sight between where you re going and what peo­ ple will be asked to do and asked to change in the process of getting there. People need to understand the connection between their per­ formance and achievement of the vision. It is important to define the behavioral changes, by role, that will be required to make the vision a reality and to determine the process for supporting and reinforcing the behavior changes. In your vision sessions ask the question, “What are the most important behavioral changes we need to make for the change to be successful?” A recommended process for facilitating this discussion is to utilize a future state opportunity map. If part of your vision is to ensure every patient experiences an excellent ambulatory office visit at your healthcare organization, based on what is known about current pain points, the group can work through identifying current challenges and opportunities for reaching a future state that supports the desired outcome. Lets look at the brief example outlined in Figure 2-2. This orga­ nization is already aware that patient satisfaction scores are low from a recent patient survey. From the data, it is clear that there are several contributing factors (or challenges) that lead to an unfavorable expe­ rience for patients when coming to see their doctor. As you work with the group, try to identify opportunities and reach consensus about what the future state could look like. When individuals are involved in this future state opportunities exercise, they begin to brainstorm and find ways they can help reach the end goal. The group should explore all challenges and opportunities related to each pain point before confirming modifications to any workflows. Some challenges (when

32

Effective Strategies for CH AN GE™

combined) can create rather complex scenarios that may need further exploration before behavioral changes can be agreed upon. In the example provided in Figure 2-2, the team identified an opportunity to prep exam rooms at the end of the prior day as a means to ensure the first appointment of the next day can start on time. In the past, exam rooms were prepped the morning of incoming appoint­ ments, and the team found themselves struggling to get started on time. As a result, patient satisfaction scores suffered. By going through this process, the team was able to quickly see the problem, identify ways they could tweak work flows, and contribute to the vision of pro­ viding patients with a more pleasurable office visit experience. Because the team took the time to map out the scenario, they were better pre­ pared to design a solution. If people understand the behavioral changes early on, and if they believe the organization is serious about improving, they may begin moving in that direction long before they are required to do so. When the vision is compelling enough, people see the changes they need to make as worthwhile because the future is so desirable. Its amazing what people are willing to do to get something they really want! This is about more than just keeping your job, its about working

Figure 2-2: Future State Opportunity Map

C ha pter 2: Vision

33

for an organization you are proud of and whose values resonate with your core.

4. Defining the end state also defines measures of success and answers the question, “How will we know when we get there?” Another advantage of having a clear picture of the future is that you can measure against it. Use your vision to define the milestones on your journey and then report out against them as you go—use it as a yardstick. Report out even when you miss a milestone. There is no way you can get everything to happen perfectly. What you want to instill is that you are on top of it, you are paying attention, and when something doesn’t go as planned you respond with a “detour” that fits with your objectives. People respect this and it builds confidence. key trip Help people understand how you’ll collectively know when you’ve met your target.

Give people milestones to work toward. If you are transparent about steps to milestones, individuals and departments will monitor themselves as no one will want to be seen as the reason for a miss. This is an important part of the engagement process. The vision should serve as a guide in daily decision making and prioritization— eliminating the requirement for constant supervision to ensure the right decisions are made. Provide status updates along the way. There are few things more frustrating than working hard to contribute to something and never getting any feedback on progress. People want to feel valued and to make meaningful contributions, and they need to see that what they are doing is having an impact. Be sure you are clear about the target you want to hit. A good way to think about this is to consider the difference between saying the goal is to get to the Super Bowl, versus saying the goal is to win the Super Bowl. In the case of a CHANGE™ initiative, the goal is not to install the system, but to leverage the system to reach the desired outcomes.

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Effective Strategies for CH AN GE™

5. If people can’t easily describe the future state to their family and friends, they don’t get it. Finally, make your vision simple enough that it can be described in a few sentences. Distill it down by creating an “elevator speech” for people to use both inside and outside of the organization. When your employees and patients can explain what the CHANGE™ initiative is all about and where your organization is going in a way that is under­ stood by their friends and family, they have internalized the vision. What you want is for a family member to hear about what s going on and respond by asking how they can get their healthcare from your organization. To sum up, begin with the end in mind and communicate it in a compelling way—this is what visioning is all about.

VISION CHECKLIST □ Identify all the key stakeholder groups and key relationships in the CHANGE™ initiative process to determine who should have a role in vision development. Every healthcare organization has powerful constituencies. One purpose of the visioning process is to create alignment and synergy across the groups—so you must have them at the table. Engagement comes through participation. □ The CEO and senior executive team drives the vision process and includes the board to ensure commitment and alignment at the top of the organization. For best results engage experienced people to plan and lead the vision sessions. If you are undertaking multiple CHANGE™ simultaneously, the vision should include all of them and how they work together to create the desired future state. You need one story that links everything together. □ Consider using a graphic facilitator to help capture the work in pictures and make the final materials appealing. People can more easily understand and accept what they can “see.” □ Include people from all levels of the organization in the process— and remember to include the patient perspective. □ This should be a collaborative process. People who participate and feel heard buy in and own the outcome. They will carry the mes­ sage to their constituents.

C h a pter 2: Vision

35

□ The need and incentive to change must be greater than the desire and incentive to stay the same. You must create dissatisfaction with the way things are now without dishonoring the organizations his­ tory. The pain or fear of the change must be paid for with the value of the vision. □ Know what your organizations real passion is in making the change—is it service? Quality? Safety? Make this explicit. □ Be certain that the CHANGE™ initiative vision is tied to the orga­ nizations overall mission and strategic plan. □ Start with common agreement on what the problem is—dont jump to solutions. People dont care about the solution until they understand you care about their problem. What business and clini­ cal problems does your CHANGE™ initiative solve? □ Share the vision broadly and often. Customize delivery to different audience requirements. To make this easy for people, produce a package of vision materials that include elements such as: • Short, compelling, behavioral description of the future written in simple language. This is the “elevator speech.” • A longer document that includes more detail about the future, including stories and pictures that describe what it will be like from the perspective of patients, employees and the organization. • A description of the process used to develop the vision and the people who participated. • An implementation plan that will get the vision in front of the entire organization and the community to build engagement. The plan should also define how the vision will be leveraged as part of the communication strategy for the project. □ Remember, great future state visions: • Tell one story and paint a picture for people to step into. • Are compelling and behavioral. • Are simple—people understand them right away without a lot of explanation. • Are used as a guide for decision making during the implementation. • Are used to define measurement of progress and final attain­ ment of the goal.

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Effective Strategies for CH AN GE™

• Unite people around a common desire and target. • Define what’s in and out of scope. • Help create dissatisfaction with the status quo while building excitement about what the organization can become.

Chapter 3

Sponsorship “Be the change you want to see in the world.” - Gandhi

In this chapter, we examine the critical role effective leadership plays in ensuring the success of CHANGE™ initiatives. For the purposes of this book, we refer to executives and others who are accountable for the success of CHANGE™ implementations and outcomes as sponsors. Sponsors use their formal authority to ensure project success. We break sponsorship into three important levels: executive, mid­ level, and front-line supervisor. We will define each level and discuss how the roles interrelate to provide a comprehensive sponsorship net­ work that delivers the required direction and support to the project. Sponsorship is a critical factor in establishing context for change and ensuring a successful CHANGE™ implementation. It is not a title but a set of behaviors and actions. We are often asked, “What is the most important change management element? If we do nothing else, what do we absolutely have to have?” To which we always answer: “Effective sponsorship. If you don t have it, don t start your project.”

THE SPONSOR ROLE DEFINED Sponsorship is the single most important factor for large, disruptive organizational change efforts. Sponsors make the hard decisions, pro­ vide the budget and resources, rally the troops as needed, reinforce desired behaviors, and model the required changes. Sponsorship fol­ lows the organizational chart; it is a line function, because only the manager has control over direct report work assignments, performance

37

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Effective Strategies for CH AN GE™

reviews and compensation. Anyone outside of the direct reporting relationship is an influencer only. The primary role of a sponsor at any level is to effectively commu­ nicate expectations and hold people accountable for outcomes. Heres an easy way to remember key elements of the sponsor role:

Express, Model, and Reinforce3 Converted to an acronym, express, model, and reinforce becomes EMR —an easy one to remember during an electronic medical records implementation! (Pointing out this acronym [EMR] is simply an aid to help you remember the importance of these sponsorship elements during an implementation. All further reference to “EMR” in this chapter or within the book will refer to “electronic medical record”) Each of the three EMR responsibilities is key to a successful project. Express: This is what you say and includes what you emphasize, your choice of words, the level of commitment, frequency of the mes­ sage, and tone of voice. Of the three (express, model, and reinforce), expressing is the least impactful. Unfortunately, it is also the easiest one to do and, consequently, the one on which most sponsors focus. The following are some important guidelines for expressing: • Tell the truth—not your truth, but THE truth. People sense when you are not being honest about the risks and difficulties, as well as the benefits, of the pending change. • When you don t know the answer to something, say so. Then back that up by explaining what you will do to get an answer and when you expect to provide an update. Model: This is what you do, as in leading by example in which “actions speak louder than words.” If what you say and how you behave are incongruent, people will dismiss what you tell them. Pay attention to what you do. Modeling means walking your talk. Highly effective sponsors understand the impact of making visible changes in their own behavior to model what they want to see in others. This is par­ ticularly true when the behavior change is difficult or painful. Good modeling examples include executives who: • Publicly demonstrate collaboration and partnership in a relation­ ship with a troubled history. • Begin using online tools for their own healthcare transactions.

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• Attend software training with staff and stay through the entire course, participating and learning along with everyone else. • Make their incentive bonuses, and those of their direct reports, predicated on the success of the initiative. • Admit mistakes with past change efforts and demonstrate how these learnings inform the current CHANGE™ effort to ensure the previous difficulties are not repeated. • Openly work to improve their computer skills if they are lacking. • Express, model and reinforce their commitment to the change. Modeling has twice the impact of expressing. If you are a tech­ nology adoption consultant think about what behavior changes your executive sponsor could make that would have a big impact on your CHANGE™ initiative. What kinds of things would make a big dif­ ference at the middle-leader level, and at the supervisor level? Have this conversation with your sponsors to help them see how they can increase their impact by displaying their personal commitment to the CHANGE™. Reinforce: This is by far the most powerful of the three sponsor behaviors. It is also the one most often overlooked. The word reinforce­ ment is carefully chosen because it includes rewards (positive) as well as consequences (negative). Yes, you must address poor performance, bad behavior, and lack of support for the CHANGE™ in your direct reports and down the line. People need to know there will be conse­ quences if organizational expectations are not met. And as we all know, people perform better when they are acknowledged and rewarded. Reinforcement is three times more powerful than expressing. It is so important that we cover it separately in Chapter 8.

key trip

Never underestimate the degree to which words and actions communicate what sponsors value.

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Effective Strategies for CH AN GE™

THE IMPORTANCE OF SPONSORSHIP Lets start by defining what sponsorship is not. Sponsorship is not “launch and leave” WeVe all seen it. The executive sponsor shows up at the kick-off meeting, cuts the cake, says a few words and disappears, never to be seen again. This is not sponsorship! When a leader takes on a sponsorship role, it is to be the ultimate owner and driver of a specific initiative. To sponsor is to be the place where the buck stops, and this can take some intestinal fortitude. Change management methodologies often refer to leadership as sponsorship. In fact, an effective sponsor exhibits many of the same characteristics of an effective leader. The two roles overlap many ways; both have authority and credibility to: • Be the ultimate decision maker. • Define and enforce nonnegotiables. • Hold highest financial accountability. • Commit resources. • Define direction. • Set the tone. • Empower and hold others accountable. • Eliminate barriers. • Resolve the big issues. • Provide reassurance to users. Effective sponsorship often requires a passionate commitment to a cause. In the case of an EMR implementation, for example, the executive sponsor is the leader of not just a software implementation but of an organizational transformation. EMRs redefine roles, ways in which clinicians practice, and the interactions and interrelationships between departments and providers—not to mention the relation­ ships between healthcare systems, physicians, other medical provid­ ers and suppliers. Patient visits and care experiences change, too, as a result of the availability of up-to-the-minute patient information and the increasing participation of patients in their own care. All of these things impact the nature of the healthcare organization. Given what is at stake and what will change, we would argue that the CIO cannot be the executive sponsor of an EMR initiative, that it must be the CEO of the organization.

Note the special advice given to sponsors in Figure 3-1.

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C h a pter 3: Sponsorship

Figure 3-1: Note to Sponsors

Note to Sponsors Though thinking about this can be overwhelming, it is also exhilarating because a well-designed and implemented EMR presents tremendous opportunities for a healthcare organization. We would argue that implementation of EMR systems is inevitable. So instead of worrying about whether or not to do it, put your energy into doing it in a way that provides a foundation to effectively transform your organization for 21st century relevance. This book provides you with tools and guidelines to make you an outstanding sponsor of what might be one of the most significant professional efforts you will ever undertake.*•

In the case of an EMR and other CHANGE™ implementations, some question if it is really necessary for the CEO to be the executive sponsor. The answer is yes for three reasons: • The disruptive and transformational nature of requires leadership and direction from the very top of the organization. Actually, the very top of the organization is the board chair, but that person shouldn’t have operational responsibility, other than managing the CEO. • The amount of resources and the degree of organizational focus required for a successful EMR implementation can only be com­ mitted from the top. • If business and clinical leaders in the organization think the EMR implementation is an IT project, they wont engage. IT is the enabler. The business must own the effort. IT provides the tech­ nical foundation for transformational change, but it is the people who determine whether the effort succeeds or fails, and this is why we say that an EMR implementation is a business and clinical ini­ tiative with an IT component. The same holds true for many other large-scale CHANGE™ initiatives.

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Effective Strategies for CH AN GE™

The CEOs role as executive sponsor is a long-term commitment. It extends from early thinking about the initiative through value realiza­ tion. In fact, ongoing, active executive sponsorship is key to achieving value. Many organizations lose momentum and fail to capture true, sustainable transformation because sponsor focus is redirected. The real goal is more global and meaningful than just installing new tech­ nology. Executive sponsors recognize the risk of focusing too heavily on go-live and instead embrace the entire transformational journey. A project looking for sponsorship is very different from a large, complex, disruptive and expensive effort such as a CHANGE™ ini­ tiative. Generally, senior executives in a healthcare organization are the ones who decide to embark on the CHANGE™ journey and then authorize and initiate the project. The decision to launch a CHANGE™ initiative is top down. With all large scale CHANGE™ initiatives, if you are in a situa­ tion in which you need to find an executive sponsor for your project because your executive leaders are not involved, you have not been working at the right level in the organization. CHANGE™ initiatives cannot be authorized or initiated from anywhere but the executive suite because of the tremendous expense and the degree of disruption that the initiative or implementation represents. Further, sponsorship responsibilities cannot emanate initially from the executive suite and then get delegated off to lower level management. That’s “launch and leave.” Sponsorship must cascade down the organization but with senior executives retaining their executive sponsorship roles and responsibilities. Cascading sponsorship is an extension of executive sponsorship, not a replacement for it. Continuing with our example of an EMR implementation, spon­ sorship is shared among the senior executives. The CEOs desk should remain the one at which the buck stops, and he or she should be active in the oversight and leadership of the initiative. But the chief medical officer, chief nursing officer and chief operating officer all have import­ ant executive sponsorship opportunities in the departments and func­ tions they oversee. So does the CIO, but we believe it is a mistake to hold the CIO accountable for success of an initiative outside the CIO s span of control, which is IT. The CEO must own the initiative because the CEO is the head of the organization.

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C h a pter 3: Sponsorship

Figure 3-2: The Action Wave

A w a re n e s s

U n d e rs ta n d in g

C o m m itm e n t

A c tio n

When working with sponsors who are not yet committed to the CHANGE™, begin by treating them like anyone else who needs to start at the beginning. Facilitate action by helping them through the action wave, as depicted in Figure 3-2. Refer to the Communication chapter in which this is described (see Chapter 6). Sponsors are people, too; they have fears, concerns, hopes and expectations that must be addressed if they are to become effective leaders of the project. If you discover a resistant sponsor, try to get to the bottom of the resistance by building trust, listening, and seeking to understand. Sponsors are critical to success of the implementation process. As such, it is important to ensure they are well equipped and comfortable in their role. Avoid the mistake of identifying sponsors but not provid­ ing them with training, support, and coaching. If they are perceived as ineffective or not believable, they will be unable to motivate others and drive change. Clearly identify your sponsors and provide them with the tools and resources they need to succeed.

S P O N SO R S H IP C A SC A D E By breaking sponsorship into three levels (executive, mid-level and front-line supervisor), we are intentionally addressing the hierarchy of a healthcare organization. The exact terms your system uses to describe these levels don’t matter, and your organization may have many more levels. What is important is that you recognize that the sponsor role is not confined to the executive suite. The role of sponsor is more or less the same at each level, but as you move up in the organization there is an increasing span of control and authority.

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Effective Strategies for CHANGE™

To be most effective, sponsorship starts at the top of the organiza­ tion and cascades down through the layers to front-line leaders. This means each successive leadership level must clearly communicate the appropriate sponsor role and expectations to the next level down. Each level must hold the one below accountable for effective sponsorship and delivery of desired outcomes. Change efforts are always more successful when there are clear and present sponsors supporting and modeling the change. In the same way that we expect direct supervisors to provide front-line teams with a supporting, reinforcing environment in which to successfully navi­ gate change, the supervisors themselves need the same support from their leadership to be successful, and so on up the chain. In most cases, the sponsorship cascade follows the direct report­ ing structure of the organization. Given this, it is surprising how often projects don’t show a clear picture of the sponsorship cascade. We highly recommend taking the time to develop a sponsor map upon which you identify all sponsors of your project—up, down, and across your organization. See Chapter 5, Stakeholder Management, for infor­ mation on conducting a stakeholder/sponsor mapping process. If you miss a level in the sponsorship cascade, you will experience a breakdown in the chain. Your sponsorship chain is only as strong as its weakest link, and a break in the chain can spell disaster for a CHANGE™ initiative. It is the responsibility of the executive sponsor to ensure that sponsorship is appropriately cascaded throughout the organization. How do you do this? Highly effective executive sponsors do three things: • Add responsibility for CHANGE™ sponsorship and outcomes to their direct reports goals and incentive plan. This removes all ambiguity about the importance of the CHANGE™ initiative. • Include the CHANGE™ initiative as an agenda item for each direct report one-on-one meeting and in the team meeting. The executive sponsor asks questions about the status of the project, successes, issues, staff morale and, very importantly, how things are going for the sponsors themselves. Repeated inquiries about the activities and outcomes keeps information and accountability flowing up and down the organization.

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C ha pter 3: Sponsorship

• Manage by wandering around—informally check in with people at all levels to hear from them directly about what is working and what is not. This kind of communication and reinforcement keeps the executive sponsor close to the project, providing opportunities to assist with resource issues and problem solving as needed. It also reaffirms the importance of the project throughout the organiza­ tion. If your organization has problems with “flavor of the month” reactions to change initiatives, managing by wandering around eliminates any confusion about the priority status of the CHANGE™ initiative. Don’t separate yourself from the people whose willingness and ability are required for success. These activities make it very clear that the executive sponsor is paying attention and actively participating. People quickly understand that the CHANGE™ implementation is a priority and that progress and status are being routinely monitored. This form of reinforcement sends clear messages across the organization. key trip

Active, committed and cascaded sponsorship is critical to CHANGE™ implementation success. ---------------------- --------------------

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L E V E L S O F S P O N SO R S H IP Now that we have talked about the sponsor role in general, we’ll take a look at some important characteristics of each of the three levels we identified earlier—executive, mid-level, and front-line supervisor. To begin with, all sponsors share the following responsibilities as they are appropriate to their span of control and level of authority in the organization.

Sponsor Responsibilities Shared at All Levels • Demonstrate personal commitment to the CHANGE™ vision and the changes that must be made to get there. • Be highly visible and consistent. Stay the course! This takes self-discipline.

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Effective Strategies for CHANGE™

• Know what results the organization is driving for and how prog­ ress and success will be measured. • Monitor progress and ensure the project is directionally correct. • Connect the project to the organizational strategy; draw a clear line of sight for others. In the case of some recent developments in payment models and accountable care, modifications to the stra­ tegic plan will be necessary so that you have something to tie the CHANGE™ initiative and vision to. • Hold all players accountable for reaching desired outcomes. Make the CHANGE™ implementation a key accountability in direct report goals and incentive plans. • Be mindful of what you communicate to peers and direct reports through what you say, how you behave, how you commit resources, what you prioritize and reward, and how you spend your time. • Ensure open, honest, two-way communication. Engage with peo­ ple to understand whats really going on. Actively listen to demon­ strate that you value feedback. • Stay engaged with direct reports to be current with project status, including successes and issues and what needs to be escalated. • Support direct reports personal transition process, and help them manage their resistance. • Express, model, and reinforce the change.3 • Advocate for the project with peers and others. • Actively participate in managing others' resistance and expecta­ tions about the change. • Coach and mentor direct reports to build individual and collective capability to effectively manage today's unrelenting pace of change. Provide change management training as needed. • Know how to get needed support for direct reports and their teams, and be comfortable asking for help. Understand how to make the best use of the resources available. • Ensure direct reports understand how the change fits into their priorities. You may need to reassess and decide if some things need to come off the plate in order to create capacity for CHANGE™ success. Stop or postpone work that interferes with the CHANGE™ initiative.

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• Celebrate progress and successes! Early on, look for quick wins to build enthusiasm and confidence. Continue to celebrate accom­ plishments throughout the project.

Executive Sponsors In addition to the previous list, executive sponsors have the following additional responsibilities: • Ensure the CHANGE™ vision for the organization is clearly defined, so people understand what success looks like. • Authorize and initiate the CHANGE™ implementation. • Do not change priorities midstream. Do not shift focus, reassign resources, or create confusion. Avoid the temptation to start other initiatives before the CHANGE™ is complete or you will run the risk of causing change overload. Commit financial and human resources to the project—what gets resourced gets done. - For a project as complex and long term as an EMR implemen­ tation, human resource assignments must be dedicated and full-time. - Engage an experienced change management leader to direct the people side of the project. • Ensure effective sponsorship is cascaded throughout the organization. • Don’t underestimate what it will take to move the organization through the transition. Anticipate and help manage the resistance. Resource the change management effort for success. • Show your commitment to the CHANGE™ by making appropri­ ate personal, and perhaps painful, changes visibly in front of the organization. • Effectively model integration by including all stakeholders and encouraging “human interoperability.” Don’t allow people the comfort of continuing to work in their silos. • Define nonnegotiables up front, thereby also defining what is negotiable and what can be tailored at a local level. • Ensure clarity about decision rights, so everyone is clear about who (individuals or committees) has final authority to make which decisions.

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Effective Strategies for CH AN GE™

• Guard against inundating people with data. Provide them with meaningful information they can understand to help them see how they are doing. Being overwhelmed with data is a distraction and can be confusing. • Mobilize the executive team and ensure ongoing support for the project. • Understand the need and actively engage in keeping the organiza­ tion involved over several years of change, including post go-live.

M IST A K E S T O A V O ID Executive sponsors are the glue that holds the project together. This is a critically important role. In the past, executive sponsors have not always recognized the importance of focusing on the people side of CHANGE™ initiatives. Fortunately, things are changing, and there is increasingly broad recognition that results are dependent on people and that change management is a key success factor. Don’t repeat the following mistakes! • Thinking that change management is someone else’s job. • Adding line items for communication and training to the technical plan and thinking you have change management covered. • Thinking a CHANGE™ initiative is an IT project and letting IT run it. • Taking the easy way out by thinking of change management and communication as overhead and therefore just a “nice to have” that can be skipped due to resource constraints. • Believing you can dictate the changes required for a successful CHANGE™ implementation, as in “Well, were installing the boxes, so they will just have to use them.” At best, this thinking is naive. • Relying on technical or project management staff to take care of the people issues. • Not showing up! Sponsorship of a CHANGE™ initiative takes con­ certed effort over the long haul. There is personal work required to maintain your own level of commitment throughout the long pro­ cess. Figure out how you are going to manage yourself, and plan how you will get help—you will probably need it.

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• Forgetting the reactions you had when you first considered a CHANGE™ initiative a real possibility for your organization. Typically, by the time large numbers of staff hear about the imple­ mentation, the senior executives are well past their initial reactions and can become frustrated when staff exhibit normal responses to a proposed change of this magnitude. Remember how you first felt, and give people time to catch up to the point at which you are now. Don t dodge the truth; be transparent.

E N G A G IN G L E A D E R S IN T H E S P O N SO R C A SC A D E E x e rc is e

Here’s a simple suggestion executive sponsors can use to engage other leaders in the sponsor cascade: Convene a group of direct reports and the next level down to review the CHANGE™ vision with discussion. • Ask the group to identify six to ten things the organization needs to do to make the vision a reality. • Once the necessary things are identified break the group into small work teams and assign each to develop a plan for their assigned tasks. Mix up the membership of the groups with people from different areas of responsibility to expand thinking and to create alignment. • The smaller work teams can convene offline to develop plans and then present the plans to the larger group for discussion and feedback. Each work team selects a leader to sponsor their plan, integrate it with the CHANGE™ project and oversee execution.

Mid-level Sponsors We haven’t said much about middle leaders yet. This does not mean they are not important! In fact, middle leaders are not only critical to implementation success, they are also key to long-term sustainability. If these leaders do not buy in to the vision of the CHANGE™; if they do not incorporate new ways of thinking into their daily work; if they do not model the required changes, they will undermine the deploy­ ment process and put benefit realization at risk. Middle leaders are the most overlooked sponsor group. This is of critical importance because sponsorship must be alive and well at

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Effective Strategies fo r CH AN GE™

the operations level or it is not sustainable. Organizations put a lot of effort into training the front line, and the executives launch and own the CHANGE™ effort, but the middle leadership level is often left out of the loop. It is very helpful to put someone in charge of focusing on middle leaders and ensuring that they are supported in making the required transition along with everyone else. Middle leaders have the same shared sponsor responsibilities listed earlier, in addition to the following: • Manage up. Report to their executive sponsor escalating issues as needed and ensure that positive and negative reinforcement is applied to their team members appropriately. Middle leaders must be brought into the CHANGE™ process early and must be prepared well if you expect them to take ownership of the vision and the process for getting there.

Supervisor Sponsors We have stressed the importance of executive and mid-level sponsors. Now were going to tell you that front-line supervisors are the lynch pin. They own the day-to-day work of their department. Their staff look to them for answers about how jobs will change, how people will be prepared, and what the impact will be to the department, good and bad. With proper preparation and support and adequate time avail­ able, supervisors will do much of the heavy lifting to bring their team members along. Here are the keys: • Train and prepare supervisors early (before their direct reports), so they have a chance to understand the technology and know what they are sponsoring. Whenever possible make front line supervi­ sors your key super users. Countless missteps will be avoided if the people who are in charge of the day-to-day work are prepared to lead the change at the front line. • Make the CHANGE™ initiative a key accountability in supervisor goals and incentive plans to make the CHANGE™ priority clear and to give them askin in the game.” • Engage supervisors in determining the impacts of the CHANGE™ initiative on their function and people. • Ensure supervisors play a significant role in workflow harmoniza­ tion and dress rehearsal design and delivery.

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• Have supervisors participate in training with their team members to answer questions about workflow, role changes, scope of prac­ tice, policy and procedure, overall implementation process, and coordination with other departments. • Have supervisors manage up by reporting escalating issues as needed to their mid-level sponsor and ensuring that positive and negative reinforcement are applied appropriately to their team members. Many studies confirm that the person employees most want to learn about job changes from is their direct supervisor. Think through the questions employees will have during the various stages of the project and ensure that supervisors are prepared to provide the answers. This goes a long way in reducing resistance and increasing feelings of safety, which builds personal confidence and a willingness to participate. Done well, these overlapping and integrated levels of sponsorship create a strong, self-reinforcing network that supports and guides the organization through change.

F R E Q U E N T L Y A SK E D Q U E ST IO N S A B O U T S P O N SO R S H IP • How do you know if you have effective sponsorship? - Things work well—issues are escalated and resolved, resources are provided, hard decisions are made, there is role and decision­ making clarity, and people are held accountable and are openly acknowledged for good performance. The project is meeting its budget and timeline objectives, and people are reasonably optimistic that the project will be a success and the future vision achieved. People want to achieve the vision. • What do you do if you discover you don’t have effective sponsorship? - Engage for commitment. Go back and renegotiate for spon­ sorship. Be clear about what is needed for success and the risks if strong sponsorship is not present. Discuss the role, find out what the sponsor is willing and able to do, discuss any gaps, determine what kind of support he or she needs, and then reach agreement about what he or she will do going forward. Its a good idea to put the agreement in writing by following up

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-

-

-

-

with an e-mail. Part of the agreement should be that you com­ mit to supporting the sponsor with regular meetings to review sponsor performance and plan for next steps—and hold them accountable. Encourage struggling sponsors to assess their own performance against the sponsor role description. Be certain they understand the kinds of support you can provide and encourage them to discuss their needs once they have completed the assessment process. Start a sponsor peer network to provide a means for sponsors from all levels to interact with each other—pose questions, share successful practices and mistakes, work together to solve com­ mon problems, and make joint decisions. If spread of home­ grown improvements is important to the organization, sponsors openly learning from each other and spreading each others great ideas will give the concept of continuous improvement some legs. Communicate broadly about the sponsor role to help people understand what to go to their sponsors for. The process of being asked to deliver on sponsor accountabilities will rein­ force the role, and most sponsors will begin to step up, as most people want to perform well and be successful. Remember that for many sponsors, effectively leading change is a new accountability. If all else fails, take your concerns up a level, and discuss the situation with the person who manages the poorly performing sponsor.

