Institutional Assessment: CPOE in Jackson Hospital

Talyia Joyner Beth Anne Smith Kelley Patrice D. Kiesling Cassandra Schmidt Auburn University/Auburn University Montgomery Joint MSN Program

Proposed Change
Computerized Provider Order Entry (CPOE)
CPOE refers to any system in which clinicians directly enter medication orders (and, increasingly, tests and procedures) into a computer system, which then transmits the order directly to the pharmacy.

Nature of Change
Hospital Policy

Complex Change

Overview: CPOE
Theories Stakeholders Guidelines and Policies Agency Mandates Major Problems Vested Interests Drivers and Resistors Implications

Unintended Consequences
More/New Work Workflow Issues New System Demands Problems related to paper persistence Negative Emotions Generation of New Types of Errors Overdependence of Technology

Change Theories
Change theories:
Lewin
Unfreezing, Moving, Refreezing

Rogers
Awareness, Interest, Evaluation, Trial, Adoption

Lippitt
Phase 1- Diagnose the problem Phase 2- Assess motivation and capacity for change Phase 3- Assess change agents motivation and resources Phase 4- Select progressive change objective Phase 5- Choose appropriate role of the change agent Phase 6- Maintain change Phase 7- Terminate the helping relationship

Change Assessment
Assessment segment
Lewin
Unfreezing- Disequilibrium is introduced into the system, creating a need for change

Rogers
Awareness- Problems are identified presenting need for change

Lippitt
Phase 1, 2, 3- Problem/need for change identified, capacity for change assessed, resources for change assessed

Needs Assessment Lippitts 7 Phases of Change

Phase 1: Diagnose the Problem Phase 2: Assess Motivation and Change Capacity Phase 3: Assess change agents motivation and resources

Lippitts 7 Phases of Change

Phase 4: Select progressive change objective Phase 5: Choose appropriate role of the change agent Phase 6: Maintain change Phase 7: Terminate the helping relationship

Stakeholders
Jackson Hospital Physicians Nurses Pharmacy Insurance companies Patients

Meaningful Use: National Policy

Adopted Electronic Health Record in 2005 as required by Meaningful Use Implemented CPOE as reimbursement incentive American Recovery and Reinvestment Act of 2009

Is there a mandate?
Meaningful Use

Major Problems
Resistance to change
Altering physician practices Redesigning inpatient care processes affects physicians, pharmacists, nurses, and ancillary personnel

Addressing Major Problems

Change strategies
Empirical-rational Power-coercive Normative re-educative

Change Strategy
Empirical-Rational
Similar to evidence-based practice in which nurses and providers utilize research evidence to transform practice; appeals to rationality and patient-centered care Natural resistance to change will be combated using tools from this theory such as education and communication

Change Theory
Effective Leaders/Impassioned Champions
Essential in all change models, because they provide inspiration, vision and support to everyone involved Physician champions- Believe in the change and work with colleagues to assist them in adapting to new system and serve as liaisons to the information systems group

Vested Interests
a personal or private reason for wanting something to be done or to happen a group enjoying benefits from an existing economic or political privilege Merriam-Webster, 2013

Gain from the change

Hospital leaders
Less errors Increased productivity

View change as a loss

Physicians
Additional job duty Larger time commitment

Unit Clerks
Eliminates need to decipher physician handwriting Saves time in order entry

Unit Clerks
May fear their job is threatened

Nurses
Directly receive physician orders Reduced need for order clarification Eliminates need to decipher physician handwriting

Ancillary staff, pharmacy staff

Reduced need for order clarification

Human Drivers/Resistors
Drivers Hospital Executives Directors Managers Practitioners Nurses Resistors Resource Management Physical Therapy Select Surgeons Practitioners Nurses

Resource Implications
Variables:
Organization size Number of sites Single integrated clinical system vs. integrating CPOE system with existing systems for laboratory, pharmacy and radiology

Implementation costs:
Network expenses (upgrading/purchasing wireless devices, adding additional workstations) Software licensing Contractor/consulting User training Information Technology (IT) support team resources Ongoing operating/maintenance costs

Resource Implications
Time
Time required to implement CPOE ranges from 1224 months Training for CPOE users
Physicians, nurses, unit clerks, pharmacists, and ancillary staff

Increased physician time spent on order entry

Evaluation Theories
Utilization-Focused Evaluation
Based on the principle that an evaluation should be judged on its usefulness to its intended users

Performance Measurement Matrix

Accommodates different data levels and data measures and traditional performance measures while taking into account the limitations of costto-benefit analysis

Conclusion
Proposed Change: CPOE Assessment and Evaluation are ESSENTIAL

References

Agency for Healthcare Research and Quality (2012). Patient safety primers. Retrieved from http://psnet.ahrq.gov/primer.aspx?primerID=6 Better Evaluation (2013). Utilization-focused evaluation. Retrieved from http://betterevaluation.org/plan/approach/utilization_focused_evaluation Caldwell, R. (2011) Jackson hospital implements use of secure and electronic medical health records. Retrieved October 25, 2013, from http://jacksonhospital.netreturns.biz/newsreleases/article_detail.aspx?id=eb050d0bc0fa-4417-9010-0aacf2cc651e#.UmpqpHCsiSo Cubbon, M (2000). Motivational theories for clinical managers. Nursing Management. 7, 6, 30-35. First Consulting Group. (2003). Computerized physician order entry: Costs, benefits and challenges: A case study approach. Retrieved from http://www.leapfroggroup.org/media/file/Leapfrog-AHA_FAH_CPOE_Report.pdf. Fung , K., & Vogel, L. (2003). Will decision support in medications order entry save money? A return on investment analysis of the case of the hong kong hospital authority. Retrieved from American Medical Informatics Association website:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1480307/pdf/amia2003_0244. pdf

References
Jamieson, D. (1982). Developing HRD and OD:the profession and the professional. Training and Development Journal, 36(1), 21. Retrieved from http://ehis.ebscohost.com.spot.lib.auburn.edu/ehost/detail?vid=6&sid=e8b206ec-00c2-4f4fa5383588ded04fd8%40sessionmgr11&hid=110&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d Lippitt, G. (1969). Training and Development is the Change Process at Work. Training and Development Journal, 23(7), 2. Retrieved from http://ehis.ebscohost.com.spot.lib.auburn.edu/ehost/detail?vid=3&sid=e8b206ec-00c2-4f4fa538-3588ded04fd8%40sessionmgr11&hid=6&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d Meaningful Use 101. (n.d.). Retrieved October 25, 2013, from http://www.medicity.com/meaningful-use-101.html Merriam-Webster Dictionary. (2013). Retrieved from http://www.merriamwebster.com/dictionary/vested%20interest. Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1), 32-37. Retrieved from https://aumnicat.aum.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=buh&AN=86746704&site=eds-live.

References
Oregon Health & Science University. (2007). Computerized physician/provider order entry: POET recommendations. Retrieved from http://www.cpoe.org Porter-OGrady, T., & Malloch, K. (2011). Quantum leadership: advancing innovation, transforming health care. Sudbury, MA: Jones & Bartlett Learning. Savings offset costs associated with CPOE: Can you afford to omit it in future strategic plans? (2001, May). Retrieved October 24, 2013, from http://www.ismp.org/newsletters/acutecare/articles/20010515.asp The effective health care program stakeholder guide (11-EHC069-EF). (2011). Retrieved from Agency for Healthcare Research and Quality website: http://www.ahrq.gov/research/findings/evidence-basedreports/stakeholderguide/stakeholdr.pdf