1. Planning for Sustainable Change
Start Early and Think Beyond ‘Go-Live’

2. Panel outline Making a Case for Change Making Early Plans
Cassie Frazer, Canada Health Infoway
Making Early Plans
Ian Hodder, Centre for Health Information, Newfoundland & Labrador
Making Change Stick
Knut Rodne, OntarioMD

3. Making a case for change
Creating awareness

4. eHealth change management is:
“…a strategic and systematic approach that supports people and their organizations in the successful transition and adoption of electronic health solutions.  The outcomes of effective eHealth change management activities include solution adoption by users and the realization of benefits.”
Pan-Canadian Change Management Network March 1, 2011
Consensus based definition
Group of CM leaders working in health IT space
Sharing best practices and ideas since November 2009

5. The change management iceberg
Management of Perceptions and Beliefs
Management of Power and Politics
Cost
Quality
Time
Bottom line: 70 % Failure
85% of our time = 15%
of the change
15% of our time = 85%
Experience shows us that we live in a very process oriented, project management focused, kind of world.
There is emphasis on cost, quality and time with less focus given to the large iceberg hidden under the water. That is – less time and energy given to consider influence, power, politics, perceptions and beliefs. 5

6. Unique industry, unique challenges
eHealth presents unique CM challenges:
Complex healthcare delivery structures
Organizational change resistance and fatigue
Emerging technologies
Health industry regulations
Strong, disparate professional cultures
Successful health IT implementations dedicate between 10-15%1 and upwards of 30% of project budget towards CM activities.2
References:
Petouhoff, N., Chandler, T., Montag-Schultz, B. (2006). The business impact of change management: What is the common denominator for high project ROI's? Graziadio School of Business and Management, Pepperdine University. [Electronic document]. Accessed at: (November 2010).
Laflamme, F., Pletraszek, W., Rajadhyax, N. (2010). Reforming hospitals with IT investments. Mckinsey on Business Technology. Number 20, Summer 2010: Accessed at (May 11, 2012).
1 Petouhoff, N., Chandler, T., Montag-Schultz, B. (2006). The business impact of change management: What is the common denominator for high project ROI's? Graziadio School of Business and Management, Pepperdine University. [Electronic document]
2 Laflamme, F., Pletraszek, W., Rajadhyax, N. (2010). Reforming hospitals with IT investments. Mckinsey on Business Technology. Number 20, Summer 2010:

7. The Value of Change Management
“Change Management, done well, done badly, or not done at all, will have a lasting impact on the sustainability of an organization.”
Les Harrison, CEO, Yellowknife Health and Social Services Authority, GNWT
-In the world of eHealth, change management has can have lasting impacts on all elements of organizational performance, including quality outcomes, project delivery, risk management and financial health.

8. A Look at the Numbers ROI of good change management
Effective CM strategies support average 143% ROI vs. 35% ROI with poor/non-existent CM.1
With execution of CM activities:2
96% of projects achieve project management objectives
95% of projects achieve IT management objectives
Consequences of poor change management
Cross industry studies suggest that with poor or non-existent CM:
“84% of projects do not hit their targets;
18% average over run on budgets;
23% average over run on schedule; and
7% do not achieve scope/ functionality.”3
“70% of health IT projects fail or do not provide end-user satisfaction.”4
References:
Laclair, J., Pao, R. (2002). Helping employees embrace change. Managing change is the responsibility of everyone in the corporation—from senior managers on down. McKinsey Quarterly. November 2002 (4), 17 – 20.
Coplan, S. Redefining health IT project success, Journal of Healthcare Information Management (HIMSS), Spring 2012, vol. 26, no 2. Accessed at (May 11, 2012).
Sauer, C., Cuthbertson, C. (2003). The State of IT Project Management in the UK University of Oxford, England.
Anderson M. Six levels of healthcare IT.Davidson PL ed. Healthcare Information Systems, Auerbach Publications, Boca Raton (2000), pp. 97–108
1 Laclair, J., Pao, R. (2002). Helping employees embrace change. Managing change is the responsibility of everyone in the corporation—from senior managers on down. McKinsey Quarterly. November 2002 (4), 17 – 20.
2 Coplan, S. Redefining health IT project success, Journal of Healthcare Information Management (HIMSS), Spring 2012, vol. 26, no 2.
3 Sauer, C., Cuthbertson, C. (2003). The State of IT Project Management in the UK University of Oxford, England.
4 Anderson M. Six levels of healthcare IT.Davidson PL ed. Healthcare Information Systems, Auerbach Publications, Boca Raton (2000), pp. 97–108

