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HIStalk Interviews Avery Cloud

September 10, 2009 Interviews 7 Comments

Avery Cloud is CIO at New Hanover Regional Medical Center in Wilmington, NC.

Tell me how your Project S is structured, what it’s designed to accomplish, and your thoughts on portfolio and service management.

Project S is exactly that. It’s a service management initiative in disguise. I’ve tried to move away from this idea of talking in a language that means nothing to my customers. We basically took service management concepts and repackaged it into something that was explicable and digestible by our audience.

What created the need to do this in the first place was an analysis of where we stood and our ability to meet service levels or to create customer satisfaction, also to build an infrastructure that would support the coming strategic initiatives that we saw down the pike.

For example, we’re moving rapidly into full-function EMR. We knew that we have to have a structure that supports remote ambulatory care environments. We have to have different service levels for that.

Analysis showed that we just weren’t set to work quite ready for that. We had a maturity study done and we had about a 1.2 level maturity against a maximum of 5. It also revealed that we need to move somewhere around a 3.2, 3.3 maturity level in order to provide the kind of services that would be required to make our organization successful. That gap represented the tools, skills, policies, standards, procedures that are necessary to deliver high levels of service.

Our goal was to create stability: stability in our systems, stability in our service, stability in our satisfaction levels. That’s four Ss and that’s how we coined the term Project S.

Is the maturity level you mentioned CMM or is there something other that you measured that with?

IBM has a customized version of ITIL. They have a service level maturity or service maturity index.

How rigorous and involved was it to get that number back to tell you where you stood?

It was pretty rigorous. It was about a two-month-long analysis.

You got some help from Compuware in putting this together. What did you find you were lacking in terms of knowledge and abilities? Were there any new things that they insisted you bring to the table that you didn’t already have in your shop?

That’s a great question. One thing we lacked was a repeatable process. That’s where adopting ITIL came to bear.

Another we lacked was skills in the right areas. We had plenty of skills, but not necessarily the presence of the right skills for the right job.

We were also lacking tools. Tools essentially mean that we weren’t in a position to automate ourselves so that we could provide higher levels of service. As you well know, you can’t do everything in a manual fashion and be efficient and effective.

Those will be the areas that pretty quickly emerged, and that’s what led us to an analysis of what our toolkit should be.

We believe in the idea of integration. Integration is something that is quite absent in many IT organizations. We tend to be the worse, we’re much worse than our customers when it comes to buying one-off tools for every problem. What we try to do is buy an integrated toolkit that helps us run the business of IT.

That, in fact, was our mantra. We wanted to manage IT like a business, and therefore put in the business systems required. A good example is that we wanted to mimic our financial department, financial and HR. We have one product that manages finance and HR, and that’s Lawson. It has materials management, and then it has payroll, it has financial reporting, accounting, general ledger — you get the drift. It’s a well-integrated product which redoubles its ability to produce efficiency than if you had individual products for each of those foci.

We wanted to help this integrate into one product set, our monitoring initiatives or monitoring processes, our early detection and warning processes, but also our project management, change management, problem reporting, our time management, our budgeting process, our IT governance reporting process, our automated workflows.

That was really important to us. The system lets us embed the knowledge of experts and the systems, therefore driving a repeatable process. I said a mouthful there, covered a lot of territory, but I hope you get some sense out of that.

I don’t want to ask you what it cost, but how much of an effort and investment was it to move from where you were to where you are?

It’s probably the biggest thing this IT organization has approached since its inception.

How did you get the support to undertake such a project in these times?

It was simply outlining the gaps between customer expectations and our ability to deliver and matching a solution to those gaps. The organization wanted those gaps filled enough that the sale was much easier.

It’s kind of interesting. I had to highlight my failures, [laughs] which really is a risky and uncomfortable approach, but in fact, it is the right thing to do. I had to highlight the fact that I had a 30% drop call rate at the help desk. I had to highlight the fact that nine out of 10 problems that we encounter are called in to us by our customers rather than us notifying the customers of the existence of the problem. In other words, they find it before we do.

