1 Introduction

Needs assessment is the systematic effort to gather data from a variety of sources on performance or effectiveness of new systems and technologies. The data collected during a needs assessment include opinions and ideas from different sources about actual and optimal performance, feelings about the problem, possible causes and possible solutions.

Interviews and reviews of RBA performance documentation, are used as a methods to elicit the necessary information. Interviews have taken place with different departments involved in the use of RBAs, in particular with administrative-, legal-, and human resource officers, with (assistant) nurses and physicians working in the acute care unite and the OR recovery unit, with technicians from the clinical laboratory, with the staff of RoboMedics Inc. Also, more informal conversation with patients and their family has been taken into account.

The information has been analyzed, and categorized by department and purpose (actuals, optimals, feelings, causes, and solutions). The result can be found in Table 1 in the Needs Assessment Section. From the data in Table 1, the discrepancies between actual and optimal performance have been analyzed, and listed in the Performance Gap Section. In last two sections in this report, Alternative Solutions are discussed and the Recommended Strategy is described.

2 Needs Assessment

Table 1. Needs assessment results by department and purpose.

.	Actuals	Optimals	Feelings	Causes	Solution
Acute care	Nurses do not like using RBAs. Nursing staff has not received proper training on use of RBAs. RBAs are not always easily accessed. Caduceus has implemented a number of cost-savings initiatives. Hospital has pre-determined which procedures are appropriate, awarding cash bonuses for providing service below the quotas. Some physicians see benefit in using the technology. RBAs save time, computers provide access to valuable medical databases and offer anytime, anywhere access.	Nurses see the RBAs as tool for improving patient care. Both nurses and nursing assistants use the RBAs with 100-percent accuracy RBA is easily accessible Hospital becomes profitable and self-sustaining without sacrificing patient care. Physicians not only see the benefit, but also become more comfortable using technology	Money is bottom line, not patient care. The hospital is using RBAs to save money and bill more efficiently. Nurses prefer to deal with people. RBA is good idea in principle. Nursing assistants feel they should be compensated for taking on additional responsibility. Hospital is focused on cost, they sometimes forget patient needs. Insurance companies are a driving force, but healthcare providers are also concerned about malpractice suits. Hospital staff has mixed feelings about Caduceus and changes they have implemented since the merger took place. Physicians like having latest technology, but are also somewhat old-fashioned. For the most part, they prefer dealing with people over machines. They are comfortable with old hand-written charts.	Nurses are frustrated with technology. Programmers keep changing design of input screens Nursing staff doesn't have time for training. Hospital keeps cutting staff. RBA located in an already crowded nurses' station. There have been some flagrant abuses: doctors ordering every test in sight. Physicians prefer to read printed charts rather than computer screens. However, the printed forms don't make it into the patient charts fast enough.	Nurse assistants want pay for the extra work
Clinical laboratory	People moving from station to station Doctors asking for stat tests when not necessary Technicians responsible for producing hard copies and computer-based copies Technician are under stress to produce more test in less time, are also being asked to diversify Technicians spend time training doctors nurses orderlies, maintain equipment Low moral	Quicker turnaround time for tests More accurate tests Better moral Reduction in errors to 0%	Technicians feel: marginalized; a lack of respect; and stressed because of diversification	Some doctors still require paper copies of results Lab not configured properly to maximize time and effort Doctors want results quickly, they put stat on everything Cuts in money and personnel Inappropriate use of personnel power Poor organizational structure	Training Less diversification Make doctors aware of appropriate lab procedures
.	Actuals	Optimals	Feelings	Causes	Solution
OR	RBA machine is efficient LPN not appropriately trained RBA machine not easily accessible Works space not conducive to efficient operations	Appropriately trained OR staff Well placed equipment	Salaries are a touchy issue Sense of isolation Tension between OR staff and technicians	RBA location not easily accessible 1st year RES feels Dr.ıs donıt know how to fill out reports	LPN suggest unionization Nurses need more training
RoboMedics	Small private company developed RBA System creates faster turn-around time and point-of-need blood analyzing RoboMedics personnel do hands-on training for IS staff and lab staff Every department gets its own training - Training appears random Use hospital as a test bed for new upgrades to RBA	Efficient and regularly updated training plan	RoboMedicsı personnel satisfied with the level of support that they provide Hospital staff members are discouraged by random approach	Robot is work-in-progress, continuing to upgrade software. RoboMedics is a loosely run company - doesnıt seem to have a plan - quick to adapt - difficulty in providing appropriate customer support	.
Public	Billing not integrated Public have mixed feelings about hospitalıs need for and use of technology	Integrated billing Better informed public	Machines made care better (2x) Robots unnecessary Robots cost - money Patients are bitter towards hospital staff	Recent influx of new technology	.