9. Change Management enables Realization of Benefits
This graph demonstrates the relationship between the breadth of change management activities and the capture of benefits and overall return on investment (ROI) of a project.
Focused and appropriately resourced change management is a driver of adoption and for achieving benefits linked to organizational performance, staff engagement and morale, as well as delivery of value to patients, providers and the health system alike.
In order to achieve realization of benefits:
Must hardwire reliable measurement processes into the ongoing operation of the health care system, including efforts to:
Link strategic goals and objectives to operational outcomes
Create synergy between existing measurement programs
Enhance technology system design for clinicians
Promote measurements that support course correction
Promote buy-in to the selection and deployment of measures
Operationalize the assessment of value and opportunities for improvement using a sustainable, reliable approach

10. What is required? Effective governance & leadership investment
Comprehensive stakeholder engagement
Workflow analysis & integration
Consistent communications
Training & education
Ongoing monitoring & evaluation
The National Change Management Framework, developed by the Pan-Canadian Change Management Network gives an overview of the required elements of an effective change management program.
More information about the framework, as well as helpful tools and resources related to each of the framework elements, are available on the Canada Health Infoway website.

11. “You can’t have a successful project without organizational CM
“You can’t have a successful project without organizational CM. It is as important as good project management. All of the elements of CM including training, communications are an integral part of a major initiative. You can’t implement without it. You will manage the change or the change will manage you.”
Roger Girard
Chief Information Officer, Manitoba eHealth

12. Thank you
Cassie Frazer, Benefits Realization Leader – 12

13. Telepathology & HEALTHe NL, Newfoundland & Labrador eHealth experience
Making early plans
Telepathology & HEALTHe NL,
Newfoundland & Labrador eHealth experience
If you look at models, research presented by Cassie, what are take home messages, considerations for early planning and sustaining change?
Key to early planning is considering many of the points mentioned by Cassie, i.e. defining benefits realization objectives, post go-live, what elements of framework do we need to assess within early project change planning for beyond go-live?
Given NL status, our operational needs are focused DIS, HEALTHe, and other ehealth projects, i.e.. Telepathology

14. Considerations & Questions, Telepathology
Early readiness planning, strategies, activities, outcomes:
Pre RFP, requirements validation
Potential implementation & adoption learning's
Readiness report and Project Steering Committee decision needs
Early clinical governance, RFP site visit evaluations
Early clinical governance informed project implementation approach; Clinical Working Group development (formalized terms of reference)
Revised CM plans, recognizing adoption targets, barriers, solutions
Take time for a broad assessment of project change to enable CQI, beyond go-live.
Although called many things, gap assessment, or readiness assessment, a key step to understand many framework elements for success project and operational needs
In case of NL Telepathology, early readiness planning informed many project initiation steps, while uncovering many current to future state needs, very early in project planning, solution requirements, work flow/process/barriers/solutions, clinical governance learning’s and application to early project implementation

15. Considerations & Questions, HEALTHe NL
Early Clinical governance needs, planning to implementation phases
Stakeholder engagement, early & often, Regional Health Authorities, acute care services, end users
Monthly Clinical Working Group (CWG) meetings:
Alignment & validation of requirements, pre-design
Engagement on Education & Training design
Production environment testing, pre-pilot, go-live
CWG engagement, post go-live strategies & activities; conferences, Regional Health Authorities, community clinician adoption

16. Considerations & Questions, HEALTHe NL
Results of early project governance, focus on Implementation & Adoption:
Mandate
“The Telepathology Implementation Leads Team (TILT) will provide advice and support to the Telepathology Project Team regarding the implementation of the provincial Telepathology network for Newfoundland and Labrador. In addition, team members will act as leads for their respective RHAs Telepathology Implementation”
Membership
Ideally, one (1) representative for each of the following areas, from each RHA will be identified by the key contacts/leads in each RHA, based on roles and expertise to take part on the team:
Information Technology
Technologist/Histotechnologist
Pathologist
Laboratory Managers
Change Management
1. Flipping back to Telepathology, we have a better needs based (draft) clinical governance structure to facilitate post go-live adoption, again, as a result of early CM planning and adoption

