In performing the Needs Analysis, three distinctive gaps were identified. If Caduceus is to attain its objectives of preventing future litigation and improving productivity, all three must be addressed.

1. Gap between hospital patient care philosophy and practice. Optimal: Physicians, nurses and laboratorians all act as a unit whose primary emphasis is patient care. Actual: Hospital has a top-down hierarchical organizational structure. Distinct lack of team effort between groups and rivalry at all levels.
   1. Perspectives:

      Laboratorians:

      Dr. Kasim: has trained others, most teamwork oriented
      Maxine Tucker: resents training less qualified people
      Gary Beavers: resents having to train others

      Physicians:

      Lack of interest and no evidence of wanting to work within teams. Treat others as subordinates rather than as partners.
      Dr. Bovasso: embraces the technology, concerned about attitudes of administration and senior staff.

      Nurses:

      Gert Greenberg: exhibits team-oriented characteristics, but is not a stated advocate. Embraces the technology from a technical standpoint, but has "people" reservations.
      Others: view themselves as "down-trodden" or victims. Don't view the technology as an opportunity, but rather are resentful of additional work.

   2. Recommendation: A solution that incorporates systemic changes and instruction.

      Systemic Solution:

      Organizational change that introduces interdisciplinary teams and stresses more "partnership" in providing patient care. Identification of measurement methodology relative to improved patient care.

      Instructional Solution:

      Interpersonal dynamic organizational development training.

      Target Audience:

      Personnel from each group to form "teams". Members should attend training as a team. Initially a low willingness to change is anticipated. To increase "buy-in", ensure participation by respected senior personnel, establish a "pilot" team perhaps using Dr. Kasim, Dr. Bravasso, and Gert Greenberg.

      Content:

      Emphasizes the inter-relationships and dependencies among the team and roles and responsibilities of each team member.
      Resources: following "pilot team" training, use that team as a training resource for other teams. Requires senior management involvement to relieve both trainers and trainees of some responsibilities to enable training.

      Goals/exit knowledge:

      Learners should be able to identify ways in which other team members contribute to the success of the patient care team

2. Gap between perceptions of the use of technology and its reality.

   Optimal: Caduceus wishes staff and patients to perceive technology positively.
   Actual: Perceptions of technology vary widely.

   1. Perspectives:

      Hospital Administration:

      Technology can enhance patient care and reduce costs

      Dr. Kasim:

      Shift to more technology is inevitable, has knowledge to act as a technology SME Medical

      Technology Staff:

      Supportive of technology, but also threatened by it.

      Physicians:

      Mixed perceptions ranging from enthusiastic support (Bovasso) to disinterest (Anderson).

      Nursing Staff:

      Also mixed perceptions, but generally see technology as meaning more work with no training or extra pay.

      Patients/Community:

      Mixed perceptions, from supportiveness (Bernaducci) to suspicion (Observer article)

   2. Alternative Solutions:

      Changing the negative perceptions involves attitudinal change. This can be accomplished to a limited extent through instruction, but other solutions must be adopted as well.

      Systemic:
      • Education/Communication - ensure that local newspapers are not the only source of information regarding the introduction of technology.

      • Initiate press releases, giving positive factual information regarding the benefits technology is bringing to health care in the hospital to the external audience.

      • Newsletters, e-mail, video-mail etc. could be used to bring the same message to the internal audience. Accelerate technology introduction - Continue "piloting" new technology such as the "palm-top" computers on a consistent basis.
      • Accelerate technology introduction wherever possible and incentivize its use, while disincentivizing the use of outdated methods (e.g. paper forms).

      • Pilot via teaching doctors to increase exposure to new and upcoming staff. Encourage technology advocates - provide support for staff such as Kasim & Bovasso, e.g. feature them in internal articles or have them serve on an Executive Director's Technology Task Force.

      • Management involvement regarding mitigation of time constraints is imperative.

      • Instructional Solution: Design an instructional module called "Using Technology to Improve Patient Care"

      • Target Audience/Learners: All levels of hospital staff. Entry-level knowledge about technology will vary considerably, based not just upon their education and training background, but also upon their openness to innovation. Training should be compulsory, structured around an existing "Patient Team" in order to allow staff with a positive attitude, and knowledge of technology, to influence others. Differing levels of entry-level skills/attitudes would be an advantage to be used in the design. Encourage collaborative learning.

