From Implementation to Optimization: Moving Beyond Operations
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1 From Implementation to Optimization: Moving Beyond Operations Session 260, March 8, 2018 Scott Aikey, Sr. Director, Core Clinical Applications Children s Hospital of Philadelphia 1
2 Conflict of Interest Scott Aikey, MS Health Services Administration Has no real or apparent conflicts of interest to report. 2
3 Agenda Session Objectives Overview of Children s Hospital of Philadelphia The Problem The Approach The Changes Governance and Prioritization Communication, Transparency, Metrics The Future 3
4 Learning Objectives Design an operational improvement initiative to evaluate current application support operational processes and staffing to identify areas of improvement Evaluate IT application team structures to accomplish the most amount of quality work with existing staff Develop key metrics and SLAs and communicate those to various stakeholders Describe the role of a Governance Committee in the intake and prioritization of key projects for EHR implementation and optimization 4
5 Children s Hospital of Philadelphia Open in 1855 as the first Children s Hospital in the US Largest Pediatric network in the US 546 Beds 7 Neonatal Units 29,468 Hospital Admissions 1,296,882 Outpatient Visits 12,120 Employees 425 Trainees $2.6 billion Annual Revenue Care Network 5 16 Specialty Care Centers 4 Ambulatory Surgery Centers 31 Primary Care Practices 15 Community Hospital Affiliations 3 After-hours Urgent Care Facilities
6 6 Network map 6
7 A Journey to an Integrated EHR 2001: Started the Electronic Health Record roll-out with Primary Care Pediatric offices (Ambulatory) 2006: Began the Ambulatory roll-out of outpatient Specialty Care practices 2007: Live with Scheduling, Registration, ADT, Hospital and Professional Billing 2011: Live with Inpatient Orders, Emergency Department, Oncology, Pharmacy, Radiology 2012: Live with Inpatient Clinical Documentation, Transplant Services and HIM 2013: Live with Patient Portal, Mobile Apps, HIE, OR System 2015: Live with Anesthesia 2016: Concerted effort on Optimization and Standardization 7
8 The Problem More than 15 years with a focus on Implementation Several incremental staffing reorganizations Continued focus on projects and implementation rather than Optimization The need to change the cultural mindset of the Organization toward Optimization, Standardization, and Innovation The need to be more prescriptive with Intake and Prioritization The changing business needs of the organization Doing more with less staff Making what we do count more 8
9 The Evolution of Support Implementation and Stabilization Working an Issue List Post Implementation Support Working a list of Enhancement requests Quick Wins Post Support support moving to Optimization Lack of Quick Wins > more Complex, Mature requests Need for Standardization, Optimization, and Prioritization Focus on Innovation Growing need for Transparency with Clients 9
10 Approach Internal IS Efficiency Use of external Consultants to discover the various areas for improvement Ground up (Kaizen events) Top down Engaging staff in a mindset change Open Dialogue with Clinical Partners Intake and Prioritization Transparency Engaging clinical partners in a mindset change 10
11 Use of Consultants Recommendations Consolidate teams with similar skills sets Legacy Implementation staff not consolidated under Operational structure Reduction of One Manager position Decentralize the Testing Functions Decentralized Testing department legacy to large scale Implementations Remediate Change Control Processes for Increased Efficiencies 11
12 Use of Consultants Recommendations Evaluate Opportunities for First Call Resolution with the Service Desk Additional Training of Service Desk Staff Job Aides Project Management Methodology (Waterfall to Agile) Project light processes for smaller projects Environment Management Consolidation 12
13 Use of Consultants Recommendations Overall Process Improvements with Ticketing Software Application Time out Setting Conversion of Tasks to Incident and vice versa Management Reports Knowledge Management 13
14 Use of Consultants Recommendations Governance and Transparency Self Service Portal Incorporate Prioritization into the request process KPIs and Metrics Making Time for Innovation 14
15 Governance Approval / Veto Strategy Enterprise Steering Committee Prioritization & Sequencing EHR Governance Committee Vetting Ideas, Problemsolving, Implementation 15 Clinical Informatics Council
16 Enterprise Steering Committee Meet monthly Primary goal is Strategic Roadmap and Long Range Planning Not just IS projects, but also includes Capital Planning Veto or Escalation Authority Membership: C-Suite (CNO, CMO, CIO, CMIO) Senior Department Chairs 16
17 EHR Governance Committee Membership 3 EHR Medical Directors CMIO & Director of Nursing Informatics Health System Director for Clinical Applications Medical Director for Meaningful Use Director of Ambulatory Nursing Clinical Champion for Dept. of Surgery Clinical Champion for Emergency Medicine Various IS Leaders as support to the group 17
18 EHR Governance Committee Meet every other week Co-Chaired by IS and Clinical Primary goal is prioritization and sequencing Historically we ve struggled with this Too many lists! (some as long as 400 items) No ability to track the work No process for ranking requests No way to say No No awareness of tradeoffs (doing A means not doing B) 18
19 Clinical Informatics Council Membership 3 Medical Directors 13 Physician Champions 30 Nursing & Ancillary Champions IS Directors IS Trainers IS Nursing Informatics Function Meet weekly to discuss enhancement requests Determines the How and the design/build Report monthly on progress Chaired by CMIO 19
20 20 Reprinted with permission from Knight Associates.
