The symbiosis of project management and change management during healthcare integrated planning
a case study of Ontario's healthcare system
Sault Ste. Marie, ON, Canada
Henry Hornstein, PhD
Sault Ste. Marie, ON, Canada
The purpose of this qualitative case study was to discover project management best practices that could be applied when engaged in integrated healthcare planning. This study analyzed multiple sources of data, which included 10 in depth interviews with project managers working within Ontario’s provincial, regional, and local levels of healthcare. The sample had experience with A Guide to the Project Management Body of Knowledge (PMBOK® Guide), and the majority maintained their Project Management Professional (PMP)® designation. In addition, 33 provincial documents, depicting project and change management processes, were further analyzed. The findings identified three necessary factors for project management success when embarking on system changes: (a) a required competency in project management methodology, (b) an articulation of project benefits, supported through data or evidence-based research, and (c) the need to apply change management strategies early in the project lifecycle. This case study addresses the need to identify project management success factors that complement the facets of change management as required for effective integration within systematic healthcare planning.
Keywords: project management; healthcare integration; change management; healthcare systems; systems planning
The economic conditions of the 21st century have led organizations toward downsizing, a lack of in-house expertise, and agency restructuring (Soni, 2004). As a result, retooling strategies are pressuring organizations to integrate, merge, acquire, downsize, or close their doors. In the province of Ontario, Canada, healthcare integration has largely been recognized as a necessary process for enhancing patient delivery and responding to fiscal restraints. This is best reflected in Ontario’s 14 Local Health Integration Networks (LHINs), which were developed in 2006 (Jiwani & Fleury, 2011). The goal of establishing these networks was to drive coordination and integration of services within health and social systems. Their authority rests within their region as each LHIN is tasked with local planning, community engagements, funding, and facilitating integrations (Jiwani & Fleury, 2011). As a result, managing change has become a prevalent issue within healthcare organizations.
Project managers cannot ignore the impact of change on the healthcare sector during integrated planning. Golden (2006) identifies a change management framework for healthcare organizations, considering the complexity of processes and variables within healthcare. Drucker (1993) claims the most complex form of organizations is found in healthcare. This is due to the number of stakeholders, multiple missions, decision makers with professional autonomy, and lack of information in managing a change process (Golden, 2006). There is no question that effective organizational change is in itself a project (Englund, Graham, & Dinsmore, 2003). Organizational change and project management share four key traits. Both involve a conscious process, an identified leader, specified goals, and a clear timeline (Englund et al., 2003).
Change management within health systems aims to link change processes with implemented outcomes (Casebeer & Hannah, 1998). Due to fiscal restraints in the 21st century, there is no question that healthcare organizations are being challenged to evaluate their current processes, in light of efficiency and economies of scale. VanDeusen Lukas et al. (2007) analyzed organizational transformation among 12 health service providers and discovered five elements necessary for change: impetus to transform based on external pressure; a commitment to quality at the executive level; engaging staff through improvement initiatives; the alignment of goals through their resource allocation at all organizational levels; and integration. However, implementing the change process required a commitment to the stages of change. Kotter (1995) discussed eight stages of change, yet Golden (2006) worked toward applying four stages of change for healthcare organizations. This research examined literature directed at change management strategies for the healthcare setting.
Managing projects has been practiced for thousands of years; however, project management as a discipline is relatively new to the field of research. Project management has evolved into a profession (Kenny, 2003), which has captured the attention of most organizations in the 21st century. An international standard for project management methodologies is published by PMI. It is A Guide to the Project Management Body of Knowledge (PMBOK® Guide) (Project Management Institute, 2008), which specifies 42 project processes that management should consider. They include initiation, planning, execution, controlling and monitoring, and closing. Global attention has been sparked due to the realized return on investment, which senior managers have observed, when project management practices have been implemented (Kwak & Ibbs, 2000). Most recently, the gravity of project management in the medical field has given rise to the application of a project approach when managing the infrastructure of healthcare and patient needs (Sa Couto, 2008).
Fiscal constraints are forcing healthcare organizations around the globe to utilize change processes (Casebeer & Hannah, 1998). In particular, the construct of healthcare integration has gained attention over the past two decades, thanks to the seminal work of Stephen Shortell’s introduction to an organized delivery system (ODS) within healthcare. The reformation of healthcare has been viewed through ODS; however, the path to achieve an ODS is through effective integration (Shortell, Gillies, Anderson, Mitchell, & Morgan, 1993). Shortell et al. (1993) offer mitigation strategies for overcoming barriers to integration. Integrated models best support superior organizational performance, complimented by strict quality improvement initiatives (Dey & Hariharan, 2006). Dey and Hariharan (2006) develop a logical framework for healthcare systems, which boasts uniformity and is rooted in the integration of clinical and non-clinical practices; yet, there fails to exist practical guidance on the application of integration within health systems (Suter, Oelke, Adair, & Armitage, 2009). This study aimed to address this gap by identifying success factors that blend both project and change management for integrated healthcare exercises.
