EHR Implementation Checklist - midwest-site
Pre-Install
Table of Contents
|EHR Implementation Checklist |2 |
|Electronic Health Record Implementation in Physician Offices: Critical Success Factors |4 |
|EHR Implementation Team |9 |
|EHR Implementation Team Role and Responsibility Matrix |10 |
|EHR Goal Setting |11 |
|Transition Readiness Assessment |13 |
|Issues Log |16 |
|Computer Knowledge Evaluation Tool for Physician Staff |20 |
|Staff Meeting Skills and Agenda Template |21 |
|Huddles |23 |
|Scanning and Back loading Tips |25 |
|Workflow Assessment Guide |27 |
|Processes |34 |
|Return on Investment |36 |
Task Date Complete___
Establishment of Project Team ___________
▪ Physician champion(s)
▪ Project manager
▪ Additional practice/department champions
▪ Subject matter experts
Development of Project Plan ___________
▪ Scope document
▪ Implementation schedule/timeline
▪ Roles and responsibilities
▪ Change management process
▪ Issue tracking and management process
Communication ___________
▪ Setup regularly scheduled meeting with vendor implementation
▪ staff
▪ Provide staff regular updates
▪ Post implementation timeline in break room and mark overall progress
▪ Utilize newsletters, email, etc. to address specific topics or issues
Mapping of Critical Practice Workflows ___________
▪ Identify problem areas and bottlenecks
▪ Re-map practice workflows based on incorporation of EHR into them
Handling of Existing Data ___________
▪ Identify key information and documents that need to be in system
▪ Develop plan for entering them into system
▪ Develop plan for handling new, outside documents and information
Training ___________
▪ Assess PC and keyboarding skills of staff
▪ Establish plan for developing staff’s PC and keyboarding skills
▪ Have vendor conduct general overview of system for all staff prior to formal training
▪ Conduct multi hands-on, task oriented sessions tailored to staff responsibilities
▪ Identify “super users” and ensure they receive additional training sessions
▪ Allow staff on-the-job learning time to familiarize themselves with system
▪ Develop appropriate education material, such as cheat sheets, quick reference
▪ cards, diagrams of new workflows
EHR Implementation Checklist continued
Task Date Complete___
System Testing ___________
▪ Conduct unit testing (i.e., single module)
▪ Conduct integration testing (i.e., interaction between two or more modules)
▪ Conduct interface testing (i.e., interaction between systems)
▪ Conduct system stress or load testing
▪ Ensure testing plans cover different scenarios and situations
Contingency Planning ___________
▪ Develop disaster recovery plan
▪ Test ability to restore system from backups prior to go-live
▪ Ensure system backup plan in place and running
▪ Arrange for regularly scheduled pick up and off-site storage of backups
Go-Live Planning ___________
▪ Determine amount physicians’ schedules will be reduced (if any)
▪ Determine rollout approach:
( Incremental vs. ‘big bang’
( All physicians vs. physician champions
( All practice locations vs. select ones
▪ Allow time during day for providers to “catch up”
( Mid-morning and mid-afternoon buffers, or
( Extra minutes per visit
▪ Ensure sufficient resources available to support staff and physicians
▪ Make sure staff and physicians know who they can go to for assistance
▪ Inform third parties and other vendors, e.g., labs, transcription, etc. of go-live date so they’re prepared to provide additional support
▪ Plan for what to do if things go really wrong
• Identify situations or points where go-live needs to be stopped
• Decide what to do if that happens, e.g., go back to paper processes
▪ Schedule midday “huddle” to evaluate progress
▪ Schedule end-of-day debrief to identify and address issues
▪ Bring food, patience, and sense of humor
▪ Plan to celebrate
Overview
Evidence suggests that implementation and adoption of electronic health records (EHRs) in the physician office has the potential to improve quality of carei, as well as provide a positive return on investment (ROI) for the physician practice.ii Although “successful implementation” may be crudely defined as improved quality of care measures and a positive return on investment, a review of the literature on health information technology (IT) project implementation suggests that successful EHR implementation should be understood in a much more complex framework.
Implementation refers to the process of introducing an EHR into a physician office. “[T]he effort of designing, implementing, and using an information system involves numerous considerations and a series of processes that change the organization, the people and the information system involved”iii. “Successful” implementation of an electronic health record in the physician office involves application of technical, project management, and organizational skills, and embodies much more than mere installation of appropriate hardware and software. As Wager et al succinctly states,
Technical success alone does not ensure the EMR will be accepted and used by physicians…[T]he success of EMR implementation and utilization depends on the integration of the system into an often complex organizational setting.iv
Additional research supports this conclusion. In a case study of five community-based practices, all of which implemented the same EHR system, the authors found that the same EHR in comparable settings was viewed very differently. They conclude that within the practices analyzed, “perceived success or failure of the EMR system appeared to be related to organizational factors that were present before or during system implementation”.v
Literature describing implementation of EHRs into physician offices emphasizes the importance of broader organizational context and the effects that EHR introduction has on office workflow and culture. Given the importance of these factors in the implementation process, evaluation of medical informatics projects is increasingly taking into account the “social, organizational, political, and other non-technical factors surrounding an information systems project”.vi In a report titled “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience”, Keshavjee et al state, “[i]nitial success of EMR implementation is largely dependant on managing the stress of the major change in the practice” and depends on a “perception that sufficient value is gained from the change to justify the costs”vii Proper planning, training, and organizational mobilization are critical success factors to EHR implementation.
EHR Implementation: Phases and Benchmarks of Successful Implementation
As the framework below reflects, a large proportion of the effort associated with implementation should occur before the actual system is installed. Critical to project success is the up-front investment of time and energy.viii To illustrate this, in an eight-phase IT project framework outlined by Worthley in his textbook, Managing Information in Healthcare, “system installation” is the seventh step in the process.ix The majority of the implementation process precedes installation, and involves problem identification, system design, and testing.