21 Audience Polling Question 1 / Slide 21 Do you use an obj. tool for prioritization of incoming work? 1. Yes, it works well 2. Yes, but we bypass often 3. No, but would be interested 4. No, why should we do that 21
22 The Prioritization Process Start with a Single List Numerous independent lists (customer based) Solicit input from various sources Develop a process for adding new items from other sources Determine Guidelines Work Effort: >100 hours needs to be prioritized Complexity (multiple teams?) Use an Unbiased Tool Make it as Objective as possible Does the result pass the gut check? Tweak the weights in the tool Plan for additions and changes to The List Make The List transparent 22
23 The Prioritization Tool Compliance & Regulatory Patient Safety Productivity & Satisfaction Financial Impact Quality & Effectiveness Weighted Score Clinical Scope 23
24 The Prioritization Tool - Multipliers Dimension Multiplier Compliance 2 Financial 2 Patient Safety 5 Productivity/Satisfaction 10 Quality/Effectiveness 5 Scope 2 24
25 The Prioritization Tool Prioritized View The Children s Hospital of Philadelphia 25
26 But what about those other requests? Individual requests that fall below the guidelines for projects Departmental specific Business Analysts assigned to various areas Begin to use the same prioritization tool for those areas Collect all data up front in intake Review with appropriate Clinical Champions Prioritize based on impact to organization Require metrics for completion Incorporate the Prioritization Tool into the Ticketing Software System 26
27 Communication and the need for Transparency Communicate, Communicate, Communicate! No one knows what we do or how much we do IS is a black box My request has been out there for months Develop tools to showcase work performed to various stakeholders Develop mechanisms for transparency of work in the queue Determine which KPIs are relevant 27
28 Open vs. Closed Incidents Opened Incidents Closed Incidents Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Open vs. Closed Work Orders Opened Work Orders Closed Work Orders Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 The Children s Hospital of Philadelphia
29 Clinical Applications Dashboard FY18 (Dec 17-Nov 18) Epic Core Clinical: Current Queue Task Volume FY18 (without Future) Queue Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Average Overall Status Care Network Dept of Medicine Dept of Surgery Emergency Dept Inpatient Maintenance Nursing Onco / Transplant Research Overall Total Epic Core Clinical: Closed Tasks by Month FY 18 Queue Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Average Overall Status Care Network Dept of Medicine Dept of Surgery Emergency Dept Inpatient Maintenance Nursing Onco / Transplant Research Overall Total
30 SPC Run Charts for Current Queue Volume FY18 Department of Medicine Queue Volume Run Chart Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Avg. Days 8 DOM Mean UCL LCL Department of Surgery Queue Volume Run Chart Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Avg. Incidents 235 DOS Mean UCL LCL
31 Audience Polling Question 2/Slide 31 Do you collaborate work with Clinical Stakeholders? 1. Yes, equal partners 2. Yes, but often tension 3. No, often at odds 4. Why would we do that? 31
32 CORE CLINICAL OPERATIONS UPDATE EHR Governance Meeting November,
33 Sample Core Clinical Update Agenda Update on Innovation initiatives Update on key ESC projects Update on Optimization initiatives Key Operational Issues Facilities Work Department Specific Updates Key Metrics 33
34 Engaging the Clinical Community Information Services Shadowing of Clinicians Unique Problem at CHOP Physical Location is an Issue Quality Build/Design only comes when IS fully understands the business IS Business Analysts spend a lot of time with customers, but the rest of the staff do not Departmental Goal spend time in clinical departments to observe daily workflows and challenges; collect opportunities for optimization Expectation of all levels of staff 34
35 The IS Role Facilitate discussion between clinical groups Numerous IS staff with clinical backgrounds Provide System options and alternatives to solve business problems Facilitate Decision Making Provide Data and Analysis for better decision making Provide regular updates on project status 35
36 Optimization Ongoing initiatives based on elbow to elbow support 80% training; 20% build Selecting those divisions with Low Provider Efficiency and Productivity score High Physician Burn out score 36
37 The Future The environment is ever-changing Adaptability and Flexibility is key Making space for Innovation Training staff to share ideas and motivate each other Matching skill sets of staff with projects and initiatives We are not done yet, and probably will never be! 37
38 Questions? Reminder: Please complete the online session evaluation Contact Information: Scott Aikey, Sr. Director, Core Clinical Applications Information Services Children s Hospital of Philadelphia aikey@ .chop.edu 38
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