So you begin outlining all these things, and then you start talking about what’s coming in the future, and you’re going to have doctors who are going to need the services of that help desk with that low performance. You’re going to have doctors who don’t want to have their systems to fail when they’re in the middle of a surgery. You’re going to have nurses that can’t administer medications to patients in pain if the barcoded med system is down.

We were able to use kind of Walt Disney’s “imagineering” approach, just tell a story about how things are and how much better things could be.

ROI was not as necessary when you looked at it that way, because when you really looked at it, the case we were making was a case of staying in business. [laughs]

Overall, is the end result that you have restructured the department and changed the staffing mix and staffing levels?

Yes. We’ve done two substantial re-orgs through this process, continued to evaluate our staffing plans, and brought on a chief technology officer. We made some major staffing changes, major training changes. Our organizational processes don’t even resemble what they used to be.

If you’re talking to your CIO peers, what would you tell them is the key to know that you need to have this done and the thoughts to entertain before they start?

I think, you know, customer’s king. The key is to evaluate the customer’s level of satisfaction with services being provided. You can’t do that without getting very involved and face to face with the customers. So that’s number one.

Also, the study of where your organization is going is vital. You’ve got to forecast what are the strategic demands coming into your organization, and what are your current abilities to support the future.

One of the things I’ve said quite often in team meetings is we have to future-proof IT. We’re not future-proofing it against outside attack; we’re future-proofing it against internal demand. The whole idea is to create an IT organization that is not a constraint to business decisions.

Did the evaluation find that the IT department was underfunded?

Oh, yeah. There were some adjustments made there also. Probably another way to look at it is funding is not in the right places. It was not just underfunded, but the distribution of money and funds — are we spending our money on the most important services and problems?

How much larger did your operational percentage of total budget need to be to meet these standards that were laid out in the evaluation?

Let’s see … what was that percentage increase? I don’t want to guess at it. Suffice it to say that it went up modestly. [laughs]

And you had that commitment going in, knowing that there were things to be accomplished that might cost money, that the folks writing the check would say, “Yes, we’ll buy those recommendations and fund them?

Right. You have to prepare an organization to accept that. Obviously, marketing the project as goals and describing what it takes to meet those goals helps prepare an organization for an additional cost.

I believe we really did an excellent job on not making those costs burdensome. If you really look at our budget, we have stayed at just about the same expense percent revenue. It has gone up slightly, but not enough to sound alarms. [laughs]

What are you doing to establish relationships with your physicians?

One of the things we’d done is strengthen our governance process. We have a group of physicians that are integral to our governance and decision making to represent physician needs. We’re also looking for better support models for docs. We know service levels required for docs are far different than anybody else in the organization. They don’t have five minutes to hang on on the phone.

We’re looking for easier ways for them to communicate to us that there is an issue. They might want to simply let us know one of the keys is sticking on a keyboard. You’ll never hear about that from them because they’re far too busy to stop and tell you if you don’t make it easy for them to do that. They’re not going to pick up a phone because they don’t like being put on hold.

All those things we’re doing from a clinical perspective. We continue to enhance their portal. We make that their one windowpane to clinical information, or one pane of glass to clinical information is what I’m trying to say. We continue to enhance the speed, we set service level agreements for response time on the full transactions that represent 80% of their work. We are spending a lot of time right now prepping up for computerized physician order entry. That’s going to be a big one for them. Those are the big things.

In summary, the two most important things if you were to ask a doc is that the systems fail a whole lot less, and they run a whole lot faster.

Are you doing anything specific to stimulus funding?

Yeah. CPOE is going to be part of the “meaningful use” definition. We’re working with our physicians not only in the hospital, but with community docs that are affiliated with our hospital, and even extending our reach to all the counties that we serve, and collaborating with other hospitals and their physicians to start talking about health information exchange and how we can better share information, and how we can help them achieve the maximum stimulus dollars available.

What kind of things are you doing with the physician practice EMRs and practice management systems? How are you tooling up to get them prepared and to get your integration strategy with the doctors going?

