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Quiet Conquest — The ITIL Entrance Into American Healthcare
By Sandra Nunn, MA, RHIA, CHP
For The Record
Vol. 19 No. 4 P. 26

Pulling off a successful sneak attack, the Information Technology Infrastructure Library—a set of rules that allows healthcare organizations to deliver IT services more efficiently—emphasizes the Help Desk’s role.

Ever since William Edwards Deming stood American business on its ear by selling the Japanese on the concepts of quality management and performance improvement, healthcare has faithfully followed in the business sector’s footsteps in pursuit of methodologies to improve every component of management and delivery. Over the last few decades, the “in” vocabulary in healthcare has included terms such as quality circles, reengineering, continuous quality improvement, total quality management, and too many others to name.

During those years, the ideas of performance improvement and process management have gradually reached the heart of healthcare. The best organizations have recognized that the edge between the very good and the great may be razor thin and often reached only through self examination, rigorous standardization, and a willingness to ceaselessly benchmark against comparable or superior organizations in pursuit of national excellence.

No longer content with high marks from the Joint Commission or the National Committee for Quality Assurance, many organizations, including integrated delivery systems, have immersed their entities in the Six Sigma model. Others have embraced the PDSA (Plan, Do, Study, Act) cycle for performance improvement based on Deming’s ideas. Some organizations, such as Presbyterian Healthcare Services in Albuquerque, N.M., integrate a variety of these tools as applicable to the range of services provided by the organization.

The Help Desk Guy
Invisible to a nurse who is quietly recording his or her notes into an electronic health record (EHR) is the IT infrastructure supporting every step of the care he or she delivers to patients. That is, until something goes wrong. Perhaps the computerized physician orders entered that morning blip off the screen, leaving the nurse stranded. Or perhaps the automatic feed of transcribed documents to the EHR suddenly becomes inaccessible. Not far down the hall, the CEO may be unable to communicate critical information to staff if e-mail is on the blink. Where is the caped crusader who can come to the rescue? It’s likely to be that someone at the end of the phone line, frequently called “the Help Desk guy.”

Not unlike records management, IT service management (service support and service delivery) has been so integral to the support structure in healthcare that it is not always identified as a high-profile area where performance improvement will yield strong visibility results. However, there is nothing more vital to an organization than superb performance in the areas that support and sustain the delivery of care or the provision of healthcare insurance to the community’s members.

An IT infrastructure built on best practices can withstand the demands of skilled care providers in pursuit of the best possible care delivery. Increasingly, IT leadership has been searching for performance improvement methodologies specifically tailored to the particular world of information management.

Finding the Answer
Donna Agnew, RN, MSN/MBA, acting chief information officer for Presbyterian Healthcare Services, has a long history in quality management initiatives on the clinical front and is an expert in the management of clinical applications development. She wanted the same opportunity to improve the IT infrastructure and was looking for a model (best practices) when she found the Information Technology Infrastructure Library (ITIL).

Agnew determined ITIL had the potential to improve Presbyterian Health Services’ management and infrastructure and hired a consulting group to determine how ITIL principles could be applied to Presbyterian Health Services’ quest to acquire the Malcolm Baldrige National Quality Award, which aligns well with ITIL’s principles of service management. The standards include recommendations on gap analyses and process improvement methodology.

In terms of ITIL’s penetration, the standards evolved in the post-Cold War United Kingdom. The solutions have now crossed country lines, languages, and currencies to become prevalent in the European Union and the Pacific Rim. As a set of best practices, ITIL can be used as a step to arrive at ISO 9000 compliance. Information service (IS) organizations can purchase ITIL and either implement it themselves or seek help from expert consultants. Arriving late to the United States, ITIL has become the standard for best IT service management practices at some of the country’s largest corporations.

Agnew explains how Presbyterian Health Services has sent 12 of its IS managers to two eight-hour sessions to initiate key staff to the impending ITIL implementation. She notes that full implementation of ITIL requirements will require a multiyear project commitment.
Agnew says, “Presbyterian Health Services will begin with the identified ‘pain points’ where improvement is sought first.” The first area will be finding more effective ways to carry out service management (ie, the Help Desk). She says, “The acquisition cost of the ITIL materials and subsequent consulting services will be balanced by continuing cost savings from efficiencies involving doing things in a standardized, consistent way.”

What Is ITIL?
The first impression of ITIL is that it’s just a stack of books. However, within that stack resides a “framework of best practice approaches intended to facilitate the delivery of high quality information technology (IT) services.”1 There are five principal elements in ITIL (see Exhibit A on page 27).

Presbyterian Health Services will apply many ITIL processes over a period of years to the applications management, database management, network management, systems management, and service management sectors of IS. ITIL processes are designed to cross all IT departments with a focus on business results and without gaps or overlap—meaning they’re efficient and not duplicative. In describing the philosophy of service management, the IT Service Management Forum (itSMF) says the three key objectives are:

• to align IT services with the current and future needs of the business and its customers;

• to improve the quality of the IT services delivered; and

• to reduce the long-term cost of service provision.2

There are two areas at the core of ITIL Service Management:

“Service Support generally concentrates on the day-to-day operations and support of IT services while Service Delivery looks at the long term planning and improvement of IT service provision.”3

The itSMF handbook also provides definitions to describe the players involved in the process of providing service. These definitions include the customer, described as “the recipient of a service”; the provider, described as the “unit responsible for the provision of the IT service”; the supplier, “a third party who provides supplies or support” for the IT department; and the user, “the person using the service on a daily basis.”4 Taken from the itSMF handbook, Exhibit B (page 29) spells out the ITIL Process Improvement Model.