17. Considerations & Questions, HEALTHe NL
Results of early project governance, focus on Implementation & Adoption:
Responsibilities
Team members will be asked to provide input and take part in activities from the following areas:
Stakeholder Communication and Engagement
Education and Training
Implementation planning
Solution User Acceptance Testing
Adoption support and reinforcement
1. All framework elements reflected in TOR

18. In Summary A strategic, tactical, relevant change plan
Early defined change scope, integrated with project scope
Early defined clinical governance
Operational plan that includes:
Ongoing monitoring & evaluation strategies for benefits realization
Ongoing Clinical governance needs for benefits realization
Strategic, tactical, relevant CM plan is possible, but in alignment and integrated with early project planning activities,
Defined as project scope is being defined

19. Making change stick
Secure Adoption & Continuous Learning

20. Funded EMR Adoption Since 2005
Adoption by Community Primary Care Physicians and Specialists Actuals & Targets to March 31, 2014

21. The Changing Environment of Adoption
65%
Upgrades & Switches
Family physicians
New eHealth apps:
(OLIS, HRM)
85%
EMR Maturity assessments
Moving from “having” an EMR to “using” an EMR (becomes an asset)
Moving from logging patient encounters to managing data in the EMR
Focus on data quality and health outcomes
- Now a deliverable under the new program
Developed an EMR Maturity Model and tool in pilot stage
Existing Users
Previous Programs
New enrollments
Enrolled physicians
2012
New
Applicants
2014

22. #1: support to new EMR adopters: From paper to electronic records
Make sure that practice is ready to take on the transformation - Readiness assessment
Stake out EMR vision & goals
Spend time on identifying needs of practice, functional requirements and understand how the change will impact workflow
Training, training, training
Change management strategies used to support sustained change:
Vision and goals: The end game here is not just about getting rid of paper charts….the EMR can do so much more and its important to state this clearly up front
At this point in the EMR journey, you have spent a significant amount of time, energy and money to get the system up and operating in your office. And, as a result of determination and patience on your part, you are now as proficient at the day-to-day tasks of entering and retrieving electronic patient information as you were with the old paper charts. This is an essential and laudable first step. But, if this is where you stay, what would be the payoff for all your efforts? The answer is simple: not much. The payoff truly comes when you begin to use your EMR system to improve patient care, obtain better health outcomes for your patients, and facilitate practice management for you.
Available Change Management and Peer Leader Support
The foundation for a successful and sustained change is created up front..

23. #2: AFTER “GO-LIVE”: EMR Maturity Assessment
Looking at the result of the EMR Progress Assessment after EMR go-live:
Most change initiatives will experience a drop in efficiency and productivity before starting to realize the benefits that justified the change in the first place
Initiate follow-up and review immediately following go-live
Important to push forward, make corrections/ adjustments, address questions/concerns
It takes time to gain familiarity, confidence and speed with a new EMR
Most change initiatives will experience a drop in efficiency and productivity before starting to realize the benefits that justified the change in the first place
Initiate follow-up and review immediately following go-live
Important to push forward, make corrections/ adjustments, address questions/concerns
EMR Progress Review, Assessment results
…it takes time to gain familiarity, confidence and speed with a new EMR…

24. #3: …AND BEYOND: Continuous improvement & learning
Continued support to EMR users through Maturity Model, CM and Peer Leader Program:
Review the results with the entire group
Identify priority key measures for improvement
Explore Root Causes
Developing Action Plan
Implement improvements
Evaluate the progress
Review the results with the entire group – celebrating the wins and looking at improvement opportunities
Identifying priority key measures for improvement
Root Causes – looking at roadblocks and resistance in the way of realizing improvements
Developing Action Plan – to address what, who and how and when
Implementation of improvements – communications, resistance management, etc..
Evaluating the progress – lessons learned and deciding on next steps for improvements
EMR Progress Review, Assessment results
...focus on “continuous improvement” and make it a part of the practice culture.

