Home health care is the fastest growing sector in providing health care in the United States (US Commerce Department, 1993). Among the reasons for this exceptional growth rate are several factors, including an aging population, patient preference for care provided in their own homes, earlier discharge from acute care settings, and reimbursement sources demanding that health care providers reduce costs while expanding patient services in a wider variety settings. As a result, home health care agencies are under increasing pressure to provide efficient, high-quality, cost-effective nursing services to growing numbers of patients. In an effort to maximize productivity and efficiency while reducing costs in home health care, one strategy has been to computerize the nursing records. However, there has been little or no research in the literature on the nursing applications of computer technology in home care settings. Based on Lippitt's Theory of Planned Change as the theoretical model, this case study examines the author's experience as a consultant to the Nursing Department of a home health care agency in automating their nursing records. Included in the discussion are an analysis of the costs and benefits derived by the agency in computerizing the nursing records, examples of how the processed throughout each of Lippitt's seven phases of planned change, evaluation of the process, and recommendations for the future.
According to recent estimates by the US Commerce Department,1, home health care is the fastest growing sector in health care today. This rapid growth is due primarily to shifting economic, social, and technical trends in the United States that are transforming the entire health care delivery system. Efforts to curb escalating health care costs, to improve quality, efficiency, and access to health care services are among the driving forces that are leading to significant changes in the delivery of health care and nursing services, particularly increasing reliance on home health care services.
Based on current growth rates, health care expenditures are projected to escalate to an estimated $1,616 billion by the year 2000, up from $809 billion spent in 1992.2 Faced with increasing pressure from both the private and public sectors to increase efficiency while reducing or controlling costs, the health care industry is restructuring the financing and delivery of services from more expensive inpatient, acute care in hospitals to home health care and community-based services. Consequently, patient referrals for home health care services have nearly tripled since 1992.3 In response to the rising demand for home care services, predictions for the number of registered nurses needed for jobs in home care by the year 2000 will increase an additional 8,000 nurses more than the number employed in 1990.4
Expanding access and improving quality of services has become increasingly important as more Americans live longer and require more health care services.5 The increased need for both acute and chronic health care services for children, the elderly, and the chronically ill has created new demands on the health care system to provide more cost-effective health care services to patients with a variety of problems. Because consumers widely prefer home care to institutional care, services provided in the patient's own home are being used increasingly.6 The ability to provide high-tech interventions at home is due partly to advancements in the technology but these technological advancements also have generated a need for registered nurses with the advanced knowledge and skills necessary to provide these services safely in the home.
Nurses and other health care professionals increasingly use information technology to gather patient data, to assist in documenting and analyzing patient care, and to evaluate patient outcomes.7 As the demands for documentation by reimbursement sources change, nurses and other health care professionals must provide evidence to payors regarding type and length of services, progress notes, and outcomes of care. For example, computerized patient record systems permit nurses to retrieve stored data quickly, to reduce or eliminate repetitious documentation, and to provide information to reimbursement sources on costs, efficacy, and quality of nursing care.
The key to coping within this rapidly changing health care environment is the professional nurse's ability to identify problems and to carry out planned change.8 Using the author's experience in automating a home care agency as a case study, Lippitt's theory is used as a model to examine the process of planned change.
The origins of classic change theory were found in the works of Kurt Lewin who identified three basic stages to planned change: (1) unfreezing, (2) moving, and (3) refreezing.9 Later work by Lippitt 10 modified Lewin's original model to emphasize problem-solving as well as the interpersonal aspects of the change process. Lippitt includes seven phases of planned change:
* Diagnosing the problem;
* Assessing the motivation and capacity for change;
* Assessing the change agent's motivation and resources;
* Selecting progressive change objectives;
* Choosing the appropriate role for the change agent;
* Maintaining the change once it has been started; and
* Ending the helping relationship.
It seems appropriate to apply Lippitt's model of planned change because this model broadly incorporates the familiar steps of the nursing process and can be applied in virtually any nursing setting. First, nurses diagnose actual or potential problems by assessing all parameters of the problem and the readiness of the environment for change. Next, the nurse develops an action plan in collaboration with the patient and other members of the health care team, which includes the objectives and goals of the plan and establishes a timeline for moving through the steps of the plan. Finally, the plan is implemented in progressive stages and includes periodic evaluation of projected outcomes at each stage and revision of the plan as necessary to meet the overall goals.
Lippitt's theory is helpful in expanding and clarifying how to manage planned change. According to Lippitt, the first stage in planned change is to accurately diagnose the problem. This stage begins with a general awareness that "something just isn't working anymore" or "this (task) would be easier, faster, better if only we could...". Awareness of the existence of a global problem can grow either in response to internal changes within the agency such as a gradual awareness that a particular form used to document services is no longer efficient or the awareness may grow in response to external forces of change, such as striking changes in Medicare reimbursements for outpatient services. While managers and staff may have a general awareness of a global problem at this stage, it is not yet clear how pervasive this problem is within the organization or what specific type of change could be made to existing processes that would benefit the organization.