As seen in Exhibit B, ITIL process improvement is an iterative activity, consisting of the same types of steps involved in the PDSA model—defining the current state of service management (gap analysis); developing a mission statement, goals, and objectives; and defining roles and responsibilities. When implementing ITIL, it’s imperative to communicate—get the word out to the organization about its current state and what the future holds.

The planning and implementation phases of the ITIL Process Improvement Model parallel the “Plan, Do” components of Deming’s improvement model, while the final metrics and measurements step is in sync with the “Study” sector. The cyclical nature of the ITIL model ensures that the “Act” part of the PDSA model will be reviewed and adjusted as required with each turn of the wheel.

Service Support
Service Support sectors begin with the initial contact with the Help Desk. Even a computer neophyte in the new healthcare world would be able to guess why the Help Desk function is necessary. After all, who do you call when something goes wrong with your computer?

However, it is often overlooked that the Help Desk is the principal operational interface between IS and the user population. What the physicians, nurses, and other care providers think of the state of the IT department is often directly influenced by their encounters with the Help Desk. Many HIM staff who now telecommute will often have positive or negative impressions of IT based on the response they receive when electronic-dependent workflow fails.

A frequent failure of IT is to underestimate the level of skill—both interpersonal and technical that is required of Help Desk staff. They can enormously impact user satisfaction and retention, support optimal productivity, and generate critical support for best practices in patient care. Help Desk staff can calm users in times of crisis, through the implementation of new software, and teach them “to fish” rather than always providing the fish. They can also skillfully prioritize requests and identify when an emergency really exists and must be addressed.

ITIL lays out a structure for attacking “incidents” and describes the need to arrive at “agreed upon service levels” prior to attempting to resolve all issues instantly and with limited resources.5 Incidents are defined as “any event which is not part of the standard operation of a service and which causes, or may cause, an interruption to, or a reduction in the quality of that service.”6

The Help Desk “owns and records” incidents and monitors the progress of resolving them. Part of this process involves quick classification of the nature of the incident. Minor incidents can be resolved without major disruption, whereas major incidents “occur when there is extreme impact on the user community, or where the disruption is excessive.”7

Problem Management
When the Help or Service Desk encounters a major incident—which indicates something’s awry in the IT infrastructure—the problem management sector is contacted. A problem “is the underlying cause of one or more incidents.”8 At all points along this spectrum, documentation of the incident or problem must be recorded. Sometimes, problems are known errors that have a root cause that can be identified and repaired.

Tracking incidents and problems is an integral part of the ITIL process improvement model because patterns of incidents or problems can often be found and fixed to prevent reoccurrences. The goal of any Help Desk is to have zero incidents.

This environment lends itself naturally to the ITIL Process Improvement Model. If there is an unacceptable level of incidents, or if the incidents are generated too frequently by failures in the IT infrastructure, a desired-state vision can be generated indicating specifically where we are now and where we want to be using the statistics gathered by the Help Desk. Using process management or reengineering can help get organizations where they want to be. The metrics and measurements piece of the model can provide the “how do we know we have arrived?” information.

Other Service Dimensions
The overlooked or sometimes neglected Service Desk function is also a critical part of change management, configuration management, and release management.

Change management can occur when decisions are made to alter the IT infrastructure in response to recurrent problems or errors, legislative initiatives, or external programs (HIPAA, etc). Change management is responsible for carrying out all changes through standardized methods, processes, and procedures. It is also responsible for assessing the impact of the proposed changes to ensure no damage, or no further damage, will occur within the IT infrastructure.

Configuration management is defined as “the control of changes, including the recording thereof, that are made to the hardware, software, firmware, and documentation throughout the system lifecycle.”1 It is through the Service or Help Desk function that change control can be managed consistently. Configuration management is not synonymous with asset management, which maintains details on assets, usually above a set value.

Configuration management has more to do with the deployment of said assets, and often that deployment can be managed through the service function. In addition, the Service or Help Desk plays a role in release management, which governs the release of new or upgraded versions of software. It is through the Service Desk function that the impact on users can be measured. If the release is carefully planned by the IT infrastructure, the effect will be minimal due to advanced training and adequate access to Help Desk support when questions arise.

Ultimately, the metrics and measurements recorded in the performance of the Service or Help Desk function permit clear measurement of the quality and performance of these critical members of any healthcare organization. ITIL lends a methodology to structure those measurements and create processes that should lead to optimal service and cost containment through solutions at the first point of possibility.

— Sandra Nunn, MA, RHIA, CHP, is a contributing editor at For The Record.

1. Information Technology Infrastructure Library. Wikipedia. Available at: http://en.wikipedia.org/wiki/ITIL

2. IT Service Management: A Companion to the IT Infrastructure Library (North American). itSMF USA; p. 4

3. Ibid., p. 6

4. Ibid.

5. Ibid. p.12

6. Ibid. p.15

7. Ibid. p.18

8. Ibid. p.19