Process The Forgotten Continuum - An Ethnographic Research Study

Process –The Forgotten ContinuumAn Ethnographic Research Study

J. Bryan Bennett, LSSGB, MBA, CPA

Executive Director

Healthcare Center of Excellence

www.healthcarecoe.org

Copyright 2014, Healthcare Center of Excellence 2

The Problem

Many are solely focusing on data and technology for their transition to becoming a data-enabled healthcare organization (DEHO)

Missing key components that will significantly improve their chances for long-term success

Will put the organization at a risk of not providing the best patient care, be disadvantaged to their competitors and may present challenges to future revenues


Investment

Organizations have put a lot of money and effort behind the technology and the training of the people Sometimes the process design,

redesign or workflow is slighted.

An ethnographic research study found that inefficient or poorly designed processes can be a contributing factor in many implementation failures In this case, physician engagement


What is Ethnography? Ethnography is a qualitative research method

that tells a story from the perspective of those being researched

It is always conducted in the field and typically involves some sort of participant observation in which the researcher actually gets involved with the activities being studied Watching how people use products in their own

environments, talking to them, and asking them questions

In this case, the researchers were trained and embedded in the various hospital units as physician support personnel to help physicians learn how to enter computerized patient orders.


Methodology

The study took place at a multi-hospital system in suburban Chicago

The system has about 1,000 physicians on staff and with privileges

The goal was to understand the challenges to physician engagements during implementation of a computerized physician order entry system

The EHR system was one of the top solutions but not the leading solution This minimized any ‘halo effect’ from physicians’

acceptance just because it was the leading solution


Methodology (continued)

The study observed over 600 of the 1,000 physicians as they entered orders in almost all hospital units including: Intensive care, transitional care, telemetry,

cardiac care, catheter lab, day surgery and labor and delivery

Physicians observed were from a variety of specialties, including: Internal medicine, cardiology, oncology,

hematology, neurology and cardiovascular surgery

The study produced 125 representative comments and behaviors The same or similar comment or behavior may

have been observed by multiple physicians


Observation Categories

Observations were classified into three categories:Process (how something is done)System (the EHR solution)Technology (the physical hardware

or solution access)All 3 continuums were addressed

People was represented by the physicians observed

Some observations were classified into multiple classifications


Results

Process or process related comments and activities was a factor in 62% of the observations

The software solution was a factor in 54% of the observations

Technology was a factor in 8% of the observations

Observations could be categorized into multiple categories


Results Distribution


Results Summary

CategoryObservations & Comments

Process Only 41%

Process & Solution 19%

Process, Solution & Technology 2%

Total 62%


Positive of Negative?

The observations were further categorized by positive and negative

Based on the tone, action or body language of the physicians. 23% of observations were considered

positive 69% of observations were considered

negative 8% of observations were considered neutral

The positive results were highly skewed toward younger physicians or those who were computer savvy from any age group


Sentiment Distribution

Sentiment


Representative Comments “I don’t have time for this; I will call from

my phone to place orders.” “I did not know I went to medical school to

become a secretary.” “This is ridiculous!! All it does is take time

away from my patients. I am with the patient now 5 minutes and with the computer 15 – 20 minutes.”

“Something is going to get missed and someone is going to get hurt.”

“I have not put orders in the computer for over 20 years and I am not starting now. I will retire before I start with this crap.”


Representative Observations Doctors would write orders on paper chart and

leave for nurses to enter in system Doctors were reluctant to ask for assistance

(even though it was obvious they were having difficulties)

A few doctors left the floor and then proceeded to call in the orders because they refused to place the orders themselves

A few doctors have slammed/pounded the keyboard in frustration

The nurses were getting very frustrated with doctors that didn't enter their own orders (because they knew they would have to enter them for them)


Upon Further Review

An examination of the comments and behaviors, and many like them, reveals that the physicians’ comments and actions weren’t about the actual software solution But were about the process of

actually entering the orders into the system

Getting physicians to overcome this hurdle will be critical in the success of any enterprise-wide transformation


Conclusions Organizations might be overemphasizing

technology to the detriment of good processes Continuum misalignment can be illustrated by an

inverted triangle with the technology receiving the most emphasis and process receiving the least

Improperly Aligned Continuums Properly Aligned Continuums

Technology

People

Process

Technology

People

Process


Failure is Not an Option

The choice and deployment of technology is just as important as training personnel which is just as important as the workflow design or redesign

Any attempt to do otherwise will result in failure

This failure could come in the form Poor physician acceptance Missed diagnosis information Unrecorded diagnosis information Leading to incorrect or incomplete business

intelligence


Processes Need Attention Too!

Automating or just adding technology to a bad process or not giving the process enough attention just results in a bad automated process. Personnel Buy-In

Delayed training

The same is true for not giving the process or workflow enough attention

This can be evident in challenges to personnel buy-in and occurs when the change is viewed as simply a software implementation as opposed to an organizational transformation


Don’t Fail Before Getting Started

Organization transformation must start from the beginning with communication and personnel training throughout the process to increase acceptance and advocacy among the staff

If training and information on the software is offered just before the software ‘goes live’ you may have already failed


Physician Engagement Challenge

Physician engagement is an especially difficult challenge, but it can be overcome

Keeping physicians involved in the process and workflow design will improve buy-in Avoid rescinding a software workflow after

it has been deployed because the process did not work or was inefficient for the physicians to utilize


Questions & Answers

Contact Information: J. Bryan Bennett, “The Professor”

[email protected]

Websites / Blogs www.healthcarecoe.org

www.himssfuturecare/blog/1266

Twitter @healthcarecoe

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