Boy, I tell you, it’s essential to have a meeting before we talk about that. [laughs] It’s probably one of the more interesting things I get to spend my time on.

Anyway, here’s our strategy in a nutshell: we are going to standardize on one system, one physician EMR that we will recommend, and we will pre-build any necessary interfaces back to our hospital systems. Therefore, if a doc agrees to select that system, and of course we can’t make them do it, but if they agree to select that system they know that they automatically are going to be joined in the information sharing with the hospital.

This is also where HIE comes. We are looking for our own kind of mini-HIE for docs that might not agree to purchase that particular system, and at least provide some way for them to participate in information sharing with the hospitals that they have admitting privileges to.

We’re differentiating very clearly between docs that we employ and docs that we have affiliations with, and trying to provide those two levels of service. We’re really trying to work out the kinks on what is going to be our support model. Are we going to be the ASP, or is there going to be a vendor ASP involved? Might there be a hybrid model? There’s still a lot of unanswered questions, but we are right in the middle of trying to sort all of that out right now.

What would your credibility have been before you did Project S as opposed to now?

They would have run me out of town for real. Don’t you write that. [laughs] They would not have even considered it because our service levels were so abysmal that there was no confidence. There was a crisis of confidence in our physician staff with IT. Rightfully so.

What had happened was the needs of the organization had grown faster than the IT of the organization’s abilities to support those needs. That’s not unusual. That is the reason you have these clearly defined and measurable maturity levels for IT organizations, because you have to match up your IT organization’s capabilities with your internal customer’s demands.

Last question. If you look back at the last couple of years, what are the smartest things you’ve done as CIO?

What a great question. Smartest thing I’ve done as CIO … probably dealing with IS as an internal business. Allowing that perception to govern how I make decisions helps me make the right decisions. That would be one.

Another one would be taking no prisoners when it comes to hiring the best. I’ve got to have a team of people who better and more ideas than I do. I want to be the idea vetter, not the idea creator. Surrounding myself with good people — it takes a while to finally get that figured out, but if you do that right, the rest of the job gets easier.

In terms of information systems, specific or technical things that I’m proud of — I kind of don’t know how to say this, because I don’t know how to say this and make it print right, but I’ve spent time with a particular vendor and greatly influenced their product direction. We use a product here, a bed management system that a particular vendor and I drew on the back of a napkin, and he turned it into a product. So I’m pretty proud of that. I didn’t get a doggone thing out of it, but I’ve got a doggone good system.

Maybe another way to put it is I’ve always worked very hard to match a technology to a problem, and not just push technology.

I’ve got to share this one, too: putting in strong governance. If you want to succeed, have strong IT governance.

I always liked somebody who’s got a really firm vision on what needs to change without getting so wrapped up in the minutiae like hospital folks so often do, so it’s refreshing to have somebody with a plan who actually made it work, especially when you get into stuff like infrastructure and staffing and IT governance, which is usually kind the Vietnam of CIOs. [laughs] You get wrapped up in all the stuff you really can’t get closure on.

That’s so true. I tell you, my boss and I had a long conversation. He said, “Avery, what you’re very good at is the visioning part of being a CIO,” and he said, “I really like that about you, and what you’ve got to do is make sure that you have a structure around you and manage the details.” Because what happens to a lot of CIOs is they get pulled down into details and never get up the 30,000 feet to see what’s going on.

Is that inherent in their background, though, when you’ve got a lot of folks who worked to move their way up through IT, which is the argument of “are you better off with someone who’s risen through the IT ranks”, or better off to get a visionary who just lets other people worry about the nuts and the bolts?

That’s an interesting debate. I’ll just tell you about me: I came up through the technical ranks. I hold an MBA, but more importantly, I have an affinity to business. When people ask me about me and my job, I tell them I’m a business person who just happens to know IT.

I’d like to think that I could run any of the departments in this hospital. A good example is that nobody is surprised when the CFO runs the pharmacy department, or the CFO runs materials management. It should be no big surprise either that the CIO can do the same, or does the same. A very good friend of mine in another hospital — he’s the CIO there — runs the pharmacy down there. Another friend of mine who’s a CIO runs the home care division.

