Tuesday, March 18, 2008

Social Networking Software for Performance Improvement

I've written several articles about the IT tools needed for performance measurement and the use of social networking tools for collaboration

Recently, Beth Israel Deaconess melded these two concepts to create a community wide collaboration for performance improvement.

The idea is simple. If problems can be solved by investigating the root cause in real time instead of just developing workarounds long after the incident, performance can be improved significantly. Our requirements for an IT solution were

1. A threaded discussion forum with issue tracking features that anyone in the organization could add/edit/view
2. Workflow which enabled escalation, documentation of responses, and a history of all entries related to the thread
3. Easy access to incident reporting and adverse event tracking systems for documentation of patient care related issues

Dell successfully did something like this with their IdeaStorms site which enables users to propose performance improvement ideas and then promote/demote them via voting. Dell's site was created by SalesForce.com using their Software as a Service platform. We considered using a Salesforce.com platform but we needed tight integration with our existing applications.

We had to implement this infrastructure on a very tight timeframe at very low cost. We wanted a toolkit that integrated with Active Directory for authentication, was compatible with all browsers/operating systems, and leveraged the talents of our existing developers.

We chose to use Windows SharePoint Services 3.0 which is integrated in Windows Server 2003 and does not require additional licensing fees. We found the platform to be a good foundation for the project, especially because our developers could leverage its out-of-the-box collaboration and communication features. Over the 2 weeks of development time, we found that requirements changed frequently as we delivered functionality that prompted users to brainstorm about additional possibilities. Rather than a traditional development project that used specifications set in stone, this project was a Rapid Application Development exercise of creating a prototype, enhancing it, testing it, gathering feedback, enhancing it, testing it, etc.

The end result was a portal called the BIDMC Spirit Portal with easy access to all our issue tracking applications, including problem logging, resolution workflow, a blog for successful cases and enterprise wide collaboration. A typical workflow is illustrated by our "Case of the Week"

At 8:30 a.m. a staff nurse on Farr 9 needed to page the medical house staff with a question about a patient admitted overnight from the Emergency Department (patient arrived on floor between 3:30 and 4:00 a.m.). The nurse paged the resident listed as covering, but that beeper was forwarded to another resident who stated he was not covering. That resident instructed the nurse to call another resident who also stated she was not covering. The nurse paged the attending physician of record who gave the nurse two additional options to page. At this point, the Nurse Manager on Farr 9 became involved, entered the issue in the web-based BIDMC Spirit portal and paged the Chief Medical Resident for help in determining coverage.

Root Cause:
There were a higher number of medical admissions than usual overnight. The patient was assigned to a different medical firm (team of residents, interns, medical students and attending physicians) than the usual firm that usually covers Farr 9 patients. The provider order entry order set did not indicate the correct firm coverage.

Solution After Investigation:
The immediate issue was fixed and the correct team assignment was notified, but it took 30-45 minutes.

Action Plan:
A Hospitalist and the Chief Medical Resident, worked on solutions with the Nurse Manager to prevent the issue from occurring again.

• Medical firms were reassigned to support increased medical volume on Farr 9.

• Farr 9 RN staff were educated about medical staff coverage and how to find medical call schedules on the intranet. We also ensured all medical teams had entries in our web-based paging system.

• Medical house staff updated our order entry order sets to accurately reflect team coverage.

• As a back up, the medical house staff agreed to either evaluate the patient if a critical issue is occurring or locate correct coverage as opposed to the nurse another intern/resident to page.

• We automated the paging system so that it generates an automated alert to the medical admitting resident once a bed is assigned for patients admitted from the Emergency Department

All of this was coordinated via BIDMC Spirit Portal discussion forums, blogs, and issue tracking applications.

As you can see, Social networking meets Performance Improvement meets Rapid Application Development. This infrastructure, which has now been used to support 300 real time problem solving events, again demonstrates the power of Web 2.0 for the healthcare enterprise!