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Foundation Members:
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CHIME Presents:
The CIO’s Guide to Implementing EHRs in the HITECH Era
CHIME Member Comments on
Chapter 15: Making Go-Live Showtime and a Celebration
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Question posed to members:
What are crucial ingredients to achieving success during the go-live phase (that first week or so when users are transitioning to a new system)? What “nuggets” can you share that were especially helpful in achieving a successful go-live?
Comments:
“Installing EMR and practice management software means a major change in work processes for everyone who works at the practice. It's not surprising that this degree of change can be intimidating. But the change is inevitable. Don't allow small issues to become show stoppers. Take a positive approach. Even if there is a feature you wish had been designed differently, don't let that slow you down.
• Schedule the go-live in close proximity to the end of the training sessions. Try to avoid a long delay between the training sessions and the go-live. No more than a week should be allowed between the end of training and the go-live. This will ensure better retention of the information.
• Reduce provider schedules: Reduce the number of patients a provider is required to see during the go-live phase. Learning an EMR can be a difficult process, especially for providers. By reducing schedules for some period of time this can take the pressure off significantly. Many practices reduce schedules by 50% for one to two weeks after the go-live and then 25% for several additional weeks. Another method that has been used is to add 15 minutes onto comprehensive examinations and 5 minutes onto follow-up visits. Note: this method may involve some planning ahead to accommodate the scheduling templates.
• Provider Adequate Resources. Be certain to supply the staff with well trained individuals such as vendor trainers, super-users, in-house project manager etc. during the go-live phase. Create a Help Desk Hotline in case trained personnel are not immediately available. Communicate the chain of support method to all users before go-live. Put a sticky label on each PC with the help desk hotline phone number. Have systems in place if bugs or issues are discovered.
• Document Lessons Learned”
• • •
“Involve all nursing management – CNO, directors, nurse managers, and charge nurses.
Require:
1. Additional staffing for two weeks prior to live event and two weeks post live event. Set this expectation up early to allow for staff schedules and agency back fill. Require all levels of management to be present these four weeks. Staff will need strong and consistent leadership as well as support.
2. Dedicated “super-users” who will round and interface with IT. Super-users are not assigned patient care duties during these four weeks. Our staff could spot our super-users, who wore specially designed shirts. One staff member said that if their colleague the super-user could learn what to do, so could they. We did not let the vendor round or otherwise interface with end-users.
3. Set up a command center staffed with IT and vendor product experts with specific phone extension and hunt group to accommodate at least three simultaneous calls. By-pass normal technical support center processes until new system is stable and victory is declared.
4. Track all issues and report resolution status back to clinical management when it is time to declare victory and resume normal support operations. Management and staff fell less apprehensive when they know all issues are logged and tracked through resolution.
5. Keep executives and Boards informed. It is not uncommon for end-users to call this population and implore them ‘for the sake of our patients make IT stop what they are doing to us.’ It is better if this group understand this human reaction to change before they receive the call. Give DOH a heads up for the same reason.”
• • •
“For major ‘house wide’ go-lives such as CPOE, revenue cycle, etc., we strictly enforce a 90 day ‘freeze’ of our technical environment (60 days prior to go-live, and 30 days after). Any changes proposed during this time period must first be conditionally approved by the Change Advisory Board (CAB), and then sent on to the CIO and the project Executive Sponsors for final approval. This allows us to have a stable environment (at least to the extent possible) so that the users are focused on managing the change in processes rather than fighting with unexpected infrastructure issues.”
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“On-site support is crucial in locations where the systems are going live. Depending on the size of the go-live, support may include up staffing, provision for meals, coaches, technical staff and a command center. Constant communication is also very crucial.”
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“Have as many ‘experts at-the-elbow’ as possible. This provides immediate problem resolution and offers on-the-spot training, particularly effective with clinicians.”