The need for a project management framework that compliments the facets of change management is required when exercising integrated healthcare processes because there is no alignment of change management and project management for the purposes of healthcare integration initiatives. The perceived project management best practices were generally defined as the methodology a project team must follow in order to promote integrated healthcare changes. This study complemented the seminal work of Shortell et al. (1993) and also supports the reality that an integrated healthcare system requires further efforts within Canada (Leatt, Pink, & Guerriere, 2000; VanDeusen Lukas et al., 2007).
Healthcare integration must be treated as a project management initiative, which leads to system changes. However, any change initiative involving integrations requires a common convergence of objectives that satisfy various stakeholders (Chreim, Williams, Janz, & Dastmalchian, 2010). Aptly put, “the nature of project management is change” (Griffith-Cooper & King, 2007, p. 14). There is no question that the PMBOK® Guide’s Knowledge Areas focus on the control element of change requests to the project; however, the areas fail to address the human components related to change (Griffith-Cooper & King, 2007). A study conducted by King and Peterson (2007) noted the importance of integrating change leaders and stakeholder engagements into the project planning process. Projects related to change have experienced high failure rates and as a result, academic interest has shifted to better understand the complexities associated with transformational change (Burnes, 2005).
Background of the Study and Research Questions
Managing change through project management processes has gained recognition over the past decade. Kumpf and Wittelsberger (2005) indicated that formal project management has been commonly found in the information technology (IT) segment of healthcare; however, healthcare projects outside of IT also require a formal system of managing projects, due to the collective impact of systems, processes, and people. A plethora of research can be identified on the application of project management within healthcare IT; yet, minimal attention has been given to utilizing project management strategies in other facets of healthcare planning. As a result, project costs, timelines, and scope creep have the potential to escalate when formal project management processes are not adopted. Projects related to change have experienced high failure rates and as a result, academic interest has shifted to better understand the complexities associated with transformational change (Burnes, 2005).
The importance of this study was rooted in the reality that many restructuring strategies within healthcare either fail to be sustainable or are less effective than anticipated (Shediac-Rizkallah & Bone, 1998). The relevance of this study to the field of organization and management was planted in reality that many managers are being held accountable to perform with fewer resources. However, many lack the tools and techniques required to perform such a task. This study aims to offer clear guidelines for healthcare professionals in accomplishing integrated tasks, while managing stakeholder anxiety.
The approach that was used within this qualitative research was a case study design rooted in an interpretivist approach. The unit case consisted of Ontario’s healthcare system, whereby a cross-sectional group of 10 healthcare project managers from the provincial, regional, and local levels were interviewed in depth, with an accompanying analysis of 33 archival documents. The benefit of this approach was to gain additional insights into identifying gaps or better understand implementation strategies (Crowe et al., 2011).
This qualitative research study blended the theories of both change and project management processes to discover project management success factors when applying project management approaches to healthcare integration projects. The research questions that shape this study are as follows:
- What are project management success factors and best practices during healthcare integrated changes?
- How might project teams consider using approaches from organizational change theory in project management?
- To what extent have project management teams integrated change management with project management techniques?
Integrated healthcare requires further attention within Canada, considering the plethora of disconnected silos among the health system (Leatt, Pink, & Guerriere, 2000). Most people would agree that the 21st century environment is demanding organizations to perform with fewer resources. In particular, fiscal restraints are forcing healthcare organizations to utilize change processes around the globe (Casebeer & Hannah, 1998). As a result, retooling strategies are pressuring organizations to integrate, merge, acquire, downsize, or close their doors. Achieving an integrated healthcare system requires strong organizational change and project management skills.
Organizational change, with the attempt to integrate a healthcare system, is not uncommon. However, any change initiative involving integrations requires a common convergence of objectives that satisfy various stakeholders (Chreim et al., 2010).
Project Management Within Healthcare
With increased fiscal restraints, integration opportunities, and a growing population, project management practices are being adopted. One study recognized that the fastest growing age group in Canada and the United States is senior citizens (Gale, 2012). In response to this, an effort was initiated to implement a senior friendly emergency facility at Mount Sinai School of Medicine in New York, New York (Gale, 2012). Similarly, the Calgary Health Region in Calgary, Canada hired a project team of healthcare architects to better design hospitals in an effort to reflect a family-centered care facility, as opposed to the traditional institutional resemblance (Buchanan, 2008). Within the public sector, government organizations are embracing project strategies such as earned value management (EVM) to better measure project performance (Kwak & Anbari, 2011). EVM offers project managers the ability to identify early signals of poor performance with greater lead time in mitigations, resulting in greater resource allocation and planning (Anbari, 2003). Claudio (2005) describes a joint partnership between the PMI’s Healthcare Project Management Specific Interest Group and the National Association for Public Health Information Technology (NAPHIT). In the summer of 2005, NAPHIT held two project management sessions and clearly stated that the responsibility of healthcare managers lies in demonstrating project management practices to healthcare funders (Claudio, 2005).
