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ADVANCING THE ORDINARY

A discussion with CCIO Annual Nursing Conference

Cerner Conference Center, London

June 13, 2013

Patricia E. Natale, RN, MSN, NEA-BC

THE DETROIT MEDICAL CENTEREight 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

TRANSFORMING PATIENT CARE…

DMC Scope of Useorders/Month, or 34.6 Million for the year12.9 Million Medication Orders600,000 Electronic Prescriptions

DMC ADE Data from 2006 – 7/2008

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

DEFINING WHAT WE ARE TALKING ABOUT

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

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)

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

WHAT IS THE ORDINARY?

IT DEPENDS……………WHOSE WORLD ARE WE DISCUSSING?

THE ORDINARY: NOT SO ORDINARY

THE STANDARD OF CARE?

THE NEW TECHNOLOGY?

THE CLINICIAN?

THE DIRECTOR?

THE IT EXPERTS?

THE TRUST?

THE PATIENT?

YOU KNOW WHAT ASSUMPTIONS MEAN…

Advancing 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…”

The ordinary……

Why bother getting involved?

Clinical practice is ALWAYS impactedDegree of change is complete unrecognition: inside out ,

upside down…Agreements with processes become new Standards of

PracticeStandards of Practice define framework of professional accountability

Full engagement of point of service staff AND leadership is imperative: more accountability

Outcome measures define impact

ANOTHER 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!

A NEW ORDINARY….

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.

ORDINARY LESSONS:

QUESTIONS WITHOUT ANSWERS FOR NOWIs 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.

THE ‘NEXT’ ORDINARY

STORIES

Medication administration: where is the scanning???

Where are the Nursing care Plans?

The Paper task list…it lives forever!

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

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

UPHILL LEADERSHIP: FINDING THAT ORDINARYWhy 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.

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.

More Fantasies

Leaders know how to use the EMR in pursuit of a result

The paper went away…Paper can be a change agentIf 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

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

What is THE NEW ORDINARY:

Uphill Leadership: Why it is not easyClinical 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

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?

FINDING THE ORDINARY

A STORY or TWO

AN OUTCOME or TWO

AN EPIPHANY OR SIX

Our favorite fantasies….

NOW, A NEW ORDINARY…..

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

Predictable Excellence

Remember:

“The people on top of the mountain did not fall there!”Anonymous

The Now New Ordinary::

Time for Questions