When the Guthrie Clinic hired Terri Couts as VP of Clinical Applications in 2016, it was for a very specific reason: her Epic expertise. To say that the Epic implementation hadn’t been going well is a massive understatement. Clinicians were leaving in droves — in many cases, citing the EMR as a key factor.
Couts, however, believed it wasn’t the technology itself, but rather, the way in which it had been deployed. And so, she led an effort to revamp the entire process, “from the time we onboarded a new clinician all the way through upgrades,” and focus heavily on building relationships with users. The strategy quickly paid dividends, as clinician satisfaction rates skyrocketed, and the organization achieved STARS 10 Epic Status.
Even more importantly, a playbook was established for future projects, helping to ensure that Guthrie would be able to roll out projects more efficiently in the future. During a recent interview, Couts talked about how her background helped prepare her for the CIO role — which she took on in July of 2021, why it’s so critical to focus on the end user, and how her team hopes to lessen the documentation burden on nurses through its Nightengale Initiative.
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- “It wasn’t the EMR; it was how we deployed it,” said Couts, who was recruited for her Epic knowledge and asked with “right-sizing the ship.”
- Going from 2-star to 10-star status with Epic required taking a hard look at “where we were, how we customized, and how we delivered changes,” and revamping the entire process.
- When it comes to training staff on a new system, leaders need to take “a salesperson approach where you’re not going to get that the sale on the first visit. You need to build that relationship.”
- Individuals with strong network and infrastructure skills aren’t always the best leaders or collaborators. “You need somebody to understand the depth of what’s happening and be able to relate it to your core team.”
- The unintended consequence of physician burnout initiatives? They increased the documentation burden on nurses, which Guthrie Clinic hopes to alleviate through its Nightengale Initiative.
Q&A with CIO Terri Couts, Part 2 [Click here to view Part 1]
Gamble: Can you talk a little bit about the role that you had before as VP of Clinical of Clinical Applications? I imagine some of the focus is similar to that of CIO; did that experience help prepare you for the CIO role?
Couts: When I first joined Guthrie, I joined for my Epic knowledge. They hired me because there had been a fair amount of physician turnover; part of the reason, as they learned during exit interviews, was related to the EMR. But if someone is leaving an organization because of the EMR, it doesn’t mean you’re not going to end up at another organization that doesn’t use an EMR. The fact of the matter is that it wasn’t the EMR, it was how we had deployed it.
My main task was to right size that ship. It’s hard to recruit, so we don’t want to lose clinicians due to technology that’s poorly deployed. At that point, I had clinical applications under my purview. Guthrie became at Epic customer in 2003; it was one of the first inpatient go-lives. We had been a longstanding customer and have continued to deploy modules.
“We revamped our total process”
I’m not sure if you’re familiar with the Epic stars rating, but it’s from 0 to 10, with 10 being an organization that’s leading the pick, that’s innovation, and that has deployed function in the EHR to enable care. We had a 2-stars rating. And so, we really took a look at that — where we were, how we customized, and how we delivered changes, and revamped our total process. From the time we onboarded a new clinician all the way through upgrades, we revamped how we managed those deployments, as well as our interaction with our clinicians. We have a rounding program now where our trainers go out and round on a bi-monthly basis with our clinicians.
“We addressed the root cause”
We’re now in our second year in a row of being a 10-star organization. We went from an 8, to a 9, to two consecutive 10’s. It has really impacted our physician satisfaction scores. When you look at Press-Ganey, there’s a question related to physician satisfaction with technology. We scored in the 99th percentile in the nation in that area because our clinicians are happy with the technology. It shows that we’ve addressed the root cause. Of course, not everybody is 100 percent satisfied. There’s noise around it, but it’s not the same.
I think the work we did to change the direction of leaving because of the EMR, to being 99 percent satisfied, was really relationship based. It’s getting out there and talking to individuals and understanding what’s the noise — what are the pebbles in their shoes? What’s causing them to dislike the EMR? What’s preventing them from caring for patients in the way that they want to care? And then, it’s acting on that.
The difference being a CIO is that I have more customers, more noise, and more responsibilities. But I think just listening, understanding, and developing that trusting relationship that they know that we will do what we can to fix the pains in their sides — that has helped me in my role.
A different approach
We’re doing a big Oracle cloud implementation. Prior to me taking this role, I had very little insight into it. It’s about 6 months delayed. But even in the short time I’ve had in this role, we’ve been able to approach it differently. Again, you need to listen, understand what the noise is, and not make excuses but make them part of the solution.
We have a new forecasted date. We feel confident in the work we’re doing now. Before there was a lot of uncertainly, because it didn’t feel like they could trust us. Now they know they can.
Gamble: It’s a big jump going from 2 stars to 10 stars. What would you say was the most important factor in being able to do that?
Couts: I think it’s being visible, especially in a rural healthcare system. Our main hospital is Robert Packer Hospital; we have a fair amount of clinics around it, and there was a perception that the hospital got everything they needed and nobody else did. Some of our clinics are pretty far from the hospital.