• How do you nurture good sponsors when you have them? - Reinforce their good behavior—sponsors are human, too, and respond to recognition just like everyone else. - Coach your sponsors. Start the discussion by asking if you can discuss their sponsorship work. If sponsorship needs improve­ ment, provide some concrete examples of things to try. And be sure to recognize them for what they are doing well. - Refer them to the sponsor peer group suggested earlier. Encour­ age them to share specific things they do that are working and

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be open about what isn’t working, seeking counsel from their peers.

• How do you make the best use of your sponsors? - A great sponsor understands the importance of sponsorship to the success of the project and will be willing to support other sponsors by talking about the role, modeling good sponsor behavior, openly sharing successful and unsuccessful sponsor practices, and actively reinforcing desired behavior. - Make it easy for sponsors to deliver needed messages— provide scripts whenever there is something specific to be communicated. - Keep sponsors visible. Get them in front of different groups in the organization to reward people, deliver messages, answer questions, and listen. - Escalate the hard calls to the right level. - Encourage sponsors from different constituencies of the orga­ nization to partner with each other and model the partnership publicly. There is real impact when leaders co-sponsor across traditional boundaries, such as medical group and management, or union and medical group, or all three together. Try it! Use the project as a way to model doing things differently. - Help sponsors with reinforcement by making it easy for them to reward good behavior and performance, as well as to deliver consequences when needed. Give them easy access to ideas, guidelines, and other resources. - Actively work with sponsors to ensure continuing commitment and to improve sponsor performance. • What if sponsors turn over during the course of the implementation? - Sponsor succession must be planned for. CHANGE™ initiatives are normally multiyear processes, and it is likely that you will experience some sponsor turnover. Plan for it, so when it hap­ pens you are prepared and can help your new sponsor get up to speed and performing well quickly.

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S P O N S O R S H IP C H E C K L IS T C h e c k lis t

Sponsorship Checklist □

The executive sponsor for CHANGE™ implementation is on board and has assumed the responsibilities of the role.



Sponsorship for CHANGE™ implementation has cascaded from the executive sponsor throughout the leadership levels of the organization down to the front-line supervisors.



All sponsors understand their sponsor role, are prepared to execute well, know what they are expected to deliver and how they will be held accountable.



The CHANGE™ implementation is a priority in the organization. Other efforts have been stopped or postponed to enable time and attention to be devoted to whatever the CHANGE™ initiative is.



The executive sponsor takes a long-term view of CHANGE™ implementation and benefits realization requirements and ensures adequate financial and human resources are committed to the life of the implementation effort.



The executive sponsor knows that change management starts at his or her door and leads by example to set the tone and direction for the effort.



The executive sponsor is active in reinforcing behaviors required for success and expects the sponsor cascade to model and reinforce at their level.

C hapter 4

Organizational Readiness Team Prescription for Success

In this chapter, we discuss how to structure the technology adoption side of your CHANGE™ initiative project. Our recommendation is that you form an organizational readiness team (ORT) comprising all those responsible for people-focused functions. Generally these functions include change management/technology adoption, train­ ing, communication, human resources, workforce planning, workflow harmonization, and user lessons learned. And if your organization is unionized, the union engagement function is part of the ORT team as well. It is also helpful to include local champions and subject matter experts (SME) from operations/user communities. Your organization may refer to people-focused functions by dif­ ferent terms, but the point is still the same—to gather everyone who supports users, as opposed to technology, and get them to integrate and work together. A successful ORT has the clear authority to lead the people-focused work. If the authority is not there or is not broadly recognized, the ORT contribution will be significantly diminished.

The organizational readiness team aligns, coordinates, and syn­ chronizes all the people-focused aspects of the project in a way that connects the dots for users. Do not leave users to do this on their own! Tell one story; begin one narrative about the implementation that builds logically over time in a way that makes sense to users. The organizational readiness compo­ nents must work together to reach shared goals, integrating and rein­ forcing each other every step of the way. Do not throw siloed pieces

55

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over the wall at users and expect them to do the sense making—you will only create confusion, resentment, and resistance. Remember, whats important in a CHANGE™ initiative with an IT component is not the technology itself but how the new technology is used to generate results. The primary objective of the implementation will vary by organization but will revolve around a passion for increas­ ing productivity and taking the waste out, or improving patient safety, or surpassing an externally recognized benchmark, or increasing mar­ ket share, or (in the case of ICD-10) getting paid, etc. The objective is to install the technology only as it is a required step, a key enabler that makes achievement of the primary objective possible. Don t lose sight of this perspective in the effort it takes to install the technology. Make the passion clear and explicit.

O R G A N IZ A T IO N A L R E A D IN E S S T E A M D E F IN E D We use the term organizational readiness with technology implemen­ tation projects because it ties together all the people-focused aspects and works well across all phases of the project. The purpose of the ORT is to lead and manage the cultural, behavioral, and operational changes that need to take place, so that users are willing and able to successfully transition to the future state. The ORT works collaboratively to develop realistic plans to prepare people and get them involved in how the implementation will be done. For a large organization in which there may be local ORTs in addi­ tion to a corporate level ORT for the project, a successful practice is to connect these teams in a network. The larger team associated with the corporate office convenes and facilitates the network, providing opportunities for sharing learnings, successful practices, tools and techniques and, in some cases, resources. This practice speeds learning, reduces variation, and makes the entire organizational readiness effort more efficient and effective. If you are large enough, subject matter areas may want to form subteams as well. This means you might have a training subteam (one for communication, for example) in addition to the larger network that all people-focused staff participate in. Again, the purpose is to align and collaborate so that ORT func­ tions reinforce each other and consistent messages are delivered to users. This is not about creating rigid standards that must be met at all

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costs, but about creating partnership, interdependency, common goals and consistency of practice, which unfolds within the framework of a mutually reinforcing network that is authorized at the executive level. Example: In one large organization, the training leads from the various locations started the practice of a biweekly conference call. At first the participants didn’t say much, few questions were asked, and most of the time was spent on updates delivered by the corporate office. But when a couple of people from outlying areas began asking for help with issues, other people offered suggestions, and trust began to grow. Soon this training conference call had a reputation as the place for trainers to be. Many more people joined and what once was a short call with a few people and not much significant content became the problem-solving body for the entire training function for the project. Trainers were united; they shared resources, tools, and lessons learned across traditional organizational boundaries, and the users were the beneficiaries. I K e y P o i n t T I *•

Organizational Readiness Team Objectives

Define strategy, structure and vision for people-focused work. Assess the organizational history of success or failure with change efforts and how this influences people’s thinking. • Collaborate across organizational boundaries— work together. • Develop overall people readiness plan and tools. Integrate ORT milestones with the technical plan. • Develop common understanding of user readiness by creating user readiness definitions, by role, for each phase of the project. • Provide clarity— connect the dots for users, create one story. • Sequence activities in a way that is logical for users and builds over time. • Coordinate resources across the organization. • Ensure success for each user by developing willingness and ability— address issues of both hearts and minds. • Create an environment that supports and reinforces users in moving to the future state. Bring people together through peer groups and conferences. Leam as you go, and instill a continuous learning culture.

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R E A D IN E S S D E F IN IT IO N S A key responsibility of the ORT is to develop and socialize readi­ ness definitions. A readiness definition describes, in behavioral and observable terms, the key characteristics of someone who is ready for an aspect of implementation. Definitions are typically created by role and can be either high level or granular, depending on the need. The definitions must be revised at different points in the implementation process to reflect evolving requirements as the implementation pro­ ceeds through phases. When developing readiness definitions, key questions to ask are: • If I walked into a facility and saw that people in x role were ready, what is it I would see that would enable me to recognize their readiness? • What are the most important things that constitute their readiness? • Are the criteria I am thinking of observable? Here is an example. A good description of registered nurse read­ iness for go-live might include “speaks positively about the change to patients and peers.” Contrast this statement with, “has a positive atti­ tude.” You cant really see someone’s attitude, but you can see how they are behaving with others and hear what they are saying. Here’s another example. A readiness definition for registration clerks might read, “Delivers great patient service during go-live.” Con­ trast that with, “When a patient approaches the registration area, the clerk steps out from behind the kiosk, makes eye contact, greets the patient and welcomes them to the facility.” It can be a tremendous help if readiness definitions are developed for multiple levels in the organization. Do not assume that people know what they are expected to do. More often than not we find that people want to do what is expected but don’t actually know what that is or what it looks like. Show them what a good job looks like. Spelling it out is a gift. This is true at all levels, from the board, to the executive suite, to mid-level leaders, to the front line. A successful practice in readiness definition development is to involve leaders from impacted areas (what do they expect their people to be ready to do?) and informal leaders from the impacted role (what is it they think they should be able to do?). Consider aspects of both willingness and ability as you draft definitions. (See Chapter 1, The

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Business Case for Change Management, for discussion of willingness and ability.)

P R O JE C T P H A SE S There are generally five main project phases for any large CHANGE™ initiative. The project begins with the initial planning phase and transi­ tions through implementation, stabilization, optimization and finally, benefit realization. The full project life cycle is introduced in Figure 4-1 and broken out in steps in Figures 4-2 through 4-6, but the focus of this book is predominantly on preparing people for implementa­ tion. Although we do not discuss the later phases in depth, the lessons we present will guide you in establishing the appropriate context and platform for a seamless and successful journey to benefit realization.

Figure 4-1: Project Life Cycle

It is important to note that although we discuss the project phases as if they are discrete, they are in fact overlapping to some degree. If you work in a large organization, different phases may be running simultaneously in different locations. In a very large organization it means some people will be going live while others want to optimize. This adds complexity, but if you are aware of it the situation is easier to manage. The concept of the project phases is a framework and a way of thinking. The phases are not discrete where one ends before another begins, but the concept is useful in planning, in understanding where different groups are at different points, and in marking progress.

Planning During the planning phase (see Figure 4-2), the ORT forms, gathers resources, develops strategy, and plans to prepare people and the orga-

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Figure 4-2: Planning Phase of Project Life Cycle * •

nization for implementation/go-live. At a high level, the following is involved: • Becoming a sponsored, recognized, legitimate part of the CHANGE™ project charter and implementation team. • Obtaining budget, staff commitments, and other resources. • Spelling out ORT team roles and responsibilities. • Conducting an organizational implementation history assessment to understand the organizational history with change efforts and how that currently influences peoples thinking about the CHANGE™ project. Factor findings into the ORT strategy and work plan. • Developing the organizational readiness strategy and approach for the project. • Developing role-based user readiness definitions that spell out behavioral, observable changes required during each project phase. • Developing a detailed ORT work plan for the implementation phase. • Integrating ORT work plan milestones with the technical work plan. • Conducting an operational and job impact assessment to deter­ mine the points at which job impacts are greatest and, at a high level, what the changes are and whether the changes will result in significant need for retraining and/or job losses. • Developing and beginning to implement realistic plans to prepare people (willingness and ability) for go-live—includes sponsor development strategy, stakeholder identification and management plan, user readiness definitions, training model and plan, commu­ nication plan, resistance management strategy, job impact assess­ ment, etc. Union engagement begins too, when needed, as does engagement with operations areas.

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Implementation Depending on the size of your organization, the implementation pro­ cess (see Figure 4-3) could mean a few events happening over a rel­ atively short period or it could mean many go-lives happening over the course of a few years. Factors that influence this phase include the number of impacted facilities, how many people and what roles are impacted, whether a “big bang” or a phased implementation approach is used, and the number and type of applications being implemented as part of your CHANGE™ deployment.

Figure 4-3: Implementation Phase of Project Life Cycle•

The implementation phase is the period when the system is launched and users begin to use the system on the job with patients and other customers for the first time. This is a period of much excite­ ment for some and much anxiety for others. Users are faced with trying to remember everything they learned prior to go-live and applying it in real-life situations. This can be overwhelming, scary, and intimidat­ ing. During the implementation phase, the ORT focuses on ensuring that users can get through their day, working closely with the support teams and sponsors to ensure that users feel supported and that the environment continues to reinforce desired behaviors. The following are key ORT functions during the implementation phase: • Delivering training and ensuring the “sandbox” (practice site), Web-based training modules, job aides, and other learning options are current, effective and readily available. • Communication is fully engaged in ensuring that users, sponsors, and project team members know what they need to know when

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they need to know it. Feedback loops are active, and comments and questions are responded to in a timely manner. • Successes are celebrated, and individuals and teams are recognized for great performance and achievement of milestones. • Plans for managing anticipated job losses are put in place. • Unions are actively involved to ensure members are well-supported to be successful in the transition and that the changes are imple­ mented according to contract terms. • User lessons learned activities begin with the first go-lives. Learn­ ings are shared broadly and recommended improvements are made to subsequent go-lives, and users are acknowledged for their contributions to this continuous improvement process. • Sponsors continue to be coached and supported to perform their roles well. Though the focus of this book is on planning and implementation, we provide a short review of stabilization, optimization, and benefits realization here (see Figures 4-4 through 4-6) to provide an overall picture of the end-to-end process.

Stabilization As you can imagine, the CHANGE™ implementation can be over­ whelming for many users and can feel like a whirlwind of new expe­ riences. Users are busy trying to apply what they can remember from training and team readiness sessions (discussed in Chapter 9, Imple­ mentation Readiness). And now that the system is becoming part of the new daily routine, users begin to see what works and what doesn’t work with the overall operational flow. Teams revisit decisions about workflows that were made before go-live and begin to make necessary adjustments to increase efficiencies on their units (see Figure 4-4).

Figure 4-4: Stabilization Phase of Project Life Cycle

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Stabilization is the time when the organization should pause to make sure users have a chance to digest the experience and assimi­ late the many changes that are taking place. Unfortunately, too many

organizations become anxious and make the mistake of jumping to the next project phase, optimization, without ensuring users are comfortable in their roles, feel well supported, and are catching on to the new system. This is true for all types of CHANGE™ initiatives. Use this important post-live time to truly stabilize your operations! Users are a bit distracted with the changes that have taken place and are at a point when they need the space to sort out their new life with the CHANGE™. They are still trying to just get through their work day and are not ready for additional changes and/or technology enhance­ ments yet. Allow users the time to get their feet solidly on the ground, cement their new learning, and develop confidence before moving on. Jumping to optimization too quickly can cause a costly setback, which will delay the entire process. Stabilization doesn’t necessarily need to be long and drawn out, but it is important to note that individual differences begin to surface again during this phase. There is a big divide in user effectiveness with the CHANGE™ at this point. Early adopters want to move forward and make enhancements to the system, while other users are trying to just catch their breath and assimilate everything that is happening. This scenario can be tricky to manage, but the biggest mistake is forg­ ing ahead without doing the work required to create a more or less level playing field by addressing individual skill differences. Most users do not learn more about the system post-live unless there is an inter­ vention. Do not assume they will eventually catch up on their own! If you don’t address the skill variation issue during stabilization, the divide will deepen with slow and average users falling farther and far­ ther behind the early adopters. During the planning phase when you develop, document and resource the project, a key success factor is planning for a solid sta­ bilization period. After everything you will go through to implement, it doesn’t make sense to put the project at risk by not fully addressing post-live needs before pressing on. During stabilization the ORT continues to support users in set­ tling into a routine using the system, helps with adjustments to roles

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and workflows, ensures user skills are assessed, and provides addi­ tional training or coaching required to attain the expected level of proficiency. User lessons learned are responded to and documented for future reference. Reinforcement of desired behaviors continues and implementation successes are celebrated. Again, this applies to all CHANGE™ initiatives.

Optimization There is a fine distinction between the stabilization and optimization phases. Typically, organizations combine the phases and view stabi­ lization as a subset of optimization. In a sense, stabilization is a span of time (short or long) during which the organization can take a deep breath, regroup, and ensure everyone is still on the same page before forging ahead into more significant change. The stabilization phase (see Figure 4-4) is analogous to the act of refueling your car and making brief pit stops during a vacation before continuing the family road trip across country. A car can only travel so far with one tank of gas, and everyone knows that vacations are no fun when everyone is cranky, hungry, and sick of being in the car. Users need the same consideration because burnout and fatigue can compromise the willingness to with­ stand future change efforts. Many say that optimization (see Figure 4-5) is the place where the action happens. If the stabilization phase has gone well, users are now becoming comfortable with their new roles and routines and are ready to become more efficient in executing the CHANGE™. This is what organizations strive for—efficient use can lead to faster returns from the significant CHANGE™ investment. Unfortunately, just as with sta­ bilization, organizations tend to rush through optimization trying to get to benefit realization, and this can actually delay achieving the goal.

Figure 4-5: Optimization Phase of Project Life Cycle

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One of the biggest mistakes organizations make at this stage is to declare victory too early and reassign project resources, discount­ ing the need for an ongoing people-focused strategy. The optimization phase is an important and exciting part of the journey but it requires fully engaged and prepared users. Just as users needed preparation for implementation, they need further preparation if they are to grow into becoming truly proficient. Developing proficiency requires targeted training, workflow improvements, support, and continued leadership. Significant work must take place during this phase, and there are many successful practices from which lessons may be learned. For now, as we said earlier, remember that your organization will be primed for a successful optimization phase only when an appropriate context for change and learning is established during the planning and implemen­ tation phase. key trip Organizational Readiness Team Role in Optimization

• Work with executives and project leads to develop and run reports to gauge user performance toward operational and clinical targets. • Conduct user proficiency assessments to surface user skill gaps and uncover broken workflows. • Partner with the training and support teams to develop targeted and timely interventions to increase proficiency. • Ensure training and support is role-based and department-specific. • Develop programs and tools to increase operational efficiencies, partnering with key stakeholder groups such as quality services, medical group, management and labor. • Coach and mentor front-line leaders in monitoring performance and providing the tools and resources needed to assess process improvements. • Obtain lessons learned from across the organization and spread best practice approaches.

Benefit Realization Benefit realization (see Figure 4-6) is the grand prize for successfully moving your organization through the phases of the project life cycle. This is where desired outcomes become a reality and the organization begins to see improvements in revenue capture, patient safety patient satisfaction, work/life balance, internal efficiencies, and so forth.

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Figure 4-6: Benefit Realization Phase of Project Life Cycle

At this point, the role of the ORT is to continue developing and delivering effective optimization programs to enhance user perfor­ mance, spread successful practices and ensure teams across all depart­ ments and facilities are learning from each other and incorporating the most effective new ways of doing things. At this point in the journey another benefit should be emerg­ ing. If you have done a good job with the human aspects of your CHANGE™, your people will have developed stronger change capa­ bilities, resulting in expanded change capacity at the organizational level. This means a more nimble, adaptable organization is forming, and this is a significant competitive advantage.

ORGANIZATIONAL READINESS TEAM Each subject matter area represented on the ORT performs a different role in preparing individuals and the organization to successfully make the changes required by the CHANGE™ initiative. But it is important to remember that the elements of organizational readiness are interde­ pendent and reinforcing. They are most effective when aligned, coor­ dinated, and synchronized. When forming the ORT (see Figure 4-7), select the best people you have, not those that you can do without. For a project with this much importance to the organization, you need the best and the brightest.

Change Management/Technology Adoption Change management typically leads the organizational readiness team, ensuring the coordination, integration, and alignment of all the peoplefocused work. Change management/technology adoption ensures that team members are embracing a systems perspective and are working in

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Figure 4-7: Organizational Readiness Team Structure

concert to weave a supportive organizational fabric (culture) for suc­ cessful change. Change management/technology adoption also leads overall sponsor support; development of role-based behavioral readi­ ness definitions; stakeholder management; and political, interpersonal and team development issue resolution.

Training Effective training prepares users to do their job in the new world of CHANGE™. It is much more than just software feature/function training. Using the system effectively is part of it, but users also need to understand how the new system fits into their job, including orienta-

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tion to new workflows, policies and procedures, and anything else that changes because of the CHANGE™ initiative.

Com m unication The role and purpose of communication supporting a CHANGE™ implementation is discussed in Chapter 6, the Communication chap­ ter. The overarching goal is to successfully drive behavior change. Communication helps set the tone for the project, delivers informa­ tion in a timely and appropriate manner, and solicits and responds to feedback about the project.

Human Resources Human resource involvement includes: • Adjusting job descriptions, titles, and reporting structures as appropriate. • Working with workforce planning to gauge job impact from the CHANGE™ and managing position eliminations, reassignments, and retirements, as indicated. • Revising recruitment/hiring criteria to reflect new CHANGE™ requirements. • Aligning incentives to reinforce the behavior changes and perfor­ mance outcomes required in the new CHANGE™ world.

Workforce Planning We call out workforce planning separately because it is such an import­ ant component of a CHANGE™ implementation. If any positions will be eliminated due to the CHANGE™, the sooner this is known the bet­ ter. Workforce planning identifies the impacted roles and determines how the position elimination process will be managed. In some cases eliminated staff can be trained to fill new roles or qualify for hard-tofill positions. Figure out all the details well before you need to give notice. The same goes for potential reassignments and retirements. All of these situations are complex processes, especially if you are union­ ized. Don’t wait until the last minute! Treat employees with respect by doing your very best for them in this difficult situation.

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Lesson Learned Not everyone will survive the CHANG E™ transition. Anticipate that roughly 5% will leave the organization. To plan for this, you need a robust, proactive workforce planning effort.

O perational Representatives If you are unionized, we cant stress enough the importance of early and frequent engagement with unions. This happens at three levels: • Union leadership. Many of these people are employed by the union, not the healthcare organization. • Represented employees. These are the people in your organization that belong to a union and are subject to the stipulations of the bargaining contract that covers them. • Represented employees with union leadership roles. Among the ranks of represented employees, there are generally leadership roles, such as steward and contract specialist. People in these roles are employed by the healthcare organization, and their union lead­ ership responsibilities are in addition to their day-to-day health­ care job responsibilities. Lesson Learned |

If you are unionized, engage union leaders early and often! Don’t wait. Get them involved in the project from the beginning.

Operational representatives do not need to attend every plan­ ning session, but they are integral to the overall success of the devel­ opment and execution of the technology adoption program. Opera­ tional representatives can include union partners, physicians, nurses, clinical supervisors, and other stakeholders depending on the exact CHANGE™ you are implementing. In some situations it is import­ ant to include representatives from many different groups within

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the organization. We cover four important operational groups here: unions, physicians, local champions and super users. (Sponsors, mid­ level managers and front-line supervisors are covered in Chapter 3 on Sponsorship.) The following comments address union participation in EMR implementations, but the advice applies to any CHANGE™ in which unions are involved.

U N IO N E N G A G E M E N T FO R S U C C E S S F U L E M R IM P LE M E N T A T IO N Marie Hamilton, RN, Kaiser Permanente, explains, “Unions recognize that the decision to implement an EMR is an organizational business decision and do not expect to be involved in the decision-making pro­ cess. But after the decision is made, organizational leaders should con­ sider early communication to union leaders with a request for their support and sponsorship. Engaging union leaders at the highest level of planning creates an environment of trust and collaboration, decreases resistance, facilitates sponsorship and engagement at all levels and is essential to ensuring a smooth implementation and transition for users. Success of the implementation becomes a shared accountability. Once union leaders are committed to sponsorship, involving them in the development of the business case engages union leaders in return on investment expectations. This is a great opportunity for union and management to understand the goals and each others roles and responsibilities. Together they can begin planning strategies and approaches to achieve the required outcomes. Involvement at this level will also facilitate early discussion about the bargaining process, which will be required to address the changes in working conditions that are inherent in technology implementation of this magnitude. When administrators and managers acknowledge the expertise of users, the IT team and union leaders will be empowered to develop engagement strategies that maximize the knowledge and expertise of both the IT and provider sides of the equation. Front-line workers want to be active participants from beginning discussions to design­ ing of workflows that address the realities of day-to-day operations. Combining IT expertise with user knowledge and credibility helps to

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minimize costly mistakes that result from inefficient processes and potentially dangerous workarounds. Users can assist IT to assess skill gaps by conducting skills assess­ ments in a safe environment. The results will provide accurate infor­ mation to inform training needs. Users are often the best resource to deliver peer training with an IT partner.” Hamilton summarizes her thoughts in the following Union Perspective.

\p------------- --Involve union leaders early, and ask them to be sponsors Involve union leaders in creation of the business case. Create a venue for open dialogue to address changes requiring bargaining, so there are no surprises (or grievances). Work with unions to create a structure for user participation at all levels of implementation, utilizing them as subject matter experts. Training will be more successful if designed and delivered by a team of IT trainers and users working together. Utilize front-line staff as expert support during go-live. Staff respond better and feel less stressed when their peers who fully understand the work help them through the process. An added bonus is that the peer support staff return to work and continue to help their team members through the transition. Unions want to know that they have a real decision-making voice in the process which so profoundly affects them. By meaningfully engaging and acknowledging their contributions, the transition will be smoother for everyone. The organization, the union and most of all, the patients will benefit.

Marie Hamilton, RN Kaiser Permanente Oregon Federation of Nurses and Health Professionals Healthcare Information Technology Committee, AFT Healthcare

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PHYSICIANS Physicians are critically important in the planning process as well. As one physician comments: Physician Perspective

Engagement, engagement, engagement! I cannot stress this enough. Physicians must be engaged throughout the whole project including decision making, design, testing, support and implementation. The project team must consider the impact decisions have on workflows and user work/life balance. Without physicians at the table, the technology will fail at supporting daily operations and lead to many problems and inefficiencies down the road. Nabil Chehade, MD, MSBS, CPC Former Director, Medical Informatics Regional Chief of Urology KP HealthConnect Regional Physician Lead Kaiser Permanente Medical Group

LOCAL CHAMPIONS key trip Local champions are your best friends.

Because all change is local, the people receiving the new technology should drive the change, with IT as the enabler. Trusted peer-to-peer influence is one of the most effective ways of moving change forward, or stopping it, which makes informal local leaders extremely valuable when effectively used. We strongly recommend that you identify, train, and get local champions involved early in the process. They will be needed from any areas that will experience significant impact from the CHANGE™ implementation.

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It is important to choose the right people for this role. When we say local champion, we mean a local, informal opinion leader. Infor­ mal leaders may or may not also be formal leaders with titles. In most cases, they are not, and you will need to look further than the organi­ zation chart to find them. The easiest way to do this is to ask around. Ask people the following questions: • Who does everyone listen to when an important decision needs to be made? • Who does the whole department turn to for advice on an issue or to solve a problem? • Who is highly respected and trustworthy? • Whom do people want representing the department on commit­ tees or project teams? When you hear the same names repeatedly, you will know who the informal leaders are. Choose well. On a technology project, it is tempting to look for the people who are technically savvy. Unfortu­ nately, though they may be easier to identify and are clearly interested in technology, technically skilled people generally do not make good local champions. The reason is that, for areas in which most peoples computer skills are average or below, the “geeks” are not seen as repre­ sentative of the team. A geeks ability to learn to use new technology is not seen as proof that anyone else will ever be able to learn it. Find other roles for the technically skilled people, and choose local champions that can truly represent their peers, both in content and technical ability. Let the technology experts on the project team represent the technical considerations. The local champions provide the knowledge of the day-to-day work in their functional areas. In our experience, the best ideas and solutions are developed when technical and content experts work together. The following selection criteria for local champions will help you identify the right people. Local champions must: • Be social influences who are thought/opinion leaders with infor­ mal power. • Be the diplomats who translate reality back and forth between the project team and their department. They carry messages with integrity and honesty. • Be able to get the right people together to reach decisions.

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• Involve team members; find the right roles to get the best from them and keep them motivated. • Persevere! • Give and receive feedback well. • Understand and effectively deal with the politics. Be trustworthy, ethical, credible, and respected. • Be willing to serve the team; be collaborative by nature. • Have a positive outlook. • Have high trust and credibility with sponsors. • Be willing and able to model the expected changes (role, workflow, etc.)—learn it first, then model and teach it to others. When team members see local champions learn, they believe they can learn too. What is the role of local champions? Essentially they represent the interests of their functional area and serve as conduits for information. They participate in project meetings, representing their department interests/needs, and then bring information back. They answer ques­ tions from team members and take concerns about the implementa­ tion of the project for resolution. The objective is to ensure the local needs are reflected in the project planning and that project informa­ tion is delivered and reinforced by respected, trusted team members. This reduces anxiety. Make certain your champions clearly understand the champion expectations and confirm that they are willing and able to perform them. An advantage of using local champions is that it is a way to get input from many through the voices of a few. Great local champions enable team members to participate and influence the CHANGE™ project through representation. This allows for more involvement without overburdening the project or the department—a nice balance.

Local champion success factors: • Have a clear method for identifying informal leaders. • Clearly define the local champion role. • Select for credibility and ability to influence peers, not on availabil­ ity or technical skill. Teach the required technical skills. • Establish a training model for champion skill development and provide CHANGE™ software training early.

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• Give local champions meaningful tasks to obtain their buy-in and maintain their engagement and commitment to the project. Mean­ ingful work includes implementation planning, system demonstra­ tions, training support, workflow redesign, issue resolution, etc. • Leverage their social relationships to gain buy-in across their department and professional community. • Use local champions to help identify resistance and determine how best to manage it. • Make the local champion role part of the job. Reduce other responsibilities enough for people to perform the role effectively.

SUPER USERS Super users can also be local champions, but they are not necessarily. The super user role is local and is generally assigned to front-line team members who want to develop deep knowledge of the system for the primary purpose of training and troubleshooting on their unit. Super users are part of the on-the-ground support network and in our view, the role should remain in place for the life of the CHANGE™. To make the best use of super users, expand the role to include ongoing participation with IT in system enhancements and issue res­ olution. People who have deep functional knowledge and are highly skilled at using the system to do the daily work are invaluable. Form a network of super users; bring them together quarterly to share learn­ ings, spread successful practices and problem solve. This is a huge step in moving a CHANGE™ from a project to a fully integrated tool for operations. Both super users and local champions play an important role in helping their team members learn and adjust to the new system. The old adage “see one, do one, teach one” fits well here. Super users and champions learn new things with the system and with workflows, which they teach others. Being coached by a trusted colleague makes a big difference to people who are frustrated or fearful. Trying some­ thing new with supportive supervision and immediate feedback is powerful—people learn and build confidence. And the medical assis­ tant who learns a new skill and then teaches it to a colleague cements the skill for himself or herself. (See one, do one, teach one.)

