Post Go Live Issue ManagementPost Go Live Issue Management

New Build, Maintenance, Enhancements etc.New Build, Maintenance, Enhancements etc.

Evanston Northwestern HealthcareEvanston Northwestern HealthcareWho we are . . .Who we are . . .

Evanston Hospital 420 beds Glenbrook Hospital 126 beds

Highland Park Hospital 240 beds 65+ Medical Group offices

ENH StatisticsENH Statistics

• Admissions (Including Births)Admissions (Including Births) → →

• Patient DaysPatient Days → →

• DeliveriesDeliveries →→

• Outpatient Visits (Excluding ER) Outpatient Visits (Excluding ER) → →

• Total ER VisitsTotal ER Visits → →

• Employees Employees → →

• Physicians (Professional Staff) Physicians (Professional Staff) → →

– ENH Medical Group ENH Medical Group → →

– House StaffHouse Staff → →

42,00042,000

195,000195,000

5,7005,700

454,000454,000

88,50088,500

7,5007,500

1,7001,700

500500

150150

Our FocusOur Focus

• EpicCare Inpatient & HOVEpicCare Inpatient & HOV• Medical Informatics & it’s role in work and issue Medical Informatics & it’s role in work and issue

managementmanagement• Work and issue management in an integrated Work and issue management in an integrated

productproduct• Evolution of the current processEvolution of the current process

– IssuesIssues– Request For ServiceRequest For Service– ProjectsProjects

PatientPatientDataData

PatientPatientDataData

HOVHOV

ENH’s Portfolio of EPIC ENH’s Portfolio of EPIC ProductsProducts

ICUICU

OncologyOncology

ADT

HIM

Hospital Billing

ADT

HIM

Hospital Billing

Evolution of Epicare IP and HOV at ENH

• Implementation Implementation – First Hospital Clin. Doc First Hospital Clin. Doc 03/200303/2003– First Hospital CPOEFirst Hospital CPOE 05/200305/2003– Second hospital Clin. DocSecond hospital Clin. Doc 06/200306/2003– Second hospital CPOESecond hospital CPOE 11/200311/2003– Third Hospital Clin. DocThird Hospital Clin. Doc 12/200312/2003– Third Hospital CPOEThird Hospital CPOE 04/200404/2004– ICUICU 06/200506/2005– BeaconBeacon 08/200608/2006– StorkStork 03/200803/2008

• UpgradesUpgrades– MU3, MU4, MU5, MU6, Fall 04, Spring 05, Fall 05, MU3, MU4, MU5, MU6, Fall 04, Spring 05, Fall 05,

Spring 06, Spring 07… Spring 08,ADT,HIM,and Spring 06, Spring 07… Spring 08,ADT,HIM,and Hospital BillingHospital Billing

Evolution of Medical Informatics Evolution of Medical Informatics • 2001 -2001 - Operations Sr. VP led an IP application groupOperations Sr. VP led an IP application group

• 2002 -2002 - Formalization of a Medical Informatics Formalization of a Medical Informatics DepartmentDepartment– Lead by Sr.VP of Medical Informatics – Reporting to the Lead by Sr.VP of Medical Informatics – Reporting to the

COOCOO– 4 Sr. Directors (IP, HOV, Ambulatory and Business)4 Sr. Directors (IP, HOV, Ambulatory and Business)– Facilitated all meetings between IS and OperationsFacilitated all meetings between IS and Operations

• 2007 - Medical Informatics moved under operations2007 - Medical Informatics moved under operations– Maintain Sr. Director Structure (IP, HOV, and Ambulatory)Maintain Sr. Director Structure (IP, HOV, and Ambulatory)– Added Project Manager positionsAdded Project Manager positions– Added a Director – Systems Integration and DevelopmentAdded a Director – Systems Integration and Development

Collecting the Work!Collecting the Work!

• Prior to Go Live: Fit testing Database-one Prior to Go Live: Fit testing Database-one avenue for reporting issues avenue for reporting issues

• During Go Live: Avenues for reporting During Go Live: Avenues for reporting issues expanded and excel spreadsheets issues expanded and excel spreadsheets proliferatedproliferated

• Post Implementation: Issue management Post Implementation: Issue management was fragmented and decentralizedwas fragmented and decentralized

• Maintenance: Added Help Desk and “Epic Maintenance: Added Help Desk and “Epic Help” buttonHelp” button

Epic “Help Button”Epic “Help Button”

Controlling the Wild Beast!Controlling the Wild Beast!

• Fit testing exported into Excel Issues List - all Fit testing exported into Excel Issues List - all teams add their spread sheets to the Issue List.teams add their spread sheets to the Issue List.

• Spreadsheets proliferated again as a place to Spreadsheets proliferated again as a place to enter and track end-user requests enter and track end-user requests

• Pivotal event: Pivotal event: – Change management process was needed. Change management process was needed. – Calendar was created where all changes to production Calendar was created where all changes to production

needed to be scheduled needed to be scheduled – Weekly call to review changes for impact on other Weekly call to review changes for impact on other

applications.applications.

