Susan Marino, CNIO, Hartford HealthCare, Chapter 2

It was five years ago that Hartford HealthCare began its journey to become an integrated system, and five years ago that the organization named Susan Marino as its first CNIO. The timing is no coincidence; in fact, it was a deliberate move by leadership to appoint someone with a deep knowledge of both nursing and informatics to help establish governance, guide the training process, and most importantly, ensure that the front-line staff was able to work as efficiently as possible. In this interview, Marino discusses the “never-ending” Epic rollout that’s becoming a game-changer at Hartford, how hear team is working to optimize the system without placing too much burden on physicians and nurses, and their biggest priorities for the coming year.

She also talks about her own journey, reflecting on the hurdles she faced early on and the “one win at a time” approach she took to bring nursing to the decision-making table, and emphasizes the importance of leveraging technology to increase satisfaction among nurses.

Chapter 1

Chapter 2

• Establishing governance to prepare for Epic
• Executive leadership engagement
• Clinical councils: “Our goal was to build a product with a system-wide focus”
• Standardized workflows & process to reduce variation
• Mandatory training “to ensure operational readiness”
• No training, no access, no kidding
• Replacing consultants with super users – “It was a remarkable program.”

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Bold Statements

While we did have a need for some variation based on complexity of care services that only practiced at one hospital, the goal absolutely was to reduce variation and create efficiencies.

It was really important to have things like, ‘no training, no access. No kidding.’ Everyone was required to go to training. We couldn’t have folks showing up on their floors trying to get through this system that was significantly different than what we had been on.

We developed internal strengths to be able to beef up so that every time we got to the next hospital, our own internal folks who enjoyed that personal development, who enjoyed going to that next organization as an expert, really understood our workflows and how the system really supported the patients in each specific area. It was a remarkable program.

We are regionally stationed so that we can be available on day-to-day basis within our organizations, not only working on the next project or initiative, but also supporting individuals who are struggling, and supporting the ongoing engagement of our super users and credentialed trainers.

Gamble:  When you talk about all the things that are priorities now, things like the virtual health, optimizing the system, and population health, what started all of that was the transformation to Epic, which dovetailed with the organization’s own transformation going from individual hospitals to a health system. Can you talk about really what was required from a governance standpoint to make sure the systems that were being put in place were going to be as effective as possible for the users?

Marino:  Right. That’s a great question, and I have to say that governance was absolutely a success factor in being able to move this huge project along. It starts with several different layers. Certainly you have an executive team layer where you have the top decision-making and work to eliminate key barriers and risks to the organization. We have a leadership team that has worked throughout the last four to five years, meeting once a week to actually take on critical issues of the week, or the address the barriers to getting our end user training completed or systems that are not supporting the program as well as it could. That executive leadership team was comprised of revenue cycle leadership, our operationally leads from each one of the hospital — CNO, VP of Medical Affairs, etc., our informatics leadership, our ITS leadership, and then depending upon what challenges we had, other clinical areas might be brought to the table on a regular basis to understand how to continue moving forward and make decisions that were consistent with our guiding principles.

What’s also critical are the clinical councils that we have within our organization. When we first started, the key councils were identified and were comprised of individuals from across the system. Our goal was to build our product with a system-wide focus so that when any one of our organizations came live, we would all be looking at very similar workflows, processes, order entry, and clinical documentation. And so while we did have a need for some variation based on complexity of care services that only practiced at one hospital, the goal absolutely was to reduce variation and create efficiencies that we really would need.

We have a cancer institute council, we have a pharmacy council, we have key nursing councils — not only one for the system, but then at each acute care space and in our post-acute space, and we have surgical councils and palliative care councils.

In the last five years, those councils have expanded. They’ve become much more efficient how they make decisions. We have now 31 councils that support our system in decision making and the governance structure so that we’re sure that the clinicians and staff have access to those conversations and can be part of the workflows and the decisions that then can escalate to a more executive team. But making all the councils and all of those governance structures work in harmony is quite the challenge, and I’m sure anyone else who has been in a very large roll out of electronic medical record systems has been challenged by that as well.