Kumpf and Wittelsberger (2005) report on a study in which the AMERIGROUP Corporation, which provides healthcare services through various health maintenance organizations, was assessed on its project management practices. Initially, it was discovered that AMERIGROUP managed healthcare projects with undefined scope, unpredictable results, and a failure to identify required resources that led to scheduling concerns (Kumpf & Wittelsberger, 2005). In an effort to address these issues, an external consulting company was engaged. Twenty AMERIGROUP stakeholders were interviewed. The data reflected a positive perception of project management with highly motivated individuals. In addition, there was no standard project management planning process in place, ambiguity surrounding the project management office, lack of roles and responsibilities, and failure to develop the skill set of project managers. Six recommendations were provided to address these concerns. These included the development of a framework for project management processes, implementation of project management tools, development of project management job descriptions, design and implementation of a project management function, identification of a plan to further the skill set in project management, and identification of coaching and mentorship opportunities for project managers (Kumpf & Wittelsberger, 2005). AMERIGROUP Corporation instituted these recommendations. The lessons learned were identified and summarized in Table 1.
|Successes in Implementing Project Management||Challenges in Implementing Project Management|
|General acceptance of a formal project management process.||Organizational culture struggled to rapidly embrace an enterprise software tool.|
|Development of project manager roles, project sponsors, and executive resources.||Project support office was reorganized, which led to a decline in support for utilizing a project management methodology.|
|Project planning tools adopted to engage project managers and teams.||Creating consistency for all projects through the utilization of charters, work breakdown structures, issue logs, communication plans, risk management plans, and decision logs.|
|Improved projections on budget and schedules.||On occasion, prior project management behaviors are reverted to when project managers question the return on project management investment.|
|Continuity of understandings between project objectives and plans.|
|Leadership recognition in implementing contractual acquisitions.|
|Comprehensive project methodology adopted by the information technology department to enhance and convert major systems.|
Table 1: AMERIGROUP Corporation’s project management lessons learned.
AMERIGROUP must be commended on the advanced commitments in responding to recommendations provided by the consultants. Certainly their successes stemmed from developing a project management plan with specialized attention on identifying budgetary and scheduling impacts. Arguably, the challenges to implementation were rooted in staff resistance, which led to the difficulty of adhering to the new project management framework for the organization.
A Synthesis of Healthcare Integration
Integrative healthcare has commonly been characterized as a multidisciplinary approach, otherwise known as integrative medicine (Bell et al., 2002); however, the definition of integration has been largely debated (Atun, Jongh, Secci, Ohiri, & Adeyi, 2010). According to Lehman (2008), the concept of integration is a common term used when sorting through the literature on change management. Integration is a transformational strategy under which intra-organizational levels engage in multifaceted functions (VanDeusen Lukas et al., 2007). In a similar manner, projects are in fact change initiatives (Wideman, 1995). This is largely due to the fact that integration enhances coordinated care, which has been identified and characterized as a series of fragmented services (Ogles, Trout, Gillespie, & Penkert, 1998). Such examples include a centralized intake system for patients, care management, and coordinated teams (Ogles et al., 1998). The genesis of integration models was a result of such fragmentations, in which health services are centered around functions, as opposed to the direct needs of patients. As a result, functional units created territorial silos within a health system that inadvertently ignore the quality of experiences of the patient, thus establishing low satisfaction ratings from patients and increased costs (Leatt et al., 2000).
The construct of healthcare integration has gained attention over the past two decades thanks to the seminal work of Stephen Shortell. The reformation of healthcare has been viewed through ODS; however, the path to achieve an ODS is through effective integration (Shortell, et al., 1993). Shortell et al. (1993) offer mitigation strategies to overcoming their identified eight major barriers to integration, as depicted in Table 2.
