CHAPTER 49
Project Management in Healthcare
Making a Difference Through Compassion, Caring, and Respect
Among the unique challenges faced by project managers in healthcare, primary importance must be placed on this: Healthcare cannot afford project failures. The risks are too great. Aside from the monetary impact and negative press, a failed project in healthcare can mean the difference between life and death.
Project management success in healthcare is thus too critical to be left up to software programs or even skilled technical controls. Seasoned healthcare project managers know success depends on their soft skills, and perhaps most crucially on cultural sensitivity and communications.
Healthcare has been slow to adopt formal project management. In the past, healthcare consisted primarily of single hospitals usually formed by charitable organizations. Projects were simple and project teams were small. Project deliverables were manageable when coordinated by someone with good organization and planning skills. These projects were frequently implemented successfully. Project management was not critical for success.
Over time, healthcare and healthcare projects have become more complex. Most projects now encompass people, process, technology, and, frequently, construction.
The benefit of project management was not evident until large healthcare systems or integrated delivery systems (IDSs) evolved. An IDS is a collaborative network that links various healthcare providers to offer a coordinated continuum of care. They are accountable both clinically and fiscally for the outcomes and health status of the population and community they serve.
Consisting of multiple hospitals, an IDS provides a wide array of services such as acute patient care, multiple medical specialties (e.g., cancer, heart disease, neurology, orthopedics, pediatrics, women’s services), physician practices, outpatient medical facilities, and affiliations with medical schools. These multihospital health systems are the most common organizational structure in the hospital industry today. Small community hospitals still exist and are often affiliated with these systems where they share services, programs, and medical staff.
In IDS organizations, large projects (and programs) are the norm. Projects are highly visible, high risk, with huge capital investments and long durations. These projects are not limited to information technology or construction. There are many interrelationships among various deliverables. Some projects extend beyond the hospital system itself and encompass affiliated organizations, increasing the complexity even more. Formal project management is critical for success.
Healthcare organizations have limited funding, schedule constraints, strict quality requirements, and competitive pressures. There are more projects to be done than resources to do them. Some projects are discretionary, but most are nondiscretionary.
TYPES OF PROJECTS
There are various types of projects in healthcare. Some projects are specific to a particular area, while others cross multiple disciplines. The need for, and the degree of, project management depends on the project.
Construction Projects
These projects are managed by a project manager knowledgeable in the construction industry. If the hospital does not have a construction department, then this position is usually outsourced. Examples:
• Building a new physician office
• Building or renovating a medical office building
• Making renovations to a department within the hospital
These project managers interact with architects, construction crews, and regulatory agencies. They plan and oversee the work to ensure healthcare codes are followed. Deliverables consist of the design, construction, interior finishes, furniture, and equipment.
Information Technology Projects
Information technology (IT) projects are usually managed by a project manager familiar with various aspects of IT. Examples:
• Major network upgrade
• New virus scanning software
• Web development
The project manager works with technical staff in IT as well as hardware and software vendors. Together, they plan and oversee completion of the work.
Process Improvement Projects
Process improvement projects are very common in healthcare. These are more complex due to the increased number of stakeholders and higher risk involved. Process improvement projects are managed by a clinical quality process improvement expert who specializes in Six Sigma and Lean techniques. Clinical processes needed to be reviewed on a regular basis to do the following:
• Improve the quality of care.
• Improve patient satisfaction.
• Comply with new regulations.
• Improve throughput and increase revenue.
Hospitals typically have several active process improvement projects at any point in time. This creates a dynamic environment for caregivers to adapt to a steady flow of process changes. Education of staff is a critical deliverable in all of these projects.
CASE EXAMPLE: DOOR-TO-BALLOON PROJECT
A process improvement project was launched to reduce the time from “door-to-balloon” for heart attack patients to less than ninety minutes.
This time interval starts when the patient arrives at the emergency department (ED) with heart attack symptoms. It ends in the cardiac catheterization lab (CCL) when a catheter guidewire crosses the suspected lesion and a balloon is inflated, relieving the blockage. “Time equals muscle” in these situations: any delay in treating the patient increases the likelihood and amount of cardiac muscle damaged.
This is an important core quality measure for the Joint Commission on Accreditation of Healthcare Organizations. The ability of hospitals to reduce the duration of this process saves lives and improves the quality of life for those patients post-discharge.
This project team consisted of nurses and physicians from the ED and CCL as well as quality management, educators, and emergency management services (EMS) personnel.
