by Laura Klein, RN, BSN

Master of Nursing Student, Memorial University of Newfoundland

Abstract

Improving patient safety within the Neonatal Intensive Care setting, specifically reducing medication errors, is an essential objective due to the vulnerability of this patient population and the difficulties noted within each aspect of the medication process.  In an effort to improve patient safety it is recommended that a computerized provider order entry (CPOE) system be implemented in the NICU.  The benefits and barriers to CPOE are described, confirming that patient safety can be improved with the implementation of this system.  Transforming any aspect of a healthcare organization is multifaceted and therefore John Kotter’s (1947-) change management model is described and applied to the CPOE project.   In order to ensure the successful implementation of an advanced CPOE system, Kotter’s change management model recognizes that effective leadership, communication, teamwork, commitment, and support are necessary.  Also, in order for change to be sustained, an organization’s culture must also change and thus the development or promotion of a safety culture must occur within the NICU.  The application of Kotter’s change management model to this project demonstrates that Kotter’s model is a credible and valid tool to use when implementing change in the healthcare setting.

Key Words

Neonatal Intensive Care Unit (NICU), Computerized Provider Order Entry (CPOE), health information technology (HITS), change management, patient safety

Introduction

Implementing a Computerized Provider Order Entry System (CPOE) to improve patient safety in the Neonatal Intensive Care Unit (NICU), using Kotter’s change model, is a complex but reliable approach for healthcare leaders to employ.  Reducing medication errors in the NICU is a multifaceted and challenging task, but is an essential goal due to the vulnerability of the pediatric NICU patient.   Concurrently, the benefits and barriers to implementing an advanced CPOE system will be identified, along with recognition that CPOE can be used to improve patient safety in the NICU.  Accordingly, Kotter’s (1996) eight step change management model will be described in order to gain an appreciation for the strategies involved with implementing change.  Finally, implementation of an advanced CPOE system will be depicted using the Kotter’s change management model.

 

Review of the Literature

 

Improving Patient Safety in the NICU

Ensuring and improving patient safety in a healthcare setting is a priority for the Canadian Patient Safety Institute (CPSI) as well as the World Health Organization (WHO).  Worldwide, studies have been performed that have identified that the risk to patients in healthcare is high (Samra, McGrath, and Rollins, 2011).  In Canada, it has been determined that7.5% of patients admitted to hospital experience an adverse event (Baker et al., 2004).   In addition, WHO estimates that, in developed countries, one in ten patients experience adverse events (“10 facts on”, 2012).  These statistics are unexpected, and more so when compared to other industries that are felt to be higher risk, such as the airline industry (Clifton-Koeppel, 2008; “10 facts on”; 2012).  An example that puts this comparison in perspective is that the possibility of an airplane passenger being harmed is one in 1 000 000, whereas there is a one in 300 chance of a patient being harmed when receiving health care (“10 facts on”, 2012).  Improving patient safety in healthcare is therefore imperative and organizations in Canada and worldwide, such as the CPSI and WHO provide valuable resources to support this necessary goal.

