ADVANCING THE ORDINARY

1. ADVANCING THE ORDINARY With Clinical Transformation

2. ADVANCING THE ORDINARY • A discussion with CCIO Annual Nursing Conference • Cerner Conference Center, London • June 13, 2013 • Patricia E. Natale, RN, MSN, NEA-BC

3. The Detroit Medical Center • Eight Hospital System • Total Revenue $3.9 billion • 1,806 licensed beds and 1,601 operating beds • 3,460 physicians • 11,637 full time employees • 353,460 ED visits • 98,000 at Detroit Receiving Hospital • 89,000 at Children’s Hospital of Michigan • 9,212 births • 968 residents and fellows

4. Transforming Patient Care… • DMC Scope of Use • orders/Month, or 34.6 Million for the year • 12.9 Million Medication Orders • 600,000 Electronic Prescriptions DMC ADE Data from 2006 – 7/2008

5. ADVANCING THE ORDINARYTODAY’S Conversation: • Defining the ordinary ‘work’ • Some definitions, concepts and value assumptions • The Nature of Clinical Practice • Uphill Leadership • Building adoption; deeper engagement • Lessons learned along the way

6. NURSING INFORMATICS CLINICAL TRANSFORMATION It is an end result… Takes place within the clinician’s world and the clinician’s workflow and the clinician’s judgment Moves data from discrete elements to part of a series ….relationships among data become ‘living’ in real time Relationships among data are pivoted into decisions to benefit the patient at that point in time Defining What We Are Talking About Nursing professionals with the knowledge and skills to develop and implement information systems that will enhance nursing workflow, promote patient safety, and elicit clinical outcomes…” (Weaver et al, Nursing and Informatics for the 21st Century, p.169)

7. Driving components of transformation… • Transformation = unrecognizable state from its original presentation...same purpose, different elements, consequence and result. • Clinical Transformation = inside out, upside down, new experience - • Telephone to Twitter • Single database; orders apparent across the enterprise: no walls

8. What is the ordinary? • IT DEPENDS……………WHOSE WORLD ARE WE DISCUSSING?

9. THE ORDINARY: NOT So ORDINARY • THE STANDARD OF CARE? • THE NEW TECHNOLOGY? • THE CLINICIAN? • THE DIRECTOR? • THE IT EXPERTS? • THE TRUST? • THE PATIENT?

10. You Know What Assumptions Mean… Advancing the Ordinary….

11. The ordinary…… . • The AH-HA!!! • What you thought was committed to during design and workflow will probably not happen “I know I said I would, but now that I am using it…”

12. ANOTHER ORDINARY… • Why bother getting involved? • Clinical practice is ALWAYS impacted • Degree of change is complete unrecognition: inside out , upside down… • Agreements with processes become new Standards of Practice • Standards of Practice define framework of professional accountability • Full engagement of point of service staff AND leadership is imperative: more accountability • Outcome measures define impact

13. A NEW ORDINARY…. • Why bother? Whether device or application… • Develop standards of adoption and processes of adoption practice • Sticking ‘it’ to the wall!!! • Accountability:every patient, every time, every where You own your practice environment, no one else does…Inherent in definition of a profession – privilege and power to influence!

14. ORDINARY LESSONS: • What do we know: A few things from lived experience: • There is ALWAYS consequence when something is done to clinical practice. • Whether the consequence is what was expected, wanted or noticed is another matter • We are accountable to understand our practice environment; its culture; its circumstances and its practitioners. • We are accountable to use this information to influence the BEST result for patients and staff. • YOU are the leader…you MUST insert patient care presence, influence and accountability at the earliest point of planning and maintain thru evaluation.

15. Questions without answers for now THE ‘NEXT’ ORDINARY • Is care REALLY better? How do we know and when should we try to find out? • What is the natural history of disruptive change at the point of service – when do people calm down, stop fussing, do what they agreed, suggest improvements? • A few Stories….what we really do when we innovate.

16. Stories • Medication administration: where is the scanning??? • Where are the Nursing care Plans? • The Paper task list…it lives forever!

17. Outcomes • Medication safety: wrong medication • Reduction in Stage 3 and 4 Pressure Ulcer • Capture of financial revenue • Sepsis alerts : mortality reduction • Quality Core measure data – 100% • Clinician Engagement • Deep infrastructure – Clinical Transformation Department

18. Complexity of Ordinary • The context of clinical practice: for a clinician or clinical lead = CHAOS • Patricia Ebright, RN DNS, Indiana University (JONA, 2003) • Studied patterns of interruptions of clinicians and how those affected decision making • Equipment , travel, interruptions, geography of assignment, waiting for systems, access resources to complete care, inconsistent communication

19. UPHILL Leadership: Finding that ordinary • Why is it Uphill…the work doesn’t conclude • Uphill = the effort to proceed toward the objective against the gravity of daily circumstance, other priorities, inertia. The endpoint= what used to be called robust-ness, sticking to the wall; sustaining the change • Leveraging the lasting change to the next level of performance: predictable excellence.

20. Fantasies • If we teach it, they will do it • Focus, attention of a clinical leader in a chaotic environment is “one” directional • Leaders can execute from beginning to end of a deliverable. • Leaders know how their units are performing at any given time. • Leaders’ workflow is predictable • Leaders spend time on their units with their colleague staff and their patients.

21. More Fantasies • Leaders know how to use the EMR in pursuit of a result • The paper went away… • Paper can be a change agent • If a report says It Happens, then • It happens… • OR • If someone says it happens… • It happens.. • AND • It happens like they say it does. • Automation makes us more efficient, allows more time at bedside/unit

22. What is THE NEW ORDINARY: • Predictable Excellence • Using influence with 2 clinician activities: • steer assessment data, order content and workflow into specific direction (based on evidence) • Present information to clinician at point of need to enable timely best decision • Levels of complexity: • Automating documentation, embedding to provide action earlier in workflow and prevent impact of distraction. Happens predictably • Adoption practice and accountability • Reporting tools to use in patient rounding, cueing action close to the time in care when it is needed

23. Uphill Leadership: Why it is not easy • Clinical transformation is inside out upside down. NOT CHANGE • Delicate choreography of the clinical expert, workflow and activities • Value of speed in the clinical environment • Culture of organization • Engagement • Grief process: familiar is better no matter how good the new is

24. Uphill Leadership: Why it isn’t easy • Nature of the End User’s definition of success • Varies by experience, minute, session • Utility: “Can I use this easily?”“If I can’t, it isn’t good” • Points of View: Informatician and Clinical Transformation • Informatician • Does it work? Is it less clicky? • Is it noise-free to the user? • Is it slick? Is it 100% dependable? • Clinical Transformation • Does it present information to the clinician when information is needed? • Does it tell the story? • Is it easy to find? • Can any clinician who needs the information see it? • Does it ENHANCE or at least support workflow? • What is the BENEFIT to the patient outcome?

25. Finding the Ordinary • A STORY or TWO • AN OUTCOME or TWO • AN EPIPHANY OR SIX • Our favorite fantasies…. • NOW, A NEW ORDINARY…..

26. The Ownership Journey • Why is it so hard???? Why do clinicians need leaders who can guide them through Clinical Transformation? • Without lived experience, resistance to new kicks in...human behavior • Without lived experience, learners become anxious • Without lived experience, learners don’t know what they don’t know • Without lived experience, planning is bound to be a mysterious experience • Lived experience always adds areas to improve which are discovered through that experience Engagement Ownership Predictable Excellence

27. The Now New Ordinary:: • Predictable Excellence • Remember: • “The people on top of the mountain did not fall there!” Anonymous

28. Time for Questions