|Major Integration Barrier||Mitigation Strategy|
|A lack of understanding toward the new core business.||Ensure that organizational units understand how they fit into the new integrated strategy, by linking them to financial plans and tactics.|
|Failure to change the hospital paradigm.||Place emphasis on key success factors, such as capitation-based systems of pay and increased primary care skill set; reward incentives for the longevity of patient wellness; and utilize information systems for communicating data to external stakeholders.|
|Failure to persuade a ”cash cow” system to accept an integrated strategy.||Hospitals are generally treated as autonomous institutions. However, emphasis needs to be on the effectiveness of systems integration that leads to performance at a regional level.|
|Lack of board understanding on the new integrated environment.||Governance should receive regular education on the new integrated strategy. Replacement of board members should focus on individuals from outside the healthcare environment and from various levels or units in the system.|
|Undefined roles and responsibilities.||Ensure that individuals who have been chosen to fulfill integration objectives have defined roles and are held accountable. In addition, management structures from within various organizations should better reflect their role in directing system-wide planning and execution.|
|Management’s inability to implement a managed care strategy.||Create practical primary care groups, backed by specialists and supported through a regional information system in managing patients.|
|Failure to execute integration strategy.||Integration strategy must be communicated as achievable, while supporting employees with training opportunities to further their management and interpersonal skills in maintaining accountability.|
|Strategic misalignment.||Alignment is gained when stakeholders better understand how the goals of the integration strategy, importance, and what requirements are needed to achieve success.|
Table 2: Eight integration barriers in an organized delivery health system.
Integrated healthcare models have evolved to focus on the continuum of care and how health services are coordinated to better accommodate the continuum (Leatt et al., 2000). Integrated models best support superior organizational performance, complemented by strict quality improvement initiatives (Dey & Hariharan, 2006). In other words, integration will increase the performance of an organization when quality improvement is a priority to the organization(s). Even though Dey and Hariharan (2006) developed a logical framework for healthcare systems, which boasts uniformity and is rooted in the integration of clinical and non-clinical practices, there fails to exist practical guidance on the application of integration within health systems (Suter, Oelke, Adair, & Armitage, 2009).
The literature discusses the evolution of integrations that have existed within healthcare. In the latter half of the 20th century, vertical and horizontal integrations were popularized. Burns and Pauly (2002) note that vertical integrations are exercised through the acquisition of primary care physicians; physician alliances are established between hospitals and organizations where services are managed and where an established organizational culture on the health maintenance of a patient is created. On the other hand, horizontal integrations exist when mergers and strategic alliances lead to the development of a multi-hospital system (Burns & Pauly, 2002). Toward the end of the 20th century, integrated delivery systems (IDS) were popularized, especially in the healthcare industry (Longest, 1998). IDS offer coordinated delivery of services across the continuum of care, such that organizations become structurally integrated with others to provide an array of services to customers (Longest, 1998). Regardless of the approach, the geneses of integration activities were an attempt to address the fact that services were fragmented and uncoordinated (Levesque, Prochaska, & Prochaska, 1999). In response to such barriers, integration is driven to combat barriers associated with sharing information, duplication of services, competing for resources, cycle time, and a holistic treatment approach that increases patient satisfaction and wellness (Levesque et al., 1999). One must be careful not to attribute integration as a means for cost savings, but rather focus on the barriers people face in receiving health services. Burns and Pauly (2002) clearly note that economies of scale and cost savings are minimally achieved during hospital mergers. However, clinical consolidations during horizontal integrations will lead to some cost savings, yet are challenged by the hurdles of politics and geography in attempting to address fragmentations.
When leading integrations, it is important to identify what services should be under scrutiny for integration. Traditional views suggest that hospitals should be responsible for acute and sub-acute care (Lega, 2007). Integration efforts suggested that many services can be offered in the community by general practitioners or other health authorities rather than being restricted to hospitals. Such changes have an impact on the governance of health organizations. Lega (2007) points out that governance models are challenged in the face of integrations, largely due to the voices of external stakeholders driving the need for integration. Such external stakeholders include the dominant political ideology, communities, employed professionals, and lobby groups (Lega, 2007). This is further demonstrated in a change management study conducted on 10 organizations, where it was found that almost all pointed at the political environment, within government or external relations, leading companies to implement significant changes (Quinn, 1978). However, the effectiveness of organizational change is contingent on the notion of readiness, which encompasses two messages: demonstrating to stakeholders a depiction of the current state versus the end desired state, and the competencies associated with individual and collective efforts to affect the change (Armenakis, Harris, & Mossholder, 1993). Thus, a driving force behind integration is the collective voices of external stakeholders, which advocate for a new service system that clearly mitigates identified fragmentations and lack of coordination in the new service delivery system.
This study utilized a case study methodology. Multiple sources of data were analyzed followed by triangulation of findings such as any combination of documents, archives, and interviews (Patton, 1999). A purposeful sampling was conducted on 10 project managers from various healthcare settings in Ontario. In addition, criterion sampling was utilized, since it is very appropriate for the purposes of qualitative research (Miles & Huberman, 1994). For the purposes of this report, interviews ranging from 30 minutes to 75 minutes in length were held with project managers who have experience with applying project management techniques during integrated healthcare projects.
