Managing change in healthcare information technology projects

the role of the project manager

Abstract

Over the last decade, most healthcare organizations have experienced major change and transformation. While this change could be attributed to a number of reasons, information technology induced change has been a major driver to the transformation initiatives seen in the health care industry. This paper elaborates on some key elements necessary for managing change and guiding the successful transition to the desired state using project management processes and techniques, including, leadership, governance, strategy, sound business acumen, communication planning, and other key project management competencies.

Information technology projects deliver new products and new software applications that dramatically changes the way business is conducted and impacts daily routine of the workforce. In the world of healthcare there have been very little tolerances for change and hospitals have historically had great resistance and fear of change. However, in order for hospitals to benefit there needs to be a mechanism for business and clinical transformation of processes to stimulate the adoption of innovation

Introduction

In healthcare, as in other industries, constant innovation in information technology brings expensive complex projects. In many cases, these new projects represent a major investment to the organization and significantly affect the way business is delivered. Implementing an electronic medical records system in a hospital or ambulatory care center wreaks havoc on the organization if they were not well prepared to address the consequences on the business, the staff, and patient care delivery.

To be successful in managing change, project managers have to understand the reasons for the change. Project managers need to have the leadership depth and sophistication to communicate the vision, maintain momentum, solve problems, and leverage both the soft and hard skills of management to bring to bear on the situation.

This paper focuses on managing organizational change using effective project management techniques, and is divided into the following sections: (1) impact of change, (2) resistance to change, (3) change agents, (4) leadership strategies to manage change, (5) the winning teams, and (6) healthcare applications, and the key success factors to effectively transform the organization and bring a turnaround.

Impact of Change

Change is not easy. People love familiarity and pattern and hate change with passion. It is only human nature. Many big organizations are living in an environment of constant change, it is the only way they can keep up with the market and continue to innovate and prosper. However, recent research has shown that change at work induce stress reaction in the brain similar to the fight and flight reaction people experience when they face extreme danger. Humans are creatures of habit, we feel comfortable in our routine and do not find it easy to let go of the known and venture into the unknown and the uncertain.

Resistance to change and naysayers

Statistics show that in an average organization 80% of the people will accept change and go with the flow, from the remaining 20%; 10% are just skeptics who usually come on board late in the process, and the remaining 10% are the diehard resisters, who will outlandishly try to kill change due to political or personality issues or just because they are so entrenched in what they do that they cannot see another way. These resisters have a negative impact on the rest of the organization and lower the morale of others. They may also develop a cohort of underground resistance and followers who may slow or sabotage the change process. It is recommended that these people be asked to leave. For a change initiative to be successful and bring around the desired transformation, resisters have to move to different teams not involved in the change initiative, or leave the company completely. It is better for both parties (Welch, 2005).

Change Agents

These are the supports of change, the get-on-with-it types, those who are excited about change and are willing to take risks. Project managers need to surround themselves with good change agents. Change agents are people who understand the business/clinical side of the organization, have a passion for information technology, and thrive on change, creativity, and innovation. These hybrid types of people play a pivotal role in implementing change, leading change teams, solving problems, escalating critical issues, and tackling persistent ones. Change agents are the right arm of the project manager; they encourage team members, motivate the staff, field difficult questions and concerns, help in dissemination of information, and serve as a conduit between upper management and the staff.

