The Red Sneaker Problem - And how to fix it

Hi fellow Informaticists, chairpersons, and other budding healthcare leaders!

There's no question - Healthcare is currently under tremendous pressure to perform. Quality needs to go up, at the same time that costs go down - And fast. In my own humble opinion, it's currently undergoing change at a pace that's hasn't been seen since the inventions of penicillin and vaccinations. 

Informaticists know that information drives behaviors, and the information doesn't just start-and-stop inside the clinical arena. To really drive down the cost of healthcare, we need to work on efficiency at all levels of healthcare. 

So there is a quiet little information problem I sometimes see, that I thought I'd share in today's post, to help you spot it and fix it. I call it the "Red Sneaker" problem.

The Red Sneaker problem sometimes happens, quietly, when a well-intentioned committee, with a well-intentioned chairperson, makes a well-informed decision.

Typically, it starts with someone in an organization learning about some new regulation, or evidence of a way to make things better : "The evidence clearly shows that patients like Red Sneakers, and they heal faster when staff wear Red Sneakers - So if we all wear Red Sneakers, costs will go down, quality will go up, and patient satisfaction will improve."

After bringing the idea to a committee who asks for a few presentations and data on the potential benefits of Red Sneakers, the committee finally votes on the question : "Should all staff wear Red Sneakers?". After some deliberation, the committee votes, and the motion is adopted : All staff will wear Red Sneakers. The committee celebrates the victory, and the secretary documents the vote in the committee minutes. People leave the committee meeting, and through emails and word-of-mouth, other people learn that the committee has voted to approve Red Sneakers for all staff.

The quiet problem that sometimes arises is that the committee was not well-positioned for success. The chairperson is new, and might not understand the parliament or committee position in the governance of the organization. The members may not be clear about the mission of the committee. The committee was not made aware of its responsibilities, authorities, or jurisdiction. And so, the vote was overwhelmingly in favor of all staff wearing Red Sneakers, but...

1. No policy was updated to reflect the new organizational standard of all staff needing to wear Red Sneakers.
2. No budgets were updated to pay for the ongoing use of Red Sneakers.
3. No local suppliers were contacted to establish the availability of Red Sneakers.
4. No employment contracts were updated to require the wearing of Red Sneakers.
5. No staff education was created for staff to understand the new standard and importance of wearing Red Sneakers.
6. No onboarding materials were updated to teach new staff about the importance of wearing Red Sneakers.
7. No workflows were designed to check for Red Sneakers before staff enter the organization
8. No backup procedures were created for staff who arrive without Red Sneakers.

Without any of this background work, the committee still announces the result of their vote, and record it in the committee minutes. Initially, things look good. With enough cheerleading and word-of-mouth publicity, they start to see some adoption of Red Sneakers: 

But without planning for these other reinforcements, Red sneakers were not well-budgeted for. Eventually new staff will come into the organization who don't know about this committee vote, and missed the publicity about Red Sneakers. The few staff still looking for Red Sneakers might not be able to find them in local stores, and there are no backup procedures for staff who forget them. And with no way to support or enforce the use of Red Sneakers, after a few months, the adoption of Red Sneakers starts to dwindle...

And so the entire discussion of the committee and the vote to adopt the new measure have not been effectively implemented. Six months later, committee members notice almost nobody wears Red Sneakers, gradually get a sense that the committee is powerless, and stop showing up to meetings. Especially in healthcare, this can be an expensive way to generate frustration and apathy.

Fortunately, it's fairly easy to prevent the Red Sneaker problem. The first step is to look out for it. If you think your committee(s) might have the Red Sneaker problem, consider some of the following : 

1. Make sure you don't have more committees than you need by ensuring that every committee has completed a yearly charter, and that all committee charters are filed in a central location in your organization, so you can look for ways to avoid overlaps and streamline your committee structure. (If you need a committee charter template to start, you can click here to read my old blog post on committee charters.)
2. Make sure your committee chairpersons have adequate training and orientation before chairing a committee, including some training about parliament, project management, and the quiet-but-problematic red sneaker problem.
3. Solidify your cost estimates before adopting a new measure, by making sure that committee chairs ask for detailed project plans and cost estimates before bringing a measure to a vote. These project plans should address the various tools and strategies you will use to introduce and reinforce the new workflow.
4. Consider having a clinical informaticist, workflow expert, or other process expert to consult or help draft the project change plan and cost estimates before adopting the new measure.

I hope this post is helpful to you in developing your own informatics skills, and supporting excellence in your healthcare organization!

Have any thoughts about workflow adoption issues or clinical governance? Want to share your own stories? Leave your comments in the comments section below!