Selection was based on criterion sampling (Miles & Huberman, 1994) for additional quality assurance. First it was expected that participants would have a university degree. It is assumed that the participants working within the project management field on the provincial, regional, or local levels would hold a minimum of a university degree and possibly a graduate degree. This demonstrated that the sample population was educated and was positioned in roles as decision makers. Secondly, in an effort to better understand the perceived success factors associated with integrated healthcare projects, it was expected that the selected sample were individuals who worked within the healthcare sector with two or more years of experience in leading or participating in integration efforts,. Finally, participants were selected for their project management experience, as participants had their Project Management Professional (PMP)® designation or experience with direct leading or participating in project management roles.
The unit case was Ontario’s healthcare system. A cross-sectional group of 10 healthcare project managers was interviewed through semi-structured questions. The benefit of this approach was to gain additional insights into identifying gaps or better understand implementation strategies (Crowe et al., 2011). Each participant was individually interviewed through semi-structured questions via the use of the Ontario Telemedicine Network’s videoconferencing system or teleconference. The videoconferencing system was arranged in a convenient location for each participant and was held in a private room. This format created a face-to-face environment with each of the selected participants.
The methodology for this study was appropriate, considering Yin (2009) indicated that case studies focus on a particular phenomenon within a real-life context. In addition, the goal of a case study is to explain, describe, illustrate, and/or enlighten. More specifically, an intrinsic case study approach (Stake, 1995) was used due to the researcher’s intrinsic interest in understanding project management success factors during integrated changes in healthcare.
According to Yin (2009), there are four analytic techniques that can be utilized in case-study research. Pattern matching, the first technique, identifies specific patterns throughout the acquired data. Second, explanation building is predominantly used in explanatory case studies (i.e., identified patterns are used to support the phenomenon). Third, time-series analysis examines the identified patterns in light of a theoretically significant trend or a rival trend. Finally, logic models are used to examine chains of events over a period of time with the goal of matching theoretical predicted events with observed events. For the purposes of this research, the techniques of pattern matching and structural coding (Saldaña, 2009) were employed.
Validity and Reliability
Pattern matching (Yin, 2009) increases the internal validity of a case study. Furthermore, Yin (2010) identifies three criteria for credibility and trustworthiness: transparency, methodic approach and adherence to evidence. Transparency was achieved through careful documentation of the research procedures. A methodic approach required following empirical research procedures and identifying biases (Yin, 2010). Finally, evidence of collected and analyzed data was rooted in any conclusions made by the researcher (Yin, 2010). Credibility and trustworthiness of the research was strong, given that, to ensure accuracy, each participant checked all transcripts. The credibility of qualitative studies was best characterized by “truth, value, applicability, consistency, neutrality, dependability, and/or credibility of interpretations and conclusions (Onwuegbuzie & Leech, 2007, p. 234).
The process for collecting the data resulted in nearly 130 pages of transcripts, which represented over 68,000 words. In addition, 33 archival documents were collected as tools and techniques for driving project and change management across the province.
A three-fold synthesized process was undertaken to analyze the raw data for the purposes of uncovering themes. The goal of each round of coding was to further highlight and filter relevant features of the data for the purposes of generating concepts, categories, themes, and/or theory development (Saldaña, 2009). The first coding cycle adopted the elemental method of structural coding. Structural Coding utilizes conceptual phrases or content-based applications that represents a topical inquiry of data, which can both be coded and categorized (Saldaña, 2009). This method was appropriate for the case study’s first cycle of coding, since it involved interviewing multiple participants through semi-structured interviews (Saldaña, 2009). The structural coding process resulted in the assignment of 83 initial codes. The second process utilized a frequency analysis for a further synthesis of the similarities and dichotomies between identified codes in the transcripts and archival documents. The greatest element of dichotomy was identified between the phenomenon of participants and those archival documents that were characterized by specific processes. The third cycle of coding adopted the meta-analysis process of pattern coding, as this revealed explanatory characteristics of the data, leading to the emergence of themes through meta-level codes (Miles & Huberman, 1994). This process summarized the first cycle of codes and grouped them into smaller sets; thus, the 83 codes were grouped into three thematic elements and brought the total amount of codes to 32.
Research Questions as Applied to the Data Analysis
As stated earlier, the constructs of project management, change management, and integration were the central focus of this study.
The Data Results in Addressing Research Question 1
Through an analysis of the interview questions and archival documents related to the research question, it was discovered that project management success was contingent on enabling expertise. Even though there was an identified gap in blending both project and change management principles, project management success and best practices are not reliant on applying change theory principles.