According to Lippitt, to accurately diagnose the exact nature and extent of the problem within the agency or the system, it is critical to collect complete data about the problem from all possible sources. Group discussions with representatives of each operational area of the agency to examine the full nature of the problem and to identify the current system's strengths and weaknesses, allows time for individuals to share how the problem effects their work and affords an early opportunity for individuals to "buy into" working on the problem together. At this point, however, each person uses his own frame of reference to define the problem and may have little awareness of the "whole picture." For example, at an interdisciplinary meeting, it would not be unexpected to have the representatives from the billing department state that their problems stem from frequent changes of payment sources (eg, from private insurance company to Medicare), which are difficult to document in a timely manner. Clinicians might describe their frustration with this problem as a need to reduce redundancy in recording similar information each time the billing source changes. This first stage often involves a continuing process of defining and redefining the problem as more information is added from different sources and as trends or patterns emerge that help clarify the overall problem.
In the author's experience when automating a large home health care agency, diagnosis of the problem began when the administrative director identified a need to improve patterns of communication, to increase staff efficiency, and to decrease overhead, in light of the many changes occurring within the home health care industry and within the agency itself. Early in the process, a need was identified for faster and wider dissemination of clinical and financial information throughout the organization. An interdisciplinary team met including members of the clerical staff, administrators and supervisors, nursing, and finance and operations manager, and Quality Assurance staff to discuss their unique problems to save time and increase staff productivity. As the discussions progressed, several general patterns emerged. For example, unit secretaries and nurses identified that current processes for collecting admission information were redundant and time-consuming, requiring two or more individuals to data-enter the same information several times on the patient record. In addition, the nursing staff identified a need to improve clinical documentation by streamlining the process and to increase efficiency by allowing multiple staff to access the same records simultaneously from the field or in the office, such as billing and nursing to access the same record simultaneously.
Over a series of meetings, it became evident that for the agency to respond appropriately to the rapidly changing demands in home health care, computer technology would be helpful in streamlining the processes for documentation. Several laptop computers and a billing software package were available within the agency. The decision was made to move to a computerized nursing record. Nurses would begin by using laptop computers on each patient visit to record limited types of data, such as visit notes. Additional applications of the computerized record system would come later. It was not clear at this point, however, exactly who would be the change agent(s), how long the process would take, or how the changeover to computer technology would be processed.
The second stage of Lippitt's model involves accurately assessing the system and the staff involved in the change along with their motivation and capacity for the proposed change. Included at this point is a thorough appraisal of the organizational structure, the formal and informal power base, and an accurate assessment of the resources available for initiating a change. Inclusion of key people during discussions such as line staff and clerical staff, and especially representatives from management, is essential to assure success of the project through personnel and organizational commitment to the proposed change. A critical component of the discussions is to recognize those factors within and beyond the system that can help or hinder efforts to produce change. Identification of the driving forces propelling the system toward change and the restraining forces against change cannot only head off potential problems but also allows sufficient time for implementing strategies to reduce or eliminate the interference. For example, a supervisor may identify a problem, and develop a feasible plan for change, but without sufficient commitment from staff and administration in support of the change, attempting to implement a change process would be foolhardy.
A thorough examination of the home care agency was required before determining whether automation was the most suitable vehicle for implementing a change. The costs and benefits of automation were weighed in terms of the available funds for hardware, software, personnel to train staff, and to install and maintain programs. The cost in downtime during implementation of the change also was estimated because there are inevitable decreases in productivity as staff became comfortable with the new system. Potential benefits were deemed to include faster and wider access of information, more consistent and complete documentation, and less duplication of effort than seen with paper systems. Other potential improvements were improved retrievability of data for chart audits and other quality control reports.
Restraining factors for the change had to be considered as well. Change often is frightening and stressful, even if the change is perceived as positive. Lack of experience with computers, a new technology for many staff members, increased anxiety for many staff. Frustration often was expressed regarding loss of productivity during training and during the early learning stages using the new system. In the implementation phase, positive strategies were designed to anticipate obstacles and to decrease the nurse's anxiety. For example, to maximize the effectiveness of the training sessions, arrangements were made for staff coverage, the amount of information given at each session was limited in scope and limited to a prearranged, specified period and sufficient time was allotted for practice sessions. To reduce anxiety for computer novices, several nurses began by playing computer games to gain a comfort level with basic computer skills. As expected, some resistance to the change continued throughout the project but for the most part, staff responded positively and enthusiastically, particularly when they realized that individualized support was readily available whenever they ran into trouble.
As with any change, a process of negotiation was necessary to obtain the best system suited to meeting the needs of the organization as a whole. For example, financial information was most useful in one format for case management and utilization review, but this format did not address the needs of the billing department. Cooperation and creativity were required to find a "best-fit" format that was most functional overall for the agency.