The most prevalent adverse event that occurs within healthcare is medication errors and therefore great focus is placed upon improving this area of patient safety (Clifton-Koeppel, 2008; Cordero, Kuehn, Kumar, and Mekhjian, 2004; Samra, McGrath, and Rollins, 2011; Taylor, Loan, Kamara, Blackburn, and Whitney, 2008).  Moreover, many research studies have discovered that medication errors occur more frequently in the NICU  due to a variety of factors (Chuo and Hicks, 2008; Clifton-Koeppel, 2008; Donze and Wolf, 2007; Gray and Goldmann, 2004; NANN, 20112; Samra, McGrath, and Rollins, 2011; Stavroudis, et. al, 2010; Stavroudis, Miller, and Lehmann, 2008; Taylor, Loan, Kamara, Blackburn, and Whitney, 2008)  Explanations of why medication errors occur more frequently in the NICU tend to focus on the increased risk of errors in all of the stages of the medication process.  The medication process consists of the following stages: prescription, transcription, preparation, dispensation, administration, and monitoring (Colpaert and Decruyenaere, 2009; Donze and Wolf, 2007).  One example of a NICU specific risk during the prescription stage is weight based dosage calculations (Clifton-Koeppel, 2008; Donze and Wolf, 2007; Gray and Goldmann, 2004; NANN, 2012; Samra, McGrath, and Rollins, 2011; Stavroudis, et. al, 2010; Stavroudis, Miller, and Lehmann, 2008).   The demanding work environment and the critical nature of the care provided in the NICU are specific examples of how errors can be made at the transcription stage (Clifton-Koeppel, 2008; Donze and Wolf, 2007; NANN, 2011; Samra, McGrath, and Rollins, 2011; Stavroudis, Miller, and Lehmann, 2008).  Examples of NICU specific errors during the preparation stage include the regular use of off-label medication as well as the predominant use of adult-strength medications that require complex dilution processes (Clifton-Koeppel, 2008; Donze and Wolf, 2008; Gray and Goldmann, 2004; NANN, 2011; Samra, McGrath, and Rollins, 2011; Stavroudis, Miller, and Lehmann, 2008; Stavroudis, et al., 2010).  NICU patients are also at risk for dispensing errors due to the infrequent use of unit-dose preparations (Clifton-Koeppel, 2008; Gray and Goldmann, 2004).  Additionally, administration errors specific to the NICU occur due to the difficulties in maintaining identification bands on these small patients as well as the nonverbal aspect of the NICU patient (Clifton-Koeppel, 2008; Gray and Goldmann, 2004; NANN, 2011; Samra, McGrath, and Rollins, 2011; Stavroudis, Miller, and Lehmann, 2008; Stavroudis, et al., 2010).  Finally, meticulous monitoring is necessary in the NICU due the fact that NICU patients have complex physiologic immaturity of all the body’s systems (Clifton-Koeppel, 2008;Donze and Wolf, 2007; Gray and Goldmann, 2004; NANN, 2012; Samra, McGrath, and Rollins, 2011; Stavroudis, Miller, and Lehmann, 2008; Stavroudis, et al., 2010).  The possibility of medication errors occurring in the NICU and the rationale behind these errors is well documented and therefore an effort to improve patient safety in the NICU is imperative.

Computerized Provider Order Entry

When implemented successfully, Computerized Provider Order Entry (CPOE) has improved patient safety (Ash et al., 2007; Barey, 2011;Donze and Wolf, 2007; Jones and Moss, 2006; Manor, 2010; Maslove, Rizk, and Lowe, 2011; McCartney, 2006; Ramirez, Carlson, and Estes, 2009; Rothschild, 2004; ).  CPOE is considered a Health Information Technology (HIT) and refers to the process of electronically ordering treatments, such as medications and procedures, by the primary health care provider. (Colpaert and Decruyenaere, 2009; Barey, 2011).  Advanced CPOE systems also include a decision support system (CDS) which refers to the use of “standardized, evidence-based practice resources [at] the point of care” (McCartney, 2006).

Benefits of Advanced CPOE

Advanced CPOE is not only proven to reduce medication errors, but has also shown to decrease the amount of unnecessary laboratory tests and improve the timeliness of radiological and laboratory tests (Colpaert and Decruyenaere, 2009; Miller, 2007; Ramirez, Carlson, and Estes, 2009). Indeed, advanced CPOE has the ability to improve patient safety in all stages of the medication process (Colpaert and Decruyenaere, 2009; Cordero, Kuehn, Kumar, and Mekhjian, 2004; Jones and Moss, 2006; Maslove, Rizk, and Lowe, 2011) .  First, during the prescription stage, handwriting and calculation errors are avoided (Classen, Bates, and Denham, 2010; Colpaert and Decruyenaere, 2009; Donze and Wolf, 2007; Maslove, Rizk, and Lowe, 2011; Jones and Moss, 2006; Manor, 2010; McCartney, 2006; Taylor, Loan, Kamara, Blackburn, and Whitney, 2008).  CDS tools within CPOE also reduce wrong dose, wrong route, incomplete, and duplicate errors from occurring during the prescription stage (Chuo, and Hicks, 2008; Classen, Bates, and Denham, 2010; Danze and Wolf, 2007; Miller, 2007;Taylor et. al., 2008).  Furthermore, errors that are typically made during the transcription phase are essentially avoided due to the fact that orders are sent directly to the appropriate departments (Barey, 2011; Donze and Wolf, 2007; Jones and Moss, 2006; McCartney, 2006; Taylor et al., 2008).  Reducing errors during the preparation stage is also possible due to the information provided by the CDS tools within CPOE regarding how to safely prepare the medication that is ordered (Stavroudis, Miller, and Lehmann, 2008).  During the dispensing stage CPOE improves the time it takes to receive a patient’s medication (Colpaert and Decruyenaere, 2009; Cordero, Kuehn, Kumar, and Mekhjian, 2004; Donze and Wolf, 2007; Manor, 2010).  CDS within CPOE assists in preventing errors during the administration phase by providing accurate and accessible information about how to administer the medication (Colpaert and Decruyenaere, 2009; Donze and Wolf, 2007).  Finally, advanced CPOE provides valuable alerts and information regarding the appropriate monitoring required before, during, and after administration of the medication (Classen, Bates, and Denham, 2010; Donze and Wolf, 2007; McCartney, 2006; Rothschild, 2004).  Based upon the evidence presented, it is clear that the NICU would benefit in a number of areas as a result of the implementation of an advanced CPOE system.

