Susan Marino, CNIO, Hartford HealthCare, Chapter 3

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

Chapter 3

• EHR rollouts & staff burnout
• “It’s meant a lot of extra learning while staying focused on patient care.”
• Dealing with naysayers — “Why would we need a nurse to help build this?”
• “Dual role” of informatics & staffing
• Guiding the Epic rollout as CMIO
• “The technology & the role came along side by side.”
• Reliance on early adopters: “It’s tough work. You have to get over the bumps.”

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Bold Statements

It’s something that we continue to look at, in terms of getting to the optimization and efficiency stages where we now go back in and make sure that we’re really trying to lessen the documentation and the number of clicks. How can we make viewing the whole record better?

The technology and the role came along side-by-side. I was very fortunate in working with some great leaders throughout the years, and it was a natural next step for me to join the executive leadership team as we began our Epic journey.

There were some areas that pushed back; that didn’t really feel it was necessary to do it electronically. But there were early adopters that you help make the case for, and they would take that system and run with it. They really helped us in developing it to make it efficient and make it work for the staff.

It’s really important that we have individuals who understand how to put those programs in place, how to work through the workflow challenges, how to make sure you have a team representing the space and the topics that are critical to understanding the technology.

Gamble:  What you’re talking about speaks to things like fatigue and burnout and really trying to staying on top of these things as best you can.

Marino:  I’m not sure we did any favors with roll out of a big Epic system in the last few years. I know it has meant taking on a lot of extra learning, while at the same time trying to be focused on patient care. That’s very difficult, and I think that has been a strain on our staff and leadership, as well as the site caregivers or physicians. So, it’s something that we continue to look at, in terms of getting to the optimization and efficiency stages where we now go back in and make sure that we’re really trying to lessen the documentation and the number of clicks. How can we make viewing the whole record, and what’s happening with the patient on a day-to-day basis, better? How can we deliver dashboards that are going to help provide data at a quick visual glance to be sure that when things are well or things that are not well, or when things that are declining are very obvious, that we can pick up on it quickly? Certainly decision support, making sure that wherever we can, we provide information that drives best practice decision making and care for our patients across the system, is a priority.

Gamble:  On top of all this, reducing cost is always part of everything, so it’s making sure people and resources are being used in the most efficient way possible.

Marino:  Absolutely. We partner with our Epic analysts, the builders. We also connect with our Lean Sensei’s. We have a large department so that as we begin looking at different components of our records of our technologies, we can do a deep dive workflow analysis looking at how each individual aligns. We use swim lanes and A3 tools to make sure that from a Lean perspective, we’re able to look at that workflow and make sure the tools are available for our clinicians at the right time, at the right place, and are not burdening their practice, but really helping them and assisting them.

Gamble:  Now, in terms of your career path, one thing that you said earlier that really stuck out to me in the beginning was that there’s no blueprint for the CNIO role, which is definitely true. Looking back at your own journey, it looks like you kind rose up through the ranks, but how did you come to this position? Obviously the organization’s transformation had something to do with it, but how would you describe the path you took?

Marino:  You’re right, there wasn’t really a degree in nursing informatics or certification at that time. It really wasn’t even titled, to tell you the truth. At the beginning, my goal and what I was being charged to do amazingly, at that point in time, was my current CNO and the CIO at Hartford Hospital saying we wanted to move forward with our clinical systems, and we need someone to help us translate. We had folks who build, but we don’t have a clinician that understands the workflow and how those connections need to be made so that as we build, that we have something that absolutely works for patients and clinical workflow. So that’s how that conversation started.

Actually, my first system implementation was the food and nutrition system. I’ll never forget the day I went to the project team meeting. Folks were sitting around the table, and as I introduced myself and my new role, they said, ‘why would we need a nurse to help us build our food and nutrition system?’ I went through my discussion around how the nurses are at the bedside; they’re with the patient. They talk to the family. They see how the patients’ intakes and outputs are being impacted. They work worked with the types of diseases that patients have that implicate the type of diets that patients should be on, their fluid balance, all of their hemodynamics — all of which are impacted by nutrition, which shows how important it was to order the right things and to provide the right food and fluids at the right time. It was about the team; there was no one type of clinician that didn’t need to be part of that environment for the patient.