Medical Equipment Projects
Medical equipment includes any device used in patient care. Most medical equipment replacement projects do not require project management. For example, an effort to replace all patient beds is a straightforward process. As long as there is a coordinator with organization skills, these projects are successful. However, often medical equipment projects require project management because the device is more sophisticated and requires network connectivity, interfaces, facility renovations, marketing/communication, training, and education. There are internal and external stakeholders. These projects could impact hundreds or thousands of employees in a large healthcare system—as well as large numbers of current and potential patients. Examples:
• Computer-aided tomography (CAT scan)
• Magnetic resonance imaging (MRI)
• Glucometer (glucose or sugar meter measuring device) replacement
Clinical staff must be involved in the decision-making process. Testing is needed and signoff must be received before the equipment can be installed in the hospital and used for actual patient care. Installation of the equipment needs to be coordinated so it does not interfere with normal operations. Formal project management is critical for these projects. Failure to do so increases risk and can jeopardize patient care if not implemented properly.
CASE EXAMPLE: SMART INFUSION PUMP IMPLEMENTATION
Fluids and medications are frequently administered to patients directly into a vein via intravenous (IV) methods. An IV pump infuses fluids, medication, or nutrients into a patient’s circulatory system. The pump regulates the rate at which the fluid is infused into the body. This is a very convenient method for medication delivery; however, harmful reactions can occur more rapidly and be more severe when given in this manner.
Hospitals can reduce/eliminate adverse drug reactions by converting to smart pumps. Safe, effective, and easy to use, this technology blocks attempts to run medication exceeding established limits, thereby preventing administration errors and harm to patients.
Implementation of this technology is not as simple as a patient bed replacement. Once the desired vendor is selected, smart pumps need to be configured and programmed with criteria such as the appropriate drug and infusion rate, and when and how warnings or full alarms should sound.
Smart pumps also track and record usage data that can be downloaded and reviewed by clinical quality effectiveness staff. Corrective action needs to be taken when “near misses” occur that could have led to patient harm. Infusion practices are assessed and new opportunities are identified for process improvements.
In this project, bedside clinicians were involved as well as pharmacists, physicians, clinical engineering staff, educators, clinical quality staff, and IT. Formal project management and a dedicated project manager were essential to ensure this project was implemented successfully.
Integrated Projects
Many projects in healthcare cross all of these lines: construction, technology, process improvements, and medical equipment. There are many internal and external stakeholders. Some work is done by the hospital system itself, while other work is contracted out to vendors. These are mission-critical projects that are required to achieve the strategic plan of the organization.
Due to their size and complexity, these initiatives are normally managed as a program under the direction of a program manager and multiple project managers overseeing their area of expertise. Examples:
• Building a new hospital
• Building a new ambulatory center
• Implementing a new service line
• Implementing clinical information system
• Making major renovations to an existing hospital
These are all multimillion-dollar capital investments impacting several aspects of the organization, involving hundreds or thousands of employees, that are visible to the entire community, and that are under the scrutiny of local and state regulatory agencies. Formal project and program management are absolutely necessary.
CASE EXAMPLE: PEDIATRIC HOSPITAL RENOVATIONS PROGRAM
Renovations were needed to a children’s hospital to meet the expectations of clinicians, patients, and families. The program was approved with a not-to-exceed budget of $90 million. The estimated duration of the program was three to five years, depending on the implementation approach selected for each renovation project.
One project consisted of changing to single-family patient rooms in the neonatal intensive care unit (NICU). Deliverables included the following:
1. Architectural design
2. Construction
3. Relocations
4. Medical equipment
6. Process improvements
7. Staff education
8. Communication
9. Information technology
One of the greatest challenges in this project was developing a phasing plan for the work. Renovations needed to be done in a way that would create the least amount of disruption to patient care.
Creation of the phasing plan required meetings with NICU leadership to evaluate options and develop an acceptable plan that would still meet the minimum capacity requirements for the hospital. A four-phase approach was selected. Work was broken down into sections consisting of twelve to fifteen patient rooms. Each section required six to nine months to complete.
It would have been much easier and faster to close down the entire unit, make the renovations, and reopen, but this is not possible in healthcare. The hospital had to maintain the ability to care for the normal volume of patients throughout the renovations.
CRITICAL SUCCESS FACTORS
Project managers are responsible for delivering projects within budget, on time, and with a high degree of quality. This requires a combination of hard skills and soft skills, but in healthcare, project managers need to be most adept with the soft skills. Project managers who are unable or unwilling to focus on the soft skills will not be successful in healthcare project management.