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“Always have someone available to answer the questions. There is nothing more frustrating to a caregiver than having a technical problem and no one to immediately answer a question. Make the help noticeable via stand-out clothing such as an odd colored shirt. Also, make one phone number available to the caregivers and ensure that someone will be available to answer the phone at all hours of the day.”
• • •
“On site 24x7war room with distinct hot-line along with 24x7rounding of all impacted departments; executive visibility - particularly the CIO; lot's of food and coffee for the go-live support team; and tight vendor escalation process for critical issues along with daily debriefings. Prepare the CEO for end-user (i.e. doctor) complaints and keep the senior management team up to date. If the patients and family members will be affected supply free beverages, prepare free food coupons and standard service recovery messaging.”
• • •
“Communication, training, and support. All the stakeholders need to understand what will change, how it will change, when the change will take effect, and how it will impact the way their care for their patients and do their jobs. Training classes and materials should provide in advance (not too far in advance) and creative methods of providing just-in-time education for item/tasks that are not done often. Make sure there is an adequate number of super-users/experts available on all shifts and provide a special help desk number just for questions related to the new system. If you are implementing a system that will impact the medical staff, it might be a good approach to have a help desk number just from the physicians, so they are not in the queue with everyone else.”
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“Super-users on the system are the greatest nugget you can have. These users around on all shifts assist the implementation team with troubleshooting issues prior to calling the help desk. These super-users should not have an assignment for the first week and a limited assignment for the second week. Having trainers, vendors support and IT staff who know the system walking around the units assisting end users is also a great strategy. We also offered Attending Physicians who did not work frequently individual support when they came on so they could navigate the system easier. A year and a half later we still have the IT CIS team on the help desk from 7am-3pm Monday through Friday with a special line the end-users can call into.”
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“Immediate access to support staff. Training, training, training beforehand. Having the clinical or other departmental staff that gets less freaked out by computer issues helping on the frontline. Focusing people on the long term, so they realize the short-term or even medium-term pain is not going to last forever.”
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“Prior to go-live - testing, testing, testing, communication, communication, communication, education, education, education. During go-live have a command center that is established with appropriate coverage to handle issues and coordinate support. Depending upon the go-live just in time training and resources available immediately to users are likely. Large resources should have senior leadership participation and total support. That would include making rounds, supporting the teams at the command center and also being a plain old cheer leader. Change is difficult.”
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“Here again it depends on the nature of the system being implemented. For nursing unit based implementations (nursing documentation, eMAR) we use a train the trainer approach with additional onsite support from Clinical Information Analysts 24x7 for the first week and scaled back for the second week. The analysts assist the trainers, so they learn to support the users. With CPOE we tried several approaches. We ended up with one-on-one physician training for an hour in a classroom. We used the above approach with nursing trainers and analysts on the go-live unit as we rolled out CPOE. The trainers would provide at the elbow support for physicians as they came on the unit until they were asked to leave due to the physician’s comfort with the system. We have an analyst on call to answer physician questions. In physician offices we provide one week on site support followed by helpdesk and on call support.”
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“Fun celebrations like free food, accommodations if necessary, getting hats/candy, etc. and publishing very visible ‘WOW’ moments.”
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“We have not gone live yet, so can't help here.”
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“Planning, planning, planning, prior to go-live. Training classes prior to during and after go-live. Customer satisfaction surveys approximately 90 days post-go-live to gain end-user feedback. Additional training 90 days post-go-live based on end-user feedback Software vendor assessment of our utilization of the system and our end-users competency, as well as our process efficiency and effectiveness approximately 90 days following go-live.”
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“Strong onsite support for training and troubleshooting. Similarly, strong executive presence / leadership.”
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“Lots of care and feeding – face time – encouragement etc. Provide extra hands to help out as they get used to the system.”
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“Three words - support, support, support. Vendor knowledgeable and IS trained people must be available 24x7 to provide the support. The support can't be minimal either. There needs to be enough people to answer questions quickly. Also track the type of questions, as commonalities will surface, indicating areas of weak training etc. When these are identified, mass communication to the users through available channels should be used to communicate the deficiency and the remedy.”