Various implementation and IT project management processes have been put forth in the literature. The outline below highlights dominant themes and factors identified with successful
EHR implementation, but is not intended to serve as a comprehensive “checklist” or sequential timeline to successful implementation. Rather, it is intended as a broad framework to identify many of the key broad and widely cited critical success factors for EHR implementation. It is broken down into three major phases: Pre-Installation, Installation, and Post-Implementation. As the literature suggests, the majority of critical success factors fall into the “preinstallation” phase.
Pre-Installation
Identify Physician Champion
In a study of solo/small physician practices in California, the authors state, “identify an EMR Champion- or don’t implement”x. The importance of strong physician leadership is underscored in the literature.
The literature broadly emphasizes the importance of a physician champion to drive HER implementation. The following characteristics are associated with this lead:
o Formal or informal authority to lead change: A well-respected leader who is “powerful enough to make things happen”. xi
o Commitment to EHR implementation and ability to sell benefits to other physicians and office staff. To be successful, physicians and office staff must “buy-in” to the project.xii
This leader must be careful to set realistic expectations.xiii
Prepare Organization for Change
Change management is critical to successful EHR implementation. Prior to implementing and installing an EHR, a leader must prepare the organization for change by identifying core values, understating broader organizational context and stakeholder concerns, understanding end-user needs, creating a vision for change, and being sensitive and responsive to organizational stress resulting from change.xiv
Identify Strategic Objectives
A critical element in preparing an organization for the change that will result from implementation of an informatics project is “identifying key core values and focusing efforts on those.”xv
Clarifying areas for practice improvement in quality and efficiency helps to focus IT solutions on these areas.xvi
o Strategic alignment of IT investments with the practice’s clinical and business strategies is one important critical success factor for organizations that wish to assess the ROI of IT investments.xvii
Gain Support of Organizational Leadership/Secure Management Commitment
The importance of organizational support is one of the most dominant factors associated with successful implementation of EHR. Support from management and/or senior leadership helps ensure adequate resource commitment, critical to successful implementation.xviii Such resources are “needed to build an infrastructure to support the system and its users over time” and include not only up-front investment in hardware and software, but also time and staff allocation. xix
In one study of EMR implementation in an ambulatory care setting, the authors found an association between perceived usefulness of an EMR and organizational support. The authors explain, “By providing strong support for the redesign effort, management can communicate its commitment to the EMR investment”.xx
Involve Multiple Stakeholders
Involve the entire staff including upper management and administrative staff in implementation
and training activities.
Being able to meet the needs of conflicting stakeholders, including physicians, nurses, office staff
and administrators, as well as vendors and patients requires a strong project manager who can
ascertain broad needs, build support, and effectively negotiate solutions.xxi
Good Project Management
Establish project infrastructure (i.e. project team, including project manager, physician champion)
to support proper planning and ongoing support of the project.xxii
Consider Workflow Redesign
• “To be successful, health informatics systems need to support- or at least not be in conflict with the
organizational structures of the organization in which the systems are implemented.”
• In one case study of EHR implementation in a solo pediatric practice, one critical success factor
identified was the minimal amount of “reengineering” that occurred in re-designing workflow:
automated processes reflected, and sometimes simplified the physician’s manual workflow.xxiii
Conduct Research
• The process of choosing software is “an important time to learn about the strengths and
weaknesses of the EMR, the vendor who is selling it and the type of support that is likely to be
required for the EMR product”xxiv
• Site visits and speaking to experts helps establish realistic expectations for physicians looking to
implement systems.xxv
Offer Hands-On Training and Testing of Software
• Hands-on training, geared at appropriate computer skill levels is critical. “Hands-on training with a
software demonstration program, or a simulated demonstration model should occur early and
often, and be tailored to the needs and work schedules of the physicians.”xxvi
Installation
“Go Live”
Go live date should be “boring” because all staff has had experience testing and using
software.xxvii- Application/installation of hardware/software: Computer hardware should be
selected and ordered well before installation. Staff should already be familiar with the hardware
from training activitiesxxviii
Cable high volume work areas and exam rooms
Post-Installation
Ongoing EMR Quality Improvement and Management
One EHR Implementation methodology suggests that after the EHR software is installed, the
ongoing management should be “handed over” to an office support team.xxix
As software, technology and medicine change, practices will continually have to adapt.
Building flexible systems and continuous improvement of management processes are among the
critical issues to consider in analyzing the success of health informatics projectsxxx
Ensure Ongoing IT Support: Vendor and/or In-House
Vendor support: The importance of proper technical support cannot be understated. Various
authors cite the importance of vendor supportxxxi
On-site technical support: It is important to have on-site support to make adjustments to the
system, and address technical issues that arise.
In one literature review, the authors report many successful implementation efforts involve
physician “super-users” who assist in training of others. “Super-users are those physicians who
rapidly become expert users such that other physicians can call upon them for assistance.”xxxii
Customizing EMR: Some reports suggest that the ability to customize an EHR to physician and
practice needs is related to the success of EHR implementationxxxiii. However, opinions in the
literature regarding the importance of EHR customization are mixed.
In a literature review of best practices in EHR implementation, Keshavjee et al found the ability to
customize software was cited in the literature much less frequently than many other critical
success factors. “Many authors neglected to mention whether their software was customizable,
whether they did any customization work or whether they thought customization of EMR software
was important to achieve success in their implementation”xxxiv
“Most implementers mentioned that special problem-solving teams involving technical people,
trainers, nurses and physicians were an important tool to help achieve course corrections when
problems start arising after ‘go-live’. Problems were considered inevitable and having dedicated
staff to help users resolve their problems and achieve productivity goals is an important tool for
implementers as they computerize practices.”xxxv
System Evaluation: Have Objectives Been Met?
