One of my colleagues recounted a story of failing to get an informatics committee approval for a BPA (interruptive best practice alert).
Here is the problem:
Occasionally, a patient will be admitted to hospital already wearing a medication patch. During hospital admission, we pay a lot of attention to the pills the patient is already taking and reconcile them with the new treatments and medications we need for the patient’s acute illness. However, it is easy to overlook any medication patches a patient is already wearing when they arrive.
Some recent examples:
a patient admitted with a blood clot in the leg (DVT) was wearing an estrogen patch that we neglected to remove (estrogen may have contributed to the clot). A patient admitted for pain control with a PCA (patient-controlled analgesia IV pain medication pump) was still wearing a fentanyl patch (absorbing conflicting pain medication through their skin). A patient admitted for blood pressure control was still wearing their clonidine patch that could interact with other medications.
Sometimes the nurse is too busy to remember to examine the patient for these tiny, nearly invisible patches. Sometimes the nurse finds one, but it is difficult to remember which doctor or clinical team is taking care of the patient. Often it is difficult to know where to write down that you found a medication patch, and then what to do about it.
My colleague determined to make this improvement: make it easy to remember to scan the patient for medication patches, document them quickly and then contact the treating doctor or team to request an order to remove or continue the medication patch.
Here are the technical pieces:
1. Add a flowsheet item on the admission navigator: Medication patch found on body: yes/no.
2. IF YES then BPA: EZ secure chat button to right clinician to order med or discontinue.
3. This change was requested and approved by Project JOY: RN click reduction program.
My colleague attended our CDS (clinical decision support) governance meeting. The proposal was rejected by the clinical leaders at the meeting, who argued: “RN’s don’t need another BPA. Go back and check with RN leadership and find another way.”
What went wrong?
It is always helpful to find a colleague to commiserate after a failed proposal and deconstruct what happened. Here are some ideas:
START WITH WHY.
Lay the groundwork vividly so that decision-makers see clearly how big a problem this is (medication error causing patient harm). It is possible my colleague was not as forceful as needed laying out WHY this is important. Have the committee feel the pressure, the anxiety, the discomfort of not doing the best we can for our patients. ONLY THEN offer your solution. NEVER come with a proposal emphasing the clever tool you built without STARTING WITH WHY.
For example, feel the difference between:
“I have an idea for an alert to make it easier for nurses to contact doctors about med patches on admission to hospital.”
Versus
“We make medication errors almost every day related to medication patches that we miss when a patient is being admitted to hospital. To make things worse, it is hard for a nurse who discovers a patch to do the right thing. Nurse leaders asked me to design something that would help.”
BRING YOUR ARMY.
If you have already obtained nursing leadership support, say so, and repeat it. If the leadership of the people who will be interrupted by your tool (interruptive BPA alert in this case) agree that this is a good idea, THEN SAY SO. You have an army backing your request. The worst BPA requests are from individual clinicians or researchers who want to interrupt OTHER people for their personal reasons (eg a cardiologist wanting all primary care docs and nurses to ask patients how many minutes they exercise per week, “because it is a good idea”. Committee response: sure, only if you get approval from all primary care leaders that they find this idea valuable. Ultimately, request denied). It is possible the CDS leaders did not understand that nursing leadership approval was already granted.
MOCK IT UP.
Make the change visible and easy to understand. You have to dance a line. Ideally, you would work with an analyst to build the actual proposed change in the non-live environment in the EHR to show how it works. However, this is a lot of work for something that may not get approved, or may have extensive revisions requested. Instead, build something in powerpoint, that requires much less effort and can still show “what it will look like when working.” This gives decision-makers an easy visual and reduces misunderstanding. And, it is easy to change if adjustments are requested. Without a visual, decision-makers may misinterpret that your request is “not serious” and “You’ve not put enough thought into the process. Come back when your idea is more mature.”
ASK FOR IMPROVEMENT, NOT APPROVAL
In this case, if you already have clinical leadership approval for your tool, be clear what you’re asking from this committee. “I need your help improving my design. Do you have a better idea?” rather than “What do you think, may I build this thing?” It will change the tone of the conversation, if you are able to do it.
PUSH FOR CONDITIONAL APPROVAL WITHOUT COMING BACK
Sometimes the committee will say “well, this fine, except for this one question we have that you can’t answer today.” If it is something you are confident you can get answered, ask for conditional approval. “If we find out the answer is A, we will build X. If we find out the answer is B, we will build Y. If it something else entirely, we will come back to discuss. If it is A or B, do we have your approval to complete this project?” Very often the answer can be yes and you cut time off of your project without having to come back to argue for approval again next month.
The Lesson Learned
Start with WHY. Bring your ARMY. Make a PowerPoint MOCKUP. Ask for IMPROVEMENT. Push for CONDITIONAL approval to avoid delay.
Try This Yourself
Try these techniques. Yes, CT Lin has created a forest of impenetrable committees to keep the EHR from becoming a “junk drawer” of everyone’s favorite pet projects. On the other hand, good ideas should not go to committee to die.
Use these techniques. Make “doing the right thing” easy.
