1. Herrin-Griffith, Donna MSN, RN, NEA-BC, CENP, FACHE, FAAN
  2. Cabibbo, Tiffany MSN, RN, CENP

Article Content

In the current environment, healthcare organizations are compelled to execute business plans and strategies that reformulate the way care is provided, reimbursement is received, and other operational goals are met. To reform delivery systems and to receive incentives designed to accelerate implementation, adoption of information technology (IT) is essential. The impact and ramifications of transformational change that implementation of IT systems creates isn't well-documented, and guideposts for nurse leaders' success are needed. Experiences shared through lessons learned are beneficial to those "in the field" leading activations while evidence develops. This article outlines 10 priorities nurse leaders should consider before, during, and after a major system "go-live" with electronic healthcare record (EHR) systems or other types of technology such as workforce management (WFM) systems. The principles can be used in decision making, critical resource allocation, and in leading total system transformation.


Principle #1: Safe patient care strategies are always at the forefront

Patient safety is a top priority for today's healthcare organizations. During significant interruptions to the care process that come with IT implementations, staff must stay vigilant of potential problems and employ strategies such as redundant systems. This open focus on safety must be positioned as the top priority. While an on-time, on-budget go-live will be part of an organization's target, putting systems in place to protect patients during a time of increased risk is essential. Some strategies that organizations use include increased clinical staffing, additional support for non-essential clinical tasks, education of clinical staff on potential risk factors, and encouragement to families and patients to speak out if they see any potential issues. Embedding the "patient first" priority with every individual in the organization can create a sense of unity around the implementation and alignment with the care purpose of the organization.


Principle #2: There must be adequate time for cultural change

Urgency surrounds building and implementation of a transformative IT system. During such times in an organization, the typical focus is on system build and training. While this work is critical, an equal effort must be made to understand how the new system changes the essence of how work is done, how professionals work in alignment, and how the change brought by the system is a permanent transformation, not just a project. A whole-system IT implementation isn't a "plug and play" tool used to input items previously on paper. Understanding existing culture and strategies to transform culture are essential to the nurse leader's and the organization's success.


Principle #3: Evaluate and change processes and workflows before system design

A deep dive into all facets of workflow before system build is also a top priority. Given implementation urgency, many organizations succumb to a very rapid schedule. A problematic aspect of not taking pre-implementation time for system design is that the time and resources for rework in the post-initial phases will most certainly be required. One tool that can help leaders with this phase of the work is "ideal state" standard work maps, designed with team input and using Lean principles to identify and remove unnecessary steps. Once the standard work maps are created for all the key workflow processes, they serve as design templates for the build team. Leaders should then make every effort possible to move the real work toward the ideal state prior to the go-live.


Principle #4: Keep the system simple and avoid overbuild

One struggle early-adopting organizations have is that many IT systems are very robust, with technology paths and capabilities that are generations ahead of the standard, non-technology-driven practices in an organization. Achieving standard outcomes in patient populations and meeting national measures for quality can make decisions about the way to structure a system much more complex than necessary. When faced with multiple options in design, reach a decision point about the "one way" that will be required on all elements, avoiding multiple options and clinician decision points and keeping the system simpler to teach and to use.


Principle #5: Ensure adequate resources for clinical leadership

Since IT system implementation represents both a technical and cultural change, having individuals embedded within the IT team who understand and practice the work is critical. Typically, organizations pull from clinical teams to populate IT teams, who-even though they're novices-have to learn the system, develop software-building capability, and understand end results in testing and implementation. Although these team members are critical, they can't effectively lead the needed cultural transformation; this responsibility belongs to clinical leaders in the organization and with IT systems, individuals who live in both the IT and the clinical operations worlds. The development of Chief Medical Information Officer (CMIO) and Chief Nursing/Patient Care Information Officer (CNIO/CPCIO) roles has become essential in the transformation.


While these positions are widely popular in larger academic centers, smaller health systems struggle with dedicating resources to such positions. This oversight can cause the organization operational issues in later stages as the implementation transitions from a technology project to full operational ownership. These roles are critical in facilitating interprofessional work, understanding end-user clinical needs, translating technology to care processes, and escalating issues of concern in the care process to the appropriate level in the organization. For system success these tasks must be completed, so lacking the CMIO and CNIO/CPCIO roles, the work will rest on the shoulders of the Chief Medical Officer and the Chief Nursing Officer, two roles fully engaged in the work of operating the healthcare organization without time to dedicate to full-time IT systems implementation work.