25. So, what have we learned about sustainable change?
#1: You need to plan to achieve sustainable change and continuous improvement #2: Even the best plans and intentions can fail if not managed/championed/sponsored properly #3: No change or improvement initiative will magically happen by itself – only continued focus and determination will make it successful #4: Evaluate the effectiveness of the change process

26. THANK YOU!
Knut Rodne

27. Questions? Planning for Sustainable Change?
Start Early and Think Beyond ‘Go-Live’

28. Reference slides

29. Emerging Focus – Clinical Governance
Challenges
Management strategies
• HIT may create new or
compound existing clinical risks.
• If there is a perception that the new
system may create risks, confidence
in the system may fall.
• Governance bodies may lack clinical governance representation or fail to make links with existing clinical governance structures.
• Where clinical risks arise across the continuum of care there may be a lack of clarity as to who is responsible and what action should be taken.
Establish robust clinical governance structures and processes, ensuring they are integrated into the project’s overall governance.
Ensure that there are links between the project’s governance and the existing clinical governance structures
Be proactive in the monitoring of clinical risks and respond promptly where risks are identified. Formalise risk monitoring systems and escalation strategies.
Include the examination of the likelihood for the generation of new clinical risks as a routine part of the system design and testing phase.
Excerpt taken directly from: NEHTA. Making Sense of  eHealth Collaboration - A Guide to Getting Started.  2012.  Pg 29.

30. A Few Questions to Consider in Planning, Implementation, Adoption & Beyond
National Change Management Framework Elements
Considerations
Governance & Leadership
Who “owns” the program after go-live?
Who will make decisions?
Who will be accountable for continuously reporting on the project?
How will issues & risks be escalated and managed?
Stakeholder Engagement
How will stakeholders provide feedback on the solution? Whose feedback will be sought? How will this occur?
How will they access technical, operational, clinical support?
How will stakeholders be involved in enhancements or modifications?
Who will be involved in the sustaining Operational Team?
Communications
How will stakeholders be kept informed about upcoming release changes?
How will their feedback reported?
How will they be kept informed?
Workflow Analysis & Integration
How will workflow be affected by future enhancements?
How will stakeholders be involved in understanding these impacts?
What education and training will be provided?
Education & Training
Who will continue to participate as clinical champions / super-users?
What training will be offered for new users? With new release cycles? Refresher training?
How will this be communicated?
Monitoring & Evaluation
What indicators will continuously be measured?
Who will capture, analyze and report on the data?
Who will ensure data and report integrity?
How does the data get reported? How does it fit into organizational performance measurement?

31. Pan-Canadian Change Management Network
MISSION: The PCCMN collaborates to successfully communicate, educate and promote the value of using change management methodologies, approaches, and tools at every stage of ehealth solution implementation and adoption.
VISION: To be recognized as a leading national Network for change management approaches and resources that support the successful adoption of ehealth solutions.
A refresh on our mission/mandate & vision which has stayed true since 2009
a grassroots collaborative of change leader enthusiasts from across the country sharing best practices and ideas since November The Network facilitates a national community of practice for change management leaders involved in the implementation of electronic health solutions, providing an environment for discussion, networking and knowledge sharing. It was founded to share experiences and identify common goals that address ongoing change management (CM) related issues and concerns within the eHealth space across the provinces and territories.
CMWG’s are formed on an as needed basis to work on deliverables of the PCCMN, and provide National expertise, insights and input to shape change management strategies and outputs to accelerate adoption and benefits realization of health information and communication technologies and the electronic health record.

32. Are you effectively leading change?
Consider these questions:
What is your organization’s approach to change management?
Do you have a formal CM process in place across your organization?
Is CM facilitated at an enterprise or program level, or project by project?
Has CM been profiled within your organization as an expectation?
Is there evidence of CM on your organizational chart?
What leadership supports are in place to support effective CM?
How have you communicated this internally?
How have you structured your team to support these beliefs?
Do you visibly demonstrate support for transformational change initiatives?
How do you deal with stakeholder resistance?
How do you measure and report on change?
What indicators do you use to track progress?
How do you measure, analyze and mitigate risk?
How do you embed these findings into ongoing reporting and communications?
These questions can help leaders determine whether they have the required processes and resources in place for effective change to take place.
For example, when considering your organization’s change management approach, consider:
Do you have a formal change management process in place across the organization?
Is CM facilitated at an enterprise or program level, or project by project?
Has CM been profiled within your organization as an expectation?
Is there evidence of CM on your organizational chart?
When considering the leadership supports required for effective CM, you may want to ask yourself:
How have you communicated this internally?
How have you structured your team to support these beliefs?
Measuring and reporting on change is also a crucial element of success. Consider the following:
What indicators do you use to track progress?
How do you measure, analyze and mitigate risk?
How do you embed these findings into ongoing reporting and communication?