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Like local champions, super users must have part of their role devoted to this responsibility. They need to participate in project and super user meetings, attend training, and deliver training and support in their department. This will not happen if they are completely tied to patient care or to a business responsibility. Find the right people and free a portion of their time so they can assume project responsibilities on an ongoing basis. C h e c k lis t

Organizational Readiness Team Checklist □

Form an organizational readiness team (ORT) comprised of all people-focused functions.



Connect local and corporate level ORT in a network for collaboration, successful practice and lessons learned spread, problem solving, and resource and tool sharing.



Ensure the elements of organizational readiness are interdependent and reinforcing. They are most effective when aligned, coordinated and synchronized.



Conduct user lessons learned after at least the first go-live events for each application. Use the lessons to improve subsequent go-lives. Circle back to users who participated in the lessons to let them know how their input contributed to improvement.



If you are unionized, engage union leaders early and often. Don’t wait. Identify, engage, train and fully utilize local champions to communicate with and influence their peers, and to inform the project team of local needs and realities. Form a network of highly trained super users as part of on-the-ground support. Use them to handle training and other issues at the department level.

S e c t i o n II

Willingness— Building Commitment

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Chapter 5

Stakeholder Management “They must have skin in the game ”

Identifying and understanding stakeholders is a critical early step in organizational readiness work. Stakeholder identification takes com­ mitment and time—you may be tempted to gloss over it or not do it at all. But remember that knowing who your stakeholders are and what makes them tick informs all the people-focused areas of the project and some of the technical areas as well. It is worth the effort and will pay big dividends when done well.

STAKEHOLDER DEFINITION The term stakeholders refers to the groups that will be impacted by the CHANGE™ initiative and whose participation or support is needed to reach the goal. This means everyone who has a stake of some kind in the changes that will occur as the organization begins to use the CHANGE™. Stakeholders can be departments, committees, or func­ tional areas. They can also be employees, patients, and companies that do business with your organization. The point is to think this through carefully to identify everyone who has a stake in the changes that will occur. As a point of clarification, generally speaking, stakeholders are groups of people and sponsors are individuals. Please see Chap­ ter 3 on Sponsorship for more information on sponsors and their responsibilities.

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THE IMPORTANCE OF STAKEHOLDER IDENTIFICATION, ENGAGEMENT, AND MANAGEMENT Technology adoption is a completely people-focused endeavor. You cannot succeed at it unless you really understand the people you are supporting—who they are, the degree of impact they are facing, their day-to-day reality, their concerns and hopes, and how they are reacting to the change at any given point. This knowledge and the ability to suc­ cessfully influence stakeholders to move from where they are to where you want them to be is a very significant contribution. Together, skilled change management/technology adoption professionals working in close collaboration with other people-focused partners deliver the user readiness on which the success of a CHANGE™ initiative depends.

Three Steps of Stakeholder Management 1. The first requirement in stakeholder management is to identify all groups and individuals, inside and outside the organization, who will be affected by the initiative. This includes identification of sponsors. The section on Stakeholder/Sponsor Identification and Mapping that follows describes a process you can use to accom­ plish this task. 2. Once your stakeholders are identified, your second step will be to create a strategy and a plan to engage them in the implementation process based on what you know about them. Build your knowl­ edge and establish a relationship as a trusted partner—get out in their world, watch what happens and listen. There is nothing more valuable than the deep understanding you gain from this activity. It is a means of correctly identifying how and to what extent different groups are impacted. This helps you understand what each stands to gain or lose and what they must do differently to succeed with the CHANGE™ initiative. The following are key questions to ask to gather the information you need: • What problems or issues do you have with the way things are currently done? • How would you improve the situation if you were in charge? • What potential opportunities do you see with the CHANGE™ initiative?

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• How much impact do you think the initiative will have on your department? • What are you most concerned about with the project? • What are the most effective ways to get information out to your department? • What is the best way for you to provide feedback to the project? • Who else in your department should you talk to about the initiative? 3. The third step is ongoing stakeholder management. This is the design and implementation of strategies to support and move stakeholders forward. It requires that you pay attention to how stakeholders are behaving and what they are saying in order to understand what their needs are at any given point. If you know them and you know at what point they are in the change process, you can provide just what they need when they need it. Some stakeholder groups will need minimal levels of information peri­ odically, and others will need to be directly involved in the project. You must know the difference on the continuum, from informa­ tion only to direct involvement to decision making. Key Tip

Understanding stakeholder needs is a means of identifying dissatisfaction. Dissatisfaction is a change enabler.

STAKEHOLDER/SPONSOR IDENTIFICATION AND MAPPING A comprehensive stakeholder/sponsor map is an important founda­ tional building block in the CHANGE™ initiative. The identification and mapping process is best conducted early in the project, as stake­ holder identification is a prerequisite to many other aspects of the implementation, such as: • Communication—Stakeholders are the audiences with whom you communicate.

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• Training—Identifying stakeholder groups is the first step in iden­ tifying roles, and this drives user-centric curriculum. • Reinforcement—Reinforcement has the most impact when it is tailored to specific individuals and groups. • Sponsorship —The stakeholder map is an important tool in identi­ fying sponsors. • Organizational readiness team—The stakeholder map helps iden­ tify areas where super users and local champions are needed. • Technical considerations—Different stakeholders may need dif­ ferent kinds of equipment or devices; the CHANGE™ may need to interface with existing software applications, managers may need to retrieve reports and other data differently, etc. You can see that the stakeholder/sponsor map plays an important role in the CHANGE™. It is admittedly a lot of work to compile, but it is an investment well made. The map will serve many uses in the project and will most likely have much broader organizational applica­ tion. A good stakeholder map lends clarity to organizational structure, shows linkages across the organization and, very importantly, helps the project team understand who the customers of the implementation are, both inside and outside the organization. The first step is to fully identify all the people and groups in your organization who will be impacted by the initiative. Cast a wide net when you do this. These are the audiences you will communicate with, influence, and train during the project. It is easy to overlook groups who need to be informed or involved that might not be readily appar­ ent. Here’s an example: A few years ago at one organization, no one thought to engage with the people who cleaned the building at night to help them understand how the EMR implementation would impact their work. Many of the individuals responsible for cleaning the equipment had no computer experience, so they did not know what to do with the machines. Later, when problems with keyboards were surfacing, it was discovered that some individuals were spraying the keyboards with liquid cleaner. The oversight of not defining environmental services as a stakeholder in the project cost the organization some unbudgeted expense in replac­ ing keyboards.

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So the first rule of thumb is to identify everyone who is impacted, regardless of degree of impact. Start with your internal groups but remember to include external groups too, such as patients, vendors, referring physicians, and legal counsel—anyone who may have a need to know something at some point in the project. It will take more time to be thorough in this effort but it will pay off in the long run. It s a case of slowing down now to go fast later. Refer to your initiatives case for change and vision to help you think about who will be impacted by the change. Then complete the following exercise to identify stakeholders and build a stakeholder map. Its not high tech, but it is a flexible process and it works.

Stakeholder/Sponsor Identification Exercise E xe rcis e

Stakeholder / Sponsor Identification Exercise 1.

Identify stakeholders from bottom up the hierarchy

2.

Use sticky notes to capture names and roles

3.

Organize on wall to map out relevant groups

See full instructions next...

EXERCISE INSTRUCTIONS □ Gather a small group of people who have insight into how the CHANGE™ initiative will impact the organization. Bring sticky notes and pens and organization charts if you have them. □ Begin by looking inside your organization. Where you look first will depend on how large your organization is and how it is struc­ tured. To simplify this process description, lets assume you are beginning with a focus on one hospital. If your organization is

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large and has multiple regions and facilities, you will need to repeat this process for each area or location that will be impacted. Start by identifying all the people, areas, and groups at the lowest level of the health system that will be impacted by the CHANGE™ you will be implementing. For each person or group that you identify, write the name on a sticky note and attach it to the wall, a white board, or large sheets of paper. Next, using a different color sticky note, identify the managers for each person or group and place their names above the names already on the wall. Continue this process, working your way up the organization until you have gone as high as needed. For an EMR implementation, this will be all the way to the executive suite of the health system. Your chart will look like a typical organizational chart. Once you have the chart put together, identify managers and other leaders who will be sponsors of the implementation. The sponsor­ ship cascade usually reflects the reporting structure in an organi­ zation. Starting at the top, sponsorship flows down the successive levels until you reach front-line management. This is also a good time to identify the informal leaders. These people may or may not have formal line authority, but are critical to influencing change. You need to know who they are in order to leverage them and their relationships. They hold the keys to unlocking partnerships that may be difficult to form on your own. Once you have completed this process for the obvious internal people and departments, think about other areas of the organi­ zation that your identified stakeholders interface with or impact. Add these areas to the chart. The next step is to think outside of the organization to identify other parts of the system (if your organization is larger than one hospital, such as an ACO), as well as people and groups that are not part of your organization, such as suppliers, patients, etc., who will be impacted. When you think you have identified all impacted parties, take a careful look at the map and adjust the sticky notes as needed. Groups that naturally fit together due to profession, function, cus-

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tomer set, or reporting structure are stakeholder groups. They run both up and down, as well as across the HCO. For example, a nurse is a member of both her medical-surgical unit stakeholder group and her broader HCO-wide nursing stakeholder group. Depending on complexity you may need more than one map to fully paint the picture. □ The final step is to create a soft version of the map(s), using a soft­ ware application. Once this has been done, you can easily share the document with others to get their input. Make final changes as needed. Again, the reason for going to all the trouble to create a stakeholder map is to inform the project team. Knowing who the stakeholders are allows you to develop understanding of their perspective and needs so that you can be targeted and specific in your plans and actions. It is impossible to be role specific and user centric if you don’t know who these people are, and you wont get training and communication right if you don’t understand the impact. Though this process may seem daunting, it is well worth the effort. You don’t have to get it all done in one sitting; in fact, we’ve never seen that happen. It takes multiple iterations to complete because many people need to contribute their knowledge. It is a fascinating process, and you will learn a lot as you work through it. key trip Don’t let the minutiae of stakeholder mapping slow you down Do the best you can to get started. Once you have a map at least partially completed, identify the top five (or so) most impacted groups and focus on getting to know them first. Fill in more stakeholders and details as they become known.

As an example in the case of ICD-10, obstetrics, orthopedics and behavioral health need to be called out as heavily impacted. When you look at areas outside of medicine be sure to think broadly. Within the revenue stream the obvious areas are coding, claims and billing. But don’t overlook benefit configuration, provider contracting, sales and

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marketing, reporting, analytics, quality, internal audit, compliance and call centers. Patients are another impacted group. You can see that there is more to this process than may be initially apparent. As you work to identify all areas impacted by ICD-10, con­ sider the following questions: • Who uses codes today? Find all areas where codes are used for any reason. • What do they use the codes for? Understand the use—is it heavy, medium or occasional? • Are there job aides, reference guides or other tools that will need to be updated? (In some cases just updating these resources will reduce the amount of training required.) • How much (and what specifically) do they need to know about ICD-10?

STAKEHOLDER ENGAGEMENT AND MANAGEMENT key trip “Coming together is a beginning; keeping together is progress; working together is success.” Henry Ford

Once you have a stakeholder map, you can begin to plan how you will engage your stakeholders in the process of the CHANGE™ initiative and how you will help manage their experience with the many changes that will impact them. Its important to identify those stakeholders who are most criti­ cal in the process. These will obviously be groups that will experience the greatest degree of change. But you should also identify groups or individuals who can positively or negatively impact the project. On the positive side, these include potential super users, local informal opinion leaders, those who have a lot to gain, and anyone with positive experience with other change efforts. On the more negative side, look

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for the resisters, those who have a lot to lose, and anyone with past negative experience with organizational change. Getting stakeholders involved in the process is a way of developing acceptance and buy-in and giving them a say in how the implementa­ tion will be handled. When people have an opportunity to participate in and influence decisions that affect them, the process becomes less about something being done to them and more about something being done with them. Next are two tools you can use to assess the status of your vari­ ous stakeholders. Both of these methods are valuable ways of thinking about where people currently are and what they are experiencing at given points during the implementation. This knowledge is invaluable in formulating communication pieces, addressing resistance, applying effective interventions, identifying people who can be of assistance, and heading off problems—all aspects of the ORT role. Use these two tools throughout the project to inform your ongoing stakeholder management process.

The Bell Curve This is a simple process (see Figure 5-1) in which you determine at a high level at what point individuals/groups fall into readiness catego­ ries of early adopters, mainstream users, or resisters. There are a vari­ ety of terms used to define each of these states, and some models break it down into five or seven states. To keep this simple, we will use three. Please see the example featured above. Your task is to identify the points at which key individuals or groups are on the bell curve. Their status will change over the course

Figure 5-1: Bell Curve

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of the project, so you will want to revisit this on an as-needed basis. Remember, the purpose of doing this exercise is that it will provide you with insights into why people are doing what they are doing so you can figure out what you can do to effectively and respectfully support them in moving forward. The objective is to move resisters to mainstream status, while leveraging the expertise of the early adopters. If you can get the middle to move over, they generally bring the resisters with them. Here is some general information about the characteristics of each of the three categories of adoption readiness and some things you can do for each group.

EARLY ADOPTERS These are the people who jump on early, love the concept of the CHANGE™ initiative, wanted it yesterday, and in fact may be ahead of some people on the project team. They tend to have a positive atti­ tude about change but can become disgruntled if they think the project isn’t executing correctly. Early EMR adopters, for example, tend to be highly computer literate and high users of technology in their personal lives. You may want to select them for roles on the project, and there are many things they can do to contribute. But they are not suitable candidates for local champion roles because rank and file users do not always relate to them. This group can benefit from: • Being productively involved in the implementation project in a way that leverages their technical expertise. • Being trained early, so they can work on groups to help think through elements such as workflow changes, training scenarios, testing, and developing job aides. • Early adopters who are not viewed as “geeks” and who are good teachers make excellent demonstrators, trainers, and super users. • Early adopters who figure out how the system can work for them (instead of the other way around) can make a significant contribu­ tion. Find them!

MAINSTREAM USERS This group, generally speaking, will survive (and even thrive) the tran­ sition to the CHANGE™ if they are provided with appropriate infor-

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mation, training, and support. They are more cautious than the early adopters but they do not tend toward negativity. They just want to know whats going on, what s happening to them, and how they will be supported to succeed. They tend to be comfortable with change and may actually be very open-minded and interested in new technology. They may or may not have good typing and computer skills. This group can benefit from building confidence through: • Early demonstrations of new software and a chance to talk to respected, informed early adopters about how the system will work and what the anticipated benefits are. • Hearing from respected local opinion leaders about how the implementation will be handled, what the anticipated difficulties might be, and that they can learn the system and be successful! • Early typing and computer skill assessment, if indicated by your project, with easily accessible courses available for skill develop­ ment prior to system training. • Opportunities to ask questions and get credible answers to their concerns.

RESISTERS This group of people tends to believe they have a lot to lose in the CHANGE™ initiative. Many of them don t like change in general, and one as sweeping as, for example, an EMR is particularly unsettling. They may have poor or nonexistent computer and typing skills and tend to be limited users of technology at home. You may have some who are computer literate but are resistant because they do not believe the software the organization is implementing is good enough. This group can benefit from overcoming concerns through: • One-on-one early demonstration of the software and a chance to ask questions about their concerns. • Detailed descriptions of how they will be supported through the transition. • Chances to talk to peers from other organizations or areas that have been through the transition and are doing well and to see the benefits firsthand. • Honest talk. Don t sugarcoat or oversell.

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• Early typing and computer skill assessment, with easily accessible courses available for skill development prior to system training. • Opportunities to express their misgivings (surfacing resistance) and be heard. • For some, becoming directly involved in the project is a great thing. When influential resisters are converted to advocates, they can be very vocal and persuasive with their peers.

The Change Curve The change curve presents a high-level overview of the process people go through when moving through change. It is straightforward and easy to understand. You will probably recognize your own experiences with change when you look at the curve. When you see the change process as a normal and predictable human experience it reduces anxiety associated with change. Under­ standing the curve helps you understand yourself and this makes it easier to manage your own reactions to change. Understanding the curve also helps you be much more effective at supporting others when they are moving through change. Review the curve in Figure 5-2 and think about changes in your life and the reactions you experienced. Do you recognize the process you went through? Just as with the bell curve shown earlier, the change curve is a tool you can use to assess the position at which individuals and groups are at different points in your CHANGE™ implementation. Make a list of people and groups you want to assess. Think through the behaviors they are each exhibiting, and determine where you think they are on the curve. It is a good idea to do this in a small group, so you can com­ pare notes and reach agreement on where to place people or groups. Accurate assessment is important. Remember to assess where your sponsors are in the change cycle too. Understanding where they are and how this impacts their lead­ ership of the change is key to providing them with effective coaching and support. Figure 5-3 describes ways to identify where people are on the curve and suggests appropriate actions you can take in response. There are a number of change curve versions available and they use different

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Figure 5-2: Change Curve (From IMA. A cce le ra tin g Im p le m e n ta tio n M e th o d o lo g y (AIM )\ 2009. www.imaworldwide.com.3 Used by permission.)

terms to describe the reactions people have to change. Some curves are more elaborate than others. For the purposes of the Identifying and Responding to Stages of Change chart in Figure 5-3, we consolidated the stages and terms into four buckets. Use the chart to plan how you will support people based on where they are. Doing this enables you to effectively manage situations that otherwise might be problematic.

MANAGING RESISTANCE The final topic we will cover in this chapter is managing resistance. People try to avoid resistance by pretending it isn’t there and hoping it will go away. This is not effective. The best way to deal with resistance is to get it out in the open. When you know what the resistance is about, you can manage it; when you don’t know what it is about, you cannot deal with it effectively. The best way to begin managing resistance is to identify those who have the most to gain with the CHANGE™ initiative and those who have the most to lose. Those who have the most to lose are likely to

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Figure 5-3: Identifying and Responding to Stages of Change

resist the change. If you reframe your thinking about resistance and see it less as defiance and more as an expression of needs, you will be more effective in your response. Find out what the specific concerns are. You may have to dig to get at the real issues. Resistance to change is a natural and inevitable human reac­ tion, even when the changes are self-imposed and considered posi­ tive. Remember when you decided to get married, or have a baby, or move to a new home? Did you experience regrets of any kind—buyer s remorse, cold feet? Did you even wonder what you were thinking when

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you made that decision? That is resistance talking. And the examples here are generally considered to be positive changes! Think about what happens when the change confronting you is externally imposed; you have no choice, and it sounds like a very bad idea. Resistance is emotional. That is why logical arguments about why one should embrace the change don t work. The more disruptive the change, the more resistance you will see. People are most resistant when they like or are reasonably comfortable with the way things are and see the change as personally threatening. Believe it or not, resisters play an important role in a CHANGE™ initiative. They often express what others are thinking but not saying, and this gets the issues on the table. For this reason, it is important to listen to resisters; sometimes you learn something of great importance to the project. As irritating as they can be, resisters are not necessarily illogical. Sometimes they see something that has been missed. Give resisters the opportunity to express their concerns and needs. Make it safe to question and disagree. Manage resistance by listening actively and acknowledging the concerns. This doesn’t mean you have to agree with them, but you do need to listen. Ignore resisters at your peril! Convert them to advocates by getting them involved in forming solutions. They will be very vocal support­ ers if they get their issues resolved and change their minds about the project.

Here is an idea for surfacing resistance: Exercise

Get a group together that includes resisters. Hold a discussion of concerns and, as the issues are raised, note them on a flip chart. When the list is complete, go through a process to prioritize the concerns. Assign small teams to work on the top few items. This surfaces resistance and gets the resisters involved in problem solving, giving them a sense of control and an opportunity to influence.

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RECOGNIZING THE DIFFERENCE BETWEEN POSITIVE AND NEGATIVE RESISTANCE Positive resistance is the process of exploring and testing the proposed change to gain the knowledge required to embrace the change. The questions and concerns are legitimate and lead to understanding and acceptance. The intent of negative resistance is to derail the change. It can be active, such as lobbying others to not support the change, spreading rumors, not attending meetings, sabotaging the change effort in some way, being disruptive and refusing to participate. Less obvious signs are being “too busy” to participate, pretending to not understand orga­ nizational intent, and continually raising concerns about budget, staff­ ing, etc. A final word about resistance: Don’t focus too much energy on resisters. Some of them may need to just go away. Let them. It is a shame when a small group of resisters succeeds in getting all the atten­ tion and sapping the energy from the project team. Your best bet is to treat resisters with respect, listen to them, and get them involved. Then focus the majority of your efforts on the people who want to succeed and just need some help to get there.

STAKEHOLDER CHECKLIST C h e c k lis ^ l

Stakeholder Checklist □

Take the time to build a stakeholder/sponsor map.



Get to know the stakeholder groups and their individual needs. Spend some time where they work listening and learning about their reality.



Stakeholders and sponsors need to be assessed at various points during the project, according to: ■ ■ ■ ■ ■ ■ ■

Their location on the bell curve Their location on the change curve The degree of impact they are facing What they stand to gain or lose with the implementation What they must do differently to succeed Level of resistance and the fundamental reason for it How they can best contribute to the implementation effort



Develop strategies to support people/groups in moving forward based on the data gathered from this checklist.



Identify and actively manage resistance. Get it out in the open.

Chapter 6

Communication “Think like a wise man , but communicate in the language of the people ” - William Butler Yeats

At the highest level, the purpose of CHANGE™ initiative communi­ cation is to drive behavior change. Communication is successful when the desired behavior change occurs. This makes the communication function extremely important. Well-done, organized, systematic, tar­ geted communication is the means by which most project stakeholders find out what they need to know about the CHANGE™ initiative and what is expected of them in the process. But the behavior change that communication is driving toward does not happen in a vacuum. In the introduction to this book, we stressed the importance of recognizing the integrative nature of all the people-focused components of the project. We cant emphasize this enough. For communication to succeed, it must be received within a supportive environment that has clear sponsorship, complemented by effective training and strengthened by a well-designed reinforcement program. This doesn't happen by itself. It requires a coordinated effort with all people-focused functions working together to align and syn­ chronize their messages and activities.

COMMUNICATION DEFINED Communication is more than just providing information; great com­ munication efforts build in feedback loops to enable two-way com­ munication in which dialog arid face-to-face interactions are particu­ larly important. Feedback is a valuable asset that helps keep the project

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team and sponsors in touch with stakeholder communities, gives early warning of potential issues, and is a way of surfacing resistance. It is also a key strategy in stakeholder engagement and management. By definition, interactive communication requires an interactive commu­ nication plan. The process of pushing out information is proactive; responding to feedback is reactive. You need both. In our view, you cant have good change management without solid two-way communication. Communication starts with stakeholder/audience identification (see Chapter 5, Stakeholder Management). The next steps are to under­ stand how and to what degree each audience will be impacted and dis­ cover the most effective means to deliver what they need to know. You also need to understand the audience frame of reference and recog­ nize their specific communication needs at any point. Armed with this knowledge, the communication team is positioned to: • Be clear about the purpose of each piece of communication with each group. • Provide the right information at the right time through a variety of channels that are relevant to specific audiences. • Receive and respond to the feedback, which informs ongoing efforts. This cycle repeats over and over during the course of the project. It is a process, not a set of materials. Communication is designed to impart knowledge or generate action. The process of delivering the products and receiving feedback is the means by which the purpose of communication is fulfilled. This makes the plan iterative. The four general reasons to communicate are to: • Raise awareness—Provide high-level, general information about the change project; this is “for your information” type of communication. • Develop understanding —Provide broader context and rationale for the change and give more details. • Gain commitment—Get people engaged and involved, willing to take action. • Initiate action—Ask people to do something; ask for behavior change.

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Different stakeholder groups require different types of communi­ cation at different points in the initiative. Some will never need more than general awareness communication. At the other end are stake­ holders who need to start with awareness and move through all levels of communication to behavior change. Knowing when to apply each requires that you know and understand your stakeholder groups and the role they play in the CHANGE™ implementation and the technol­ ogy adoption process. In this chapter, we will explore important aspects of effective com­ munication. This is not meant to be a course on communication but rather a discussion of what we have learned (mostly the hard way!) about effective communication during large software implementation projects that we believe are applicable in any CHANGE™ initiative.

THE IMPORTANCE OF COMMUNICATION In many ways, communication is the life blood of the project. It flows across all boundaries, impacts all stakeholders, and helps establish and maintain the tone of the project. Through communication, people learn about everything from their first exposure to the case for change and the vision to specific local details and the call to action, such as: • When are we scheduled for training? • What is our go-live date? • What kind of on-the-ground support will we have? • Will the new system be easier to use than what we do now? • How will my job change? • What is expected of me? Good communication dispels rumors, builds confidence, and helps people feel part of what is going on. It can add a touch of humor to relieve anxiety. And when it is really good, it is a way for the organi­ zation to say to impacted employees: aWe know you and care about you. We understand your concerns and are working to address them. We want your ideas. You are a valuable asset to the organization, and we are investing in your success. We cant do this without you—your active participation is vital.”

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Of course these messages must be backed up with appropriate action, but the process of communicating these things helps create an environment of trust. This is a very important contribution to the proj­ ect and the organization. Great communicators who can craft these messages in a way that engages and motivates are worth their weight in gold! “In times of change, trust-building behaviors are positively related to an organizations capacity for change. Conversely, trust-breaking behaviors are associated with a decrease in capacity for change.” Mar­ garet M. Rudolph, PhD, Consultant, Vancouver, British Columbia, Canada. We never work on large-scale change projects without being linked at the elbow with a great communication team. Best of all, this part­ nership is fun—most communicators are creative and have excellent ideas about how to effectively engage people. With an implementation as significant as any of the CHANGE™ initiatives we articulated in the introduction of this book, we recommend you fully utilize the tal­ ents of your communication staff. Assign the best; dedicate them to the effort, give them some creative license and a budget—and watch what happens. You will be amazed at what is possible.

key trip Most people are very uncomfortable when they feel consciously incompetent, but care givers are particularly resistant to situations that undermine their confidence and put them into a “novice” state. There is good reason for this. A patient can be harmed by an incompetent provider. Effective communication acknowledges this concern and helps people understand how the organization will support them through the transition to CHANGE™.

COMMUNICATION PLANNING You must develop a communication plan, no matter how small your organization. A communication plan can be very simple or long and

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complicated. What you need depends on the size and complexity of your organization. The purpose of a communication plan is to enable delivery of planned, consistent, targeted, timely communication to the right groups, at the right times, using the most effective medium with built-in means for two-way communication. Thinking all this through in advance improves the likelihood that your communication activities will proceed smoothly and be effective and has the added advantage of making it much easier to respond effectively to unforeseen communi­ cation needs when they arise (and they will!). Develop the communication plan early in the project. You wont know everything at that time; just plan for what you do know and real­ ize that the plan will change and evolve over the course of the project, requiring regular updates. Here are the basic things to include in a communication plan, fol­ lowed by Table 6-1, which provides an example: • Target audience/stakeholder groups. • Objective of each communication (awareness, call to action, infor­ mational, set expectations, develop commitment, etc.). • Vehicles/mediums for delivery. • Who the communication is from and who is responsible for pre­ paring it. • Frequency and duration of the communication, if ongoing. • Dates/timeline for delivery. • Feedback mechanisms. • Status and any notes.

Table 6-1: Sample Communication Plan Template S ta k e h o ld e r G ro u p / P erson

P u rp o se o f C o m m u n ica tio n

V eh icle / D elivery M ethod

S e n d e r/ D eveloper

F re q u e n c y / D uration

Dates / T im e line

Feedback

S tatus / Notes

Medical Assts.

Supporting Physicians with In Basket

Policy Revision

Labor Steward

Weekly

T-9 until Go-live

Q&A in Team Meetings

Introduce in Team Meeting

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SUCCESSFUL PRACTICES FOR EFFECTIVE COMMUNICATION What follows are some simple truths about communicating. This is not rocket science! Much of it is common sense: treat people with dig­ nity and respect; tell them what they need to know—what the organi­ zation expects of them and how they will be supported. And do it in a friendly and engaging manner, using vehicles that are effective for the users.

1. Know Your People This is the first rule. If you don’t take the time to identify and under­ stand your stakeholders, your communication efforts will not be tar­ geted. They will be too general to be meaningful and appealing and will most likely be ignored. Who are the stakeholders? They are all the groups, teams, com­ mittees, and individuals that have a stake in the change. Having a stake simply means that people will be impacted by the change and its out­ come in some way and/or that you need something from them in order for the change to succeed. In Chapter 5 on Stakeholder Management, we stressed the need to understand a stakeholder groups frame of reference. This means understanding the point of view, culture, language, way things are done, and the issues of the group. Another way to think of this is WIIFM, or “Whats in it for me?” This is an important question for any individ­ ual or group. Each person wants to know what the proposed change means to him or her, good and bad. To communicate effectively, you must be able to articulate WIIFM in the language used by the group.

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Key Point Communication Keys Three keys to effective communication with any stakeholder group are understanding and adapting messages to their: 1.

Language (way they speak, words they use, may mean actual language such as Spanish)

2.

Frame of Reference (where they’re coming from)

3.

What’s In It For Me?

jEElM· O ne of the best ways to persuade others is with your ears - by listening to them.” - Dean Rusk

A word of advice: Get out, listen and observe how people who will be impacted by the change currently do their work. There is no substitute for this! You cannot sit in an administrative building and really understand the day-to-day reality, the issues and stressors, the workflows and the opportunities that present themselves to front-line caregivers, pharmacists, receptionists, billing staff, and the many oth­ ers who are impacted by a CHANGE™ implementation, unless you spend some time in their world. You cant communicate effectively if you don’t know the audience—where they are coming from and the degree of impact they will experience from the change. Understanding your stakeholders enables you to make your communication style and content appropriate and effective for the intended audiences, which is the whole point.

