how to ready for your organization for clinical transformation · 5. data governance •developed...
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How to ready for your organization for clinical
transformation
Karen Martin, Centre for Addiction and Mental Health
Mary Sanagan, Deloitte
1
Centre for Addiction and Mental Health (CAMH)
CIS Project Background and Timeline
Lessons Learned Summary
2
Key Learnings 3
1
4
2
CAMH – Origins
1846
Provincial Lunatic
Asylum, with 250 beds
3
1999 – Merger: Four Founding
Organizations
Queen Street Mental
Health Centre
Addiction Research
Foundation
Donwood Institute
Clarke Institute
Of Psychiatry
4
1999 to Current Day:
Urban Village
550 beds
Over half a million ambulatory
visits each year
4 Pillars of Care:
Clinical care
Research
Policy
Health Promotion
5
Why Change?
To improve patient safety and quality of care delivery, CAMH will standardize
processes and implement a Clinical Information System (CIS)
• Reduced risk of
medication errors and
adverse events
• Time savings for staff
• Reduced duplication of
documentation
• Support reporting
accountabilities
• Improved interdisciplinary
care, communication, and
collaboration
• Integration with provincial
initiatives
• Accurate information at the
point of care
• Duplication of
documentation
• Increased risk of adverse
events
• Difficulty in accessing
client clinical information
• Inability to effectively
collaborate
Current State of CAMH Clinical Information Future State of CAMH Clinical Information:
One Integrated Solution
6
Why Change?
To improve patient safety and quality of care delivery, CAMH will standardize
processes and implement a Clinical Information System (CIS)
• Duplication of
documentation
• Increased risk of adverse
events
• Difficulty in accessing
client clinical information
• Inability to effectively
collaborate
Patient
Scheduling
Workload
Measurement
Systems
Registration
System
Consent &
Authorization
Medication
Processing
Medication
Mgmt
Clinical
Documentation
Dietary
System
Clinical
Reporting
Lab System
Order &
Results Mgmt
Hybrid: System + Paper
Paper
Current State of CAMH Clinical Information Future State of CAMH Clinical Information:
One Integrated Solution
Legal
Documents
CIS
Consent &
Authorization
Patient
Scheduling
Alerts &
Notifications
Clinical
Reporting
Collaborative
Communication
Tools
Clinical
Documentation
Registration
Workload
Measurement
Laboratory
Processing
Order &
Results Mgmt
Medication
Processing
Medication
Mgmt
Legal
Documents
Pharmacy
System
Document
Imaging
System
Document
Imaging
Pharmacy
Management
• Reduced risk of
medication errors and
adverse events
• Time savings for staff
• Reduced duplication of
documentation
• Support reporting
accountabilities
• Improved interdisciplinary
care, communication, and
collaboration
• Integration with provincial
initiatives
• Accurate information at the
point of care
7
Oct 2010-
Mar 2011
Apr 2011-
Sept 2011
Oct 2011-
Mar 2012
Apr 2012-
Sept 2012
Oct 2012-
Mar 2013
Apr 2013-
Sept 2013
Oct 2013-
Mar 2014
Apr 2014-
Sept 2014
Oct 2014-
Mar 2015
Months 1-6 Months 7-12 Months 13-18 Months 19-24 Months 25-30 Months 31-36 Months 37-42 Months 43-48 Months 49-54
Project Timeline
Procurement
Analysis
System Design, Build and
Unit Test
Maintenance
User Testing,
App and User
Training
Go-Lives
CIS Purchase and Project Funds Released
= Board Approval Gate
Clinical Transformation
Projects
Phase
Phase Legend
Post
Ass’t
Cost Approval
Project
Complete
We Are Here
8
Oct 2010-
Mar 2011
Apr 2011-
Sept 2011
Oct 2011-
Mar 2012
Apr 2012-
Sept 2012
Oct 2012-
Mar 2013
Apr 2013-
Sept 2013
Oct 2013-
Mar 2014
Apr 2014-
Sept 2014
Oct 2014-
Mar 2015
Months 1-6 Months 7-12 Months 13-18 Months 19-24 Months 25-30 Months 31-36 Months 37-42 Months 43-48 Months 49-54
Lesson Learned #1: Use your
procurement timeline to drive early
clinical transformation
Procurement
Analysis
