For Sajid Ahmed, the chance to build a new hospital and provide care to more than a million underserved patients was too good to pass up. But it wasn’t going to be easy. In order to succeed where the previous facility was (very publicly) shut down, MLK Community Hospital would have to do two things: expand care outside the four walls and leverage technology to improve outcomes. In this interview, Ahmed talks about what it will take to achieve those goals, why he believe culture is the most important innovation, and the challenge of going big bang with an EHR before workflows were established. He also discusses his “no fax machine” policy, the trap many hospitals fall into, and the one thing he would’ve done differently.
- Big-bang with Cerner
- Optimization since day 1
- “There are pros and cons to being a green field.”
- From 0 to 2,500 policies in 6 months
- No fax machines — “I’m still fighting that battle.”
- Building a culture of adoption
- The golden rule: “Will this support high quality care?”
There are pros and cons to being a complete green field. When you go from having no policies to developing 2,500 in a span of six months, and you get brand new people in who are working off of a paper workflow, the reality sometimes is different from what you imagined.
There’s that old reflex, because a lot of the hospitals around our neighborhood are delivering care without high-tech support. And it’s not their fault. It’s a lot of capital effort. It’s a lot of adoption and training. It’s a lot of changing mindsets.
We wanted to make sure we didn’t break the golden rule, and that is: will this support high-quality care? Will this support bottom-line efficiency, so that the organization can support the staff and be financially sound and provide high-quality care? It always came down to high-quality care, high touch care.
We always try to be sure the workflow and the care needs drive what technology will support. But I will tell you, this was a unique opportunity for myself and the team that if you build it, they will come. And they have come, and used the technology.
Gamble: When did the hospital actually open its doors?
Ahmed: We opened the ED on July 7, 2015. We got licensure at the end of April, and we were accredited in early June. We saw our first patient on May 14 — the way it works, we had to see at least 30 patients and have one discharged to earn accreditation from the Joint Commission.
When we opened for licensure, when we had everything ready. We had gone big-bang with Cerner. And it was truly a big bang. Nine month prior to April, there was nothing in place. We had just moved in to the brand new facility in September of 2014, and we were just in the beginning of the design and build of the EHR. At that point we had hired less than 100 people, so we had to staff up fast. In about nine months, we hired close to 750 people.
We connected all of the medical devices to the Cerner EHR, which we call the collaborative care system. So 58 devices were connected to the interface: the smart bed, the patient interactive system, screens, monitors, you name it, and we launched it big bang. For the last 12 months we’ve been updating it, and now, we’re in the middle of an optimization and process improvement initiative driven by workflow improvement.
Gamble: I imagine the optimization phase is particularly interesting when an EHR is implemented before any workflows have been established.
Ahmed: Oh, yes. There are pros and cons to being a complete green field. When you go from having no policies to developing 2,500 in a span of six months, and you get brand new people in who are working off of a paper workflow, the reality sometimes is different from what you imagined. We’ve been doing optimization in real-time since we opened, and we also put in a framework for Lean Six Sigma. We’ve been doing formal process improvement initiatives since about six months after we opened, and we’re realizing those benefits now.
In fact, I’m very proud to say that our scores for quality are some of the highest, both regionally and nationally. We’ve set our sights pretty high. Right now we don’t have any CMS star ratings because we haven’t gone through their black box yet, but the estimation is that we will definitely score in the three-star range for our CMS quality scores. And that’s a testament to the work this team has done.
Another cool thing is that we went from zero to HIMSS Level 6 in four months, meaning four months into opening, we qualified and got validated for HIMSS Level 6. We didn’t have enough data for validation for HIMSS Level 7; we’re getting that at the end of this year and hope to qualify for HIMSS Level 7. We’re right on track; we are 100 percent CPOE. Those are the pros. The cons are we still have adoption challenges because we’ve hired people from disparate systems with different skill sets and experiences coming from hospitals that aren’t as digital or as ours.
One thing I did was something that I’ll either be known for or will make me go down in history as the worst CIO ever: I banned all fax machines from the hospital.
Gamble: Interesting. How did that go?
Ahmed: I’m still fighting that battle. Right now, there are no fax machines in the hospital. Faxing capability has been turned off on the multifunction printers, with one exception. I had one colleague that resisted, but he was my only outlier, and he wasn’t in the clinical space. So in the clinical department, there’s not a single manual fax being done or received. We’re fully electronic through our EHR, and even administratively he’s the only exception, so it’s safe to say we are a no fax machine zone.
Gamble: I can imagine there was resistance. How did you deal with that? Was it something where people had to realize this is the new order?
Ahmed: Yes and no. I’d like to think I was winning that battle, but a little while ago, one of my directors told me they caught a fax machine order just before it went through. And some of the managers we hired in the clinical space just didn’t know what technology was available. And so we’ve worked very hard to hold people’s hands and educate them about the technology. In some cases, our process improvement initiatives have found that many of the new nurses and doctors don’t know what technologies we have that could support and leverage it. That’s been one of our challenges: continuous education. We realize we need to be doing continuous education and implementation.
Remember, we’re challenged with staffing. We’re dealing with a number of traveler nurses, so there’s a lot of rotation. The folks that have been there now for more than a year have become great proctors and great educators, but there’s that old reflex, because a lot of the hospitals around our neighborhood — except for Cedars and UCLA — are delivering care without high-tech support. And it’s not their fault. It’s a lot of capital effort. It’s a lot of adoption and training. It’s a lot of changing mindsets. All that considered, I can see why there are challenges in the industry.