Barriers to CPOE

The success of advanced CPOE systems has been researched but several issues have emerged that should be considered prior to the implementation of a CPOE system (Maslove, Rizk, and Lowe, 2011; Ash, et al., 2007; Campbell, Guappone, Sittig, Dykstra, and Ash, 2008).  Consequently, identification of conflicting evidence regarding the benefits of CPOE, as well as various technical and organizational barriers associated with CPOE, will be described.  Certainly, successful implementation of an advanced CPOE system requires awareness of all of these potential challenges.

There is conflicting evidence regarding the benefits of CPOE and both sides of the issue deserve consideration.  The study “Meaningful Use of Computerized Prescriber Order Entry” (Classen, Bates, and Denham, 2010) analyzed this evidence and concluded there were some significant pitfalls within these studies that created such negative findings.  First, studies that were performed twenty years ago are not comparable to the current CPOE systems due to the technological advancements that have been made (Classen, Bates, and Denham, 2010).  Also, there are limitations with the evaluation methods used at that time and therefore the impact of the CPOE system was not accurately assessed (Classen, Bates, and Denham, 2010).    There has, however, been more recent research that associated an increase in errors with the implementation of a CPOE system.  The study “Meaningful Use of Computerized Prescriber Order Entry” (Classen, Bates, and Denham, 2010) also analyzed these results and identified that the conclusions of these studies are not reliable due to inaccurate measurement techniques and an inadequate implementation process.  Further examination of the conflicting evidence, therefore, suggests that much of the negative results regarding CPOE are not valid.

Also, there can be technical barriers with the introduction of any new technology, but many of these issues can be avoided through awareness and appropriate planning.  Technical issues related to an advanced CPOE system consist of limited interoperability, poor information technology (IT) support, inadequate backup systems during electrical outages, upgrades, maintenance, or network issues, as well as limitations with actual system design and an inability to advance with the rapidly changing technology (Ash, et. al, 2007; Campbell, et al., 2008; Georgiou, Ampt, Creswick, Wesbrook, and Braithwaite, 2009; Jones, and Moss, 2006; Manor, 2010; Maslove, Rizk, and Lowe, 2011; Ramirez, Carlson, and Estes, 2009)  All of these technical challenges are associated with poor system design and planning and must be addressed during all stages of implementation.

In addition, organizational barriers that an advanced CPOE system may have on a healthcare setting must be considered in order to achieve success.  First of all, financial commitments required to not only implement but also support this type of technology must be made (Campbell et al., 2008; Donze and Wolf, 2007; Jones and Moss, 2006; Colpaert and Decruyenaere, 2009; Maslove, Rizk, and Lowe, 2011).  Other organizational barriers that have been identified are workflow concerns, resistant stakeholders, ergonomic concerns, uncommitted executive and poor leadership, as well as a loss of situation awareness (Ash et. al, 2007; Campbell et al., 2008; Colpaert and Decruyenaere, 2009; Donze and Wolf, 2007; Georgiou et al., 2009Jones and Moss, 2006; Manor, 2010; Maslove, Rizk, and Lowe, 2011; Miller, 2007; Ramirez, Carlson, and Estes, 2009; .  Organizational barriers are complex, as they involve all members of the healthcare organization and therefore overcoming these barriers can be challenging.

Implementation of an advanced CPOE system in an effort to improve patient safety is a legitimate and recommended strategy; however, awareness of the barriers to implementing an advanced CPOE system is only one aspect of ensuring success.  Familiarity and application of a recognized change management model is also necessary in order to meet the challenges of organizational change.