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“Conduct a thorough and critical go/no-go evaluation pre live. Make 100% sure you're ready. Anticipate areas likely to experience bumps (access and printing come to mind). Require training prior to granting access and be prepared for last minute, during go-live training for straggler, folks back from vacation or leave, etc. as well as for undertrained topics or corrections required as issues arise. Set accurate expectations upfront (timing, sequence, likely problem areas, approaches for resolution, length of support, etc). Don't ‘sugar coat’ it. It's going to be hard. Also set appropriate expectations on when users can expect to hear back regarding open issues, etc. Where you have control of volumes, cut schedules to allow users to go through the learning curve, they'll get through it faster; If you don't, add extra staff to protect learning curve time for your clinicians. Over communicate (about the good, the bad, and the ugly) and be visible. Have project leadership as well as clinical, operational & executive leadership out and about. Stack the deck (don't go cheap here). It's better to be over resource and pull back than to find yourself. Close the loop with your users (end of shift tends to be a good time to sync). Don't lose your sense of humor. Don’t panic, and bring your towel!”
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“The most crucial nugget is listening. Be present, everywhere, and listen. Have easily identified resources the users can go to for questions. Take notes. Be available and do not take a hard line on any topic or request for change. A hard ‘no’ creates anxiety for the end user. Ask the end users their preferred communication mechanism for announcements and post fixes or changes. Deliver on simple, low hanging items. This encourages optimism and long term support for the teams and the solution/processes.”
• • •
“I actually think that go-live phase starts several weeks prior to the actual go-live. Core Team members needs to be selected for the development of the application. These members need to come from the department(s) utilizing the applications. A group of super users need to be identified and trained on the system. Both of these groups should be scheduled to cover all departments/shifts during the go-live week.
First critical step is a controlled parallel. Normally this should be five weeks before go-live. In this phase, you select a number of patients per day and run them through the existing system/process and then also through the new system. Control parallel should last five working days. Core Team members handle the controlled parallel. This helps to determine if there is functionality that was missed in the build. It also should be used to ensure that the new system is dropping the charges to the patient accounting system appropriately and that there are no billing issues .If there are billing issues, this gives you enough time to resolve them or delay go-live until resolved.
Next, three-four weeks prior to go-live is an end-user parallel. During this period, a number of patients are run through the new application/system on every shift. Purpose is to ensure that everyone has a chance to utilize the new application in the test environment. This helps discover access issues, functionality issues and also allows end users time to use the new system. It re-enforces the training they have had and gives them so “hands on” experience with the new system. It does create double work on the staff but it prevents many go-live day issues.
The day before go-live, a final check of all equipment needs to be done. If possible, a validation of user log-in should be completed.
At go-live, super users and core team members need to be scheduled to work with the staff. Positive attitudes from the core team members is essential! They need to be in the units as they go-live to address issues; help process flow; and maintain ‘calm’ with the staff. A command center needs to be established so that issues can be called and resolved ASAP. Food should be provided to the department/unit. Positive reinforcement from the senior staff on the system should be sent out, etc.
Go-live is more than day one. This process needs to continue for at least a week and then a higher level of support needs to be provided to the department for several weeks until there is a stabilization period.”
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“The crucial ingredient is extra support capacity by both the internal resources and any applicable third parties. Whatever is recommended for headcount support to be there, double it, even if this means people end up being under-utilized. Go-live is show-time and you want it to both look like and actually show that you’re prepared for any scenario. The assumption, of course, is that all the testing, training, and validation have proceeded accordingly to get you to this point.”
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“We blanketed the hospital with experienced EMR resources in order to achieve a smoother activation. For the first two weeks, we had two people on each patient care unit, 24x7. This was incredibly expensive but a big contributor to adoption and non-eventful activations. In addition, we had super-users on every unit that were supplied by various depts. such as nursing and allied health.