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l

To make your communication even more effective, find ways to help people translate EMR project messages into their own words. The easier it is for front-line staff to tell the story their way, the more likely it is that they will accept it and tell others about it.

Please refer to Chapter 5 on Stakeholder Management to learn more about identifying, engaging, and managing stakeholders.

2. Tell the Truth! Be open and honest. People can smell a rat, and its amazing how quickly this happens. In the· long run, it is much easier to be honest and transparent, even about the hard issues. Here are some guidelines: • If you don’t know the answer to a question, say you don’t know and then explain what you are doing to get the answer and when you expect to have it. • Set up a regular communication schedule so people know when they will hear from you. This reduces anxiety because people know when they will be updated and can ask questions. - Example: Project updates will be provided every Tuesday morn­ ing by broadcast e-mail. Q&A sessions to be held monthly by video conference. Once a quarter, all-hands lunches with leaders will be scheduled at staggered times. • If you have a leadership role, get out and talk to the various stake­ holders. Do more asking and listening than telling. Follow up on concerns that are identified. This builds trust and makes people feel valued. • Cover both the advantages (upside) the new system will provide, and be open about anticipated issues and challenges (downside). Challenges can include anticipated difficulties with the initiative, the implementation process, or learning certain software appli­ cation features. This is key to managing expectations. Tell the full story. Do not sugarcoat.

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• Admit when you or the project makes some kind of mistake. Believe us when we say there is no way you will get everything right with a CHANGE™ initiative. Be honest about it. Admit what went wrong; explain whats being done to fix it and how you will avoid repeating the problem. • Acknowledge issues with past change efforts in the organization. Help people understand how these important lessons have been factored into CHANGE™ planning so they are not repeated. • Communicate even when you don’t have anything new to report. Simply state there are no changes since the last update, and things are proceeding as planned. Remind people when they can expect to hear from you again. • In the effort to develop support for the CHANGE™ project, we stress all the advantages of the new system and talk about the prob­ lems associated with the current state. But to those who are uncon­ vinced, this may not be believable. Counter this situation by also being candid about the potential difficulties with the initiative, and acknowledge the perceived strengths of the current way of doing things. In as legitimate a way as possible, associate positive things about the current state that people want to retain to the future state described in the vision. Q uote

“A person who has had a bull by the tail once has learned 60 or 70 times as much as a person who hasn’t.” - Mark Twain

3. Gather User Lessons Learned for Continuous Improvement One of the important things to realize about an EMR implementation, for example, is that it never really ends. After go-live there will always be software upgrades, new applications, bug fixes, new hardware and devices, and new employees, not to mention continuing discovery of ways to improve workflow and care delivery from untapped capabili­ ties of the system. For example, have you taken training in Microsoft

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Word after having used it for ten years and discovered all kinds of fea­ tures and tricks you didn’t know about and could have been using? That’s the way EMRs are, too. It will be a continuing learning and discovery process that will translate into improved care delivery and administrative processes. Bake the idea of continuous improvement into the project from the beginning. Help people see that everyone has a responsibility to continue learning, both from successes and mistakes. Remember, you won’t get it all right the first time. Creating a continuous learning envi­ ronment, “test and learn,” is a strategy for dealing with this reality. One way to introduce and reinforce the idea of continuous improvement is to gather user lessons learned after key application go-lives. This process asks users to comment on various aspects of their preparation and go-live experience to determine relative effectiveness and gather suggestions for improvement. The general areas to assess include sponsorship, communication, training, the go-live process, and support functions. We recommend conducting the inquiry six to eight weeks post go-live. This timeframe seems to be the sweet spot. Users are far enough past go-live to have stabilized, but the memory of their preparation and go-live experience is still clear. Conducting a formal user lessons learned process helps people see that the organization is serious about improving and underscores the value of user input. It also helps to create an environment in which it is safe to try new things. When you encourage people to try things and provide opportunities for practice, they learn faster. If your organization is large or if you are using a phased implemen­ tation approach for your CHANGE™ initiative, user lessons learned can add value immediately. A serious continuous learning message is delivered when the successes and mistakes of one go-live are used to improve the next. In fact, even users who go through a difficult go-live feel good when they know that their experience is being used to make things better for others. For this reason, we strongly recommend that you circle back to lessons learned participants to let them know how their feedback is being used to improve the project. Everyone appreci­ ates knowing when their contribution makes a difference. If your organization is small or if you are doing a big-bang go-live, a user lessons learned process is still worth the time and effort. Gather-

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ing feedback gives users a chance to participate and be heard, and the lessons will be valuable in planning your next implementation project. You can gather lessons learned in variety of ways—focus groups, interviews, or surveys. Whatever your method or combination of methods, communicate the findings broadly for the biggest impact. The whole point is to share the learnings and make the identified improvements. Do this and you will be on the road to establishing a continuous learning culture.

4. Use a Variety o f M edium s You may think this goes without saying, but this rule is so important that it must be mentioned. Different communication vehicles are more effective than others with different groups. Your job is to know what methods work with your various stakeholders. One size doesn’t fit all. Its so easy to think that e-mail is the best communication method—everyone has it, its inexpensive, and its 24/7. Whats not to like? The real question is whether e-mail is an effective vehicle for the people you are trying to reach. In some organizations, there are people who do not have computers. If you rely heavily on e-mail, they won’t get the messages. And even if you are targeting man­ agers who do have computers, it is likely that they are overwhelmed by e-mail. How will you get their attention? The answer is that you need many different ways to reach people. E-mail is only one tool. There are many other means at your disposal: newsletters, bulletin boards, videos, CDs, conferences, meetings, broadcast voice mails, flyers, letters mailed to homes, websites, train­ ing programs and materials, posters, drawings and contests, demon­ strations, staff meetings, supervisors, sponsors, lunches, parties and so on. Identify what currently works for your audiences and add to this with new ideas. L e s s o n L e a rn e d

Spending time up front on face-to-face communication and dialog takes time, but it pays off in the long run by answering concerns, dealing directly with resistance, increasing understanding and building acceptance. Starting this early accelerates change throughout the project.

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Be creative. Try new things. With a big CHANGE™ initiative, its important for communications to have a different look and feel. If it all looks like it always has it will be very hard to get anyone’s attention. If your organization relies heavily on e-mail, you might want to try roadshows as a different means of connecting with stakeholders. If you do an ICD-10 roadshow for providers, for example, model the need for alignment across disciplines by including a variety of roles as present­ ers—not just physicians but also coders and billers. Measure the effectiveness of your communications. Are they accomplishing what they are designed to accomplish? How do you know? As you identify what is most effective, do more of the things that really work. And don’t forget about the people who are hard to reach. You may need to be your most creative to reach them. They will appreciate the effort. Remember that people learn in different ways. Be sure your deliv­ ery methods include all forms—written, oral, visual, and experiential. It doesn’t hurt to ask people what method of communication they prefer. One final thought. Be mindful of when to use a formal tone and process and when to be more informal and engaging. To some extent, this is determined by the target audience. It is also influenced by whether the message content is about non-negotiables, such as legal or financial requirements, or whether you are seeking commitment to changes that are not required by law.

5. There Is No Such Thing as Overcom municating! People have a hard time believing that you cannot overcommunicate. In fact, the most common communication error in software deploy­ ments is undercommunicating. Has a leader ever told you that he or she has already issued the message too many times? That they feel awkward saying it again? That they believe no one wants to hear it one more time? And yet the truth is that even if the message has been delivered multiple times, you do need to say it again. Perhaps not in exactly the same way, but you need to recommunicate the key points over and over during the life of the project. Of course you want to ensure that the

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message is being understood by the target audiences. If it isn’t, refine it before repeating it, but keep repeating it. And test for understanding. Repetition and redundancy are goals, not things to be avoided. People need to hear messages multiple times before they really incor­ porate the meaning. Sometimes people don’t fully understand what was said the first few times, or they don’t believe it. The fourth or fifth time around may be when they begin to get it. This is one reason why having different communication vehicles at your disposal is so important. There is an old saying that when the last employee gets it, you can stop delivering the message. This is just a fact of life. Keep communicating!

COMMUNICATION IMPLEMENTATION CHECKLIST □ The purpose of communication is to drive behavior change! □ Build a communication plan early in the project. □ Ensure that early communication about the CHANGE™ initiative comes from senior leadership (sponsors) and clearly conveys their authorization and support. □ Provide scripts and talking points for leaders to help ensure consis­ tency of messages. □ Clarity is a gift! Spread it around. □ Know your stakeholders; understand their frame of reference and what’s in it for them to make the change. □ Remember the need to connect with people on an emotional level. □ Be honest and transparent in your communication. □ Use communication to help manage expectations. □ Encourage open discussion of rumors. Failed change projects often have inaccurate rumors about the change that were not addressed. □ Remind people of what will stay the same. □ Use a variety of communication mediums and be creative in your messaging. Creating a different look and feel will help get attention. □ Conduct a robust user lessons learned effort. □ Every communication product should have a feedback loop.

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□ Remember that avoiding pain is a greater motivator than doing something for positive reasons. □ For communication to succeed, it must be received within a sup­ portive environment that has clear sponsorship and be compli­ mented by effective training and strengthened by a well-designed reinforcement program. □ Communicate, communicate, communicate!

S e c t i o n III

Ability— Developing Requisite Skill

109

Chapter 7

Training Strategy Effective training teaches people how to do their job, not how to use the system.

An argument was made earlier about the importance of organizational context when delivering training. Training is a crucial step in the implementation process, and to be most effective, it must be delivered in an environment that supports growth and learning, and where users understand the role they play in achieving the CHANGE™ vision. Assuming the proper context is in place, the onus is on training to “connect the dots” for users—that is, to link what users need to know with the knowledge of how and when to apply their new skills to take advantage of system capabilities. Connecting the dots is a powerful way to embed use of the system into user roles and responsibilities. It s a bigger picture way of thinking. The goal is not just to teach sys­ tem features and functions but rather to support users in becoming critical thinkers who efficiently and effectively reap the benefits of the new technology, whether the benefits are providing better patient care, meeting new coding requirements, using data to make informed deci­ sions, or other objectives the CHANGE™ initiative envisions. Key Tip An effective CHANGE™ training program is user-centric meaning it is role and workflow based, not system based.

Ill

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USER TRAINING DEFINED Training is the means by which an organization teaches employees effective use of a new system and consequent role changes. In other words, how does the new system integrate into and change the way work is done and, as expressed in the questions that follow, what does that mean for individual roles and responsibilities? “What do I need to do differently to be successful? If I change, how will it benefit my patients and the organization?” Even the best system wont produce anticipated results if it is deployed in an environment focused on “this is how weve always done it.” Training comes in many formats—classroom, instructor-led, proctored free time, Web-based, written, etc. There are also different levels of training needed to support a CHANGE™ initiative. With ICD-10, for example, many people will only need general awareness training and this can easily be done with e-learning modules and/or in staff meetings. Coders, on the other hand, need in depth training on the code set changes and how to use them. And then there is the role-based training that gets into the details needed to perform different jobs in the ICD-10 world. The training strategy must discern between these different needs. One other important aspect to consider is whether any groups need some kind of pre-education. For example, do your coders need anatomy, physiology or microbiology training to prepare for the new ICD-10 world? If there is a need and it is not addressed before ICD-10 training begins you may experience competency challenges. The best training is that which uses a combination of methods, taking into account the variety of ways adults learn. An effective CHANGE™ training program is user centric, meaning that it is role and workflow based, not system based. Effective training teaches peo­ ple how to do their job, not how to use the system. Here is a real-life example, as shared by a check-in clerk at one particular facility: “I attended seven hours of training, but when I got back to my desk, I didn’t know how to check in a patient!” This chap­ ter presents a program called The Connect-the-Dots Approach that will help you avoid making this costly mistake.

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THE CONNECT-THE-DOTS APPROACH There is a rather simple way to help users connect the dots during training. The model featured in Figure 7-1 makes training relevant to users, facilitates sustainable performance improvement, and sets the stage for effective use of the newly learned computer skills on the job, creating the opportunity for meaningful use. This is done by directly connecting business reasons for the change, expectations of users, and impacts of system misuse with workflows, system training, and time for practice. There are two aspects of this: organizational and individual. If you are successful in building relevance for users and are able to help them connect the dots, you will unleash a world of human poten­ tial other healthcare organizations will envy. Its an amazing transfor­ mation, when done well.

Effective training is a partnership between training and oper­ ations. Connecting the dots runs counter to transactional training approaches in which the focus is on completing feature/function training and checking it off the list. Not all training is delivered in this system-centric way, but it is not uncommon to hear complaints that training lacks a strong connection to operations. When training focuses too heavily on system features and functions, the critical clini­ cal and business aspects are shortchanged and the real purpose is lost. This reinforces the suggestion made in Chapter 4 on the Organiza­ tional Readiness Team to involve operational thought partners in the planning process to ensure the training accurately and effectively sup­ ports operations. If operations is at the table to review, comment on and approve the training curriculum, users are sure to receive relevant role-based training. Physicians, department managers/supervisors,

Figure 7-1: The Connect-the-Dots Model

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and labor representatives are extremely helpful partners in making certain the training content is on target. The Connect-the-Dots Approach is a means to strengthen the relationship between training and operations by creating a partner­ ship. When everyone agrees that training is the logical place to connect the new system with day-to-day clinical and business practice, curriculums are developed that are meaningful to users in their respective roles, scope of practice, priorities, and specialty or department. The goal is to tie the learning to a compelling case for change and to deliver the content in a way that is most useful for each audience.

key trip It is helpful to have at least one trainer with clinical experience present when training clinical users. In the inpatient setting, using nurses as trainers can be very beneficial. Bring in retired nurses if necessary and train them well. Respected nurses can support and coach physicians in effective use of the system, helping them become productive users more quickly.

Effective training is workflow based. If you want users to under­ stand how the technology can increase operational efficiencies, give them workflow-based training. We recommend revising workflows as much as possible before training. But remember, you will learn a lot more about the system when you begin to use it in daily operations. That means that workflows will typically be revised more than once. Manage expectations about this. Though it may seem frustrating, revising workflows based on team experience is a great way to get people involved in lever­ aging the system and taking the waste out. To quote one executive, “You wont finish revising workflows until after go-live because no one knows what the damn thing (system) is before they use it in real life!” The problem is that in a typical situation, during the scramble to prepare for implementation, trainers are not always kept abreast of clinical workflow modifications. The result is that trainers train what they know and users primarily learn features and functions of the sys­ tem. Trainers demonstrate the systems capabilities but are unable to

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show users how the system fits into the new workflows. This may well be one of the biggest mistakes with training during an implementation, and it is usually out of the trainer s control. If workflows are not revised in time and if code is not frozen, trainers cannot build workflow-based curricula in the production environment. Its that simple. This is one important reason why we insist that the organiza­ tional readiness work plan be integrated with the technical work plan. Missed-opportunity situations like this must be anticipated and planned for if the organization is to get the highest value from the expensive training required for effective implementation readiness. Key Tip Left to their own devices, end users do NOT eventually figure it out over time.

Training and support are required for success. During the last few years, the notion developed that users do not need much attention and support in preparation for CHANGE™ implementations. Instead, the belief is that users will figure things out for themselves over time. This would be nice if it were true, but unfortunately it is not how things happen for most users. Technically skilled early adopters can be rela­ tively self-sufficient, but the majority of users come from a different frame of reference, set of experiences, level of comfort with technology and other individual differences that make it difficult or impossible for them to learn on their own. The notion that users can become profi­ cient without intervention runs counter to our experience. Out of necessity, users do whatever they can to survive and get through their day. When they are not well prepared for change, they regress to old habits and workarounds and invent new workarounds to fill the gap. Poor preparation and attention to the people side of an implementation lead to cementing of poor workflows and inadequate use or misuse of a new system. There is a sense of security in use of established processes, regardless of their effectiveness. Leadership is required to ensure that new workflows are implemented and used. This doesn’t happen by itself.

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Over time, users may refine their abilities to use the new technology and even become better prepared to ask more sophisticated questions during follow-up training, but this is a big risk to take when so much is on the line for the healthcare organization. Given that users ultimately determine whether a new system will deliver the hoped-for benefits, it is prudent and logical to invest in fully preparing them, pre and post go-live, to deliver results. Post-live support is essential to ensuring adoption does not stop below necessary proficiency levels, let alone the desired levels. Work after go-live is just as important as that before go-live if the changes that can be driven by technology don’t fall short of potential. Remember that business value is limited by poor adoption. All training should build relevance from both an organizational and individual level for the users. As the training curriculum is being developed, we recommend following the Connect-the-Dots format to ensure users are engaged in their learning and get the utmost value from it.

Connecting the D ots to the O rganization Set the context for training in the beginning of a session so participants understand why they are there. Find a brief, succinct way to present the case for change, expectations of users, and how inefficient use of the system has a negative impact on the organization (see Figure 7-2). The best case scenario is to have an executive sponsor of the CHANGE™ present this section of the training. It takes only 10-15 minutes, but the impact is incredibly powerful. Having an executive sponsor deliver this message eliminates any ambiguity about the importance of the training or the CHANGE™.

Figure 7-2: Connect-the-Dots Model (Organizational Connection)

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It is truly amazing to witness the dedication of some leaders as they dart from medical center to medical center (or hospital to hos­ pital) to be present for a rolling schedule of training sessions across an organization. These individuals take the role of executive sponsor seriously and deliver the case for change in a compelling way. Making the effort to be present at initial training sessions sends a clear message and helps users see that leadership is not just paying lip service to the implementation but actually changing their behavior to champion the cause. This is an example of executive sponsorship at its best! It is helpful to sponsors if you provide them with a script for these presentations. Review Table 7-1 for some talking point ideas. Keep in mind that the message is much more believable when sponsors put it in their own words and speak with conviction. If the message is delivered by reading from a piece of paper, what gets communicated is the lack of passion about the topic. Users are easily turned off by this type of delivery, so coach your sponsors on how to deliver an effective message.

Connecting the D ots at the Individual Level Connecting the dots at the individual level (see Figure 7-3) is pretty straightforward, but it is important to reiterate that the effort is greatly enhanced when the business case for change is already understood. What people need to know now is how the CHANGE™ initiative will impact their day-to-day work and their job. Effective training delivers the answers in a way that is relevant and understandable to users. One of the best techniques is to emphasize how certain workflows and skills will benefit the user.

Figure 7-3: Connect-the-Dots Model (Individual Connection)

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Table 7-1: User Training Talking Points for Sponsors Topic

Detail

Defining the business case for change

The purpose is to define what the organiza­ tion is trying to accomplish via the new EMR system. Many times, the technology affords a way to improve upon a current outcome, so the executive is encouraged to compare how the organization is currently performing with how the new technology can help reach the envisioned future state.

Sharing goals and expectations from leadership

The intent is to highlight specific goals that the organization wants to accomplish and share what leadership expects of users in reaching these objectives. Share recent policy and other changes that are relevant to the discussion.

Highlighting targeted impacts

Executives help connect the dots by sharing how users directly impact patient safety, rev­ enue capture, operational efficiencies, cost cutting, patient satisfaction, care delivery, and a host of other critical organizational priorities. Users need to understand how effective and ineffective use of EMR impacts the organiza­ tion’s ability to succeed. Don’t assume that users are always aware that a simple click can have a major downstream impact on the patient and the organization.

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Physician Perspective For the majority of physicians, technology that assists them in being both knowledgeable and efficient is quickly incorporated, whereas EMR procedures that have no immediate clinical benefit are simply felt to be a nuisance. For example, showing a provider how to bring up a list of key clinical resources with one click, while still in the patient's EMR, has been much easier to adopt than entering past surgical history, organized by CPT code, into a remote EMR entry field. Kenneth Goodman, MD Associate Director, Center for Continuing Medical Education Department of Family Medicine Cleveland Clinic

Role of front-line supervisors: It is extremely helpful to have a front-line leader (such as a clinical supervisor, physician lead, or some equivalent to a department administrator) working with the trainer in the training session. As the trainer demonstrates the new system, discusses workflows, and reviews critical new skills, users think of many questions that are beyond the ability of the trainers to answer. Instead of leaving the questions unanswered and users feeling anxious, the attending front-line leader is there to reinforce new workflows, explain role and responsibility changes, review policy adjustments, and address scope of practice concerns. There is no better person to address these questions on the spot than a users direct supervisor. This doesn’t mean everything can be resolved in training. It does mean that users can raise their questions and get their minds back on training. The better prepared supervisors are to actively participate and support their staff, the better training and go-live will be. Workflow: Remember that trainers should not be the first source of new information about role and other job changes. This is not their responsibility. However, trainers should be prepared to discuss workflow changes necessitated by the system, as this is critical to user ability to begin to align the system with their everyday work. Users need to

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clearly see the relationship between the new system and how the work of the unit gets done. The system will not be used in a vacuum but within the context of the daily activities of the unit or department. It is not good practice to allow trainers to focus on system features and functions and send users back to direct supervisors to discuss workflow related questions after training. Remember to include discussion on how users interact with any existing systems that will stay in place and cover handoffs with ancil­ lary departments. Practice: Users must have adequate time to practice with the new system before going live. New skills must be ingrained. And users who are new to computers will fare much better if they can become com­ fortable with the computer. Build a practice environment (sandbox), and make it easy for people to access it. Ensure the sandbox mirrors the production environment and provides role and domain-specific scenarios. Some organizations mandate practice and provide protected time for it. Some provide a practice classroom with a proctor where users practice on their own, but the proctor is available to answer questions. Supervisors must ensure everyone does practice and that questions are addressed. It is helpful if some informal leaders begin practice first and then encourage and support others to do so. Fear is a barrier to reten­ tion. Practice builds confidence. An important aspect of effective practice is having real-life sce­ narios to work with. Role and specialty-specific situations help people learn how to do their real work. Ensure that the scenarios you provide are relevant to users. No hypertensive patients for surgeons! key trip I hear and I forget. I see and I remember. I do and I understand. - Confucius

Ancillary support: At certain points during training, it is a very helpful to have knowledgeable ancillary sponsors present so that flow, interface, and handoff issues with orders and results can be discussed.

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Updating information: We advise that you limit the number of job aids you provide. They can be overwhelming and cause confusion if not done well. To avoid the “drinking from a fire hose” syndrome, we recommend preparing a short, simple reference booklet. If you teach to the tools in the reference booklet as part of training, the tools will be used on the job. As lessons learned are gathered, workflows are revised, and deci­ sions are made after go-live, be sure to update the booklet and dis­ tribute to all. Have clear accountability and a process for doing this. Common complaints post-live are that changes and fixes are not con­ sistent or are not broadly communicated. (See Table 7-2 for training principles.)

SUPPORT STRATEGY Training is required to ensure users understand how to do their jobs effectively, but users also need on-the-ground support and continued reinforcement once the system is implemented. This is another exam­ ple of the need for organizational readiness integration in which each component supports and reinforces the other to get the desired out­ comes. Training alone is not sufficient to achieve objectives. Learning must take place in a supportive environment and must be reinforced and coached. Without reinforcement and support, it doesn’t matter how much you train and communicate, you are not as likely to get the results you seek. Because organizations differ in size, budget, and scope of appli­ cations being implemented, the intent of this section will focus more on overall strategy for supporting end users and reinforcing desired behaviors, as opposed to drilling down into the details about specific support models and ratios. It goes without saying, but the more sup­ port that can be provided in the weeks after go-live, the better.

On-the-Ground Support The hope is that every user receives excellent training and is afforded multiple opportunities to practice newfound skills before his or her team goes live with the new system. Even with the best preparation, it is difficult to remember everything learned during training, especially when there is a rather steep learning curve. Providing on-the-ground

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Table 7-2: Three Guiding Principles for Effective Training Principle

Detail

Demonstrate relevant

Demonstrations of the new EMR system should be succinct and rehearsed ahead of time. Compare the way things used to be done with the new way of using the EMR. Define role and responsibility changes for those in atten­ dance. Don’t fall into the trap of showing mul­ tiple ways of accomplishing the same task, as it can overwhelm users and cause confusion. Place more emphasis on workflows and how the technology can help, not just on features and functions.

workflows

in new EMR system

Highlight critical system skills

During training, users must learn critical skills by role, and develop understanding of organi­ zational priorities and goals for use of the sys­ tem. The average person cannot retain dozens of different tasks and techniques when using a new system, so it is best to focus on only what the user needs to know and limit the lessons to multiple shorter sessions, as opposed to fewer longer ones. Emphasize small things that save time and result in increased operational effi­ ciencies. Show users how the skills relate to a manageable work/life balance. After go-live, the training should dig deeper into other fea­ tures and functions within the system that can further support operations.

Provide opportunities for practicing the new skills

Users need to see, touch, experience, and practice the new skills and workflows. Provide adequate time during training for participants to practice so the skills can be ingrained. Also establish a practice environment (or sandbox) so users can practice outside of training at their own speed to gain comfort and confidence. It is best to provide protected time for practice to help ensure users do it.

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support for users during implementation is critical to the successful transition to the new way of doing things. On-the-ground support varies from hospital to hospital, region to region, and organization to organization. Regardless of the actual support model, the end goal should always be to help “ready users” become “confident users” of the new technology. This is important, because oftentimes, the support strategy is too transactional. This can be counterproductive and actually turn “ready users” into “dependent users.” Transactional support is well intentioned, but it is focused on demonstrating tasks without ensuring the user can perform the tasks. This is problematic in the long run and very difficult to reverse. The biggest mistake an organization can make is falling into the trap of adhering to a reactive mode of delivering support in which sup­ port resources are so eager to answer questions and demonstrate how to accomplish tasks in the system that users are not actually learning. This phenomenon cripples the ability to transform users into critical thinkers because they unconsciously grow reliant on seeking help when issues or questions arise rather than being trained to think through the situation. What happens when the support resources are no longer at the elbow? The objective should be to provide timely, targeted support in a way that leaves users capable of working through the same or sim­ ilar problems on their own. Another common mistake a support team can make is to focus too heavily on the features and functions of the system and not rein­ force operational workflows. This also impedes the ability of users to transition from “ready” to “confident” status because they learn only what buttons and links to click on without fully understanding the big picture. Users definitely need to learn the requisite system skills, but more importantly, they need to know why and when to perform these functions and be cognizant of the downstream effects of their actions. It is not uncommon to see waves of users struggling with a new system, such as an EMR, even years after go-live because they haven’t been sup­ ported properly. Support resources must understand the departmentspecific and role-based workflows and incorporate this knowledge when providing support. And they must understand that the overall purpose of support is to create self-sufficiency, not dependency.

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Remember that the best support is often provided by people who have experience doing the work. Users really appreciate having an experienced peer to learn from. This is true for both clinical and busi­ ness functions. Knowledge of the workflows, terminology, and roles and responsibilities is a big plus. This is one reason why local champi­ ons, super users, and supervisors can be such great support providers. When more weight is placed on the technology than on opera­ tions, issues are bound to arise because people get stuck and are not able to move beyond the technology. It is important to remember that the new system is merely a tool to support operations; it shouldn’t drive operations.

Growing Internal Capacity Another focus of the overall support strategy is to effectively grow internal capacity among users. That is, users must learn to sustain themselves after a certain period of time because support cannot be provided at the rich go-live level forever. It is way too expensive. By way of analogy, parents need to learn to let go of their children at some point and trust they did everything they could to develop confident, stable, independent, and capable citizens. Just as we don’t see parents accompanying their children in a college classroom or in a work set­ ting, support resources must ensure users are able to support them­ selves at some defined point. Much too often organizations struggle with how to meet the growing demand for support even years after go-live, as they have created a scenario in which the project support team is viewed as the first line of defense for questions or problems that arise. The best way to increase internal capacity on a unit is to engage early adopters and local champions in becoming active in the overall support effort from the very beginning. Additionally, front-line super­ visors must be actively involved because it will be their job to monitor performance and offer first-line support as part of their ongoing role. Early adopters, local champions, super users and front-line supervi­ sors benefit from being trained early and then repeating the training with their teams. This gives these operational support resources the knowledge that enables them to intervene effectively when team mem­ bers need help. The project support resources serve as an extension of

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the operational support effort. They coach and mentor the front-line leaders so they can fully assume the first line of defense role after the project support resources are disbanded.

Paying It Forward A successful practice approach for preparing front-line leaders to sup­ port their teams and champion the overall implementation effort is to have them participate with teams that go live before their own. This way the leader gets firsthand go-live experience and is much better prepared when their own team goes live. This builds user confidence because they recognize that their leader has experience and is a cred­ ible support resource for the team. Paying it forward is a great way to develop capacity in an organization. Another way to do this is to create a support network for the front­ line supervisors. Hold weekly calls throughout the rollout schedule during which front-line leaders can talk with one another about their go-live experiences and offer advice and support. Even if front-line leaders (typically the lead nurse, clinical supervisor, and/or depart­ ment administrator) arent involved in a go-live in the near future, it is extremely helpful for them to attend the weekly call to hear the issues, challenges, and lessons learned being discussed by their peers. This is invaluable data that will help front-line leaders speak confidently with their teams about what to expect.

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TRAINING CHECKLIST

key trip Training Checklist □

Chunk the training; no one is able to drink from a fire hose.



Focus only on the critical skills at go-live; show tricks and tips later.



Training is part of a continuous improvement process. Provide multiple learning opportunities for users before, during, and after go-live.



Training is not just about features and functions; workflows and content are king.



Establish a context for sustainable learning up-front; even houses need a foundation to rest on.



Focus on developing critical thinkers, not robots that just push buttons and links.



Understand your definition of success, and ensure you can capture data to monitor progress toward goals.



Ensure training is targeted to role, scope, and specialty to make it relevant to users.



Help users understand how the implementation of the system changes relationships and handoffs between departments.