Taking “a salesperson approach”
I think rounding and taking the time to go out and see people is so important. It’s almost like a salesperson approach where you’re not going to get the sale in the first visit. You need to build that relationship. Now, they save their questions for our trainers who go around because that’s their Epic person. They know that when they show up, they’re going to get some time for customizing their workspace and allowing them to have some control and helping them understand the why behind why do we need you to click this button.
When people understand that, they’re more likely to buy into it. Whenever you force something, everyone is going to have their opinion at first.
Gamble: Right. We hear that a lot. Do you think you have more clout being a nurse, like having worked in the field?
Couts: I do. Initially, people didn’t know I was a nurse by background. I moved from Ohio; they didn’t really know me. But I can understand the language of the medical field; having worked in the field, I know exactly how frustrating it is when you have a patient staring at you and there’s a piece of technology that’s making you feel stupid.
I like to use this comparison. Do you remember when Microsoft made a big change on Word where all of the dropdowns were different, and how frustrating that was? This was the same thing. We need to understand that and make sure we don’t purposefully cause it — that’s a big focus of ours.
Gamble: It seems people are coming to the CIO role with different backgrounds and different strengths, and a lot of them didn’t come from IT management roles. How do you think that will continue to shake out?
Couts: I do. I think it’s a trend that will continue to grow, primarily because you can get good network people. You can get good infrastructure people, but they’re not always the greatest leaders or the greatest collaborators. You need somebody to understand the depth of what’s happening at the hospital, and be able to relate it to your core team and help them understand why it’s important to respond in a certain way. It’s that translation that there’s always a patient at the end of that technology. If you have somebody who is just focused on IT, they don’t always grasp it. That’s why I think it’s important to have clinicians in that space — or at least someone outside of traditional IT roles. Because driving transformation is not about deploying technologies. It’s how you transform the care that you provide.
Gamble: You’re talking a lot about change management. There’s a lot of focus now on how to approach that — it hasn’t always been that way.
Couts: And rightfully so. It was about your technology stack; getting the right stack in place. Everything changes, and so has this. Now, just having the technology stack is not the answer; you have to be able to use it in a way that impacts care.
Gamble: Absolutely. And the nursing role is changing too. Do you think more nurses will advance to leadership roles because of the unique knowledge they have?
Couts: Yes. However, with the nursing shortage, it’s going to be interesting to see how that transformation occurs. There’s a whole shift to people not wanting to be in healthcare anymore. And so, I think we need more clinicians in leadership roles — not just nurses, but all clinicians.
Gamble: One thing that’s been a positive from these last two years is that there’s more emphasis on burnout, and hopefully there’s more of a conscious effort to try to reduce that.
Couts: It’s so funny; I remember when physician burnout was the hot topic five years ago. It still is, but now we’re transitioning to the nursing documentation burden. We put more on our nurses while we were trying to reduce physician burnout.
The Nightengale Initiative
So now, we’re trying to reduce their clicks. We’re trying to reduce the noise. I think sometimes we get a little too restrictive on the services that other support staff can provide. We’re taking the approach from a nursing standpoint of, is it the right person to be doing that care at that time? We have a program called the Nightingale Initiative where we’re looking at reducing the documentation burden on our nurses.
One thing we’re addressing is admissions. The admission database is something you fill out for every patient that comes into a hospital bed. There are a lot of questions to ask, most of them regulatory, that have to be addressed during care, but it doesn’t tell you when.
Looking at it holistically
Some of the questions are things like, can they climb a certain number of flights of steps. If someone is in an ICU bed, is that the most appropriate time to assess that? And does it have to be nursing? Can it be physical therapy or some other care continuum? It was taking our nurses an average of 70 minutes to complete the nursing database; we’ve been able to reduce it to 30 minutes just by looking at those types of concepts.
Again, looking at it holistically — not how many clicks a nurse needs to do, but is it the right care for the right person at the right time? It’s similar to the five rights. We want to make sure we’re not documenting twice, and that we’re getting the most value add from the data we collect.
Gamble: That’s really interesting. It’s not going to happen overnight, but it’s important to take steps in that direction.
Couts: Right. And again, Covid is forcing our hand. You know COVID again is kind of forcing our hand. We don’t have a ton of resources, and our resources need to be providing direct patient care — so how can we provide care differently?
Another thing that we’re doing is looking to do is have a virtual admissions nurse. Right now we have a fair amount of nurses in IT. They take one shift a month where they act as an admission nurse and fill out those admission database questionnaires for the nurses to relieve them of that burden. But eventually, once we have our command center set up, we’re going to have it virtually where they can have conversations with a patient no matter where they are, and not have to walk around and find that admission nurse to go into that patient’s room.
Hopefully, it provides more complete and accurate data collection. I think that virtual nurse will actually grow in her scope of what she’s able to do and not do, based on her being able to do more in a remote location than if she was staffed hospital employee.
Gamble: It will be interesting to see how things like that unfold. These are things we wouldn’t have thought of years ago — or wouldn’t have thought were so necessary.
Couts: We probably thought, ‘you can’t do that on a screen. No way.’ But how many times do we have interactions, even text messages, where we’re able to schedule appointments bi-directionally? Healthcare just needs to catch up.