      • Content/Task: Develop a CBT to be used as a "pre-requisite" that describes how technology is currently being used. Develop interpersonal dynamic training to introduce a new perspective about technology that could cause a more positive shift in attitude, with staff choosing to use the available technology or looking for new ways to use it. Providing conceptual knowledge regarding the ways in which technology is beneficial to hospital operations would be more important then detailed declarative knowledge about how the technology works.

      • Time Frame: Because willingness to attend training is already very mixed, the instruction sessions would need to be short and interactive. To diffuse the positive attitudinal change throughout the hospital, it would need to be completed within a reasonably short time frame - possibly three months.

      • Training Resources: Technology advocates and SMEs should be available to help in the design. If regularly scheduled staff training or briefings already exist, the modules could be designed to take advantage of these. Senior management involvement required.

      • Goals/Exit level Knowledge: Instructional goal - "At the conclusion of this training session, learners will be able to identify ways in which the introduction of new technology can aid them in their task of better patient care". Learner follow-up support: The alternative solutions mentioned above will provide much of the support required by the learners as they try to transfer their new attitudes back to the workplace.

   3. Perspectives

      Hospital Administration:

      Believe training is only variable impacting RBA TAT. (Interestingly, their stated intention is that the RBA will move the laboratorians closer to patient care, but it has actually eliminated the interaction between laboratory and medical staff

      Physicians:

      Vary in their level of understanding as to what impacts RBA TATs and how to use results. Insistence on paper forms will continue to impact TATs.

      Nursing Staff:

      Have acquired practical knowledge as to how to operate the RBA, but are frustrated by the changes in the operating interface.

      Nursing Support Staff:

      Have not been formally trained on the RBA, are wary of using it incorrectly and being blamed.

      Medical Technology Staff:

      Have statistics indicating rejected results are a minor issue with RBA TATs. Believe that training is less of an issue than just following procedures

      Robomedics:

      Understand that RBA TATs can be impacted by uncontrollable factors. sometimes these things just happen. Appear to believe that the machine is straightforward enough that even a manual would be more confusing than helpful.

   4. Actual Performance Problems:

      Appropriate personnel for running tests not designated; consequently, some do not know how to use the machine. RBA user interface is continually changing RBA is in an inconvenient place

      There are no clear procedures in place for the following:

      1. General use of the RBA
      2. Follow-up, i.e. placement of hard copy in patient's file
      3. What to do in case of unusual occurrences, such as a power outage, including calibration

   5. Alternative Solutions

      Systemic Solutions:

      1. Management needs to designate who will have primary responsibility for the operation of the RBA machines
      2. Management needs to draft a list of procedures covering the appropriate use of the RBA, follow-up, and what to do in case the RBA is not functioning, such as a power outage. The input of current staff should be sought in designing these procedures - they have practical experience on what works and what doesnt. .
      3. Work with office manager to find better placement of RBA equipment.
      4. Management needs to get a handle on the beta-testing program to ensure changes to the RBA coincide with appropriate instruction/documentation procedures. Robomedics needs to be convinced that their plan to go public will be in jeopardy of their Beta site is not enthusiastic in their support of the RBA.

      Training Solutions
      1. Initial training of appropriate staff on the RBA machine. Target Audience: Learners should include all those authorized to use the RBA. Most likely include doctors, nurses, nurses aids, and orderlies. These learners vary in their comfort level with using technology as well as their attitudes towards the increasing amount of technology being used in the hospital. Therefore, training should consist of some information on the reasons for using the RBA, and a brief summary of the RBA's functions.
         When: Training should be scheduled immediately upon development of written procedures and design of course.

         Content/Goal: Learners need to be able to do the following:

         1. Operate the RBA machine with 100% accuracy
         2. Follow designated procedures regarding use of machine, operation of machine, printing and filing of reports, calibration, and what to do during power outage. Resources: Hands-on instructor-led course. Learners should practice on machine until they reach both the desired accuracy and a high comfort level. One RBA machine will be designated for use only for training during the class, so as to avoid interruptions. Perhaps the hospital should purchase or lease an RBA machine only for training. May want to develop a CBT that provides an emulation of the RBA.

            Follow up support: Management will designate several experts' on RBA machine who will be responsible for answering questions or providing refresher' information to members of their team

      2. RBA system update training

         Target Audience: Same as above
         When: Whenever there are updates in the RBA that affect user interface.
         Content: Same as above
         Resources: Same as above
         Environmental Constraints: Allocating time for training will be a major constraint. Creative scheduling will have to be done in order to implement training. Perhaps training could be done at the end or beginning of a shift. However, employees would need to be compensated for the extra time spent. Senior management involvement is imperative.