It is quite possible that nothing like this has ever happened before.
Gentiva Home Healthcare, one of the largest agencies in the nation, rolled out a new clinical point-of-care software system to all 264 branches in 10 weeks. Even more remarkable, from the project's beginning in September through today, the organization has experienced no productivity decline.
"In my 30 years in the information systems industry, I have never seen an implementation proceed like this," Gentiva's Chief Clinical Officer told us. "We carefully measured clinician productivity before, during and after each branch's go-live day and it never dipped."
The massive process of rolling out a new clinical application for 264 branches happened at a pace of 22 to 27 branches per week from early September through the first week of November last year. An effort that large does not happen without thorough planning and preparation, and it could serve as a model for other organizations. We asked Senior VP and CCO Charlotte Weaver, RN, MSPH, PhD, FAAN, to describe the Atlanta-based provider's successful strategy and implementation.
The story evolved in identifiable steps:
1. Select the right partner
After looking at all of the major software vendors over an extended period of time, Gentiva decided it did not want to use client/server architecture or any system that required clinicians to synchronize data from field devices to servers. Even a hosted system with a small app to be used when out of range of Wi-Fi or cell towers was off the table. One failed attempt to customize the core code of an online store-and-forward system convinced company decision-makers to focus their search on 100% online systems only. (See related story, HCTR, Feb. 1, 2006) They decided to search for a vendor that offered 21st-Century software, which to them meant cloud-based technology that could scale to support their massive user base and 40-state patient census.
Their choice was a California software company named DeVero, which offers an entirely cloud-based solution. It requires an Internet connected device and stores no patient data on that device. "They have been excellent to work with," Weaver told us, "even with the 3-hour time difference. Every time we wanted a 9am Eastern Time telephone conference, they were right there." Working together, the entire implementation, including real-time integration with Gentiva's proprietary back end financial system, was 14 months, she added.
2. Avoid classroom training that takes clinicians out of the field
DeVero and Gentiva developed a series of virtual courses and made them available to clinicians at all 264 branches online. "DeVero's software essentially consists of onscreen forms that they designed to be identical to the paper forms our clinicians were already using," Weaver continued. "This made the process of completing OASIS assessments and visit notes very easy to learn, which was important because we needed to train 12,000 people in 40 states and we did not want to put any of them in a classroom for a week or two. By the time each branch's turn came, its staff was ready to start using the software. They all saw the same number of patients during the first week of implementation that they had seen the previous week."
3. Identify and train staff who are unfamiliar with chosen field device
Gentiva decided it best to run its new point-of-care system, which employees know as GentivaLink, on iPads in the field and laptop or desktop computers in the office. Management was surprised to learn during the pilot phase how many clinicians were not familiar with iPad idiosyncracies such as on/off, navigation, wireless setup and the like. They did find, however, that each branch always had some staff who were iPad savvy. So they established a self-staffed training program where the local experts spent a couple of hours with newbies to get them comfortable with the iPad on the day before go-live.
4. Enforce a pre-implementation checklist, including pre-testing hardware and networks
Every branch had to complete specific tasks before its assigned go-live date. If not, that branch's start date was pushed to the final week. As word spread that this standard was being strictly enforced, the need to reschedule a branch quickly disappeared. "Virtually everyone wanted this to happen," Ms. Weaver remembers. "Once we started, and word got around to clinicians how valuable this was and to branch managers that there was no productivity impact, no one wanted to miss their turn."
The preparation checklist itemized tasks that a branch had to complete during the three weeks leading up to its go-live date. It included migration of records from the current system to the new, training courses must be completed by every staff member, network capacity and all other devices had to be tested for suitability and compatibility.
5. Conduct one or two controlled pilot rollouts in carefully selected branch offices
Most home care companies that are smaller than Gentiva – which is all of them – may find that one pilot is enough but, with the need to convert 264 locations, Gentiva tested the DeVero rollout in 8 branches for 60 days then stopped to assess. After making some changes they did another 8-branch pilot before beginning their 25 per week pace.
"We stopped to test our assumptions," Weaver said. "We made some tweaks to our virtual training program, asked DeVero for some changes, and then moved forward with the second pilot, made some more tweaks and then were ready for full rollout."
6. Provide ongoing support and re-training opportunities
"Adult learners often need to go through a virtual class a second or third time to build on their experiences gained in the real world," Weaver explained, "so we made sure that was available and encouraged. We know adult learners need help from on-site, in-person support people and we were not going to do that, to provide support people for 25 branches at a time. Making virtual classes available for viewing at any time, plus making job aids and workflows available, provided the on-site support that they needed."
Unforeseen benefits and hindsight lessons
"We accomplished something fairly radical in the industry," Ms. Weaver said. "We think it was possible because we are using nothing but 21st-Century technology." In addition to undiminished productivity throughout implementation, Gentiva officers and branch managers have noted other advantages.
Progress made on one identified problem
Committing to a cloud-based documentation system has some built-in issues, Weaver acknowledged. Not every patient's home lies with reach of a cell tower. She estimates Gentiva has as many as 25% of its clients in rural areas; in some of these homes, mobile devices cannot connect. "Some nurses have learned that in iffy areas they might be able to get a connection in the kitchen but not in the living room," she explained. "So they document in the kitchen in that house."
Others have had to settle for taking notes in the home and entering them into the system as soon as they pick up another signal. Gentiva has developed a tool to help clinicians capture key data in those rural homes.
Asked whether this inconvenience was enough to influence Gentiva to ask DeVero to develop a small app that could be used on the mobile device, Weaver said absolutely not. "We do not want the HIPAA risk of having any patient data stored on the devices. We are willing to work around the few instances where a rural home is out of reach."
Weaver categorizes another obstacle noticed after implementation as minor. The conversion has been a bit more challenging for office staff, who have to manage the integration between GentivaLink and the company's proprietary financial system. Many of them have needed more training and support, especially as integration between the two systems is gradually perfected. "They have already begun to recognize data patterns that will cause an error," she explained. "Now they save a lot of time by making corrections before putting it through."
Conclusion: a significant net gain
Since implementation, the Gentiva CCO concluded, not only has the company avoided the temporary productivity decline that typically accompanies a point-of-care software implementation, but clinicians have also spoken frequently about improvements to their quality of life. "I don't have to spend evenings and weekends doing paperwork," many of them tell her. Responding to speculation that Gentiva's experience is going to put DeVero, a much smaller operation than Gentiva, on the map, Ms. Weaver quickly replied, "Well, they deserve to be."
©2014 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. email@example.com