Evaluation of the EMR implementation provides opportunity to assess adoption and ascertain
whether new problems have arisen.xxxvi
i Miller, R. H. and Sim I. Physicians’ Use Of Electronic Medical Records: Barriers And Solutions. Health Aff, 2004; 23(2): 116-126.
ii MacDonald K, Metzger J. Achieving tangible benefits in small physician practices. First Consulting Group. Oakland, CA: California
Healthcare Foundation. September 2002. Available at:
.
iii Kaplan B. “Addressing Organizational Issues into the Evaluation of Medical Systems.” J Am Med Inform Assoc 1997; 4(2):94-101.
iv Wager K et al. Impact of an Electronic Medical Record System on Community-Based Primary Care Practices. J AM Board Fam Pract 2000; 13(5): 333-348
v Wager K et al. Impact of an Electronic Medical Record System on Community-Based Primary Care Practices. J AM Board Fam Pract 2000; 13(5): 333-348
vi Kaplan B. “Addressing Organizational Issues into the Evaluation of Medical Systems.” J Am Med Inform Assoc 1997; 4(2):94-101.
vii Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001. Report online. Available at:
viii Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.
ix Worthley JA. Managing Information in Healthcare: Concepts and Cases. Chicago, IL: Health Administration Press; 2000.
x Miller, R., Sim, I., and Newman, J. (2003). Electronic medical records: Lessons from small physician practices. California HealthCare Foundation. Available at: . Accessed on: 6/3/2004.
xi Wager 2000, Disastrous; Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.
xii Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.
xiii Casey A, Drazen E, Metzger J, Patrino K. “Eleven Critical Success Factors for Implementing Electronic Medical Records.” Available online at:
; Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.
xiv Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.
xv Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.
xvi Worthley JA. Managing Information in Healthcare: Concepts and Cases. Chicago, IL: Health Administration Press; 2000. ; MacDonald K, Metzger J. Achieving tangible benefits in small physician practices. First Consulting Group. Oakland, CA: California Healthcare Foundation.
xvii Arlotto P. Pam Arlotto, Healthcare IT Strategist, Shares Insight on the ROI Process and IT J Helathc Inf Mgmt Fall 2003 17(4) 18-19.
xviii
xix Wager K et al. Impact of an Electronic Medical Record System on Community-Based Primary Care Practices. J AM Board Fam Pract 2000; 13(5): 333-348
xx Dansky KH, Gamm LD, Vasey JJ, Barsukiewicz CK. Electronic medical records: are physicians ready? J Healthc Manag. 1999 Nov- Dec;44(6):440-54; discussion 454-5.
xxi Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.
xxii Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001. Report online. Available at:
xxiii Cooper J “Organization, Management, Implementation and Value of EHR Implementation in a Solo Pediatric Practice”. J Healthc Inf Manag 2004; 18(3), 51-55.
xxiv Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001. Report Online.
xxv Casey A, Drazen E, Metzger J, Patrino K. “Eleven Critical Success Factors for Implementing Electronic Medical Records.” Available online at:
xxvi Dansky KH, Gamm LD, Vasey JJ, Barsukiewicz CK. Electronic medical records: are physicians ready? J Healthc Manag. 1999 Nov- Dec;44(6):440-54; discussion 454-5.
xxvii Casey A, Drazen E, Metzger J, Patrino K. “Eleven Critical Success Factors for Implementing Electronic Medical Records.” Available online at:
xxviii Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001
xxix Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001. Report online.
xxx Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.
xxxiCasey A, Drazen E, Metzger J, Patrino K. “Eleven Critical Success Factors for Implementing Electronic Medical Records.” Available
online at: ; Cooper J “Organization, Management,
Implementation and Value of EHR Implementation in a Solo Pediatric Practice”. J Healthc Inf Manag 2004; 18(3), 51-55.
xxxii Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of
Implementation Experience” Canada: COMPETE, 2001. Report online.
xxxiiiCasey A, Drazen E, Metzger J, Patrino K. “Eleven Critical Success Factors for Implementing Electronic Medical Records.” Available online at: J “Organization, Management, Implementation and Value of EHR Implementation in a Solo Pediatric Practice”. J Healthc Inf Manag 2004; 18(3), 51-55.
xxxiv Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001. Report online.
xxxv Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001. Report online.
xxxvi Worthley JA; Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer- Verlag. 1995.
Selecting the right people for your EHR implementation team is a critical step in a successful implementation. In general, members of your team should be enthusiastic, well respected, and forward thinking. Team members should bring to the project differing perspectives on how the EHR will be used and provide a wide array of skills and knowledge. The size of your practice will determine the size of your implementation team. For smaller practices, one person may be managing several of the areas of responsibility listed below.
Physician Champion
An EHR implementation should not begin without a physician champion. The role of the physician champion is to act as a liaison between the physicians in the group and the implementation team. The physician champion acts as a point of reference for how things are done from a clinical perspective and how physicians need the EHR application to function. The physician champion is responsible for keeping the physicians up to date on the progress of the EHR and for maintaining physician “buy-in” to the project.
Project Manager
The project manager is responsible for keeping the project moving. In most implementations, there is a vendor counterpart to this position. The project manager is responsible for monitoring the work plan to ensure that the project is on schedule; maintaining a list of vendor and practice issues that need to be resolved; scheduling implementation-related events, such as hardware deliveries and live dates; and delegating tasks to the other members of the implementation team. In a small practice setting, the project manager is usually responsible for communicating updates to the rest of the practice.
EHR Builder
This person is responsible for building and customizing any EHR application areas such as templates, drop-down boxes and pick lists. This person will know more about how the EHR functions than any other person in the practice. This person may also have regular communication with the EHR vendor.
Application Trainer
Depending on the size and needs of the practice, an application trainer may be necessary. This person would be responsible for training new practice staff on the EHR application. This person may also assist with building tasks.
Registration User Liaison
This team member is responsible for providing input into the registration process. This person will become the EHR super user for the registration area.
Billing User Liaison
This team member is responsible for providing input into the billing process. This person will become the EHR super user for the billing area.
Medical Records User Liaison
This team member is responsible for providing input into the medical records process. This person will become the EHR super user for the medical records area.
