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The New Life Clinic (NLC) was established in 2005 as association partnership by a group of doctors is. The clinic has six owners and about 15 other working doctors and 20 other staff members. One third of staff is a permanent employee of clinic other two third works on sharing basis. NLC is a primary health care clinic providing service to the local community. NLC also provides consulting services to international patients, who seek medical in the UK and US for specialty treatment. Clinic handles s more than 5000 patients every year. NLC is busiest in primary healthcare and, there is an increasing need to provide links to specialist clinics and hospitals regarding referrals. NLC refers patients to specialist clinics both local and International.
NLC defined its vision of a patient-centric information system to meet the objectives of an Electronic Health Record, EHR-system. NLC is working with medical technologies to achieve EHR-System and, develop its medical information technology for the future. Continuous improvement in healthcare and updating skills of staffs' skills is the core policy of clinic. All the practicing doctors at NLC are highly qualified, and had more than five years of working experience in the UK and US. CLC is located in very posh are of Karachi, Pakistan. The residents are diplomats, doctors, bankers, businessmen all very rich and with high standard of living. Use of internet is very common.
Q.I -A. Major Organizational change in NLC
The major significant organizational change in New Life Clinic was the introduction of Electronic Health Record -system. The new system replaced the old paper based medical records- business transformation.
(I) -Introduction; An Electronic Health Record (EHR), also called Electronic Medical Record (EMR), is computerized health information of an individual patient in a digital format. EHR includes patient's medical history, medications, allergies, immunization status, laboratory findings, radiology images, and billing information. Clinics and hospitals create EHRs, store, and share with different health care providers. Clinics and hospitals create EHRs, store, and share with different health care providers. Electronic Health Record-system enhances automation as well as streamlines workflow with increased safety, as well as reliability through an evidence based decision support system.
(II)- Objectives of Electronic Health Rerecord- System
The main objectives in making a change were; Replace paper medical records with an electronic health record to increase physician competence, standardize patient care, and reduce medical errors and cost.
1)-Physician competence; EHR-system provides physicians a strong clinical decision support system, based on clinical guidelines to prevent diagnostic errors, and improve the quality of treatment. Having access to HER-system physicians can get comprehensive health information about patients on fingertips rather than chasing paper records.
2)-Online services: EHR-system enables Physicians to make online referrals, share medical histories, and data of patients with other service providers in the UK, and US.
3)-Standardized patient care; EHR-system enhances patient-physician interaction; provide patients a secure access to their EHRs to view key component of medical records, laboratory test results. EHR-System provides patient online access to communicate with physicians to request prescription renewals, and make appointments request prescription renewals and make appointments. EHR-system replaces manual handwritten prescription with electronic medical prescription to avoid medical errors.
4)-Reduce healthcare costs by avoiding duplicating of expensive imaging procedures and medical errors.
Q.II) -A. Main drivers of the change:
New Life Clinic is under management of medical professional. Continuous improvement in quality is the core of its policy. International medical regulations had influence on the practice conduct of New Life Clinic due to due to international referral services. The fast changing medical technologies and changing patient preferences forced healthcare providers to redefine their patient care goals and objectives.
a)-The main drivers of change were; 1) New technology of Electronic Health Record .2) Changing business model of medical practice.
As part of the Clinic's review of data, patients had problems with prescriptions and delays in referrals. There were also some reports of errors in prescriptions. Therefore, in an effort to understand the issues, and identify opportunities for a change, a root cause analysis was completed using the fishbone diagram.
b) - Fishbone Diagram: The main objectives of using fishbone diagram analysis were:
1) Determine the root cause of a problem using a structured approach.2) Indicate possible causes of variation in a process. 3) Encourage group participation and everyone to learn more about the factors at work and how they were related. 4) Identification of areas where data need to be collected for further study.
Process: The senior member of clinic led the process of root cause analysis. He had extensive experience in modernizing medical practice and quality improvement concepts.
The procedure had representation from each section of the clinic, and involved doctors, nurses, administrators, coordinators, and patients. As part of the process, data from Clinic's CQI program were reviewed.
Findings: The Clinic's administrator defined the problem of delay in referrals, and errors in prescriptions.
The goal of the root cause analysis was to identify the primary reasons for delay in referrals and medical errors.
