CareNet Implementation Across our Network

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CareNet Implementation Across our Network
Heather de Jong, Maureen Rydall Melissa
Comyn GBIN Grey Bruce Information Network Date
Apr 26, 28/09
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Geography of GBIN
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Demographics of GBIN
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Our Cerner Journey

• 1998 Traditional build Cerner resources onsite
  mentoring GB build staff
• GB Build with Cerner support
• Solutions RadNet, PharmNet, PowerChart, PM,
  interface with another lab vender for Owen Sound
• Phased in to other sites over the next few years
  as facilities grouped into Organizations and then
  GBIN network formed

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GBIN Cerner Journey

• 2006 ASC build Cerner works remotely with
  Subject Matter Experts
• Cerner build using client submitted information
• Solutions PathNet, Clinical Reporting and
  Workload - Network wide (Big Bang)
• FirstNet (tracking triage), SurgiNet and
  Scheduling Owen Sound site only, Rolled out to
  other sites later

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GBIN Cerner Journey

• 2008 Solution Centre Build
• Cerner works remotely with Subject Matter Experts
• Cerner build using client submitted information
• Solutions CareNet, eMAR, MRP, CPDI, PCLA, Resp
  WL
• Phased in approach of all smaller sites over a
  year time (8/10 sites complete to date) with Owen
  Sound being last

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Initial Scope

• Initial Scope Inpatient Med/Surg Nursing
  Admission Database
• Decision learn from past do not want broken
  processes
• New Scope Admission, Care to Discharge of
  Inpatient Adult Med/Surg patient

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Final Scope of Project

• Cerner provided Start content, the build team
  was encouraged to take as much as was appropriate
• Rural site focus but it must work for Owen
  Sound
• Adult Inpatient Med/Surg rural site - became
  the mantra

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The Team

• Steering Committee with Nursing membership from
  all 11 sites initiated July 06 that met monthly
• Build team 2 persons - Fall 06
• 2 Nursing Admin GB, 1 each SB, HDH
• CNO consensus from each organization
• CEOs committed to this e-initiative

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Project Charter Goals

• 1) Enhance patient safety by providing clinical
  decision support and decreasing clinical errors
• 2) Design, implement and evaluate a GBIN,
  standardized, multi disciplinary tool for
  integrated documentation of the med/surg
  inpatient electronic record
• 3) On line patient assessment tools forms
  ensure timely, efficient consistent data
  collection

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Project Charter Goals

• 4) Achieve quality data collection by having
  identified rep on Nursing Leadership, Nursing
  Practice, Professional Practice, Risk Management,
  etc
• 5) End user input for desired device prior to go
  live (ability to trial hardware)
• 6) Create a tool that will enhance recruitment
  and retention of health care professionals

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Project Charter Goals

• 7) To become 'paper lite
• 8) Reduce redundant tasks and duplication to
  create efficiencies in workflow
• 9) Improve communication throughout GBIN by
  providing real time access to information
• 10) Implementation of evidence based order sets -
  Open Source Order Sets and Pathways

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Project Charter Goals

• 11) Process mapping to determine workflow
  processes that may need to change with the
  implementation of Clin Doc
• 12) Gain the skills to support ongoing the
  Communication, Education Roll out Plan of
  CareNet
• 13) Design a product that meets the initial roll
  out needs and will support future application
  growth

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Project Charter Goals

• 14) "As smooth as possible" Implementation
• 15) Effective Feedback Loop with each go live
• 16) Effective testing and validation

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Project Charter Risks

• 1) Insufficient hardware
• 2) Insufficient wireless connection
• 3) Inadequate staff training
• 4) Insufficient downtime process

• Frustration / not support real time charting
• Pt safety / Staff frustration
• Pt safety / Staff frustration
• Pt safety / disjointed chart

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Project Charter Risks

• 5) Insufficient administrative support
• 6) Poor Staff buy in
• 7) Retention of staff
• 8) Insufficient human resource pool at go-live
  for staff support - includes both Endusers and
  Superusers

• Pt safety, human resources issue
• Poor Moral
• Poor moral, human resource pool reduced
• End User frustration, Patient safety at risk and
  human resource pool stressed

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Project Charter Risks

• Training costs not budgeted for
• Not enough end user input early re. product
  design and hardware

• Over budget
• Product that does not meet the end-user needs

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Project Steps

• Collect Information
• Analyze look for outliers
• Design
• Build
• Test
• Implement
• Evaluate

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Initial Steps

• Information gathering met with groups who used
  the paper chart to assess their needs, what they
  got from the chart
• Consulted disciplines included Allied Health
  (Physio, OT, RT, Social Work, etc), Discharge
  Planning, Coders, etc
• Onsite Assessment for each area, project
  introduction and start of relationship

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Build Phase

• Initially looked at standardizing form, build of
  orderables Spreadsheets
• Worked with Cerner weekly calls, some trips to
  Kansas City them on site GBIN
• Focus group (from Steering Committee) met
  biweekly to look over Cerner Start Content
• Looked at content Canadian content

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Build Issues

• Build issue Cerner tool Content Manager and
  GBIN code level
• Phase X client
• Start content over rode some Production
• Start content from different sources that did not
  match eachother differing DTAs
• Build was not complete enough to fully test but
  Testing started

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Build Issues

• Introduction of Open Source Order Sets after the
  project started
• Pathways not well supported in paper format by
  Nursing or Physicians at all sites

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Testing

• Testers (RN/RPN) endusers from all organizations
• Due to build issues on Cerners end not
  everything was built out to test by the deadline
  for testing (forms, folders)
• Time set aside in the project plan for Unit
  testing not enough since the build was delayed on
  Cerners side
• This was challenging since no extra time was
  available in the project timeline

