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Transforming Organizational Culture through Decision Support at Bloorview Kids Rehab


Hakim Lakhani, Lynn Guerriero, Linda Hatton and Christopher Lau

ABSTRACT
The establishment of a decision support management and planning process at Bloorview Kids Rehab in Toronto, Ontario, has driven operational and physical changes at Canadas largest childrens rehabilitation, teaching and academic health centre. Decision support provides Bloorview management with integrated, evidence-based and user-friendly tools to plan programs and allocate resources; measure organizational, program and staff performances; and provide timely accountability to the provinces Ministry of Health and LongTerm Care. Not only has Bloorview shifted the internal culture to engage staff in planning the decision support system and developing meaningful data, but the hospital has also situated decision support within the hospitals Planning and Organizational Effectiveness Department, supporting an integrated model of organizational performance. Users and managements endorsement of decision support processes is foundational to our organizational and program effectiveness.

IN CONTEXT: DECISION SUPPORT AND BLOORVIEW KIDS REHAB

At the end of the 20th century and into the early years of the 21st, various decision support processes specific to healthcare settings and predicated on information technologies have proliferated in Ontarian, Canadian and North American settings from local community hospitals to tertiary and quaternary academic health science centres. Reports indicate that Canadas business-intelligence market in healthcare grew 10% from 2003 to 2004 (Himmelsbach 2005), with a predicted compound annual growth rate of 8.1% up to 2008. The use of such information technologies has two core objectives: (1) to better understand how hospital resources are used and (2) to demonstrate, in an evidence-based way, an institutions commitment to quality care and efficient operations. As argued by Kron (2004), the challenge in healthcare has never been a lack of data, even prior to the increasingly central role of decision support
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Transforming Organizational Culture through Decision Support at Bloorview Kids Rehab Hakim Lakhani et al.

tools and organizational structures in developing and deploying information. There has traditionally been a wealth of data, notoriously fragmented and often incomplete, making analysis and knowledge distillation from such sources an ongoing challenge (2004:15). Nowhere is this challenge the problem of being data rich but information poor more critical to address than in Ontario (though it may be equally critical in various jurisdictions in Canada and globally). With the installation of the McGuinty Liberals in 2003, the Ministry of Health and Long-Term Care cited its Information Management Strategy as essential to the provinces transformation of the healthcare system, under the Canadian universal healthcare model, to one that is more patient-centred, is safer, provides better access to care and contains costs. At the federal level, Romanow (2002) also cited health and information technologies as an essential foundation of healthcare reform. Bloorview Kids Rehab in Toronto, Ontario, is in a unique position nationally. We are the only childrens rehabilitation treatment centre of such size and scope in the country. We have also undergone fundamental organizational and directional changes over the past dozen years. Among these have been the merger of Bloorview Childrens Hospital and the Hugh MacMillan Rehabilitation Centre in 1996; Bloorviews fully affiliated status as a teaching hospital of the University of Toronto in 2002, making it Canadas first such centre in pediatric rehabilitation and delivering the countrys largest training program in developmental pediatrics; the founding of our Research Institute in 2004 and the establishment of three research chair positions; and the major rebuilding of Bloorviews physical plant, completed in 2006. Bloorview sees 7,000 clients through 52,000 outpatient visits and 600 in-patient admissions annually. It has 850 employees, including 300 clinical staff, and approximately 1,000 medical students and medical residents in training. Our nine most commonly seen types of clients have such conditions as cerebral palsy, acquired brain injury, muscular dystrophy and developmental disabilities. Clinicians and scientists growing understanding of the genetics of these conditions and the use of evolving biotechnology tools are increasing, as are the complexity, acuity and frequency of certain of these conditions in the pediatric population. Toronto is also the centre of growth in Canadas rehabilitation population, growth that is particularly evident in the age group of 10- to 19-year-olds. In short, Bloorview must deliver on our vision, a world of possibility, through a broadened scope of practice that builds the provinces capacity in pediatric rehabilitation and increasingly emphasizes research and innovation as fundamental to evidenceinformed treatment of disabilities in children even as we maintain our high degree of client and family satisfaction and stay responsive to issues of timely care, quality and cost efficiency.
CHANGING THE CULTURE: DEVELOPING, USING AND SHARING INFORMATION
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With IBM Cognos software, I can look at everything from workload and over-workload;
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Transforming Organizational Culture through Decision Support at Bloorview Kids Rehab Hakim Lakhani et al.

