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
Conflict of Interest Scott Aikey, MS Health Services Administration Has no real or apparent conflicts of interest to report. 2
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
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
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 Network map 6
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
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
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
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
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
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
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
Use of Consultants Recommendations Governance and Transparency Self Service Portal Incorporate Prioritization into the request process KPIs and Metrics Making Time for Innovation 14
Governance Approval / Veto Strategy Enterprise Steering Committee Prioritization & Sequencing EHR Governance Committee Vetting Ideas, Problemsolving, Implementation 15 Clinical Informatics Council
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
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
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
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 Reprinted with permission from Knight Associates. www.knight-assoicates.com
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
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
The Prioritization Tool Compliance & Regulatory Patient Safety Productivity & Satisfaction Financial Impact Quality & Effectiveness Weighted Score Clinical Scope 23
The Prioritization Tool - Multipliers Dimension Multiplier Compliance 2 Financial 2 Patient Safety 5 Productivity/Satisfaction 10 Quality/Effectiveness 5 Scope 2 24
The Prioritization Tool Prioritized View The Children s Hospital of Philadelphia 25
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
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
Open vs. Closed Incidents 750 700 650 600 550 500 450 400 1400 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 1200 1000 800 600 400 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
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 18 14 20 11 15 11 12 5 10 8 11 14 12 Dept of Medicine 38 35 51 41 35 35 42 28 38 32 30 36 37 Dept of Surgery 55 54 60 58 58 57 59 56 65 69 64 71 61 Emergency Dept 36 27 27 27 22 24 35 43 46 40 55 54 36 Inpatient 102 91 84 84 79 77 76 69 69 70 74 86 80 Maintenance 167 175 199 190 206 212 178 184 192 153 124 123 175 Nursing 49 52 52 48 31 24 36 39 33 34 33 30 38 Onco / Transplant 20 18 23 26 28 38 45 28 24 30 31 34 29 Research 7 7 13 12 6 7 9 11 14 16 18 20 12 Overall Total 620 587 667 606 589 595 606 576 607 568 545 583 596 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 16 24 25 34 25 36 16 32 27 30 26 28 27 Dept of Medicine 15 32 26 43 35 34 42 36 30 38 54 43 36 Dept of Surgery 15 30 24 29 18 27 26 34 16 27 38 34 27 Emergency Dept 18 31 16 39 16 18 24 29 13 18 16 15 21 Inpatient 22 40 31 39 30 29 30 26 25 18 33 13 28 Maintenance 49 49 59 82 142 87 165 211 175 224 180 131 130 Nursing 22 14 24 18 23 12 13 12 20 13 27 31 19 Onco / Transplant 9 7 4 8 12 5 29 21 19 13 13 11 13 Research 6 6 8 8 8 4 4 10 7 3 5 4 6 Overall Total 224 301 280 408 380 335 448 468 391 431 496 374 378
SPC Run Charts for Current Queue Volume FY18 Department of Medicine Queue Volume Run Chart 60 40 20 0 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 100 80 60 40 20 0 Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Avg. Incidents 235 DOS Mean UCL LCL
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
CORE CLINICAL OPERATIONS UPDATE EHR Governance Meeting November, 2017 32
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
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
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
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
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
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@email.chop.edu www.linkedin.com/in/scott-aikey-a4960b15 38