Change Management Model

All healthcare organizations need to ensure they are providing safe and quality care, but in order to achieve this goal techniques on how to successfully implement these changes into an organization are as imperative as awareness of current recommendations, research, and technology (Noble, Lemer, and Stanton, 2011).  A change management model that has been successfully applied in the business industry is John Kotter’s (1947-) eight step change model (Campbell, 2008; Noble, Lemer, and Staton, 2011).  The business industry has had the financial resources to master change management and therefore applying Kotter’s (1996)  model to support and facilitate the implementation of an advanced CPOE system in a healthcare setting, which lacks the same financial resources, will be described (Noble, Lemer, and Stanton, 2011).

Prior to discussing Kotter’s change management model, it is important to discuss his foundational principles.   Kotter has identified and offered solutions to eight common errors made by organizations when implementing change.  Additionally, Kotter asserts that it is necessary to appreciate the differences between management and leadership.  Finally, it is vital to follow each step in Kotter’s model to successfully implement change.  In summary, Kotter’s change management model was derived from the acknowledgment and comprehensive analysis of other’s failures, recognition of the importance of providing consistent leadership, and awareness and respect for each step of the model.  Therefore, appreciation of these key elements throughout the application of Kotter’s eight step change management model is vital.

Kotter organizes his eight step model into three phases (Campbell, 2008).  Phase one, creating a climate for change, includes the first 3 steps in Kotter’s model: establishing a sense of urgency, creating the guiding coalition, and developing a vision and strategy.  Phase two, engaging and enabling the whole organization, consists of Kotter’s next three steps: communicating the change vision, empowering employees for broad-based action, and creating short-term wins.  The final phase, implementing and sustaining the change, incorporates the final two steps in Kotter’s model: consolidating gains and producing more change and anchoring new approaches in the culture.  These steps involve commitment and complex plans and projects, which require patience and reflection throughout the process in order to successfully implement organizational change (Kotter, 1996).

Phase One:

Creating a Climate for Change 

The first step in Kotter’s change model, establishing a sense of urgency, involves a leader’s ability to cultivate awareness for change as well as eliminate complacency.  Obtaining the cooperation of the whole team through the development of a sense of urgency ensures that the team is motivated and committed to the change (Kotter, 1996).  Kotter suggests that eliminating complacency is another key element in ensuring the commitment of the team and nine sources of complacency are described and include the absence of a major and visible crisis, too many visible resources, low performance standards, narrow functional goal within the organization, measurement tools that focus on the wrong performance indexes, lack of sufficient performance feedback from external sources, a culture of blame, denial, and encouraging a false sense of security from the executive (Kotter, 1996).  In other words, Kotter believes that the presence of contentment, self-righteousness, arrogance, and egotism within the organization will inhibit a leader’s ability to validate the need for change and therefore gain the support of the team.

Once a sense of urgency is established, team development should then become the focus.  Successful transformations rely on a group rather than an individual and, therefore, ascertaining the necessary composition of a successful team is the next step in Kotter’s model.  Creating the guiding coalition, according to Kotter, includes finding the right people, creating trust, and developing a common goal.  The desirable attributes of a team member include experienced and credible key players that possess strong leadership skills (Kotter, 1996).  Strong leadership is, in fact, the most important characteristic, as this is the trait that will drive the change, as opposed to management which organizes and guides the process (Kotter, 1996).  Kotter also explains that creating trust is necessary to support teamwork, and that sharing a common goal, such as a dedication to quality, will sustain commitment.  The combination of these skills and elements within a team will therefore foster and facilitate change within an organization.

Once a team has been established, Kotter believes that it is important to then create a vision.  The purpose of this vision is to illuminate the objective for change, as well as provide direction and inspire others to support and participate with the change (Kotter, 1996).  Moreover, a successful vision has six main elements: imaginable, desirable, feasible, focused, flexible, and communicable (Kotter, 1996).  In other words, a valuable vision involves expressing the goal in an appealing and clear manner that is achievable, adaptable, and straightforward.  It is also important to realize that creating a vision takes time and follows a certain process (Kotter, 1996).  This process starts with an outline, which is then evaluated by the coalition utilizing teamwork techniques as well as logical thinking and visualizations (Kotter, 1996).  This process is generally not straightforward, but dynamic, with progression forwards and backwards resulting in an outlook that will foster a successful transformation (Kotter, 1996).

