Académique Documents
Professionnel Documents
Culture Documents
I
mplementing a computerized OR • interface with at least three other
management information system computer systems; and
(ORMIS) requires an enormous • subsume some of the work of three
commitment of human resources for separate and independent informa-
the various tasks associated with pre- tion technology (IT) departments.
paring for, launching, using, and main- A rigorous, two-year process of eval-
taining such a system. In December uation, demonstration, and discussion
2000, in recognition of the need for with the vendors who responded to the
seamless fluidity of patient information RFP resulted in a contract with one
sharing between ORs, procedure ORMIS designer. The hospital submit-
rooms, affiliated nursing care areas, ted a Certificate of Need application to
and other affiliated facilities, The Johns the Maryland Health Services Cost Re-
Hopkins Hospital, Baltimore, Mary- view Commission. This state require-
land, released a request for proposal ment is designed to
(RFP) to identify and select a single,
unified, vendor-developed ORMIS. promote cost containment by decreas-
This process also included a considera- ing both service duplication and invest-
tion of the future construction of new, ment in excess capacity. . . . Certain
acute care towers, which are envi- health care providers must obtain state
sioned to encompass and integrate a approval for substantial changes in
majority of these service areas. The their scope of services or for capital
ORMIS needed to include scheduling, investments.1
perioperative, and procedural nursing
documentation; an anesthesia data re- The Certificate of Need was approved
cord; case cart and materials manage- in April of 2003, and a final contract
ment; patient tracking; day manage- was executed in June of that same year.
ment; professional fee billing; supply
billing; instrument tracking; and
report-generating functionality.
The selected system would be target-
ABSTRACT
ed for deployment throughout the peri- IMPLEMENTATION OF AN OR MANAGEMENT
operative and periprocedural areas information system (ORMIS) requires a significant
within The Johns Hopkins Hospital and commitment of human resources.
the Johns Hopkins Bayview Medical
THE EXPERIENCES OF THE PERSONNEL at The
Center. This included more than 85 OR
Johns Hopkins Hospital, Baltimore, MD, as they
and procedure rooms and all affiliated
transitioned to using a single, unified, computer-
preparation and postanesthesia care
ized ORMIS are detailed in this article.
units (PACUs). The system would
• replace five other legacy systems; INCLUDED ARE DISCUSSIONS of the nursing
• affect approximately 500 nurses; resources involved in the process, the lessons
• encompass seven separate depart- learned, and the work that remains to be completed
ments; for the hospital to fully utilize the system. AORN J
• incorporate real-time, online nursing 87 (March 2008) 585-596. © AORN, Inc, 2008.
documentation at the point of care;
© AORN, Inc, 2008 MARCH 2008, VOL 87, NO 3 • AORN JOURNAL • 585
MARCH 2008, VOL 87, NO 3 Saletnik — Niedlinger — Wilson
TABLE 1
Attributes of Different Success Factors*
System Information Usage User Individual Organizational
quality quality attributes satisfaction impact impact
Ease of use Completeness Number of Changed patterns Communication
User satisfaction
entries and collaboration
Response Accuracy of Attitude Direct benefits
time data Frequency of Impact on patient
use User-friendliness Changes in care
Time savings Legibility documentation
Duration of use Expectations habits Costs
Intrinsic Timeliness
features Self-reported User computer More Time savings
creating Perceived usage competence administrative
extra work usefulness tasks Reduced number
Location of of staff members
Perceived Availability data entry Time of day for
ease of use documenting Number of
Ease of Frequency of procedures
Usability comprehension use of specific Documentation required
functions frequency
Availability Consistency
Information
Ease of Reliability recall
learning
Format Accurate
Rigidity of interpretation
system/
built-in rules Integration of
information/
Reliability overview
Security Information
awareness
Ease of
access to Efficiency and
help effectiveness of
work
Data
accuracy Job satisfaction
* Originally published in Van Der Meijden MJ, Tange HJ, Troost J, Hasman A. Determinants of success of inpa-
tient clinical information systems: a literature review. J Am Med Inform Assoc. 2003;10(3):238. Reprinted with
permission from Elsevier, Philadelphia, PA.
those in authority to make decisions (eg, di- ing departments in the six affected divisions
vision chiefs, directors, assistant directors, (ie, the Wilmer ophthalmological OR, general
managers) also were intimately involved in all OR, Weinberg ORs, Bayview ORs, endoscopy
aspects of the selection, analysis, design, im- suite, cardiovascular diagnostic laboratory).