Technical Support
This team member is responsible for the daily maintenance of the EHR servers, including running backups and applying upgrades to the system. This person should receive training from the vendor on recommended server maintenance. This person may also assist with developing and maintaining interfaces.
|Role |Responsibility |Person Assigned |Comments |
|Physician Champion |Acts as a liaison between physicians in the group and the | | |
| |implementation team. Provides point of reference from a clinical | | |
| |perspective, including how physicians need EHR to function. Keep other | | |
| |physicians up to date on progress and maintain “buy in”. | | |
|Project Manager |Day-to-day ownership of project, monitor workplan to keep project on | | |
| |schedule, track issues for resolution, schedule implementation related | | |
| |events, communicate the project’s progress to remainder of staff | | |
|EHR Builder |Building and customizing of any EHR application areas: templates, | | |
| |drop-down boxes, pick lists. Person with most knowledge about EHR’s | | |
| |functions. | | |
|Application Trainer |Training of new staff on EHR, assist EHR Builder | | |
|Registration User Liaison |Provide input on registration process. Become a super user for | | |
| |registration area. | | |
|Billing User Liaison |Provide input on billing process. Become a super user for the billing | | |
| |area. | | |
|Medical Records User Liaison |Provide input on the medical records process. Become a super user for | | |
| |medical records area. | | |
|Technical Support |Daily maintenance of EHR servers, run backups and applying system | | |
| |upgrades*. Assist with developing and maintaining interfaces. | | |
| |(*not applicable for ASP model approach) | | |
|Other: | | | |
| | | | |
The purpose of this tool is to help you define your goals for quality improvement and to help you target which features of the EHR will be critical to your quality improvement efforts. If you can define your goals, you can define your needs. If you can define your needs, you can select an EHR system that will meet your needs.
Getting Started: Start with a workflow analysis and identify the bottlenecks and inefficiencies that exist today. Decide which bottlenecks and inefficiencies you want to improve and assign them a priority. It doesn’t matter so much where you start—as long as you start somewhere.
In setting priorities, you may want to consider the following:
• In what areas is our performance far from ideal?
• What improvements do we think our patients will notice most?
• Where do we think we can be successful in making change?
• What groups of clinicians and staff should we involve in each item, and what is their readiness for change?
Goal Definition: Set clear, measurable goals for what can be done to improve the existing conditions. You may want to state some of your goals in a patient focused manner—such as decreasing the time patients wait for prescription refills or increasing the number of patients who receive preventative health reminders. Tell your patients about these goals. Let them know that you are trying to make their experience in your office better.
Have some fun with goal setting. Involve everyone in the office by asking for creative suggestions on ways to eliminate inefficiency.
Action Plan: For each goal, define a plan of action for achieving the goal. What specific steps do you need to take to reach your goal?
Measuring Success: Determine how you will measure the success of your action plan. Keep it simple! Don’t get hung up on statistics, sample size and complicating factors.
Incorporate your baseline measurements from the workflow analysis. You’ll need something to compare your quality improvement efforts to.
If you don’t meet your measurement for success the first time, re-evaluate, and try again. Quality improvement is a never-ending task.
Examples:
|Goal: |Decrease the number of pharmacy phone calls regarding prescriptions. |
|Action Plan: |Use the e-prescribing feature in the EHR to eliminate paper and handwritten prescriptions. |
| |Utilize the drug interaction checking feature of the EHR to guard against drug interactions. |
|Measure of Success: |In two months, have an 85% reduction in pharmacy phone calls. |
|Goal: |Decrease transcription turnaround time and reduce transcription cost. |
|Action Plan: |Use clinical charting within the EHR to eliminate the need for transcription services. |
|Measure of Success: |Within two months of EHR live, reduce the cost of transcription by 80%. |
|Goal: |Improve the quality of patient care for CAD patients. |
|Action Plan: |Use the EHR’s health maintenance tracking to monitor antiplatelet therapy. |
|Measure of Success: |95% of patients with CAD have been prescribed antiplatelet therapy. |
|Goal: |Decrease waiting room time for patients. |
|Action Plan: |Encourage patients to use the PC’s in the waiting room to update their demographics and insurance|
| |information. |
|Measure of Success: |Within one month, 75% of patients wait no longer than 10 minutes in the waiting room. |
More sample goals to consider:
1. • Improve patient access to the physician
2. • Decrease the number of times the physician leaves the exam room during a visit
3. • Increase the quantity/quality of patient education materials given to the patient
4. • Decrease the number of calls to the lab for results/follow up
5. • Increase the number of patients who receive reminders for age/sex appropriate preventative health measures.
6. • Increase the number of patients who actually receive preventative health exams/procedures
References:
Building a Mind-Set of Service Excellence. Paul Plsek, MS. AAFP Family Practice Management, April 2002.
Organizational change can be smooth and straightforward or filled with setbacks and challenges. While you cannot plan for every eventuality, you can take steps to ensure that your organization is ready for change. To address potential problems, it is necessary to assess your group to determine where those problems may arise.
This readiness assessment is intended to give you the data you need to locate and address areas of potential concern before they become problems during a time of transition.
Taking this assessment
You can take this assessment yourself to clarify your observations about the readiness of your organization to implement changes. For a wider view of the organization, it is recommended that you have a number of people from across the organization fill out the survey. The more people who fill out the survey, the better gauge you will have of your organization’s readiness for change. Encourage honesty in answering. This should be a reflection of how the organization currently is, not a reflection of an ideal.
Other uses
While this tool is primarily designed to reflect strengths and weaknesses in the organization prior to change, it can also assess the climate of group before and after a change. Often, it is a good idea to reassess at some point after a change has been made in order to show that the change has been an improvement.
It can also be useful to gauge whether different levels in the organization are operating under the same assumptions about openness and performance. If managers and staff are not on the same page, there is more likely to be resistance to any efforts at making changes.
Evaluating the Results
To evaluate the results of the survey, average the total scores of all the people who filled out the survey. This will give you an overall picture of whether your organization is ready for change.
Next, add the scores for each question individually so you can average the answers for each one. This will allow you to pinpoint your organization’s strengths and the problems that need to be addressed to promote smooth transitions. It is helpful to have the aggregate answers to show, in an impersonal way, areas that need to be addressed. Leadership and trust are potentially divisive issues, so it can be helpful to be able to address them in a non-confrontational manner.
Transition Readiness Assessment
Choose one:
___ I am filling out this assessment for the organization as a whole.
___ I am filling it out for a particular site, department, or other part of our organization.
Which one?
