CHAPTER 11

Healthcare IT Project Management

Brian Gugerty, Amy Flick

   In this chapter, you will learn how to

•  Define the terms project, program, and project management

•  Describe project critical success factors that are unique to healthcare

•  Identify resources that help you learn more about project management such as the Project Management Institute and the Healthcare Information Management Systems Society

•  Initiate a project, including:

•  List several project team member and project stakeholder roles and communication strategies

•  Describe how a project manager works with a project team and stakeholders to develop SMART project objectives

•  Plan a project, including:

•  Construct a work breakdown structure for a healthcare IT project

•  Effectively estimate project activity durations and schedule project resources

•  Execute a project, including:

•  Manage project resources and stakeholders to maintain project scope, time, quality, and budget parameters

•  Monitor and control the project in the executing phase

•  Close out a project, including:

•  Describe principles and practices to effectively close out a healthcare IT project

Today’s healthcare enterprises are increasingly complex, and healthcare information technology is essential to making their operations more effective and efficient. Project management is one tool that can be used to maximize the effectiveness of information technology within healthcare enterprises. In this chapter, we will define a project and project management techniques in broad, cross-industry terms, as well as begin to convey how project management works within HIT initiatives. In order to reinforce concepts in the text and demonstrate healthcare IT project management principles and practices, the chapter includes a ten-part use case centered on one project.

Projects, Project Management, and Healthcare IT

A project is a temporary venture undertaken to create a unique product, service, or result. A project has a defined beginning and end with specific objectives to be achieved at the completion of the project. The end of a project is reached when the project’s objectives have been achieved, when it is determined that its objectives will not or cannot be met, or when the need for the project no longer exists.¹ Projects have a clearly specified objective or scope of work to be performed, a predefined budget, and usually a temporary organization whose work concludes when the project ends. While the project is temporary, the product, service, or result created is usually meant to be long lasting or permanent. Some examples of projects include building a house, designing and implementing a new business process, developing software, implementing an electronic health record, and revamping a healthcare organization’s web portal. Any type of ongoing or continuous work such as manufacturing or planning the monthly schedule of nurses on a hospital unit is not a project because these tasks follow their respective organization’s existing procedures and are ongoing.

A program is a group of projects that relate to each other and are managed together so that they can achieve benefits and goals that may not be achieved by managing them separately. A program may include additional work outside of the projects in the program that is necessary for achieving the program goals but is not part of the projects within the program. While a project may be part of a program, it can, and often does, operate independently of a program. On the other hand, a program always has projects.

Project management is the application of knowledge, skills, tools, and techniques to project activities in order to meet a project’s requirements.¹ A project manager (PM) facilitates the planning, scheduling, and controlling of all activities that must be done to meet a project’s objectives.

Critical Success Factors for Healthcare IT Projects

Within healthcare project management there are many interrelated elements, or success factors, that must be kept in balance in order to achieve project success. Among the most important are:

•  Empowerment of a project management approach from the top of the organization

•  Control over the project by the project manager

•  Very high quality standards

•  Effective handling of healthcare organizational and operational complexity

The foundation of successful project management is the people who manage or work on the projects themselves. Their levels of communication, leadership, negotiation, team building, decision making, and motivation combine to direct the trajectory of a project. Adding to this foundation is the culture of an organization and its values, beliefs, attitudes, behaviors, traditions, and structure. The methods employed by the organization to work both on a routine, or continuous, basis and on a project basis influence the success of a project. And, planning and information management are critical to the success of a project. The approach to a project needs to be well defined, appropriate processes need to be determined, and the work schedule needs to be developed properly. Thus, the first critical success factor for healthcare projects is empowerment of a project management approach from the top of the organization and participation in focused ways in working with project managers to organize and execute tasks on projects.

Another critical factor to a HIT project’s success is control over the project by the project manager. All projects need to be controlled and directed properly in order to track the progress of the project, compare it to the original plan, take necessary corrective action, and monitor the performance of all parts of the project to ensure the project is completed in accordance with the project goals and strategies outlined in the project initiating phase.

HIT projects need to be held to very high quality standards, maybe not quite as high and exacting as the nuclear power industry, but oftentimes the quality does need to be close or equal to that level of exacting quality. Skimping on a barcode-assisted medication administration implementation may have fatal consequences, whereas skimping on the quality of certain parts of a house you are building will not. For example, opting for the lower-end shower for the guest bathroom instead of the most expensive one will hardly be noticed. Administering the wrong medication to a patient could cause a patient to become ill or even be fatal. Thus, finding a way to maintain high quality throughout the life cycle of a HIT project is a critical success factor.

Peter Drucker characterized the modern medical center as “the most complex business and social arrangement in the history of mankind.”² There are many different organizational divisions and many, many roles in a modern healthcare enterprise. HIT projects often involve many different clinical disciplines such as doctors, nurses, respiratory therapists, and others; operational departments such as laboratory, pharmacy, radiology, and others; and both internal IT technicians and professionals and external IT consultants and vendors. Moreover, the healthcare industry has a huge number of regulations and a wide variety of highly complex payment mechanisms. Large-scale HIT projects impact most of these divisions and roles in a healthcare organization and deal with many regulations and billing challenges. For a HIT project, effectively dealing with healthcare organizational and operational complexity and the many people involved in healthcare organizations is a critical factor for success.

The Project Management Institute, PMBOK, and PMP

The Project Management Institute (PMI) is a not-for-profit membership association for the project management profession. PMI works to advance the project management profession by developing globally recognized standards, certifications, research programs, and professional development opportunities. PMI’s standards for projects, programs, and portfolio management are the most widely recognized standards in project management across industries, including healthcare.

