Case Study: The Hospital Innovation Unit Strategy |1
Procurement and Innovation Adoption in Health Systems Case Study: The Hospital Innovation Unit Strategy Dr. Anne Snowdon RN, BScN, Mc, PhD, FAAN Chair, World Health Innovation Network Scientific Director & CEO, Supply Chain Advancement Network in Health Odette School of Business University of Windsor
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Table of Contents Introduction and Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Project Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1. Identifying Health System Priorities and Needs—Research and Design for Innovative Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2. Prototype, Pilot Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 3. Implementation and Early Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Diffusion, Scaling and Widespread Adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Key Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1. Establishing Effective Leadership/Decision-Making Structures . . . . . . . . . . . . . . . 8 2. Building Public Profile as an Innovative Organization . . . . . . . . . . . . . . . . . . . . . . 8 3. Engaging and Sustaining Staff Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 4. Challenges with System Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 5. Lack of Clearly Defined Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 6. Selecting Appropriate Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 7. Confusion Over Procurement Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
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Introduction and Background This case study is one of a series entitled: Procurement and Innovation Adoption in Health Systems. The purpose of these case studies is to provide real-world evidence of the impact of innovation procurement practices to inform policy, build capacity for innovation adoption in health systems and to be used as education tools for organizations considering, or involved with, innovation adoption, evaluation and scalability in health systems. The case studies provide an overview of the barriers and facilitators of innovation adoption, the opportunities to strengthen innovation adoption processes for vendors, innovators, industry, government and health system leaders. In particular, the cases will describe the processes of introducing innovation into health systems and, where relevant, the impact of existing procurement processes on innovation adoption in healthcare organizations. The case methodology uses the innovation adoption framework described in the report of the Ontario Health Innovation Council (2015).1 The innovation journey framework begins with identifying the health system priority or need for an innovative solution and captures evidence of impact and outcomes as the innovation project is designed and implemented by health organizations. The case follows the progress of the implementation of innovation and describes outcomes relative to the potential for the innovation to be adopted and scaled across the health system. Innovation projects were empirically studied using key informant interviews to examine the experiences and outcomes of innovation teams in the Ontario health system. Key findings emerged from the analysis of interviews conducted by the WIN research team. The findings are organized according to each phase of the innovation adoption journey with key lessons learned summarized at the end of each innovation case. This case summary is an adaptation of the original full-length case study report and has only been altered to ensure the anonymity and confidentiality of the key participants and project team. The intent of this summary version of the case is to provide an overview of the key findings and lessons learned to build knowledge and capacity for innovation across health systems through knowledge dissemination.
This project is funded by OntarioBuys, an Ontario government program, which makes investments to support innovation, facilitate and accelerate the adoption of integrated supply chain, back-office leading practices and operational excellence. OntarioBuys helps drive collaboration and improve supply chain processes in Ontario’s broader public sector. The views and opinions expressed in this case study do not necessarily reflect the official policy or position of the Government of Ontario.
1
Ontario Health Innovation Council. The Catalyst: Towards an Ontario Health Innovation Strategy [Internet]. 2014. Available from: http://www.ohic.ca/sites/default/files/OHICReport.PDF
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Project Summary This innovation project engaged key participants from the health system, industry, healthcare professionals and a hospital union. Themes that capture the experiences and perceptions of all stakeholders engaged in the project are captured in the case and summarized in the following case summary.