Issues were explored using the following five main causes:
1) Environment, 2) Procedures, 3) People, 4) Equipment, 5) Technology
The first cause explored was the environment and four related ideas found by this group were:
1) Time available 2) Waiting time 3) Physical space 4) Availability of services
The team discussed the environment and found that all the services were good and in time. There was less waiting time at the reception for confirmed appointment. However, there was less physical space available for storage of medical records and X-rays film.
2) The second cause explored was procedure; it was found it did contribute a lot to the existing problems of delays in referrals, and appointments. The three related ideas found by this group were;1) Referral procedure 2) Identification of errors in prescription 3) Appointment process
The team discussed and found that procedures used within the clinic for appointments and referrals were very time consuming. Appointment staff was very busy in making appointments and answering patients' questions. International partners in the UK and US were insisting to send electronic record. The physical storage for medical records was less and patient's demands were very high. The team analyzed procedure of appointments and decided that procedure could be a possible cause. The team also suggested that technology should be linked with the procedure. As staff was unable to handle all the things manually and meet high demands of patients..
3) The third cause explored was, people. This was categorized by staff and patients. The team agreed on the issue of people handling mails ineffectively. But, there was scanty evidence of delay in referrals due to negligence.
4) The fourth area explored was equipment, including what was needed to conduct medical examination, test and generate reports. The two related ideas found by this group were:
1) Trained staff was available to help the patients.
2) Physical equipment needed to carry out the procedure were new and in good conditions.
5) The fifth area explored was Technology, including data storage, software, and access to internet. The three related ideas found by this group were.1) Software for medical prescription was not available 2) Computerization of all medical records was not proper due to lack of software. 2) Online access to patients on website and access to medical records were repeatedly in demand by international hospitals and other physicians.
Technology: The team analyzed the data of suggestion, comments and demands regarding Use of IT. The report prepared by It staff after doing Forced Field Analysis, - The principle, developed by Kurt Zadek Lewin (September 9, 1890 - February 12, 1947). The principle provides a framework for looking at the factors that influence the situation, either for or against. Q.II)-B. The forces of influence in this case were helping forces, pushing towards goal.
1) International hospitals, where the Electronic Health Record System was in use and they kept insisting to send records online in digital format.
2) The international patients who traveled to the UK and US for specialty treatments and demanded EHRs instead of paper records.
3) The increased use of internet was also the main factor, because patients were more aware and had knowledge of accessing services online.
4) Surrounding culture; the clinic was in one of the posh areas of Karachi, Pakistan. Almost every house had access to broadband internet; the level of education was very high. Residents of the area were diplomats, businessmen, doctors, bankers and other rich people with high standards of livings. Internet was already in use for online banking, shopping, home delivery, and for communication with relatives aboard. Therefore, the patients expected the same standard of services as they had received in the UK and US.
Conclusion: After detailed discussion, inputs from all stakeholders, and evidence from the collected data of Forced Field Analysis. It was possible to come up with a consensus on the point of a conclusion. That delay in referrals and errors in prescription were due to manual handling of paper record. Secondly, patients' dissatisfaction with manual paper records was due to delays and also due to increased awareness of Electronic medical records .These was the key drivers to force the change of Electronic health Record system and that resulted in a new business model of medical practice.
Q.III)-A. Evaluating Effectiveness of change management:
Change management is a structured approach to transitioning individuals, team, and an organization from a current present state to a desired future state. To access the effectives of change management, I applied, John P Kotter's 'eight steps to a successful change' framework to assess the effectiveness. Establish a sense of urgency.
1. The change agent clearly defined problem, and need for improvement. The change was necessary and urgent. The leader shared the knowledge and views that he had about the situation. Market was examined and competitive relatives were discussed. The objectives of change were real and relevant i.e. reduce the healthcare cost, improve quality of care, and promote evidence based care. To further understand the process, the change agent did it in another way of mobilizing team's commitment. He arranged for the team to look outside the box. He took them on a tour of a leading organisation to see other ways of doing the same thing firsthand. The reason for improvement was clear and benefits were measureable. Moreover, the project was within clinic's fund limits.