Phase Two:

Engaging and Enabling the Whole Organization

Once a vision has been developed, Kotter then focuses on the importance of communicating the vision to all the stakeholders.  First, successfully accomplishing the first three steps in Kotter’s change model will help to facilitate communication of the vision (Kotter, 1996).  Kotter also identifies effective communication techniques that can be used to convey the vision.  These techniques consist of frequently communicating the vision through multiple methods, using clear and uncomplicated language, with the assistance of images (Kotter, 1996).  At the same time, communication should not be one-sided nor should any discrepancies be ignored (Kotter, 1996).  Finally, leadership’s actions need to be consistent with the vision to help ensure trust and acceptance of the change (Kotter, 1996).

Ensuring the support and participation of employees during a transformation is challenging and, as such, Kotter describes how increasing or ensuring empowerment influences employees’ contributions. Therefore, empowering employees for broad-based action is the next step in Kotter’s change model, in which he has recognized barriers to empowerment that include poor communication, negative organizational influence, lack of appropriate training, inconsistencies within an organization, and unsupportive management.  Identifying and eliminating these obstacles, then, are necessary to ensure employees are empowered and consequently contribute, strengthen, and promote change.

Implementing change is a lengthy process that requires patience and, as a result, Kotter’s next step acknowledges that creating short-term wins is a valuable tool to provide encouragement and credibility to the change management process.  These beneficial short-term wins should be clear, observable, and relevant to the transformation (Kotter, 1996).  The objectives of short-term wins that Kotter identifies include justification, trustworthiness, drive, and support for the planned change.  Short-term wins also allow the team to celebrate as well as modify the vision through reflection (Kotter, 1996).    The benefits of short-term wins cannot be ignored and therefore must be planned, produced, and supported by committed, competent managers (Kotter, 1996).

Phase Three:

Implementing and Sustaining the Change

Consolidating gains and producing more change is the next step in Kotter’s model.  Successfully implementing change requires leadership, and it is in this stage of Kotter’s change management model in which a lack of effective leadership is noticeably detrimental. This is due to the fact that short-term wins can create a sense that change has been successful and therefore decrease the sense of urgency (Kotter, 1996).  Consequently, establishing a solid foundation through the successful implementation of the previous steps within Kotter’s model is required prior to undertaking any further action.  Building on these steps, the guiding coalition is able to embark on implementing their vision through executive level leadership, frontline and middle level management, as well as train and endorse new personnel to provide further support for the project (Kotter, 1996).  As a result, the ability of organizations to successfully implement change will be determined by the team’s persistence, awareness, and appreciation for all of the steps identified by Kotter, in conjunction with leaders that are able to consistently motivate, communicate, and promote the transformation.

The final step in Kotter’s change management model, anchoring new approaches in the culture, recognizes the challenge of sustaining organizational change.  Specifically, Kotter reflects on the influence of an organization’s culture in relation to change management.  Culture is described by Kotter as powerful, influential, inflexible, and invisible but, despite these characteristics, Kotter suggests that change will not be sustained without the necessary cultural changes.  In order to anchor cultural change, members of the organization must be supported and shown that the change is both credible and adaptable (Kotter, 1996).    Consequently, transformations should involve planning and support beyond the actual execution of the change in order to ensure that the change is maintained.    In conclusion, declaring that a change is successful requires that the change be sustained within the organization.

Application of Kotter’s change management model

Change within any organization aims to be successful, but not all transformations are positive or effective and therefore not all are maintained.  Successfully implementing change within a healthcare setting is important, particularly when the improvement to the quality and safety of patient care is the goal.  Implementation of an advanced CPOE system in the NICU is intended to improve patient safety and therefore Kotter’s change management model will be used to guide the process.    Accordingly, validation that Kotter’s model can be applied to the healthcare setting will be demonstrated.

Phase One:

