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OrganizationalStructures

forClinicalTransformationBy:MaryStaley‐Sirois,PT,MBA&ColinKonschak,MBA,FHIMSS,FACHEThe healthcare industry is in the process of transforming itself using technology. These

transformationeffortsfocusonmovingfrommanualprocesses,oftenbasedonhistoricalpractices,

to technology‐enabled or even automated processes. The overall effort involved in such a

transformation creates a tremendous amount of disruption to all aspects of the organization,

creatingtheabsoluteneedforacommitmenttomanagingchange.

Thispaperexplores, throughcase studies, theclinicalandcultural considerations in implementing

andmanagingworkflowchangesatthreelargehealthcaresystems.

Introduction

Thescopeofclinicalandculturaltransformationinhealthcaretodayisprofoundandall‐inclusive.It

requirescollaborationbetweenallclinicalandtechnicalareasofahealthcareorganization,

necessitatingnewgovernanceandorganizationalstructures.

Thetransformationismulti‐dimensional,takingonmedical,clinicalandculturalimplications.Onthe

medicalandclinicalsides,effortsfocusondeterminingandimplementingbest‐practice,evidence‐

basedprocessesthatsupporttheadoptionofclinicaltechnologies.Ontheculturalside,theclinical

transformationeffortsrequirehealthcareorganizationstoworkcollaboratively,bringingtogether

groupsofphysicians,nurses,pharmacists,ancillarycareproviders,andinformationsystempersonnel

tochallengethewaythingsaredonetoday.Theresultsofsuchcollaborationarenewcareprocesses

andpractices,aswellasdatastandardsandintegritythatbettersupportapatient‐centricapproachto

care.Thesedevelopmentswillensurepatientsafety,qualityofcare,workflowefficiencies,care

timelinessandeffectiveness,andoverallcaregiverproductivity.

Theoveralleffortcreatesatremendousamountofdisruptiontoallaspectsoftheorganization,

creatingtheabsoluteneedforacommitmenttomanagingchangeateverypointalongtheway.

Becausethescopeofthisclinicalandculturaltransformationissoprofoundandall‐inclusive,

organizationsmustcreatenewgovernanceandorganizationalstructuresthatensurecollaboration

acrossclinicalandtechnicalareas.Tosucceed,organizationalchangestructures,committeesand

teamsshouldensure:

• Leadershipalignmentattheseniorexecutivelevel,includingboard‐levelsupport

• Participationofmulti‐disciplinaryend‐userworkteams

• Sponsorshipbyclinical,operationalandphysicianleaders

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Essentially,thoughthegoalforeachorganizationappearstobethe

implementationofatechnology,the

organizationsfocustheirgoalsonstepsthataffectuseofthetechnology.Thus,theirendgoalsare

actuallytheadoptionofthetechnology.

• FacilitationfromITpersonnel

Recurringtheme

Thecasestudiesthatfollowexplorethreelargehealthcare

systemsthataretransformingclinicalcarethroughthe

implementationofworkflowchangessupportedbytechnologies.

Therecurringthemeinalloftheorganizationalstructuresisthe

presenceofphysicianandnursingchampionshipalongwith

carefulalignmentoftheorganization’soperationalentities.

Essentially,thoughthegoalappearstobetheimplementationofa

technology,theorganizationsdefinegoalsthatalignwiththe

utilizationofthetechnology.Thus,theirendgoalsarethe

adoptionofthetechnologyintheprovisionofhighqualitypatient

care.

Finally,inadditiontoaddressingorganizationalclinicaltransformationmodels,effortsweremadeto

provideexamplesofclinicaltransformationdepartmentreportingwithintheoverallorganizational

leadershipstructure.Today,trendsrevealreportingoftransformationdepartmentsthroughtheChief

InformationOfficer(CIO);however,commentsfrommanagementindicatespecificchallengeswiththis

structure,namely,alackofclinical/medicalprocesschangeimpactingleadership,understandingand

appreciation.