1. Identifying Health System Priorities and Needs—Research and Design for Innovative Solutions The Hospital in this case developed an innovation unit strategy that was to serve as a “sandbox,” or testing unit, to evaluate health innovations for implementation and scalability across the hospital. Initially, this innovation unit strategy would be used to implement various technologies to streamline communication among staff with the ultimate goal of enhancing quality of care. The Hospital embarked on this strategy by engaging multiple industry partners, who each brought to the hospital a technology product that was to be integrated to create a comprehensive solution for the innovation unit. The Hospital purchased each technology product from individual vendors before the project commenced. The Hospital had planned to integrate these previously purchased technologies to create a seamless and intuitive communication strategy between patients and staff on the innovation unit. The Hospital’s vision was to integrate the technologies to create a complete solution to ensure patients could communicate with staff at all times. Each vendor was conscripted as a partner to implement the comprehensive solution in the designated innovation unit. Essentially, this integration required co-design for how the technologies would be integrated to achieve the desired solution. The feasibility of integrating unique technologies provided by different industry partners was not determined or identified during the early phases of the project. It was not clear to either the vendors or the Hospital as to how they would procure future innovation that was added to the integrated suite of products, co-created by the current companies involved in the innovation unit project. The Hospital believed that they could demonstrate a clear return on investment from the integrated solution in terms of patient safety and satisfaction, cost of care, staff accountability and operational efficiency that would more than offset the cost of the required investment in each technology product. The Hospital aimed to bring their clinical expertise in patient care together with the expertise and experience of large global national companies to create a steering committee for the project that was perceived to be the “best of the best” to provide strategic and operational leadership. It was the vision of the Hospital leadership that this steering committee was not only a requisite for successfully integrating the disparate technology solutions, but also as a model for supporting the scalability strategy across all of the patient care areas of the hospital. There was a clear sense that for such a project to be successful and expeditious (i.e., successful in meeting its timelines), the steering committee needed to include senior decision-makers from each industry partner organization to have the authority needed to make decisions on how to overcome the
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technical challenges of integration. However, when the steering committee was constructed, some of the industry partners elected to assign sales personnel to participate in the steering committee who were not authorized to make decisions on behalf of their respective companies. The Hospital leadership later viewed this representation of sales staff as a limitation for the progress of the innovation unit strategy. The technologies selected for the integrated solution included a communication device to be carried by clinical staff, enabled by a software to connect to digital tools at the patient’s bedside, ultimately allowing patients to communicate and get help from staff when needed. When it came time to implement the integrated solution, it was anticipated that staff may have concerns about personal privacy, which may result in significant resistance from clinical staff to adopt the technology into their practice routines. The Hospital proactively addressed these potential challenges by working with the union leadership to explain the intent and use of technology, (i.e., improving patient care and satisfaction) so that any concerns associated with use of the technology could be reduced or prevented. One of the Hospital’s key strategies was to identify “change agents” among the clinical staff that would be responsible for promoting the concept and value of the innovation strategy to their colleagues. These staff members were able to envision how the technology could help them in practice and shared their insights and ideas with other staff to support adoption of the integrated technology. The leadership team at the Hospital also embarked on a public campaign to promote the concept of the innovation unit that they disseminated widely. Through a series of knowledge dissemination activities, the Hospital created a high degree of awareness of the innovation unit strategy across the province. The leadership team leveraged the public relations strategy as an opportunity for the Hospital to build profile as an innovative organization that is engaged with industry leaders in implementing new and innovative solutions to advance and strengthen patient care. Industry partners were committed to the success of the public relations campaign project as it offered a strong image and profile potential for their company focused on health innovation, in the media and across healthcare industry.
2. Prototype, Pilot Testing While the aim of the innovation unit strategy was to test technology that could be integrated into clinical processes across the Hospital, there was no defined plan outlining which features of the multiple technologies would be integrated, nor the order in which this would take place. Similarly, the outcome objectives or functional features of the technology integration were not clearly defined at the outset of the project. However, the priority of the project described by the hospital was to create a fully functional integrated technology strategy, incorporating devices carried by clinical staff, connected directly to patients in order to meet their needs efficiently and effectively. The hospital team selected an Agile development methodology approach to guide the project strategy, based on the fact that it closely aligned with LEAN methodology principles, which the Hospital had been using for the past four years. The Agile methodology consists of implementing a series of short technology “sprints” to deploy
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incremental, or phased, technical functionality delivery. The key aspect of a “sprint” is the use of deadlines that document the timelines in which steps towards the final integrated solution will be undertaken. The functionality for each step in the process is scoped clearly to ensure there are no delays and to avoid falling behind schedule. The “sprint” phases were also designed to ensure the users (clinical staff) have some functionality to test at each step of the integration process, keeping them engaged and connected to the project process as it was implemented. The “sprint” technical functionality was predefined by the technology partners, so that functionality not completed in one step was carried over to the next step, to ensure progress was being made. This step-by-step approach kept the clinical staff engaged in testing each phase of progress towards fully integrating the technologies. Although not unexpected, at the beginning of the project, there were a number of delays due to challenges with integrating the software of each vendor’s technology and digital platforms. As each step in the Agile strategy unfolded, a number of challenges with integrating the technologies were experienced and the project timelines fell behind schedule. The outcome of these delays resulted in each sprint phase testing less and less functionality than planned for each sprint. One of the key observations from some of the industry partners was the decision-making authority of representatives on the project steering committee. Some industry partners assigned sales staff to the steering committee, rather than senior decision-makers, which was perceived to contribute to decisions that resulted in poor design and functionality of the integrated solution. There was a strong view from some of the partners that certain members of the steering committee were too sales-oriented with not enough technical expertise, which resulted in a focus on selling the features of their products, rather than a focus on how to integrate the product with the other vendor technologies to inform steering committee decisions. Another consequence of the strong sales representation of some partners on the steering committee were delays in making decisions. The challenge of not having senior industry representatives for some of the industry partners on the steering committee resulted in delays in making key decisions that had a negative impact on project timelines and outcomes. One vendor partner perceived that the major challenge for this project was a lack of design goals and specification, which are important for ensuring the right functionality and design of the solution. The project goals were delineated by hospital leaders and were focused on the idea of an ongoing innovation journey, with no clearly defined project outcomes or design goals. This lack of clarity of outcomes or functional specifications was identified as having a negative influence on the success of the project. The prototype phase of the project experienced a large number of technical challenges for the project team, including the complexity of integrating proprietary software to achieve the desired integrated functionality of the technologies and the challenge of vendor partners working together without clear and accurate expectations of the scope, goals or outcomes of the integration of the technologies used in this project. As attempts were made to integrate the various technologies and associated product software, errors in the solution prototype were very difficult to find and overcome, which was further
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challenged when one of the vendors had a planned system upgrade right in the middle of the integration process. Managing the technology integration proved to be a much larger than anticipated undertaking due to the lack of “fit” between technology software, the difficulty pinpointing the source of error and the interruption caused by system upgrades by one of the vendors. The technological complexity of the project was significant, given the large number of vendors engaged and the varied technologies with unique software infrastructure that were required to integrate to create the desired solution. In addition, project leadership decisions were challenged by the varied representation of each vendor partner that ranged from sales people to company CEOs.
