Running head: Evaluating an Organizational Change: Moving to Electronic

Evaluating an Organizational Change: Moving to Electronic Documentation

Susan Mateo
HCS 587
Jennifer Culotta
May 19, 2014

Evaluating an Organizational Change: Moving to Electronic Documentation

Evaluating an Organizational Change: Moving to Electronic Documentation

Evaluating the effectiveness of an organizational change requires a look back to
the beginning of the change process to review all the steps taken up to the current
moment. The proposed change of moving to an electronic documentation system is
based upon the regulatory requirement for continued Medicaid and Medicare
reimbursement (usfhealthonline.com, 2013) and the coming implementation of
accountable care organizations (ACOs). The electronic system will be the primary
vehicle for achieving the meaningful use (usfhealthonline.com, 2013) standard and
interoperability requirements [needed for] exchanging standardized clinical data with
care partners (Healthit.gov, n.d. para. 3). A review of the process components follows.
Organizational and Individual Barriers, Factors Influencing the Change and
Organizational Readiness for Change.
When proposing and implementing an organizational change, there are barriers
at both the organizational and individual levels as well as other factors influencing the
change itself and the readiness of the organization to change. Expected organizational
barriers include: lack of computer hardware systems and Ethernet jacks for plug-ins,
lack of wireless network, lack of in-house IT professionals to educate and support users,
and lack of knowledge of software among staff. Expected individual barriers include:
fear of inability to learn program, fear of impact on established day to day work
activities, concerns of intrusive organizational oversight of individual work activity,
concerns of increased workload either directly due to use of EMR system for
documentation or as a result of EMR decreasing work load and facility increasing
patient to worker caseload, and concerns over procedures related to system down times

Evaluating an Organizational Change: Moving to Electronic Documentation

and /or crashes. Factors related to the organization itself include covering the costs of
hardware installation, creating schedules of training, delays in installation related to
barriers in the facility, and staff meetings to address concerns and questions. Factors
influencing organizational readiness for this change involve adequate and timely
communication, staff members experiences with EMR and the system's graphical user
interface design, [which can] affect implementation outcomes (Lawhorne, 2010, p.
459).
Theoretical Model, Internal and External Resources Supporting the Change
Kurt Lewins Field Theory of unfreezing, moving and refreezing provides a
framework for achieving this change (Spector, 2010). Unfreezing is achieved by staff
meetings regarding the EMR rollout and explaining the mandated timelines of
regulations as well as proposed timelines for implementing the EMR system. Moving is
achieved through ongoing communication via staff meetings, hardware installation and
software training itself. Refreezing occurs as the number of proficient staff increases to
100% trained and competent staff using the system. Internal resources supporting the
change include organizational funding for the EMR system, facility leadership
commitment to compensate employees for time in training, EMR experienced
employees invested in assisting skill acquisition, and appropriate training environments.
External resources include expert contractors and corporate trainers.
Methods to Monitor and Communication Techniques to Address
Issues Related to Implementation
Progress with implementation will be monitored by the use of the alerts reports
and the open tasks reports by the team nurses and nurse managers along with frequent

Evaluating an Organizational Change: Moving to Electronic Documentation

rounding by nurse managers to check in with staff throughout the implementation

process. Strategic communication via vertical, horizontal and diagonal flows of
communication achieved linking the needs of the staff to the organizations mission and
deadlines. Multi-directional communication allowed leadership to support and answer
staff questions and concerns openly and to create an atmosphere of expectation and
readiness to receive training. Continuous communication between the installation
personnel, facility administration and staff regarding hardware, between IT trainers and
end-user staff, among floor staff with each other, and between staff and leadership
contributed to maintaining the alignment between staff and the organizational mission.
. The Relationship Between the Organizations Processes and Systems and
Personal or Professional Roles within the Organization
Kurt Lewins model of Force Field Analysis describes change as a set of forces
that work in different directions. Some forces and interests in the organization wanting
the change may be offset by forces and interests seeking to preserve the status quo. In
order to implement change, the driving forces, must be greater than the strength of the
restraining forces (Borkowski, 2005). The driving forces include corporate commitment
to the change and provision of training, the CNAs ability to realize the impact of their
care on the patients care plan, their perceptions of themselves as effective members of
the team, regulatory requirements impact on the facilitys viability, and increased
communication resulting in improved team work and quality of care. The restraining
influences include individual fears of inability to acquire new skills and to the amount of
time needed for skill acquisition, and nurses initial reluctance to generate and review
the alerts and open tasks reports, and staff concerns that the reports will be used as a

