The "Do's and Don'ts" of Installing Computer Systems

by Vince Ciotti and Karl Sydor

Tremendous advances have been made in computer hardware and software since those halcyon days in the mid-sixties, when Hospital Information Systems (HIS) were first introduced. In the hardware arena, today's Personal Computers costing only a few thousand dollars offer the same raw computing power and storage capacities as did room-sized mainframe systems costing millions of dollars then. HIS applications have likewise grown far beyond the early financial modules to where today they encompass every ancillary department and some are even automating bed-side patient care.

However, the process of installing such systems has unfortunately made far less progress, with poor conversions still occurring with disquieting frequency and resulting in unhappy buyers, disgruntled users, and even unemployed hospital executives! In this time of vastly decreased hospital reimbursement, few institutions can afford to repeat past implementation debacles which can threaten the hospital's very financial survival.

This article will attempt to codify techniques that have been learned over many years in installing diverse systems for numerous vendor firms. They are presented in "Do and Don't" fashion to serve as a checklist to guide readers in better installing systems in the future. First, the "Do"s:

1. Use A Project Management System

Ironically, one of the latest developments in computer systems are PC-based programs that manage the many tasks, people and deadlines of a complex computer conversion. Such products as Time Line for the IBM PC and MacProject for the Apple Macintosh cost only a few hundred dollars and produce elaborate PERT & GANTT charts that can greatly aid in managing the resources needed to bring a conversion in on time and under budget (see samples in Figures 1 and 2). Of equal importance, they allow the hospital staff far more involvement in assigning responsibilities and setting agendas for periodic review meetings, rather than leaving the vendor to manage the project. Even if your budget can only afford lowly Lotus 1-2-3, you should automate "to-do" lists, tracking who is supposed to do what, and when, so slippages can be detected early, reminder notices sent out in a timely fashion and extra resources allocated to problem areas.

2. Involve All Management Levels

Since an HIS impacts all levels of the hospital, all executives and managers need to be involved in the implementation process. Figure 3 illustrates how multiple levels of the institution should be involved in various committees:

• The CEO or COO should chair and/or attend monthly Steering Committee meetings that include the CFO, MIS Director, and the VPs over ancillary departments and nursing.
• The MIS Director should chair biweekly Application Committee meetings with the Managers of all departments impacted by modules being installed.
• Task Forces of working Supervisors should meet weekly to jointly complete system Master Files and Code Tables, as well as draft policy recommendations and procedures for management approval.

Involve several levels of vendor personnel in these committees as well: the Regional or Area Manager at the Steering Committee meetings and the Installer at the Application Committee and Task Forces.

3. Develop Detailed Work Plan

Ideally, during contract negotiations for the new system, a detailed work plan should be drawn up and agreed upon by both parties in advance. The plan should include the specific number of days that are required to perform each step, and the "deliverables" that should result when each task is complete. Most vendors supply a "boilerplate" which lists the steps required for conversion. As might be expected, however, most of the work in their plans is assigned to hospital employees, and the hospital should carefully ascertain just how often vendor installers will be on site and exactly what they will do. Such a detailed plan can reveal any hidden charges the vendor will make for "extra" days on site by their staff while the hospital can still negotiate the price. Figure 4 shows a sample one-page work plan, which corresponds to each box in the PERT chart in Figure 2 above.

Lastly, manage this plan! Have regularly scheduled status meetings with and check off tasks as completed or get them back on track, if needed.

4. Prioritize Applications by Your Needs

In what order should the various applications such as Patient Accounting, Order Entry and Laboratory be installed? The vendor would be wise to implement those that maximized his cash flow first, to collect any "acceptance" monies as early as possible. The hospital's priorities are different: install those applications first that have current contracts expiring or offer the greatest benefits in terms of FTE reduction or cost avoidance. Also it is often wise to start with a relatively "safe" application like Accounts Payable to test the overall hardware, operating system and basic application software, while only risking the hospital's cash outflow rather than inflow.

5. Lower User Expectations

If your vendor selection process was wisely done, user departments should have had ample time to learn the system's weaknesses as well as strengths, so that they have no "Ivory Tower" expectations. By telephone referencing other users of the vendor's products, perusing borrowed User Manuals and sitting with their peers during site visits, users can be made to realize that buying a new system is only the start of their hard work, not the solution to their problems. This is probably the chief responsibility of any consultants you hire, but one they can only perform if they have had hands-on experience selling and installing systems for vendors.

6. Test, Test, Test

Many people have now been in the HIS industry for ten or twenty years, giving them a tendency to think that their "hard knocks" experience alone will enable to avoid most common pitfalls. In truth, the increasing complexity of HIS applications has kept the gamut of potential problems far ahead of the ability of mere mortals to avoid them, and only a full system test can reveal unpleasant surprises in advance. Take a handful of patients through preadmission, ADT, order entry/charge posting, bill printing, cash application to write-off, and you are guaranteed to find some switch in some system table somewhere set wrong! The exercise also provides an excellent training vehicle for users as well, giving them a chance to see how well they retained information giving in training sessions, which can have transpired several weeks or even months before the actual conversion. Check and double check the results; take nothing for granted.