System Design, Build and
Unit Test
Maintenance
User Testing,
App and User
Training
Go-Lives
CIS Purchase and Project Funds Released
= Board Approval Gate
Clinical Transformation
Projects
Phase
Phase Legend
Post
Ass’t
Cost Approval
Project
Complete
9
Procurement Timeline
and Process
RFSQ Release
Preferred Proponent(s) Shortlisted
9
RFSQ Close
Bidders pre-qualified
RFP Release
Proposal Due
Evaluation
5/20 6/17 8/2 9/6
10/4
10/21 1/21
Board Approval
RFP response Period
Evaluation
7/15
Executive Approval of pre-qualified
vendors
5/10 2/28
RFSQ Development
Conference Room Pilots
11/16 11/18
Deadline for Questions
Issue Amendments
10/11
Contract Activities Prequalified
Respondents Meeting
9/22
& Deadline for responding to questions
Finalize scores
Key aspects of procurement approach to ensure Behavioural Health unique needs are met:
• Assessed market with a Request for Supplier Qualifications (RFSQ) and pre-qualified vendors
• Issued a Request for Proposal (RFP) to pre-qualified vendors
• Rigorous evaluation process including clinicians, administrators, managers, directors and executives, overseen by a
Fairness Advisor
• Evaluated vendors based on submitted proposals that assessed their ability to meet functional/non-functional
requirements, vendor demonstration scores, and financial pricing submissions
• Separately reviewed technical and financial pricing submissions to ensure compliance with best practice procurement
standards
10
Lesson Learned #1: Use your
procurement timeline to drive early
clinical transformation
Clinical Transformation Projects initiated April 2011:
1. Admission, Discharge, and Transfer (ADT) Data Quality
2. Workload and Reporting
3. Centralized Intake
4. Benefits Measurement
5. Data Governance
6. Clinical Documentation Standardization
7. Medication Management
11
Lesson Learned #1: Use your
procurement timeline to drive early
clinical transformation
Readying the organization for the system implementation can also lead to positive and valuable
outcomes prior to and irrespective of system deployment
Clinical Transformation Projects Impact
1. Admission, Discharge, and Transfer (ADT)
Data Quality • Clean data, ready for migration
2. Workload and Reporting
• Provincial and administrative requirements for
workload capture and clinical reporting
• Improvements possible irrespective of CIS
workload and reporting functionality
3. Centralized Intake
• Identified root cause of access barriers for
patients
• Achieved organizational consensus on new
centralized model
12
Lesson Learned #1: Use your
procurement timeline to drive early
clinical transformation
Clinical Transformation Projects Impact
4. Benefits Measurement
• 8 qualitative and quantitative indicators to measure
4 benefits
• Baseline metric collection highlighted:
• 11% of lab orders are duplicate
• 64% of discharge summaries are completed
on time
• >10 sources of information must be reviewed
to get the full patient story
• 60 clarifications from pharmacists/day are
required for incomplete or illegible med orders
5. Data Governance • Developed an organization-wide data governance
strategy, including data owner identification
6. Clinical Documentation Standardization
• 634 ~170 61
• Less time will be spent with vendor assessing
clinical content
13
Insert messy cahyee picture
14
Example Output: Clinical
Documentation Recommendations –
The Flow
14
Admission Discharge Client/Patient Care
15
Clinical Transformation Project #7:
Medication Management
15
Value Stream Mapping exercise resulted in 70 opportunities/wastes to
address prior to the CIS implementation
16 16
Organizational
Readiness
Assessment
Value
Proposition
Change
History
Leadership
Support
Workforce
Readiness
Existing
Planning
and
Policies
Competing
Initiatives
Lesson Learned #2: Understand
your organization’s culture to drive
decision making and planning
assumptions
17 17
Organizational
Readiness