The third phase of planned change involves identifying a change agent to implement the proposed change. Depending on the type of identified problem, the resources available, and the specificity of skills needed for the change, the person or persons needed to "do the job" must be identified. The change agent can be any member of the organization and may be more than one person, depending on the nature of the change. If the problem requires resources beyond the capacity of the organization for managing specific portions of the change, designating both an internal change agent who knows the system and hiring a consultant as an external agent with specific skills may be an appropriate and cost-effective approach. Nurses are ideal candidates to act as change agents because they possess leadership skills as well as a unique knowledge of the system necessary to implement change.
In this case, a member of the clinical staff was asked to implement the change because she had clinical and technical experience within the agency and the computer skills necessary to do the job. During the project, she became a certified specialist in Nursing Informatics, with technical skills that include hardware, software, data management, training and business reengineering experience. As a result, this nurse had a clear understanding of the philosophy, goals, and processes of the organization, as well as the expertise necessary to manage and organize the change from a paper system to a computerized record system.
Because other nursing staff was not available to do some detail work, a consultant with educational and computer experience was brought in to assist with the development of the project, particularly developing standardized care plans, writing a coding scheme for admission orders, and assisting with the medications database.
The fourth stage of planned change involves specifying the objectives of the change, mapping out exactly how to get where you are headed, and the length of time you anticipate the plan will take. Gathering data from the literature or from other agencies who have implemented similar changes is very useful in planning the actual change. By conferring with others who have preceded you in similar endeavors, it may be possible to avoid unforeseen pitfalls. A pilot or trial period of the project also may be helpful at this point in heading off problems, to allow for periodic evaluation of the change, and to modify the plan if necessary.
Stage four involves the hands-on "nuts and bolts" of implementing a nursing informatics system. For each specific area of documentation to be automated, we first analyzed the existing procedure along with the paper system flow of information. For example, to automate the medications documentation system, we first closely examined all current standards and procedures for documentation. We also examined the flow of information from the field to the office to assure that all current information would be available to everyone who needed it. If we had not examined the current system for the collection and distribution of information regarding medications, vital information might have been missed and medication errors could have resulted.
To assure that at no time would a practitioner be working with out-of-date information, care was taken to plan the transition. To obtain this result, patient records had to be labeled clearly and consistently so all practitioners knew where to look for current information. Concurrently, we posted notices and sent written documentation to all staff, keeping them informed of the changes taking place and which stage we were at any time. After the records had been changed over to the automated system, we undertook a quality assurance study to guarantee that all nurses were using the system correctly.
Similar steps were taken for the automation of other parts of the record. Overall, we compared and contrasted the old system with the proposed new system, taking the best portions of the old system, discarding what was less than optimal process, and adding value where we could benefit from the technology. Thus, we attempted to learn from our previous experiences and improve processes overall while changing over to the new system, keeping in mind the importance of maintaining patient safety, quality assurance, and confidentiality.
Making change "divisible" also was useful in the process of automation. Leaders of this process did not overwhelm staff with too much change at once. Modules were chosen to begin the automation process with ones that would be used daily so that the computer would become part of the day-to-day activities of staff and so that newly learned skills would not be lost due to lack of use.
Phase five involves choosing the appropriate role of the change agent. The role of the change agent during the change process is critical to the success of the plan. Failure to define the role of the change agent can result in confusion and a breakdown in communications. Knowing the "chain of command" and how to get help when the inevitable problems arise enhances the chances of successful change.
The role of the change agent in the automation process is multifaceted. In fact, there were several change agents leading various portions of the project. Here, the change process benefitted from having an individual experienced with clinical informatics and with the needs of the home care agency. This individual led the training and project coordination aspects of the project and provided user support and troubleshooting. She also served as liaison between clinical, clerical, and technical staff and provided information to the QA department to aid them in deciding how standards were being met using the new system. Other facilitators of the change process were the network and software administration/support staff who are vital in maintaining and supporting the entire on-line computer system.
Phase six includes diffusing the change beyond the pilot project to the larger organization and maintaining the change once it has been initiated. The key to maintaining the change is keeping the lines of communication open. Frequent, ongoing discussions by staff regarding the change will need to continue as each step in the plan is implemented, evaluated, and revised as necessary.
The process of automation is a dynamic one, requiring that the system be flexible in adjusting to changes occurring both internally and externally. Maintaining the system requires ongoing quality assurance on the data, including evaluation of the users knowledge and use of the system. Over time, users may simply forget some of what they learned during training, particularly by staff who use the system infrequently(eg, per diem staff). As periodic evaluations bring new products and information to light, updating the hardware and the software in the system may be necessary. Training of new staff and periodic retraining of staff also may be necessary to maintain the quality of the data and to assure that documentation is complete and accurate.
Phase seven involves termination by the change agent, leaving the system or the organization to maintain the change. Ideally, individuals who are knowledgeable and committed to implementing the change have been identified beforehand and have been groomed to take over for the original change agent.
As a system becomes integral to the day-to-day functioning of the organization, many individuals become familiar with the current operation of the system and how to implement the stages of change. Ideally, with the frequent introduction of new technology, the role of the change agent no longer rests with one or two individuals but can be generalized to a greater portion of the staff as they identify new problem areas requiring change.