PMI has published A Guide to the Project Management Body of Knowledge (PMBOK Guide), which is a recognized standard for the project management profession and provides guidelines for managing individual projects. We will use the PMBOK Guide Fifth Edition to direct this chapter’s discussion of project management for healthcare IT professionals.

PMI offers a certification called Project Management Professional (PMP). The PMP is the most important and most widely recognized certification for project managers. The PMP demonstrates that the holder of the certificate has the experience, education, and competency to lead and direct projects. PMI has recently introduced a new entry-level certification for project practitioners called the Certified Associate in Project Management (CAPM). CAPM is designed for individuals with less project experience and is intended to demonstrate that those holding this certificate have an understanding of the foundational knowledge, terminology, and processes of project management. PMI believes that project managers with either of these certifications benefit from increased marketability to employers and higher salaries. As an additional resource to PMI members, PMI has created “communities of practice,” which are online communities for professionals in a wide variety of industries to meet online and in other forums with other professionals in the same industry to discuss ideas and grow their community’s understanding of project management. There is a healthcare community of practice that focuses on bringing an international perspective to implementing project management knowledge in the healthcare industry.³

Other Project Management Resources

An organization that provides training in project management is the Lewis Institute. We will use examples provided by the Lewis Institute to help you better understand project management. While the PMBOK Guide is a recognized standard for the project management profession, the Lewis Institute does a very good job of explaining project management concepts clearly and simply. Another reliable source of information on healthcare IT project management topics is the Healthcare Information Management Systems Society (HIMSS). HIMSS is the organization that awards the Certified Associate in Healthcare Information and Management Systems (CAHIMS), one of the two certifications this book is designed to help readers achieve. You can search on “project management” at www.himss.org and find many resources on healthcare information technology project management.

Major Project Management Constraints/Objectives

Four major variables can act as constraints, as well as objectives, in project management. These variables are

•  P   Performance requirements, both technical and functional

•  C   Labor and other costs to do the project activities

•  T   Time required to complete the project activities

•  S   Scope or magnitude of the job to be done

These variables directly affect the successful management and completion of a project. This is particularly true in the healthcare industry where quality is of the utmost importance. In this discussion of P, C, T, and S, you can think of performance as the equivalent to quality in HIT projects. Because a high degree of quality or performance is required in healthcare services, the costs associated with the HIT projects may be high as well. In other industries where quality or performance is less important than the cost of the product or service, a project may be able to be completed with lower costs. The project management triangles shown in Figure 11-1 illustrate the relationship between performance (quality), cost, time, and scope of a project.⁴

Figure 11-1 Project management triangle illustration of the P, C, T, S relationship

The performance (P) or quality lines in the two triangles in Figure 11-1 are the same length. One of the most powerful aspects of the P, C, T, S “formula” is that it reminds the project manager that if the scope of a project increases, the amount of time and budget required to complete the project will also almost always increase. Figure 11-1 can be described as follows: holding steady for the performance or quality while completing the project activities and objectives, an increase in scope will lead to an increase in both time until project completion and the cost of the project. So, for example, when an enthusiastic stakeholder or project team member says, “We can add computerized physician order entry to the electronic medication project and make an even bigger impact,” the PM can use the P, C, T, S formula to interject the hard realities of this change into the discussion in order to keep the project on track. The PM needs to constantly monitor for “scope creep” to ensure that the costs, time, and performance remain at acceptable levels. Throughout the course of the project, the PM will need to make a variety of decisions in order to help maintain the scope of the project. The project management triangle is a very helpful tool in doing so.

Figure 11-2 Project management work breakdown structure illustration

TIP   If the scope of a project increases, the amount of time and budget required to complete the project will also increase. A project manager needs to make sure these increases remain at acceptable levels, or he will be faced with scope creep, which may jeopardize the project’s success.

Project Team Roles and Stakeholders

The people, or organizations, who are actively interested in and involved with a project and who may affect or be affected by the results of the project are considered the project’s stakeholders. A stakeholder may use their position of power to steer the project, its deliverables, and the project team members in a certain direction. The project team itself needs to identify the stakeholders and understand their expectations of the project in order to manage their influence as well as expectations so that they can ensure a successful outcome of the project.⁵ Project team membership in HIT projects varies due to the large variability in types and size of HIT projects. Some of the roles of HIT project team members are project manager, clinical analyst, business analyst, network engineer, clinical application specialist, subject-matter expert, hardware/device technician, and other roles from finance, quality measurement, and compliance monitoring. Some organizations have clear delineation between project team members and project sponsors and/or project stakeholders. Some organizations have less clear delineations and one person can even have overlapping roles (i.e., project team member and project stakeholder). Use Case 11-2 presents an example where there is not a clear delineation between project team members and project sponsors and/or project stakeholders.

Effective Communication in Projects

Effective communication in all projects is essential to their overall success. Project managers spend most of their time communicating with the team members and stakeholders in order to ensure the project is planned and executed in accordance with the project’s objectives and strategies. Project information should be available to all project team members and stakeholders as appropriate. Project documentation, minutes, status reports, and so forth should be optimally available and accessible. Many organizations have a SharePoint site, Wiki, or like repository as a “single source of truth” for the project. However the project information is shared, the project manager is responsible for making sure relevant information is available to team members and stakeholders, managing stakeholder expectations, and reporting on the performance of the project.¹

A project manager is responsible for a wide range of forms of communications in a project, including the following:

•  Internal (within the project) and external (customer, other projects, the media, the public)

•  Formal (reports, memos, briefings) and informal (e-mails, ad hoc discussions)

•  Vertical (up and down the organization) and horizontal (with peers)

•  Official (newsletters, annual reports) and unofficial (off-the-record communications)

•  Written and oral

•  Verbal and nonverbal (voice inflections, body language)

The communication skills that a project manager, team member, or stakeholder possesses can directly affect the effectiveness of the communications within a project as well as the success of a project. The following communication skills are important to have and will lead to more effective communications:

•  Listening actively and effectively

•  Asking questions to ensure better understanding of situations

•  Fact finding to find or confirm information

•  Setting and managing expectations

•  Persuading a person or organization to perform an action

•  Negotiating to achieve mutually acceptable agreements between parties

•  Resolving conflict

•  Summarizing, recapping, and identifying next steps¹

It is important to hone or develop these skills so that you can be an effective communicator and project manager.