And answer this:
The change for which I am assessing our transition readiness is as follows:
1. _ _ Most people think that the change in question is a necessary one.
2. _ _ Most people agree that — given the situation — the change represents the best way of dealing with it.
3. _ _ The organization's leaders have shown that they are committed to the change.
4. _ _ In general, the middle managers are behind the change.
5. _ _ So are the supervisors or first-line managers.
6. _ _ The details of the change are being communicated to those who will be affected as quickly as it is practical to do so.
7. _ _ There are effective ways for employees to feed back their concerns and questions about the change.
8. __ And those concerns and questions have, thus far, been responded to in a pretty honest and timely way.
9. _ There aren't a lot of old scars or unresolved issues around here.
10. _ _ The organization has a history of handling change pretty well.
11. _ _ The organization's leadership has a history of doing what it says it will do.
12. _ _ . . . and of saying what it is going to do before it does it.
13. _ _ I think if this is what the leadership wants to do, they can pull it off successfully.
14 _ _ Decisions generally get made in a timely fashion around here.
15. _ _ When people get new roles or tasks, they can usually count on getting the
training and coaching that they needed to do them.
16. _ _ When faced with new and challenging situations, the organization forgets
turf-issues and gets problems solved.
17. _ _ It is safe to take an "intelligent" risk in this organization; failure in a good cause or for a good reason isn't punished.
18. _ _ There is a pretty widely understood vision of what the organization is seeking
to become and to accomplish.
19. _ _ While the higher-ranking people obviously get paid more, we feel like we're all in this thing together.
20. _ _ People's commitment to their work here is as high as it was a year ago.
21. _ _ Although the pace and extent of change around here is great, it is also workable.
22. _ _ Management generally practices what it preaches.
23. ___ There is basically no argument about what the organization's problems are
around here.
24. _ _ The organization's leadership generally shows an awareness of and concern for how change will affect the rest of us.
25. _ _ People generally understand how things will be different when the change
is finished.
_____ TOTAL SCORE
|Describe Issue |Internal issue |External/Vendor Issue |Date Communicated |Date Resolved |
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|Technological Skill |Yes |No |Unsure |
|Functional Skills – I can/am able to: | | | |
|Use a computer mouse to point and click | | | |
|Use a computer keyboard | | | |
|File Management- I can/am able to: | | | |
|Create and rename a folder | | | |
|Move file(s) from one folder to another | | | |
|Save and delete a file | | | |
|Find a file using Windows explorer | | | |
|Zip and unzip a file | | | |
|Empty the recycle bin and retrieve a deleted file from the bin if necessary | | | |
|Operations – I can/am able to: | | | |
|Use the task and tool bars | | | |
|Right click the mouse to bring up special menus | | | |
|Access computer functions through the ‘start’ button | | | |
|Shut down the computer using the ‘start’ button | | | |
|Reboot using the ‘shutdown’ function on the start button | | | |
|Minimize, restore, and/or resize a program’s window | | | |
|Create a shortcut to a program to the desktop | | | |
|Printing Basics – I can/am able to: | | | |
|Set up a page in portrait or landscape form and use the header and footer function | | | |
|Use print preview and send a document to the printer | | | |
|Pause or delete a print job | | | |
|Change the printer from printer settings | | | |
|Set a default printer | | | |
|E-mail fundamentals – I can/am able to: | | | |
|Check mail, compose mail, and send a new message | | | |
|Send an attachment | | | |
|Set up mailboxes | | | |
|Forward mail to someone | | | |
|Set up an address book and send e-mail to more than one address simultaneously | | | |
|Word Processing Functions – I can/am able to: | | | |
|Create and save a new document | | | |
|Save a document to a different drive | | | |
|Save a document as a different file type | | | |
|Check spelling and grammar in a document | | | |
|Internet Use – I can/am able to: | | | |
|Use and change search engines and search using keywords | | | |
|Print the screen | | | |
|Save an image to file, download, and save a file | | | |
|Reload a page | | | |
Before your staff meeting:
1. Create and distribute an agenda with clear goals and outcomes
2. Assign meeting roles
|Meeting Roles |Responsibilities |
|Leader |Prepares agenda BEFORE the meeting, moves agenda, elicits participation |
|Recorder | Visual record for group, next actions list |
|Timekeeper | Verbally announces amount of time remaining and when time is up |
|Facilitator |Helps to manage group process, to balance participation, to keep |
| |group focused on objectives |
During the staff meeting:
1. Clarify aim/goal: What we will get done?
2. Review roles: Leader, Recorder, Timekeeper, Facilitator
3. Review agenda
4. Work through agenda items
5. Review meeting record: review flipchart record, make changes/additions, and decide what to keep for meeting record
6. Plan next actions and next agenda: Who will do what offline and aim for next meeting?
7. Evaluate the meeting: What went well? What could be improved?
After the staff meeting:
1. Follow-up on action items
* From Improve Your Medical Care, Dartmouth
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|STAFF MEETING AGENDA |
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|TOPIC |TOPIC LEAD |TIME |
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|Plan Aim/Goal and Agenda for next meeting: |
|Evaluate/Process Check (How can we improve this meeting?): |
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The idea of using quick huddles, as opposed to the standard one-hour meeting, arose from a need to speed up the work of improvement teams. Huddles enable teams to have frequent but short briefings so that they can stay informed, review work, make plans, and move ahead rapidly.
Huddles have a number of benefits:
• They allow fuller participation of front-line staff and bedside caregivers, who often find it impossible to get away for the conventional hour-long improvement team meetings.
• They keep momentum going, as teams are able to meet more frequently.
• The enable Plan-Do-Study-Act (PDSA) cycles to proceed rapidly.
Directions:
1. Discuss the huddle concept with the team and explain that huddles are a tool for speeding up improvement.
▪ Various people can present them at various times during the day in different department areas so that every employee on every shift has an opportunity to hear the daily huddle.
1. Agree on the time and place that huddles will occur.
▪ Beginning of day: review of the day, review coming week and next week
▪ Mid day review/ End of day review
▪ Frequency of daily review dependent on situation
▪ To keep huddle focused and short, no one should sit
2. Bring the team together in the place that is most convenient for the team members who have the least time available for meetings.