to the flow of children through the clinics; to staff sick time; to the allocation of staff to specific programs. The data analysis I can do from Cognos software is essential in collaborating with my staff during performance reviews and led to an evidence-based proposal for more operating budget to prevent staff burnout. (Andrea Tsuji, neuromuscular and spina bifida programs) As indicated earlier, the decision to install a constellation of decision support mechanisms at Bloorview Kids Rehab was in line with other healthcare institutions moves in this direction around this period. The way in which Bloorview collaboratively planned and carried out this process, and the corporate and financial resources that such a relatively small health centre (albeit mighty in scope) atypically put to decision support (Kron 2004), have predicted the accolades that Bloorview Kids Rehab has since received. Decision support does not have one accepted definition. That of Marakas as an organized set of tools intended to impose structure on portions of the decisions-making situation and to improve the ultimate effectiveness of the decision outcome (2003:29) fits with Bloorviews conception. Decision support is a corporate analytical tool, a core enabler in implementing organizational strategy and in motivating or redirecting effort (Longest 2003). At Bloorview, the system builds on and extends beyond information technology (IT) components. Our efforts and data are focused on utilization management, quality improvement, planning and personnel performance management. From the start, decision support was a senior management, not a project management, imperative. Reflecting that orientation, the decision support staff of three were situated, non-traditionally, within the health centres Planning and Organizational Effectiveness Department rather than in corporate services/information systems; hence, there were structural linkages between, as well as single senior leadership for, decision support, quality, patient safety and risk management. This allowed for the development of a fully integrated performance measurement and reporting model, with decision support playing the central role in data and information reporting. As a top-down strategy, it nevertheless actively engaged both the departments holding data (custodians) and the data users (e.g., clinical program managers, administration, senior [executive] team members and the board of trustees) in planning the system, with senior leadership also participating on the Decision Support Steering Committee. Decision support continues to add data capability in collaboration with end users and to respond to information requests in collaboration with data custodians. Active collaboration is far from a nicety, far from a device of internal relations correctness. It is perhaps a less typical approach among organizations establishing a decision support system, yet it is an identified key to success in implementing new technologies or their functions (Kron 2004; McGregor 2006). The main return on investment that Bloorview aimed to gain from decision support was a breaking down of our silos of information and an improved quality of data. These silos were barriers to integrated knowledge and, indeed, barriers to ready access to useable, reliable information barriers that exist in many healthcare settings.

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Transforming Organizational Culture through Decision Support at Bloorview Kids Rehab Hakim Lakhani et al.

BEFORE DECISION SUPPORT

Prior to launching the first phase of IT infrastructure for decision support, Bloorviews different departments collected data according to their own metrics, terms of reference and needs, be they finance, human resources or health records data, for example. Hospital executives and senior managers were likely to use a spray and pray strategy to these various areas to glean important information for planning and decisionmaking. At that time, different departments might have yielded different answers to the same question. Information silos and data discrepancies at Bloorview were also exacerbated by the realities of two newly merged organizations, with data at varying stages of depth. These barriers were reinforced by practical ones the time it took to develop one-off reports, time potentially doubly wasted in the duplication of data collection efforts from one department to another and then the time and effort to laboriously produce spreadsheets on paper and pray, in the case of the data custodian (or the report writer), that his or her efforts would be user-friendly enough to be read and considered.
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AFTER DECISION SUPPORT: PUTTING PEOPLE AND PROCESSES TOGETHER WITH TECHNOLOGY

Everyone up the chain uses the system: staff have access to stats related to their work, and input their own. We managers are frequent users, both of the Meditech/IBM Cognos system and the resources of the decision support team. And directors and VPs go into the system to communicate online with managers, for planning and decision-making and to report to the ministry. (Monica Gemeinhardt, manager, child development teams) Bloorview Kids Rehab developed a comprehensive decision support system that transformed how information is accessed, used and shared. Fundamental to system is that the technology (Figure 1) is the glue for data sharing, rather than the goal itself. Apart from the more technical aspects of the system, Bloorview embraced the following key features in our decision support to ensure success: Recruited in-house expertise who blend IT expertise with the teams motivation and experience in understanding Bloorviews clinical business Developed an ongoing, collaborative decision support plan and rollout, as described previously Proved the benefit of centralized decision support services and analysis first through the teams real-time response to challenging information requests and only afterward demonstrated what the technology itself could do Developed a user-driven system, both in terms of data needs and the technologys ease of use Established the foundational data system of modules and the business-intelligence system all built on consistent definitions on the data points (sick time, unique client, etc.), a system to which all licensed users have access Developed canned reports that integrate commonly used data for managers analysis and decision-making for example, from workload, staff performance and clientsatisfaction cubes; the system is also flexible enough for online users to create their own reports from within a cube and to accommodate senior leaderships requests for customized reports
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Transforming Organizational Culture through Decision Support at Bloorview Kids Rehab Hakim Lakhani et al.