Creating a Climate for Change 

The three steps within this phase of change are establishing a sense of urgency, creating the guiding coalition, and developing a vision and strategy.  As previously stated, there is a great deal of evidence to support both the need for improving patient safety in the NICU and the benefits of an advanced CPOE system in the NICU.  Developing a summary using this evidence, including alarming statistics with attention grabbing graphics, a video presentation, or an interactive display will assist in creating a sense of urgency in the NICU (Campbell, 2008, Cohen, Eustis, and Gribbins, 2003, Noble, Lemer, and Stanton, 2011).  Identifying valuable members to form a guiding coalition is a crucial step within healthcare due to the numerous professions which will be affected.  Physicians, nurses, pharmacists, respiratory therapists, educators, informaticist, managers, unit clerks, laboratory technicians, radiology technicians, and information technology specialists are all team members who should be involved when implementing an advanced CPOE system.  Creating committees or consultant teams that involve each profession is an example of how to identify members for the guiding coalition (Campbell, 2008, Cohen, Eustis, and Gribbins, 2003).  Once trustworthy and experienced team members are identified, it is important to then ensure that they hold strong leadership skills that will support and promote change within the NICU (Kotter, 1996).   Finally, the vision, which will be evaluated by the team, should accurately and concisely reflect the goal of the project (Kotter, 1996).  A vision statement for implementing an advanced CPOE system should therefore promote the benefits of the system within the NICU to both patient safety, specifically a reduction in medication errors, and to the employees, such as a decrease in workflow and increase in quality care (Jones and Moss, 2006).  This vision statement should also be motivational yet adaptable for NICU personnel and be easily expressed and shared by staff (Kotter, 1996).  These introductory steps should be continually reflected upon and adapted by the NICU coalition to help ensure the successful implementation of an advanced CPOE system in the NICU.

Phase Two:

Engaging and Enabling the Whole Organization

The next three steps occur within the second phase of Kotter’s model: communicating the change vision, empowering employees for broad-based action, and creating short-term wins.  The successful implementation of an advanced CPOE system will require all of the employees involved to move from an awareness of the project to an understanding of why an advanced CPOE system is being implemented, to endorsement, and then commitment of the project and finally to advocating for the new system (Campbell, 2008).  In order for this to be accomplished, it is imperative that the vision statement is communicated (Kotter, 1996).  Various techniques should be used to communicate the team’s vision, such as creating a case study that demonstrates the new system in action, creating a video presentation, or inviting current users of CPOE from various professions to promote the new system.  The leadership team needs to encourage regular conversations about the new CPOE systems in order to address employee concerns and questions.  The creation and distribution of frequently asked questions, as well as arranging question and answer sessions, is one method that could be used to help gain employee support and understanding (Campbell, 2008).  The team can base these documents and meetings on the research that has been performed which describes what employees concerns are during implementation of a CPOE system (Georgiou, Ampt, Creswick, Westbrook, and Braithwaite, 2009).  Ensuring that employees feel involved with the change process will also assist in gaining their support and commitment.  Additionally, the use of regular updates via e-mail and newsletter in conjunction with a web portal are two techniques that could be used to help ensure employees are provided with current information when implementing a CPOE system in the NICU (Campbell, 2008).

Throughout Kotter’s change process employees should become more aware and involved. Consequently, their support for the new vision should increase and this, in turn, should result in greater empowerment among employees.  Awareness and recognition of the perceived barriers to implementing an advanced CPOE system and refuting these barriers is also an important task.  As previously described, there are well documented barriers to the implementation of an advanced CPOE system, and therefore the team needs to address these concerns.  Ensuring employees have opportunities to attend training sessions and communicate their concerns will help eliminate these barriers and subsequently empower staff members.  Empowerment is an important emotion to secure, but the final step in this phase aims to validate the intended change by planning and creating short-term wins (Kotter, 1996).  Implementing an advanced CPOE system should involve various committees or consultation groups; publicizing the successes of these groups is one method that should be used to create short-term wins (Campbell, 2008; Jones, and Moss, 2006).  Also, the installment of an advanced CPOE system will require numerous changes, and the introduction of some of these changes prior to implementing an advanced CPOE system will be necessary.  These changes, such as the introduction of order sets, will show employees some of the benefits of an advanced CPOE system and subsequently increase the system’s credibility (Campbell, 2008).  In summary, recognition of CPOE’s benefits to patient safety and workflow should be considered and utilized by the team when planning and creating short-term wins.

Phase Three:

Implementing and Sustaining the Change

During the last phase of Kotter’s change management model the final two steps, consolidating gains and producing more change, and anchoring new approaches in the culture, will be implemented.  Identifying effective leaders and ensuring that all employees remain focused on the vision is imperative at this stage (Kotter, 1996).  Once again, reinforcing the vision at this stage using various methods of communication as well as strong leadership skills within both management and the coalition team will help NICU employees remain focused.  Training and ensuring awareness of extensively trained super users during the implementation of an advanced CPOE system will not only help support NICU employees during this stage but also help identify any unexpected problems that may arise (Campbell, 2008; Classen, Bates, and Denham, 2010; Jones and Moss, 2006; Manor, 2010; Ramirez, Carlson, and Estes, 2009).

