Welcome back. In the last lecture, we planned our solution to the clinical problem that we had observed as our case study. In this lecture, we'll actually implement the solution. This will be the do part in our plan, do, study, act, or the PDSA cycle. Specifically, we will talk about whether we should choose a phased roll out with a pilot versus a big bang rollout, and we'll discuss more about these terms. Then we'll choose an appropriate site for a pilot for maximum impact, then we'll talk about the changes in the information system that we're required to support our redesigned workflow. What is a big bang rollout? The big bang rollout approach involves a rapid rollout of multiple users on new functions and features all at once. Now imagine you were moving from a paper-based system to a system where the provider has to enter the orders electronically on a computer. Let's say that the same providers or most of those providers that are there in your inpatient hospital also go to clinic A, clinic B, in the emergency room back to the inpatient hospitals. Because it's a hospital system, the patients also travel between these settings. Now in this case, would it be possible for you to have a electronic system at one part of the hospital, but have a paper-based order entry in another part of the hospital? Probably not. It will be too disruptive. So, when changing one part of the system becomes too disruptive to other parts of the system, you're forced to go with a big bang roll out. In contrast to this, let's look out what a phased roll out with a pilot means. A pilot provides an opportunity to implement a new process on a small-scale; see how it's doing, receive input, that helps us to identify any weaknesses in the process that can be addressed before you scale it up and implement it facility-wide. Let me ask you a question. If you go back to our case study to solve our problem, what would you prefer? A big bang or a phased rollout with a pilot? Now to recap, our workflow change was implemented in order to decrease the number of missed therapy treatments. Before you answer this question let me give you another fact. I will also tell you that the workflow changes that we are implementing in order to decrease the missed therapy visits involves mostly therapists, not nursing stuff, not other members of the hospital. These therapies are assigned to particular units at a time, four months. What do you think? Well, the answer is you'll probably go with a phased roll out. To answer why? Because the fact that these therapists are mostly located in one unit, changing the workflow in that particular unit will not disrupt the workflows in other units of the hospital. So you can start a small pilot, see if your workflow is working, and then scale it up to the entire hospital or the system, and that is the approach we took. Well, once you have figured out that you will do a pilot, the next question becomes where to pilot? Again, coming back to our example, this is what was happening in our medicine unit versus our neurology unit. In the medicine unit, we were missing a lot of therapy visits. Approximately 31 percent were missed therapy sessions delivered versus recommended, so there was a lot of opportunity for improvement here. In the neuro unit, yes, 10 percent of the visits were being missed, but the opportunity of improvement was much less as compared to the medicine unit. So if you had to pilot, where would you pilot? Well, there is something called the picture which helps you make this decision. If you look at the chart, and you weigh how easy it is to implement versus what is the payoff. The idea is typically to choose a side where the payoff would be high if your pilot is successful while it's still relatively easy to carry on the pilot. Now, if I tell you that it is as easy or as difficult to implement the pilot in the medicine unit as in the neuro unit, but if your pilot is successful there will be a larger impact because the opportunity is much greater in the medicine unit, where would you pilot? Well, the answer obviously, yes, you will pilot in the medicine unit. Great. Finally, let's put on our informatics hat again and see what are the changes in the information system that are required to support this redesigned workflow. If you remember, we said that instead of having a sequential workflow, we'll have a parallel information flow that would allow the therapy coordinators to know almost in near real-time which patients are missing therapy so that they can take a corrective action. Now as you can imagine, the changes in the information flow that you would need to implement for your redesign of the workflow will depend on what workflow you're trying to redesign. But again, are there guiding principles? Well, let's look at them. Do you recognize these principles? In the earlier section, you might have been introduced to the five rights while you are implementing the clinical decision support systems. While redesigning workflows in healthcare or redesigning information systems to support your workflow redesign, you can take help or guidance from the same five principles. That is, you need the right information delivered to the right person in the right format so as to answer a specific clinical question through the right channel in the right time in the workflow to support your workflow redesign goals. Again, let's go back to our example and see how did we measure up, and hopefully, by doing that it'll become more clear. So this was our workflow. 9:30 AM everyday morning, we used to extract the functional status score from the electronic medical record displayed in front of a group of clinicians, and they used to determine which of these patients are functionally impaired but are missing therapy and therefore they require therapy. After this determination they used to use the hospital secure paging system to deliver the information to the bedside therapist saying that Mr. Jones is likely to miss therapy today, please go and see him before the end of the day because he is functionally impaired and he really needs therapy. So that was the workflow. How are we measuring up to the five rights? Were we extracting the right information? I would say yes because we know that functionally impaired patients need therapy. The data that we were extracting was the functional status and we were basing our decision on these functional status. So it was probably the right information. Was it being delivered in the right format? Again, I would say yes, because after being vetted by a group of clinicians, a very specific actionable information was being provided to the bedside therapist. That is, this patient is likely to miss therapy, he's functionally impaired, please go and see this patient. Was it being delivered via the right channel? Probably yes. We were taking help from the secure messaging system that was provided by the hospital and we were delivering this information to the hand-held devices carried by the therapists while they were seeing patients on the floor. Was it been delivered to the right person? Again, yes, because it was being delivered to the therapists who are in a position to go and see the patients. Was it being delivered at the right time at the right point in the workflow? Again, I would say yes, we were delivering the information that this patient is likely to be missed, please go and say this patient in the morning at around 10 O'clock. So the therapists could effectively go and see these patients before the end of the day so that these patients do not miss therapy during that day. That is how in our particular workflow we were satisfying the five rights. Let's recap. What did we learn? We learned that there are two types of approaches while we're doing a workflow redesign. One is the big bang and one is a phased roll out with a pilot. When you think that changing the workflow in one part of the system will be very disruptive to the other parts of the system, you'll probably choose the big bang. The advantage of choosing the phased roll out with a pilot that you can probably learn from your mistakes, iterate and improve and then scale up. Next, we learned that we should choose a site to pilot where you have the maximum impact with least amount of resistance to change. Finally, we saw the five rights describe typically for our clinical decision support and said that this can be used as a guidance while we're designing our information systems for best practice. See you in the next lecture.
