My hospital recently implemented a radiology transcription system that is tied to our electronic health-record system. Additionally, another hospital that uses the same radiology group implemented that system as well, interfacing it to the hospital's EHR system. The go-live was simultaneous at both hospitals, per the radiologists' strong request; all six radiologists were trained together, and voice profiles were initiated for all six for use at any location, including their homes.
Things went swimmingly well through most of the process. The HL7 interfaces all worked. Integration between the systems went fairly well, although not without some heartburn. At my facility, the transcriptionist training went very well and the go-live did as well, and things appeared to be just fine. Within three weeks of going live, we were hitting in excess of 80% completed reports with no transcriptionist intervention within 15 minutes of the completion of the radiological study. We were ecstatic. But that was not the end of the transition by any stretch of the imagination.
First, the nursing department reported that the new transcribed reports did not look the same as they were used to. Then, healthcare information management and coding employees reported that the path to the report that they needed to code the account did not work (this was also true of the traditional method they were used to, but not the alternative method that had always been present). Certain clinics that were used to getting faxes or remote printed reports reported that the transcribed radiology reports were not coming (which was not exactly correct—they were being faxed, but they had a different header and therefore looked different).
So this was the conundrum—on the one hand, we had a group of radiologists who were doing great with a new system; we were delivering a service level never thought attainable, and patient safety was enhanced significantly by providing completed reports faster than ever. But some constituencies had not been included in the process, and hence the ugly change monster raised its head.
I have been at this game for nearly 40 years. I know better than to have missed this one. In my defense, not once in the process did the difference in appearance of the report ever come up. That was discovered in final interface testing, when the reports arrived in the EHR system. The issue was caused by differing supported formats—over the years, we had tweaked our report format to be unique to our environment, unbeknownst to those of us on this project.
So what did I miss here? Why was this change, seemingly so simple, going so well on the difficult parts (actually making it work, and training the radiologists and transcriptionists), and yet create so much heartburn in other areas?
The answer is simple. As Lynn Vogel (CIO at the University of Texas MD Anderson Cancer Center) has said, "Everyone gets to play." Or put another way, we failed to communicate all the way downstream.
Lessons often have to be learned repeatedly. Such was the case here. We are a small organization, a critical-access hospital, with a medical staff (mostly independent practitioners) of fewer than 30, and about 500 employees on campus. Seems like it should have been simple enough to have at least gotten the word out, but we did not.
Our project is fully functional today, and the vast majority of the pain is now behind us, but this all leads to the answer for the question that is the title of this column: Why is managing change so darned hard and yet so critically important? The answer to that question is that without great change management processes and techniques, even the greatest benefits or projects can come up short without thorough, comprehensive communications, which is a huge part of the change management process.
For us, it was simple. We had followed sound project methodology here, yet missed a critical component: identifying and informing all impacted constituencies. Had we done that very simple thing, we could have enjoyed a smoother implementation and go-live.
It is not always possible to be aware of every eventuality that may arise when a project commences, and sometimes you have to proceed on less-than-perfect information. However, projects almost always mean change for someone, so change management processes need to be employed. No matter how well we do them, it will be difficult for some folks to accept change, but expending the effort upfront is always worth the time.
While we could not have foreseen all of the eventualities of the changes that this new system would bring to our organization, we could have determined who the users of the end product were. A simple step would have been to tell them change was coming, that we were not completely sure of all of the exact specific details of these changes, but that the project team would do everything possible to minimize the magnitude of the pending changes and would try to mitigate any impact. That simple notification would have lessened the surprise when changes appeared. We were eventually successful at the mitigation piece. Nearly all of the impacts were either eliminated or solved to the point that the change was accepted by the vast majority.
So, at the end of the day, what did the team and I learn? Answer: There is no substitute for communication, and there is no such thing as too much communication. Even when you do not have all the answers to every possible question, managing change proactively means communicating about the pending change, soliciting input, processing the input and crafting solutions to minimize the impact.
Most people respond more positively with knowledge than without. Build your project plans. Delve into the details. Lay out timelines and action plans, but don’t forget to manage the change process. Even if that management is simply communication that change is coming, and framing the expectations thereof, it is a step that can be the lynchpin to success.
Project and change management is a discipline and profession that is much more complex than I can fully address here. However, there's a lot of value in focusing on the basics and exchanging thoughts on how to avoid basic mistakes.
Yes, at times it is difficult to see the forest for the trees. My cumulative experience, reinforced by this recent event, has taught me repeatedly that it is always worth the effort. Managing change is hard, no matter the size of organization—in fact, it’s probably harder the larger the entity becomes, but its importance cannot be overestimated.
Stephen Stewart
Chief information officer
Henry County Health Center
Mount Pleasant, Iowa