2. Introduction of EHR-System was an organizational structural change with consequences of advancement in information technology. The new business frameworks required highly qualified personnel to operate new system. The organization hired skilled staff not only to operate the system but also started a training program to retain the existing staff. This effort encouraged group to work together and in result a guiding team was formed. This assisted greatly to execute the change without greater resistance. The hired consultants had experience and reputation of managing Electronic Health record projects. The team had coordination, Commitment, and Competence. These three components were essential for introducing change
3. getting the vision right was the leadership, because that was the leader who was taking the team to where they couldn't go on their own. There was clear and detailed vision of the future. The change vision was aligned with the organization's strategy of continuous improvement. It involved key stakeholders in defining and detailing the change vision. Again, workshops were conducted in developing the change strategy. High-level benchmarking was conducted to identify best practices, reference sites and competitor information. The was a good reason behind the change which was supported by evidence based practices. The leader emphasized positive reasons for change that motivated the workers. This comprised the transition team that drove the change initiatives, and facilitated the implementation. This helped team members and employees to interpret the core objectives. The management team set out the "7 S" framework to help diagnose the current health of organisations and to help develop their visions for the future. The 7SFramework (McKinsey) consists of the following.
- Structure (roles, responsibilities, organisation, structure)
- Strategy (direction)
- Staff (numbers and skills)
- Style (leadership and management approach)
- Systems and procedures
- Shared values (ways of doing things, operating style)
- Skills (Corporate strengths and skills, general competencies).
A vision was expressed at different stages of change. A High level vision played key role at the start. They build on the problems and threats that provide the case for change, but addressed them positively. They motivated the staff by showing benefits. Outline visions of services helped staff from finding problems to building solutions without involving detailed negotiation on changes. A detailed vision of service and organisation helped staff to imagine their future work life and roles. A vision of the journey provided a structure for communication during the change. The service model was made for building support for change. The benefits were; improved outcomes for patients, and better futures for staff. The service model helped subsequent translation of change in terms of:
- Structure (new roles and responsibilities across professions)
- Staff (changes in skill mix)
- New skills (multidisciplinary working)
- Systems and procedures (new protocols for referrals)
- Management style (focus on outcomes as well as process)
- Shared values (the emphasis on assessing and responding to the full range of patient needs).
At this step learning was kicked into play in this process of change. By having teams with new goals and accountabilities the leader facilitated learning through all members of the team. This step helped agents of change to identify those who cannot fit in the new organisation.
Involvement of all members in proposed change encouraged participation and created an environment of cooperation and support. This facilitated Clinic's strategies, and planning for future. The management involved all stakeholder, medical societies, and NGOs in healthcare, and also some international hospitals. The co-operation and pro-active support of stakeholder were important. Workshops were conducted to address the issues and stake holder agreed to support and commitment. There were a good communication and common understanding among the stakeholders about the degree and scope of change needed. The management succeeded in communicating the change in a very clear and concise way to win the heart and minds of entire organization. Progressing effectiveness was traced through Staff Surveys. Stakeholders were managed on an on-going basis. Communication was instituted through weekend updates, emails, and letters. Questionnaire and staff satisfaction surveys were quite effective in determining the views of employees and allowed people to voice their opinions about the change program.
5. Empower others to act on the vision. The staff was empowered with new skills, and encouraged for open dialogue and communication. The staff committee was formed to monitor performance and reward them on success. Staff regularly took part in continuing education, and was awarded with credits. Obstacle of jobs dissatisfaction removed and security of job and reward was in place. A continuous support from top and feedback system was in place. The management was able to create positive environment in the organization.
6. Plan for and creating short-term wins. Change is realised when it becomes the normal way of working, this requires proof that performance has improved and will continue in the future. Quick wins were identified in the forms of electronic health records being printed and stored in one location. That saved time and efforts that were used in compiling paper records.
Senior management communicated results delivered through quick wins to the organisation.
The quick wins increased the momentum and also early positive feedback was very encouraging. That was essential for the on-going success of a change management program. First milestone was celebrated and, People were rewards for their improvement with recognition, promotions and money.
7. Consolidate improvements and producing still more change.
Having the credibility and success of quick wins, the management looked for further improvements. Hired more professionals, and rewards for existing employees and more change agents were created. People as new roles, responsibilities and skills felt honored and wave of courage emerged for further improvement.