So a chief information officer is not a propeller-head. A good one is a business person. You think like a business person, and you recognize the importance of your specific trained professional discipline, which is IT, but you don’t let it rule you.

I think there are advantages to having a technical background because it does help you understand when your people are talking to you. I’ve seen the other side of the thing where the person did not come up through the technical ranks. It must be horrifying to be a person who has a strong grasp of the business but has no clue about technology, because the language we IT professionals talk on can be scary.

That’s why, frankly, a lot of CEOs are uncomfortable with IT reporting directly to them. If you’re not the kind of CIO who’s a business person, your CEO is not going to take to you. CEOs don’t want to hear about the bits and bytes and stuff.

I’m going to share this with you real quick. One of my crusades is to make my organization think about what we do from the customer perspective. Don’t tell me that the systems are up 99% of the time. Tell me how many hours you were down, because that’s how the customer looks at it. Don’t tell me that the server 214 is down. Tell me how many patients are getting backed up in the ED. Tell me how many fewer registrations I’m going to do per day because of this. Tell me what my impact’s going to be to the bottom line.

Part of our monitoring effort here is to cause our monitor to tell us what’s happening in the business based on what’s happening in IS. You’re not seeing a whole lot of IT leaders thinking that way, and that’s a problem.

I really want to pick up my phone and say, “You can probably expect a two or three percent decrease in collections today because we have some stress on one of the segments on the network that prevented as many bills going out.” That’s a different phone call than if I called my CFO and said to him, “Just wanted to let you know that your people are going to be a little frustrated because systems are running slow today.”

So I think that is really what IT leaders have got to strive for, the user viewpoint, the user view of the services that IT provides.

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Currently there are "7 comments" on this Article:

  1. I think this is great that a CIO and a healthcare organization recognizes the value of performance for an EMR. I mean think about it, we can’t just expect that buying an EMR, using stimulus money, will automatically cause clinicians to use it. We have to make sure it performs to their satisfaction — only then will we get the clinician adoption we have wanted for the last 20 years. Way to go Avery!

  2. How refreshing – someone who realizes that all of his technology is really just a means to an end, in this case care of the patient. This is no place for egos – we’re here to serve the needs of others. Sit behind a keyboard too long and that message gets lost. Kudos for keeping your eyes on the prize. With that kind of approach, you may yet end up running the whole hospital someday.

  3. Regarding this passage:

    You’re talking to your CIO peers, what would you tell them is the key to know that you need to have this done and the thoughts to entertain before they start? “I think, you know, customer’s king.”

    The fact that this advice seems to garner constant repetition among HIT leadership circles, especially when the “customers” are those with patient care obligations and responsibilities, should be a cause of deep reflection and introspection among those in HIT.

  4. You said:
    “I really want to pick up my phone and say, “You can probably expect a two or three percent decrease in collections today because we have some stress on one of the segments on the network that prevented as many bills going out.” That’s a different phone call than if I called my CFO and said to him, “Just wanted to let you know that your people are going to be a little frustrated because systems are running slow today.”

    If the network is stressed, what about calling and having to say that patients died because the right patient did not get the right treatment at the right time? Who cares about collections?

  5. Avery, my dear,

    Let me be perfectly clear. Patients are not customers.

    ‘You’re going to have doctors who don’t want to have their systems to fail when they’re in the middle of a surgery. You’re going to have nurses that can’t administer medications to patients in pain if the barcoded med system is down.’

    I am enthralled with your intellect. Whatever gave you this idea?

  6. Avery,

    Enjoyed reading your infomercial. You fail to clarify if electronic ordering has been implemented.

    If so, what complaints are you hearing from the doctors, or is this topic off limits as in most hospitals of nondisclosure, and will you truly be honest as most hospital admins are not? Are the adverse events always due to “user error”?

    Have you determined if there is accurate reporting of the adverse events from electronic ordering? Is there insufficient validation or doctors who are afraid to complain due to fear of “code of conduct” retaliation?

    Is the emperor wearing clothes? Many have their doubts.







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