3. Have a clear set of objectives for every huddle.
4. Limit the duration of the huddle to 15 minutes or less.
5. Review the objectives of the huddle for that day, review the work done since the last huddle, act on the new information, and plan next steps.
▪ Gear the information so it is meaningful for the attendees. Recognize individual or team effort, illustrate company mission in motion, share a corporate fact, fact of the day, benefit or policy update, highlight employee information such as birthdays or anniversaries and end with a motivational quote of the day
▪ To ensure effective huddles, the following activities can be assigned by staff member
▪ Medical Assistants- Consider possible bottlenecks that may arise in the schedule (e.g., two high- needs patients scheduled back-to-back), set up procedures and request outstanding labs and reports, make sure needed forms are in charts, Cancel scheduled appointments for patients who have been hospitalized
▪ Nurse- Consider phone contacts or rescheduling appointments if providers have too many patients, look for potential patients who could have nurse visits, identify potential slots for double booking if needed
▪ Front Desk- Alert staff to chronic no shows, chronic late or disruptive patients, do chart prep: ensure enough blank progress notes, name of patient on all sheets; have new patient sign request for information if possible
▪ Provider- Review list of scheduled patients. Help Nurse and MA’s plan flow and anticipate patient needs, request needed lab, procedure and ED reports, let staff know of any potential for double booking, check for patients that always take a lot of time (patients with lots of co-morbidities, complaints, elderly).
6. Huddle frequently, as often as daily, when many PDSA cycles are being tested and the team needs to share information frequently.
Huddle Worksheet
What can we proactively anticipate and plan for in our work day/week? At the beginning of the day, hold a review of the day, review of the coming week and review of next week. Frequency of daily review is dependent on the situation, but a mid-day review is also helpful. This worksheet can be modified to add more detail to the content and purpose of the huddles.
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|Practice: ____________________________ Date: _____________________ |
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|Aim: Enable the practice to proactively anticipate and plan actions based on patient need and available resources, and contingency |
|planning. |
|Follow ups from Yesterday: |
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|Heads Up for Today: (include special patient needs, sick calls, staff flexibility, contingency plans) |
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Transitioning patient data from paper charts to the EHR is probably the most time consuming and resource intensive task on the EHR implementation workplan. Careful thought and consideration should be given to this process. Time spent planning the scanning and backloading process will be time well spent.
Scanning refers to the process of electronically scanning your paper medical records into the EHR. Backloading refers to the process of manually entering information into sections of your EHR.
Scanning is a quick process and many practices will be tempted to scan all documents from the paper chart into the EHR. Practices may feel that scanning everything is the “safe way” to proceed and thus they will avoid the possibility of not having a piece of information they need to offer patient care. Unfortunately, scanning every document into the EHR could end up being more of a hindrance than a help. Too many scanned documents will slow the providers down as they try to find information on the patient. Ask any provider in your practice, flipping through a paper chart for a lab result is a frustrating experience. You will want to be sure not to duplicate this frustration in the EHR.
Depending on your EHR vendor, scanned documents may or may not be searchable and reportable so keep this in mind if you are planning to generate reports on specific data elements.
Backloading information such as allergies, medication lists, and past medical history into specific sections of the EHR is a more resource intensive process but the end result is an organized, searchable, reportable record of the patient’s medical experience.
Backloading of data can also be a good “hands-on” training exercise for the staff.
As you begin to plan your scanning and backloading methodology, discuss the following questions/concepts with your implementation team:
▪ Which paper charts will be scanned? All charts? Just patients that have been seen in the past five years?
▪ Which parts of the charts will be scanned? Which parts will be manually backloaded into the EHR?
▪ If sections of the chart will be manually backloaded into the EHR, who will enter the information and when will they enter it?
▪ Who will scan the paper charts? Staff? Temps? A scanning service?
▪ In what order will the paper charts be scanned? (Newest to oldest? Based on appointment schedule?)
▪ How will scanned documents be indexed in the EHR? Will there be separate sections for referrals, office notes, and other documents?
▪ How will new documents that are received in the mail every day be handled?
▪ What type of scanner is needed? Is there enough physical space for a high volume scanner?
▪ Will scanned documents be searchable/reportable? Be sure to ask your EHR vendor.
▪ What will we do with the charts once they are scanned? Will we store them offsite? Shred them?
▪ If paper charts are to be scanned, you may need to develop a paper to electronic transition plan so your staff will know where to look for a patient’s chart. For example, should they look on the shelf or in the computer for the patient’s chart?
Other practices facing this decision have opted to manually backload an historical patient summary including the past medical history, medications, allergies, etc into the EHR. Only the most critical documents from the patient’s chart were scanned into the EHR.
Charts were “prepped”—meaning that the historical patient summary was manually entered and the pertinent chart pages (current progress notes, advance directives, release of information, etc) were scanned into the chart—based on the patient appointment list. In anticipation of the EHR being live, the practice began prepping charts for the first two months of appointments after the EHR live date. Charts were then continuously pulled and prepped based on the appointment list until all charts were scanned.
An electronic archive was created on a server separate from the EHR to electronically store the entire patient chart. The entire patient’s chart was scanned into the archive and will be kept for the time required by law. The physical paper chart was then shredded. The purpose of the electronic archive is to keep all patient records post-EHR live, in accordance with law, without having to maintain space for the paper charts or bear costs of offsite storage.