Alignmentmustprovideclearandhighlysupportedlinesofcommunicationbetweentransformational

leadersandclinical/medicalstaffoperationalleadersatalllevelsoftheorganization.Sowhile

healthcareorganizationscontinuetolookfororganizationalalignmentbestpracticeforpositiveclinical

transformation,theleadershipofclinicaltransformationalignedwiththeCIOcouldputthetechnology

implementationgoalsatrisk.Itisimperativethatclinicalinformationsystemimplementationsare

championedbyseniormedicalandclinicalleadersworkingincompletealignmentwiththeCIO.

CaseStudyOne:ReorganizationAroundaNewClinicalApplication

HealthcareOrganizationOne(HO1)isa12‐hospitalhealthsystemthatisimplementingaclinical

centerpieceapplicationthatwilladdressscheduling,access,emergencydepartment(ED),orderentry,

andclinicaldocumentation.HO1begantheirclinicaltransformationeffortsbycreatingadepartment

ofclinicaltransformation(CT).TheCTdepartmentreportedtotheChiefOperatingOfficer(COO),who

inturnpartnerswiththeinformationsystemsdepartment(IS).Atthestartoftheirclinical

transformationjourney,HO1hadnoseniormedicalornursingofficer;andthelackofalignmentofthe

CTdepartmentandIScreatedsignificantissues.

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Eventually,aChiefMedicalOfficer(CMO)andChiefNursingOfficer(CNO)joinedwiththeChief

MedicalInformationOfficer(CMIO)toreorganizetheCTdepartment.Thegoalsincluded:

• TobetteralignwiththeworkofIS;and,

• Becomeabridgebetweentechnologyandclinicaloperations.

Undertheneworganization,theCTteamreportstotheVicePresidentofApplications(VPA)through

theDirectorofCareModelIntegration(CMI)(seechartbelow).TheCMIroleincludesadottedline

reportingrelationshiptotheCMIO.Inaddition,thetechnologyimplementationprojectmanager

reportstotheVPA,creatingacohesiveandcollaborativeteamunderasingleseniorleader.

HO1’sOperationalLeadershipStructure,ReportingtotheCIO

TwodistinctgovernancestructuresnowfunctionunderthedirectionoftheCIO–ISandclinical

informatics.

ISgovernanceforthe

organizationis

overseenbyanIS

GovernanceCouncil

(ISGC).Chairedbythe

COO,membershipon

theISGCincludesthe

C‐levelleadersatthe

systemlevelaswellas

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theCIOandhisseniorleadershipteam.

TheExecutiveCommittee(EC)overseesclinicalinformaticsgovernancefortheorganization.This

includesthedataandworkflowthatwillbeimpactedduringimplementationoftheelectronichealth

record(EHR).TheCMOchairsthiscommitteeofseniorclinicalleaders,includingphysicians,nursing,

quality,patientsafetyandIS.Inputtodiscipline‐specificdataandworkflowcomesthroughthe

system‐level,interdisciplinaryand/ordepartmentalclinicalcouncils,witheachcouncilco‐chairedbya

physicianandanoperationalleader.

Hospital‐levelgovernanceforIS(aswellasclinicaldataandprocessstandardizationthatisaresultof

theEHR)occursthroughFacilityImplementationTeams(FIT).TheFITisco‐sponsoredby:asenior

hospitalexecutive,aphysicianleaderandrepresentativesfromvarioushospitaldepartmentsandthe

medicalstaff.

CaseStudyTwo:Enterprise‐buildLocalizedat22Hospitals

HealthcareOrganizationTwo(HO2)isa22‐hospitalhealthcaresystemimplementingaclinical

centerpieceapplicationthatwilladdressscheduling,access,ED,orderentry,medicationmanagement,

andclinicaldocumentation.

Inaddition,theyareimplementingasystemstandardRIS.LikeHO1,theyarecreatinganenterprise

buildwithlocalizationattheaffiliateorhospitallevel.Theoverallprojecttimelineissixyears.

HO2CommitteeStructureforEHRProject

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TheCEOchairsthesystem‐levelEHRandProcessTransformationSteeringCommittee,with

membershipincludingtheC‐suiteleaders.ReportingtothiscommitteeistheEHRIntegrated

LeadershipCommittee,whichismadeupofoperationalleadershipfromthefouraffiliatesthatare

targetedforgo‐livefirst.Reportingtothiscommitteearetwolinesofwork‐thetechnicalbuildand

operationalstandardization.