Process Groups and the Project Life Cycle

Project management is achieved through the application of standardized processes to project activities in order to meet the project’s requirements. PMI has identified 47 project management processes and has combined these into five categories, or process groups, by which all projects should be managed: Initiating, Planning, Executing, Monitoring and Controlling, and Closing.

These process groups, due to the more or less sequential nature of projects, have been further streamlined by the authors by combining the Executing and Monitoring/Controlling groups and commonly put into the following project life-cycle framework:

•  Starting the project (initiating phase)

•  Organizing and preparing (planning phase)

•  Carrying out the project work while monitoring and controlling it (executing phase)

•  Closing the project (closing phase)

Projects vary in both their size and complexity. But, regardless of the size or complexity of a project, all projects follow very similar life-cycle structures.

These project management processes and the life-cycle framework by which they are often discussed apply across all industries. There is wide-ranging belief and acceptance that effectively using these project management processes will improve the chances of a project’s success.

Project Initiation

While some may not consider the project initiation phase as important as some of the other phases of a project, such as project execution, this cannot be further from the truth. The time spent at the beginning of the project in the initiation phase is incredibly important to the success of a project. The more careful project initiation and planning that is done, the better a project’s chances of success are. Projects usually don’t fail at the end because of the work done on the project in the executing phase, but they often fail because not enough time and effective effort was spent in the beginning to properly initiate a project. The initiating phase often begins with a fuzzy charge from a superior to a project manager, such as “Implement an EHR system.” Then, with thoughtful initial planning, a project charter and problem and mission statements are created, and finally project objectives are set and prioritized. When a PM has clear, well-defined project objectives, he or she can exit the initiating phase and is well on his or her way to successful project completion.

Project Charter and Scope

Before any work on a new project can begin, it’s advisable to create, and have approved, a project charter. The project charter is a high-level document that outlines the objectives and requirements of the project and serves as the official authorization for the project. PMI’s Initiating Process Group consists of the processes that need to be performed in order to define a new project or even to start a new phase in an existing project. The Initiating Process Group defines the scope of the project, identifies the project’s stakeholders and project manager, secures the financial resources necessary to begin the project, and obtains the required authorization to begin the project or phase. The project manager and the project management team help write the project charter, which is then approved and officially authorized by the project initiator or sponsor.¹

The project charter and scope statement begin a recurring theme throughout the life of a project that is of great importance to the success of that project: mutual understanding of a project’s goals and objectives. Although this sounds simple to achieve, it isn’t because of the organizational and operational complexity so prevalent in healthcare, competing demands, many different stakeholders and project team members with different foci, and other factors. Mutual understanding of a project’s goals and objectives must be foremost in a PM’s mind during the initiation phase and revisited during critical junctures thereafter.

Project Charter

The organization initiating a project assigns a project manager to the project. The project manager is integral to the success of the project because it is their responsibility to see that the project achieves the objectives outlined in the project charter. The PM must focus on the following:

•  Achieving specified project objectives

•  Controlling the assigned project resources to meet project objectives

•  Managing the four project management variables (as well as risk): performance (quality), cost, time, and scope (PCTS)

The PM must constantly monitor all of these areas in order to ensure that the project is progressing in accordance with the project charter, is reaching milestones, and finally achieves the goals outlined in the project charter. As discussed, efficiently balancing the competing demands of the project’s overall scope, schedule, budget, quality requirements, available resources, and risk will lead to successful project completion. It is the PM’s responsibility to manage all of these factors to reach the successful completion of the project.

Project Scope Statement

Following the development and authorization of a project charter comes a more detailed description of the project and its goals through a project scope statement. The project scope statement is essential to the project’s progress and builds upon the major factors such as required deliverables, known or assumed risks and constraints, and other variables that are identified in the project charter. Additionally, the project scope statement takes into account any other risks, constraints, or variables that may not have been known at the time the project charter was written. When the project scope statement is being developed, more information regarding the specific details of the project is available, so the scope can be defined more clearly and with greater accuracy.¹

The PMBOK Guide outlines the following sources of information that the project management team uses to help develop the project scope statement:

•  Project charter

•  Requirements documentation (describes how individual requirements meet the business and clinical needs for the project)

•  Organizational process assets (examples include policies, procedures, and templates for a project scope statement and files and lessons learned from previous projects)

•  Expert judgment (examples include other units within the organization, consultants, stakeholders, industry groups, and subject-matter experts)

•  Product analysis

•  Alternatives identification¹

When a project scope statement includes a sufficient level of detail and information to define the project, the project management team has a better chance of being able to successfully manage the project.

Project Problem/Vision/Mission Statements

Because proper project initiation is critical to the success of all projects, we will also walk through the principles the Lewis Institute uses to teach project initiation. Depending on the project and the project manager’s and project team’s preferences, the steps outlined here can substitute for the PMI scope statement process. The creation of these “statements” is best led by the PM but with the full participation of project team members and, when appropriate, stakeholders. The project initiating phase includes the following components:

•  Project problem statement   A problem statement defines the problem at hand and the reason for initiating a project and helps to develop a suitable solution for the problem. It’s a good starting point to then go on to construct a project’s vision and mission.