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Clinic Name: ________________________________________________________
| |Hours of Operation | |Hours of Operation |
|Monday | |Friday | |
|Tuesday | |Saturday | |
|Wednesday | |Sunday | |
|Thursday | | | |
Practice Schedule:
|Provider Name |Daily Schedule |# Patients/day |Accepting New Patients |
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List all office staff members and describe job responsibility:
|Name |Job Responsibility |Full/Part Time |
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Background Questions:
|Questions |Details |
|General Layout: |# Exam rooms: |
|Obtain copy of floor plan/evacuation route |# Workstations: |
| |# Offices: |
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|Identify Project Leader | |
|Chart Confidentiality: |(Need for new P&P’s related to security/access to EMR |
|Current policies related to security of |(P&P regarding storage of paper records, on and off site |
|PHI/chart storage/access to PHI | |
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|Current PC use by staff: |(Provide Windows Training CD |
|Staff familiarity with Windows technology? | |
|Need for Windows training? | |
|Renovation Plans: | |
|Any plans for future construction, relocation,| |
|renovation of office? What is timeframe? | |
|Known Staff Changes: | |
|Any plans to add new staff? Are any existing | |
|staff expected to leave in near future? | |
|IT Support: |(Provide resource list |
|What IT support is available? On-site or | |
|contracted? List name and contact information | |
|Remote Access: | |
|Will providers or other staff need access to | |
|system remotely? Any remote access in use | |
|currently? | |
|Exam Rooms/workstations: | |
|Will workstations be placed in exam rooms? Is | |
|additional furniture or mounting devices | |
|needed? | |
|Wireless Devices: | |
|Plans for a wireless network? Type of device? | |
|(Tablet PC’s, laptops or hand held devices) | |
|Scanning Technology: | |
|Does practice currently use scanning software | |
|to store pt information? If not, plans to | |
|implement? Capable of multiple documents? | |
Workflow Overview:
|Process |Overview |
|Patient registration process |New patient: Existing patient: |
| |(Demographic form? (Update demographics? |
| |(Insurance verified-card copied? (Update insurance-copy card? |
| |(HIPPA form? (HIPPA form? |
| |(New patient packet sent? (Co-pay collected? |
| |(Co-pay collected? (Forms added to chart for MA? |
| |(Forms added to chart for MA? |
| |(Picture of patient taken? |
| |(How is arrival communicated? |
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|Appointment scheduling: Who makes |(% of appointments made by phone vs previous visit? |
|appointments, % of same day appt, % of| |
|new patients/day or month? Allow walk | |
|ins? Hours for walk ins? | |
|Triage and Clinical Phone calls: |(Automated phone system? Rx calls: |
|Include Rx renewal process |(Who handles? (Accept pt and pharmacy calls for refills/questions? |
| |(How handled? (P&P’s for handling requests? |
| |(Process for returning pt calls (Standing protocols? |
| |(# calls for MD directly |
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|Other phone calls: | |
|How are messages communicated to | |
|staff? | |
|Medical Records: |(Regular appointment |
|When and by whom are charts pulled? |(Same Day appointment |
|Who files information in charts? What |(Nurse visit |
|is filed in the chart? What’s done |(Phone calls |
|about missing charts? |(Incoming results |
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|Describe Pre-visit tasks: |(Who does |
|Include printing of fee slip, chart |(Reminder calls |
|preparation, pre-vist appt | |
|confirmation | |
|Billing: |(Keeping current PM software? |
|Including onsite billing vs billing |(Would consider new PM software? |
|services | |
|MA/Nursing tasks: |MA/Nurse: Nurse only: |
|Related to patient visits |(Room patient? (What’s MD responsibility? |
| |(VS, weight taken? |
| |(Brief hx, meds reviewed? |
| |(What is documented? |
| |(Routine exams/set-ups? |
| |(How is patient ready status communicated to MD? |
| |(What happens with no-shows? |
| |(Is there provider variation? |
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|Provider tasks: |Exam: Correspondence: |
|Related to patient visits |(Reviewing the chart? (Review of messages |
| |(Placing orders (Review of labs/results |
| |(Requesting MA assistance? |
| |(Documenting visit? |
| |(How is provider kept on schedule? |
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|Dictation/Transcription: | |
|How often is dictation done? How | |
|(digital vs tapes)? How are | |
|transcribed notes sent back? Any | |
|transcription done on-site? | |
|Laboratory: |(MA’s draw? |
|% of on-site vs outside lab use? Where|(Process for removing and returning pt to exam room? |
|drawn on site? % tests per lab? How |(list outside labs: |
|are results reports received? How |(How are results communicated to patients? |
|often? |(What happens if pt can’t be reached? |
| |(What is the tracking process for labs/results? |
| |(Is there a lab-specific printer/fax for results? |
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|Referrals: |(Any process for verifying pt completes referral? |
|How are referrals ordered? Authorized?| |
|Scheduled? Tracked? Is there a | |
|referral coordinator? | |
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|Patient Check-out: |(When is visit documentation completed? |
|Describe process. |-As visit concludes |
| |-Immediately after visit at workstation |
|Is there variability among providers? |-Between visits, when MD has time |
| |-At the end of the day |
| |-Days/weeks later |
| |-Usually within _____ hours |
| |(What happens to the chart? |
| |-Goes with pt to checkout |
| |-Goes to the MD office |
| |-Sits at a work area for MD to complete when time permits |
| |-Other: |
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| |(Super-bill/Encounter form: |
| |-Who documents on super-bill? |
| |-Where does it go at end of visit? |
| |-How does it get there? |
| |-What are the steps until a bill is dropped? |
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| |(Coders |
| |-Do they have the information they need? |
| |-How do they get their questions answered? |
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| |(Who checks the patient out? |
| |(How are follow up appointments made? |
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|Patient correspondence: | |
|Missed appointment calls/letters, etc.| |
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Forms and Letters
Collect copies of all standard forms used: Fee slips, patient encounter forms, referral forms, nursing order forms, lab order forms, lab report forms, immunization records, etc. Also obtain copies of any standard letters that are sent out, missed appointments, reminders, etc.
Chart Review
(Review several charts from each provider and summarize how organized
(Is there an up-to-date face sheet with problem list, current medication and allergies?
(Are notes typically hand-written, transcribed, or completed forms?
(What is the volume of outside correspondence is chart?
(Do all providers use the same method to record notes?
(How are phone notes recorded in chart?
(Are there in-house procedures performed that are documented on forms?
(Do they use drawings or graphics as part of their chart documentation?
(Other?
*Review, adapt, and distribute the Core and Supporting evaluation form to ALL Practice Staff. Be sure
the list is accurate for your practice and then ask staff to evaluate the CURRENT state of these processes. Rate each process by putting a tall mark under the heading which most closely matches your understanding of the process. Also mark if the process is a source of patient complaints. Tally the results to give the Lead Team an idea as to where to begin to focus improvement from the staff perspective.