And that’s where it started, really. This was before electronic order entry at that point, so things just grew from there. We started bringing on additional analysts. I was put in a manager position to continue building the team, and then a director position. At that point, I balanced not only an informatics director role, but also an operational position with building a central staffing office and flow pool. That gave me the chance of a dual role where not only that I had the team and the personnel, but I also brought in the workforce scheduling technology and other key technologies to help understand how best to see those staffing challenges and changes throughout the day, how to do that electronically, and how to give staff the opportunity to do self-scheduling. That way, not only could do things that were best for them, but that would also meet the needs of an organization and how we then tie that in with bed planning so that we had a central staffing area that would bring up what patient movement we had during the day, where were our key staffing needs were going to be, and how would we make that work for the organization.

So the technology and the role came along side-by-side. I was very fortunate in working with some great leaders throughout the years, and it was a natural next step for me to join the executive leadership team as we began our Epic journey.

Gamble:  Something like being able to make their own schedule is not necessarily a huge undertaking, but it can make a significant difference for the staff.

Marino:  Sure. And there certainly were areas where they really adopted it. There were some areas that pushed back; that didn’t really feel it was necessary to do it electronically. But there were early adopters that you help make the case for, and they would take that system and run with it. They really helped us in developing it to make it efficient and make it work for the staff.

And it’s tough work. You have to get over the bumps, but they were proud of being able to be part of that. And because of that, we had data available to make your staffing decisions much more quickly and more efficiently.

Gamble:  It’s interesting; you had that experience early on in your career with having to make the case for nursing representation and having to demonstrate why it’s so critical to have nursing at that decision-making table.

Marino:  Absolutely. That took time. It took patience. It was one step at a time, one win at a time. As I was able to bring technology and engage folks in developing those technologies and getting the adoption, it would just make the case for, okay, what’s the next project and who needs to be there to help make sure our projects were successful? So as we did that, informatics became a regular player.

When our software decision-making was happening, we would be the ones to do vendor searches and visit other sites to look at how our vendors were integrated into practice and how the project went, so that we could look at what the pros and cons were for whatever we were trying to do an analysis for. Over time, we built that reputation and the confidence in the organization for the talent that our informatics staff had in moving us forward in digital health.

Gamble:  Right. And as we see digital start to take shape, it will be interesting to see how nursing is impacted.

Marino:  Absolutely. It’s exciting. I think we’ve watched the challenges of our workforce — there are safety issues. There’s physical injury. Just with the length of the day, the complexity of the care, there’ are so many opportunities where technology can help, but we can’t make it a burden. So it’s really important that we have individuals who understand how to put those programs in place, how to work through the workflow challenges, how to make sure you have a team representing the space and the topics that are critical to understanding the technology — understanding the patients, understanding our physicians, and supporting our physicians, and that’s what we do.

Where I spend a lot of time is really making sure our informatics analysts, our CMIOs, have the ability to engage in professional development; to go to the conferences where they can be educated. Some of our staff are certified in Epic, and we have physician builders. So we’re really excited about what’s coming and how our clinical staff have been able to grow and learn along with the new technologies coming.

Gamble:  I agree. I think it’s going to be really an interesting thing to watch unfold.

Marino:  Absolutely.

Gamble:  Okay, we’ve certainly touched on a lot. I think this has been really interesting, and very valuable for CIOs, CMIOs, for all leaders to hear this perspective. So thank you so much for taking some time to talk about what your organization is doing.

Marino:  I appreciate you asking me to do this. Thank you. It’s been extremely rewarding. Again, I’m humbled by the opportunity that I’ve been given (or earned) within my organization and the people that I work with every day. It’s great to be able to say, especially after 20 or 30 years within the organization, that I really enjoy what I do and I really look forward to where we’re headed.

Gamble:  Great. And I definitely would like to touch base with you again down the road. I’m sure that there’s going to be a lot more to talk about in the next year or so.

Marino:  Thank you, Kate. I appreciate it.