Innovative healthcare project management for environmental remediation
Sandra J. Matheson
Hanford Environmental Health Foundation (HEHF) began business in 1965 as a not-for-profit organization. HEHF was awarded the contract for occupational health services at the Hanford Site in 1966, when the Atomic Energy Commission (AEC) decided to diversify its operations and services at Hanford.
The purpose of occupational health is to help protect the health and safety of the industrial worker. It is exactly what its name implies—provision of medical and industrial hygiene activities related to the health and safety of the worker. Where general medicine is still largely treatment-based, occupational health endeavors to keep workers healthy through prevention-based services.
Hanford Environmental Health Foundation was originally established to provide (1) occupational medicine services; (2) health education; (3) industrial hygiene services; (4) environmental monitoring and analysis; and (5) a database for long-term health systems analysis.
Other than the transfer of environmental monitoring and analysis to other contractors in the early 1990s, Hanford Environmental Health's mission has remained the same. Throughout the years, however, HEHF has changed and modified its specific services to reflect advances in the field of occupational health.
Inherent in the delivery of occupational health services are changes in service delivery that must occur as the industry it is serving changes. Although science and technology has been a constant mission at Hanford, the mission of the rest of the site changed in the late 1980s from production of nuclear materials and waste management to environmental clean-up of the site. Production of nuclear materials was permanently shut down. This end to an era leaves a variety of facilities, built and operated over a 50-year period, that must be removed and a surrounding environment that must be remediated.
Health risks to workers can be much greater in a clean-up environment than in a production site. In production, the same work in the same location is repeated day after day, week after week. The health risks to the worker are generally well-identified because of these repetitive cycles.
In a clean-up site, workers may be continually faced with new health hazards. The hazards workers face when cleaning up one facility may be quite different from the hazards they face at the next facility. This will most certainly be the case for a site such as Hanford, where many of the structures are 30 to 50 years old, and where much of the building's history may be lost. This poses many challenges to an the occupational health program.
How Does an Occupational Health Program Meet This Challenge?
Since 1990, HEHF has developed a change in philosophy of occupational health to meet the needs of the Hanford site. Traditionally, HEHF provided physical examinations to determine an individual's fitness for their work. Their work environment was also monitored through industrial hygiene services. The element these had in common was that they addressed the individual one-on-one. Each individual was looked upon as a separate entity with unique characteristics.
Over the last four years, HEHF has moved towards a public health approach to the delivery of occupational health services. Instead of viewing the site's population as 17,000 or 18,000 individual workers, the work force is viewed as groups of individuals with similar health or safety risks. For example, journeyman painters may have many risks in common, but have significantly different risks than office workers.
Prevention, the basis of occupational health, may be delivered more efficiently and cost effectively through a public health approach. By identifying groups of workers with common risks, increasingly effective risk management can be developed. For example, it is of relatively little value, but may be very expensive, to examine all employees on the site using the same physical examination. The risks of a 25-year-old office worker in an administrative building are going to be quite different from that of a 60-year-old electrician preparing a facility for demolition. These differences are even greater when considering gender.
HEHF has begun implementation of a public health philosophy through the use of targeted exams. Not all workers receive physical examinations, and for those that do, the examination is targeted at their specific job tasks, previous health history, age, and gender. In addition, HEHF is exploring the concept of Health Risk Management, where the risks to workers are analyzed using a sophisticated evaluation process, and appropriate services to mitigate those risks are identified and implemented. Based on this analysis, benefits in terms of health or productivity can be measured. This approach assists in identifying the most effective risk management measures to implement.
Service Development Benefits from Project Management
Like most businesses, HEHF recognizes the necessity of continually lowering costs while improving services. HEHF is a service organization, and has in the past made minimal use of project management tools. However, with the necessity to minimize the costs of ongoing services and the need to efficiently implement new services, HEHF has recognized the need for effective project management.
HEHF had been organized internally under a functional approach by profession. Physicians, nurses, psychologists, health promotion specialists, industrial hygienists, and chemists were all organized by profession and managed by someone of that profession. However, the services provided by HEHF required cross-functional activity on a regular basis. This resulted in confusion regarding who was in charge of various services, and some organizational dissonance in delivering those services. This also made it difficult for employees and customers to clearly understand the significance of the services provided by HEHF. Perception of very high cost services was one result.
In 1994, HEHF reorganized personnel around the product or service delivered, combining all employees involved in the delivery of a product line into a service delivery team. The organization charts in Figures 1 and 2 illustrate the difference between the two organizations.
Product line organization provides improved quality, cost, and timeliness of service delivery. It not only simplifies and improves productivity and cost tracking, but enables the efficient addition or elimination of services. Under a functional organization, a change in service level impacts several groups, and can therefore be extremely difficult to efficiently adjust human and other resource levels.
HEHF has a very interesting case study in the implementation of a new service under both the functional and product line organization. In 1993, HEHF initiated a pilot project to determine the demand for occupational urgent care services at the work site. Occupational urgent care is the treatment of minor job-related illnesses and injuries to help the worker maintain his or her health and return to the job site. The service was planned for expansion to two locations if the pilot project demonstrated adequate demand and benefit to site workers.
The pilot project was set up to determine the demand for on-site care for minor occupational injuries and illness. The referral source was limited to HEHF nursing personnel located in Health Service Centers around the site. No public notification or other advertising occurred during the pilot phase. The criteria for success were the number of visits and the cost per visit. The pilot project would be considered a success if a sufficient number of visits could be generated to keep one physician occupied full-time at a cost that approximated similar services at physician clinics.
The results of the pilot project were very positive. A clear demand for and benefit from this service were demonstrated. However, the internal development within the company was plagued with operational problems. The pilot project was initiated under the functionally organized company structure without using a disciplined project management approach.
Occupational urgent care is a service that involves three disciplines—physicians, nurses, and technicians and clerks. The professional group in charge of implementation was frustrated by their inability to control the time and availability of necessary personnel located in other groups. Employees outside of this professional group did not fully understand the service or their role in it. As a result, there were varying levels of anger, fear, confusion, and distrust among co-workers.
These problems resulted in the need to initiate a well-structured project to created a plan to implement occupational urgent care. Project management principles were used in the development of a business plan. The plan was completed in time to meet the commitment dates for starting the new service and maintain critical customer satisfaction. In addition, employees who had previously feared working in the new service were part of the implementation plan development and were ready to implement on the targeted date.
Simultaneous with the completion of the implementation plan and startup of the service, HEHF implemented the new product line organization structure. Nearly all employees providing occupational urgent care are managed as one team, and are operating effectively in a self-directed manner. Comparison of the development of a new service with a misaligned organization structure and without a structured project approach illustrates the operational problems that can be avoided with thoughtfulness and planning. Although the quality of service did not suffer under either approach, the stress on personnel was very high when using an unstructured approach.
Project management will be taking on an increasingly important role at HEHF. New services or modifications to existing services will be evaluated for feasibility using a consistent evaluation process. Even more importantly, as the company adjusts to its new organization structure, many new opportunities to modify operations will be presented. Each of these opportunities will be evaluated through the use of careful project planning and management to ensure the most rapid, effective, and least disruptive changes possible.
This is a new way of thinking for our organization, but one that will most certainly be adopted willingly, and one that is long overdue.
Sandra J. Matheson is president and CEO of Hanford Environmental Health Foundation, a contractor to the U.S. Department of Energy. She has 20 years of management and financial experience.
PM Network • March 1995