Leadership Strategies to Manage Change

John Kotter, Professor of Business and Management at Harvard Business School, a pioneer in the field of change management and an author of few bestseller books, developed an eight step model for a change program that could lead to a comprehensive organizational transformation and success under any condition, the eight step model is follows (Kotter, 2005):

  1. Set the stage:
    1. Develop an awareness of the need to change in the organization and the need for and immediate action – create a sense of urgency
    2. Select change leaders and put together guiding teams of change agents, these are the catalysts of change (the steering committee)
  2. Make the decision:
    3. Decide on what needs to change and change to what form, i.e. have a vision and a strategy to execute the vision
  3. Make it happen:
    4. Communicate frequently and profusely to promote understanding of the initiatives and obtain a buy-in into the realities of executing the change plans
    5. Empower others in the organization to act on the change plans – remove barriers and obstacles from the way and enable the change teams to act swiftly and energetically
    6. Produce quick wins – to gain momentum and bring visibility and credibility to the process
    7. Stay focused – don’t get distracted by politics or minutia, keep pressing-on relentlessly
  4. Make it stay:
    8. Create, foster, and celebrate the new culture to sustain the new change in organizational behavior and make it the new tradition.

These eight process groups give a methodology-like approach to managing change and bringing about sustainable transformation. However, it is worth noting that it is not as simple as it might appear on paper. Many other facilitative processes are needed to work hand in hand with this eight step process to make it a success. These facilitative processes may include, a general sense of common-sense and realistic understanding of the external and internal environment, a strong emphasis on building and maintaining relationships and building bridges across teams, departments, and silos; a very elaborate and rigorous communication plan, with a high dose of patience, resilience, and perseverance.

Change is difficult and emotional – it reaches the core of our being. Emotional and social intelligence will go a long way in supporting the change initiative. Because of this, it is generally acknowledged and recommended to use a reputable consulting company to support and assist the change agents / the change leaders through the change process - to help navigate the uncharted waters of the future state.

The Winning Teams

The change guiding teams, lead by change leaders/change agents also known as change catalysts, need to have the right chemistry and characteristics to be successful. Jack Welch in his book “Winning” points to five key success factors needed to transform the organization, and bring about the desired change, (Welch, 2005). Jack labels these success factors, the 4-E and 1-P Framework to building winning teams, Jack believes this framework is applicable across industries and borders:

The 4-E and 1-P Framework for Successful Teams:

  1. Energy – positive energy, action, enthusiasm, and drive.
  2. Energizing others – inspiring others
  3. Edge – the courage to make tough yes/no decisions and take risks, i.e. effective leadership
  4. Execution – the ability to get things done
  5. Passion – deep, heartfelt, authentic excitement about work, change, and renewal

This framework is one of many others available for guidance in building successful teams; it is one of the most comprehensive and straightforward models. Patrick Lencioni also has a great reference model for building functional teams that focuses on building trust and accountability (Lencioni, 2002). From Jack’s five elements above, I’m personally fond-of “execution” without which nothing can actually happen, it is the crux of executive ability and the core driver of transformation and success (Bossidy, 2002).

Putting Things in Perspective – Healthcare Applications

It is a well known fact that projects bring new products to organizations. In the case of information technology the new products are software applications that dramatically changes the way business is conducted on a daily basis and impact daily routines and work habits of employees. In the world of healthcare tolerance, for change is miniscule and, historically, hospitals have had a hard time adjusting to change and innovation and have shown great resistance and fear of change. However, in order for hospitals to keep in step with the business and consumers’ demands and benefit from new technologies, they need to embrace change and approach information technology with an open mind. To achieve this state, there needs to be a mechanism in place for business and clinical transformation of processes to stimulate the adoption of innovation in healthcare information technology by clinicians, therapists, nurses, and physicians (Brady & Hassett, 2000; Larson, 2000). There are few good success stories and lessons learned from early adopters that can benefit the healthcare industry at large.

While managing change is a part of every successful program, it is the responsibility of the program manager to ensure adequate processes are in place to involve various organizational members and prepare them for the change ahead to build understanding and secure buy-in at all levels. Project management methodology and other facilitative processes could be used to successfully manage change and mitigate the risk of innovation adoption. Using project management methodology, the project/program manager is able to create a stakeholder analysis matrix, a governance board, a communication plan, a risk management plan, a status reporting dashboard, and a change management plan. The good use of these tools within the context of relationship building and a solid feedback loop could prove very valuable to the organization undergoing change and transformation.

