How to ready for your organization for clinical transformation · 5. Data Governance •Developed an organization-wide data governance strategy, including data owner identification

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


Lesson Learned #1: Use your

procurement timeline to drive early

clinical transformation

Procurement

Analysis


Unit Test

Maintenance

User Testing,

App and User

Training

Go-Lives

CIS Purchase and Project Funds Released



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

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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

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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

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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

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Insert messy cahyee picture

14

Example Output: Clinical

Documentation Recommendations –

The Flow

14

Admission Discharge Client/Patient Care

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Clinical Transformation Project #7:

Medication Management

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Value Stream Mapping exercise resulted in 70 opportunities/wastes to

address prior to the CIS implementation

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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

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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

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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

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Lesson Learned #3: Focus early on

value driven communications irrespective

of system and project branding

• Aiming to provide an overview and eye-catching information

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• Aiming to be fun and

informative

• Non-traditional

• “Cuts through the

noise”

• Featured on intranet

• Leveraged for

presentations

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• Butterfly logo

• Dedicated

intranet URL

• Dedicated

email address

• Coffee mugs

• Stickers

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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

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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

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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

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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

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Lesson Learned #6: Create contracts

for working group members to ensure

clarity of role and accountability

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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


Lesson Learned #7: Set up a Board of

Trustees gating process to ensure buy-in

and escalation as needed

Procurement

Analysis


Unit Test

Maintenance

User Testing,

App and User

Training

Go-Lives

CIS Purchase and Project Funds

Released



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

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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

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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

Questions?

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