Reflection-Story Telling

Challenge    I am a member of a large healthcare organization, and work in a Lead-Clinical Informatics RN  position.  Clinical Informatics has been likened to a bridge between the IT world and the clinical  providers world, integrating clinical standards, regulations, processes and procedures for patient  care into the EHR (Electronic Health Record).  Clinical providers include physicians, advanced  care practice providers, nursing, therapists and various ancillary staff.  As a Clinical  Informaticist, one of the processes for which I am responsible, is the design of templates,  flowsheets, order sets, etc for documentation purposes all the while assuring patient safety and  regulation compliance.     Selection    In order to accomplish this goal, I must consult with the discipline or disciplines that will be  affected, across multiple departments, and across multiple health sites. This is in order to  understand not only their workflows, but the challenges that they face with implementation of a  new initiative or functionality. Storytelling is the design tool that I utilize most often in scenarios  such as this. Storytelling is a tool used to gain insight into the user's world, by putting their  experiences, needs, and wants in the center of the design process. Even if the new initiative or  functionality is part of a national initiative or brought about by a new governmental regulation,  therefore not up for debate as to whether we take or do, I still need to know the workflow and  the impact to the end users.    Application    I was tasked with the implementation of a new specimen processing module that’s purpose was  to increase patient safety when lab specimens are collected.  At the current state, the process of  labeling the specimens at the bedside, at the time of collection, was not consistent. This lack of  documentation can be quite harmful if specimens were mislabeled with another patient’s  information, increasing the chance of errors in patient care.  Should the error be discovered,  resulting in the need for recollection of specimens, there would be a delay in care as well as  increased discomfort to the patient. The new initiative included the functionality of requiring the  viewing of patient lab orders, documentation of the collection, and labeling of the specimens by  the staff at the bedside utilizing the process within the patient's electronic chart.    The initial scope of the implementation included only our main hospital laboratory, with others to  be added going forward.  I met with the directors and managers of the laboratory, as well as the  directors, managers and VP of Nursing, in order to instruct them on the new functionality and  process.  Nursing was included in the discussion as nursing would be impacted in various  incidences, on various units where they are the specimen collectors rather than lab personnel.

During this time I listened to their thoughts and concerns regarding the new process as well as  answered their questions.  They were made aware of the need for my documentation of  workflows, as well as “day in the life” stories. Additional meetings were scheduled with them for  the purpose of updating them on the progress of the project, as well as to include them in the  deployment plans for the patient care areas. Another key aspect for the project was the  discussion around the new hardware requirements and the placement of it on the various units  and laboratory.  This provided me with raw numbers of items needing to be purchased.    After this “kick off” meeting, I arranged times to visit each patient care area in order to observe  the nurse's current processes,and obtain user stories.  I am fortunate in that our staff are always  very open to giving their opinions, asking questions and verbalizing their needs as well as best  case scenarios for their work.  During this time, I also met with laboratory staff responsible for  the processes of receiving the physician orders, through the collection of specimens, and the  distribution of said specimens to the different departments within the laboratory.  While my  primary purpose was to obtain workflows and user stories, I used this time to also begin  educating staff regarding the new module, new process.  These informal times lent itself to  candid discussions of the overall current state.    The use of storytelling as a means of design was invaluable.  Through the workflows and user  stories, we were able to design additions and modifications to the new module that were more  reflective of their actual environment.  This enabled us to respect the integrity of the new  process module while incorporating the majority of end users wants and needs.    Insight    By applying the storytelling design tool, I was able to obtain information that I would not have  otherwise been able to ascertain through simple meetings.  It also afforded me the ability to  identify the discrepancies between what was assumed the processes were vs the reality.  As is  more often the case, managers and directors can be removed from the day to day functions of  their own departments.  It was definitely invaluable to be with the “frontline” staff and learn  exactly what the processes and workflows were, as well as the challenges that they faced in  performing their jobs. One of the key deficiencies I found was in the way the Emergency  Department was labeling their specimens.  At some point in time, they were given a pass in  labeling the specimens in the proper manner, instead sending them to the lab for them to do  before processing.  Obviously this could not continue for two reasons. 1) It was in violation of  standard practice and procedure, and 2) the new process would not support their workflow.  I  immediately addressed the errors with departmental leadership, in order to guide them to  compliance in standard procedure, even before the implementation of the new process. Going  forward, we were able to design a workflow, within the new functionality, that assisted them in  such a way that maintained standard procedure for collection and labeling of specimens.  Equally as important was the ability to take their unique challenges into consideration and offer  solutions.

Approach    In conclusion, I would use the storytelling tool again as it provides clear insights into the what  areas required modifications to the new process, in order to meet the needs of the end users.  Had I not spent time with the laboratory and nursing staff “in the trenches”,  I would have found  us implementing a product that would have been flawed for their use, from the beginning.  Through collaboration with these departments, Clinical Informatics, and the various analysts  within the technology department, we successfully launched a product that was far more  intuitive to their own process and needs.