Theme: Project success is enabled through competency. Identifying the thematic component of competency was derived through the interview questions. The PMP® designation is one of the most widely recognized credentials in the field of project management today. Over half of the participants had earned a PMP designation, yet 60% of respondents indicated that a PMP designation was not necessarily an enabler for project success. Participant A1, when asked if the PMP designation enables project success, replied:
I don’t know if the designation makes you a better project manager. I think you need a certain skill set to be able to do it. So I think you know if you come with that skill set I think you will be fairly well equipped.
When participant B5 was asked to weigh the importance of experience versus the PMP designation she stated:
I certainly think the PMP designation is important. It certainly gives you that foundation. Just because you have experience doesn’t mean that you are doing it correctly; not that there is a right and wrong way, but having experience you get the knowledge gain. But the foundation, some of the elements of project management I still think it is critical to know at a basic level.
Participant B4 indicated that project management experience was a greater enabler than the designation. More specifically, he stated, “Experience is key as well. Others that come from organizations where you know there is a mature seasoned project manager and the buy-in to structure project management, that is definitely an enabler.”
In analysis of the archival documents, seven project management templates were identified as providing opportunities to document the skill set required. A project-planning template, provided by participant A5, required a listing of the project team members’ roles, responsibilities, and the identified skill set that each member brought to the project team. Participant A1 utilized a change management plan in conjunction with a project charter. The document identified that when projects are supported by change management teams, it is important to identify strong leaders with the right mix of experience and skills. Participant B4 offered a project evaluation template that was completed at the closing phase of a project. The project team was required to compare and contrast the identified project skill set in the initiation phase of a project, against unidentified or misaligned skill sets that were noted during the course of the project.
It was clearly evident in both the transcripts and archival documents that project management competencies gained through experience and training were considered enablers of project success. The PMP designation provides the foundation for structuring a project through its lifecycle.
The Data Results in Addressing Research Question 2
The second research question focuses more on change theory and what participants identified as key enablers of initiating change through their projects. Upon analyzing the data, a key theme was revealed as a dominant approach in driving changes in healthcare projects. Project teams drive change when the project benefits have been clearly conveyed.
Theme: Clear articulation of project benefits. Seventy percent of participants indicated that they clearly describe a project’s benefits when embarking on new projects, which will lead to system changes. Fifteen of the archival documents required project teams to identify the benefits related to the outcomes of the project. Participant B3 noted that stakeholder buy-in is achieved when the stakeholders understand the benefits. She stated, “You have to get the buy-in. You have to build that burning platform, right? You have to convince people that there is a need for a change before you can get them to change.” A provincial project status report provided by participant A2 required specific documentation on the project outcomes and the realized benefits during a particular reporting period. As similar projects are being implemented across the province, when communicating to stakeholders, former project status reports can be referred to as a reminder of the project benefits. One of the core challenges behind articulating the benefits is that realized benefits will likely differ across stakeholders. Participant A5 stated:
I think being able to succinctly articulate benefits to various audiences around, you know benefits to a senior position at an organization might be different to the front line, to even physicians. But even the different actual service areas in hospitals, you know we are just rolling out to EDs (executive directors) now. I think some of the things they are interested in are very different than an in-patient is interested in.
Participant B4 provided a project deployment planning tool that requires the project team to list the main objectives and benefits from the stakeholders’ perspective. This process provides an opportunity to document perceived benefits, which are viewed through the lens of the stakeholders. This tool further requests the project team to document the critical success factors, as perceived by the stakeholders.
An additional technique to conveying the benefits comes from the use of data management. Participant A5 related benefits to data when she said:
So being able to articulate some of the benefits and the why you are doing this to those various audiences is key, and also, potentially in line with that, having some data. Again, more so with some stakeholder groups, but anything you have [when] you have potentially data to support [it].
In review of the analyzed documents, 11 documents required project teams to utilize data management for engaging stakeholders and shaping decisions. In particular, participant A1 provided a sustainability model that her organization adheres to. When embarking on projects, the model assesses various elements related to staff, organization, and the process. The process component requests the project team to elaborate on whether or not the benefits are obvious to the stakeholders and supported by credible evidence. Once the model has been populated, it quantifiably assesses each element and ensures that communication of benefits is evidence-based.
The Data Results in Addressing Research Question 3
Ninety percent of participants indicated during the interview that a knowledge and process gap exists in blending change theory and project theory. Participants with project and change management designations agreed that both fields fail to integrate curriculum that blends both theories together. In analysis of the raw data, integrating change management early in the project lifecycle was viewed as central importance.