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Testing

• Testers became familiar and involved in the
  process
• Good PR for the project
• Good sharing of information/difference
  similarities of processes (2 bed vs 30 bed size
  issues) within the tester group
• Started the process for looking at for SuperUsers

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Testing

• Opportunity to get away from the bed side and be
  part of something new
• Synonyms all the ways to say the same thing
• Networking between site and corporation staff

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Roll Out Plan

• Initial ASC go live Apr 21/08
• Due to issues with testing the date was pushed
  out 6 weeks
• New Date June 16/08 Meaford / Durham
• About 3 months prior to the initial go live set
  the proposed Roll Out

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Roll Out Plan

• Aim to have the sites all live first year
• No Summer / Christmas go lives
• Training 3-6 wks prior depending on staff to
  train
• After initial site summer off (to breath) find
  and fix major issues
• Owen Sound would be last most complex, all
  Allied Health, OB, Mental Health

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Roll Out Plan
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Training/Education

• Build team given crash course in Registration
  Pharmacy order entry to meet training needs
• SuperUser training (5 rounds now) new and tweaked
  each time
• EndUser training GB/HDH vs. SB
• Build team overview of new application to Help
  Desk and other application Specialists

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GB/HDH Training

• Nursing staff using the system 16 hours in
  class hands on training, initial instruction and
  scenario based
• Training on site by peer SuperUsers
• View only for all staff not nursing on the unit
  but who would have viewed the patient chart (ward
  clerks, Allied Health, Health Records, etc)

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SB Training

• Team of Director of Patient Care RPN
• Rolled out to each SB site
• Super Users 4 day training
• End users 7.5 hour training (2 to 1)
• 3 weeks support post go live with peer Super
  Users available 24/7

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SB Implementation

• Staff scheduling initial week
• Communication board
• Ensured Super User to staff ratio
• Altered staffing during first week to ensure as
  many as possible could be part of the process

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Go-Live Support

• SuperUsers first line of support
• Initial Week HIS Application Specialists (M-F)
  on site in the trenches
• HIS Help Desk 24/7

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Go - Live

• May /08 First Super User Class
• June 16/08 Meaford / Durham
• Summer off from go-lives
• Sept 22/08 Lions Head / Chesley
• Oct /08 2nd SuperUser class
• Nov 1/08 Wiarton - scheduled

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Go - Live

• Dec 1/08 Kincardine
• Dec 8/08 Wiarton actual
• Christmas break
• Jan /09 SuperUser Training class
• Feb 2/09 Markdale
• Mar 2/09 Southampton
• Apr 20/09 Hanover

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First Shift
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Go-live Whats Next

• SuperUser training
• Next June 1/09 Walkerton
• Later Owen Sound

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The Good

• Little extras slogans, T-shirts, food
  (chocolate)
• Great Cerner team excellent rapport with the
  GBIN team
• Debriefs each day at go-lives allow the team to
  recap good information sharing
• Debriefs about 6 weeks post golive once the
  dust settles
• HIS team support remotely at go-lives of
  CareNet

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The Bad and Ugly

• Optimize the training (too early enough hours,
  hand pick trainers)
• Stick to removal of paper security blankets at
  golive or right after (eg paper Kardex)
• SuperUsers that were trained but did not teach or
  support at go-live
• Physicians on board does anyone really ever get
  this

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Lessons Learned

• Process, Process, Process map out workflow
  prior to electronic
• Make the electronic process match or change the
  workflow prior to introducing electronic
• As much as possible dont break the flow
• Identify areas that should remain on paper
  where electronic does not yet support

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Lessons Learned

• Hand pick great SuperUsers
• Allow for extra time in the testing phase
• Have testers do Integration Testing to pick up
  potential process issues
• Requested that the Cerner team remain constant

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Lessons Learned

• Avoid the silo effect
• Look beyond the initial golive to the support
  needs of Nursing units post implementation
• There can never be too much Communication

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Lessons Learned

• Dedicated staff
• Resources available to support implementation
• Functioning Hardware
• Nurses will be in survival mode initially What
  did you do on paper

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Even after a few shifts
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Words of Wisdom

• Revisit the weak charting areas about 6 8 weeks
  post go live once the basics are there
• For successful eMAR - CareNet and PharmNet teams
  MUST communicate well
• This is a Journey not a Destination a Marathon
  not a Sprint

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Words of Wisdom

• Each area will find a way to make it their own
  embrace this since it means they have taken
  ownership
• There is no cookie cutter approach/one size fits
  all to this each site, Nursing area or group
  bring their own dynamics to the table
• This is a Paradigm shift in the way Nursing
  Nurses - it takes about 30 days for them to
  really find their new nursing grove

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Where are we going

• Future Directions Owen Sound ???
• Allied Health
• Barcoding meds administration
• CPOE

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Moving Forward

• Good People
• using
• Better tools
• for
• Best Outcomes

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Contributors

• Sue Downs Wanda Taylor
• Maureen Rydall Melissa Comyn
• Trent Fookes our Pharmacist
• All the staff at the sites live with CareNet, for
  putting up with this intrusion into their neat
  little Nursing lives, for being open to learning
  new tricks, having their pictures taken and
  keeping their senses of humour especially the
  first few days into CareNet

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Questions

• Heather de Jong hdejong_at_gbhs.on.ca
• Susan Downs sdowns_at_gbhs.on.ca
• Maureen Rydall mrydall_at_sbghc.on.ca

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