33. What can you do as a leader?
Governance & Leadership
Establish a clear, concise vision for the change initiative
Create time-bound, measureable, specific goals to evaluate success
Conduct a realistic evaluation of the internal climate to improve focus of leaders and team efforts on key challenges
Improve visibility and focus for executive/sponsor support
Increase accountability for change initiatives
Improve and expedite the decision-making process
Stakeholder Engagement
Provide a means to communicate and validate issues and barriers and ensure proactive management of these items
Communications
Provide stakeholders with timely information and allow for interaction with change leadership and project team
Engage in open & honest conversations
Training & Education
Equip stakeholders with the necessary training, information about new processes, technologies, and skills required in order to achieve success post-change
Monitoring & Evaluation
Evaluate the success of the change initiative against vision and goals
Continually monitor performance
Reinforce change messaging with stakeholders
Reference for leadership actions:
Department of Health & Human Services (HHS) Office of the National Coordinator for Health Information Technology (ONC)  Change Management:
Strategies and Resources for the State HIE Program Accessed at (October ).

34. Change Management Promotes:
Speed of adoption – improved stakeholder engagement, improved ease of uptake
Utilization – improved adoption rates
Proficiency - i.e.., effective use & improved efficiency
Avoidance of unnecessary costs – i.e.., due to resistance, need to re-plan, employee turnover etc.
Improved access to information
Animation note: Benefits Realization and Check Mark appear upon click
Benefits Realization

35. National CM Framework Governance & Leadership Stakeholder Engagement26
National CM Framework
Information & perspectives garnered through CMWG activities resulted in creation of a National CM Framework, based on six core elements:
Governance & Leadership
Stakeholder Engagement
Workflow Analysis & Integration
Communications
Training & Education
Monitoring & Evaluation

36. Available Change Management Resources
A Framework & Toolkit for Managing eHealth Change – People & Processes
Online Toolkit Repository
Sample of tools provided in CM Guide PLUS many more offerings
English version:
French version:
Join us on LinkedIN

37. PM & CM - Working Together
Define
Project Objectives
Common Goals and Metrics for Success
Communicate
Reporting Relationship
Roles and Activities
Responsibilities and Deliverables
Crystallize & document PM vs. CM roles
PM shares information for communication
CM creates communication deliverables
PM determines training schedules
CM determines training approach
PM informs sponsors
CM coaches sponsors
Role documentation
The language and defined deliverables are very important –
e.g. Training
PM –determines the Microsoft project training schedule at the high level the actual Training deliverables are managed by the CM and Training team.

38. Three Pillars of Benefits Realization
Know your objectives
Identify and manage the critical success factors to get there
Measure & iteratively improve
Critical Success Factors
Objectives
Measurement & Improvement
Benefits Realization
There are a lot of different theories about BR, but essentially it is about getting to a desired end-state. Infoway’s approach essentially incorporates three perspectives: BE, CM and Adoption. A focus on all three is required to achieve BR. And within that, you need to establish your objectives, your critical success factors, measure and iteratively improve.
Change Management requirements are embedded within each of these pillars

39. Infoway Benefit Evaluation Framework
In looking at the framework, how many of you have organizational scorecards or performance monitoring systems that would include elements such as displayed on the right hand side of the framework?
Idea: IT projects are not always driven as an organizational initiative; sometimes they pop up as something that is aside from organizational objectives. How many of you have objectives that align with the right hand side of this framework as part of your organizational goals, e.g., managing costs, ensuring access to services, reducing adverse events etc.?
For how many of you are your IT initiatives aligned to meet these objectives?

40. Increasing focus on adoption and benefits
Common scope of IT projects
NET BENEFITS
System quality
Quality
Use
Clinical Adoption
Information quality
Access
User Satisfaction
Service quality
Productivity

41. Maturity model – stages of EHR adoption
Adoption is a process, not an end state
Clinical Transformation
Fully integrated
Advanced functionality
Data drives quality
improvement
Maximum Benefits
Occasional use
Not well integrated
Low functionality
Low measurement
and analysis capability
Low-hanging benefits