•  Project vision   The project vision provides a clear picture of what the final result will look like. The project vision communicates a shared understanding of the project’s goals or endpoints to the project’s team members and stakeholders. The project vision will answer the following questions: “What will the final result of this project look like?” and “How will the project deliverables affect our customers?”

•  Project mission statement   The project mission statement describes the overarching goal or objective that the project manager and project team is hoping to achieve and reminds the team of the ultimate purpose of the project. The mission statement should satisfy the needs of the project team, customers, and stakeholders. Additionally, the mission statement can help motivate or even inspire the team to work together to reach successful completion of the project. Important questions that you should ask as you develop the mission statement are “What are we going to do?” and “Whom are we doing it for?” and sometimes “How will we do it?”

SMART Project Objectives

The project scope statement or problem/vision/mission statement exercises done by the project team ready the team to craft project objectives that will guide the project and be used to determine project success. Within a project, the project team will undertake project activities in order to reach the desired objectives or the end of the project or phase. During the project initiation phase, you should ask the following questions of the stated project objectives: “What is our desired outcome?” and “How will we know when we achieve it?” By answering these questions, you will be able to ensure that the planned project activities will lead you to the desired end state of the project. It is important to note that the objectives should not state how they are achieved. The methods that will be used to achieve the project objectives will be developed in the next phase of the project life cycle, planning.

The common acronym SMART is a helpful tool you should use when developing project objectives. Project managers use SMART objectives as a way to ensure that project phases and results are successful.

•  S   Specific. Project objectives need to be specific and unambiguously explain what the project’s objectives and plans are. Furthermore, a single objective should encompass a single concept, although it’s okay to “roll up” subobjectives into one objective when setting overall project objectives.

•  M   Measurable. An objective needs to be measurable in order to make sure the team is making progress toward successful completion of the project.

•  A   Attainable. An objective needs to be able to be achieved with a reasonable amount of effort.

•  R   Relevant. The objective needs to be important to the organization or make a positive impact on a particular situation.

•  T   Time-limited. A deadline for project and/or phase completion needs to be set in order to help the team focus their efforts on completing their tasks in a timely manner. Therefore, the subject of the objective must fit into the timeframe of the project.

Developing SMART project objectives helps ensure that project managers can successfully plan, schedule, and control all of the activities that must be done to meet a project’s objectives.

TIP   Project objectives need to be specific, measurable, attainable, relevant, and time-limited (SMART) in order for the project to be well planned, scheduled, and controlled.

Planning a Healthcare IT Project

With the project charter approved, the problem/vision/mission statement written, and SMART project objectives set, a project manager and his or her team are well on their way to planning a successful healthcare IT project. The next step in successful project management that we will discuss is critical to the project and must be completed before work on the project begins. A project implementation plan must be developed before the team can begin project execution. While the project initiators or sponsors may be eager to begin the actual work of the project, it is in the best interest of the project and its stakeholders to carefully plan the work that is to be done. If you take the time up front to properly plan, you will save time and avoid costly errors in the long run. A rule of thumb is that one hour spent on planning saves three hours on execution. Equally important as developing the execution plan, the PM needs to make sure that there is a shared understanding of what is going to be done by the entire project team. Project planning will answer the following questions (who, what, when, where, why, and how):

•  What must be done?

•  How should it be done?

•  Who will do it?

•  When must it be done by?

•  Where will it be done?

•  Why will it be done is answered by the justification given in the project charter and/or the SMART objectives. However, for project planning purposes, why will it be done the way proposed as opposed to another way is good to ask.

•  How long will it take?

•  How much will it cost?

•  How good does it have to be?⁵

If the project manager can ensure that he or she has developed a strong plan for the work to be done in the project as well as a shared understanding of the plan, then the PM has demonstrated one fundamental aspect of control over the project and will be able to continuously assess the project’s progress and take action to correct any deviations. Without a plan, there is no control.

The Work Breakdown Structure (WBS)

One of the most important tools in project planning is the work breakdown structure (WBS). The purpose of the WBS is to organize and define the total scope of the project.

WBS Defined

Taking the project’s objectives and required deliverables into account, the WBS is a diagram that outlines the actual work that needs to be accomplished by the project team. The WBS establishes the interactions between all of the various components of the project and its deliverables.¹ The process of creating the WBS breaks the project’s work and deliverables down into smaller, more manageable components, which helps the project manager maintain control of the project and helps provide clear direction to the team as to what work needs to be done. A WBS creates a visual representation of the project in its entirety and is a very valuable communication tool for the project manager, project team members, and project stakeholders.⁶ Said another way, a WBS is a graphic representation of a project as a whole.

WBS Principles

Before you can successfully create a WBS, you must understand the difference between a project deliverable and a project activity. A project deliverable is the output or product that is created by the project’s activities. A project activity is what you need to do in order to produce the deliverable or product. A WBS is a collection of all important project activities.

TIP   A project deliverable is a desired end state, and a project activity is the action that leads to the desired end state.

To create a WBS for a project, the project manager will need to take the project scope statement, the project requirements from the organization initiating or sponsoring the project, and the organizational processes assets, such as policies, procedures, WBS templates, and files and lessons learned from previous projects, and break them down into smaller, more manageable components or levels until the work and deliverables are defined at the work package level. It is usually advisable to recruit the project team members and sometimes certain stakeholders into the process of creating the WBS, but ultimately, the PM is responsible for creating a comprehensive and effective WBS. Figure 11-2 depicts the levels of the WBS.