This does not mean healthcare project managers can disregard the hard skills. Project managers still need to create a project schedule, evaluate the critical path, address variances, and take corrective actions. The project manager needs to be willing to make tough and frequently unpopular decisions. Finding the right balance between soft skills and hard skills can be challenging. The successful healthcare project manager focuses on two primary areas: attitude and relationships.
Attitude
Attitude is a culmination of what we believe and feel about ourselves and the situation. Project managers’ attitudes impact the way they manage the project, the way the project team members approach the project, and ultimately the success or failure of the project.
Successful healthcare project managers always display a positive attitude. This does not mean that every day is perfect. There will be times when things go awry. How the project manager responds to those events sets the tone for the project.
The project team needs the project manager to stay positive, maintain his or her professionalism, and be willing to take the necessary actions at all times, even in the face of adversity. A negative attitude causes doubt in the ability of the project manager and fear of failure for the project as a whole.
Successful healthcare project managers also display an attitude of service. The project manager does not own the project. The project manager is responsible for completing project management tasks and bringing project management expertise. Other project team members bring different skills sets to the project such as clinical, technology, construction, education, and so on. The project manager must ensure that the team operates in a cohesive fashion to achieve the goal and objectives of the project.
Most of the project team members are responsible for patient care and do not have any time to waste. The project manager must make the project work as easy as possible for the clinicians assigned to the project. The project manager can do this in a number of ways:
• Remove roadblocks that can keep the clinical project team members from completing their project tasks in the most efficient and timely manner.
• Lift the project burden by taking on tasks that do not require clinical decisions. There is rarely enough administrative staff to do these tasks. Project management is considered overhead and a non–revenue-generating function. Project managers need to show value in other ways by making it easier for the clinicians to take care of patients and work on the project.
• Make the project work as easy and pleasant as possible. This includes keeping the project team organized, which can frequently add more work to the project manager.
• Adopt a rule of “no surprises.” Send information out ahead of time so project team members know what is expected. This allows them to come to all meetings prepared.
• Display a “can do” and “will do” attitude whenever the project sponsor or project team member needs assistance. The words “not my job” are not in the healthcare project manager’s vocabulary.
TABLE 49-1. KEY STAKEHOLDERS IN HEALTHCARE PROJECTS AND PROGRAMS
Relationships
Project management in healthcare is all about relationships. Depending on the project, stakeholders can come from a variety of sources. Some are clinical and others are administrative. While not a comprehensive list, examples of stakeholders include those shown in Table 49-1.
The most frequent stakeholders in any healthcare project are nurses and physicians. Establishing solid working relationships with these groups is critical.
Nurses
In most healthcare systems, the number of nurses typically outnumbers any other job group. People enter the nursing profession for a number of reasons, some for all the reasons described below. Project managers in healthcare will encounter nurses from all these perspectives:
Altruism
Altruistic nurses are concerned about the welfare of others. Many feel nursing is a “calling.” They want to make a difference in the world by helping people. Unassuming and unselfish, these nurses freely give of their time and talents. They find satisfaction knowing they touched someone’s life. These nurses may worry about their patients when they are called away for a project meeting. Their minds may not be fully engaged in the agenda topics. At times they may appear to be preoccupied or uninterested in the meeting. This should not be misconstrued.
Project managers need to recognize and embrace the strong people skills of these nurses and the value they can provide to the project. Some project managers will need to get out of their hard skills comfort zone to make this happen. Engage in casual conversation with these nurses and show that you are interested in them as people and not just as project team resources.
Interest in Science
Some nurses enjoy the science side of nursing. These nurses are more task-oriented. They like to do things in a certain order every time. They take pride in the quality of their work. The project manager needs to show how the project will benefit them and make their work life better. When they enter a project meeting they want to get down to business.
These nurses are very interested in the nursing profession as a whole. They keep abreast of changes by reading journals, being involved in committees, and being members of professional organizations. Project managers need to include these nurses in the evaluation phases of a project. These nurses will be able to translate the nursing practice into the technology or equipment and vice versa.
Nurses interested in this aspect of nursing are motivated by knowing that their expertise is appreciated on the project. The project manager needs to recognize their technical skills.
Flexibility
There are many opportunities and different areas in which a nurse can work. Nursing is one of the few careers that offer such an abundance of choices. Nurses are able to move from one specialty to another to gain valuable experience across the nursing spectrum (e.g., surgery, pediatrics, emergency department, labor and delivery, oncology, etc.). Nurses with a broad range of experience provide a wider perspective. Project managers are very fortunate to have these nurses on the project due to their breadth of experience. They bring lessons learned from many areas of medicine to the project table.
