Workflow & Process Transformation
- Healthcare Projects
Northeast Georgia Health System, Inc.
EDI recently helped Northeast Georgia Health System (NGHS) develop their plan for deployment of their new, online clinical documentation application. This was an important step in this hospital’s goal to have a complete Electronic Medical Record (EMR) system at their hospital campus. NGHS encountered several key issues on this project. Following are some of the issues they faced and how they dealt with them, as well as some important lessons NGHS learned along the way:
Before the hospital began to turn its attention to the “Last 100 Feet”, many important decisions had already been made. For example, the owner had decided on the EMR provider; they had teams in place to lead the rollout, capture feedback, and provide input and support; they had gone through extensive training; they had a well-developed schedule for rollout and go-live; and from a software and back-end perspective, everything was understood and moving forward.
However, NGHS still needed to determine the types and locations of the end-user devices for the hospital’s clinical areas and departments. They also needed to understand what, if any, upgrades to the existing space were necessary and what power and communications connections were required to support the rollout. EDI’s Clinical Connection Team met with NGHS key hospital team members to help them determine and understand exactly what they needed in this instance.
In a traditional care delivery model using paper-based records, most charting occurs after the fact, away from the patient’s bedside. It is widely accepted that real-time or bedside charting at the point-of-patient/caregiver interaction is more accurate and timely. This is a policy decision to be made by the hospital’s leadership and reinforced from the highest levels. NGHS’ executive leadership had decided as a matter of policy that bedside or real-time charting was going to become part of their patient care model.
Another important decision by NGHS was a “zero wait” policy for access to the electronic medical record (EMR). They were willing to make the necessary investment to ensure that any caregiver could access the EMR system without having to wait on a device. They also stated clearly that if there were any doubts about how many devices were needed, EDI was to err on the high side and add more.
These policies were intended to influence safer practices and higher quality healthcare. They were supported at the board level; NGHS leadership made it clear to everyone why certain changes to processes would be necessary with this rollout. These policies shaped how the NGHS chose to complete the “Last 100 Feet”. (link)
The remainder of this case study discusses NGHS’ key steps in negotiating the “Last 100 Feet”.
Unit Workflow Review
One of the first key steps is to understand and evaluate a hospital’s workflow. How many users need to interface with the system? Where do these interaction need to occur?
NGHS department champions provided their knowledge of how many doctors and ancillary staff were on the units and when. Unit secretaries collected supporting data for 3 days, on multiple occasions, recording specifically who was in the station during peak activity hours. Observers spent time documenting activity on the units to help validate workflow and staff counts. Physicians provided their input through interviews.
EDI used this information to develop formulas for determining a baseline for device locations and quantities within a unit. When there was doubt, we added devices based on the NGHS’ policy to “err on the high side”.
Benchmarking
NGHS was eager to learn how other similar hospitals had addressed the issues of the “Last 100 Feet”. (link) How many devices did they deploy? What kinds of devices? Where? What were their issues? Interviews with a number of similar institutions uncovered several key trends.
Hospitals are early in the journey to a full EMR, and most are still in the process of rolling out their systems. There was no clear consensus on the best approach. Some hospitals used carts; some used hallway stations; some used handheld tablets; many used a combination of solutions. Some had computer workstations in the rooms; some did not. In the most mature systems observed, there were approximately 1.5 devices per bed.
One important issue observed was that battery life was a problem for COWs (computers on wheels). No one had a place to put the COWs when not in use. Special outlets needed to be added to provide convenient plug-in for recharging. Maintenance plans, including active battery life monitoring, needed to be established. Even still, “dead” COWs were found on all observed units.
Device Selection
Physical space, power, and network infrastructure constraints were key factors in NGHS’ decision to use wireless computer carts as the primary device to be used in the patient rooms. NGHS also deployed wall-mounted workstations and desktop workstations in significant numbers at nursing stations, charting areas, medication rooms, and other key locations.
The computer cart selection was very important. Key performance criteria for NGHS included work surface, mobility, adjustability, cable management, power capacity, infection control, appearance, and other ergonomic factors. One activity that proved valuable was a visit with hospital staff to the HIMSS Tradeshow. Hospital staff were able to touch, observe, and discuss the features and benefits of all the devices NGHS was considering. This “show and tell” changed opinions on many of the devices; some devices moved off the list and others moved to the top.
When you cannot use a HIMSS’ or other tradeshow, having vendors supply samples for use by the hospital staff also proves helpful. A 2- to 4-week test period allows the devices to be tested by many different staff, giving better feedback.
Physical Site Review
The next important step was a physical site review to make sure devices could be placed where desired and that the necessary infrastructure (power, network connectivity, space, etc.) was available. The unit workflow review gave NGHS a good idea of what equipment would go where. Combining this knowledge with a detailed facility review allowed us to make minor adjustments in device locations to take advantage of, or compensate for, existing space, power, and connectivity issues.
EDI created drawings that documented the detailed site review information indicating where new power and network connectivity were necessary. These drawings also indicated minor space renovations required to accommodate the new devices.
End-User Review
It was important for EDI to review the “draft” recommendations and plans with NGHS’ unit leadership and staff. This was an essential step in seeking end-user buy-in to the final outcome. In order to more clearly communicate with end-users, the key findings, recommendations, and drawings were structured around individual units of the hospital.
Unit staff provided valuable feedback that helped “fine tune” device locations and counts. By conducting the review on the unit, additional staff were able to participate and “get a look” at the plan’s progress. EDI’s goal was to leave each unit meeting with a finished product and no loose ends.
Summary
Through this negotiation process of the “Last 100 Feet,” NGHS was able to clearly define several issues for all stakeholders:
- Where would devices go and why?
- What devices would be used at each location?
- What infrastructure and facility upgrades were necessary to support the devices?