Below the Project level, all of the components are called project activities. Colloquially many people call project activities tasks. But, since Task is a level in a WBS, it’s better to call all of the components of work to be done project activities.

How many levels should you break the work down to? That depends. WBSs in the construction industry and engineering projects commonly involve many levels, up to 20 in some cases. More than four levels (Project, Task, Subtask, and Work Package) are often unnecessarily complex for HIT projects. The rule of thumb is to break down the project only as far as you need to easily manage it. For example, if you have a great network engineer with whom you have worked on other projects, you might simply have a task that says “Manage network” with no subtasks below it. On the other hand, if you have a new network engineer on the project, you might need to have “Assess, plan new components, and test network” as subtasks, and you may even break down those subtasks further into work package activities so that together you and the new network engineer can effectively manage all the important activities related to the network infrastructure for the project.

The Work Package level is the lowest level in the WBS. Very simply, the work package groups project activities that fit together logically and that can then be assigned to one person or team to execute. Once the Work Package level has been reached, a project manager can dependably estimate the cost of the project, develop an accurate schedule for the work to be completed, and, finally, better manage and control the work.¹ For the WBS to be an effective tool for the PM, it must answer the project planning questions outlined earlier as well as ensure a shared understanding among the project team of the objectives.

TIP   The project manager can reasonably estimate the cost of the project, develop an accurate schedule for the work to be completed, and effectively manage and control the project activities after a WBS has been created all the way down to the Work Package level.

Another important principle in constructing WBSs is that a WBS tells you nothing about sequencing. Sequencing of project tasks or activities comes in the next step, scheduling of project resources.

Estimating Time, Cost, and Resources

Once the project manager has created the WBS all the way down to the work package level, the PM can begin estimating the time, costs, and resources necessary to successfully achieve the project’s objectives. After these estimates have been created, the PM can develop a realistic schedule, budget, and plan for the project.

Key Points About Estimating

Taking the time to properly plan a project’s activities increases the probability that the team will achieve the project’s objectives on time and within budget. If the project has been planned well to this point, then most likely time, cost, and resource estimates will be accurate. Here are a few key points for developing accurate estimates:

•  Understand what is required.

•  Prioritize activities and tasks.

•  Decide who needs to be involved.

In HIT projects, usually the greatest resource expenditure is on the time of project team members (project manager, clinical analysts, business analysts, network engineers, clinical application specialists, subject-matter experts, hardware/device technicians, and others from finance, quality measurement, and compliance monitoring). Thus, the main thing the project manager will be estimating is project activity duration. This will account for the vast majority of resources and cost in most HIT projects.

Essentially, what you are estimating as the PM is the probable project activity duration. The bell curve applies here. In a project with 100 activities, some of your estimates will be over, and some of your estimates will be under the actual time required to complete those tasks. If you, your project team, and the stakeholders have done your very best to estimate the duration of each of the project activities, the over/under will average out, and your overall estimate will be reasonably accurate. A word about padding: padding, or increasing a project activity’s estimated duration time, is common. But, padding at the work package or subtask levels or overall project level inevitably leads to more cost because of the well-known “student effect”—the project activities fully consume the allotted time. Therefore, padding should be avoided.

How do you estimate project activity durations? One way is to look at historical records of similar project activities done in similar projects in the past. How long did the project activity actually take? Another way is to ask the person who will be responsible for doing the project activity. They usually have the best idea of how long it will take, and if they don’t know right away, a series of questions by the project manager or dialogue with other team members will help you develop a reasonable estimate. If you have used the methods described earlier for estimating, then chances are you will have a relatively accurate estimate of the work and will complete the project successfully.

Developing the Project Schedule

With the work necessary to achieve the project’s objectives defined, the WBS created, and the project activities and costs estimated, the project manager is now ready to develop the project schedule. The PM will need to take into account the project activities, estimated time to complete the activities, required resources, and project delivery date to develop the project schedule. This is an important step in the process and one that may have several revisions throughout the life of the project. The project schedule outlines the target start and finish dates for all project activities and milestones. A milestone is an identifiable or noteworthy event that marks significant progress on the project.⁷ Time and resource estimates will need to be reviewed, and often revised, to create an approved project schedule that will serve as a baseline to track project progress.

Purpose of Scheduling

If the project manager is able to continuously maintain a realistic schedule as project work develops and changes, the PM will be able to keep the project moving forward and will be able to inform team members and stakeholders of the project’s status. If the project manager sees the project deviating from the schedule, the PM can take appropriate measures to get the project back on track or make any necessary updates to the project’s budget and scope. Without having an accurate project schedule and without monitoring the progress of the project’s activities and revising the schedule, as needed, it will be hard for a project manager to have good control of the project and will make completing the project on time and on budget almost impossible.

Introduction to Scheduling Techniques

In project management there are many different techniques that can be used to help develop and maintain an accurate project schedule. We will discuss several of them here. One area that is outside the scope of this chapter is a detailed discussion of project management software. Microsoft Project and many other good project scheduling and management software application products are readily available. In the vast majority of HIT projects, a software application tool will be used to develop and maintain the project schedule. These tools have many helpful features that greatly simplify creating a schedule. What we will provide here are principles, practices, and advice that will ideally make your use of these essential products more powerful and effective.

