MISSION IMPOSSIBLE A Clinical Transformation Endeavor:

The Lippincott Project

A System Approach to Improvement.Kathleen Hierholzer March 2012

Based on Work Submittedfor Capstone Practicum

NUR 685

Description, Analysis, and Implications of the Experience

Project Objectives

• ADOPT a single, online, evidence-based repository withsystemwide access

• EMBED access at point-of-care

• REDUCE expenses incurred in redundant procedural policycreation and maintenance

Stakeholders

• NURSING -improved access to information and consistency across system

• PATIENTS -care delivered by nurses using best evidence

• SYSTEM - reduced nursing expenses, improved community reputation for provision of best quality of care and safety

Software as a System (SaaS)

LNPS is an example of SaaS. •a “single-instance, multi-tenant architecture”(Carraro & Chong, 2006, para. 5).

•as an externally-hosted application, it can be placed in a network environment

•SaaS allows healthcare systems to have their own version, or “instance”, of the Lippincott software.

System Strategy

1. Seven specialty areas were created

2. Each specialty group to review all procedures and make a collaborative decision to adopt, reject, or personalize Lippincott’s version of the procedure.

3. The team was to create one standard procedure which everyone in the system would follow.

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System Strategy Continued

Access design had not been established. And access design became a problem.

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Project Work Plan

1. Content experts review current policies/procedures

2. Collaborative decision made to adopt, reject, or personalize Lippincott’s version of the procedure; create one standard for the system

3. Team “recorder” documents decisions as “Drafts” in LNPS

4. Nurse Executive reviews and “Publishes” the draft in LNPS

5. IT arranges network access to our system’s “instance” of LNPS

6. Local Leaders train administrators in new access

7. Nursing Education staff support change management

8. Nurse Executives agree on Roll Out date

9. Evaluation 8

Network AccessibilityLNPS (the system’s instance) is accessible by

• ATHENS username and password authentication for remote access

• in the EMR in a dropdown list under “enterprise links”

• as a “FAVORITE” (bookmark) on all networked computers

Issues and Obstacles Encountered

1. Policy/Procedure Reviews – timeline for completion

2. Regulations/Compliance - assurances needed

3. Network Accessibility – decision on interface needed

4. Change Management and Education- planning required

5. Development of an Effective Structure and Process for Upkeep– support position required

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Developing Effective Process and Structure for Maintenance

•Administrator role needed to provide organized institutional oversight:

1.Establish Process for Reviews

2.Allocate Resources

3.Establish a Procedure Approval Process

4.Establish User Levels & Upkeep of Usernames

5.Establish Process to Stay Current

6.Maintain Back-Up CDs

7.Activate EBN Resources 18

Establish Procedure Approval Process & Process to Stay Current

•Establish a structured “procedure approval process”:

•WHO will be responsible for

1. drafting

2. publishing

3. quarterly LNPS updates

4. maintenance of all customized procedures

5. adding users to the system

6. Removing “old info” from policies and adding LNPS link

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Future Plan for Embedding the LNPS Link to each Procedure

• The policies and procedures for each facility will need to be brought back to their respective committees for update.

• At that time, the policy statements will remain unchanged; the procedure piece will be replaced with the link to the opening page of LNPS, and the nurse will search that web page for the appropriate procedure.

Evaluating the End Product

• Pre and post surveys will demonstrate the usefulness and usability of the LNPS as the portal for all clinical nursing procedures in the system.

• ROI data will demonstrate the value financially to the system.

Evaluation

Evaluating outcomes by stakeholder category:

From the nurse’s perspective…From the patient’s perspective…From the system’s perspective…

Evaluation benefits to the organization:Reduced nurse turnover …Gradual refinements in clinical transformation activities…

Evidence Supporting Decisions

Challenges to evidence is essential.

Values Challenge- example: visitor search on behavioral health unit

Safety Challenge example: transdermal patch disposal

Research Challenge - example: depth of intramuscular injection

ROI

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Return on Investment?

Analysis

• An effective process and structure is lacking for the following:

• Project Manager to provide organized oversight

• Establishment of a Process for Updating Reviews

• Establish authority for Resource Allocation

• Establish a Written Procedure Approval Process

• Establish Process for Assigning User Access

• Establish Protocol for Maintaining Back-Up CDs

• Establish means for evaluating use of system, and collecting feedback on its usefulness.

Implications of the Project

1. Shared governance in action is inspiring! Taking ownership of procedural policies helps further the professional growth professional affiliation of nurses across the system.

2. An evidence base is important for Magnet status, but always essential for best practice! Many current procedural policies in the system had been written without providing evidence.

3. An informatics specialist at the executive level helps assure a focused project. Clearly articulated roles, accountability for deliverables, and availability of resources will prevent stagnation of the project.

4. Project sponsorship is not the same as project management.

Lessons Learned

• Project manager is the essential role.

• Communications is the essential skill.

• Maximize the help available from informatics software producers.

• Human and financial commitments are essential elements of a successful implementation.

• Politics and change are inescapable issues.

• Engagement must be nurtured.

• http://www.youtube.com/watch?v=5Pb5WV1RnXQ

Planning

• Project Sponsor – Needssystem life cycle knowledge!

• Work Plan – Need one!

• Resources – Define them!

Mission Impossible?

Impossible? Continued…..

Analysis

• Steering Committee –Need someone at the helm!

• System Proposal – Vital to a technology project!

• Process Model – Should result from collaboration

Design

•Contract – Use vendor resources!

•Use scenario- Is this better than before?

•Interface – Design for user!

Impossible? Continued…..

Implementation

•Testing- User satisfaction factor!•Support & Maintenance-

Success requires vigilance!•Assessment –Learn from

experiences!

Impossible? Continued…..

SummaryIn 2010, the healthcare system purchased a SaaS program from a

leader in digital nursing support, Lippincott Williams and Wilkins.

Their intention was to adopt this repository of nursing knowledge, customize it in small ways, and embed it as an electronic support at the point-of-care for their clinical nurses.

Two years into the 3 year contract, the system has yet to realize an efficient return of investment on the software.

Without a project manager, without a work plan listing tasks and deadlines, without assignments for essential functions, implementation has been impeded by scope creep.

Work continues, and the project will be implemented, but with major modifications both in the original process design and in the point-of-care access.

MISSION POSSIBLE!

With nurse informaticist providing structure and process.

Thank you for your questions.