plementation, and ongoing evaluation of the In a separate investigation of information
system. The sociotechnical approach on a proj- systems in health care organizations, Berg5
ect of this size also required enormous re- wrote that implementation of a patient care
source allocation, particularly from the nurs- system will have a fundamental effect on the
approximately 15 years of experience working CLINICAL NURSES. Clinical nurses were involved
with information systems in nursing and in all aspects of the project as well. Prior to the
health care. The position initially was titled software selection, an open invitation was ex-
“program coordinator,” but it evolved into the tended to all nurses to attend the vendors’
clinical systems manager for surgical nursing. demonstrations of their systems. Many nurses
Although the system selection was made participated by asking questions, and they
before this position was filled, the clinical sys- provided feedback by completing a survey.
tems manager was included in the Steering Throughout the planning process, nurses were
Committee membership roster, the Nursing involved in many tasks such as reviewing
Documentation Committee, the Technical preference cards for physicians with whom
Committee, and the Reports Committee, and they worked. They also reviewed equipment
also served as an invited guest when required lists for accuracy and supply lists for com-
in the Scheduling Committee. pleteness. As the process for screen develop-
The clinical systems manager has been the ment began, a subcommittee was formed and
liaison between nursing leaders and the IT chaired by one of the nurse managers from the
implementation team. Informatics expertise RN Documentation Committee. This group
enabled her to analyze the clinical needs ex- consisted of clinical nurses from every special-
pressed by staff members and leaders and ty, a nurse educator, the project leader, and the
apply that knowledge as the ORMIS system clinical systems manager on an ad hoc basis.
was developed and implemented. This group provided critical input into the
Though nurses frequently are included in an screen design, and all members were trained
implementation team under the direction of the to be super users. Hardware selection also was
IT department, they often are presented with discussed with the nursing staff members who
conflicting demands related to the project time- provided the input that ultimately led to the
line and the development of the system. The selection of computers on wheels for use in
clinical systems manager was employed by the each OR or procedure room.
nursing department, which allowed her to em- NURSE EDUCATOR. The OR nurse educator was
phasize clinical needs and incorporate those included on the RN Documentation Committee
needs into the system. This individual was able and was integral to the development of the
to provide input in the screen designs for the computer skills refresher course and the train-
system, placement and design of hardware to ing for the clinical documentation rollout. The
support the system, dictionary development, educator was able to bring feedback to the RN
and process redesign. She added a unique point Documentation Committee on the issues and
of view with both her IT and clinical expertise. questions that others raised throughout the
NURSE MANAGERS. Nurse managers were in- training process so that adjustments could be
volved in several aspects of the project. Nurse made when necessary.
managers were members on the RN Documen- CASE CART FACILITATOR. The case cart facilitator is
tation Committee and represented all specialty the nurse who developed the existing case cart
areas that would be affected by the system. As system for the ORs several years before and who
each OR and procedure area prepared to im- oversaw the management of the preference
plement the system, the nurse managers in- cards. This nurse was a member of the RN Doc-
volved in those services took on the responsi- umentation Committee, the Scheduling Commit-
bility of preparing staff members and ensuring tee, and the Case Cart and Materials Manage-
that necessary templates had been developed ment Committee, as well as an ad hoc member
and clinical nurses in their areas had complet- of the Report Generation Committee. This indi-
ed the assigned tasks. Each nurse manager vidual was responsible for updating all of the
also was trained to be a super user (ie, a staff preference cards as well as assisting in some
member who receives additional training and areas with the creation of preference cards where
acts as a resource for other staff members dur- none existed. As a member of the Case Cart and
ing their training on the system). Materials Management Committee, the case cart
systems. The clinical documentation system becoming overwhelmed with the information.
was designed, however, to eliminate as much It also was easier to accommodate other staff
paper as possible. members’ schedules when the hours were
The committee translated the existing paper scheduled this way. For example, nurses
documents into requirements for screen lay- could attend a class in the morning and then
outs in the selected system. It was tempting at be available in the afternoon to provide lunch
first to create electronic documents that mim- breaks or relief in the OR for the remainder of
icked all existing paper documents, but this the shift.