• Still not enough!Still not enough!

Birth of the RFSBirth of the RFS

• Requests needed to be centralizedRequests needed to be centralized

• Implemented the use of an existing Implemented the use of an existing Request For Service (RFS) system Request For Service (RFS) system – Direct entry by end usersDirect entry by end users– Entry by MI & ISEntry by MI & IS

We feel we are in control - JustWe feel we are in control - Just

• ENH Spreadsheet issues list ENH Spreadsheet issues list – Managed by IS TeamManaged by IS Team– Weekly call with EpicWeekly call with Epic

• RFS database RFS database – User requests – Enhancements, New build, User requests – Enhancements, New build,

MaintenanceMaintenance– Strange little collection of issuesStrange little collection of issues– ProjectsProjects

It is Not the Perfect Solution!It is Not the Perfect Solution!

• RFS perceived as “Black Void”RFS perceived as “Black Void”

• Within Medical Informatics User request process differedWithin Medical Informatics User request process differed– Inpatient requests came from multiple users, groups and Inpatient requests came from multiple users, groups and

administrationadministration

– HOV came from Managers and AdministratorsHOV came from Managers and Administrators

• Design issues hindered RFS managementDesign issues hindered RFS management– Inpatient team Database created Inpatient team Database created – HOV Ring binder!HOV Ring binder!– Double data entryDouble data entry

• Weekly RFS callsWeekly RFS calls

Mutiny!Mutiny!

• Classified everything in the RFS systemClassified everything in the RFS system– Defined what went on the Issues List Defined what went on the Issues List – Defined what would stay in the RFSDefined what would stay in the RFS

> Required Required > DiscretionaryDiscretionary

– Created a third category – ProjectsCreated a third category – Projects

• Made changes to the RFS SystemMade changes to the RFS System

• Mapped out ideal RFS workflow Mapped out ideal RFS workflow

RFS Process WorkflowRFS Process Workflow

End user wants tosubmit an RFS

IScommunicatesback to USER

RFS notsubmitted or

Cancelled or NotApproved

RFS submittedRequest received

IS ApprovedProject prioritized

User ApprovedSent on toInformation

Systems

Dept Mgrapproval?

Userapproved?

IS approved?

RFS re-worked?

Does IS haveenough info?

User communicatesback to end userand/or managerPlaceholder or

AwaitingInformation

Y Y Y

NNN

Y

N

IS begins work onthe RFS

In progressIS builds

IS communicatesback to User or

end user asapplicable

IS tests

IS coordinates testtime

Does IS needUser or end

user?

Is testingsuccessful?

Testing conducted

RFS ready forsign off by

User and/orend user

Y

N

N

Y

YAwaiting informationuntil more

info provided

Notification sent toEnd user that

request has beenapproved

Build and Testcompleted

Awaiting sign off

Shown to Useror end user?

IS coordinatesdemo for User or

end user

Approved?

User/end userworks with IS to

rebuild and/or test

N

Y

N

RFS ready for signoff

IS forwardsappropriate

documentation forsign off

YUser and end user

signs offSigned off

Is trainingneeded?

RFS Completed

Y

Green boxes indicate actions that take place outside of the electronic RFS process

SUBMIT

&

APPROVE

BUILD

&

TEST

SIGN

OFF

EPIC REQUEST FOR SERVICE (RFS)

N

RFS moved toProduction

TrainingDepartmentcontacted

Y

N

ProjectsProjects

• Lived on a spreadsheetLived on a spreadsheet

• Worked on ad HocWorked on ad Hoc– Operational demandOperational demand– Analyst availabilityAnalyst availability– Available functionalityAvailable functionality– No dates or timelinesNo dates or timelines

• Things not getting done but perception of Things not getting done but perception of constant changeconstant change

• No operations ownership of projectsNo operations ownership of projects

The Projects Project PlanThe Projects Project Plan

More Projects Project PlanMore Projects Project Plan

So……….So……….

• We have:We have:– The Issues ListThe Issues List– RFS SystemRFS System– The Project PlanThe Project Plan

• Now we need:Now we need:– Operational ownershipOperational ownership– CommunicationCommunication– PrioritizationPrioritization

OwnershipOwnership

• ENH Issues List SpreadsheetENH Issues List Spreadsheet– Managed by an IS team memberManaged by an IS team member

• RFS SystemRFS System– MI review new requests and classify themMI review new requests and classify them

• Project PlanProject Plan– Steering CommitteeSteering Committee

CommunicationCommunication

• ENH Issues List SpreadsheetENH Issues List Spreadsheet– MI/IS biweekly call with EpicMI/IS biweekly call with Epic

• RFS SystemRFS System– Monthly RFS Reports for discretionary requestsMonthly RFS Reports for discretionary requests