Key success factors at the leadership level in healthcare organizations

  1. Setting vision and strategy roadmap
  2. Formation of governance board to set direction, to prioritize work, and to allocate resources
  3. Designate an executive sponsor, departmental champions, and program manager
  4. Define reporting requirements for status reporting in order to keep projects moving forward
  5. Manage users’ expectations; prepare them for casualties, stress, and general sense of ambiguity

Key success factors at the program level

  1. Communication – clear and frequent dissemination of information
  2. Building a strong project leadership team/steering team and other action/functional teams
  3. Providing education and training on the new changes – workflow and technology
  4. Forming integrated problem-solving teams to address critical and complex issues
  5. Empowering staff and end-users to change things, by removing barriers and obstacles
  6. Adoption - make the change stick by reinforcement, until old traditions are replaced with new
  7. Frequently celebrate success by honoring contributors to keep the motivation and momentum
  8. Monitor and measure key indicators – using a dashboard to report progress and benchmarks
  9. Involve those affected by the change in decision-making – e.g. choice of computer carts, COW
  10. Other creative actions e.g. monthly prizes for high performing teams, provide snacks & drinks

Working with Physicians – Physicians Adoption

Most physicians are non-salaried, non-hospital employees; many have patients in different hospitals and different health systems that use different technologies from different vendors which makes the situation more complex. Having a well defined clinical adoption methodology for the continued use of new information technology tools is key to the success of the transformation effort, below are some ideas:

  1. Communicate value and benefits of the change in terms of patient care and patient safety
  2. Involve physician leaders in the process early on
  3. Provide multi-channel learning and training opportunities including web, CBT, labs, and other
  4. Be available to answer questions and provide quick fixed
  5. Have a process to handle enhancements requests and other unusual developments

Training and Education – hard-won lessons learned from previous engagements in HIT projects

Organization leaders need to foster a learning culture within the context of live long learning organizations (Senge, 1990) where continuous learning is a core element of the culture supporting change initiatives, business improvement, and transformation.

  1. Provide for different shifts (around the clock) instructor-lead training classes
  2. Provide for contemporary models of training – CBT and web enabled training
  3. 24 x 7 open computer lab for practice available for all shift and on weekends
  4. On the job/real time training when rolling out new technology
  5. Provide cheat-sheets/with summaries of steps easy to fit in pocket or stick by the computer
  6. Develop colorful booklets – easy to carry and store in a pocket
  7. Have a hard copy short manual with the key facts and how-to tips
  8. Well prepared and equipped training rooms – convenient seats and handy printers
  9. Train-the Trainer program – start early in the process and give enough time to practice
  10. Recruit super-user early and keep them involved and motivated
  11. Be prepared with the business process maps and new workflows
  12. Have a day-in-the-life scenario prepared for exercises and simulation
  13. Walk them through a patient flow in the system several times until in sticks
  14. Answer questions in details, especially when it relates to the chart, where will the chart be? How can we access information? What is the new patient chart? What can we print?
  15. Prepare the users to some of the challenges and frustrations they will face in the early stages of rollout.

In conclusion, to be successful in managing change in healthcare organizations, program and project managers need to adhere to some key fundamental practices in managing change and adopt a well rounded change management strategy along the following lines:

  1. Governance structure that aligns business leaders with clinical leaders
  2. A relentless focus on business processes design and clear mapping of workflow
  3. Due diligence for a thorough organizational and business impact analysis
  4. Early involvement of clinicians at various levels (starting with requirements and design)
  5. Constantly communicate the vision, loudly and clearly, and show commitment to stay the course
  6. Have a strong, ongoing program for training and education – customized to different needs
  7. Have a well thought-of communication plan that takes feedback into the loop, and act on it
  8. Have a well structures maintenance and support program including a 24 x 7 Help Desk
  9. Regular reporting using dashboards with simple statistics to grab people’s attention
  10. Select a handful of measurement criteria for benchmarking and system evaluation

These ten strategies and tactics used by healthcare organizations appear to have a significant impact on the engagement and adoption of the new changes and technologies by various clinicians.