was intentionally avoided to eliminate the dou- The first four-hour session covered the ba-
ble and sometimes unnecessary documentation sics of the electronic document system and a
that was occurring. In addition, the basic lay- review of each screen. The second four-hour
out of the screens prevented this from happen- session focused more on the clinical aspects of
ing because interventions and information the system and included how to document an
were grouped differently in the electronic doc- entire case successfully. Having clinical staff
uments. After the basic application had been members in the training room for each session
designed by the IT team, members of the Nurs- was helpful, because staff members had many
ing Committee actively participated in the questions that required the response of a clini-
screen development; building; testing; and ulti- cian, especially related to changes in work-
mately, in the final approval of the system. Ap- flow and work processes.
proval for screen design was obtained from the The first groups to be trained were the des-
Nursing Documentation Committee as well as ignated super users from the clinical staff.
from selected end users who met under the di- Super users were selected from each service
rection of the nurse managers participating in and usually were nurses who volunteered for
the larger group. this role. Clinical staff members and managers
agreed that the individuals who volunteered
TRAINING to be trained as super users were making a
In an effort to establish a baseline of com- commitment to support not just their own
puter skill competence, a questionnaire was service area but all service areas during the
distributed to all RNs who worked in the implementation phase. Super users or IT staff
ORs. Based on the results of this, e-mail ac- members provided around-the-clock support
counts were established for all staff members during the implementation. These staff mem-
to help enhance their basic computing skills. bers were paid at a special rate designated for
This provided an opportunity for the nursing nurses working to provide system support.
staff to gain comfort with and skills in inter- Though it easily could be overlooked, it is
acting regularly using a computer. In addi- essential to designate a training room when
tion, a basic computer skills training class was implementing a system of this magnitude. The
made available for those self-identified indi- nurse educator and the clinical systems manag-
viduals who required more assistance. er worked together to procure the appropriate
Training was one of the more challenging furniture and equipment to create a training fa-
parts of the implementation. Although initial cility that would support the training needs
efforts were made to schedule extra staff during implementation as well as the needs of
members during the training dates, the imple- future orientees who would be trained to use
mentation date was changed several times the ORMIS software. In The Johns Hopkins
throughout the process, making scheduling of Hospital, the training area commonly used for
additional staff members extremely difficult. orientation of new nursing staff members was
Further, the content that needed to be covered renovated to facilitate the required computer
during training required approximately eight training. Ergonomic computer desks in which
hours of classroom time. The decision was the computers could be stored were selected to
made to divide the training into two separate accommodate a variety of training that would
four-hour sessions to prevent staff members occur in that one classroom.
NURSE SATISFACTION. The project developers also plates for specific procedures. In addition, as
wanted to measure nurse satisfaction with the new initiatives are developed, changes continu-
system; therefore, a pre-implementation survey ally need to be made to the screens to collect the
was used to evaluate satisfaction with the exist- necessary information both for quality and
ing documentation system. Several months process improvement.
after the implementation of the new system, a It is important to note that no system is per-
postimplementation survey was made avail- fect. Users are required to work within the
able for the nurses to complete via the facility’s limitations of any system that is selected. A
intranet. The developers intend to conduct an- health care organization must continue to
other survey of nurses after they have used the work with the software vendor when signifi-
system for one year or longer to determine their cant changes are required.
level of satisfaction and to identify any changes
that are needed. EVALUATING THE COSTS AND BENEFITS
Meyer and Driscoll6 presented the results of
LESSONS LEARNED two case studies related to the implementation
Nursing managers thought that nurses of comprehensive perioperative IT systems.
would want to practice with the system after Their findings indicate that one hospital in the
their training session and before the go-live study was able to
date. A training version of the software appli- • capture millions of dollars in lost revenue
cation, therefore, was placed on selected com- through charging by exception from prefer-
puters in the ORs and staff workrooms. The ence cards;
training version was made available to all staff • provide the costs per procedure by surgeon,
members along with the training scenario data. leading to improved decision making;
Despite encouragement to practice with the • make schedules more efficient;
system before it was implemented, few staff • provide data on block time and equipment
members took advantage of the opportunity. usage; and
Communicating as much information as • improve multidisciplinary and patient
possible in as many forums as possible is rec- relations.6
ommended. Staff members commonly said that The second hospital they studied was able to
they were not aware of an aspect or implemen- • make a $500,000 to $750,000 one-time reduc-
tation date for the system. For this implemen- tion in on-hand inventory;
tation, verbal communication included written • improve billing accuracy, which captured
notices in newsletters, e-mails, hand-outs, and 5% more charges;
announcements made to staff members at reg- • enhance decision making through the study
ularly scheduled meetings. of trending data; and
It is difficult to estimate the time and re- • increase regulatory compliance.6
sources needed for this type of project, particu- Implementing a comprehensive perioperative
larly when implementation dates are subject to system can help organizations improve process-
change. The amount of nursing resources re- es, reduce costs while increasing revenues, and
quired for this type of project is enormous. The enhance caregiver satisfaction. Operating room
preparation work involves months of tasks to managers can increase the success of imple-
create or update lists with necessary information. menting an ORMIS by following the framework
After implementation, the system also re- of Delone and McLean2 and incorporating the
quires maintenance of preference cards and factors of that framework proposed by Van Der
templates and updates to the screens to make Meijden et al.3
them as efficient and effective as possible. Some
clinical services elected not to create many tem- CHALLENGES FOR THE FUTURE
plates before the system was implemented. Now that the system has been in effect for al-
After staff members had used the system for most one year and a variety of services are using
awhile, there were many more requests for tem- it, there have been many requests for revisions,
and certain changes are needed. Some of the additional training is required when changes
screens have been particularly challenging and are made. As staff members continue to access
have required modification. These include the the system and use it to analyze data, the posi-
specimen screen, the count screen, the position- tive impact of the system is being realized.