8. Institutionalize the new approaches. To articulate the new behavior corporate success a leadership development seminars were in place. So the leaders create more leaders. The change agent played his role and ensured the change was stretched, the right people were in place, and the new organisation was up and running. The management was successful in meeting the purpose of change and created a learning organisation that did not exist before. This new organisation was able to monitor learning process. Task was shared among all participants in the process and that created a long term capacity for continual learning. That step was aimed to elicit renewal without imposing.
Q.III)-B-Managing resistance to change management
The New Life Clinic had developed a culture of facilitating learning throughout the process of change management. Therefore most of the ambiguity was clear at very start. The fact of change is that irrespective of effective change management, people are affected by the change..The resistance and its response were divided into three parts. To effectively manage resistance, the management constituted a compliance committee of experts to address the concerns, regarding technology, security, and other issues.
The management adopted following steps to mage the resistance:
- The staff at medical record section had some problem with operating new system and was struggling. The support team managed it through facilitation, working with them to achieve the goals of change
- Resistance from new patients regarding security of was managed through education. The support team educated new patients through demonstration and seminars.
- Involvement: all the stake holders were involved in understanding this system through repeated seminars and coaching classes.
- Two members from the customer service team were least interested and had hardly participated in seminars. First they were dealt with counseling and then negotiation. This step helped management to identify that they couldn't fit in the new organisation. The coercion step was the last resort, and finally they were fired from the job.
- Physicians' attitude: This was the hardest task to assess physicians' readiness for new change. Keeping in view the fact that many costs -saving and quality improvement ideas had failed in the healthcare sector due to lack of physicians buy -in. New life clinic was also faced with the same situation in case of specialist physicians who were not the employees of clinic but used to work as external consultants.
That attitude was due to the lack of physician's familiarity with the changed environment of practice. Secondly, specialist physicians are acknowledged as the highly educated people. Therefore, they were a bit reluctant to learn from juniors, as this was difficult for them to accept incompetency. That attitude showed concerns about physicians' autonomy and also concern of quality care.
To dispel this attitude, management hired a senior clinical doctor who was sometimes a professor in the US and was very familiar with Electronic health records. This helped in providing physicians from through question and answer secession. Physicians liked this way of learning from the senior colleagues. This strategy was very successful and many senior doctors from other hospitals came to join the sessions.
QIV) A. assessing success of change in achieving goals:
Assessment of success of change management was important for managers to know how successful or 'effective' change was, and stakeholders wanted information on whether the objectives were being met. The success was assessed using the best practices for organisational-wide change management frameworks
Commitment from the top:
Vision: There was a compelling, and inspiring vision of the future state, and there was a direct link between the vision and the key drivers for the business. The vision had quantifiable measures for success and he vision was authorized, and sanctioned, by higher authority. The change was led by an identifiable, senior management who had personal credibility, past experience and spoke enthusiastically about it. The chair of the committee had clinical credibility and a set of social skills that made him effective with a diverse set of stakeholders. The situation and the team needed an approach that emphasized flexibility, but which over time moved from setting the pace and negotiating to developing and coaching. He actively looked for leadership from others and in critical stages sought out advocates who could solve problems.
2. Stakeholder consultation: The co-operation and pro-active support of stakeholder was important. Essential Stakeholders and sponsors were identified and their level of influence assessed and mapped through stakeholder analysis. Workshops were conducted to address the issues and stake holder agreed to support and commitment. There was a good communication and common understanding amongst the stakeholders about the degree and scope of change needed.
3. Strategy: Senior management was clear and understood how the change will be achieved in broad terms. The risks of the project were considered and mitigating actions identified. A structure was set up to guide and manage the change (steering group, project board, etc.) Members of the senior team had taken on responsibilities for aspects of the change program. A high-level plan, with indicative timescales was produced for the change. Senior Team Commitment: All members of the senior team discussed and understood all the implications of the change. They explained the vision in vivid and inspiring terms. Even in private they spoke supportively of the change programme. Other key influencers outside the change team were contacted and they were supportive
4. Performance indicator: Performance improvement assessment helped physicians to assess current clinical care to their patients according to established evidence-based guidelines. Short survey evaluating knowledge, attitude, and competence of physicians showed significant improvement in the new system. Patient surveys were also conducted evaluating, convenience, interaction with physicians, and waiting times. Results showed there was increased patient-physician interaction, and patients felt the personal touch of care, and waiting time was markedly lessened which otherwise was wasted in collecting paper records.