Thetechnicalbuildisconsideredtheorganization’sArchitecturalModel.Duringbuildsessions,

operational/clinicalfrontlineleadersandstaffaddresstechnicalconsiderationssuchasnavigation

tools,headersandtheoverallapplicationlookandfeel.

AnIntegratedRevenueCycleCommitteeandtheIntegratedClinicalCommitteeoverseeoperational

andclinicalstandardization,includingdatacontentanddefinition,documentationflowsheetsand

workflow.

Thesearechairedbykeyoperationalleadersandalthoughintegrated,arefocusedonspecific

functionalareas.

SimilartoHO1,HO2hasaCTdepartmentreportingthroughtheCIO.Itisthroughtheprojectstructure

abovethattransformationalprojectactivitiesoccur.

CaseStudyThree:TwoClinicalInformationSystems,OneImplementationTeam

HealthcareOrganizationThree(HO3)isa43‐siteorganizationfocusedonimplementingtwomajor

clinicalinformationsystemvendors.Whiletheyareusingdifferentvendors,chosenbasedoncurrent

businessneedsandpractices,asingleprojectteamleadsthetransformation.Inspiteofthedifferent

clinicalapplications,theorganizationiscommittedtoassimilaraspossiblecareprocesses,practices

anddatastructures.

HO3’sHigh‐levelOrganizationalStructure

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TheprojectreportsthroughtheCIOviaaVicePresidentofClinicalImprovement,whoisresponsible

forthetransformationaswellastheapplicationimplementationareas.Theseteamsworkwith

hospital‐basedprocessandapplicationdesignteams.

TheTransformationLeadisresponsibleforoverallprojectgovernance,changemanagement,process

redesignandstandardizationanduserreadiness.Theseeffortsareparamounttothesuccessofan

EHRimplementation.ItissignificanttonotethattheTransformationLeadthatinitiallyreported

throughtheCMOwasrepositionedwiththearrivalofanewCIO.

Becauseoftheimportancefortransformationdepartmentstobetightlyconnectedtoclinicaland

medicalstaffgovernance,HO3establishedadottedlinerelationshipbetweentheVPofClinical

ImprovementandtheCMO.Thisthenpresentsitselfthroughalignmentwiththeclinicalinformatics

structurethatexistsateachofthesystem’shospitals.

HO3OrganizationalStructure

AtHO3,thehospitalimplementationsteeringcommitteeconsistsoftheclinicalinformaticistalong

withanexecutivebusinesssponsorandaclinical/medicalstaffleader.

IndustryDiscussionwithHIMSSAnalytics

AttherequestofDIVURGENT,theleadershipofHIMSSAnalytics,www.himssanalytics.org,discussed

knowntrendsinhowtheCTdepartmentandclinicalapplicationsisstructuredwithinhospitalsand

healthcaresystemstoday.Dependingontheorganization,theCTdepartmentreportstoIS,nursing

leadership,medicalstaffleadership,andhighleveloperationalleadershipsuchastheCOO.HIMSS

Analyticsexpertsagreedthatnospecifictrendsnowexistconcerningthisreportingstructure.

Theydidnote,however,thatnomatterwhatthereportingstructure,bestpracticewouldsupportclear

alignmentofstrategy,goalsandworkactivitiesbetweentheCTdepartmentandtheclinicaland

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medicalstaffleadership(CNOandCMO).InfurtherdiscussingthefutureoftheCTdepartment,they

indicatedthatitcouldevolveintoonedepartmentwithoverallresponsibilityforaformalinformatics

strategy.

Thisgroupaswellasleadersofthethreehealthcareorganizationsfeaturedhereforcasestudies,

expressedsomefrustrationoverallwithhospitalleadershipteams.Theyexpressedthathospital

leadership,includingtheCIO,didnotfullyappreciatetheneedtoconsidertransformationalprocess

andpracticeactivitieswellinadvanceofthetechnologyimplementation.