Assessment
Change
History
Workforce
Readiness
Existing
Planning
and
Policies
Competing
Initiatives
Risk aversion to
decision-making
Everyone is unique
Change is variably
mandated
Varying understanding of
CIS value
Want active, visible
executive sponsor
Responsive to peer
leadership
Varying IT literacy
Limited resource capacity
organization-wide Unionized environment,
inclusive of IT
Lack understanding of
how initiatives are
prioritized
Varible priorization of
initiatives
Lack of clarity and
variable enforcement of
policies
Fiscal funding cycle
drives planning
Desire for efficiency
Key Findings from Organizational
Readiness Assessment
Value
Proposition
Leadership
Support
Key personnel often
on multiple change
activities
18 18
Organizational Readiness
Recommendations
Change management Leadership and
governance Implementation
• Targeted and tactical change
management strategy
• Clearly identify CIS benefits,
value proposition, and metrics
for success
• Engage existing stakeholder
groups to manage sensitivities
regarding duplication of effort
and impact on stakeholders
• Promote adoption of the CIS
using value proposition as the
primary driver
• Identify clinician champions to
ensure needs of various
clinician types are represented,
and staff have peers in
leadership roles
• Connect with key groups to
obtain information regarding
any competing priorities to
ensure alignment
• Update organization structure
to better support decision-
making processes at the ‘right
levels’
• Do not allow exceptions to CIS
participation/compliance
• Leverage existing work
regarding resource capacity to
identify target areas (programs,
stakeholder types) and develop
approach to implementation
• Assess IT literacy at intervals
leading up to go-live (requiring
a minimum score) and provide
tailored training to individuals
requiring remediation
• Ensure follow-up with
stakeholders at specific
intervals post-implementation
to support continuous
improvement, provide on-going
communication, and to gather
feedback
19
Lesson Learned #3: Focus early on
value driven communications irrespective
of system and project branding
• Aiming to provide an overview and eye-catching information
20
Lesson Learned #3: Focus early on
value driven communications irrespective
of system and project branding
20
• Aiming to be fun and
informative
• Non-traditional
• “Cuts through the
noise”
• Featured on intranet
• Leveraged for
presentations
21
Lesson Learned #3: Focus early on
value driven communications irrespective
of system and project branding
• Butterfly logo
• Dedicated
intranet URL
• Dedicated
email address
• Coffee mugs
• Stickers
22
Lesson Learned #3: Focus early on
value driven communications irrespective
of system and project branding
Dedicated an inter-professional team to change management
across the organization
Developed approach that synthesizes several “best-practices”
that include:
Aiming to coordinate approaches, activities, messages and
schedules across the organization
23
Lesson Learned #4: Distribute
decision making by creating decision
thresholds
Major Impact
Moderate Impact
Low Impact
Mid Level Decisions
High Level Decisions
Detailed Decisions
~ 25% of decisions
~ 10% of decisions
~ 65% of decisions
Major Impact Committee Threshold:
Cross-organizational impact or patient safety concern
Impact to overall project scope or budget
Example: Will CIS training be mandatory?
Moderate Impact Committee Threshold:
Impacts more than one clinical program, discipline or CIS functionality
Requires modifying existing policies to fit with practice changes
Example: Will CAMH utilize mandatory fields to enforce documentation completeness?
Low Impact Committee Threshold:
Involves a single program, discipline or CIS functionality
Utilizes existing policies to drive CIS functionality decisions
Example: In which order will the fields be on the admission assessment?