Several analytical techniques underpin the algorithms of project management scheduling software that produce Gantt chart–like project schedules. By far the most common scheduling analytical technique is the critical path method. To use a project management software scheduling application that employs the critical path method in a project with interdependent activities in order to develop a chart-like depiction of the project schedule, a project manager needs to know the following:

•  All project activities that are required to complete the project (from WBS)

•  The time each activity will take to complete

•  The relationship between all activities

The PM will then be able to calculate the critical path, which is the longest path (in time) from project start to project finish. The critical path indicates the minimum time necessary to complete the entire project.⁸ The longest path in the diagram is the critical path, and any activity on this path is considered a critical activity and must be executed on time to keep the overall project end date on time. Oftentimes in a project there will be activities that are not on the critical path; these are referred to as slack or float activities. Slack or float activities have the flexibility to be delayed without delaying the total project beyond its target completion date.⁹ When the float of an activity or path is negative, meaning there is no flexibility, it is called supercritical. As a general rule, two critical paths in one project should be avoided. And, any activities that have significant risk associated with them should be considered float activities.⁹

Scheduling Resources in Projects

All projects rely on a variety of resources to actually do the work outlined in the project documents. Resources include but are not limited to people, materials, equipment, and money. Without adequate resources, a project will have difficulty reaching the target completion date or may not achieve its objectives. At this point in the project, the project manager must identify the resources required for successful project completion and then plan, or schedule, the resources so that the team can work effectively.

Resource allocation is the process of assigning to each project activity in the plan the necessary resources that have previously been identified. Some activities may require more than one resource, and depending on the nature of the activity, the amount of resources required may vary at different points throughout project execution. The project plan may need to be revised to account for resource availability.

Scheduling resources before any work begins on a project allows the project manager to see where resources may be overloaded and make adjustments to the project plan. However, one technique frequently employed by PMs is to not worry too much about overloading resources on the first pass of project activities and focus instead on the sequencing and relationships between project activities. This is because one of the most powerful features of project management software, as well as being a significant aide to the PM, is resource leveling.

Resource Leveling

Most likely, at some point in a project the demand for a resource, or resources, will outweigh the availability of the resource(s). Resource leveling helps the project manager handle this problem and keep the project on track .The process of revising a plan’s schedule (start and finish dates) in order to account for resource availability is called resource leveling and is used to optimize the distribution of work among resources. Figure 11-4 illustrates two types of resource leveling techniques: time-critical leveling and resource-critical leveling and the differences between them.⁹

Figure 11-4 Time-critical vs. resource-critical resource leveling

Resource-leveling techniques are applied to project schedules that have already been analyzed by the critical path method and can often lead to changes in the critical path as well as potentially other parts of the project.¹

Factoring in Resource Availability

To create a schedule, the project manager will need to begin by inputting the actual time it will take to complete each project activity. Then, resource availability must be factored into the schedule to determine the duration (in calendar time) it will take to complete the project work. The PM needs to know the actual availability of their team members when developing a schedule; without this, the PM cannot create a meaningful schedule.⁹ When factoring in resource availability, it is important to understand that people’s productivity can be affected by the following three factors:

•  P   Personal. People must take breaks.

•  F   Fatigue. They get tired.

•  D   Delays. They are waiting for something.

It has been found that in a standard eight-hour day, you will get only about 80 percent, or 6.4 hours, of productive work from a person. This loss in productivity comes from P, F, and D.⁹ Additionally, “setup time”—the time a resource takes to initiate a project activity—associated with starting each new project activity or segment of a project activity should be accounted for. If the PM can prioritize tasks and have team members working on fewer project activities at one time, setup time will be decreased, which will help the overall project schedule. One suggestion for this is to give each team member a “priority-one” activity and a backup activity. When there is a break in the work on the “priority-one” activity, team members can move to their backup activity.

Executing, Monitoring, and Controlling HIT Projects

The project charter and problem/mission/vision statements have been written, the objectives have been outlined, the WBS has been created, and the time, cost, and resources have been estimated; in addition, a schedule has been developed, and resources have been allocated. So, execution of the project’s deliverables is ready to begin. All of the careful, thoughtful planning that has been done up front will help ensure that execution goes smoothly, according to plan, and that the project objectives are achieved. The execution phase of a project includes completing the work outlined in the project plan in order to meet the project requirements, coordinating resources, and performing the activities in the plan.¹ Additionally, during the execution phase the project manager will need to constantly monitor the progress of the project and make any necessary changes to the plan in order to keep the project moving in the direction of achieving its objectives.

Execution Principles, Issues, and Opportunities

The execution phase of the project is the time when the work that has been planned for the project actually gets completed, a large portion of the project’s budget is spent, and the plan may be updated or a new plan baseline may be established as a result of the work being done. These changes may be made because activity durations varied from the expectations in the plan, changes occurred in resource availability or productivity, or other unanticipated risks arose after execution began. If the changes are of a large enough scale, change requests will need to be initiated and subsequently approved so that the project management plan or documents can be revised and a new baseline established if necessary.¹ During the course of the execution phase, the project manager is responsible for managing the team to perform the work necessary to achieve the project’s objectives. Some of the project manager’s responsibilities include the following:

•  Acquiring the project team, tracking their performance, and helping improve their skill sets

•  Performing quality assurance audits

•  Distributing important information to the team and stakeholders

•  Managing stakeholder expectations¹

TIP   During project execution, the project manager is responsible for seeing that the work that needs to be done to achieve the project objectives is completed according to the plan and, if not, for initiating project change requests.