We had a very extensive training program, which included instructor-led training classes; self-paced classes with an instructor in the room; CD’s for home and office-based training; videos offered on our intranet; plus a sandbox or test system with scripts provided by us so they could actually train on a real system at any time. Despite the huge training effort, which included refresher training immediately before activation, many physicians did not attend, and many other caregivers did not retain the information. So the on-site activation resources were very critical to our success.”
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“Assuming you have designed planned and tested appropriately the key to go live week is three things: support, support and support. Throw in a little food, kill ‘em with kindness, be there when they need you, be visible, put in horrendous hours, and do the right things right the first time. Seriously, at go live it is all about support and encouragement. Sometimes you have to resell everything during this period.”
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“Heavy use of user champions as power users and plenty of support from IT and vendor.”
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“First of all, you have to plan well for go live week. That means six months before go-live, I generally have a dedicated system cutover analyst begin the work of interviewing all end-users to understand how their processes are going to change; to understand the interconnectedness of the current systems and how they will transition to the new system; and putting together a minute by minute cutover plan that describes each detailed step of the transition from old system to new. During cutover weekend, that plan becomes the script to follow and monitor.
Second, you need to prepare for the worst, even though you've planned for success. The go live weekend and following week needs to be staffed on the floors and in a call center specifically for the go live, 24x7, until it's not needed any more. That way, as problems occur, there is a group of dedicated people who will focus on the issue and resolve it. We have generally prepared for two weeks of post-live support, but have dismantled after one week due to the good pre-planning.”
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“For any implementation, we establish a real time Incident Command Center where users can call to report problems. Problems are routed electronically to the most appropriate staff member for resolution, and closure. Any ‘hands on’ resolutions are immediately sent to a super-user assigned to a specific area during implementation, to ensure that the issue is resolved. This ‘hands on’ process includes real-time user re-training.”
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“1. Train, train, then train some more.
2. Provide go-live support close to end users, since the reality is that very few focus during the training, opting to really start figuring things out only when they have to, which is go-live....so having go-live support in each dept, and in sufficient quantities to support the staff, is a must.
3. Communicate, communicate.....there is no such thing as too much communication, so keeping staff informed of the implementation process from selection, to design and build, through training, etc....helps make them feel they are part of the process.. layout the go-live plan for the first few weeks so users know what to expect, how to contact the help desk...
4. Design quick ‘wins’ into the implementation...typically EHR implementations are long, and done in phases over significant periods of time.....build achievable "wins" into each phase, and celebrate them along the way, so staff sees the results along the way, and understands their role in helping achieve them...particularly during the go-live period
5. Provide food to the staff during the go-live.....nothing helps cheer up people like some pizza and cookies!
6. Set up a centralized clearing house for problems and issues, with sufficient staff to respond quickly....providing staff with a sense that their problems, questions, and issues are being handled and resolved quickly.
7. Be prepared to offer overtime if needed....try to schedule the go-live during the least busiest day”
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“Over staff for longer than you think. Having knowledgeable staff walking the floors and at the ready to assist 24x7 for 3 weeks or so seems to work for us. Also, all of the clinical informatics people we have still work on the floor part time 0.2 or so, so that they can see what is and is not working and bring it right back to development.”
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“Sufficient training and LOTS of at-the-elbow support - fully trained super users on the clinical units.”
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“Two things are essential; training and testing. When training, train as close to go-live as you can get. When you are training a lot of nurses, those that training first are likely to forget what the learned. Train super users first and then involve them in the training. When training physicians, train them one on one in time blocks of 15-20 minutes.
A test plan needs to include unit testing, integrated testing and parallel testing. Involve as many end users in the testing as possible. Find and involve super users. Make them special and make it so anyone who thinks they have a knack for it wants to be one. If possible and after the formal parallel test, keep it going informally for a time, right up to go live. Be sure to track groups doing it, how well they are doing it, and publicize the results. Make it competitive and a positive way.
Have someone available 24x7 for the two weeks following go-live that is ready to assist the users. Someone who is really good, those we call super-duper users or core team members.
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