*Steps for improvement: Explore improvements for each process based on the outcomes of this assessment tool. Each of the processes below should be flowcharted in its’ current state. Once you have flowcharted the current state of your processes and determined your chage idea use the PDSA Cycle Worksheet to run tests of change and to measure.
|Primary Care Practice Know Your Processes |
|Core and Supporting Processes |
|Processes |Works |Small Problem |Real |Totally Broken |Cannot Rate |We’re Working |Source of Patient|
| |Well | |Problem | | |On It |Complaint |
|Appointment System | | | | | | | |
|Messaging | | | | | | | |
|Scheduling Procedures | | | | | | | |
|Order Diagnostic Testing | | | | | | | |
|Reporting Diagnostic Test Results| | | | | | | |
|Prescription Renewal | | | | | | | |
|Making Referrals | | | | | | | |
|Pre-authorization for Services | | | | | | | |
|Billing/Coding | | | | | | | |
|Phone Advice | | | | | | | |
|Assignment of Patients to Your | | | | | | | |
|Practice | | | | | | | |
|Orientation of Patients to Your | | | | | | | |
|Practice | | | | | | | |
|New Patient Work-ups | | | | | | | |
|Minor Procedures | | | | | | | |
|Education for Patients/Families | | | | | | | |
|Prevention Assessment/Activities | | | | | | | |
|Chronic Disease Management | | | | | | | |
|Palliative Care | | | | | | | |
Return on Investment (ROI) analysis is one way to build a business case for implementing an EHR. The term means that decision makers evaluate the investment by comparing the magnitude and timing of expected gains to the investment costs.
Simple ROI is the most frequently used form of ROI and is the most easily understood. With simple ROI, incremental benefits of the investment are divided by the cost of the investment. In other cases, the term refers to the cumulative cash flow results of an investment over time. Since so many different ROI metrics are commonplace and the term itself does not have a single, universally understood definition, it becomes important to be sure that decision makers define ROI the same way and that everyone understands the limits of the concept when used to support business decisions.
When looking at ROI for an EHR implementation, the major categories of savings are cost reduction; revenue enhancement; improved administrative efficiency; and improved clinical efficiency, patient care and service. These categories mirror the promised benefits of the EHR, because ROI analysis is really nothing more than the process of confirming that the system is delivering its expected benefits.
EHR Savings to Consider
Cost Reduction
Reduced transcription costs
Reduced internal and external copying expenses
Labor savings
Malpractice insurance savings
Lower paper chart and storage expense
Reduced paper office supply costs (paper, chart materials, prescription pads, etc.)
Revenue Enhancement
Increase in health maintenance services
Improved coding accuracy
Increase in the number of visits per day
Increase in the amount of revenue-generating space (if the medical records area is used for something else)
Improved Administrative Efficiency
Fewer chart pulls and less filing
Universal access to charts
Reduction in phone tag
Improved intra-office communication
Fewer call-backs from pharmacies
Easier compliance with chart requests and chart audits
Improved Clinical Efficiency, Patient Care and Service
Higher quality documentation
Built-in protocols and reminders
Improved medication management
More efficient signing of charts
Patient callbacks and telephone triage
Patient education and involvement
Electronic clinical decision support
For the ROI analysis, also consider the cost of implementing the EHR. Listed below are some of the costs of implementing an EHR.
Software license fees
Hardware costs and maintenance fees
Vendor implementation fees
Internal network upgrade expenses
Software upgrade costs
Vendor support costs
Training costs
Costs to scan/backload paper charts into the EHR
Cost of employee overtime to implement system
Cost of temps or others to help with implementation
Temporary loss of revenue if you are planning on a reduced schedule during the live event
Additional IT staff expense
Resources:
1. 1.
2. 2. The Dollars and Sense of Electronic Medical Records: The bottom line case for an EMR. Practice Partner Forum. A publication of Physician Micro Systems, Inc. 1999.
3. 3. The Electronic Physician: Guidelines for Implementing a Paperless Practice. Allscripts Healthcare Solutions. 2005.
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EHR Implementation Checklist
Electronic Health Record Implementation in Physician Offices: Critical Success Factors
Electronic Health Record Implementation in Physician Offices: Critical Success Factors
Electronic Health Record Implementation in Physician Offices: Critical Success Factors
Electronic Health Record Implementation in Physician Offices: Critical Success Factors
Electronic Health Record Implementation in Physician Offices: Critical Success Factors
EHR Implementation Team
EHR Implementation Team – Role & Responsibility Matrix
EHR Goal Setting
EHR Goal Setting
Publication No. 4031-OH-017-2/2005-. This material was prepared by Ohio KePRO, the Medicare Quality Improvement Organization for Ohio, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. For more information, please call 1-800-MEDICARE (1-800-633-4227), or visit CMS’s Web site at . Material reprinted with permission from Lumetra.
Adapted from Organizations In Transition, vol. 13, #4
© Copyright 2004 William Bridges and Associates. All rights reserved. Contact us at staff@
Answer each question with the following numbers:
4 = The statement is definitely true or accurate.
3 = The statement is largely (though maybe not completely) accurate or true.
2 = The statement is only partly true or accurate.
1 = This is only occasionally (but not very often) true.
0 = The statement is utterly false.
Transition Readiness Assessment
Staff Meeting Skills and Agenda Template*
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[pic]
[pic]
[pic]
HUDDLES
HUDDLES
Scanning and Backloading Tips
DOQ-IT Workflow Assessment Guide
Scanning and Backloading Tips
Processes
Return on Investment (ROI)
Return on Investment (ROI)
DOQ-IT Workflow Assessment Guide
DOQ-IT Workflow Assessment Guide
DOQ-IT Workflow Assessment Guide
DOQ-IT Workflow Assessment Guide
DOQ-IT Workflow Assessment Guide
DOQ-IT Workflow Assessment Guide
Computer Knowledge Evaluation Tool for Staff
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