References

Brady, M. & Hassett, M. (Editors). (2000) Clinical Informatics. HIMSS Guidebook Series. Chicago, IL :HIMSS.

Bossidy, L., & Charan, R. (2002) Execution: The Discipline of Getting Things Done. New York, NY: Crown Business.

Collins, J. (2001). From Good to Great – Why Some Companies Make the Leap…and Others Don’t. New York, NY: Harper Business Press:

Cooke, H. & Tate, K. (2005). The McGraw-Hill 36-Hour Project Management Course. New York, NY: The McGraw-Hill Company

Deluca, J. & Enmark, R. (2002). The CEO’s Guide to Health Care Information Systems. 2nd Ed. San Francisco, CA: Jossey-Bass,A Wiley Company:

Drucker, P. (1992). Managing for the Future – 1990s and Beyond. New York, NY: Dutton Press.

Glasser, J. (2002). The Strategic Application of Information Technology in Health Care Organizations. 2nd Ed. San Francisco, CA: Jossey-Bass, a Wiley Company.

Goldsmith, J. (2003). Digital Medicine -- Implications for Healthcare Leaders. ACHE Management Series. Chicago, IL: Health Administration Press.

Kerzner, H. (2001). Project Management – A Systems Approach to Planning, Scheduling, and Controlling. 7th Ed. New York, NY: Wiley & Sons.

Kottor, J. and Rathgeber, H. (2005). Our Iceberg is Melting. New York, NY: St. Martin Press.

Larson, J.A. (Editor). (2000). Management Engineering. HIMSS Guidebook Series. Chicago, IL: HIMSS

Lencioni, P. (2002). The Five Dysfunctions of a Team: a Leadership Fable. San Francisco, CA: Jossey-Bass.

PMI, (2004). PMBOK ® Guide: A Guide to the Project Management Body of Knowledge. 3rd Ed. Newtown Square, Pennsylvania, USA: Project Management Institute, Inc.

PMI, (2003). The PMI Compendium of Project Management Practices. Newtown Square, Pennsylvania, USA: Project Management Institute, Inc.

PMI. (2002). Project Manager Competency Development (PMCD) Framework. Newtown Square, Pennsylvania, USA: Project Management Institute, Inc.

Rad, P.F. & Levin, G. (2004). The Advanced Project Management Office. CRC Press: Boca Raton, FL

Senge, P. (1990). The Fifth Discipline – The Art & Practice of the Learning Organization. New York, NY:Doubleday Currency.

Welch, J. & Byrne, J. (2001). Jack: Straight from the Gut. New York, NY: Warner Books.

Welch J, & Welch, S. (2005). Winning. New York, NY: HarperCollins.

Appendix A

Managing Change in Program Management – Best Fit Model

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Appendix B:

Managing Change – A multi-tier Action Plan / Checklist for the Project Manager in Healthcare Information Technology:

  1. Plan for Change Manaement / have a well articulated short term and a long term goals
  2. Create a Communication Plan for regular dissimination of information
  3. Provide a rigoreous program for training and education
  4. Building a strong team / provide for empowerment / foster partnerships with the users
  5. Have a clear and crisp BPM component
  6. Plan for a Command Center operations during Go-Live
  7. Work in partnership with the executive sponsor and champion / set & manage expectations
  8. Provide on the job / ontime (just in time) training / do formal knowledge transfer sessions
  9. Work with human resources to review competency requirements and job descriptions
  10. Celebrating success & achievements with the team

© 2007, Laura Aziz, PhD, PMP, RN
Originally published as a part of 2007 PMI Global Congress Proceedings – Atlanta, GA, USA

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