Unless you are Kaiser saying, ‘we’re going to do X, Y, and Z’ and have a mandate, it becomes really difficult. We’ve been very fortunate to have the leadership from our medical group and other key leaders say, ‘you have the tools, figure out how to leverage them.’ A lot of our people came to Martin Luther King from other places because we’re such a brand new hospital. So I think we will eventually have that cultural saturation of adoption — but no fax machines,
Gamble: Getting to HIMSS Stage 6 was a priority, and your organization achieved it pretty quickly. Was the key motivator there?
Ahmed: To be honest, my goal wasn’t to achieve any particular ranking, HIMSS or otherwise. When we designed the hospital and looked at the infrastructure and the technology we could put in, we had a glossy-eyed moment where it was, ‘We can implement this; we can implement that.’ One example of blue-sky thinking was that we were implementing RTLS throughout the hospital, and as we slowly began to flush it out, we wanted to make sure we didn’t break the golden rule, and that is: will this support high-quality care? Will this support bottom line efficiency, so that the organization can support the staff and be financially sound and provide high-quality care? It always came down to high-quality care, high touch care with the patients. And when we looked at RTLS as an example, we said we won’t even have a baseline for a lot of the things RTLS is useful for. It’s a great fun factor. But we weren’t sure.
Another example is that post-implementation, we spent a lot of time and effort in patient interaction systems. There are 45-inch plus monitor screens in every patient room that are connected to the system and can provide education, but the utilization of those systems has turned out to be fairly low. It’s more something that’s cool to have versus a must-have. Maybe as the population demographics shift and the younger population that’s more savvy with the technology will come in, they’ll use it, but for now, usage is low.
On the other hand there are things that are a must-have, like high-density wireless throughout the hospital. To prepare for the future, we put in fiber cable throughout the hospital, and we put in a high-end infrastructure for networking and data transmissions. For a hospital of our size, I made sure that our primary and secondary Internet lines were one gigabyte. So we put in a gig line right off the bat, and we might increase it later because we want to support more telehealth initiatives and we want to provide support for wireless devices, which is where everything is going.
Gamble: So clearly enabling a mobile environment has been a key priority.
Ahmed: Absolutely; we went full mobile. Every nurse, every doctor, every environmental services, security, and ancillary support person throughout the hospital has a mobile device. Right now that’s an iPhone, which has a mobile app called CareWear Connect. With these phones, you can call, you can text, and you get bed alerts for nurses that are assigned patients. You can share information through this device, but if you walk outside of the four walls of the hospital or the campus, you lose access. It becomes a brick. And it’s device agnostic. You can pick any iPhone that has that app — and actually, for the doctors we put it on their BYOD devices — turns off and disconnects from the systems to avoid PHI getting out once they leave the hospital.
So we’re using mobile technologies. We have docs right now rounding with hospitalists and using iPads to demonstrate how they can document. We have touchscreens throughout the hospital in preparation for full touch documentation. We use Nuance Dragon Speaking for all of our documentation. We use Dynamic Documentation so we use voice.
We’ve done a lot of cool things in the mobile space. In fact, we were a beta partner with Cerner and help develop a lot of their code for the mobile app. \That’s one cool innovative thing, although that’s a little bleeding edge for my liking; I want it to be cutting edge, not bleeding edge, so we have to overcome the challenges. Cerner went in full force with us, dedicating time and people onsite and so we were able to do this without negatively impacting patient care. Now when you tell the nurses and doctors, ‘we’re thinking of taking the phones back and doing something else,’ they say, ‘no, we love this. We want this.’ We do all our code alerts to the phone as well, and of course with redundent backup systems. I’m really excited; it’s worked out well. I’m really proud of the mobile solutions we’ve put in, and a lot of cool technologies in place.
But, going back to your comment, a lot of this was designed and planned without achieving a certain stage. We had just launched in July of last year, and so when Cerner came, they said, ‘Hey, you guys are all fully digital — you might want to see what you qualify for.’ And when we did the assessment, we immediately qualified for 6 and we could have potentially qualified for 7, but we didn’t have the requisite 4 to 6 months of data. Still, there was that thought of, ‘Well, should we just do it?’ But we said, no, let’s do 6 now and let’s make sure that everyone’s using the technology to support the care. We don’t want the technology to drive the care; we want the care needs to drive the technology need.
In some cases, there was a little give and take, but I think when given the opportunity, a lot of our folks blue-skied at themselves when they came on board. They looked at technology and said, ‘look at what we could do and what’s available.’ And we do a lot with technology; we use iPads in the ED waiting room for registration and signage. We always try to be sure the workflow and the care needs drive what technology will support. But I will tell you, this was a unique opportunity for myself and the team that if you build it, they will come. And they have come, and used the technology.
One strategy that’s been key is that in other organizations, department heads drive what technology is going to be used. Everyone has their pet projects. Doctors are very smart folks and I love them dearly, but in our institution, we came up with a basic strategy that I’ve held myself and everyone else to. I don’t want to manage so many different vendors. I want to invest in key vendors to develop key technologies. And that’s why we went with Cerner — they had a good innovation roadmap.
I try not to do one-offs. I try to make it consistent so I don’t have to deal with so many interfaces. I think that’s helped, because when we’ve had doctors say, ‘we really liked this other technology,’ or ‘We’d really like Cerner to do what Epic does,’ we can say, ‘We already have the technology. In some cases, it’s better, in some cases, it’s not as good, but let’s do what’s best for the hospital, because by using another technology, we’re going to spend time building and investing in something that maybe doesn’t work so well when it’s plugged into everything else.
So that was one of our core strategies when we launched in our design, rather than focusing on choosing certain attributes, and I think that’s really helped.