Rethinking the Committee Charter

Modern healthcare needs people to work on it. Like a garden, it needs pruning, trimming, weeding, planting, and a lot of care to keep it alive and vibrant. You will probably need committees to help you do this.

Committees are the workhorses of an organization - They help you get things done, hopefully, by coordinating the actions of different parts of your organization, and so they are useful in coordinated change management. From Google :
According to Wikipedia, committees are :

• "a necessary aspect of organizations of any significant size" and are
• "a way to formally draw together people of relevant expertise from different parts of an organization who otherwise would not have a good way to share information and coordinate actions" and
• "can also be empaneled with experts".

The exact parliamentary practices here seems to vary broadly, from Robert's Rules of Order to other blogs and books on parliament, but committees typically come in one of three flavors :

• Executive Committee - A committee with well-defined executive powers usually spelled out in a charter or organizational by-laws
• Standing/Permanent Committee - A subunit of a political or deliberative body established in a permanent fashion to aid the parent assembly in accomplishing its duties.
• Working/Ad Hoc Committee - A group established to accomplish a particular task or to oversee an ongoing area

By the way, for more about committees, see :

• This 1915 full, public domain version of Robert's Rules
• This Dummies.com Robert's Rules cheat sheet

Anyway, committees also have their challenges. The problem with committees, generally, is that operationally :

• You need them to carry out a significant amount of work for your organization, but
• ...they have to be staffed with several highly-trained people, and so ...
• ... if they're not run efficiently, they can be a drain on resources.

So ideally, you want a committee to be well-run, efficent, and productive. 

How to get a committee to be well-run, efficient, and productive?

I find one of the most challenging things when creating a committee is defining the committee to achieve clarity. So I looked at some of the most common questions I hear about committees : 

• Why does it exist?
• Who created it? When?
• Who's going to run it?
• Who's going to participate in it?
• What powers/authority does the committee have?
• How often will they meet?
• Who will it report to? Who will oversee it?
• How will it vote? Who will vote?
• What's the quorum?

And so to help achieve clarity on these issues, I rethought the "Committee Charter", and drafted the following sample one-page template :

This DRAFTED charter template, in one page, then facilitates operational clarity by encouraging both committee members and the overseeing body to define their terms, and agree to :

• Committee mission (Why is the committee needed?)
• Committee responsibilities (What is the expectation for this committee?)
• Committee chairperson(s) (Who will run this committee, set the agendas, conduct meetings, ensure minutes are kept and approved, and report the activities/actions of the committee?)
• Committee membership (both voting and non-voting members - Who can vote? Who can't?)
• Meeting frequency (How often will this committee meet?)
• Delegated authorities (e.g. "to send emails on behalf of another person/committee"?)
• Voting Type (How will the members approve motions?)
• Quorum (What's the minimum number of people that need to be in a room for an official meet?)
• Charter Review (How often will this charter be re-examined? When will it be reapproved?)
• Measures of success (How will we know if the committee is effective?)
• Oversight body (Who will this committee report to?)

It's pretty short-and-sweet, but in one page I think it gets the job done quite well. As always, if my writing inspires you, remember to tailor it to your needs. Let me know if you have any other charter templates you like, and why you use them!

Remember, this is all just academic discussion, and your mileage may vary! Check with your local regulatory bodies before developing governance tools in your area. Feel free to send thoughts, comments, or questions - I always enjoy getting feedback from other people looking to improve healthcare!

CMIO Survival Skills

While a CMIO is there to help implement the technology, so much of the job is process, workflow, and governance. So since I've now been in the role for five years now, I thought I'd take a moment to look back and reflect on the things I've learned in the last five years that I think are valuable CMIO skills.
Here are the 13 most important skills I can think of, off the top of my head, in my usual tongue-in-cheek style : (Remember, as always - Your mileage may vary, depending on your circumstances.)