Implementation of an advanced CPOE system will require a big change in NICU culture and, thus, anchoring new approaches in the culture is required for change to be successful.  Clearly, ensuring and encouraging a patient safety culture is very important in any healthcare setting.  There is a great deal of literature that advocates for creating a safety culture as part of the implementation of an advanced CPOE system and the NICU will benefit from this evidence (Clifton-Koeppel, 2008; Gray and Goldmann, 2004; Jones, and Moss, 2006; NANN, 2012; Samra, McGrath, and Rollins, 2011).  The guiding coalition and management team can use this evidence throughout all stages in Kotter’s change process, such as promoting the establishment of a culture of safety in their vision statement.  The creation of a safety committee, identification of employees who are safety stars, and performing weekly safety huddles on the frontline will also help establish and maintain a commitment to the culture of safety within the NICU.  It is expected that if the NICU’s culture can be modified to support the implementation of an advanced CPOE system then this change will be successful.

Conclusion

The impact of unsuccessful change management within the NICU is exacerbated by the vulnerability of the patient population.  Appropriately, improving patient safety within the NICU, specifically reducing medication errors, through the implementation of an advanced CPOE system is well documented.  Healthcare is a complex organization that requires an effective change management strategy, such as Kotter’s, to ensure changes are implemented successfully.  The three phases of Kotter’s change management model are comprehensive and require constant reflection and adaptation throughout the process.  The application of Kotter’s model to the implementation of an advanced CPOE system in the NICU demonstrates both the scope and sophisticated quality of Kotter’s model within a healthcare organization.

References

10 Facts on Patient Safety, (2012).  Retrieved from http://www.who.int/features/factfiles/patient_safety/en/index.html

Ash, J.S., Sittig, D.F., Poon, E.G., Guappone, K, Campbell, E., and Dykstra, R.H.  (2007).  The extent and importance of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association, 14(4), 415-423.  doi: 10.1197/jamia.M2373

Baker, G.R., Norton, P.G., Flintoft, V., Blais, R., Adalsteinn, B, Cox, J, Etchells, E., Ghali, W.A., Herbert, P, Majumdar, S.R., O’Beirne, M., Palacios-Derflingher, L, Reid, R.J., Sheps, S, Tamblyn, R.  (2004).  The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada.  The Canadian Medical Association Journal, 170(11), 1678-1686.  doi: 10.1053/cmaj.1040498

Barey, E.B. (2011).  Computerized order entry.  In V.K. Saba and K.A. McCormick (Eds), Essentials of Nursing Informatics (5^th Ed, pp. 303-316). Toronto, ON: McGraw-Hill.

Campbell, E.M., Guappone, K.P, Sittig, D.F., Dykstra, R.H., and Ash, J.S.  (2008).  Computerized provider order entry adoption: Implication for clinical workflow.  Journal of General Internal Medicine, 24(1), 21-26. doi:10.1007/s11606-008-0857-9

Campbell, R.J. (2008).  Change management in health care.  The Health Care Manager, 27(1), 23-39.  doi: 10.1097/01.HCM.0000285028.79762.a1

Chuo, J. and Hicks, R.W. (2008).  Computer-related medication errors in neonatal intensive care units.  Clinics in Perinatology, 25, 119-139.  doi: 10.1016/j.clp.2007.11.005

Classen, D., Bates, D., and Denham,C.R.  (2010).  Meaningful use of computerized order entry.  Journal of Patient Safety, 6(1), 15-23.  doi: 10.1097/PTS.0b013e3181d108db

Clifton-Koeppel, R. (2008). What nurses can do right now to reduce medication errors in the neonatal intensive care unit.  Newborn and Infant Nursing Reviews, 8(2), 72-82.  doi: 10.1053/j.nainr.2008.03.008

Colpaert, K. and Decruyenaere, J.  (2009).  Computerized physician order entry in critical care.  Best Practice and Research Clinical Anaesthesiology, 23, 27-38.  doi: 10.1016/j.bpa.2008.07.002

Cordero, L., Kueh, L., Kumar, R.R., and Mekhjian, H.S. (2004).  Impact of computerized physician order entry on clinical practice in a newborn intensive care unit.  Journal of Perinatology, 24(2), 88-93.  doi: 10.1038/sj.jp.7211000