Monitoring Progress in Projects

Throughout the course of the execution phase, the project manager is also responsible for monitoring the progress of the project. Monitoring the project includes tracking, reviewing, and controlling the progress and performance of the project as well as identifying and mitigating any risks that may have developed during the progress of the project; strong risk management is important to the success of the project for the following reasons:

•  Improves project performance

•  Ensures quality does not take a backseat to cost and schedule

•  Reveals developing problems early

•  Determines what needs to be done to mitigate identifiable risks

•  Identifies areas where other projects should be managed differently

•  Keeps clients informed of status

•  Reaffirms organization’s commitment to the project

Project Control and Evaluation

Project control is achieved by analyzing where one is compared to where one is supposed to be and then taking corrective action to resolve any discrepancies that exist. The project manager controls the direction of the project and helps ensure its success by regularly, and consistently, monitoring the project’s performance and measuring that against the project’s plan and objectives. If the PM sees the project progressing in a different way than outlined in the plan or sees any stalling, the PM needs to initiate any necessary changes to the plan.¹ Just like in all of the other phases of project management, there are systematic review techniques that the PM should use.

Kinds of Evaluation Reviews

We suggest three kinds of evaluation reviews—status, design, and process—that the project manager can use during the course of the project to systematically ensure that the project is progressing according to plan and will achieve its objectives.

•  Project status review   The project status review should occur weekly on shorter projects and monthly on longer projects. This review looks at the current status of the project. Specifically, it reviews the P, C, T, S of the project using something called an earned-value analysis that we will discuss in the next section. The status of critical tasks must be updated at this time. The future status of the project is also considered in this review, including projected deviations from the schedule. Any risk factors contributing to problems in the project need to be identified and solutions need to be developed, if possible. The status of critical tasks must be updated at this time. And finally, risk management principles should be applied, if necessary.

•  Project design review   The project design review examines a product, service, or software design to see whether it meets the project requirements. The questions that need to be asked are “Does it work?” and “Can we make it work?”

•  Project process review   The project process review happens at major project milestones or at completion of the project; it evaluates whether the project was done well and what needs to be improved, and it develops a list of “lessons learned” from the project that can be applied to future projects.

Earned-Value Analysis

Oftentimes a project management team will use a schedule report to review the progress of a project. Unfortunately, this will not provide the team with a true picture of the project’s status because it does not take into account the effort or work that has been put into the project, which may be greater than anticipated but slowing down the overall progress. To properly assess the status of the project and account for any deviations from the plan, the project manager should conduct an earned-value analysis. The earned-value system is an integrated cost-schedule tracking system that looks at the project’s P, C, T, S to help the project manager, team, and stakeholders understand the true status of the project. An earned-value analysis integrates the following factors in order to accurately assess the project’s performance and progress:

•  Cost variance   Any difference between the estimated cost of an activity and the actual cost of an activity

•  Schedule variance   Any difference between the scheduled completion of an activity and the actual completion of that activity

To determine the cost and schedule variances, the project manager will need to use the following equations:

where:

•  Budgeted Cost of Work Scheduled (BCWS)   The budgeted cost of work scheduled to be done in a given time period

•  Budgeted Cost of Work Performed (BCWP)   The budgeted cost of work actually performed in a given time period (i.e., earned value)

•  Actual Cost of Work Performed (ACWP)   The amount of money actually spent for completing the work in a given time period

Using the earned-value analysis will help provide a clear and realistic understanding of the project’s progress as well as an understanding of why it may not be progressing according to the plan. With the click of a button, Microsoft Project and other project-scheduling software products produce earned-value analysis data once the schedule is updated with percent activity completion across all project activities.

TIP   An earned-value analysis looks at the project’s P, C, T, S to help the project manager, team, and stakeholders understand the true status of the project, and it integrates cost and schedule variances in order to accurately assess a project’s performance and progress.

Changing the Plan

If after conducting project evaluation reviews and an earned-value analysis the project manager finds that there has been a significant change (+/– 5%) in P, C, T, S, then the PM may need to initiate an official change in the project’s process. The PM will need to fill out an official project change form or document to request the change in the project by outlining where the change has occurred and why and how the project will be amended if the change is approved.

Closing the Project

You have now seen how a healthcare IT project progresses from the initiation phase to the planning phase and then on to the execution phase, with its emphasis on monitoring and controlling processes. All that is left is to confirm that all aspects of the project’s activities are finished so that the project can be officially complete. At the time of project closing, the following activities may take place:

•  The project is accepted by the project initiator or sponsor.

•  A post-project review is conducted.

•  Lessons learned are documented.

•  Any necessary updates are applied to the organizational process.

•  Project notes are filed for use in future projects.

•  Any other close-out procedures required by the project sponsor or organization are performed.

Additionally, the entire project management team should look at how the team has worked together to achieve the project’s objectives. Specifically, the following team processes should be evaluated:

•  Leadership

•  Decision making

•  Problem solving

•  Communications

•  Meetings

•  Planning

•  Giving feedback to team members and others

•  Conflict management

Once a project is complete, it is important for the project team to take some time to conduct a post-mortem analysis to evaluate what went well throughout the course of the project as well as what did not go well during the project. Through this analysis, the team will develop a list of lessons learned regarding the project specifically, as well as about project management in general, and will look to carry these lessons learned over into future projects.

Chapter Review

In this chapter, we took the rather extensive subject of project management and broke it down into an easy-to-understand explanation in order to provide you with the knowledge necessary to understand how essential project management is to healthcare IT. Given the constraints of this book, we did not go into as much detail or explanation of some of the specific techniques described in the chapter, such as the WBS, critical path method, earned-value analysis, and others. We highly recommend the Project Management Institute’s A Guide to the Project Management Body of Knowledge, the Lewis Institute, and the Healthcare Information Management Systems Society (HIMSS) as sources for additional information on the subject.