Principle #6: Lead for cultural change instead of for completion of a technical project

Information system tools brought into an organization can range from a simple data housing system to one that can transform the care process, leading to better patient/consumer outcomes. The latter is the intent of fully developed systems. This principle also applies to resource management systems in which implementation creates entirely new ways to manage costs, assess productivity, and allocate key resources to the care process. Leaders should emphasize how work could and should change so longer-term benefits are realized. While the technology correctness is essential, the organization's leaders should lead using culture change strategies rather than strictly a linear "start to finish" approach.


Principle #7: Ensure a long-term governance and change management system is defined

There will be many adjustments and changes once the go-live has occurred. Strategies for dealing with issues arising during the first hours will be different than those arising during the first days, weeks, and then months. Essential is a "hotline" for issues requiring immediate resolution to keep the system live, and systems that allow individuals to bring issues forward must be organized and simple to understand. In the early hours, system users are in survival mode. In successive days, a leveling of urgency occurs, but the concept of stabilization applied to the care system and the technology as a tool are months, if not years, away.


Two keys for success are defining a change management process and creating a longer-term governance structure.


1. Defining the change management process: This process includes how issues are classified, typically technical, care process or flow, or safety or regulatory in nature. A funneling process to sort the issues and how they get deployed and prioritized for resolution is essential. The steps in the process will include elements to help team members log issues, scan for other reported issues, group similar items, and assign them to the appropriate resource. An essential element is including tools for tracking and providing feedback to users.


2. Creating a longer-term governance process: For the longer term, decisions on priorities will have to be made and a governing board that includes authorized decision-makers along with key clinical and IT stakeholders is a proven approach. This governance group will sort issues, prioritize resolution, and allocate resources to address the organization's largest concerns. The governance team and process will continue to work into the later stages of the activation, including optimization efforts.



Principle #8: Prepare for adequate training in the classroom and in clinical departments

Training for an IT system implementation is critically important; the magnitude of learning shouldn't be underestimated. While direct in-classroom hours for each professional can be accurately predicted, "less visible" factors and costs are frequently left short. Training isn't solely a classroom event. Other considerations should include staffing backfill costs for clinical staff during training hours, and time spent mentoring in the clinical environment just before and in subsequent weeks after the go-live date.


There are several other factors to consider regarding training. First, a trainer's effectiveness hinges on understanding adult learning principles and the clinical environment in which the system will be used. Trainers who know only the technology may miss intricacies relevant to clinicians in care decision processes. Timing of training is also essential: too early and the product isn't developed to a stage allowing robust training; too late in the process and the organization is rushed to get individuals through before implementation, putting undue stress on the organization. Training needs don't end with implementation and, in fact, can increase over time as users become savvier and have more questions about how to effectively use the system. In addition, every system will continually evolve with optimization efforts and product upgrades. Development in this area is an ongoing organizational need.


Principle #9: Develop professional team integration strategies

It's assumed that all clinical team members work in concert to provide services to patients. What's often missing, though, is depth of appreciation for what each group brings to the care process. With system go-lives, the interdependence of the specific disciplines becomes transparent, and a decision made by one group often impacts another. Interprofessional collaboration in every phase of the processes outlined in these principles is crucial. Some organizations report that this effort brings the disciplines together in a way that achieves new levels of care collaboration and understanding.


Principle #10: Care strategies for team members during transformation are essential

Individuals deal with change and the stresses of new technology in various ways. Ranging from excitement and enthusiasm to complete emotional and physiological stress, responses are as varied as the individuals involved in system change. Preparing for such a wide range of reactions and developing strategies to reward and support employees are important. This is a role that those individuals not on clinical teams (such as human resources professionals and plant operations teams) can play to contribute to overall success. In addition, tactics such as establishing a call center for emotional or behavioral support, providing snacks and meals, and ensuring employees take appropriate breaks all help produce better results.


Moving forward

Implementation of various initiatives, such as EHR and WFM systems, is a significant milestone in an organization's history and a change that most healthcare organizations will go through at some point. Even for those organizations that have been at the leading edge, use of the principles noted above during major system upgrades, in downtime crisis events, or during other major system changes can move an organization toward success.