Provide a sandbox for practice and exploration on own time; it must mirror production and contain role- and specialty-specific scenarios! Make sure users have sufficient time to practice before going live on the unit.



Partner with Operations when delivering training to reinforce new workflows/roles/ responsibilities and help integrate the system into the day-to-day work.



Be strategic with job aids; keep them short and simple to not overwhelm. Teach to the aids in training. Keep them updated as things change.



Make sure front-line leadership/sponsors are trained ahead of time, so they know what they are preaching and can support their teams. They should play an active role in training, workflow redesign, role and responsibility changes, and issue resolution. Support them with timely information such as scripts, frequently asked questions, training schedules, go-live dates, etc.

Chapter 8

Reinforcement Reward what you want to see.

Reinforcement is the most underutilized means of driving behav­ ior change in organizations. Reinforcement is a means of making the incentive to change greater than the incentive to stay the same. Leveraging the power of reinforcement delivers clarity of purpose and focused energy to your CHANGE™ initiative and by so doing, speeds up the process of change.

REINFORCEMENT DEFINED Reinforcement refers to all means an organization utilizes to recognize and reward desired behavior and deliver negative consequences for undesired behavior. When reinforcement aligns incentives with the desired future state, it is a key driver for achieving business objectives: “...in the workplace, there is no accelerator with more impact than purpose-based recognition.”4 Please note that we use the word reinforcement intention­ ally because it encompasses both positive and negative response to employee actions. key trip Reinforcement = Rewards + Negative Consequences

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Don’t dismiss reinforcement as just “soft stuff” or “being nice,” sentiments often associated with appreciation programs in which rewards are not tied to clearly defined behavior changes and outcomes. Reinforcement isn’t about thanking people for extra effort—the real question is not how hard someone worked but what was accomplished. There is nothing wrong with appreciating employees, but a welldesigned reinforcement program is much more than appreciation. Reinforcement programs with strategic intent require: • Clarity about the specific behaviors and performance outcomes you are looking to reward. Employees must understand the desired target. • Organization-wide understanding that good performance against the stated expectations will be rewarded, while there will be nega­ tive consequences for poor performance. • Expectation-setting with leaders so they understand that deliver­ ing reinforcement is part of their job. Reinforcement is a tool to help the organization stay on purpose, drive to desired outcomes, and maintain momentum. • Reinforcement guidelines for leaders so they know the full range of reward and consequence options available, as well as the process for delivering them. To provide this, you must have a reinforce­ ment program in place. • Assurance that leaders are prepared to do a good job deliver­ ing both positive and negative reinforcement. Many people are uncomfortable delivering negative consequences. But don’t over­ look the fact that some people even feel uncomfortable delivering positive feedback. Both of these skills can be learned and develop­ ing them is a productive investment. • Connection with emotions. Reinforcement efforts that don’t evoke feelings miss the mark. K e ^ o in ^ l

It’s not enough to just tell people what outcomes are expected. People need to know how to achieve the outcomes. When you tie reinforcement to specific behaviors or actions, it’s easy for people to understand how they can be successful.

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We want to drive home two critical success factors: 1. Because actions speak louder than words, effective reinforcement programs are: • Predictable; • Consistent; • Specific; • Certain; • Immediate; • Applied fairly; and • Aligned with organizational values and objectives. 2. Employees who are prepared to succeed: • Are clear about what they are expected to achieve and how to get there; • Have the skills to meet the expectations; • Have the time available to achieve the expectations; • Know how their performance will be evaluated; and • Receive regular feedback on performance. Anything less in either area causes confusion, and confusion slows down change. In other words, doing these two things well accelerates change.

THE IMPORTANCE OF REINFORCEMENT Without reinforcement, leaders who talk about CHANGE™ initiative vision and goals are just cheerleaders. Its the reinforcement program that makes organizational priorities clear and backs up words with action. Corporate America is fond of saying “you get what you measure,” but its really “you get what you reinforce,” which means you get what you pay attention to. When measurement is a means of reinforcement, it is a tool that drives behavior change. Think of reinforcement as a day-to-day management tool, not just something to be pulled out on special occasions. Key Tip Don’t let the perfect be the enemy of the good. Recognize progress and directionally-correct behavior in addition to success. Success is most often the cumulative effect of many small steps.

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INCENTIVE ALIGNMENT One big pitfall in change management efforts is not aligning formal incentives. We ask people to change behavior and then we continue to reward them for old behaviors. Guess which behaviors people exhibit in this situation. We cant overemphasize the need to purposefully acknowledge and reward people for the new way, not the old. Mis­ aligned incentives can derail your project. Ensure that your technology adoption plan includes a section for reinforcement. A critical piece of this is to work with your human resources team to review the performance management system. Assess the gap between what employees are currently being incentivized to deliver compared with what they need to deliver in the new CHANGE™ world. What are the behaviors and outcomes you are seeking? How can the formal performance management system align with and sup­ port the objectives of the CHANGE™ initiative? Aligning strategic performance incentives with CHANGE™ initiative objectives is a foundational building block for success. Remember that all incentive programs for all employees impacted by the CHANGE™ implementation must be evaluated and realigned. For example: It does no good to send front-line staff to EMR train­ ing, provide on-the-ground support for them, and incentivize them to use the new system in their daily work but forget to align the incentives of middle leadership to the EMR project. When middle leaders and their front-line staff drive to different goals, the result is confusion, morale issues, and failure to meet objectives. Don’t make this costly and preventable mistake! Key Tip If your project is suffering from inconsistent sponsorship try incorporating accountability for CHANGE™ implementation success into sponsor incentive plans— and watch sponsor engagement and performance improve.

KNOW YOUR PEOPLE Rewards and recognition have significantly more impact when they are thoughtfully targeted to individuals or groups. “Generic” acknowl­ edgement is well meaning but misses the real value of the emotional

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connection with people. It is not always possible to make every rein­ forcement situation personal, but it pays to take advantage of know­ ing your peoples preferences and responding accordingly whenever possible. If you are a manger, it is your responsibility to know what is meaningful to your team members. When you make rewards personal, you communicate that people matter. Example: If you have staff with small children, aged parents, or family members with disabilities, you probably know that flexibility with work hours is highly valued. Though these employees may appre­ ciate being recognized and given a branded coffee mug, a t-shirt, or a movie ticket, you might be able to have a bigger impact the next time they get a call from home by allowing them the freedom to deal with the problem without feeling conflicted. This is admittedly easier to do in administrative areas, but when possible this attention to the employees real needs goes a long way in building loyalty and incentive to go the extra mile for the organization when needed. Add a specific acknowledgement and thank them for great CHANGE™-related work as you let them leave early to handle their personal situation and you have connected the reward with project performance in their mind. The following tool is a guide. Use it to develop greater understand­ ing of your people to make reinforcement efforts more meaningful. You can ask people to use the form to indicate what their preferences are, you can interview them, or you can jot down ideas about individ­ ual preferences as you learn more about people in the course of work­ ing together. Either way, you are identifying rewards and recognition options that are highly valued by your people. A word of caution: Not everyone appreciates public recognition. Making the assumption that everyone wants the spotlight is a common mistake. Getting to know your people will ensure that you offer praise and recognition in a way that feels good to the employee, ensuring the greatest positive impact. Perks like tuition reimbursement can never take the place of a front-line supervisor who sets clear goals, communicates, builds trust, holds employees accountable, and then recognizes in an effective manner.4

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tool Rewards & Recognition Preferences N am e :_____________________ I prefer recognition that is:



Public

□ Private

A

Either

I most appreciate receiving recognition from (check

A

all that apply):

□ My supervisor □ My supervisor’s boss

J

□ Other company leaders

□ O ther:____________________

I value being acknowledged when I (check

My team members Anyone who thinks I have done a good job

all that apply):

□ Achieve my goals □ Make an extra effort, go out of my way □ Do something special for a patient □ Complete a significant project □ O ther:_________________________ Rewards that are valuable to me include

(check all that apply):

□ Public recognition □ Thank you from my supervisor □ Thank you from team members □ Team events like a lunch or dinner

□ ϋ J □

□ □

Ji Scheduling flexibility

A day off A preferred assignment

Bonus or other monetary reward Company logo items/gear Training opportunities Lunch with a senior executive

Additional comments about your recognition preferences:

Key Tip Positive reinforcement has the most impact when the rewards are meaningful to users. The way to get this right is to know your people!

POSITIVE REINFORCEMENT Rewards, recognition, incentives, and yes, even appreciation come in many forms. Know your people, understand your company guide­ lines, and be creative. Combine the three and you will be on the way to unleashing the power of reinforcement to move your organization forward. Most HCOs have standard guidelines in place. If you are a leader, it is your responsibility to be familiar with what the organization pro­ vides. Authorized tangible and intangible rewards are important in

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part because they come from the top of the organization. Make sure your people understand that executive leadership approves and autho­ rizes these rewards for your use in recognizing and rewarding their performance. But don’t take the easy way out and rely solely on the formalized reinforcement of your performance management system—perfor­ mance appraisal, salary and bonus, promotion and incentive plan. Though these programs are very important means of establishing structured foundational support for rewarding employees, they are by no means exhaustive. And they are typically the least flexible of your options. Another limitation with formal programs is that they usually happen long after the fact. Reinforcement is most effective when it occurs as close to the event being acknowledged as possible. In many cases, just beginning to use the organizations reinforce­ ment mechanisms as a tool to support behavior change can make a big difference. Companies budget for rewards and recognition, but these funds are not always fully utilized. Don’t worry about trying to have the most creative program around at first. Simply using what is readily available may be just what you need to get started. As you focus more on knowing your people and working within your guidelines, you can expand your efforts. If you are having trouble getting started with reinforcement, you might want to consider engaging a small group of employees to come up with reward ideas that will resonate with their peers. Ensure the team sticks to company guidelines and ask them to identify both tan­ gible and intangible ideas so there are a variety of choices and not all of them require budget. Remember, a simple, sincere thank you is sometimes all you need to give. We have heard so many stories about the handwritten thankyou notes sent to employee homes being posted on the refrigerator, the thank-you e-mail saved in a file for years, and the pride of receiving a public thank you. We can’t recommend this simple method enough. It’s easy, doesn’t require planning ahead, and the price is right. Be sure to celebrate. Even directionally correct behavior and small successes deserve attention as you seek to build momentum. Go for some early wins and celebrate together. Social time builds relation­ ships and teamwork.

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Positive reinforcement isn’t valuable only because it rewards spe­ cific efforts or outcomes but because it also is a means of reinforcing organizational values and objectives.

Employee Personal Responsibility This chapter has discussed ways organizations can encourage people to make desired changes and reward them according to performance out­ comes, but employees have responsibility too. Ask them to step up and learn to use the CHANGE™ effectively and contribute to a success­ ful implementation. Committed employees do a better job. In healthy relationships, accountabilities go both ways. Be clear about what you will do for your people, and be clear about what you expect from them in return.

NEGATIVE CONSEQUENCES Negative consequences for poor performance are usually dictated by company human resource policy. Serious options include issuing formal warnings, initiating a formal improvement plan and, at the extreme, termination. But long before you get to this point you must deliver clear messages about your expectations, what you think it will take to turn things around, and when you must see changes. Generally you start with a discussion of the perceived gap between what is expected and what is being delivered. Give the employee a chance to respond to your concerns. Try to reach an agreement about how performance will improve. And let the employee know what the next steps will be if the desired changes are not made. Follow com­ pany guidelines and if you don’t see results, move to the next level. If the situation is serious you should consult with your human resources representative. But don’t dodge the issue! Another way to apply negative consequences is to reduce or elimi­ nate rewards and recognition for nonperformers. This is a more subtle approach but can be very effective. Another reinforcement method is to make old ways progressively harder to do, while simultaneously making the new way easier. For example, a new EMR system will automatically make some processes more desirable. If you can intervene to intentionally make old ways increasingly difficult to do, you will be ahead of the game. Some exam-

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pies of this include only accepting paper forms two days a week, pro­ viding short turnaround on electronic submissions with delays built into paper submissions, charging a department for continued use of transcription services, not allowing certain processes to be conducted on paper after a certain date, and so on.

checklist Reinforcement Checklist



EMR implementations change many things in an organization, and this is an evolving process. Help leaders effectively support staff by ensuring they understand new performance expectations and what a good job looks like with the EMR in place.



Facilitate delivery of reinforcement by making it easy for leaders to understand the rewards and consequences they have at their disposal.



Make sure leaders know they are accountable for providing reinforcement that supports new expectations. If they are slow to take on reinforcement responsibilities try reminding them.

ϋ

Help leaders understand how to use reinforcement constructively and effectively to achieve the behaviors and outcomes the organization is seeking. The more comfortable they are, the more often they will do it sincerely— and the more impact it will have.



Remember that public recognition sends clear messages about what’s expected and what will be rewarded. Most employees will respond to this.



When employees know their contributions are valued and rewarded, they are more engaged and more accountable.



Align the value of the reward with the importance of the contribution. Ask employees to commit to doing their part to ensure a successful transition to electronic medical records. The organization will do a lot for users during the implementation; employees do their part by fully engaging and contributing.

C h apter 9

Implementation Readiness Just what the doctor ordered...

There is a great deal of activity in the months leading up to go-live to ensure the organization is well positioned for a successful launch. With a clear focus on the people side of the implementation, much attention is centered on preparing users to effectively incorporate the CHANGE™ into daily operations. Assuming the appropriate context is in place to reinforce and sus­ tain desired behavior change, the objective is not only to equip users with the necessary skills and information they’ll need to be effective in the transition but also to execute a strategy aimed at instilling a much needed level of confidence and critical thinking in users. For example, experiencing an EMR implementation can conjure up a slew of emo­ tions and thoughts, ranging from sheer delight to anger, utter frus­ tration, and self-doubt. The goal is to provide users with a supportive context, adequate training, and enough opportunities to build confi­ dence so that a seamless transition into life with an electronic medical record system occurs. Experience has shown that the faster an individual can adapt to life with the CHANGE™, the more likely the user will overcome the distractions inherent in an implementation and think more critically about how best to leverage the new system to achieve organizational goals. If users are overwhelmed with the technology and the changes inherent in the process of going live, they will continue to be distracted to the point where they remain focused on just getting through the day.

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Organizations fare much better when they help users overcome their challenges before implementation because having to address these issues after go-live impedes the organizations ability to optimize, grow, and realize a return on investment. If a process is not established early on that focuses on the people side of the implementation, the orga­ nization will lose momentum and be faced with having to backtrack. This is a significant undertaking after the fact and can be extremely expensive and frustrating. Much to the surprise of some executives and operational leaders, many users still struggle with a new system even years after go-live. These individuals are either identified through performance indica­ tors or fall through the cracks and go unnoticed and unsupported. Whatever the reason, a struggling user means the new system is not being utilized effectively, which results in less than optimal outcomes for patients and the organization. Needless to say, a struggling user is also one who is literally drowning in work, as exhibited by phy­ sicians who fall behind in their EMR In-basket or in completing their documentation. Over time, people become reluctant to seek help because it seems safer to hide under the radar, go unnoticed, and not risk the humiliation of being thought incompetent. These problems are difficult to unravel after implementation. Hopefully, by raising these concerns, we will convince you to develop a strong preimplementation people strategy. Again, business value is limited by poor adoption.

IMPLEMENTATION READINESS DEFINED If you ask people in the healthcare industry how they would describe a ready user, you are likely to hear a variety of definitions. Most often the criteria that surfaces centers on possessing fundamental computer skills (e.g., typing, using a mouse, surfing the Internet, managing files, copy/paste, keyboard shortcuts), acquiring the requisite system feature/function skills, and having a good handle on department workflows. (Please see Chapter 4, Organizational Readiness Team, for more on ready user definitions.) The Ready User Model featured in Figure 9-1 argues that faster returns are obtained when your strategy shapes users into being better business partners and critical thinkers. Placing too much emphasis on

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Figure 9-1: Ready User Model

the technology creates users who learn what buttons to click but are rarely able to explain the downstream impact of their actions. They tend to be myopically focused on just completing tasks within the sys­ tem when the real objective in shaping ready users is to instill a deeper level of understanding of the system and its direct impact on individ­ ual, departmental, and organizational outcomes. Consider the Ready User Model shown in Figure 9-1. The Ready User Model suggests that there is a hierarchy of needs a user must satisfy to truly become a “ready user.” The idea is that individuals want to make sense of their world and they benefit from knowing how their actions and performance contributes to the bigger picture. As the context continues to build from the bottom toward the peak of the pyramid, users see greater relevance and become

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more engaged in the training and support they receive leading up to implementation. The first readiness factor, Vision, sets the stage by defining the overall purpose of the CHANGE™ implementation and describing the desired future state. It refers to the vision of the organization and helps users see the light at the end of the tunnel. It should be compelling, exciting, and possible. The second readiness factor, Goals and Expectations, is a natural extension of Vision because it brings clearer purpose to users. Both parts of the factor, goals and expectations, translate the vision into actionable targets. Goals are a step closer to reality and enable users to connect more easily with what work needs to be done. Goals and expectations are critical organizational factors in establishing a suit­ able context for change. The third factor, Roles and Responsibilities, provides context for users because they can better see how they fit into the bigger pic­ ture. When users can make the connection between themselves and the organization, they become engaged in the preparation process. This factor is also critical in establishing a suitable context for overall change. The fourth factor, Workflows/Policies and Procedures, is yet a closer look at how users fit into the change effort. Getting involved in decisions that drive internal efficiencies on the unit and how these modified processes improve the effectiveness of the team helps to fur­ ther personalize the context surrounding users. Individuals see more clearly how they fit into the changes that lie ahead and how they con­ tribute to benefits realization. The fifth factor is Personalized Content. For example, EMR sys­ tems offer sophisticated automated tools that enable users to be more efficient, effective, and faster at navigating through the technology and providing targeted care to patients. Establishing personalized content helps users configure the system in a way that is more consistent with and more supportive of their work style. As they further understand how the system can better support their daily operations, users become more fully engaged.

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Physician Perspective When it comes to physicians, it’s all about saving time during the day. The key to speed is staying away from the mouse and utilizing the system tools, such as .phrases (dot phrases). Use of these tools reduces the need for much manual data input, and actually leads to two actions (data input as well as data extraction) with one stroke. This makes things faster for the physician and makes the overall decision process more sound and efficient. Safaa Al-Haddad, MD Internal Medicine University Hospitals Cleveland, Ohio

The sixth factor, Skills, speaks directly to attaining requisite sys­ tem skills and ensuring the user is capable of appropriately performing key functions according to the organizations expectations. Interest­ ingly, many people seem to think that feature/function training is the only way to bring people up to speed. The Ready User Model argues that training is more effective and sustainable when done within an appropriate context, as one step in an overall process. The seventh and final factor, Practice, is incredibly important for users to really build confidence using the new system. The old adage that “practice makes perfect” is right on the money. Users need ample time and opportunity to practice their skills in an environment typi­ cally known as the sandbox, the practice environment that mimics the final production site. During practice, users get to play around with the system without tainting real data, allowing them to gain needed com­ fort with the technology before having to use it when it counts. With­ out enough time for practice, users are not able to prepare adequately for go-live and, therefore, will not be good critical thinkers on the job. If users are distracted by the technology, it will interfere with their abil­ ity to fulfill their job requirements. Adequate practice is essential. When all seven readiness factors are satisfied, users can comfort­ ably grow into ready user status. They will have the skills and the con­ fidence to meet performance expectations. Training people is easy but developing critical thinkers and business partners who have an eye on

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the end goal is much more difficult, but also much more beneficial. In Chapter 7 on Training Strategy, we go into this in more detail, outlin­ ing a recommended strategic approach to the delivery of training and discussing factors that impact training effectiveness.

THE IMPLEMENTATION READINESS PROGRAM A proven method for ensuring front-line leaders and users are well prepared for go-live and life after go-live is to execute a planned imple­ mentation readiness program for all departments, specialties, and domains of practice. Our recommended process, the Implementation Readiness Program, occurs during the months leading up to go-live, provides support and training during go-live, and then concludes with five weeks of additional support post live. It is a defined, system­ atic hierarchy of steps designed to build skill, confidence and critical thinking ability. The approach was originally developed to support EMR deployments, but the concept and tactics can be effectively used to support any large scale CHANGE™ with a technology component. The Implementation Readiness Program consists of four segments or stages (see Figure 9-2), which take place sequentially as described next. The entire program runs for 20 weeks, from T-14 to T+5 (refer­ ring again to Figure 9-2).

Figure 9-2: Four Stages of the Implementation Readiness Program

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WHO FACILITATES THE USER PRELIVE READINESS, GO-LIVE TEAM TRAINING, AND USER POST-LIVE TEAM MEETINGS? The Organizational Readiness Team (ORT) plays a key role in plan­ ning and executing the implementation readiness meetings, but the best practice approach is to support the front-line leadership team in facilitating these meetings. This generally necessitates some coaching and mentoring, as many front-line leaders are not comfortable serv­ ing in this role. However, good front-line leadership results in better team performance in the long run, so it is worth the effort to prepare all front-line leaders to be effective sponsors and facilitators of their teams preparation for implementation. The Leader Implementation Readiness meetings are the first part of the Implementation Readiness Program. These sessions are designed to prepare front-line leaders for their important role in preparing teams for go-live and supporting them post-live. This role is a critical success factor for all CHANGE™ initiatives.

1. LEADER IMPLEMENTATION READINESS The Leader Implementation Program consists of four planning ses­ sions for which the ORT partners with each team or department front­ line leadership group. The leadership group may consist of a physician lead, department administrator or clinical supervisor, and a union steward or lead. Identify leaders that are key to success of the change you are faced with. As stated in Figure 9-2, there is a series of four weekly preparatory meetings for front-line leaders (see Figure 9-3) facilitated by the ORT. The objective is to prepare these leaders to effectively lead their team(s) through the User Pre-Live Readiness stage of the program (see Figure 9-4).

Figure 9-3: Stage One of the Implementation Readiness Program

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Figure 9-4: Leader Implementation Readiness Meetings

Objective The objective of the Leader Readiness Meeting #1 (see Figure 9-5) is to ensure that all front-line leaders are trained in advance of their staff. This guarantees that the leaders are comfortable and know what to do to lead their team; and they are familiar with system capabilities, so they can better champion the technology.

Figure 9-5: Leader Readiness Meeting #1

Timing Held 14 weeks before go-live (four weeks before the team Implementa­ tion Readiness Meetings begin).

Duration Training may vary and be spread out over time. Front-line leaders should begin with a Web-based overview course and then attend instructor-led courses.

Details Front-line leaders will repeat system training with their teams. The benefit of being pre-trained is that it gives leaders the experience to better support their teams during training. This early knowledge also prepares leaders for workflow and role redesign and any potential pol-

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icy and procedure changes. Pre-training is good modeling and rein­ forces the importance of the CHANGE™ implementation.

Objectives The objectives of the Leader Readiness Meeting #2 (see Figure 9-6) are to provide an overview of the implementation process, reiterate the front-line leaders role, and introduce the support resources that will help them facilitate their teams through the preparation process.

Figure 9-6: Leader Readiness Meeting #2

Timing Held 13 weeks before go-live (three weeks before the team Implemen­ tation Readiness Meetings begin).

Duration Two to four hours.

Details Leader Implementation Readiness Meeting #2 provides front-line leaders with all of the information they need to understand the change they and their teams are about to experience. Logistics are also cov­ ered. The team readiness schedule is reviewed so rooms can be booked for these sessions.

Objectives The objectives of the Leader Readiness Meeting #3 (see Figure 9-7) are to review the workflows under consideration and to discuss a process for reaching team decisions about consequent changes to roles and responsibilities.

Figure 9-7: Leadership Readiness Meeting #3

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Timing Held 12 weeks before go-live (two weeks before the team Implementa­ tion Readiness Meetings begin).

Duration Four hours.

Details Leader Implementation Readiness Meeting #3 is important because front-line leaders need to understand how workflow discussions impact the overall success of team preparation. Front-line leaders need an opportunity to review their workflows to determine which deci­ sions can be left to the team and which decisions will be determined at a leadership level. The decisions made at a leadership level should be made prior to introducing the workflows to the team and are con­ sidered “nonnegotiables.” Front-line leaders introduce the workflows to the team and partner with the ORT to demonstrate the associated tasks in the new system.

Objective The objective of the Leader Readiness Meeting #4 (see Figure 9-8) is to ensure front-line leadership is prepared to deliver the Forest and Trees presentation (see Figure 9-12) to their teams in the upcoming team Implementation Readiness Meeting #1.

Figure 9-8: Leadership Readiness Meeting #4

Timing Held 11 weeks before go-live (one week before the team implementa­ tion readiness meetings begin).

Duration Four hours.

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Details Front-line leaders are provided the Forest and Trees presentation and asked to determine who will deliver which parts. Given that each team may have two to three different leads (physician, nurse, union repre­ sentative, manager), it is important to coordinate speaking parts. Leaders are most believable and compelling when they can put the presentation into their own words. The Presentation Personaliza­ tion Guide (see next “ΤοοΓ box) can help sponsors craft their own messages. Tool

Presentation Personalization Guide

• • • • • • •

Based on what I know, this is what I am excited about... What concerns me the most is... This is how I am preparing for our implementation... This is how I see using the system... This is how I believe we can support one another... I know our patients are really going to be pleased with... Our team in particular will benefit from this technology because...

2. USER PRE-LIVE READINESS The User Pre-Live Readiness Program (see Figure 9-9, Stage Two) pro­ vides users with an opportunity to understand how they fit into the big picture as it equips them with the necessary skills and knowledge to be successful. Executing the program requires organizational com­ mitment and relies heavily on leadership to ensure adequate time is allotted for the team to convene and work through their preparation together.

Figure 9-9: Stage Two of Implementation Readiness Program

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Figure 9-10: User Implementation Readiness Program

Organizations differ in size, number of locations, and so forth, so the exact implementation readiness approach will need to be custom­ ized to meet the requirements of your CHANGE™ initiative and the needs of your users. The User Pre-Live Readiness program highlighted in Figure 9-10 offers a structure that is intended to develop user confi­ dence and critical thinking, both crucial for a successful go-live and an effective transition through subsequent phases of the project life cycle. The objective is to begin with a broad picture of the future and succes­ sively drill down and connect the dots for users so they can understand their roles in meeting targets. The content outlined in Figure 9-10 is EMR focused, but it can be easily adapted to fit other CHANGE™ initiatives. The User Pre-Live Readiness Program structure outlines a tenweek schedule of meetings leading up to go-live. The initial kickoff meeting is strategic in nature, and then subsequent meetings go into much greater detail pertaining to what users can expect at go-live. The first meeting occurs ten weeks before go-live (or T-10) and the

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last readiness meeting occurs one week before go-live (or T-l). Train­ ing and support continue weeks after go-live, and this will be dis­ cussed in detail after exploring the activity that takes place before implementation.

Objectives The objectives of Implementation Readiness Meeting #1 (see Figure 9-11) are to kick off the implementation experience and provide a department or team with an overview of the new technology capabil­ ities and promised benefits, what users can expect during the coming months, and an explanation of the rollout schedule.

Figure 9-11: User Pre-Live Readiness Meeting #1

Timing It is suggested that this first readiness meeting take place ten weeks before go-live.

Duration Ideally, the meetings should be two to four hours in duration. The time allotment will vary, depending on the number of participants. Provide enough time to allow for discussion.

Details This first meeting is with a department or team as a whole. An execu­ tive sponsor should present the overall strategy and vision and describe the purpose of implementing the CHANGE™. The goal is to paint a compelling picture of the future that engages users. Keep in mind that this maybe the first time employees hear about the CHANGE™ initia­ tive. Some may have heard rumors about drastic changes ahead. This is a great time for the executive sponsor to connect with users and create excitement and energy around the technology, the anticipated benefits,

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Figure 9-12: Forest and Trees Concept

and the need to meet regulatory requirements if applicable. It is also a time for users to ask questions and air concerns openly. During this first meeting, a “Forest and Trees” presentation is delivered to engage users in the bigger picture (or forest) and drill down to details that are important to them (the trees). This presenta­ tion sets the stage for implementation readiness meetings to follow. It builds user understanding of the overall purpose and objectives of the project and provides a high-level view of what users will experience in the implementation process. Just like the Forest and Trees presentation used during the first meeting, the entire Implementation Readiness Program takes the approach of starting broadly and then moving into more detail through successive meetings until users know what they need to know to suc­ ceed at go-live and beyond. As an example, for an EMR implementation, a good Forest and Trees overview presentation (see Figure 9-12) communicates, but is not limited to, the following key pieces of content: • What an EMR is and why it is being implemented. • The future state vision. • How the EMR fits into the overall strategy of the organization. • The benefits and opportunities presented by the technology (for patients and the organization). • Things that might be difficult during the implementation. • Anticipated returns on the investment. • What will change (how things are currently, how things will be different). • Project details, overview.

