Chap 18. Organizational and cultural change considerations

1. Chap 18. Organizational and cultural change considerations

2. 18.1 Introduction • CDS in this chapter • Computer-based “passive and active referential information as well as reminders alerts, and guidelines” • Only computerized CDS • More complex : Interface and access issues specific to IT

3. Organizational issues in decision support have not been systematically studied and little has been published about them • Guidance based on experience • Organizational aspects of implementing clinical guidelines • Issues related to electronic prescribing with decision support • CPOE

4. 18.1.1 Framework for addressing organizational change and transitions

5. 18.1.2 Identifying the barriers and facilitators for implementing CDS system • 7 barriers to paper-based clinical practice guideline • Lack of awareness • Lack of familiarity • Lack of agreement • Lack of self-efficacy (confidence) • Lack of outcome expectancy • Inertia of previous practice • External barriers • Lack of time and support staff • IT related barriers • Poor screen design • Lack of computer skill • Lack of direction due to unclear instruction • Inaction because of mis-timed interventions • Emotional barriers • Annoyance • rage

6. Variables related to organizational characteristics are more important than either guideline characteristics or the external environment

7. 18.1.3 Stakeholder analyses and Lewin’s force field analysis as useful techniques

8. 18.2 Organizational issues related to clinical decision support • Differences among kinds of organizations and cultures • Issues of control, autonomy, and trust • Difference between commercial and locally produced decision support • Upsides and downsides to clinical decision support from the user perspective • Cognitive, emotional, and environmental issues • Addressing the issues judiciously

9. 18.2.1 Differences among kinds of organizations and cultures • Teaching hospital vs non-teaching hospitals • General • Hierarchy • Severity of disease • Rate of implementation • Governance and control issues • Clinical pathway • Easier in community hospitals in US • Educational effort in teaching hospitals

10. 18.2.2 Issues of control, autonomy, and trust • Organization vs Clinician • Big Brotherish • Implementation is easiest for CDS modules that clinicians do not care about • Making anything mandatory may be more difficult in a community hospitals • Many of the control, autonomy, and trust issues are related to the culture of the organization

11. 18.2.3 Difference between commercial and locally produced decision support • Locally produced DS • Hard to develop and maintain • More easily accepted • Fragmented often • When a need or gap is identified, a decision support module is developed • Commercial DS • May cover the entire spectrum of needs • Less fragmented • At a lower level of sophistication but improving all the time

12. 8.2.4 Upsides and downsides to clinical decision support from the user perspective • Downside of CDS • Too controlling, and can evoke strong emotions • Alert fatigue • Undermine education and learning • Wendt et. al.(2000) • The fact that routine medical work needs broad knowledge support, yet most CDS modules provide advice on something very specific • The idea that much decision support is not patient-specific • The loss of interpersonal discussion • The questionable validity of some of the suggestions • The questionable quality of data that the clinician has given the system • The additional time on the part of the clinician • The problems with interface designs that are not intuitive • The lack of integration between different parts of some systems such as results retrieval and CPOE

13. 18.2.5 Cognitive, emotional, and environmental issues • Physicians may want discussion and psychological support when making difficult decisions • Social aspect of decision making is advantageous • University of Virginia (1989) • Residents threatened to strike because of implementation of medication ordering system • Negative emotions • Guilt, anger, sadness, hostility, disgust

14. Ways to decreased barriers from 10 commandments outlined by Bates (chap 5) • Be mindful of time constraints and demands • Deliver information in real time at point of need • Suggest and do not stop an action unless critical • Take advantage of the easy and high impact interventions by doing them first • Avoid asking for more information than is absolutely necessary • Be responsive to feedback • Manage the knowledge base so that physicians trust the content offered them

15. 18.2.6 Addressing the issues judiciously • Barriers that can be lowered in Individual clinician level • Kinder language in alerts, screen design, fine tuning alert conditions • Emotions • Education, training, and communication • Lack of awareness • Lack of familiarity • Lack of self-efficiency • Lack of computer skill • Change culture and social system • Inertia • Combination of better technology and education and adequate technical support • Time constraints

16. Technology barriers • Design problems • Lack of clarity • Lack of trust in the input data • The higher level organizational issues of power, control, autonomy, and trust of administration need to be evaluated and addressed • From the eyes of clinicians

17. Force field analysis for a decision support initiative

18. 18.3 Planning with these issues in mind • Early planning, structure for continuous planning • Financial overview • Intangible benefits (better patient care) vs tangible ones (reduction of duplicate tests) • Should include goals, objectives and action plans

19. 18.3.1 Vision and philosophy • Vision • Clearly worded statements • A philosophy behind the vision • The attitude • The clinicians is usually right • A rule should not block or stop a clinician from doing what he feels is best for the patient • No system is perfect • Rule of thumb • One can anticipate only about half of the problems before it is perfected • On should not implement a new decision support module every time physician behavior change is desired

20. 18.3.2 Organizing for planning • Committee for CDS • General principles for success • Physicians need to be heavily involved in the work of the committees • Take advantage of the social needs of clinicians • Rewards for the committee members • A communication plan to provide backup for every decision support module that is implemented • Training and communication

21. 18.4 Development, implementation, and modification • Preparing • Committee work • Providing resources for support and training • Strategies

22. 18.4.1 Preparing • For individual decision support module development • Look first at paper-based decision support • Computer-based information systems are often blamed, when a standard policy that routinely has been ignored is suddenly exposed after it has been automated • When a new CDS module is being designed, clinician users must be included in the interface and screen design deveompment

23. 18.4.2 Committee Work • Determination of what needs to be in place at both basic and more advanced levels over time • Establishment of a process and identification of responsible people for screening for new knowledge • Identification of a mechanism for updating and revision of decision support modules • others • Getting groups of clinicians together to evaluate systems in the later phase

24. 18.4.3 Providing resources for support and training • For new clinical stuff • Classroom setting -> continuous ongoing training

25. 18.4.4 Strategies • Strategies for each organization based on different culture • Surgery is usually good place to start • To go for the low hanging fruit • General order sets with defaults • Dosages of medications at recommended level • Alerts about allergies • Drug/drug interactions • Suggestions for corollary orders • Provision of searchable information resources • Vendor user groups of physicians • Share experiences • To allow personal order sets in the beginning and then move away from them

26. 18.5 Evaluation and maintenance • Have data to back you up and gain involvement: impact assessment and other techniques • Soliciting clinician feedback • Knowledge management • The importance of ongoing organizational support