Evaluating an Organizational Change: Moving to Electronic Documentation

form of punitive micromanagement. Addressing the restraining forces while supporting

the driving forces will increase the positive momentum of the change.
Determining the Effectiveness of the Organizational Change after Implementation
Use and satisfaction are two key measures of the success of any information
system including EMR system success (Wager, et.al., 2008. p. 63). With this particular
organization, the change to EMR documentation effectiveness was tied to actual use by
the CNA staff. Due to the continuous reinforcement of use expectations via nurse
manager rounds for verification of documentation completion, generation of alerts and
open task reports by nurses, and one on one re-teaching as needed to reinforce the
actual mechanics of the system, actual use of the EMR system was effectively
implemented. However, accuracy of documentation and meeting of timelines for
entering information, responding to alerts and shift to shift reporting required other forms
of evaluation.
At 30 and 60 days past implementation, an audit by the MDS nurses revealed
consistency and improvements in documentation of patients abilities and levels of
assistance needed for activities of daily living (ADL) performance. Continued verification
of open task and alerts reports by nurse managers revealed increasingly timely
documentation of tasks by CNAs and follow-up by staff nurses of alerts. Nurse
managers also conducted random and opportunity driven interviews with CNAs for
feedback on how use has impacted the flow of work. CNAs reported improved work
flows and increased ability to answer patient families questions about patient care and
patient status.

Evaluating an Organizational Change: Moving to Electronic Documentation

Possible Outcome Measurement Strategies Related to Organizational

Change Processes
Van der Meijden, Tange, Troost, and Hasman, (May/Jun, 2003), view the
success dimensions proposed by Delone and McLean for management information
systems as valid for patient care information systems as well. They proposed to
subdivide success measures into six separate categories within which several attributes
could contribute to success for that category. The categories are: system quality
(attributes: usability, accessibility, ease of use), information quality (attributes: accuracy,
completeness, legibility) , usage (attributes: system usage, information usage, or both,
including number of entries and total data entry time), user satisfaction (attributes:
alternative measure of system value in cases of obligatory use), individual impact
(attributes: effects of the system or the information on users' behavior, including
information recall or frequency of data retrieval or data entry), and organizational impact
(attributes: effects of the system on organizational performance).
Measuring Quality, Cost, and Satisfaction Outcomes
According to Rantz, et. al. (2010), Medicaid cost reports provide information on
costs related to EMR implementation and to staffing levels. MDS-based quality
indicators and quality measures provide data on residents responses to the EMR based
interventions. The facility realized total costs increases with the implementation of
technology. Resident outcomes of ADLs, range of motion, and high-risk pressure sores
improved with the implementation of EMR. Resident and staff feedback anecdotally,
from repeated and regular interviews by leadership also support continued
improvements and effectiveness in care. On-going hardware and software costs as well

Evaluating an Organizational Change: Moving to Electronic Documentation

as costs of continual technical support for the EMR and constant staff orientation to use
the system must be allocated in future budgets. EMR contributes to the quality of
nursing home care and enhances resident outcomes with improved documentation and
intervention in clinical care.

Evaluating an Organizational Change: Moving to Electronic Documentation

References
Borkowski, N. (2005). Organizational behavior in health care. Sudbury, MA: Jones and
Bartlett Publishers
Healthit.gov (n.d.) Retrieved from:
http://www.healthit.gov/policy-researchers-implementers/long-term-post-acutecare
Lawhorne, L.W., (September 2010), Long-Term Care and the Electronic Medical
Record. Journal of the American Medical Directors Association Volume 11,
Issue 7, Pages 459461.
Rantz, M.J., Hicks, L., Petroski, G. F., Madsen, R. W., Alexander, G., Galambos, C.,
Conn, V., Scott-Cawiezell, J., Zwygart-Stauffacher, M., & Greenwald, L.
(September, 2010) Cost, Stafng and Quality Impact of Bedside Electronic
Medical Record (EMR) in Nursing Homes. Journal of American Medical Directors
Association. 11(7) pps. 485493
Spector, B. (2010). Implementing organizational change: Theory into practice (2nd ed).
Upper Saddle River, NJ: Pearson Prentice Hall
Usfhealthonline.com (February 8, 2013) University Alliance. Retrieved from:
http://www.usfhealthonline.com/news/healthcare/electronic-medical-recordsmandate-january-2014/
Van der Meijden, M. J., Tange, H. J., Troost, J., Hasman, A., (May/Jun 2003).
Determinants of success of inpatient clinical information systems: A literature
review Journal of the American Medical Informatics Association 10(2) 35-243.
Wager, K. A., Zoller, J. S., Soper, D. E., Smith, J.B., Waller, J. L., & Clark, F. C.

Evaluating an Organizational Change: Moving to Electronic Documentation

Assessing physician and nurse satisfaction with an ambulatory care EMR:

one facilitys approach. (Jauary-March, 2008) International Journal of Healthcare
Information Systems and Informatics, 3(1) pps. 63-74 IGI Global