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Project governance structure. Implementation schedule (rollout plan). Support model (how users will be supported). Clinical content (what is it, why it is important). Sources for additional information. System overview and, if time allows, an opportunity to play with the system. • Sponsor endorsement of the product and the implementation project. • Readiness plan and logistics. The first implementation meeting is an ideal time to ensure users clearly understand that they are expected to actively participate throughout the entire readiness process. Sponsors should strongly encourage users to take an initial pass through the Web-based training (WBT) before they attend Implementation Meeting #2 the following week. This is an important step in preparing users to contribute to workflow discussions. Users need to develop some understanding of the CHANGE™ early so they don’t become lost and therefore disen­ gage from the process. A powerful way to encourage users to take the WBT is to ensure that all sponsors and front-line leaders take it before the Implemen­ tation Readiness Program begins. This enables the sponsors to speak from experience and share how the WBT helped them gain an under­ standing of what the system is all about and how it will support oper­ ations. This is an example of sponsors modeling the behavior they expect from users. A best practice in preparing users for upcoming workflow dis­ cussions is to provide predesigned video demonstrations (e.g., devel­ oped in Camtasia, Captivate, or some other video capture software program). Encourage users to view these videos on the organizations intranet. Users often adopt the videos faster than the WBT because the videos are generally very short in duration (between one and four minutes) and do not require any action other than watching demon­ strations of a task within the system. The videos can be viewed at the users convenience—between patients, on break, or at home (if the user has virtual access to the intranet). Sponsors should strongly encourage users to utilize both the WBT and the video demonstrations to prepare

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for the next Implementation Readiness Meeting. Remember, the WBT and videos are only effective if people watch them. This is enabled by ensuring everyone has access to a computer, and it helps if users have dedicated time to initiate their learning. Some organizations make early viewing mandatory. It is important to note that users will need to possess a fundamen­ tal level of computer skills in order to use the EMR system. This first Implementation Readiness Meeting is a good time to communicate how users can develop their computer skills and stress the importance of not waiting until go-live to address this. At ten weeks before go-live, there is still enough time to get help, practice, and fine-tune these skills. It is strongly suggested that the ORT incorporate a fundamental com­ puter and typing skills assessment into the readiness process, as well as provide access to courses and support for users who may require it.

Objectives The objectives of Implementation Readiness Meeting #2 (see Fig­ ure 9-13) are to initiate discussion around impacted workflows (if required) and to show live demonstrations of the systems capabilities as it pertains to these workflows.

Figure 9-13: User Pre-Live Readiness Meeting #2

Timing Nine weeks before go-live.

Duration Four hours in duration. Typically, in an EMR implementation there are 80+ different workflows to review with the team, and it requires a significant amount of discussion and system walkthroughs to identify points at which roles, responsibilities, tasks, and flow may change at go-live.

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Details Implementation Readiness Meeting #2 typically occurs a week after the kickoff meeting and involves a detailed exploration of how key workflows of the team might change. Some workflow changes may be pre­ determined by leadership, but there are opportunities to tailor much of the flow to support how the team delivers care. When leadership predetermines certain aspects of a workflow, it generally means that the change is nonnegotiable and is a result of a desire to standardize certain processes for consistency or to streamline a known pain point. Do not make the mistake of just letting the system automate the way the team presently serves patients and other customers. Workflow dis­ cussions are an opportune time to work as a team to find better ways of delivering care, sorting out inefficiencies and streamlining processes to transform the work. Part of readiness preparation involves running through relevant workflows using the system to demonstrate the system capabilities. This helps users get a sense of how the system will support them with daily operations. Workflow demonstrations need to be repeated to ensure everyone in the group is following along at a comfortable pace. The team also needs to think through any role changes that might be required to increase efficiencies when using the system. Of course, this process is always smoother when users have taken the initiative to learn about the system prior to the meeting by leveraging the WBT and video demonstrations on the intranet. During this meeting, it is extremely helpful for the front-line supervisor or lead physician to review organizational goals with the team and ensure the team is working productively to incorporate the impending changes into their daily operations. As a reminder, it is also very helpful if the leader speaks about his or her personal journey with the CHANGE™ initiative. What are they doing differently? What skill development are they working on? What have they had to change in their own behavior?

Objective The objective of Implementation Readiness Meeting #3 (see Figure 9-14) is to continue with workflow reviews, as well as look at how schedules may be impacted at go-live. This is also a good time to assess

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where users stand with their level of acceptance with the technology and to surface any potential resistance to the preparation process.

Figure 9-14: User Pre-Live Readiness Meeting #3

Timing Eight weeks before go-live.

Duration Four hours in duration. Workflow discussions become intense and require much discussion among team members. Key stakeholders may be invited to the meeting as workflow integration points may involve other departments or functions within the organization such as, but not limited to, pharmacy, lab, radiology and business services. The integration points will vary depending on the CHANGE™ initiative.

Details For an EMR implementation: In an ambulatory setting, because users will be working on a reduced schedule for the first weeks of go-live, it is especially helpful to invite department schedulers to this meeting to discuss what physician schedules will look like during implemen­ tation. It is important to confirm the schedules at this time, because physician schedules are typically determined two to three months in advance. With reduced schedules, it is a good idea to bring in extra staff during and post-live to help ensure patient access isn’t adversely impacted. Physicians and other team members appreciate having extra staff on hand during their transition back to a full schedule. One option is to increase hours of per diem physicians or identify interested staff physicians to work extra hours to support another facil­ ity or team go-live. In addition to helping ensure patient care is well supported during implementation, these physicians have the oppor­ tunity to experience an implementation before going live themselves. This is similar to the Paying It Forward suggestion described earlier

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and is a great way to engage early adopters in your medical group. Phy­ sicians appreciate and respond favorably to support offered by their peers, so this technique goes a long way toward accelerating the tran­ sition process for them. During the meeting, more focus is placed on reviewing workflows and perhaps conducting relevant system demonstrations again. Although several implementation readiness meetings are slotted for workflow discussions, work outside of these meetings is required to refine the workflows. Generally workflow conferences are established with an arrangement in which team representatives are excused from the unit to work through the remaining workflow modifications, which are then reviewed during the scheduled implementation readi­ ness meetings. Experience shows that workflows are one of the biggest problems after go-live. To avoid this, ensure your teams place enough emphasis on ensuring workflows were modified to take advantage of the new technology. Implementation Readiness Meeting #3 is also a convenient time to assess the teams overall engagement and level of buy-in. A brief survey (as shown in Figure 9-15) is administered at this time by the ORT to gauge perceptions and uncover any potential resistance that might stand in the way of future meetings and training. Knowing what people are thinking at this point in the game is critical because you still have enough time to address any lingering negativity and/or unwillingness to participate. Encountering these issues during go-live is much too late, making it hard to intervene and get people back on track. Figure 9-15 is EMR specific but can easily be adapted to fit other types of CHANGE™. It is important for sponsors to continue encouraging users to take their WBT. Many users say they had to take the WBT several times before they began to feel comfortable with the systems capabilities. Sponsors themselves should take the WBT multiple times through­ out the readiness process and share how this is helping in their own development. Users generally find new things that interest them every time they go through the WBT, and each implementation readiness meeting will cover new topics and generate more questions about the system. Viewing the WBT multiple times can help reduce user anxiety.

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Figure 9-15: Sample Readiness Assessment SA = Strongly Agree A = Agree N = Neutral/Undecided D = Disagree SD = Strongly Disagree

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Of course, this process strongly relies on the users initiative to learn about the system, unless it is mandated. Note: This readiness assessment uses a five-point response scale. Another option is to reduce the scale to four points, eliminating the “Neutral/Undecided” option. A four-point response scale forces a favorable or unfavorable response and mitigates the risk that a respon­ dent answers neutrally because he/she is disengaged. But for the pur­ poses of assessing user readiness for an EMR implementation and identifying potential resistance, we prefer the five-point scale, as the “Neutral/Undecided” response is actually useful information.

Objective The objective of Implementation Readiness Meeting #4 (see Figure 9-16) is to review the results of the readiness assessment as a team. In addition, subject matter experts may be invited to present and/or attend the meetings to address relevant topics including, but not lim­ ited to, coding, messaging, scope of practice, and so forth.

Figure 9-16: User Pre-Live Readiness Meeting #4

Timing Seven weeks before go-live.

Duration Four hours in duration. Depending on the readiness results, the ORT and front-line leaders may need to engage in team problem solving to ensure the preparation process is meeting individual needs. There may also be various SME presentations that help connect the dots for users.

Details For an EMR implementation: Given that readiness meetings tend to be held a week apart, there is time to analyze the data from the readiness survey and review them with the team leads prior to User Pre-Live

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Readiness Meeting #4. The results may indicate that future meeting content needs to be modified. It is a good idea to engage the front­ line supervisor in presenting the data to the team and facilitating a discussion around concerns. Users do not move progressively toward readiness when they feel their concerns are not being addressed or when they feel things are moving too quickly. Make sure you dedi­ cate enough time for discussion in your readiness meetings. These dis­ cussions enable users to sort out their confusion and resistance in a healthy manner. The Implementation Readiness Model lists suggested discussion topics for each meeting, but exactly when specific topics are covered may vary from organization to organization. In an EMR implementa­ tion, for the fourth meeting, the model recommends deeper discussion about coding and preparing users to introduce the system to patients during go-live. You must ensure users are ready to deliver a consistent, positive elevator speech that promotes the system. Modify the focus of this meeting to fit with whatever CHANGE™ initiative you are focus­ ing on. When indicated, some organizations choose to introduce special­ ized training in which clinicians learn how to utilize a computer when a patient is present. Without appropriate training, clinicians can alien­ ate patients and unknowingly make them feel ignored during a visit. If using a computer in the exam room is a new concept for some people, it is wise to orient clinicians to appropriate use to prevent the patient care experience from being compromised. You may also want to include other stakeholder groups or SMEs in your meetings when it is useful to review handoffs and/or integra­ tion points that may be changing. The coding department, pharmacy, lab, patient safety and other key stakeholder groups may want time on your agenda to hold these discussions. We highly recommend that you do this as it gets everyone on the same page. This is also a great way to enhance relationships, which will serve you well throughout the implementation process. If other teams or departments have already gone live in your region, hospital, facility or department, invite representatives from those teams to the implementation readiness meetings to discuss their experiences and how the system is impacting operations. This first-

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hand report provides useful information and can reduce anxiety for the team that is preparing to go-live. Talking with peers and colleagues about lessons learned is time well spent.

Objective The objective of Implementation Readiness Meeting #5 (see Figure 9-17) is to initiate preliminary training and to hold discussions around necessary scripting. This is the time that a practice environment (i.e., sandbox) is introduced to provide a safe place for users to freely nav­ igate. Most users get a lot of value from being able touch the system, as opposed to just seeing and hearing about it. Think of it this way: hearing a lecture then watching a video about how to ride a bicycle is one type of experience. Getting on the bicycle and trying to ride it for the first time is something else entirely!

Figure 9-17: User Pre-Live Readiness Meeting #5

Timing Six weeks before go-live.

Duration Four hours in duration. Workflow discussions continue, and facilitated WBT begins for users. This training format is very helpful for users, as they have a chance to learn at their own pace, with support. The differ­ ence between this and the WBT recommended during the first weeks is that this WBT is facilitated by support resources from the project team and operations that are there to field questions and provide help.

Details With six weeks left before implementation, users should have viewed the WBT on their own time, reviewed the videos and participated in a facilitated WBT session. This initial training helps users acclimate to the advanced training that will be delivered closer to go-live. As

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a side note, detailed core systems training will be delivered through­ out sub- sequent implementation readiness sessions, but the extensive training happens closer to go-live. Just-in-time learning has become a best practice in the industry because there is so much to learn that when training is conducted too early, users forget the skills. This is generally due to the inability to use the skills in real practice before go-live. Practicing skills and using them when it counts are signifi­ cantly different things. Many users say the early Web-based training really helped them retain skills learned during the advanced systems training at go-live. Having a fundamental knowledge of system capabilities is also extremely helpful for users during the readiness meetings. It enables more sophisticated questioning and better workflow decision making. As said earlier, a common problem is that many people do not take the initiative to learn on their own. It wastes everyone else s time when unprepared users dominate classroom training with questions, keep­ ing their colleagues from getting what they need. Additionally, these people are not value-added contributors to workflow discussions in the readiness meetings because they are uninformed about how the system works. Make sure users have taken the WBT on their own time, at least once, before participating in the facilitated WBT session.

Objective The objective of Implementation Readiness Meeting #6 (see Figure 9-18) is to continue with workflow reviews, as well as look at how sup­ port will be provided on the unit during the weeks of go-live. Further training is introduced to users and generally the focus centers on the importance and usefulness of establishing personalized content within the system in situations where that can be done.

Figure 9-18: User Pre-Live Readiness Meeting #6

Timing Five weeks before go-live.

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Duration Four hours in duration.

Details This meeting occurs just five weeks away from the big event. With all the discussion about workflows and the start of system-related train­ ing, users find comfort in learning how they will be supported during implementation. This is a good time to invite a representative from the support team to review support ratios and availability. Typically, sup­ port is weaned off in weeks two and three after go-live. It is extremely important that users understand this and fully engage in their prepara­ tion and readiness process. Early adopters, super users and other infor­ mal champions will be available after go-live, but the extra support will drop off at some point. It is a good idea to stress the importance of taking the readiness process seriously because users will be expected to meet performance goals shortly after they make the transition to the new system. Make sure they are aware they must take full advantage of the support provided early on because it will not always be available to them in the same manner. With EMRs, fantastic tools are available in most systems to increase efficiencies and streamline processes, such as documenting in a chart or ordering procedures, medications and ancillary ser­ vices. These tools operate from decision-tree logic and rely on sys­ tem content. Some organizations take the time up-front to identify department-specific content, and others choose to let users custom­ ize their own content (or both). Users can take advantage of the time provided in the readiness meetings to personalize their own content, which will help at go-live only if they understand how to access and leverage this content. Because the experience of go-live can be so mentally consuming to most users, their focus is truly about getting through their day. Limited attention is placed on accessing their personalized content. Our advice is to introduce the concept of personalized content in the readiness meetings, then revisit it with supplemental training a few weeks after implementation. Users approach their personalized content differently after go-live, because they have a better understanding of its advan-

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tages and application after some real experience. This increases their interest in finding more efficient ways to accomplish tasks.

Objective The objective of Implementation Readiness Meeting #7 (see Figure 9-19) is to continue with workflow reviews and provide more oppor­ tunity to take Web-based fundamental training.

Figure 9-19: User Pre-Live Readiness Meeting #7

Timing Four weeks before go-live.

Duration Two to four hours in duration.

Details For EMR implementations, as stated earlier, workflows can be the big­ gest challenge at go-live if not properly reviewed and modified before­ hand. Even if the team completes all the workflow decisions, it is a good idea to review them once more. It also helps to furnish hard cop­ ies of workflow documentation so users can follow along, make notes as needed, and have the copies for future reference. Create a workflow binder for everyone on the team and when workflows change, replace old versions with updated versions. Note: Most users do not have Microsoft Visio or PowerPoint on their computers, so don’t rely on these. Visual diagrams are helpful, but workflows in an outline format are useful too. With the outline format, front-line leaders can ensure the documents are easily updated when workflows need to be adjusted in the future. When users must rely on resources outside of their team to update the documents, the updates don’t happen in a timely manner. It is important to keep your work-

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flow documentation current, so everyone understands and so that new employees can be effectively oriented to the team.

Objective The objective of Implementation Readiness Meeting #8 (see Figure 9-20) is to ensure every user has login instructions and knows how to access and use the sandbox (the practice environment that mimics the live production site). The sandbox may be open to users weeks before this readiness meeting, but it is important to provide time for users to utilize the practice environment when trainers are available to coach and guide the process. Users also begin the training cycle with instructorled training (ILT) during week eight because go-live is around the cor­ ner. The objective is to embrace a just-in-time training approach to best accommodate the complex nature of an EMR and the myriad new skills that need to be learned and remembered.

Figure 9-20: User Pre-Live Readiness Meeting #8

Timing Three weeks before go-live.

Duration Four hours in duration. With EMRs, workflow discussions may con­ tinue and training is provided regarding charting skills and InBasket management. After training, the majority of the time should be spent on allowing users to practice in the sandbox environment. Typically, users complain of limited time to practice, so having four hours of ded­ icated time is very beneficial. By this time, early adopters have taken advantage of the sandbox on their own time. All users are encouraged to use the sandbox on their own time, but users frequently report that they just couldn’t find the time to practice. The week eight meeting is mostly dedicated to practice, but one session is not sufficient for go-live preparation. Users must take the initiative to review the WBT

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and online video demonstrations, and practice as much as they can. All of this pre-work has the added advantage of preparing users to for­ mulate sophisticated, relevant questions during their ILT sessions.

Details Individuals can practice at their own pace in the training room or even practice as a group. It is most beneficial when they noodle through a workflow together, using the system, without direction from the facil­ itator. That is, the team practices its workflows as the screen is pro­ jected on the wall in front of the group. A physician or nurse drives the computer navigation, while the rest of the team members offer their thoughts on next steps. When questions surface, the facilitator can jump in and provide direction or assistance. However, it is important to stress that the facilitator should give the group the opportunity to figure out the steps on their own and not jump in to help too quickly. Enabling users to think through the processes and support themselves is a critical step in their development, and this tends to be a huge missed opportunity in some training strategies. In an acute care environment, the luxury of attending facilitated weekly sessions may not be as easily accomplished as in an ambulatory setting. The ORT and operational leaders need to be creative and find ways for users to support one another on the unit or provide backfill to provide users with some dedicated practice time during business hours. Perhaps a rolling schedule of practice time can be established during which users have access to dedicated offices or areas at the nurses’ station to practice privately without interruption. Staffing the practice area with a few support resources is helpful so users can con­ veniently get help as questions or issues arise. Users in an inpatient setting may not be able to take a lot of time away from their work, so the idea is to try to provide them with multiple but shorter opportu­ nities to squeeze in practice time. Sponsors play a big role in making this happen by actively dedicating computers, providing backfill, and coordinating the schedule so that support resources can be available throughout the day.

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Objective The objective of Implementation Readiness Meeting #9 (see Figure 9-21) is to actually simulate a realistic scenario in which users play out their roles in the exam room, nurses station, and/or physician office by following department-specific and role-specific workflows.

Figure 9-21: User Pre-Live Readiness Meeting #9

Timing Two weeks before go-live.

Duration Four hours in duration. Do not provide less than four hours to con­ duct the dress rehearsal. The more time devoted to this preparation technique, the better.

Details By now, users have had multiple opportunities to learn about the sys­ tem, have taken the WBT on their own time, attended a facilitated WBT session, viewed online video demonstrations, worked with their respective teams to confirm new workflows, attended live workflow demonstrations, received basic system training, and have practiced these newfound skills and workflows in the system. Although they will receive deeper systems training closer to go-live, at this point users should already have a good foundational set of skills with the system and workflows and be ready to take their preparation to the next level. The dress rehearsal is a critical element in any implementation readiness program, but it is frequently overlooked because of the time and effort involved in planning and arranging it. Nonetheless, users are far more effective using the new technology when they have had ample opportunities to practice in scenarios that closely match real-life conditions.

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Think about a dress rehearsal before a wedding. The wedding party conducts a dry run of the ceremony. The wedding facilitator helps everyone involved understand their role, where to stand, and what to do during the ceremony. This is similar to a technology implementa­ tion dress rehearsal, and users benefit greatly from dry runs of workflows and scenarios that frequently occur in their daily operations. The learning is most relevant and sustainable when the dress rehearsal is conducted on the teams own unit. Do not conduct it anywhere else. In an acute care setting, it is more challenging to conduct the dress rehearsal than in the ambulatory setting. In acute care the dress rehearsal is sometimes done on the floor in a dedicated area, but there will likely be real patients surrounding these dedicated practice sites. Although the acute care dress rehearsal is logistically more challeng­ ing, it actually has the benefit of more closely mimicking a real-life sce­ nario. Our recommendation is to maintain flexibility through the dress rehearsal process. You may be faced with interruptions and might even need to postpone completing the dress rehearsal if a patient situation arises and colleagues need help. Patient safety and care always come first! (See page 173 for one organizations approach to inpatient dress rehearsal.) The ORT works closely with operational leaders and the imple­ mentation project team to develop department-specific scripts that will guide the dress rehearsal. The scripts should outline a typical day-in-the-life of the user, from patient intake to patient discharge. In an ambulatory setting three people should be assigned to an exam room—a physician, a nurse, and a patient. The script provides every­ thing that should be said by the participating individuals, including how patients are greeted and roomed in real life. The facilitator and/ or trainer may play one of the three roles or choose to be an onlooker. As in an earlier Implementation Readiness Meeting, the facilitator and/or trainer must not intervene too often but rather step in if confu­ sion or questions arise. Users must work together to fulfill their roles in the dress rehearsal, making decisions that they will use in real life, without the benefit of a facilitator. Again, the objective is to enable the users to think through the process and try to solve their own problems before having real patients in the mix. A common preparation pitfall is for facilitators and trainers

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to intervene too regularly. Although well intended, the impact is actu­ ally counterproductive because it impedes the critical thinking and learning process that must take place for users. Successful practice ideas: • Have doctors and nurses switch roles during dress rehearsal to experience each others process. This is a valuable and revealing learning experience. • Dress rehearsal is a good opportunity for the facilitator/trainer to identify those having problems completing the test scenarios and arrange to give them extra help before go-live.

Objective The objective of Implementation Readiness Meeting #10 (see Figure 9-22) is to begin advanced system training. Training is best retained when conducted close to go-live.

Figure 9-22: User Pre-Live Readiness Meeting #10

Timing One week before go-live.

Duration Four hours in duration, allowing ample time for questions and discussions.

Details At this point, users should have a solid understanding of what the organization is envisioning and how they fit into the bigger picture. Also, the context for learning should be well supported, with front­ line supervisors reinforcing desired behaviors and performance expec­ tations. It is most effective when front-line supervisors are present during the core training sessions to field any outstanding issues or workflow questions.

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For an EMR implementation, advanced training exists beyond go-live and continues throughout the first, and in some cases, the second week of going live. Users work to assimilate everything they have learned and make informed decisions regarding the best ways to utilize the system to fulfill organizational expectations and meet the needs of their patients.

3. G O -L IV E T E A M T R A IN IN G As highlighted in Figure 9-23, the focus of the third stage of the Imple­ mentation Readiness Program is to provide just-in-time training.

Figure 9-23: Stage Three of the Implementation Readiness Program

Objective An Implementation Readiness Meeting (see Figure 9-24) is held the day of go-live because the preparation process continues. Users receive advanced, comprehensive training the morning of go-live and then go back to their floor or unit to work a reduced schedule or workload. A team debrief is scheduled at the close of the shift.

Figure 9-24: Go-live!

Duration Four hours training in the morning, reduced schedule or workload, one hour debrief meeting at the end of the shift.

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Details This is it! Go-live has arrived. For an EMR go-live, users receive advanced system training in the morning and reduced schedules or workload in the afternoon. The training reinforces earlier training, but it also addresses any logon issues and other questions the team may have before using the EMR for the first time with real patients. During the training, it is important to remind users that resources are nearby to support them through the day. The difference between the train­ ing received at go-live and prior training sessions is that the Systems Training #1 focuses on bringing all of the training together. Users are asked to work through pre-scripted scenarios that are relevant to their role and specialty. In a sense, it is training and practice all wrapped into one with the intent to build user confidence that they can do it! Executive sponsors play a huge role at go-live and should be pres­ ent at the go-live training, as well as being visible during go-live on the unit or floor. Users appreciate the moral support. It also reinforces how important this implementation is, so important that the senior executives are on hand to troubleshoot as needed and to show their appreciation for all of the hard work of preparing for this transition. Team debriefs are critical at the end of the day of go-live and during subsequent readiness efforts. This enables users to unwind and share their experiences, frustrations, and thoughts about the go-live experience. This forum must be provided so users are not left to their own devices to sort out what just happened to them. Also, it is import­ ant to surface any potential issues or outstanding levels of resistance so the sponsors, front-line supervisors and support team can intervene effectively. Team debriefs are helpful for users to reach closure for the day and gives them renewed energy for tomorrow.

4. POST-LIVE TEAM MEETINGS The day of go-live is just the beginning of the overall transition and change that users will experience (see Figure 9-25). The act of install­ ing the system is not the final stage of implementation. Many argue that life actually begins after go-live. As such, for EMRs, the prepa­ ration continues with five more weeks of recommended training and team debriefs, as shown in Figure 9-26.

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Figure 9-25: Stage Four of Implementation Readiness Program

Figure 9-26: Post-Implementation Preparation Model

The post-implementation focus is on more advanced system train­ ing and ensuring team debriefs are occurring on a regular basis. Users are now applying their newfound skills and knowledge in a real-life setting, and they are becoming more sophisticated in their utilization of the technology. New questions are coming up, along with ideas for improvement. This is not the time to reduce support. Users need to stabilize and increase their level of confidence, and those who are struggling must not be allowed to fall further behind. Holding forums during which teams speak openly about their experiences and collabo­ rate on solutions is a valuable part of the preparation process and also helps teams begin to support themselves. The five post-implementation meetings will not be reviewed indi­ vidually because the purpose of these meetings is the same: bring the team together in a supportive environment, provide opportunity for open discussion and problem solving, and deliver additional training. Support resources should be focused on working with front-line lead­ ers to ensure they are comfortable in their roles and that they have the tools and resources to manage team performance. Strong leaders have

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strong teams, so efforts to coach and mentor front-line leaders, as well as their teams, must continue. The Implementation Readiness Model is based on a significant amount of experience implementing software implementations, but it is important to note that it is not a cookie-cutter approach. That is, every organization is different and should customize the model to account for the culture, business priorities, actual software/applications to be implemented and other operational considerations. It is great to see the latest developments, innovations and creative solu­ tions that organizations are generating to effectively prepare users for CHANGE™ implementations. Some successful practices are in place and others are still emerging. Consider the following two successful practice stories that provide specific examples.

NorthShore University HealthSystem's Approach to Training fo r Their EM R Implementation NorthShore has a ChiefLearning Officer who is part of Human Resources, and that person led the EMR training effort and spent a lot of time teach­ ing clinicians how to teach adults. We made training mandatory for all levels of employees and medical staff Our professional staff passed a rule that said you need to use Epic to take care of patients in the hospital and that you cant use Epic without passing the course. That applied to our employed physicians, as well as to community physicians who admit patients to our facilities. We offered basic computer training for anyone who was uncomfort­ able with a mouse, etc. We did this privately, and I am sure many went to their kids for help as well. We didnt want to embarrass them in the class, and we didnt want them slowing down the class.

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Go-live Training Things changed over time, butfor thefirst three hospitals that came up on the EMR, we required in-classroom training. We offered two options— either four-hour classes over four consecutive days or eight-hour classes over two days, with both days occurring on the weekend. Overall, the idea was that if we were going to disrupt their day, we should at least let them pick the time. The exam was competency-based; they had to demonstrate that they knew what to do. Physicians took the test as part of their class; we thought it would be hard to get them back one more time. Other staff returned to their departments and were given access to a practice environment. We then asked their super user to do the competency exams. We wanted the departments to tell us that their staff was ready, not us telling them. We did almost all of this training off-site, so it was impossible to lose a doctor to answering a page and going to the floor. We also offered refresher training, since it was impossible to train everyone close enough to go-live. Our departmental chairmen and their opinion leaders attended the first session, and they all passed. It was hard after that for any other doc­ tors to say that they didn't have the time or could not pass the test. We used floaters in the classrooms. These were people who were not teaching but checking on students to be sure they were on the right screens and offering quiet help to be sure students could move along and keep up. Some of these floaters were physicians who were our physician advisory committee members. For the current go-live, we have recruited and given extra training to some of their opinion leaders to perform this floating role.

Training Now Online training is now available for physicians in our original three hos­ pitals. We needed to do this to allow rotating house staff to be ready when they came on site. Many of the house staff have had access to Epic or other EMRs at other hospitals. They were joining a group of users on a floor or in a department who were already experienced users of Epic (herd immunity). A new hospital is joining us in December that has no herd immunity, so we've returned to classroom training for these physicians.

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Upgrades/New Releases The amount of training for any new functionality factors into our deci­ sion on what we bring live each year. We need to be sure that we can train the staff on the new functionality or module. This is often the limiting factor in what we include in an upgrade. The training needs and team are part of our work plan discussions and not an afterthought. We now have hospital-based trainers who come to your elbow after being paged. They do not have classroom responsi­ bility. Some of our users take advantage of this service to learn a newer; more advanced feature. Others, who do not come to the hospitals often and dont have Epic in their office, use it to get through an admission. Tom Smith CIO (retired) NorthShore University HealthSystem Evanston, IL

BayCare Health System's Approach to Training fo r Their EM R Implementation It is extremely important to align all activities that focus on the “peo­ ple side” of EMR implementation early in project planning. All activities necessary for ultimate adoption of system and cultural change must be planned and intentional. They must build on the successful completion of prior tasks, allowing team members and leadership to clearly envision each stepping stone on the path to transformation. One activity that has proven successful within an inpatient setting is the utilization of a “mock practice” or “dress rehearsal” prior to activa­ tion of the new workflow processes and technology. This activity entails using real patient data documented in a non-production environment running parallel to the delivery of clinical care within the patients room or appropriate clinical area. In other words, a nurse, accompanied by

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someone from the support team, delivers patient care and uses a prac­ tice site in the process to approximate what will happen at go-live and thereafter. Care must be taken to ensure that each team member par­ ticipating in the rehearsal has completed all training requirements and clearly understands all objectives and requirements to completing the rehearsal Patients and other providers were made aware that a “prac­ tice” session was being completed within their area. Signs were posted stating “Experienced Nurse, New Computer System” to help patients and visitors understand that the new system was being implemented. There are many factors that come into play when planning this type ofactivityy and alignment of key project and facility/user personnel is elemental to success. Once the decision to incorporate this type of activity into your acti­ vation has been solidified, the work can begin. Stakeholders will come to the table eager to see every piece of functionality, from every part of the system, in every workflow scenario possible, and in every impacted area. The first step of this planning is to help “scope” what is both appropriate for the size and magnitude of the implementation and what is feasible from a preparation and support model. We have found it very successful to be open to suggestions and recommendations but finalize all agreed activities within a brief scope document. This helps align expectations across all parties. The key to success is to have all parties clearly under­ stand the logistics, preparation, and expected outcome of the rehearsal. A few key factors to help guide your team in scope decisions might include:

• What are other activities that are going on within the facility (e.g, training, device deployment, other competingfacility initiatives)? • When should this rehearsal begin (date and time of day)? • Which departments will be included in the rehearsal, which depends greatly on the overall scope of your activation (e.g., ED, Radiology, Lab, Telemetry, Pharmacy...)? • How many participants will be involved (nurses, physicians, techs, etc.)? • How many visitors will you allow to observe the activity without disruptingpatient flow/satisfaction (many others will want to see the system)? • How long will the activity run (12, 24, 36, or 48 hours)?