We also covered the four phases of a project (initiating, planning, executing, and closing) and broke out the major activities in each phase as they apply to healthcare information technology so that you are better equipped to work in project management in the healthcare industry. At the start of the project, or the initiating phase, you will develop a project charter and outline the project’s scope and mission. Then you will need to develop SMART objectives and finally prioritize the project’s objectives. After you do this, you will move into the planning phase where you will develop the WBS and estimate the time, cost, and resources needed for the project. Once you’ve created the WBS and have strong project activity duration estimates, you can develop the project’s schedule and schedule/allocate resources for the project utilizing the critical path method and resource leveling techniques we described. Then you are ready to move to the executing phase and begin monitoring and controlling processes in earnest. In this phase, the project “work” gets done, and you will be responsible for monitoring the progress of the project and maintaining control over the project. We described several types of evaluation reviews, including an earned-value analysis that will help you monitor and control the project’s trajectory. We also described how to make changes to the plan, if and when necessary. Once the work of the project is complete (and ideally the objectives have been met), you can move on to closing the project. In this phase of project management, you will conduct a post-mortem analysis of the project to see what went well and what did not, and you can develop a list of lessons learned that can be applied to other projects in the future.

You learned that a project is a temporary activity that is undertaken by a team in order to create a unique product, service, or result in a defined time period, and project management is the organization or facilitation of all of the planning, scheduling, and monitoring or controlling of all the activities or tasks that must be done to meet the project’s goals or objectives. Utilizing the project management process and techniques described in this chapter will significantly increase your chances of managing projects successfully and will help you to be a more valuable asset to an organization. The project management process can be applied to projects in all industries, not just healthcare. You can take the skills you have learned here and apply them in many different situations and ideally be successful at whatever it is you have set out to accomplish.

Questions

To test your comprehension of the chapter, answer the following questions and then check your answers against the list of correct answers at the end of the chapter.

    1.  Project management techniques are useful tools for healthcare IT project managers to have because it helps them do what?

         A.  Teach their project team how to cut corners so they can get their work done more quickly

         B.  Manage computer projects better

         C.  Facilitate the planning, scheduling, and controlling of projects

         D.  Execute healthcare IT projects without having to create a plan

    2.  What is the purpose of a work breakdown structure?

         A.  To create a diagram of all the people on the project team and what work they will do

         B.  To break the project down so that the scope of the project is decreased and the project can be executed more quickly

         C.  To create a visual representation of the project so everyone can understand the purpose of the project

         D.  To break the project’s work and deliverables down into smaller, more manageable components, which helps the project manager maintain control of the project and helps provide clear direction to the team as to what work needs to be done

    3.  What process group occurs during all phases of a project’s life cycle?

         A.  Monitoring and controlling

         B.  Watching and listening

         C.  Executing and closing

         D.  Planning and finishing

    4.  For a project manager to accurately estimate the time, cost, and resources necessary to achieve a project’s objectives, what will the project manager need to do?

         A.  Understand what is required and decide who needs to be involved

         B.  Prioritize project activities

         C.  A and B

         D.  None of the above

    5.  The process of moving project activities out until resources are available, even if it means the project end date slips, is called what?

         A.  Time-critical leveling

         B.  Scheduling adjusting

         C.  Resource-critical leveling

         D.  Project leveling

    6.  What does a project manager need to know to determine the critical path?

         A.  All project activities that are required to complete the project (from the WBS)

         B.  The time each activity will take to complete

         C.  The relationship between all activities

         D.  All of the above

Answers

    1.  C. Project management knowledge and techniques are useful tools for healthcare IT project managers to have because it helps them to facilitate the planning, scheduling, and controlling of projects.

    2.  D. The purpose of a work breakdown structure is to break the project’s work and deliverables down into smaller, more manageable components, which helps the project manager maintain control of the project and helps provide clear direction to the team as to what work needs to be done.

    3.  A. The monitoring and controlling process group occurs during all phases of a project’s life cycle.

    4.  C. For a project manager to accurately estimate the time, cost, and resources necessary to achieve a project’s objectives, the project manager will need to understand what is required, decide who needs to be involved, and prioritize activities and tasks.

    5.  C. The process of moving tasks out until resources are available, even if it means the project end date slips, is called resource-critical leveling.

    6.  D. To determine the critical path, a project manager needs to know all project activities that are required to complete the project (from the WBS), the time each activity will take to complete, and the relationship between all activities.

References

    1.  Project Management Institute. (2013). A guide to the project management body of knowledge (PMBOK guide), fifth edition. Author.

    2.  Drucker, P. (1986). Management tasks, responsibilities, practices. Truman Talley.

    3.  Project Management Institute. (2016). Healthcare community of practice. Accessed on July 20, 2016, from www.projectmanagement.com/Practices/Healthcare/.

    4.  Lewis, J. (2010). Project planning, scheduling, and control. McGraw-Hill Education.

    5.  Project Management Docs. (2012). What is a stakeholder? How to identify, analyze and manage project stakeholders. Accessed on June 30, 2016, from www.projectmanagementdocs.com/articles/what-is-a-stakeholder.html.

    6.  Mathis, M. (n.d.). Work breakdown structure: Purpose, process and pitfalls. Accessed on December 1, 2016, from www.projectsmart.co.uk/work-breakdown-structure-purpose-process-pitfalls.html.

    7.  Mantel, S. J., Meredith, J. R., Shafer, S. M., & Sutton, M. M. (2001). Core concepts of project management. John Wiley & Sons.

    8.  Levy, F. K., Thompson, G. L., & Wiest, J. D. (1963). The ABC’s of the critical path method. Harvard Business Review, 41, 413–423.

    9.  Lewis, J. (2003). The project manager’s pocket survival guide. McGraw-Hill Education.

  10.  Miller, E. (2013). Multitasking. Accessed on August 28, 2016, from https://ekmillerlab.mit.edu/tag/multitasking/.