What do psychiatrist Elisabeth Kübler-Ross’ seven stages of grief have to do with a PACS (picture archiving and communication system) implementation? Actually, quite a lot, according to health IT program managers at UPMC Enterprises in Pittsburgh, who use them as a basis of their change management framework.
During an April 25 webinar hosted by the Society for Imaging Informatics in Medicine (SIIM), Bruce Gay, senior program manager, and Stacy Norman, senior product manager at UPMC Enterprises, described the formal change management process they developed for a PACS replacement effort, and said it could be applied to many types of informatics projects.
Norman said one of the challenges they faced in developing a plan for a successful rollout of a new PACS system was the sheer size of UPMC. It has 41 hospitals, 78 imaging locations, 245 radiologists, and does more than 4 million exams per year. It had three legacy PACS and 14 different archives where images were stored. “One selling point was the consolidation into one system and the use of one vendor neutral archive,” but that required a huge data migration. “We had 18 months to do it,” she added.
UPMC Enterprises is the innovation and commercialization arm of UPMC. Its employees are involved in building or buying problem-solving solutions and partnering with other organizations to build and commercialize them. They are partnering with the vendor on this next-generation imaging system and want to include features that would delight radiologists. For instance, the new system would allow radiologists to see content pulled from the EHR without requiring them to navigate out of their imaging software.
“At the end of the day, we need the radiologists to be happy with the new products,” Norman said. One of their goals in working with the vendor was to be a show site for its successful implementation. “We can’t do that with grumpy radiologists,” she added. “We had to do the replacement without disruption to patient care and without stressing the radiologists out too much." When they started on the project with one community hospital that has seven radiologists, they realized that going forward they would need a formal change management plan and brought in a change management consultant to help.
So how do Kübler-Ross’ seven stages of grief come into play? Gay said that although her work focused on how people process death and dying, it has been applied more broadly to how people cope emotionally with bad news or change. He said co-workers go through these stages in response to any big new health IT implementation. The seven stages are shock, denial, anger, bargaining, depression, testing and acceptance.
Gay said here is what happens in the shock phase: “When we communicate change, there is initial paralysis. On the outside, they appear to have no reaction. Inside they are frozen and the news has not yet taken root. As informatics professionals, we can help pre-empt the shock by communicating how the changes are going to improve things.”
In the denial phase, the shock wears off, but the person pretends they haven’t heard the message. Gay said IT professionals need to continue to message about the change, so they can’t avoid it.
In the anger phase, the IT team is going to be blamed. They are confused and angry about changes being made to their work flow. Norman said this did happen with the PACS replacement, in part because the previous system was home-grown, so radiologists had pride in it. In this stage, Gay recommends giving them space to express their anger. In hospitals, the anger will not always be in an open forum, he noted. “The storm will blow over,” Gay said, “and then they can move on to bargaining.”
In the bargaining phase, they may seek an unrealistic false hope of a way to get out of doing the change. Gay said the messaging has to be consistent here from clinical and IT leadership about the benefits of the change.
Depression, Gay said, is inevitable and is a passive state. The goal here is to communicate that they are not isolated and to give them a lifeline of stability.
The testing phase is where they seek alternatives to move away from change. Gay said to stay on message and help individuals move back to stability as the project becomes operational.
In the acceptance phase, people start to take ownership of themselves and their actions and start to see positive results, and appear more content.
To cope with these inevitable phases of resistance and acceptance, the UPMC team developed a PACS deployment cycle with six phases.
Planning: When they started they found they might not have answers to certain user questions or had conflicting messages to users. The change management consultant recommended they be able to answer three basic questions consistently. The Head: the logic behind the change and who made the decision. The Heart: what do other clinical champions think? What is in it for me? How are they going to benefit? One answer is that they previously had 14 repositories they had to search to get a complete imaging history. That is not going to be a problem anymore, Norman said. They will be able to see the patient record in one shot.
Discovery: They spent hours just observing the work flows of radiologists.
Synthesis: People who understand the new product observed radiologist to confirm work flows, document the differences and tailor training guides.
Training: Individualized training with radiologists shortly prior to go live. “We trained for comprehension and retention,” Norman said. “As they use it, we sit there and watch and answer questions to make sure they understand it. We also asked the vendor to understand that mindset and our objectives. We got their buy-in for messaging.”
Go-Live: They started out staffing up with one support person for each radiologist, but found they didn’t really need that many and soon reduced the number.
Post-Go-Live Support: The UPMC team learned they didn’t message well and explain the timing for going back to relying on standard support. They were getting calls at 7 a.m. on Saturday morning. “One lesson learned is that you have to set clear expectations for the transition back to standard support processes post-conversion,” Norman said. Gay said in the post-go-live, they looked for pain points and product enhancement requests to give the vendor. “We had a period of support, observed gaps and rolled those changes back into the product development cycle.”
Norman said that having a clear change management process made subsequent implementations go much smoother. “We saw a marked difference between site one and site two,” she said. “At site two we had budgeted two weeks of support. After day three they sent us packing and said they didn’t need us. That was a great achievement for us.”