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• How will the project team provide support to the facility during the rehearsal (e.g., at-the-elbow support, remote production!security support)? • Will there be extra staff brought in to provide patient care, while those involved in the activity are allowed to “practice” real-life sce­ narios within the practice domain of your system (how many, who pays their time, skill sets needed)? A few key objectives to this type o f activity that help obtain buy-in from all parties include:

• Validating the future state design to meet end-user operational needs. • Obtaining end-user input on how the system will work in their daily working environment. • Pre-testing the activation support procedures and model. • Providing the best and most thorough opportunity to validate overall flow of data, availability of data for viewing, and hardware usage. A few key benefits that come out o f dress rehearsals include:

• End users will use the system in a real patient care setting and iden­ tify issues or gaps that need mitigation prior to go-live. • Provides “practical practice”for end-users post-training. • Provides an opportunity for go-live support to have practical experi­ ence with their support role. • End users become familiar with new devices!device functionality. • End users can use this opportunity to practice what they have learned. This helps highlight those areas of training that need addi­ tional emphasis or job aides. • Validation of production support and device strategies occurs. • Informal wireless devices are tested. • Solidifies “buy-in from facility!department leadership.

Ronnie D. Bower, Jr., MA Director of Applied Clinical Informatics Tenet Healthcare Corporation Dallas, TX

Se c t io n I V

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C h a p t e r 10

The Journey You cant make an omelet without breaking any eggs.

A CHANGE™ initiative often takes on a life of its own, so it is extremely important to understand what you are getting into and prepare well for the journey. The lessons shared in this book are based on years of experience managing the people side of many business projects with an IT component (not to mention the largest civilian EMR implemen­ tation in the world). The intent is to help you plan and experience a meaningful implementation of the CHANGE™ initiative and achieve new heights for your organization. The quality of your journey will be determined by how well you establish a supportive context for change and manage the people side of the implementation.

OWNERSHIP One of the hardest things for any organization embarking on a CHANGE™ implementation is to understand that an implementation of this sort is a business initiative, not an IT project. This is an extremely important concept because, as we have said repeatedly in this book, the new technology itself isn’t what is important. The critical factor is whether the technology is embraced and used once it is installed. It s counterproductive for organizations to place so much emphasis on installing the technology that they don t take the time to make sure it is fully adopted and incorporated into daily operations. To avoid this problem, create a strong partnership between IT and appropriate oper­ ations areas, with operations as the owner and IT as the enabler.

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If strong and active engagement from operations and senior leader­ ship is not present, escalate the issue to the project steering committee. You may need to reassess the effectiveness of executive sponsorship or even re-evaluate the level of engagement from the steering commit­ tee. If operational leaders don t take ownership of the CHANGE™, the journey through implementation and beyond will be long, arduous, and frustrating, and you run a significant risk that the initiative will fail.

BOILING THE OCEAN With all the pressures in our healthcare world today it is tempting to try to do everything at once. This is a costly mistake. It takes discipline to prioritize and sequence the work. Take the time to figure out which things enable the others. For example, if you are going to embark on large-scale organizational transformation, do the human resources, communications and finance work first. This will create a stable foun­ dation to serve the other areas of the organization as they go through their transformation process. Its a leadership decision. You can decide to make things easier or you can make them as hard as possible. If you want to avoid change saturation, “chunk” the work. Ask yourself, how much is too much for a role, a department or a facility to bear? What is the change capacity and how do I know this? Do I really understand whether a target pop­ ulation can effectively manage another CHANGE™? How might we reasonably sequence changes so that they build on each other, leverage economies and reduce duplication? Creating a portfolio view of your current and pending change ini­ tiatives can help you understand the interdependencies and opportu­ nities for sequencing. A “heat map” will help identify change impacts for different groups. This information can help you consolidate and sequence changes to make them more consumable, thereby lessening the burden on the organization.

MANAGING PERCEPTIONS A new system presents tremendous transformative potential for an organization. But if users feel the technology is “being forced down their throats,” or if they aren’t sold on the value proposition, it will be

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difficult to generate the required level of buy-in from operations lead­ ers and staff. Instead, resistance will develop and it will come from all angles. Establish an environment of open communication about the anticipated journey to get the resistance out in the open so it can be dealt with effectively. There are two good ways to establish an atmosphere of trust and open communication. First of all, honesty still remains the best policy, so tell people the truth about what to expect and, if you are uncertain about something, don t be afraid to say so. Users respect leaders when they tell the truth. People want to hear the real story, including antici­ pated benefits, risks and potential difficulties. Secondly, provide forums in which users feel safe sharing their thoughts, concerns and questions. These can be team meetings, depart­ ment meetings, special sessions called by the project leader, feedback loops, etc. When people have the opportunity to work out their uncer­ tainty and issues openly, they get the information they need. This limits what they are able to “make up” and short-circuits the effectiveness of rumors. Anxious people who lack information fill the gap with specu­ lation and half-truths. After time, these stories become believable and have the power to negatively influence the way users view and utilize the CHANGE™. Avoid this common scenario by ensuring that users have opportunities to freely and comfortably get answers and make sense of things in a supportive environment.

Matching the Intervention with the Challenge If you are in a twenty-foot ditch, it stands to reason that a four-foot ladder will not be enough to bring you back to level ground or stable footing. Don’t let organizational pressures minimize the CHANGE™ effort. Managing change in a technology initiative is about giving peo­ ple the guidance, support and tools they need to be successful, so be sure to match the level of intervention to the level of change needed. It is always best to be proactive and employ a sound change strategy from the start, but realistically there are times when the people side of the effort is overlooked or not addressed well. Don’t underestimate the level of effort it will take to give users solid grounding. Throw­ ing training at them and hoping they will eventually catch on doesn’t work. Embrace the process and recognize what it takes to lead through

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the journey and how to establish long-lasting change. It can get messy climbing out of a ditch, but it gets messier if the organization doesn't properly mitigate the risk of users falling into the same or similar ditch again. Make the investment in your people and give them the support and tools they need so they can contribute to the organizations growth.

POINTING FINGERS When users resist the implementation of a CHANGE™ initiative, they often project their frustration and fear onto the technology and claim the new system is the source of all of their problems. “If only we could go back to the way things were.” In the case of EMRs, the new technology creates transparency that surfaces broken processes that existed long before the EMR implemen­ tation. People are not always happy when they realize that the EMR serves as a huge magnifying glass that calls attention to problems and inefficiencies that were hidden before. The good news is that, properly implemented and adopted, the EMR will help streamline and improve efficiency. The hard part is that people don't always want to change established processes, especially when there is some personal benefit in how things have always been done. Inevitably, the EMR becomes the object of resentment and is blamed for all the users' headaches. It is common to hear new users claim life was better before the technology. This can happen with any change. A good example is that providers who have time management issues before an EMR implementation will continue to have time man­ agement issues after the EMR implementation. The difference is that now the EMR will be blamed for the problems. We suggest three things. One, sometimes you have to remind peo­ ple that life wasn't all that great in the past. Pick the time to say this carefully. Two, in all of our experience, we have yet to encounter any­ one who gets through a few weeks post-live and wants to go back to paper or an outdated system. It just doesn't happen. And three, we strongly recommend that before go-live , you make as many nonsystem-related changes as possible. Do not burden the go-live process by encumbering users with changes that do not require use of the system. You will only create resistance.

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Here’s an example. In acute care settings, if one objective is to have nurses begin documenting at the bedside using an EMR, there is no reason why you cant begin bedside documentation months in advance of go-live, using the paper chart or whatever is the current method. This has several benefits. One, bedside documentation will not be blamed on the system. Two, the bugs in establishing bedside documentation practice will get worked out before go-live. And three, nurses wont have to try to use an unfamiliar system and change their documentation patterns all at the same time during go-live. The point is to make go-live as easy as possible for users, not to complicate it unnecessarily. With ICD-10 there’s a similar opportunity to help doctors move into new required behaviors before ICD-10 goes live. If you can start dual coding 6-12 months ahead of go-live, doctors have time to get used to the changes in a nonpressured way and this helps to mitigate a potential productivity decline at launch. An added benefit is that the sooner doctors begin to use ICD-10 the more opportunity there is to make refinements before go-live. Identify and implement everything that can be done ahead of go-live. You and your users will be glad you did!

MANAGING AMBIGUITY CHANGE™ implementations are full of uncertainty and ambigu­ ity, which affects people in different ways. Some users are fine sifting through uncertain times, and others find the lack of order and answers to be very uncomfortable. Be mindful of ambiguity and how people deal with it. Ambiguity can be very scary for users. Its a natural reaction but can spiral out of control if not managed well. You don t get the best from people when they are distracted by worry about the future. Ambiguity will always be present when things are in flux and subject to change. Manage user expectations by letting them know there will be uncertainty and what the organization is doing to find solutions to open questions; commu­ nicating honestly and frequently; soliciting and responding to feed­ back and getting users involved in the project.

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LIFE AFTER GO-LIVE Heres a news flash for many people—the journey never ends! In fact, things really get rolling after go-live. Don t be fooled into thinking that go-live is the big event, and life calms down afterward. Instead, the journey continues and, depending on how well users were prepared for implementation, you may be in store for a whole lot more than you bargained for. But if a good context for change was established before go-live, the transition to post-live will be much smoother. Remember, the context is important because it creates an environment in which users are engaged and look forward to improving their skills post-implementation. Go-live is like a wedding. Two people spend a great deal of time preparing for the big event and then look at each other when its over and wonder where the time went (despite the many decisions and stress involved in planning the effort). The married couple now begins to settle down and learns to coexist. With merging lifestyles and healthy sacrifices, the couple engages in life collaboratively, with both parties eager to make adjustments along the way to ensure a happy life together. The wedding is a big event but, like a CHANGE™ implemen­ tation, its what happens afterward that really matters. Unfortunately many optimization efforts fail to bring home antic­ ipated returns, largely because optimization begins before users are ready for additional changes. After go-live, users need to adjust to using the system in real time with real patients. Some struggle to adapt to the new routine. Others may be stuck at go-live, trying to under­ stand how to see a patient and use a computer at the same time. This can be a difficult period for users, and they need time and support to sort things out and stabilize. Allow them to adjust before launching enhancements and additional technology. They wont be able to grasp new skills and information when they are still trying to get comfort­ able with what they learned for go-live. To revisit the bicycle analogy used earlier in the book, its hard to learn trick moves if you haven’t mastered balance and gear shifting first. Life after go-live is where the action is. The organization needs to put its energy into ensuring that users are comfortable in their roles, able to use the system efficiently, and can learn how to leverage the sys­ tem to contribute to outcomes. This requires a post-live strategy (and

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budget!) to make sure performance targets are set, expectations are communicated, outcomes are measured, and customized training and support are delivered to those who require additional help.

CHANGE™ IMPLEMENTATION RISK FACTORS • Failure to cascade sponsorship through the organization to front­ line operations. • Not establishing a comprehensive governance structure (beyond executive sponsors) for making decisions, prioritizing, and manag­ ing the rollout. • Not getting medical staff, labor unions, and other key stakeholders engaged up front. • Assigning change management/technology adoption responsibili­ ties to technical or project management staff. • Rewarding behavior that is inconsistent with the vision by neglect­ ing to realign incentive programs to reinforce people for future state behaviors and outcomes. • Not addressing the need to facilitate behavioral change by support­ ing people to develop new skills and new ways of thinking, in addi­ tion to learning features and functions of the software. • Failure to establish an ORT early in the process and, instead, waiting until things go wrong and people are upset. “Ambulance brigade” change management is more difficult and expensive as damage control is the first step. • Underestimating the degree of resistance that will be experienced and not preparing for it. • Not holding sponsors accountable for effective sponsorship. Allow­ ing sponsors to get away with not supporting the transformation. • Thinking that technically skilled people make good champions, or selecting local champions based on title or availability instead of informal leadership ability. • Letting past success and strengths get in the way of what needs to be done to succeed in the future. Past success may be the greatest threat to transformation. • Forgetting to update job aides, policies and procedures, job descriptions, etc., to reflect and support the new reality.

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• Letting intellectual capital (the content in consultants or vendor implementation peoples heads) walk out the door without doing comprehensive knowledge transfer. If you re getting outside help, make sure you retain as much knowledge as possible when they leave.

FINAL THOUGHTS • Doctors and nurses communicate with each other less in the begin­ ning stages of an EMR implementation. They are so focused on the new system that they forget to talk to each other. But the EMR shouldn’t be seen as a replacement for collaboration and human interaction. Counsel people about this during team readiness meet­ ings prior to the EMR launch to avoid development of bad habits. • It takes time for many users to overcome concern that the new sys­ tems will do their jobs for them. It is very important to reinforce that a system is merely a tool that will support them in their work. • Some organizations form cross-functional workgroups to resolve important issues as an alternative to having leaders make all the decisions. Workgroups are a way to get others involved. Include some who are resistant to ensure all voices are heard. Members of the workgroup represent their teams and bring local input to the problem. This extends the reach of the workgroup, often resulting in broader buy-in for proposed recommendations. • User confidence in the organization is eroded when leaders are perceived as clueless about what lies ahead and how this will impact users and departments. Knowledgeable, effective leadership reassures users that all of their hard work and change will eventu­ ally lead to positive outcomes. Sponsors at all levels play an enor­ mous role in communicating the importance of the CHANGE™ and modeling the path to a positive future state. • One of our primary goals in writing this book is to help people see that a CHANGE™ implementation can transform the organiza­ tion by building change capability and capacity. When the next big change project comes up (and it will be soon!), imagine a world in which users expect change management support, sponsors willingly resource the people side, and the organization has broad skills to do change management well.

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• A CHANGE™ implementation is not an event; it is a long-term process which, if sustainable, never ends because the CHANGE™ becomes part of operations and is the “way we do things around here.” This is another way of saying that go-live is just the begin­ ning of the future state, not the end goal. • Accepting the computer and openly engaging in process improve­ ment can be threatening to people. Some organizations implement job security programs or offer a retention bonus to encourage peo­ ple to look openly at opportunities for performance improvement using the EMR without feeling they are putting their jobs at risk. • Remember to think through any potential impact to patients (such as longer wait times), particularly during go-live. People are often supportive and understanding when they know something big is going on, but you have to tell them about it. Having signage and staff on hand to answer questions and troubleshoot goes a long way in gaining patient acceptance. • Leverage what you’ve got! People are busy and schedules are tight. • In every way that you can, leverage existing meetings, roles, com­ mittees, task forces and events to support the CHANGE™ effort. Avoid setting up parallel structures whenever possible. • To the extent possible eliminate distractions before, during and just after go-live. Successful practices include putting other proj­ ects on temporary hold, reducing e-mail volume, and canceling all non-CHANGE™ related meetings. Focus the organizations energy on the CHANGE™ deployment. • If computers in clinical areas are a new thing in your organization, support your staff by providing them with training on effective and respectful use of the computer with a patient present. • With CHANGE™ implementations, the idea is to find a way to ensure everyone has skin in the game regarding the success of the implementation. The incentive must outlive the event of go-live and carry forward through life post-live if sustainability and bene­ fit realization are to be achieved. We hope you have enjoyed taking this journey with us and that we have provided ideas and insights that will help you support your users and your organization through a successful electronic medical record or other CHANGE™ implementation.

C h apter 11

Lessons from the Trenches As we said in the preface to this edition, a lot has changed in the four years since this book was first published. We were curious about how the book was being used and whether the concepts and tactics were useful in the evolving world of EMR implementation. We were also curious about how the changes in healthcare and the broader environ­ ment were impacting application of our recommendations. So we reached out to a few people in a variety of roles to gather their lessons and learn from their firsthand experience. One thing we learned is that our book is very useful in the real world; it pro­ vides practical advice and insights, but it is far from exhaustive. We knew when we first wrote it that there is much more to be said about things such as IT governance, human psychology, and the evolution of technology, just to name a few. But there are other books that delve deeply into these topics and more, and we encourage you to seek them out while also learning from professional associations, colleagues in other organizations and the emerging knowledge in neuroscience and change management. As the book was originally intentionally focused on EMR imple­ mentation, the following comments are mostly EMR specific. They provide additional insights directly from the trenches, and we offer them in closing.

Paul Cohen, Deputy CEO, Barwon Health, Geelong, VIC Australia Barwon Health is a large tertiary provider of acute health services for the community of Geelong, serving a catchment city and surrounding region of around 400,000 people. In addition to acute health services, Barwon Health has a comprehensive range of community-based pro-

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grams including chronic disease management, home nursing, mental health and aged care services. We also have established electronic links to around 150 local general practitioners. This interconnectedness of care across our community has required a vision and implementa­ tion plan for the development and sharing of clinical records focused on improving the care of our community. The journey we have been on has taken more than a decade, and we still have a little way to go, although the path is easier and a little more travelled than when we started. Around five years ago, at a Health-e-Nation conference in Mel­ bourne, Australia, I had the opportunity of listening to Claire McCa­ rthy as she presented her experience and lessons around implementa­ tion of integrated clinical information systems across large systems. As a hardened informatics conference attendee, I rarely took notes, but something in Claires presentation struck me deeply in respect to our own local challenges, and I remember writing furiously, attempting not to miss any of the ten points she presented. Even across the cultural divide between our health systems these points struck me as deeply pertinent and important. They involved a series of actions we can all probably relate to. I wont repeat them as they are listed in the book, but key points include the need to have a clear strategy, implement in small bites and feed wins back to stakeholders so they understand the upside as well as the negative points that will be raised as organisations drive change. Ensure executive level champions will support and drive change. One key lesson that we applied early was to write a short, simple strategy that explained what we were about to do, why and what would improve as a result. Claires advice was to imagine explaining the strat­ egy to family. Would they understand it and want to be part of the journey? It was a key message that we understood and implemented. In addition, start with the problem. What are we trying to fix? Do we have support that this is seen as a problem by our clinical staff? If we can get a common understanding about the problems, we have a chance of then agreeing with our clinical staff and other key sys­ tem users on solutions. In turn, this achieves their buy-in and support as issues arise along the way. They then support resolving issues as opposed to using them as barricades.

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While we all understand the need for executive champions and clear strategy that describes a vision and the implementation steps ahead, it is interesting to see how few organisations follow this course. At Barwon Health, we re-wrote the strategy and over the past ten years it has remained a short, circa ten page, document. It is intended for reading by people who don’t work in IT or information disciplines. Similarly our customer base has supported management of issues and largely been patient as we slowly move toward the vision. Barwon Health is seen as one of Australia’s leading health organ­ isations, particularly in respect to the development and use of clini­ cal information systems. This journey was based originally on some advice we received at Claires presentation all those years ago and we still try to keep the lessons front of mind. I was, therefore, particularly pleased to see Claire at another Health-e-Nation conference three years ago, sharing a platform with our new chief information officer, outlining and presenting some of the lessons we had learnt to a new audience. It was great to see how far we had progressed and also that we were now able to share rather than simply receive advice. We look forward to our next series of challenges, in particular, implementation of our medications management system next year. You can be assured that as we now enter planning mode, the list of lessons learned will be read through again and implanted into our project and other plans.

Michael Geist, MD, FACP, Medical Director of Informatics, PeaceHealth Medical Group This book is an excellent distillation of key change management prin­ ciples. We found it to be a quick read and an easy way to get those project team members who were new to EMR implementations up to speed on the concepts they needed to understand. We had a very short timeframe to get our project up and running. This book was comprehensive enough that we used much of it as the blueprint for our change management and communication strategies. There is the saying that “all battle plans get thrown out the moment the first shot is fired.” Almost immediately after our project was approved we had the first of several budget cuts and the timeline moved up. And throughout our implementation we found ourselves

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contending with scope changes pushed down from the executive lead­ ership as new service lines were acquired or created. Furthermore, unrelated to our EMR implementation, major support divisions of the organization underwent staffing cuts and reorganization. Finally, key clinical and operational leaders at the manager and director level kept turning over just before each phase of our rollout. Yet, even though it was challenging (and stressful), this environ­ ment markedly facilitated the change management around our imple­ mentation of the EMR. Our project had been identified by executive leadership as “critical to our organizations future,” so competing ini­ tiatives were set aside. Because of the reorganizations of key support areas (IT, HIM, HR, etc.) there was no organized resistance. So, we were able to central­ ize the decision making and engage stakeholders through streamlined committees and groups set up to make rapid decisions for the project. We had included in our business plan key principles that we deliberately had our executives and board members endorse. These were incredibly helpful to keeping the project on track throughout its implementation. We proactively repeated them to every audience we encountered throughout our implementation. They included: • The EMR project was not an IT effort, but rather a medical group optimization initiative. Therefore, changing workflow and stan­ dardizing processes was absolutely going to happen. Change was the whole point of the effort. • We would maintain an enterprise-wide, system focus in design, build and implementation. There would be no “opting out” by indi­ viduals, departments or regions on any aspect of the project. • Decision making was centralized in the project team structure. Stakeholders were consulted regularly to provide input, but they were not given veto power. • We would use the vendor s off-the-shelf settings and content as our starting place and deviate only when it could be shown to be absolutely necessary. This kept us on time and on budget, but also served to bypass lengthy negotiations to reconcile differences in processes and workflows in the organization. • We implemented the EMR using the vendors methodology and even though they did not always get it right, we stayed on track

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and spent less effort cycling back to fix the things that did not work than we would have spent trying to figure out how to get it perfect ahead of time. • A key part of this was that we were not going to request software modifications from the vendor. It kept our folks focused on using the system as designed rather than trying to second guess how the tools should work. We did have to bend on this requirement when it became clear that our organization had a unique mix of billing methodologies that necessitated a minor rewrite in code. • Providers and leaders were held accountable for using tools. We mandated training and testing of competency before allowing access to the system. • Leaders of IT, operational and support services (finance, HR, HIM) were clearly directed to ensure that adequate resources were provided to the project team. • The project did arrange for and effect the required infrastructure enhancements prior to the scheduled go-live. • And while we staffed the initiative primarily with internally found personnel, we quickly found value in bringing in consultants experienced in the setup of our particular EMR. They were able to coach and bring along our internal team members much more quickly. • Significant resources were budgeted post live for ongoing practice redesign and mastery of the Epic tools. The importance of being armed with a board-approved list of principles cannot be understated. Equally key was making them the first several slides of any presentation to introduce the project to a new audience. Setting the ground rules up front spared our team and the organization from endless unproductive debates. Books like this are helpful at the beginning of a project, before the challenges and changes in implementation convert a static description of an ideal state into a messy dynamic of moving pieces and personal­ ities. I would like to see several chapters on the practical (and tactical) political skills and strategies of managing the daily issues that arise as ones project tests the limits of individual resilience. Things like: • Practice not blinking when you tell someone something they do not want to hear.

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• Be patient and transparent in explaining to those challenging a decision on how and why it was made. • Anticipate the needs of key stakeholders (a.k.a. surgeons and inter­ ventionists) and do not feel you need to limit the attention to them to be the same as others in order to be fair. • When you have a run-in with one of those key stakeholders, get to their supervisor/hospital executive before they do and be the first to explain what happened. • When you know there is going to be a run-in with a key stake­ holder, warn the executive ahead of time. • Know when to boldly say “MAKE IT SO” so that team members or groups don’t waste time making a choice of minor impact. • Keep your radar up and know when specific stakeholders need to weigh in on what appears to be a trivial default setting or feature of the application, but actually has significant consequences.

Marc Chasin, MD, MMM, CPE, CHCIO, System Vice President, CMIO & CIO, St. Luke’s Health System I definitely see this book as applicable in other environments. In the introduction you mention ICD- 10/BI and Analytics, and Clinical Inte­ gration to name a few, but I would expand the use of these concepts more broadly. My organization, as well as many others, is taking the leap toward accountable care. This takes change management to an entirely different level. Not only do you need to engage your technol­ ogy stakeholders but now you need to engage patients and payers as well as clinicians who are independent—a whole different environ­ ment. It is crucially important to the success of our transformation from volume to value. Initially I read the book cover to cover. I then observed my organi­ zation in action and then went back to utilize the approaches and strat­ egies described. I employed aspects of all the strategies referenced in the book. However, if I were to choose which ones were most impact­ ful I would say establishing a vision for change, constantly communi­ cating that vision while creating a burning platform, and spending the time required to get leadership ready. One thing that wasn’t in the book, but is inextricably tied to change management efforts, is proper IT governance. It is imperative that these

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enterprise implementations not be seen as IT projects. They need to be seen as clinical transformation projects with an IT component. This is where effective IT governance plays a crucial role.

Mary Carroll Ford, MBA, Sr. Vice President and CIO, Lakeland Regional Medical Center, Lakeland, FL We were implementing our EMR, and were searching for all litera­ ture from thought leaders to make our implementation as successful as possible. We bought multiple copies of the first edition for our leaders and staff. (The book) was great for our EMR implementation. How­ ever, I could have substituted “EMR” for many other initiatives. I have a very specific, and perhaps to some, startling example. I was recently at a board retreat and we were discussing our Community Health initiatives. I was moderating the group on “Access to Care” and we were discussing what individuals or groups from the community or state we should include. In the book, you discussed “resistance” to change and the difference between positive and negative resistance. One key strategy we landed on is to only include those individuals and committees who would bring positive energy to the task. This thought­ ful focus on engaging those people who will drive success versus those who will wear us down has been a key differentiator for me in my proj­ ect leadership. We found the chapter about communication especially helpful. One comment that came back to the technology team on our EMR project was that we had communicated in “English” and the clinical teams felt empowered to bring value, make good decisions and own the tool, simply because they understood what was being delivered. I think that reading the whole book, or even just parts of the book, helped our clinical leaders realize that this change was not unique to us, and helped the technical staff work through issues that other hospi­ tals had already conquered. There’s something to be said for realizing that this is doable, and success is achievable. This book is steeped in the principles related to an EMR implemen­ tation. Nicely done, but if you ask what I might suggest its that in the project life cycle it can feel pretty cut and dried on the plan, implement, stabilize, optimize and get benefit realization. Quite frankly, the EMR vendors like to get it implemented, get paid, and then let us take it from

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there. We did it a little differently. We calculated the most important safety benefit, which we felt was our medication administration. Once we had enough developed to roll that out, we rolled out med admin (in the middle of the project) without the charts and all the other basics. This was against the recommendation of the vendor and really outside of the project life cycle. We were cautioned by everyone that this would result in chaos, that it did not follow proper order, etc. In fact, we expe­ rienced an unintended benefit: it allowed us to have every caregiver on the system eight months in advance of our implementation. We were able to make sure all security worked and all printers, scanners, etc., functioned properly, which we never could have done in a test or pilot mode. So, I would encourage more small wins, and encourage the organizations to reap the benefits immediately if possible. Then, we formed a team that is still in existence to optimize. We ended the project and now the optimization is a continuous effort. I think that I would put more emphasis on the role of the CIO to truly have an executive sponsor other than himself or herself. Also, the Chief Nurse should be articulate and front and center on this initiative; get quotes from both the CIO and the Chief Nurse. At the end of the day, IT moves on to the next project and the tool is left for the users to manage their daily activities—operational or strategic; therefore, the sooner the “user” owns the system, the sooner the benefits come and the technology team can focus on the next “winner.”

Ronnie D. Bower, Jr., MA, Director of Applied Clinical Informatics (Adoption, Sustainment, & Communications), Tenet Healthcare Corporation When I am engaged in planning for organizational change manage­ ment, I ask myself, what does this audience need to know? Organiza­ tional needs vary greatly based on size, complexity, impact of change, level of resistance, and cultural readiness. Regardless of needs, there are key lessons that tend to be consistent across initiatives that can help propel organizations to higher success rates. The following items are topics that I have found to assist organizations in achieving more successful adoption of their health IT initiatives.

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1. Effective Communications I have observed that almost every organization struggles with commu­ nication in some fashion. The challenges vary as greatly as the orga­ nizations themselves, but most leaders agree that communications do not always filter to the desired levels, messages are not interpreted the same way at all levels, and/or messaging is not consistent across all lev­ els within the organization. Communication issues are often correlated with lower physician, staff, and patient satisfaction scores. When a sig­ nificant project threatens the status quo, a sound communication plan takes on a new level of importance for the organization. Organizations that have established a clear communication plan, one that matches the phasing of their projects strategic plan, tend to have higher levels of adoption and satisfaction. Leadership often articulate the need for a strong communication plan, but obtaining buy-in and plan adherence can prove to be more difficult once the project has been initiated. Since leadership attention is often pulled in multiple directions, maintaining a focus on your communication plan throughout the project can be difficult but is necessary to assure that team members and physicians all move along the adoption curve. With this in mind, some lessons learned regarding communica­ tion plans include: • Create a solid communication plan with buy-in from everyone (sound examples are included in this book). • Don t make your plan too complicated; keep it simple so everyone understands the tasks. • If you need a resource for deploying communications, allocate one; make sure they understand their role and that you arent over­ whelming their already full plate. • Share the plan with leaders, and not just executive leaders; include managers/directors/team leads. • Make sure all managers list your project as a standing agenda item on their department meeting agendas. • Make sure you have a feedback loop to gauge impact and under­ standing of your communications. For example, have super users share what they are hearing or not hearing about communications at a department level.