Job Security
There continues to be a shortage of nurses due to the changes in healthcare and the aging population. People are living longer and will need healthcare. Some nurses enter the nursing profession because of the job security it offers, especially if this is a second career. The perception is that you do not have to worry about job security in nursing. Some of these project team members may view their position more as a job than a profession. While still valuable project team resources, these nurses may not display the same passion for the profession. The project manager needs to establish clear roles, responsibilities, and expectations.
Nurses from all of the above perspectives want to be a valued member of the project team. They believe they can make an impact on changes in healthcare by participating in projects. At the same time, the project manager must be aware that nursing can be a high-stress, fast-paced job. Nurses may be working twelve-hour shifts. The project manager needs to be sensitive to the pressure nurses are under when scheduling project team meetings. Meetings must always be scheduled at the nurses’ convenience—not the project manager’s.
The project manager must be respectful of time constraints and not add to the stress. All project activities must be organized with clear roles, responsibilities, and due dates.
Physicians
People enter the medical profession for a number of reasons and these reasons have changed over time. The project manager’s relationship-building techniques differ depending on the physicians’ viewpoint.
Altruism
We are seeing more and more doctors who are choosing medicine for this reason. They are passionate about their field and willing to fight for the interests of their patients. Similar to nurses, these physicians have the best interest of mankind at heart and want to heal people of illnesses; they see medicine as a “calling.” Altruistic physicians cultivate relationships with patients and their families. Physicians treasure the gratitude they receive for helping someone through a difficult illness. Approach these physicians from the point of view of a shared goal in helping patients.
Prestige
Being a physician is honorable and held in high esteem in our society (the “white coat”). A doctor is not simply someone with special skills; doctors preserve life, bring life into the world, and diagnose problems in the lives of people. They are healers, revered and powerful. They deserve our respect and at the same time can be difficult to work with if they are not convinced of the importance of the project goals.
Compensation
The medical profession can be a financially rewarding career, especially in the specialty fields. But this doesn’t come without personal sacrifice. Many physicians work grueling hours and are on call through nights and weekends.
Regardless of the reason why doctors and nurses decided on a career in healthcare, they make many personal sacrifices. They frequently work long shifts. Some physicians are not only practicing medicine in the hospital but they also have a private practice, do research, and teach. The pace is fast and tiring. The project manager must be accommodating and willing to bend the rules to meet the needs of the project and stakeholders.
Physicians are usually honored to be asked for their advice and want recognition for the tangible results they obtain. When preparing a progress report, the project manager should cite the physician who is responsible for that achievement.
As with nurses, physicians expect organization and structure. They do not want their time wasted in unproductive project team meetings. If this occurs, the project manager will find that the physicians refuse to attend the meetings or appear to be disgruntled when they do attend.
Project managers must be flexible and willing to work around the physicians’ availability when scheduling or rescheduling project meetings. Even though some physicians may be perceived as being difficult to work with, the project manager still needs to display the same degree of respect for them as with all other project team members. The success or failure of a healthcare project hinges on your ability to gain the confidence of the physicians on the team. Physicians who are resistant to organizational changes will have great influence on their peers, so work early and proactively to get them on board.
CONCLUSION
Healthcare is one of the most complex and challenging industries for project managers today. The industry is changing dramatically, as is the science that generates the need for new equipment, clinical approaches, and facilities. Project managers need to be fully committed to the project twenty-four hours a day, seven days a week, and willing to do whatever it takes to ensure the project is successful. And rarely does the healthcare project manager have the luxury of managing only one or two projects.
Managing projects in healthcare is a very humbling experience. Even with all the challenges, pressures and stress, there is nothing more rewarding than knowing that, at the end of the project, lives may be changed or saved.
DISCUSSION QUESTIONS
Discuss the cultural divide between clinical stakeholders and project management practitioners. What are some project communications strategies to help overcome these?
Given the impact on human lives, what ethical issues would you expect project managers in healthcare organizations to face (whether working on information technology or clinical projects)? How would you handle these?
RECOMMENDED RESOURCES
François Chiocchio, et al, Stress and Performance in Health Care Project Teams (Newtown Square, PA: PMI, 2012).
Randy Englund and Alfonso Bucero, The Complete Project Manager (Vienna, VA: Management Concepts, 2012).
David Shirley, Project Management for Healthcare (Boca Raton, FL: CRC Press, 2011).