ing screen, and some of the charge screens with- Overall, staff members’ reception of the soft-
in the system (eg, for implants). Nursing Docu- ware has been positive, and most facility per-
mentation Committee members continue to sonnel have adjusted well to the changes.
answer questions and receive users’ concerns, It takes the commitment of the entire health
and they work to make appropriate adjustments. care team to realize the type of success we have
They also continue to prepare for implementa- had at The Johns Hopkins Hospital. This commit-
tion of the system in other service areas. ment must be sustained from the planning stage
Another required functionality of the through the implementation to the ongoing main-
ORMIS that needs to be developed is a routine tenance of such a system.
mechanism to review the documentation that
the nursing staff members have completed. REFERENCES
When the system was first introduced, some 1. Schneiter EJ, Riley T, Rosenthal J. Rising health care
nurse managers chose to have their staff mem- costs: state health cost containment approaches. Nation-
bers print two copies of final reports so one al Academy for State Health Policy. http://www.nashp
.org/Files/GNL46.pdf. Accessed January 9, 2008.
copy could remain with the chart and the 2. DeLone WH, McLean ER. Information systems
other copy could be reviewed for accuracy and success: the quest for the dependent variable. Inf
completeness. There is a need to standardize Syst Res. 1992;3(1):60-95.
this process and to determine how often this 3. Van Der Meijden MJ, Tange HJ, Troost J, Hasman
documentation should be reviewed. A. Determinants of success of inpatient clinical in-
formation systems: a literature review. J Am Med In-
Some functionality of the system (eg, use of form Assoc. 2003;10(3):235-243.
the Perioperative Nursing Data Set [PNDS], 4. Berg M. Patient care information systems and
imaging capabilities) has not been fully uti- health care work: a sociotechnical approach. Int J
lized, and additional efforts are warranted to Med Inform. 1999;55(2):87-101.
incorporate these features. Refinement of the 5. Berg M. Implementing information systems in
health care organizations: myths and challenges. Int
system’s use of the PNDS is a future goal. Use J Med Inform. 2001;64(2-3):143-156.
of this standardized terminology, however, 6. Meyer M, Driscoll E. Perioperative surgery in the
will require further education of nursing staff twenty-first century—two case studies. AORN J.
members. As described by Doyle,7 the PNDS 2004;80(4):725-733.
establishes a standard nursing language using 7. Doyle M. Promoting standardized nursing lan-
guage using an electronic medical record system.
a taxonomic structure, and it provides the op- AORN J. 2006;83(6):1336-1342.
portunity to collect and compare data to pro-
mote an evidence-based model for nursing
practice. Laurie Ann Saletnik, RN, MSN, is the as-
The system also contains the ability to store sistant director of surgical nursing at The
and link images; however, this functionality Johns Hopkins Hospital, Baltimore, MD.
needs to be developed further. Images of diffi-
cult set ups, unique instruments, and pre- Margaret K. Niedlinger, RN, MIS, BC,
ferred patient positioning can be made avail- CPHIMS is the clinical systems manager at
able to help nursing staff members who use The Johns Hopkins Hospital, Baltimore, MD.
the system. This feature has not yet been fully
utilized. Marisa Wilson, DNSc, MHSc, RN, is an
Although ongoing changes are required to assistant professor at the University of
further customize the system, the essential ele- Maryland School of Nursing, Baltimore.
ments of the system remain unchanged. Little