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2. Quality Super Users/Support I am very passionate about this topic because I have found that a great super user is worth his/her weight in gold. I continually hear this from other professionals, so I started asking myself what makes a great super user, and how can I help organizations move average/good super users to “great super users.” Some proven elements to help create and main­ tain a strong super user program are: • Establish a detailed written super user plan. This doesn’t have to be complicated but must be specific enough for your facility to make a super user “super.” • Establish a sound super user selection criteria process that out­ lines the behavioral characteristics needed for super user success. Placing the criteria into a spreadsheet helps leadership to rank and categorize specific criteria and identifies specific areas of focus for super user development. • A specific super user training program with checklists or specific criteria helps assure super users are competent in appropriate sys­ tem functionality and workflow processes. • Additional training on the emotional impact of change and orga­ nizational change management helps super users understand their role as change agents within the project and helps normalize reac­ tions to change that they may encounter while providing front-line support. • Releasing super users from clinical care is an issue for every department, so have a sound plan to address this proactively in order to reduce support issues at go-live. Organizational leader­ ship must assure super user availability during peak support times within the project life cycle. Leadership can be very creative in this process but a detailed action plan must be applied to address situations when a super user or other support person is no longer available to provide front-line support. • Leadership often minimizes the fact that some super users will need to remain involved in the project after go-live. Many super users are engaged for support and return to clinical care but an ongoing primary super user, per clinical area, is necessary to assure continued adoption of functionality and workflow processes.

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3. Emotional Impact of Change Many organizations underestimate the emotional impact that their health IT initiatives will have on leadership, team members, and phy­ sicians. The level of change impact and the cultures current capacity for change are often minimized during the planning phases of the project. This reduces the ability to be proactive in handling resistance and causes a reactionary culture to emerge. Adding training sessions specific to personality and conflict resolution, effective communica­ tions, and methods to handle resistance assist both super user and leadership in dealing with the daily stressors of organizational change management.

Vicki Davis, PMP, Former Epic Training Director, Providence Health & Services Training 20/20: The Power of Hindsight As the EMR Training Director, my journey began with 24 trainers and a scope of 9 hospitals and 143 clinics. In six months the training team grew to over 350 managers, trainers, project coordinators, scheduling and registration staff, training deployment leads and training room coordinators required to support a scope that grew to deploying train­ ing to 21 hospitals and 340 clinics across 5 states. My training journey was filled with long hours, lack of sleep, laughter, constant fires, unrealistic expectations, a tremendous sense of accomplishment, and deep joy working with training leadership and staff to accomplish an unprecedentedly rapid deployment. The follow­ ing are some things I learned along the way, all of which I wish I had known at the start! • Training go-live occurs before application go-live and starts with super user training, which is 8-12 weeks before the system go-live. Don’t let the project team forget this is your big event and timeline. • Curriculum is best built around competencies. - Work with Clinical Champions and SMEs to establish key com­ petencies, by role, and build pre-go-live training around the competencies. - Build specialty-specific provider training.

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• Set expectations early that EMR training is a continuum of educa­ tion that runs for roughly a year. - The first phase, pre-go-live, is a combination of eLearning and live classroom that teaches system and high-level workflow nav­ igation. This training provides only 20% of what staff need to learn over the next six months. - The second phase of learning, system use with “at-the-elbow” support, begins at go-live and runs the next 4-6 weeks. - The remaining learning comes from on-the-job experience over the next 3-4 months. ■ Build education milestones from pre-go-live through the first six months. Include checkpoints/milestone dates; deliver competency evaluations pre and post live; deliver topicspecific workshops; and conduct focus groups to track and monitor end-user understanding and efficacy with the system. ■ Facilities generally underestimate the need for at-the-elbow support and ongoing education requirements. • Build go-live, immediate post-live and ongoing training and resource plans at the same time. - Set up local structures to support training during go-live and post deployment. - Remember to include nonclinical groups impacted by the implementation as part of training and access planning, such as: ■ Finance team - To locate data and access GL reporting, they need a data crosswalk between the old HIS system and the new EMR. ■ Contractors - Check with local human resources to understand local contractor and vendor needs and any requirements. ■ Students/residents - This staff often receives training “at the elbow” and may use a generic access. With an EMR imple­ mentation, training and proficiency demonstration may be required prior to access being granted. ■ Third-party vendors - If other applications will be used in conjunction with the new EMR, advance planning is required to determine how people will be trained and gain access to these additional applications.

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■ All affiliate organizations and joint ventures - Think through training and interfaces required. ■ Community providers - Nonemployed providers with hospi­ tal privileges, proctors and consultants all need training and access. • Partner early with clinical and business informatics (back office, admissions, finance, claims). - Build and review the education materials together. - Create logical handoffs between pre-go-live training and at-theelbow support informatics provides. This should be a collabora­ tive process. - Establish feedback loops with informatics so curriculum can be adjusted based on the at-the-elbow experience informatics has with users. • Training staff participation in deployment events beyond the class­ room training: - Set training schedules to enable trainers to support dress rehearsals, workflow sessions, go-lives, and physician engage­ ment centers. Trainers play a critical role. - Establish an educational community with local trainers to keep them connected and learning from each other after go-live. ■ Share successful practices, identify and remediate areas where end users are struggling, update materials, etc. • Training room logistics - Training rooms will become a HOT commodity; plan accordingly. ■ Training rooms will be in demand for dress rehearsals, cut over activities, command center, etc. ■ Establish a single point of contact for facilities and other project staff that may need classrooms during the training cycle. - Establish training room specifications early in planning. ■ List all of the equipment needed beyond the work sta­ tions and computers, such as printers, projectors, phones, scanners. - At least six months before training begins prepare facilities for converting space into classrooms.

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■ Classrooms are often in locations not known to staff; maps and directions will be needed. ■ Ensure trainers have security access to buildings/floors during training hours (which are often outside of normal business hours) if they are not local. ■ Check local facility dress codes and inform training staff. • Training environment - Hire a dedicated technical person with a training background to create the bridge between database administrators and the trainers. • Establish hourly employee travel policies for training. Include daily meal limits, rental car policy (and sharing for reduced spending), hotel and flight parameters, and allowance for trips home. Clearly articulate these expectations when interviewing. • Define lead-time required to create new materials, build patients, train trainers, update the learning management system, build schedules, and register students for the next training deployment cycle. Training environments and materials must be updated quickly when needed. Map this workflow to establish realistic turnaround times and manage expectations.

Adrienne Edens, CHCIO, FCHIME, Vice President & Regional CIO, Sutter Health East Bay Region The book is a great resource; IVe used it for writing questions for the CHCIO exam, and also as recommended reading and source mate­ rial for Success Factor 2: Making Change Happen for the CHIME CIO Boot Camp. One of the things that Cara Babachicos (from Partners in Boston) and I are doing with our Boot Camp presentation is to discuss how to manage change management even after the system is installed. Many of us cant get our organizations to adopt a full change management program, and some organizations are in a hurry to meet Meaningful Use criteria, so there’s a lot of after-the-fact change through optimiza­ tion projects and organizations that are adopting Lean that also need to put effective change management groups and processes in place. So a chapter on what you can do after the implementation to continue (or

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even to start) effective change would be a good addition for those who couldn’t get it done up front. The sections of the book that have been most valuable to me are: • The Future State Opportunity Map; • The chapter on sponsorship, although unfortunately, many of us still have do to projects without effective sponsorship; • The Organizational Readiness Team, although I think they often need a good change management facilitator. They have competing priorities and many aren’t really good at seeing the changes that need to be made in their own departments—or want someone else to do it for them. Sometimes you get a mediocre result because they aren t up to taking on the level of change that’s really needed. Our Organizational Readiness Team at a previous employer was really poor, and we didn’t get great change leaders assigned until after the implementation when the process problems were evident. • The chapter on reinforcement, although you need some pretty enlightened leaders to make this a priority. One thing that I think needs to be addressed is the need to stan­ dardize information (procedure and charge masters, item master, surgical services, monitoring devices, etc.) and processes (admitting, charge capture, patient flow, job descriptions) as part of the change preparation. It’s surprising how many organizations start to design a new system before they’ve tackled the fundamentals of standardizing their information and processes first. They don’t assess how people’s jobs will change and don’t develop staffing models for the new system. There is material on some of this in the Implementation Readiness chapter, but I think many organizations risk losing a critically import­ ant opportunity to standardize significant portions of their data and processes and should address it when they’re standing up their change management efforts for the initiative. There are other “gotchas” that I’ve seen or heard about: • Super user and physician champion programs need to be set up and funded as permanent roles, not just for the initial implementation. • The space for a team to work together is often underestimated or ignored. The change team needs a work space that can accommo-

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date lots of operational and SME resources meeting to develop the change workflows, job descriptions, etc. • Including downtime processes and training as part of the imple­ mentation and change initiative is a key activity. Downtime when you have a fully electronic medical record is a major change from what clinical staff are used to on their older systems. Thoroughly mapping the impact of the revenue cycle changes is critical. Lots of hospitals are experiencing shifts in their reimburse­ ment that they didn't expect because they didn't understand the impact of the decisions they made when they set up the charging mechanisms in the EMR.

Michael Strachan and Mary-Ellen Vidgen, Program Managers, Mater Health Services, Brisbane QLD, Australia We've found that what we learned from the book has broad applicability beyond EMR implementations. For example, our healthcare facility has implemented new payroll and talent management (staff performance management and planning) systems in the last two years and both of those initiatives adopted many of the same change management prin­ ciples outlined in the book. Both projects had dedicated change teams. Conversely, our Patient Administration System implementation six years ago was managed prior to our organization adopting more formal change management tools and methodologies and certain “people and processes” aspects of that project were problematic. Our organisation had an epiphany and is in the process of a mind shift around the definition of a “successful project.” There is a gradual change in the minds of staff within the Information Management Divi­ sion, project steering committees and project sponsors that success is not solely defined by a technical go-live. Success is measured by adop­ tion of the new tools and the realization of benefits. Projects are now funded beyond go-live to assist with post go-live support, business as usual transition and benefits monitoring. Previously there was mini­ mal emphasis on this, and we still have a way to go. The organization has acknowledged the benefits offered by a ded­ icate change team and have invested in growing the organization's change capability and capacity.

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The concepts in the book that weVe found to be the most helpful are: • Cascading of sponsorship to middle level sponsors. Our clinical portal project sponsor worked collaboratively with the clinical specialty directors to ensure the implementation of electronic test ordering and acknowledgement was successful. • The importance of developing and sharing a vision. Our Mater Shared Electronic Health Record (electronic version of the antena­ tal patient held record) was “dreamt about” for years by our direc­ tors and clinicians in our obstetric hospital. When the funding became available via an external grant, everyone already had a very clear picture of what we needed to do and why we were doing it. • Emphasis on the fact that EMR implementation projects are not technology projects. That resonates strongly in the clinical busi­ ness. The change team members on the project were considered advocates for the business rather than people with allegiances to the IT department. Thus, the clinical business has developed a sense of trust that the project has a dedicated focus on “looking after their people.” • Different communication approaches are required for different stakeholders—one size does not fit all. • The book talks about a key question—“How will this decision impact the user?” The change team members push the project team members to consider this every time a decision is made.

Dick Taylor, MD, Chief Medical Officer and Managing Director, Medsys Group LLC “Nothing endures except change ” - Heraclitus “No [battle] plan survives contact with the enemy ” - Helmuth Karl Bernhard Graf von Moltke The following comments are based on my years of experience with multiple EMR implementations in multiple healthcare systems, with an emphasis on the most recent. During this last EMR implementation, where I served as Chief Program Officer, we ran across Claire McCarthy and Doug Eastmans book on change management. It was at once practical, detailed, and seemed to address directly the challenges we thought we would meet

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in the years ahead. I purchased a copy, reviewed it, and then purchased several more to provide to my leadership team. As we moved through early implementation (including imple­ mentation planning, which for change management is in itself simply the first step in the actual implementation), it became clear that the ground on which we were standing had shifted somewhat from what Claire and Doug were describing in the first edition of their book. One key is that the organization was already strongly electronic, particularly in the outpatient arenas. More than half of the employed physicians had EMRs and were largely or completely paperless when we began. That is, this was a replacement for them, not an initial imple­ mentation. As it turns out, this was important in countless ways large and small. A second fact is that by the time our active rollout began in 2011, nearly all of the clinical users were far more engaged with technol­ ogy than they had been even five years earlier. The advent of iPhones and Android cant be overstated—again and again, we dealt with users whose understanding of what they thought the technology could do was far removed (and generally far advanced) from what the technol­ ogy was actually going to do. This is a reversal of previous years when clinicians (in particular) were uniquely insulated from technology in general and operated in some unpredictable ways. In simpler words, the battle in 2012 was not mostly with the physician who “didn’t go to medical school to learn to type;” it was with the iPhone-toting clini­ cian who was incredulous that the EMR didn’t allow them to use their own device to practice medicine. A third critical factor was that the initiative was perceived from the beginning as something far more than an IT endeavor. Where many of the EMR implementations Claire and Doug described (and the ones I’d been through before) were IT-led (and driven jointly, hopefully, by IT and operations), this effort was from the beginning highly visible to the board, the executive suite, and the senior leaders of the organiza­ tion. The sheer price tag was enough to get that level of attention, let alone the possible disruption to operations.

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Sponsorship I enjoyed the thorough discussion of sponsorship in this book. In my last EMR journey we had the good fortune to have high-level exec­ utive sponsors who were amazingly active throughout the program. Executives from clinical programs, operations (including senior health system executives), and administrative services attended twohour weekly meetings for more than two years, guiding our large and complicated program. We turned overall program governance over to this group, along with tasking each member to carry the banner back to their own personal area of responsibility. The dedication from this group was amazing. We learned some things that might profit others. We quickly found that some executives are more attuned to the tasks of sponsorship than others. We juggled the membership of this group frequently, accept­ ing that some people who really ought to be there just didn’t show up. We also worked hard to nurture sponsors’ needs to learn, decide, and control. Governance was always active, and we planned extensively for every meeting.

Does it work? Page 3 of the book contains a “key point” that is indeed critical: the assumption that the software being installed actually works. As was observed, if it doesn’t work, all the change management tactics in the world can’t solve the underlying problem. What might benefit from some discussion, though, is what it means for the software to “work.” One of the biggest challenges in any software implementation is to align the users’ personal definition of “working software” with the reality of what the software actually does and how it does it. Every major software implementation that I have lived through has run up against this point, usually more than once. In one situation the physicians at the pilot facility eventually reached the point of active rebellion because of the collection of things that “didn’t work” and the users’ perception that we were not effectively closing this gap. It wasn’t that the system was actually failing the majority of clini­ cians, or that the problems they were facing were intractable. Rather, it was that the sum total of real, credible, and as-yet-unaddressed prob-

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lems found an unholy interaction with many influential physicians personal change-adoption curve and it created the credible and lasting impression that we in the overall program had messed this thing up so badly that it wasn’t worth keeping. Fixing this, and we did fix it, required that we devote an incredible amount of time to that facility and its users even as we prepared to implement elsewhere. Personal engagement with the users using some of our most senior people, finding creative solutions to problems, and prioritizing staff to what might seem like “optimization” in the face of basic build needs elsewhere all contributed to a successful realign­ ment. This also gave certain key users a chance to come through their own process of change adoption and to de-escalate in ways that were beneficial. Every program will have moments like these. The most important thing I think we learned is that “works” is always in the eye of the indi­ vidual user. If enough of them decide, whether or not its actually true, that the system “doesn’t work,” it doesn’t matter what you do, you will have a huge problem on your hands. Focus on the individual user expe­ rience and handle the inevitable real problems as quickly as humanly possible, and you will find great success. Miss any constituency too long or in too many ways, and you will certainly come to regret it. A footnote: as a direct result of this experience, we piloted at the go-lives a new physician engagement experience that prioritized solv­ ing the small problems and engaging the physicians one-on-one in an active “command center” environment. This physician engagement strategy, which grew out of the fire of a major discontent, was one of the most successful things we did as a program.

Organizational Readiness Team We implemented a formal organizational readiness team in our pro­ gram, and learned a great deal in so doing. In the end, much of what we did—training, physician engagement, “at-the-elbow” support, and optimization techniques—wound up looking much like what was in the book. There’s a learning curve to this, though, and much of it is organizational. Our greatest success in training, for example, came from a “pause” we took in our go-live schedule (really, a rescheduling in the middle of deployment to settle some significant issues). During

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the “pause,” we took the opportunity to rewrite much of our physician training, reducing the number of hours required and increasing the connection with the profession. The result was universally improved training satisfaction and uneventful go-lives. This is one area where von Moltke’s dictum (see above) is visibly true. It is accurately and frequently observed that in a large system you will see dozens of go-lives, but that each user only goes live once. The shorthand is that “your fifteenth go-live is their first.” This is also true for training, post-go-live support, optimization, and every one of the distinct phases discussed. The fact is that as soon as you go live in your first facility in a multistep go-live project, you probably have users and fragments of the team in every one of the “phases,” and you will have them there for months. We eventually worked most of this out, using a variety of techniques and organizational tricks. Our Orders Management Task Force, for exam­ ple, focused almost exclusively on optimizing the experience of clini­ cians already live, even as others were continually updating the training so that the OMTF work could be delivered on day one to users lucky enough to go live later in the cycle. Organizations should look at the period of deployment as a multi-threaded engagement with every user and ensure that all of the threads will receive resources and visibility.

Stakeholder Management The book goes into great detail on management of stakeholders, and a lot of it—mapping and segmentation, for example—is perfect. I want to discuss one area that is more complicated, though, and thats resis­ tance management. One dimension to consider is the reason for resistance. If the rea­ son is that the software simply doesn’t work for the purpose at hand, you as a project team have a fairly simple task, which is to make it work. If the user is being truly honest with you—a separate and highly contentious question at times—resolving the usability or workflow issue will dissolve the resistance.* If the user continues to resist despite * In fact, more than once we saw a “resister” move immediately to the “early adopter” role to test and demonstrate something that was crafted personally for them. This is an important, although expensive, tactic in stakeholder management to be used with creative discretion.

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the objective resolution of their concerns, or if (as happened many, many times for us) the “goalposts shift” every time the concerns near resolution, you have a different reason and you have to dig further. In the end, some users are indeed seemingly wedded to resistance. In one situation a clinician famously sent an e-mail to hundreds of col­ leagues expressing deep and permanent discontent with the way that certain clinical decisions were being made, and it was clear from the content of the e-mail that there was no significant negotiation to be found. That leads us to another interesting dimension of resistance, which I call the “so what?” dimension. Some users will resist and in so doing drag dozens or hundreds of fellow travelers to that end of the curve. In any organization, there are people who are by their position or by their social standing people of influence. There are others who are pariahs and known troublemakers. Knowing which is which is critical to your management of resistance. If you have credible and reasonable resistance from a highly influ­ ential user, you must, at all costs, manage this actively. If, conversely, you have irrational and argumentative resistance from a user who is already written off by the rest of the community, you may have found one of your candidates for 5% attrition. You will certainly have found resistance that you manage in a more indolent manner. “So what if they refuse?” turns out to be a critical question, and one whose answer can save you a great deal of time and trouble. In this vein, one of the best tools is a two-dimensional “heat map” of discontent, where you map both the strength of resistance and the influence of the user, and focus the majority of your attention accord­ ingly. Keeping these kinds of maps up to date and using them con­ sciously turns out to be a critical success factor, especially when you’re managing stakeholders during high-pressure situations.

The Ready User A great note for me is the concept of the “ready user.” The idea that skills build on training, and both build on goals and expectations is one that resonates well. One thing I would like to comment on, however, is the interaction between the ready user and the concept of support. If you consider readiness statements useful (and I do), you prob­ ably want to consider statements around the users perception of the

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support they believe will be offered once the system is live. At the base, the most important statement is probably “as a ready user, I believe that I will be supported through the change process” This must be reinforced in training while you also emphasize that users don’t have to know everything on day one. The implication, of course, is that they will learn quickly once they’re live, and the subtle nuance to this is that every user will continue to have help to traverse that learning curve. Introduce users to the concept of “at-the-elbow” support, on-site tutors, engagement specialists, and super users (or, for physicians, “zone leaders” from their own ranks). When users know that help is a few simple steps away, and that there’s no need to call to the “no help desk” during those anxious first few days, they relax and focus more effectively. From the organizational side, we had to aim for “as a ready orga­ nization, we know that the support processes will be adequate to deal with issues large and small.” Rather quickly, we learned to begin issue resolution before go-live, allowing each organization to practice issue definition, triage, and tracking in a “top ten at ten” format. The goal of this was not primarily to manage pre-go-live issues, although it cer­ tainly helped late in the process, but rather to teach each organization that the management would work and how it would work. We tolerated over-prioritization, under-definition, and all of the myriad ills that you find in the first days of go-live, but since we were doing so while the issues were still largely hypothetical, we could allow the organization to appreciate those ills and mitigate them without having to be quite so prescriptive. By the time we were actually live, most of the facilities had reached a good practical tempo that greatly contributed to issue management in the actual heat of the moment. It was a dress rehearsal that was itself a performance, and it was hugely important.

Pace A final note is that EMR go-lives have a unique tempo and pace. I recommend graphing the reported issues. What I have seen is that the shape of the graph is identical every time—high on the Saturday of go-live, lower on Sunday, and peaking on Monday, with reports dimin­ ishing until the weekend. Another double “peak” over the following weekend (lower, but shaped the same), and then trailing out was seen.

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The height of the graph—the actual number of reported issues—varies, and decreases with virtually every go-live, but the shape of the graph never varies. So it is with user adoption. In my experience users vary in their acceptance rate, but the midpoint of acceptance seems to be about a year. For the first six weeks, they’re stunned and simply glad to get through the day. For the first six months, they’re annoyed. Little things grate on them. Big ones are intolerable. For the first year, the system is probably the thing they think about the most, even as (late in the year) they decide it’s really not so bad. In the second year they don’t notice it, and by the end of the second year, they wonder how they ever worked without it. I’ve never seen this curve sped up for an individual, although there are ways to make the lows less bad and the highs more frequent. I learned that one to two months post-live is the “panic time” for executives—the time that we are most likely to be asked to do extra work and devote unexpected resources to newly angry users. I learned that you need to designate senior leaders for the first six months or so to be personal concierges for the facility executives. And that after six months to a year, there is no value and little tolerance for those con­ cierges and they can move on. Installing an EMR is much like a major orthopedic surgery—a new joint, or a surgically repaired fracture.* After a period of pain and relative disability, and with a lot of physical therapy and re-training, you wind up stronger and more able than you were before you started. But healing takes time, and physical therapy can’t be rushed. Bones only heal so fast, and the body needs its time. So, too, it is with EMR implementation. Even with the best of implementations, there is pain and annoyance and a time of disability. Your job in leading an imple­ mentation is not to prevent these, but to help the organization through them and to emerge on the other side feeling like it was worth it.

* Actually, its more like a total skeleton transplant than anything else I can think of. You’re ripping out old structures and replacing them with something completely dif­ ferent. Powerful and strong, with lots of great reasons, but it’s still major surgery.

References and Additional Suggested Resources References 1. Bridges W. Managing Transitions, Making the Most of Change. Reading, MA: Addison-Wesley, 1991. 2. Kubler-Ross E. On Death and Dying. New York: The Macmillan Company, 1969. 3. IMA. Accelerating Implementation Methodology (AIM); 2009. http:www.imaworldwide.com. Accessed November 15, 2009. 4. Gostick A, Elton C. The Carrot Principle. New York: Free Press, 2009.

Additional Suggested Resources Association of Change Management Professionals (ACMP), http://www.acmpglobal.org Bradberry T and J Greaves, Emotional Intellegence 2.0. San Diego: TalentSmart 2009. Emerson T and M Stewart, The Technology Change Book. Alexandria, VA: ASTD Press, 2013. Heath C and D Heath, Switch: How to Change Things When Change is Hard. New York: Broadway Books, 2010. Liberating Structures (facilitation techniques), http://www.liberating structures.com/

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Patterson K, Grenny}, Maxfield D, McMillan R and Switzler A. Influence^ The Power to Change Anything. New York: McGraw-Hill, 2008. Prosci (change management research, education and tools), http://prosci.com SCARF (neuroscience model), http://scarf360.com/index.shtml

Index t = table entry / = figure entry

c Champions, local, 72-75 CHANGE™, definition of, xv Change implementation. See Implementation issues Change management, 1 - 1 9 ability to change, 16 benefits of, 4-5 case study of successful practice, 18 -19 components of change implementation, 3/ contrasted with technology adoption, 5-6 creating environment for success in, 1 1 - 1 8 definition of, 2-4 impact of change on people, 6-9 key elements of process, 14 - 15 key questions, 13 organizational fabric model, 1 I f people and, 6-9 positive aspects of, 17 - 18 purpose of, 4 responsibility of organizational readiness team, 68 “skill versus will” matrix, 12 / systems perspective on, 1 0 - 1 1 , 1 1 / willingness to change, 15 - 16 Communication, 95-108 checklist for, 107-108 definition of, 95-97 importance of, 97-98

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keys, 101 lessons learned from experience about, 197 planning for, 98-99, 991 practices for effective, 100 -10 7 reasons for, 96 responsibility of organizational readiness team, 68 template for planning, 991 Connect-the-dots approach to training, 1 1 3 - 1 2 1 individual level, 1 1 7 - 1 2 1 , 117 / models, 11 3 / 116 / 117 / organizational level, 1 1 6 - 1 1 7 , 116 /

E Express, model, and reinforce (EMR), 38-39

H Human resources, and organizational readiness team, 68

I Implementation issues, 179 -18 7 ambiguity, 183 life after go-live, 18 4 -18 5 ownership, 179 -18 0 perceptions, 18 0-182 pointing fingers, 18 2 -18 3 risk factors, 18 5-186 sequencing of changes, 180 Implementation readiness, 13 7 - 17 5 case studies of successful practices, 1 7 1 - 17 5 definition of, 138 -14 2 go-live team training (stage 3), 168-169, 168/ leader implementation readiness (stage 1), 14 3-14 7, 143/ 144/ model of ready user, 139/ and organization readiness team, 143 post-live team meetings (stage 4), 16 9 -17 1, 170/ pre-live readiness (stage 2), 147-168, 147/ 148/ readiness assessment sample, 156/ readiness factors, 139 -14 2 ready user model, 139/ sample readiness assessment, 156/ stages of, 142/ stage 1, 14 3-14 7, 143/ 144/

Index

stage 2, 147-168, 147/ 148/ stage 3, 168-169, 168/ stage 4, 16 9 -17 1, 170/ Insights from experts, 18 9-212. See also Lessons learned from experience

L Lessons learned from experience, 18 9 -212 on communications, 197 on emotional impact of change, 199 on organization readiness team, 208-209 on pace of go-lives, 2 1 1 - 2 1 2 on “ready users,” 2 10 - 2 11 on software, 207-208 on sponsorship, 207 on stakeholder management, 209-210 on super users, 198 on training, 199-202

o Operational representatives, 69-70 Organizational readiness team (ORT), 55-76 champions, local, 72-75 checklist for, 76 definition of, 56-57 function of, 55 lessons learned from experience about, 208-209 local champions, 72-75 objectives of, 57 operational representatives, 69-70 physician engagement and perspective, 72 project phases. See Project life cycle responsibilities of, 66-70, 67/ role in optimization, 65 structure of, 67/ super users, 75-76 and union engagement for implementation, 69-71 Ownership of EMR implementation, 179 -18 0

P Physician engagement and perspective, 72 Project life cycle, 59-66, 59/ benefits realization phase, 65-66, 66/

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implementation phase, 61-62, 6 1/ optimization phase, 64-65, 64/ planning phase, 59-60, 60/ stabilization phase, 62-64, 62/

R Readiness, definitions of, 58-59 Readiness for implementation. See Implementation readiness Reinforcement, 12 7 -13 5 checklist for, 135 definition of, 12 7 -12 9 importance of, 129 incentive alignment, 130 negative consequences, 13 4 -13 5 positive, 13 2 -13 4 targeted to individual or group, 13 0 -13 2 tool for communicating preferences, 132

s Sponsorship, 37-54 “action wave” illustration of, 43/ advice for sponsors, 4 1/ cascade, 43-45 CEO as executive sponsor, 4 1-4 2 checklist for, 53 express, model, and reinforce (EMR), 38-39 FAQs about, 5 1-5 3 importance of, 40-43 leader engagement, 49 lessons learned from experience about, 207 levels of, 4 5-51 executive, 47-48 mid-level, 49-50 supervisor, 50 -51 mistakes to avoid, 48-49 responsibilities of all levels, 45-47 executive, 47-48 mid-level, 49-50 supervisor, 50 -51 role definition, 37-39 user training talking points, 118 f

219

Index Stakeholders, 79-94 bell curve of readiness, 87-88, 87/ change curve, 90-91, 9 1/ checklist for, 94 definition of, 79 engagement and management of, 86-94 early adopters, 87/ 88 mainstream users, 87/ 88-89 resisters, 87/ 89-91 three steps of, 80-81 identification and mapping of, 81-86 exercise for, 83-85 lessons learned from experience about, 209-210 management, three steps of, 80-81 resistance change curve, 90-91, 9 1/ exercise for surfacing, 93 managing, 91-93 positive and negative, contrasted, 94 stages of change, identifying and responding to, 92/ Super users, 75-76 lessons learned from experience about, 198

T Training, 1 1 1 - 1 2 6 checklist for, 126 connect-the-dots approach to, 1 1 3 - 1 2 1 individual level, 1 1 7 - 1 2 1 , 117 / models, 1 1 3 / 116 / 1 17 / organizational level, 1 1 6 - 1 1 7 , 116 / definition of, 112 go-live team training, 168-169 guiding principles for, 122i importance of, 16 - 17 lessons learned from experience about, 199-202 responsibility of organizational readiness team, 67-68 support strategy, 1 2 1 - 12 5 growing internal capacity, 12 4 -12 5 on-the-ground support, 12 1- 1 2 4 paying it forward, 125 talking points for sponsors, 118 t

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u Union involvement in implementation, 70 -71 in planning, 69-70 User training. See Training

v Vision, 23-36 alignment, 26-28, 27f alignment model, 27/ benefit of defining, 30 checklist for, 34-36 definition of, 23-25 development of, 24-25 elements of defining, 28-34, 32f future state opportunity map, 32f importance of creating, 25-26 Start, Stop, C ontinue tool, 30

w Workforce planning, and organizational readiness team, 68