1. Hospital Governance 101 -  It's not enough to just know the clinical side of governance. You need to know the administrative side too. Both of these wings of hospital governance intersect with each other in different places, and knowing where they meet with your bylaws is vitally important. You will be navigating both, so it pays to know the landscape. Bonus points are awarded if you can diagram your committee structure by heart. :)
2. Document Management - Understanding the basics of how documents are created, drafted, approved, and published is essential. Bonus points are awarded for knowing the details of these steps well - For starters, I wrote a post on the importance of knowing the difference between DEV, TEST, and PROD - These environments typically exist for computer projects, but in reality they apply to all construction and document development (even that email you just sent!). Know them well, why they exist, and how to use them to your advantage in your organization.
3. Definitions and structure of your Clinical Tools - You should know your clinical tools like the back of your hand - Exactly how your organization defines them, drafts and builds them, tests and reviews and vets them, approves them, and publishes them. You should be able to look at them and have opinions on whether they are as effective as they can be. For starters, the CMIO's checklist is a good place to start working on this. Bonus points are awarded if you can recite your organization's definitions off the top of your head. :)
4. Compliance with State and Federal Regulations - You will need to know these well, and will probably be asked to help your organization comply with some of them. Even if you don't know them very well, you need to have a good relationship with your regulatory people, and know where to look when you have questions. Bonus points are awarded as you gradually learn this landscape better.
5. Project Management and managing 'the technical details' - You will need to know the basics of this - Whether or not you have a separate project manager to work with, you will be involved in many projects. Knowing what to expect at different stages when undertaking large month- and year-long projects is very helpful. As for the technical details, you may not want to know how sausage is made, but if you (or your organization) wants to eat sausage (pardon the metaphor), then someone will have to worry about the technical details. If it's not you, then make sure you have a good relationship with the people who understand the details, and work with them closely when undertaking new projects. 
6. Parliamentary Basics - You will probably be asked to chair a committee or two, and be a member of others. Knowing how to properly run a meeting and conduct a committee is crucial. For starters, Robert's Rules of Order is a fantastic place to start. Also make sure you have a formal, written charter - It not only establishes your authority, it establishes the chain-of-command and is essential for good performance and when questions come up. And a tip : Always publish your minutes after approving them at the next meeting. If you wait to format and approve your minutes, they will just build up and you'll have to play catch-up later.
7. Meaningful Use, emerging Health IT Trends, and Workflow Analysis - It's almost impossible to keep on top of every detail, but you should have a good understanding of the Meaningful Use rules, timelines, and how your organization is responding to them. You should also understand the basics and be able to comment on various existing and emerging HealthIT, clinical, and legal trends, including your statewide HIE effort, NHIN, ICD-10, clinical decision support, mobile devices, HIPAA, eDiscovery, etc. Finally, you should understand the basics of workflow analysis and why it's necessary to implement all of this technology. A good way to learn to think in a linear fashion is to read food recipes - This will help you think about the relationship between process and outcomes, and help teach you to write a good procedure.
8. Safety through Information - Safety is not just resident workforce hours and barcoding your medications. Safety needs to be built into all of the documents and information you're overseeing. First, know what a good order set and a good protocol look like - Then learn what good documentation, good policies, good procedures, good guidelines, and good workflows look like. This is one of the big reasons organizations look for a CMIO, so always look for opportunities to improve safety with every tool you see.
9. Networking - Virtually every hospital is going through Meaningful Use together. You will help save yourself a lot of headache if you know the other CMIOs in your area. Use social networking (e.g. Twitter), or call them up, introduce yourself, and meet them just to talk shop every once in a while. The Interstate 91 Informatics group I've set up has been invaluable to me and others in helping to share lessons and best practices. Look to see if there's any regular gatherings in your area, and try to get to at least one of the national conferences every year (e.g. HIMSS).
10. Teambuilding, cheerleading, politics - You will undoubtedly meet other doctors, nurses, pharmacists, and other ancillary staff, and need to meet with them. Often, EMRs demand more collaboration between clinical specialties, so you will have to know how to encourage people to work together. Don't try to play sides or favorites - Treat everyone equally and you'll be able to build those teams.
11. Budgeting realities - Implementing an EMR is expensive. There are costs at every step of the way - Technical costs, training costs, costs to change workflows, staffing costs. "Flexible budgeting" is optimal, but in today's climate, most organizations are focused on cutting costs. Be prepared to work with your budgeting people, and always ask yourself, "What if we don't get everything we ask for?"
12. Informatics Education - Whether you're the "Chief Medical Information Officer" or the "Chief Medical Informatics Officer", you will be discussing Informatics with many people, probably while you are defining this emerging role in your organization. The term is sometimes frightening to people, until they start to understand it. Don't try to teach too much at once - Small, frequent feedings are better, so try to meet with leadership for frequent, short meetings. Bonus points are awarded if you help set up an entire Informatics department.
13. Statistics and Process Improvement - After your EMR go-live, you will probably be asked to help optimize the EMR - That means, looking at the results from go-live, and looking for ways to improve results, e.g. higher achievement of core measures, higher CPOE rate, etc. Learn how to get utilization data out of your EMR, and look for statistical relationships that help you improve your processes. Know what a Venn diagram, control chart, pareto diagram, and fishbone diagram are. Bonus points are awarded if you can write your own SQL code! :)

It has been enormously rewarding to me, and if you find yourself in the role, I hope it's equally rewarding to you. Although the first CMIOs appeared on the scene back in the 1990s, it's still a relatively new position (especially in the northeast), so be prepared for a lot of change and ambiguity when you start down the road. 

As always, I enjoy simultaneous teaching and learning - Feel free to leave questions, comments, or thoughts below!