How Small Organizations Stay Focused On The Big Picture

Regardless of size, in HIT, the world is changing.

My hospital is small. We are a 25-bed critical access facility with a 49-bed long-term care unit located on campus. We have two remote clinics staffed by physician assistants and three employed physicians. Our primary care group has 13 providers. Additionally, we have an ophthalmologist, two podiatrists, five dialysis units, two optometrists, and two dentists located on campus who are independent of the hospital.

When you add it all up we have over 500 FTEs for which we provide IT support. The hospital itself has about 325 FTE and runs just a little over $50 million in annual gross revenue (reasonable for a CAH, but small by most standards.) We are located in a town of 10,000 people and a county of 20,000. To say we are rural is to put it mildly. We have an IT staff of four with two clinical IT FTEs, counting the CIO.

Although we are small, we face the same breadth of issues as our larger brethren. While our larger friends may have more subspecialties, departments and politics to consider, the full scope of issues is roughly the same. The difference is that my staff has six (counting me); some facilities have 100 times that in human capital — and perhaps financial capital as well. Just the difference in sheer numbers allows larger facilities to have more depth of resource and specialization of talent.

So what does a small guy do? The good news is that we too can get the job done. We are all experienced at wearing multiple hats, dealing with both financial and human capital scarcity. I am not saying this makes the job easier, but we have done this before. It is easy to focus on the resources we don’t have, and at the same time fail to recognize the advantages we do have.

First, we do not have to turn the Titanic. For example, my medical staff is fairly small. That gives me the opportunity to have a personal business relationship with each of them. I’m able to see them all every day, which is a huge advantage. That, coupled with having established credibility with them, makes discussing needed changes much easier than if I had a staff of 500 or more.

The same scalar advantages apply to all other constituencies, especially the clinical areas. While the change we have to implement is as broad as that of our larger friends, the depth of penetration we have to achieve is less, lightening the load somewhat. Still, the enormity of the task is overwhelming.

I have found that the keys are focus, communication, and strategic resource augmentation. I choose to set a big-picture view of the tasks ahead of us. Right now, we have 30-plus projects on our “to do” list. I keep that list in front of my steering committee, even as I seek to focus us all on the top two or three priorities of the moment. If we try to attack everything at once, the impact would be disastrous.  Focusing on the items right in front of us — those priorities we can tackle and accomplish near term — helps keep the team headed in the right direction. Admittedly, we start every discussion with an overview of the big picture, but then we come back and say, “Let’s eat this elephant one bite at a time”.

Communication is essential as well. For example, MU 2 has 16 core objectives and four menu sets. That in and of itself seems daunting, but when we communicate with the team where we actually stand against these after three years of attestation for MU 1, the enormity of the task gets whittled down to size substantially. That isn’t to say it is easy, but if you communicate well about what is actually required, the task becomes manageable. ICD-10 may be another beast that cannot be whittled down in size, but it can be attacked in pieces, making the task more feasible.

Communicating the “why” of this journey is as important as the “what” or “where” of the trip. We try always to tie communication back to the patient and the mission and vision of the organization. There is a reason we are doing this and it is all about quality of patient care and outcomes. Hopefully when we achieve these goals, we will also have a positive impact on bending the healthcare cost curve in the right direction as well. We preach these mantras constantly in every discussion and presentation we have. Making sure folks understand why all the effort is needed is a huge factor in making change happen.

Still, at the end of the day, the small guys don’t have all the resources they may need. In our case, two glaring issues uncovered this point: HL7 interfacing and security assessment. While we do a lot of HL7 interfacing, we do not have a go-to “HL7 expert.” We do a great job managing the 50-plus connections we run every day, but developing new connections is not our strong suit. The same can be said of security. We do a good job of maintaining our security environment, but none of us had ever been charged with conducting an overall assessment. We know the technical side well, but were not as strong with the administrative and physical parts of the security equation.

Further, we are probably way close to the security forest to see the trees and underbrush. This is where strategic resource augmentation has paid great dividends. Fortunately, we had an HL7 interface engine and partner to assist on that front, and we also found a security consultant. After all, if you need an auditor for the financials, why not security? Both, in my book, are as good as they come in their discipline, and did well by us.

So in conclusion, yes, the journey is difficult for the smaller facility, but the disparity isn’t as great as one might think. It is true that we have fewer resources — both capital and human — than our larger counterparts, but we also have the nimbleness of being small. While we too tend to committee things ad nauseum, ours are smaller, fewer and tend to act faster. And yes, we have clinician issues to deal with, but we also have the advantage of being able communicate one on one. We have the chance to tell our story and “preach our gospel” on a person-to-person basis rather than through mass communications.

We may not have all of the required expertise — particularly in specific disciplines like HL7 and security in my case — but we have people who can and will step in to help. Hopefully we have cultivated those relationships along the way, but heaven knows the resources are knocking at our doors, constantly.

Our leadership challenges are the same as those faced by our larger friends, and change management is just as demanding for us. However, we can capitalize on the advantages that smaller facilities do have; focus on the end goal of the patient, communicate why we are doing what we are doing, and supplement our resource pool from outside when needed. Thus far, it is working in southeast Iowa, and I think it will work elsewhere.