Continue to commit financially to the infrastructure and technology required by decision support; a recent Canadian healthcare technology surveys showed that hospitals commit an average 2.5% of their operating budgets to IT (Zeidenberg 2006; Irving and Nevo 2005) whereas Bloorview is among the few that allocates >5% annually, of which a significant component is directed to the decision support system Continue internalized training and retraining on the technology, responding to the style and pace of learners, and using Bloorviews own data as the training tool, for greater familiarity and relevance to the end-users: formal group training, just-in-time one on one and learning from manuals; formal training, per trainee, is equivalent to >0.03 of a full-time staff position
Figure 1. Timeline of decision support activities and technology infrastructure

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THE TEAM AND THE TECHNOLOGY: SHINING A LIGHT ON DATA

We are at the point, with decision support at Bloorview, where the impact on patient care will be quite phenomenal. (Shelia Jarvis, president and chief executive officer) Information is the biggest piece in accountability. We have more than 1,000 trainees in the specialties at Bloorview, and we report twice a year to the ministry on the volume of medical students and residents, their patient encounters, etc. Because we can pull reliable data readily from the system, the ministry understands better what is involved in education in a hospital that is also an academic and research centre. (Dr. Golda Milo-Manson, chief of medical staff )

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Transforming Organizational Culture through Decision Support at Bloorview Kids Rehab Hakim Lakhani et al.

In September 2007, the Canadian Council on Health Services Accreditation accorded Bloorview Kids Rehab full accreditation, with no recommendations. The council cited us in particular for two leading practices: (1) for decision support, transforming a culture to fact-based decision-making; and (2) for the Growing Up Ready Program, preparing youth to transition to adult life. Both are recognized as leading-edge practices nationally and internationally. The Conference Board of Canada has also recognized Bloorview for the quality and depth of data in the performance indicators we submit regularly to Bloorviews Board of Trustees, and we received the Cognos Performance Leaders Award 2007, citing Bloorviews ability to transform the organization from more anecdotal decision-making to fact-based decision-making. Other marks of our decision support success include the following: Senior leadership, front-line managers, clinicians and staff report that our decision support team and business-intelligence system have made looking at data easy, contributing to high use of the system and resulting in more time to actually analyze data. For example, physicians have begun to use IBM Cognos 8 BI cubes (Figure 2) to analyze clinical data and have requested additional cubes. The investment of time, effort and money into getting clean data has paid off in our organizations pride and confidence in what we can report. We are energized and have asked the decision support system to do even more. Decision support has now linked data across several cubes, for example, patientoutcome measures and length of stay, enabling us to discharge children or keep them in hospital longer based on their progress rather than on anecdotal information or an arbitrary standard. Says Sheila Jarvis, We have no benchmarks on this linkage in pediatric rehabilitation in North America that we can find. We are establishing the benchmark. Bloorview decision support has begun to develop proactive reports in such areas as transition planning as children become adults. Family members are very anxious about theirs and their childrens ability to cope with the transition. Decision support analyzed what programs and services would have to be duplicated in the short term at the Toronto Rehabilitation Institute in order to transition the first group of clients aged 15 and over to the institutes adult clinic, while maintaining quality of care. Bloorview is now working on a long-term transition plan for all Bloorview youth who will eventually need adult services. Decision support and the business-intelligence system are also enabling more effective practices; for example, Bloorview has met and exceeded our goal of setting admission dates for children within three days of external referral, thereby positively affecting wait times. Decision support also enabled us to present a compelling case for funding to the Ministry of Health and Long-Term Care, eventually resulting in the establishment of permanent satellite clinics in the community. The decision support team also transfers knowledge, sharing our expertise, advice and cross-training, along with IT support, with other pediatric rehabilitation centres locally and provincially. We have now presented our successful program, by invitation, to a dozen hospiElectronic Healthcare, Vol. 7, No. 3 Online Exclusive 2008

Transforming Organizational Culture through Decision Support at Bloorview Kids Rehab Hakim Lakhani et al.