3. Implementation and Early Adoption The many technological challenges involved in integrating the various devices and software technologies caused delays in implementation of the integrated solution in the clinical unit. However, the staff remained extremely committed to the project and, despite the delays, there were very high technology adoption rates among the clinical staff in the initial phases of the project. During these early phases, the clinical staff were highly motivated to use the technology solution, as they had worked with project partners to cocreate the functionality of the solution to support clinical care processes. As such, there was a 100 percent adoption rate at the time of the launch of the first integrated technology “sprint.” However, over time, the staff adoption rate dropped to zero, as each sprint phase of testing was unable to deliver the functionality requested and co-designed by the staff. Thus, the drop-in staff adoption of the technology was due to the delays in each sprint to test a lack of core functionality implemented for each sprint, which precluded any progress in level of improvement in communications over the current system. A limitation of the Agile methodology, as suggested by the technology partners and steering committee, was that it created a mismatch of the requirements the clinical staff were requesting and expecting, and the functionality actually delivered at each planned sprint. This resulted in staff losing interest in the project over time, as each phase of the technology offered few, if any, changes in functionality to support planned improvement in patient care processes. Hence, staff adoption rates were poor towards the latter phases of the project. Upon reflection, the Hospital team realized that more focus on defining the value of the functional features of the technology should have been more clearly delineated to support progress of the project. The outcome of co-creating the functionality with the staff resulted in disappointment—staff spent time creating functionality that was expected to be highly valued. However, the functionality designed by staff could not be achieved, leading to disillusionment, disappointment and declining engagement in the project.
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4. Diffusion, Scaling and Widespread Adoption The integrated technologies produced by this project had no connectivity to the existing clinical infrastructure systems at the Hospital. Thus, it was not feasible to integrate the Hospital’s patient record infrastructure with the technologies selected for this project. The project could not generate meaningful data or communication functionality for staff, which resulted in no opportunity to scale the solution to other clinical units, as had been envisioned by the Hospital. In addition, had the integration strategy been successful, the hospital would have been required to issue a Request for Proposal (RFP) and proceed with open and fair evaluation of all responses in order to provide the software solution necessary for the integration strategy. The Hospital team learned key lessons about creating and implementing an innovation strategy; while the vendors experienced very limited success and no return on investment for their time and resources committed to the project.
Key Findings 1. Establishing Effective Leadership/Decision-Making Structures The Hospital leadership had developed a project governance structure that was inclusive of all key players, including vendors, clinical staff and the Hospital leadership team. The early phase focused on establishing engagement and leadership processes to guide the project, including vendor representation on a steering committee. This inclusive engagement approach was an important strategy. However, as project outcomes were delayed and progress was slow, it was subsequently realized that the need for strategic vendor decision-makers on the project steering committee became critical in order to have the authority to open proprietary IP (software that enables functionality) of each industry partner to support the integration of the various technologies. The representatives on the steering committee (senior leaders and sales representatives) did not have the necessary autonomy or authority to make effective decisions over the course of the project. One key lesson learned in this case was the importance of having the necessary expertise and authority available to make strategic design decisions for a project working with multiple technologies to be successful. Hospital expertise was needed to select the most appropriate technologies available that would work best for achieving project goals. Technical expertise was required on the steering committee to ensure appropriate design decisions were made. In both cases, neither the hospital leaders nor vendor sales staff assigned to the steering committee had the necessary expertise for strategic decisionmaking to support the success of this project.
2. Building Public Profile as an Innovative Organization The Hospital leveraged this project’s innovation strategy to build public profile for the Hospital and vendor community, which resulted in national award recognition. A key
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outcome of the project was the positive attention to the goals and innovation strategy underpinning this project. This positive image and profile for the executive team and industry partners emerging from the collaboration has resulted in all partners being perceived as innovators.