Gamble:  You talked about wanting to reduce variation, while being aware that there is going to be some variation because you’re dealing with so many different types of needs. I imagine that’s a difficult balance to try to achieve.

Marino:  Absolutely. In supporting those governance structures, we had training councils. We have a change management council who really watched from rollout to rollout how our organizations and our operational leadership were supporting each one of the roll outs. Were their staff going to the meetings where they were getting educated? Were their managers going to classes where they were learning how to transform their charges? And how they were charging and monitoring charges in their areas, making sure that they all understood the workflows that were being brought to each specific area, and then of course, the policies and procedures that all had to accompany all these new workflows and the changes that were coming with the roll out. So yes, many supportive services, as well at the governance structure made it quite the orchestration to be sure that the deliverables all came in time for roll outs.

Gamble:  I imagine there were steps that had to be taken to adjust for things like bed management and even employee scheduling. What were some of the things you did to kind of keep all of that on track during the implementation?

Marino:  When we were beginning to look at each organization and the strategy for go-live, taking into account the size of the organization and the staff that would be available, it was really important to have things like, ‘no training, no access. No kidding.’ Everyone was required to go to training. We couldn’t have folks showing up on their floors trying to get through this system that was significantly different than what we had been on. We had five Legacy systems before going to Epic. So it was really ensuring that we had operational readiness.

We had an entire program where each organization, as they were preparing about six months out from go-live, would start an every-other-week meeting with key managers, directors and leaders from the organization. We had an entire pathway of topics, of education, of data to support them watching along us, were their staff signing up to go to training, had they attended training, who were the outliers, how do we get to those outliers, and what communication structures did we put in place to be sure that there was a cascading down throughout the organization.

We relied extremely heavily on key operational components within Hartford Healthcare. We use lean daily management. All of our areas have daily huddles so that communications were able to be cascaded in a very consistent way throughout our organizations. Those were absolutely hallmark to the success of each organization. And then certainly the staffing of those go-lives was critical, making sure that ahead of time that we prepared areas that were challenged by staffing, whether we brought in temporary staffing or came up with another solution.

One of our most successful programs was the fact that as we rolled out our first go-live, it was 100 percent covered by consultants who came in and stood at the elbow with our end users as we turned the software on. For the first two to three weeks, they provided support 24×7. After the rollout of our first two hospitals, we had a credentialed training program and a super user program and we developed internal strengths to be able to beef up so that every time we got to the next hospital, our own internal folks who enjoyed that personal development, who enjoyed going to that next organization as an expert, really understood our workflows and how the system really supported the patients in each specific area. It was a remarkable program, and by the time we hit our final hospital, Backus Hospital, in October, we probably provided about 70 percent of the support for that go-live. So not only did we have an engaged staff supporting the organization, it also helped with us with cost savings in hiring external consultants.

Gamble:  That’s a big difference. I’m sure it’s nice to have those kind of numbers to show that what you’re doing is really working.

Marino:  And the staff that travels to the other organizations were proud. They were glad to be there to be able to help get folks through the first difficult days. They made great friends. They mostly would support the specialty area that they had come from, so they know the practice, they know our patient populations, and now they can help their new colleagues learn key skills, and they’re very proud of that. There was a lot of conversation, new friends across the system. Now in our councils, we have folks that know each other much better because of their participation in either the credentialed training or the super user program.

Gamble:  Being a nurse, I’m sure you have an increased understanding of some of the challenges they face, and there’s a real emphasis on your part and on the part of the clinical informatics team to use whatever tools or processes you can to help make sure that nurses’ issues are being addressed, and that they’re able to work at the top of their license.

Marino:  Absolutely. We have about 26 nurses and physicians and a PRN staff who were committed to this entire project, from the time of development going through all of our different components of build and design, integration, testing. Through the building the curriculum and teaching and supporting our new staff, they have been an invaluable component of success for the organization. They continue to be there in those organizations. We are regionally stationed so that we can be available on day-to-day basis within our organizations, not only working on the next project or initiative, but also supporting individuals who are struggling and new hires, and supporting the ongoing engagement of our super users and our credentialed trainers so we can continue that professional development expansion of the services we try to provide.

Gamble:  Right.

Chapter 3