The staffs' survey showed increase in work out put, workload of paper records was reduced with electronic health recur system. The time wasted on compiling paper records was being spent on further learning of system. Employees were awarded with rewards, new roles and responsibilities and equipped with new skills. There was ultimately improvement in professional practice and patient care by implementing changes.
Communication: The effective Stakeholder Communications and Management were set to win the commitment change. Ongoing effectiveness was traced through Staff Surveys. Stakeholders were managed on an on-going basis. Communication was established through weekend updates, seminars, emails, and letters. Questionnaire and staff satisfaction surveys were quite effective in determining the views of employees and allowed people to voice their opinions about the change program. The essential of change were communicated in clear and simple manner.
Technology and culture alignment: The current culture of New Life clinic was conducive to proposed change of Electronic health record system. The staff had skills to use technology and good technology infrastructure was already available there to accommodate the change.
Quick wins and measurable results: Quick wins were identified in the forms of electronic health records being printed and stored in one location. That saved time and efforts that were used in compiling paper records. Senior management communicated results delivered through quick wins to the organisation. The quick wins increased the momentum and early positive feedback was very encouraging and essential for the on-going success of a change management program. First milestone was celebrated after feedback was very positive.
Continual learning: The New Life Clinic developed a process of continuous learning throughout the period of change. To produce the most effective conditions for learning a Preplanned audit and learning, performance reviews as part of normal business, and external audit and inspection program was set in place.
Risk assessment: A well assessed risk management plan was in placed. Careful evaluation at each step made it possible to avoid nay unwanted surprised. Gathering information on agreed metrics and audit assessment were the key point of risk assessment method. Alignment and integration throughout the business: the need for a group of champions who can work well together to ensure direction, support, and drive for change.
When the success of change was measured in the light of Beckhard's definition of OD
'Organisation Development is an effort planned, organisation-wide, and managed from the top, to increase organisation effectiveness and health through planned interventions in the organization's processes, using behavioral-science knowledge.' Beckhard, R (1989).
The statement of success was established, that proposed change of electronic health record System in the New Life Clinic was: the change was planned with clear vision and goals. It was organization wide and was managed from top. The change improved staff performance and patient care. The process of change was managed on the principles of behavioral science.
Conclusion: Introduction of EHR-System in medical practice replaced the paper based records. . This change had almost achieved all the desired goals. The success of the change was supported by:
- The clear vision of future and its goals
- Stakeholders' support and keen involvement throughout the process.
- A well organized communication system and learning environment.
- Improved performance indicators of medical practice
- Quick wins and measurable results
- A well managed risk assessment plan to avoid any surprises
- Continuous learning culture managed by behavioral science knowledge principles.
In the light of established facts of successful change and organization development .It is suggested that change was very successful in achieving desire objectives of Electronic Health record system in due time and within fund limits.
Q.IV).B- Assessing the need of improvement:
The assessment of management success provided in the information helped to indentify the places for further improvements. There are two suggestions
1- ) Continuing Education program: Continue the process of continuous learning and impellent it as a program. Adopting a continuous learning program will establish structure and process that will cultivate learning environment. The program will enable staff to make adjustments based on feedback in order to more closely meet priorities. The CE program will help staff develop skills, open new venues of work and will develop courage humility to change. Furthermore, Continuous learning is a way to keep the existence in fast changing and competing world.
2- ) Continuing medical education (CME) /CPD program: CME program should be made as a part of work. CME program expands and updates medical professionals' skills, knowledge with recent developments. Skills such as medical practice management, medical information technology, auditing in practice and communication are invaluable to doctors today. CME is mandatory for physicians in the United States. In the United Kingdom CPDs are also in practice and many medical organizations run CPD programs.
Medicine and the information age, Jeffery S Rose (1998)
http://en.wikipedia.org/wiki/Kurt_Lewin on,21sy, Jna,2010
http://www.metricationmatters.com/docs/LeadingChangeKotter.pdf , on 22-01-10
Do this by citing RDI (2009) in the main text and in the bibliography put:
RDI (2009) Module Title, Unit number or title, lesson number or title, page number.