Donze, A. and Wolf, M.  (2007).  Safety in the NICU: Preventing medication errors with computerized provider order entry.  Nursing for Women’s Health, 11(6), 612-617.  doi: 10.1111/j.1751-486X.2007.00253.x

Georgiou, A., Ampt, A., Creswick, N, Westbrook, JI., Braithwaite, J. (2009).  Computerized provider order entry: What are health professionals concerned about?  A qualitative study in an Australian hospital.  International Journal of Medical Informatics, 78, 60-70.  doi: 10.1016/j.ijmedinf.2008.09.007

Gray, J.E. and Goldmann, D.A.  (2004).  Medication errors in the neonatal intensive care unit: Special patients, unique issues.  Archives of Disease in Childhood Fetal and Neonatal Edition, 89, F472-F473.  doi:10.1136/adc.2003.046060

Jones, S. and Moss, J.  (2006).  Computerized provider order entry: Strategies for successful implementation.  The Journal of Nursing Administration, 36(3), 136-139.  Retrieved from http://journals.lww.com/jonajournal/pages/default.aspx

Kotter, John P. (1996). Leading change. [Books24x7 version] Retrieved from http://common.books24x7.com/toc.aspx?bookid=3479.

Manor, P.J.  (2010).  CPOE: Strategies for success.  Nursing Management41(5), 18-20.  doi: 10.1097/01.NUMA.0000372028.99240.7f

Maslove, D.M., Rizk, N., Lowe, H.J. (2011).  Computerized physician order entry in the critical care environment: A review of current literature.  Journal of Intensive Care Medicine, 26(3), 165-171.  doi: 10.1177/088506610387984

McCartney, P.R. (2006).  Using technology to promote perinatal patient safety.  Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(3), 424-431.  doi: 10.1111/j.1552-6909.2006.00059.x

Miller, R.A. (2007).  Care provider order entry (CPOE): A perspective on factors leading to success or to failure.  IMIA Yearbook of Medical Informatics, 46(1), 128-137.  Retrieved from http://www.schattauer.de/en/magazine/subject-areas/journals-a-z/imia-yearbook/imia-yearbook-2007/issue/special/manuscript/8429.html

National Association of Neonatal Nurses (2012).  Medication safety in the neonatal intensive care unit: Position statement #3055.  Advances in Neonatal Care, 12(2), 133-141.  doi: 10.1097/ANC.0b013e31824235cd

Noble, D.J., Lemer, C., and Stanton, E. (2011).  What has change management in industry go to do with improving patient safety?  Postgrad Med, 87, 345-348.  doi: 10.1136/pgmj.2010.097923

Ramirez, A., Carlson, D., and Estes, C.  (2010).  Computerized physician order entry: Lessons learned from the trenches.  Neonatal Network, 29(4), 235-241.  Retrieved from http://neonatalnetwork.metapress.com/content/121252

Rothschild, J.  (2004).  Computerized physician order entry in the critical care and general inpatient setting: A narrative review.  Journal of Critical Care, 19(4), 271-278.  doi: 10.1016/j.jcrc.2004.08.006

Samra, H.A., McGrath, M., and Rollins, W.  (2011).  Patient safety in the NICU: A comprehensive review.  Journal of Perinatal and Neonatal Nursing, 25(2), 123-132.  doi: 10.1097/JPN.0b013e31821693b2

Stavrioudis, T.A., Shore, A.D., Morlock, L., Hicks, R.W., Bundy, D., and Miller, M.R. (2010).  NICU medication errors: Identifying a risk profile for medication errors in the neonatal intensive care unit.  Journal of Perinatology, 30, 459-468.  doi:  10.1038/jp.2009.186

Stavroudis, T.A., Miller, M.R., ad Lehmann, C.U.  (2008).  Medication errors in neonates.  Clinics in Perinatology, 35, 141-161.  doi: 10.1016/j.clp.2007.11.010

Taylor, J.A., Loan, L.A., Kamara, J., Blackburn, S., and Whitney, D.  (2008).  Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit.  Pediatrics, 121(1), 123-128.  doi: 10.1542/peds.2007-0919

Author Biography

Laura Klein is a Registered Nurse, Patient Care Coordinator, at the Royal Columbian NICU in New Westminster, B.C.  Laura is also a Master of Nursing student at Memorial University of Newfoundland where she is focusing her studies on nursing administration.

EDITOR

Teresa Birznieks