tals, healthcare networks and governments provincially, nationally and internationally, including Ontarios Ministry of Health and Long-Term Care; the King Faisal Specialist Hospital and Research Centre in Saudi Arabia; and the Irish government as it undertakes major reforms to its healthcare system.
Figure 2. Meditech integration with business-intelligence software (IBM Cognos 8 BI)

LHIN = Local Health Integration Network WeeFIM = Functional Independence Measure

CONCLUSION AND NEXT STEPS

There is no doubt that getting it right transforming an organizational culture so that our data are shared, accurate, reliable and in sync with the data reference points used across the healthcare system involved significant development time. Maintaining quality data, training new staff and retraining staff on new system capabilities and remaining committed to our corporate model of transparency, supported by data, all require ongoing surveillance and vigilance. Consistency and quality of data in each data set and subset in such a business-intelligence system as ours, which is geared toward linkages, is not only critical but challenging. There is some evidence that clinically specific decision support systems contribute to improved clinical decision-making and patient satisfaction (Erstad 2003). More comprehensively, because of our team and our technology, Bloorview Kids Rehab is on the cusp of making a number of meaningful links across our benchmarks (in program service and clinical care, efficiencies and, ultimately, internal research, external research and our teaching) to results for our kids. This is the next big step in decision support at Bloorview, linking more cubes for meaningful analysis.

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Transforming Organizational Culture through Decision Support at Bloorview Kids Rehab Hakim Lakhani et al.

Further goals will include balancing our research, teaching and care missions to ensure that all these are served, using our decision support data tools; providing more proactive or projective reports on such questions as target lengths of stay or incidence of specific conditions among children in the community; integrating the electronic health record for each patient into our decision support system; and developing e-learning modules on the system. That such a relatively small centre (though a national standard bearer in our field) is making this decision support investment in time, money, effort and expertise, matched in Canadian healthcare by only some much larger entities, speaks to how accountable Bloorview Kids Rehab is to our mission, on behalf of our kids: to defy disability.
REFERENCES
Canadian Healthcare Technology. <www.canhealth.com/news>. <AU: Please provide author, year of publication, article title and date article was retrieved.> Erstad, T.L. 2003. Analyzing Computer Based Patient Records: A Review of Literature. Journal of Healthcare Information Management 17(4): 5157. Himmelsbach, V. 2005. Signs of Intelligent Life. Computing Canada 31(8): 1213. Irving, R., S. Nevo. 2005. 2005-06 Report on IT in Canadian Hospitals: Current Capabilities and Upcoming Acquisitions. Thornhill, ON: Canadian Healthcare Technology. Kron, R. 2004. JHIM Quick Study: Healthcare Business Intelligence and Real-Time Decision Support Systems. Journal of Healthcare Information Management 18(3): 1416. Longest, B.B., Jr. 2003. Government Relations in the Healthcare Industry. In P. Leatt and J. Mapa, eds. Westport, CT: Greenwood Publishing Group. <AU: If this is a chapter in a book, please provide the book title or chapter title (whichever does not appear here).> Marakas, G.M. 2003. Decision Support Systems in the 21st Century. Upper Saddle River, NJ: Prentice Hall. McGregor, M. 2006. What Decision-Makers Want and What They Have Been Getting. Value in Health 9(3): 18185. Romanow, R. 2002. The Future of Healthcare in Canada. Ottawa: Health Canada. Retrieved November 7, 2008. <http://www.hc-sc.gc.ca/english/pdf/romanow/pdfs/HCC_Final_Report.pdf>. Zeidenberg, J. 2006. Survey ranks top IT projects in hospitals across Canada. Retrieved May 6, 2008. <http://www.canhealth.com/may06.html>
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About the Authors

Hakim Lakhani is the Vice President of Organizational Effectiveness at ErinoakKids, Centre of Development and Treatment. At the time of writing this article, he was Senior Director of Organizational Effectiveness at Bloorview Kids Rehab. Hakim founded the Decision Support department at Bloorview in 2002 and lead the organization through this journey of information enrichment. Lynn Guerriero is the Director of the Wait Times Information Program at Cancer Care Ontario. At the time of writing this article, she was the Senior Director of Community Programs at Bloorview Kids Rehab. Linda Hatton is the Senior Director of Information Systems at Bloorview Kids Rehab. Christopher Lau is a Decision Support Analyst at Bloorview Kids Rehab.

Electronic Healthcare, Vol. 7, No. 3 Online Exclusive 2008