7. Develop Written Procedures

Clerks have an uncanny ability to hear us wrong when we give the most mundane instructions - it is never our inability to enunciate our desires correctly, but rather their inability to hear what we meant! To circumvent this "Murphy's Law" of communications, put what they are supposed to do in writing. You may discover for yourself some surprising complications ("Just what F-key is that?") and save untold confusion on Go-Live night. Plagiarize vendor's user manual for the skeleton of your procedures, then customize just how you want it done at your hospital. A consultant should be able to contribute samples from past installations and other users of the vendor's product may be willing to share theirs. Enrich these procedures with samples from real life situations, and refer to enclosed sample screens and computer reports to minimize misunderstandings. Integrate these procedures into your training program so the users know how to perform their job functions with the new system.

8. Use Your Reference Clout

It is an unfortunate axiom that most installations occasionally produce adversarial situations between the vendor and hospital: "whose people are supposed to perform that task..., who pays for that step..., that's not what the salesman told us...," etc. Hospitals sometimes give in to vendor pressure after they have signed the contract, believing that once they bought the system they lost their negotiating "clout." In actuality, during the critical conversion time period, your hospital can still have tremendous leverage as a reference, either bad or good, to other hospitals considering the vendor. At the next HFMA meeting, make it a point to sit next to any "prospect" hospitals currently evaluating systems and inform them of your difficulties with the vendor. Be fair to not "cry wolf" and exaggerate, but let them know of the dispute and how you wish it could be resolved. They will probably appreciate hearing about the potential problem they themselves may have some day and the vendor may become surprising amenable to making you a happy user again.

9. Praise as Well as Punish

Most hospitals have had ample experience complaining to vendors about program bugs, missing features or down-time problems, and most vendor organizations have built up elaborate procedure to insulate their busy executives from such "low-level" complaints and queue them into lines for Customer Service Representatives or system "Wish Lists." Compliments on the other hand are so rare that they often get right to the top of the vendor's organization and pay surprising dividends in making your hospital one of the "squeaky wheels that gets oiled" when you do have a complaint. Think of how rarely you receive letters of commendation from patients lauding the courtesy and professionalism of a hospital employee and how wonderful they are for everyone's morale! Writing a sincere letter of praise about an installer or telephone support person to the vendor management will probably be an equally rare event for them and your hospital will receive even better service from him or her in the future!

10. Screen Prospective Installers

This final "Do" is possibly the most important and yet most often overlooked. If you were hiring an HIS Coordinator to manage the conversion, you would arrange several interviews with key players in the hospital and call their past references. Likewise, the vendor's installers will play an enormous role in the success or failure of the installation, and should be met in person in a pseudo-interview setting to check both their qualifications and mesh with your hospital's people and culture. A phone call to their last installation site may reveal potential problems or put your mind at ease. It is wise to insert a "right of refusal" clause in your contract that gives you the ability to screen installers. If the vendor refuses, caveat emptor!

So much for the things to "Do." The "Don't" category following was sadly compiled from bitter experiences wherein system were installed poorly or, in some cases, not at all:

1. Don't Pay All Monies Up Front

Since the installation process is fraught with risks and your institution runs the risk of not getting the system to work properly, you should make the vendor share in that risk and be motivated to see that the installation succeeds. An "Acceptance Fee" should be set aside from the license fee and installation charges to be paid upon the successful completion of the installation. How do you define successful? Your original RFP criteria, which the vendor promised to meet in their proposal, comprise the clearest definition of the system's objectives. Merely delivery of the hardware and "booting" the software should not earn complete payment; rather, the satisfactory completion of the installation Work Plan, with all major features functioning as sold. If the vendor will not grant such payment terms, it may indicate their own fears about the installation!

2. Don't Train "Green" Installers

Every new vendor installer has to learn somewhere; the best training program and documentation are never a substitute for the "University of Hard Knocks." And that first installation is usually the installers worst, with inevitable oversights and misunderstandings as the new employee learns the ropes of their programs, procedures and policies. Don't let your hospital be their training ground: call the past sites where the installer worked and check their background: was it the same product your installing? On the same equipment? If not, insist on a veteran installer before you become one of the "war stories" that installers bandy about over drinks.

3. Never Be an "Alpha" Site

After 20 years in the business, we are still amazed at the willingness, indeed, even sometimes eagerness, of otherwise intelligent hospital executives to be the first users of a newly developed system. No one in their right mind would like to ride along on the first test flight of a new commercial airplane or be the first patient operated on by a surgical intern. Yet, somehow, the glamour (actually, incipient notoriety!) of being the development sight of a new computer system has seduced dozens of former executives at hospitals around the country. Our advice to such first-time buyers is: make sure you're fully vested in your pension plan! First installations are like first dates: both parties stumble about, committing horrendous faux pas that will be the subject of jokes in future years. Just say NO!