3--Performance gaps

• RBA placement does not facilitate use. They need to be easily accessible.
• Personnel organization and responsibilities are not clear or efficient (organizational chart, disputes between doctors, nurses, lab technicians; legal comments about unauthorized person running tests)
• Skill levels of personnel on the use of the equipment is below requirements
• Procedures are unclear (completing paper work, using stat designation)
• Employee morale is low as is respect for fellow employees. Lab technicians complain about doctors, doctors complain about nurses, and nurses complain about administrators.
• There are multiple ways of reporting test results and maintaining patient charts. However, the printed forms don't make it into the patient charts fast enough.
• Poor communication between all employees but notably there exists a distinct problem between technical staff and nurses and doctors.
• There have been some flagrant abuses: doctors ordering every test in sight.
• The nurses are frustrated with the technology. The programmers keep changing the design of the input screen.
• Nursing staff doesn't have time for training. The hospital keeps cutting staff.

4--Alternative Solutions

1. Organizational Review -Conduct an organization review to determine if re-alignment of organizational structure of duel reporting will alleviate responsibility issues. Review possibilities of developing "ambassador teams" that represent each shift and each department (cross-functional teams -- doctors, nurses, lab tech, etc.) that are charged with learning the operations and procedures, then they cascading the training / procedures / changes to the rest of the shifts). A good method for hosting this type of meeting, especially at first, is a nominal group technique. Each perspective is represented an anonymous. All points are brought to the table and discussed by all parties (representing all perspectives). The solutions are ranked by the participants several times to refine their priorities. The solution that best fits for the entire organization emerges.

2. Environmental Analysis - Complete a environmental analysis to determine optimal room configurations, placement of the RBAs.

3. Training and Communication Strategy - Develop training and communication strategies to assure competency of all responsible for interfacing with the RBA (doctors - forms and output; nurses - forms, operation, and outputs; lab technicians - operations, output, and calibration); team building activities to build better working relationships; communication mechanisms to notify everyone of changes in equipment, procedures, etc. Build-in immediate feedback for inappropriate use of the RBA. Training should be people oriented: face-to-face peer training, not just laminated instruction cards.

4. Revise Procedures - Revise working procedures to enhance effectiveness of the RBA - simplify forms, if possible, have RoboMedics develop a handhold device to enter patient data.

5. Inform community - Effort needs to be spent towards informing the public, and the staff, about the RBAs and new technologies in general. The statistics state that the machines are making things better. Provide those statistics and examples of best practices so that the staff and public will understand that the machines are facilitating effective healthcare by providing improved response time and better record-keeping.

6. Incentive programs - The hospital should re-examine its incentive programs. Eliminate those programs (cash bonuses) that jeopardize patient care. Develop other reward mechanisms for efficiency and skill mastery that are based on the patient's well being and overall satisfaction. Reward structures should be equitable and work toward, not against, the hospital's goal of patient-centered services. They should not provide rewards for ordering less tests than required.

5--Recommendations


To address organizational and personnel issues:
Develop cross-functional teams on all shifts (include members from each department, each job)
• Develop schedule that is flexible to handle work schedules
• Clearly define each persons role and the responsibilities, develop incentives and measures for each role
• Train lead team for each shift on the entire workings of the RBA - provide train-the-trainer training so they can train the rest of the shift
• Rotate teams into and out-of lead team responsibilities (every 6 months) to provide incentives to all department personnel
• Team building activities should be developed both on-site and off-site to build trust and good working relationships among all workers (doctors, nurses, lab technicians, etc.)

To address the knowledge and skills deficiencies:
Develop training for the lead teams on complete operations of the RBA - full procedures, how to interpret reports, and calibrations.
• Give lead team materials to "train" others on the specific functions they are responsible in regards to the RBA
• Set part of the purpose for the shift meeting to be an update of the RBA (problems during last shift, updates in software or operations)
• Training should be hands-on, supported by Electronic Performance Support Systems in the system itself. Also, procedural posters should be posted around the machine.

To address RBA technical updates:
Develop an upgrade plan that includes communications material and "training" for lead teams, All machines get updates at the same time, all upgrades are planned in advance and all lead teams notified of upgrades.