To distribute decision making, set up committees to make decisions based on their decision making threshold
24 24
Medical Advisory
Committee
Clinical Care
Committee
Health Records
Committee
Discipline Specific
Professional
Practice Councils
(RN, OT,
Psychologist etc)
Clinical Practice
Council
CIS Steering
Committee
Operational
Committee
Project Committee
Legend:
Clinical Doc
Taskforce
Registration
/Scheduling
Task Force
Medication
Management &
CPOE
Task Force
CDS
Taskforce
Taskforce
(n…)
Pharmacy &
Therapeutics
Project Leadership
Team
Lesson Learned #5: Best utilize
your existing committee structures to
make clinical content decisions
Existing operational committees
currently accountable for clinical
practice and content decisions
Typical CIS project committee
structure
25 25
MAC
Clinical Care
Committee
Health Information Committee
(will include representation from P&T and
Clinical Care Committees)
Discipline Specific
Professional
Practice Councils
(RN, OT,
Psychologist etc)
Clinical Practice
Council
CIS Steering
Committee
Decision making
Advisory
Workgroup
Legend:
Clinical Doc
Taskforce
Registration
/Scheduling
Task Force
Medication
Management &
CPOE
Task Force
CDS
Taskforce
Consulted and
informed during
decision making
process
Taskforce
(n…)
P&T
Lesson Learned #5: Best utilize
your existing committee structures to
make clinical content decisions
CAMH CIS project committee structures
26
Lesson Learned #6: Create contracts
for working group members to ensure
clarity of role and accountability
27
Oct 2010-
Mar 2011
Apr 2011-
Sept 2011
Oct 2011-
Mar 2012
Apr 2012-
Sept 2012
Oct 2012-
Mar 2013
Apr 2013-
Sept 2013
Oct 2013-
Mar 2014
Apr 2014-
Sept 2014
Oct 2014-
Mar 2015
Months 1-6 Months 7-12 Months 13-18 Months 19-24 Months 25-30 Months 31-36 Months 37-42 Months 43-48 Months 49-54
Lesson Learned #7: Set up a Board of
Trustees gating process to ensure buy-in
and escalation as needed
Procurement
Analysis
System Design, Build and
Unit Test
Maintenance
User Testing,
App and User
Training
Go-Lives
CIS Purchase and Project Funds
Released
= Board Approval Gate
Clinical Transformation
Projects
Phase
Phase Legend
Post
Ass’t
Cost
Approval
Cost
Review
28
Lesson Learned #8: Keep the
system implementation in mind when
planning for the upfront clinical
transformation projects
Assumption:
CIS vendors have different implementation approaches, may result in re-
work if using the wrong assumption for planning
• Focus the prep work on pre-CIS value however with the future CIS
implementation activities in mind
Results:
Extremely prepared for contract negotiations
Can commit to aggressive implementation timelines
29
Lesson Learned #9: Behavioural
Health is more the same than different
Assumption:
Given the unique Behavioural Health functional requirements only a
few vendors could meet our needs:
Less “procedure-driven”
Specific provincial reporting needs
Heavy reliance on narrative documentation
Behavioural health-specific processes and routines (e.g.,):
Interdisciplinary care
Treatment activities not always defined by discipline
Care beyond the walls of the hospital
Ability to tell the patient’s story/journey through the tool
Result:
The large integrated CIS products have the necessary components,
it’s how they are used together that is unique to Behavioural Health
30
Lessons Learned Summary
1. Use your procurement timeline to drive early clinical transformation
2. Understand your organization’s culture to drive decision making and planning assumptions
3. Focus early on value driven communications irrespective of system and project branding
4. Distribute decision making by creating decision thresholds
5. Best utilize your existing committee structures to make clinical content decisions
6. Create contracts for working group members to ensure clarity of role and decision-making
accountability
7. Set up a Board of Trustees gating process to ensure buy-in and escalation as needed
8. Keep the system implementation in mind when planning the upfront clinical transformation
projects
9. Behavioural Health is more the same than different