Finally,weassumethatthegoalofatechnologyimplementationisnottheimplementationitself,but

theadoptionofthetechnologyintoclinicalandmedicalstaffpracticeandworkflowprocesses.

Therefore,thehealthsystemsdiscussedheremaintainedsignificantfocusontheimportanceofawell‐

definedandwell‐supportedchangemanagementstrategyandplan.ThisissomethingforwhichaCT

departmentisuniquelyqualified.

Conclusions

Whilehealthcareorganizationscontinuetolookfororganizationalalignmentbestpracticeforpositive

clinicaltransformationoutcomes,themovetoplacementundertheCIOputstheappreciationfor,and

supportof,theimpactonclinical/medicalprocessesandpracticeatrisk.Alignment,ifreportingtothe

CIO,mustprovideclearandhighlysupportedlinesofcommunicationbetweentransformational

leadersandclinical/medicalstaffoperationalleadersatalllevelsoftheorganizationinordertobe

successful.

AboutTheAuthors:

MaryLawrenceStaley‐Sirois,PT,MBAisPresidentofResurgenceConsulting.Ms.Siroishasnearly20yearsofhealthcareoperationalandstrategicplanningexperienceacrossawidespectrumofproviderandacademicenvironments.Asaphysicaltherapistbyclinicalbackground,shehasworkedwithlargeandsmallhealthcaresystemsontheplanningnecessaryforclinicaltransformationasaresultofanEHRdeployment,organizationgovernanceandchangemanagement,medicalandclinicalstaffcollaborationonbestpracticeandevidence‐basedprocesses,regulatorycompliancereadinessandissueresolution,organizationalbudgetdevelopmentandrelatedbenefitsrealizationprojection,anddetailedprojectplanning.

Ms.Sirois’workisfocusedonleveragingtheskillsandteamofthehealthcareorganizationinthedeploymentofstrategicinitiatives‐fromproductdevelopment,tooperationalmanagement,totransformationofclinicalprocessandpractice,toEHRadoption.Ms.Siroisiswell‐publishedonHIPAAcomplianceandisapublicspeakerinhealthcareoperationsandregulatorycompliance.Inadditiontoherworkinthehealthcareprovidermarket,Ms.Siroisworkscloselywithinternationalorganizationsforthedevelopmentofoperationalandeducationalprogramstoimprovehealthcareindevelopingcountries.

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ColinB.Konschak,MBA,FHIMSS,FACHEisaManagingPartnerwithDIVURGENTandleadstheAdvisoryServicesPractice.Heisahighlyaccomplishedexecutivewithover17yearsofexperienceandrecognizedachievementinqualityservicedeliveryandprojectmanagement.Mr.Konschakhasextensiveexperienceinhealthcareoperations,P&Lmanagement,accountmanagement,strategicplanningandalliancemanagement.Hisbroadhealthcareexperienceencompassespharmaceutical,provider,payer,informationtechnologyandconsulting.Mr.KonschakisaregisteredPharmacist,possessesanMBAinhealthservicesadministration,isboardcertifiedinhealthcaremanagement,andisasixsigmablackbelt.HeisanAdjunctProfessorwithOldDominionUniversityleadingclassesintheirMBAprogramonPerformanceImprovement,NegotiationandBusinessEthics.Mr.Konschak’scommitmenttothehealthcareindustryisevidentinhisparticipationinsomeoftoday’sleadinghealthcaretradeorganizationsincludingservingastheimmediatePastPresidentoftheVirginiaHIMSSChapter,andachievingandmaintainingFellowstatusinboththeHealthcareInformationManagementandSystemsSociety(HIMSS)andtheAmericanCollegeofHealthcareExecutives(ACHE).

AboutDIVURGENT:

Foundedbyateamofconsultingveterans,DIVURGENTisanationalhealthcareconsultingfirmfocusedsolelyonthebusinessofhospitalsandotherhealthcareproviders.DIVURGENTprovidesadvisory,interimmanagement,revenuecyclemanagement,projectmanagement,andmodelingandsimulationservicestohelpimprovepatients’lives.

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