Theme: Change management is integrated early in the project life cycle. Participants were asked if the stages of change management were considered when developing their project plans. Participant A1 pointed toward the initiation phase of the project. She indicated, “During the initiation. Getting people involved, hearing from their perspective what their risks or their issues are, and then trying to plan around that.” In other words, the project work plans are not necessarily followed until the project team has an understanding of the affected changes. Participant B1 pointed out, “So setting up change management at the very beginning ended up benefiting at the end.” Participant B2 shared that their change management plans are separate from their project plans, but the change management plans are built early in the project lifecycle. She elaborated by stating:
So part of initiation, and we do our project charters, so at that point we are already starting to build the change management plan. So we actually now or starting to, we have formed a formal document that is specifically for the change management. And it is interesting when you are doing the charter, it is the best time to ask those change management questions, because upfront you are identifying the governance structure for your project and a lot of that will help you with your change management. You also are identifying the as is state, the benefits and all that, and that helps you find deliverables that need to go into the charter. So right upfront you are doing both of them, then obviously as you build your charter and project plans and such things, you are building your change management plan. But basically they are going hand in hand and the work plan for both is evolving at the same time.
Participant A1 shared a change management plan that requests the project team to clearly identify key activities in the project, which will enable stakeholders to adopt the change. This plan is built early in the project lifecycle as it does not specifically indicate when the plan should be developed. Participant B1 provided a project tactical plan that requests the change objectives to be included in the scope statement of the project. In addition, project teams had to clearly document their chosen strategies for managing the system changes that were resulting from the project. Other documents analyzed in this study also included references to change management; however, it was in relation to actual project change requests. Thus, it was discovered that there was an overlap in terminology between documenting change management and change requests.
The emphasis on engaging stakeholders in the project planning became a relevant feature in the transcripts. Participant B5, when asked if change management and project management were interdependent and contingent on stakeholder engagement, stated:
Ya, absolutely and it’s got to be done early on. I think too often we get into the middle of the project before started getting that buy-in and engagement and communication and by then it’s too late. You already lost them. You really need to spend time up front doing that.
Upon analyzing both the transcripts and archival documents, it became clear that change management planning needs to be integrated into the project planning processes early in the project lifecycle. The planning aligns with the project as stakeholders are engaged and needs are understood. Once the stakeholder needs are understood, the change management plan begins early in the initiation and planning phases of the project.
Discussion, Implications, Conclusion
Summary of the Results
It was identified that the largest difference between participant responses and the archival documents were characterized through the formality of applying a project management process. All of the participants were aware and valued the five PMBOK® Guide processes in project management; however, participants treated the processes as a guide for moving projects forward. Similarly, since participants agreed that there was a gap in blending both disciplines, participants were more likely to integrate change management into project management from an intuitive perspective, rather than through specific processes.
Change management is an active approach that engages stakeholders in the decision-making process, which includes monitoring their concerns and having the stakeholders take initiative in mitigating their concerns. Participant B1 aptly stated, “A lot of people will say that change management is really easy; communication, communication, communication. And to me, I think the big part of change management is engagement.” Participant A1 further recognized the challenge in blending change and project theory when she stated:
There’s all kinds of other documents on change management, but like you say they are not really blended in with the project management framework…It’s not really, it’s not really an area of focus for project management, whereas it should be, because that is probably why a lot of projects will fail, because you don’t focus enough on the people part of it.
The variables of stakeholder communication and engagement have become dependent as success factors for healthcare projects. Thus, when healthcare project managers adopt a project lifecycle, which was designed outside of the healthcare industry with minimal emphasis on stakeholder management, it is only natural to understand why the gap exists in blending change and project theory.
Wells (2012) conducted a qualitative study that investigated the supports and benefits offered by adhering to project management methodologies (PMM) in information technology and information systems. It was found that 47.9% of the sample considered strict adherence to PMM as a hindrance to project delivery. The project managers considered PMM to focus on management, compliance, and control, as opposed to guidance and support when embarking on projects. Much of the archival documents related to project management in healthcare offered a close alignment to the five processes of project management; yet, the participants indicated the value in utilizing project processes, but expressed the need for some fluidity during integrated healthcare changes. This was largely due to the integral relationship healthcare has with its stakeholders
Project managers within Ontario’s healthcare system strive to integrate change management with project planning, yet wrestle with the fact that their project documentation templates fail to include dominant characteristics of change theory. Participant B5 summarized the ambiguity around blending both disciplines when she stated:
The stages don’t line up. I mean we talked about that earlier, the stages of change don’t clearly align to the stages of project management, and so I think that’s where people get confused in how you blend the two. I certainly think there’s value, but I think that’s an area of weakness and it’s a big knowledge gap right now.