4. Don't Rush the Conversion

Computer conversions inherently take time, due to the labor involved in designing forms, creating master files, writing procedures and training people. Generally, the more time, the better the forms, procedures, training, etc., will be. Unless you have an expiring contract, the only reason to rush the conversion is to hurry the payment of the acceptance fee to the vendor. Don't! Take your time, do it right, and don't let thinly-veiled vendor greed or gullible users hurry the job.

5. Don't Run Impossible "Parallels"

Payroll is one of the few applications areas where a parallel run can and should be run to detect errors and compare final results between old and new systems. Billing, AR, Order Entry and most other applications are impossible, unless you can hire two staffs to run both systems and a cadre of consultants to figure out the "Apples to oranges" results. The new system should be different or why convert?

6. Don't "Hog" User Manuals

Most vendors produce quite an impressive array of documentation for their systems, handsomely bound in imposing binders and festooned with their corporate logo and product names. Like the legal volumes in a law firm, they look quite impressive when stacked on shelves, and that is too often exactly where they end up as users in the trenches struggle via trial and error to figure out just how the new system functions! Avoid the temptation to decorate your office with manuals that workers need; the only good manual is a dog-eared one! Place yours where they will get the most use: with users.

7. Don't Skimp on Overtime & Temps

Conversions are difficult times for a well-run hospital where staff is already at a minimum due to shrinking reimbursement and budget constraints. In the financial planning for a new system, plan ahead for your billers and nurses to work extensive overtime and allow for generous allotments of temporary help to key in mass corrections and help unclog jammed "in" boxes. As the old saw has it, don't be penny wise and pound foolish. A few dollars for such interim assistance can make the millions invested in a new computer pay off. If the dollars aren't in the budget, are the inevitable increase in receivables or reduced cash flow that result from a poor install?

8. Don't Tolerate Internecine Warfare

The relations between departments can sometimes become heated during even the best of times. Computer conversion sadly exacerbate such tensions, and the results can make the Battle of the Bulge seem playful, as Nursing spites the Finance Department, or Admitting shows MIS who's boss, with the computer system being the toy both parties fight over. Hospital executives must jump in with both feet as negotiators and, if need be, Theory X managers to restore order and cooperation among user departments. Today's integrated packages require teamwork, or data bases are corrupted and the "GIGO" (Garbage In, Garbage Out) theory prevails. It takes CEO power, not CPU power, to end such petty bickering.

9. Don't Let Vendors Delegate Work

As we enter the third decade of HIS, most vendors have developed elaborate "boilerplate" work plans that run several inches thick and detail the many steps required to install their systems. There is usually a column on the left next to each task that indicates "Hospital" or "Vendor" responsibility. And usually, the "Hospital" entries far outweigh the "Vendor" tasks, as would be the case if you were preparing the agenda for anyone else! This trend has reached the ludicrous stage where we recently encountered a vendor install plan where they only proposed to visit the hospital twice: once to hand out the tasks and once to see that they were done! Don't be too shy to ask the vendor what tasks they will perform, and complain up their chain of command if you don't like the answer. Remember, it takes a concerted effort to install a system, not a solo performance.

10. Don't Underestimate Install Challenge

The long-range planning and vendor selection process are often exhaustive and drawn out affairs that can take several years to complete. The installation process is sometimes looked upon as a near after-thought, with the job being a simple one to delegate to the staff. Unfortunately, the job is actually more like a marriage: getting to the altar is the easy part. Making the relationship work takes much more time and effort than the courting process. Don't let the CEO and COO drop out of day-to-day involvement just when you need their help and support to bring the system up. Remember, far more systems have been purchased than have been installed, and only hard work and attention to detail by management and workers from both the hospital and vendor will make your installation a successful one.

CONCLUSION

This list of "Do's and Don'ts" for installing systems is offered to help hospitals avoid past implementation debacles. It is hardly an all-inclusive compendium of errors, but rather a helpful checklist to review before embarking on a computer conversion. As we enter the nineties and HIS products become even more esoteric, encroaching ever closer to the direct administration of patient care, hospitals need to be more and more careful that the process of installing systems advances as much as the systems themselves.

ABOUT THE AUTHORS

Vince Ciotti is a partner with HIS Professionals, Inc., a management consulting firm in Boonton, NJ. He is a member of the New Jersey HFMA chapter and Information Systems Editor for their HFMA Newsletter "ECHO."

Karl Sydor is also a partner with HIS Professionals, Inc., in their Pompano Beach, FL, office. He is a member of the Florida HFMA chapter and chairman of their MIS Committee.

Reprinted with permission from the June, 1990 issue of Healthcare Financial Management.