3. Engaging and Sustaining Staff Engagement The leadership team proactively engaged the staff union and made a compelling case highlighting the value of the project for both clinical staff and patient care outcomes. The union was assured that the leadership team was committed to maintaining the privacy of the clinical staff while implementing the technologies. This early engagement with the union was effective in garnering their support and paved the way for the clinical staff to actively engage in the project activities such as co-design of the integrated solution. The inability of the integrated technology solutions to meet staff expectations for desired functionality was detrimental to maintaining staff engagement and adoption of the technology as the project progressed. The Agile methodology selected, which used incremental development and testing sprints, proved to be ineffective in supporting the integration of the technology for application to clinical processes in the innovation unit.
4. Challenges with System Integration The project was plagued by technical integration challenges, largely related to the diverse types of technologies selected by the hospital, that were never designed to be integrated with other proprietary products. Each of the vendors had “stand-alone� technology products designed to be introduced into a clinical environment, independently of other technologies. This project attempted to integrate these various technologies, which proved to be so difficult that the integrated solution was never achieved. System integration with hospital infrastructure was not possible due to the inability to integrate the technologies.
5. Lack of Clearly Defined Goals The innovation strategy was not able to facilitate flexible and rapid deployment of innovative solutions as defined by the original project objectives. Failure to achieve the project outcomes was an important learning opportunity, which did help define how the innovation model could be redesigned to be more successful in future. Clear and wellscoped objectives, that are both achievable and measurable, could have contributed to the success of the project. For example, the required expertise and insights on the steering committee could have better informed decisions on how the technology interfaces could be integrated to create the desired integrated solution. Clearly defined goals and the necessary technological expertise to inform decisions would have supported the success of this project.
6. Selecting Appropriate Methodology The Agile development methodology was selected as the methodology of choice by the Hospital, based on its experience of LEAN methodologies, which had similar types of
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methods already integrated into the hospital setting. The Agile methodology is one used routinely for developing a new prototype product. However, it is not a methodology that is used in industry or healthcare for creating technology integration. Hence, the Hospital’s expertise in selecting the best methodology for this project may not have been adequate, which may have contributed additional challenges for the implementation of this project.
7. Confusion Over Procurement Processes There was a lack of insight or understanding regarding how the co-created technologies could be procured once they were designed and tested as part of the innovation strategy. Neither the vendors, nor the hospital were able to define how the integrated solution would be procured to support scalability, had it been successful. There were agreements in place on how the Intellectual Property (IP) would be controlled among vendors and the hospital, however, if the technologies were to be scaled to other clinical units in the hospital or in the community, this procurement challenge would need to be overcome. In future, clarity of procurement of co-designed solutions would have to be addressed to support the adoption or scalability of the solution into other clinical environments.
Conclusions The innovation unit strategy was envisioned by the Hospital as a sandbox for designing and testing technological solutions, to bring innovation to clinical care processes in hospital clinical units. The project, however, was described by project leaders as failing to achieve these project goals, with the result being an inability to demonstrate value in terms of clinical outcomes and care processes. The vendors who participated in this case held similar views that the project goals were not achieved. The complexity of the technology engaged in the project was significant, given the large number of vendors and the varied technologies with proprietary software infrastructure that was a challenge to integrate to create the desired solution. In addition, project leadership decisions were challenged by the varied representation of each vendor partner that ranged from sales people to company CEOs. The lack of senior representatives on the steering committee resulted in delays in key decisions that had a negative impact on project outcomes. Although initially successful in garnering support from clinical staff, the delays due to integration issues ultimately meant that the technology integration was not able to achieve core functionality, which precluded staff from adopting the technology. This project has shed light on the complexities of integrating multi-vendor products in a live clinical environment. The complexity of integrating proprietary software, vendor partners working in collaboration and limited clarity of outcomes or functional specifications were identified as having a substantial influence on the outcomes of the project.
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Authors The World Health Innovation Network would like to acknowledge: Representatives from the World Health Innovation Network Project Lead, Phillip Olla, Senior Research Associate Anne Snowdon, Academic Chair Carol Kolga, Senior Research Associate Renata Axler, Senior Research Associate Ryan DeForge, Senior Research Associate Melissa St. Pierre, Research Associate Deborah Tallarigo, Knowledge Dissemination Specialist
Produced by: Dr. Anne Snowdon, Academic Chair, World Health Innovation Network, and Scientific Director & CEO, Supply Chain Advancement Network in Health, Odette School of Business, University of Windsor Original release date: March 2018 World Health Innovation Network T: 519.253.3000 x6336 E: winhealth@uwindsor.ca Windsor, Ontario