• Project PlanProject Plan– Monthly Score CardMonthly Score Card

PrioritizationPrioritization• ENH Issues List SpreadsheetENH Issues List Spreadsheet

– IS & MIIS & MI

• RFS SystemRFS System– Essential to business moved into IS work queueEssential to business moved into IS work queue

> Patient SafetyPatient Safety> Impacts BusinessImpacts Business> RegulatoryRegulatory

– Enhancements assigned to operations VP for Enhancements assigned to operations VP for prioritizationprioritization

• Project PlanProject Plan– MI & IS review, estimate work hours, and scheduleMI & IS review, estimate work hours, and schedule– Steering CommitteeSteering Committee

Current StateCurrent State

• Shifting Project PlanShifting Project Plan– To meet Regulatory RequirementsTo meet Regulatory Requirements– Unanticipated changes in ProjectsUnanticipated changes in Projects

• Refinement of RFS WorkflowRefinement of RFS Workflow– Rules of Engagement for the RFSRules of Engagement for the RFS– Reclassification of RequiredReclassification of Required

RFS Rules of EngagementRFS Rules of Engagement

• Types of RFSTypes of RFS– Required - SRequired - Services that have an immediate ervices that have an immediate

impact on patient safety, revenue or impact on patient safety, revenue or operations. operations.

– Discretionary - EDiscretionary - Enhancements that improve nhancements that improve or increase efficiency.or increase efficiency.

• The The Modification Type - Modification Type - Assigned by Assigned by Medical Informatics, in collaboration with Medical Informatics, in collaboration with Information Systems and/or the Requestor, Information Systems and/or the Requestor, as necessary.as necessary.

Rules of EngagementRules of Engagement1.1. Until the Until the Modification TypeModification Type is defined, the request should remain is defined, the request should remain

in the status of in the status of Request ReceivedRequest Received

2.2. Status changed from Status changed from Request ReceivedRequest Received to to Approved Approved by MI only by MI only after approval and prioritization from the designated VP or higher after approval and prioritization from the designated VP or higher level administrator.level administrator.

3.3. IS and MI will collaborate on the order in which the prioritized IS and MI will collaborate on the order in which the prioritized Discretionary RFS are to be completed (Ex. If there are 10 #1 Discretionary RFS are to be completed (Ex. If there are 10 #1 priorities, the MI Sr. Director will determine order).priorities, the MI Sr. Director will determine order).

4.4. Information Systems will assign Information Systems will assign Approved Approved RFS to application RFS to application coordinatorscoordinators

5.5. Information Systems is responsible for marking an RFS as Information Systems is responsible for marking an RFS as CompleteComplete in the system. in the system.

6.6. Monthly production report runs (i.e. reminder or tickler systems) Monthly production report runs (i.e. reminder or tickler systems) should be tracked outside of the RFS system. should be tracked outside of the RFS system.

Rules of EngagementRules of Engagement• An RFS must be created for:An RFS must be created for:

– Help Desk calls that require more then 30 minutes to complete. This Help Desk calls that require more then 30 minutes to complete. This includes total resolution effort; analysis, build, test, and implementation. includes total resolution effort; analysis, build, test, and implementation. etc.)etc.)

– For every Request for Change (RFC); including code changes.For every Request for Change (RFC); including code changes.

• Multiple RFS must be created for regularly scheduled maintenance, Multiple RFS must be created for regularly scheduled maintenance, according to the schedule (ex. 1 RFS per month for monthly according to the schedule (ex. 1 RFS per month for monthly maintenance, 1 RFS per quarter for quarterly maintenance, etc).maintenance, 1 RFS per quarter for quarterly maintenance, etc).

• All RFS must have a defined scope.All RFS must have a defined scope.

• Each application team must open its own RFS for integrated projects.Each application team must open its own RFS for integrated projects.

• All parties are responsible for keeping the RFS system accurate and All parties are responsible for keeping the RFS system accurate and current.current.

• Any change to the RFS process must be approved by the RFS Any change to the RFS process must be approved by the RFS Committee, chaired by Medical Informatics and Information Systems.Committee, chaired by Medical Informatics and Information Systems.

There are still……….There are still……….

Clandestine Spread SheetsClandestine Spread Sheets

• Things are more organizedThings are more organized• Less gets lostLess gets lost

But……… But……… All cynicism aside All cynicism aside

Unrecorded requestsUnrecorded requestsThings that get done becauseThings that get done because

of who you are or knowof who you are or know

In SummaryIn Summary

• Long JourneyLong Journey

• Classified Requests/IssuesClassified Requests/Issues

• Formalized the processes Formalized the processes

• Returned ownership of change back to Returned ownership of change back to OperationsOperations

• Improved CommunicationImproved Communication

Contact InformationContact Information

• Kate Reynolds, RNKate Reynolds, RNKReynolds@enh.orgKReynolds@enh.org

• Janet Ryan, BS, RNJanet Ryan, BS, RNJRyan@enh.orgJRyan@enh.org