The fact that participants engage in this intuitive integration further supports the identified gap in the literature, and the fact that the five PMBOK® Guide processes are structured in a manner that are not necessarily conducive to change theory. Recently, PMI released the fifth edition of the PMBOK® Guide. Certainly, PMI recognizes the discipline of change management; however, project management must continue to broaden approaches beyond project management change requests. The identified theme of integrating change management planning into the early processes of the project lifecycle speaks to the fact that project management cannot be treated as a universal approach to any integrated healthcare project. Leybourne (2006) conducted a qualitative study on six organizations, only to discover nearly universal support in applying an improvisational approach to project management. It was discovered that improvisational approaches are valuable when engaged in a project and change setting (Leybourne, 2006). When B1 was further asked how he applies the five processes of project management, he stated, “We don’t necessarily follow it to a tee…planning and initiation often get muddled, this is where the agile project management comes in. Often we can’t plan fully before we start.”
This study aimed to identify the project management success factors during integrated healthcare changes. The results of this study demonstrated the challenges associated with blending the theory of project and change management and practically applying them to integrated healthcare planning. Three themes were identified through a meta-analysis of raw data. It was found that competency, leadership support, adherence to project methodology, genuine stakeholder engagement, articulation of project benefits, commitment to communication, integrating change facets early in the project lifecycle, and integrating change intuitively into project planning led to project success.
Implications of the Study
The results of this study identified a definitive gap in blending the disciplines of change and project theory. Moreover, it was evident that change management and project management were treated as independent of one another. During the past decade, the project management field has made small strides in reconciling this gap. The theoretical constructs of project management, change management, and integration were discussed earlier in this study. The identified themes addressed project success factors and identified the essential characteristics of project teams engaged in integration healthcare projects.
The majority of participants in this study indicated the importance of risk management planning as a facet of project management. Kumpf and Wittelsberger (2005) identify the need for further planning to gain additional skills in project management and identify coaching and mentorship opportunities. The study echoed the need for mentorship and coaching as learning techniques for new project managers, and suggested that new project managers be aligned with seasoned project managers to better learn how to apply the project management processes and gain experience in the field. Armenakis et al. (1993) indicate that organizational change is contingent on demonstrating to stakeholders the competencies associated with individual and collective efforts to affect the change. Project and change management recognition, through an effective track record of success complimented by the right credentials, will offer stakeholders the assurance they need in a time of change. One of the participants in the study indicated that he gains stakeholder support when they are aware of his project management competencies and expertise at the onset of the project.
A project management success factor, identified with overwhelming support, was the need to convey the project benefits to internal and external stakeholders. In addition, the importance of conveying project management benefits to those organizations that require leadership support when adopting the methodology became clear. Wilson, Rogowski and Popplewell (2003) identified the importance of providing a cost-benefit analysis to support the goals of an integration project. Project teams must engage in research initiatives to communicate data, in an effort to gain further buy-in. Armenakis et al. (1993) point out that the effectiveness of organizational change is contingent on a demonstration to stakeholders of the current state versus the desired end state. Relationships rooted in trust and transparency are beneficial when engaging with decision makers. However, the study indicated that clear project benefits, supported through data are essential for project success. Lewin (1947) demonstrates that change exists when organizations unfreeze the current state. Communicating the benefits and supporting the project initiative through the use of data can accomplish the unfreezing process. Freezing behaviors takes place, not solely based on motivation alone, but rather on both motivation and action (Lewin, 1947).
Projects that initiate change can lead to ambiguity. Project managers need to be comfortable working in this type of environment. Hagen and Park (2013) point out that those project managers who drive change in ambiguous environments will demonstrate innovation, entrepreneurial traits, and are adaptive. Likewise, improvisational approaches are valuable when engaged in a change project setting (Leybourne, 2006). Project planning within integrated healthcare planning requires improvisation due to the necessary management of stakeholder engagement, considering the health sector is not a static environment. This study has indicated that agile techniques may be an important consideration for project teams to adopt, considering nearly half of the participants advocated the value in utilizing such techniques. Agile methodologies were given attention, considering their attempt to address rapid and volatile environments, particularly in the software industry. However, agile advocates suggest it is more appropriate as a people-oriented approach when projects lead to environmental adaptations (Syed-Abdullah, Holcombe, & Gheorge, 2006). Furthermore, agile has been a choice methodology, due to its inherent flexibility in projects (Christopher, 2000).
Government organizations have felt the economic constraints of the 21st century, which has led to downsizing, a lack of in-house expertise, and agency restructuring (Soni, 2004). Such pressure has led to government outcomes leading to integrations, mergers, downsizing, or closures. In the province of Ontario, Canada, healthcare integration has largely been recognized as a necessary process to enhancing patient delivery and address fiscal restraints. Managing change has become a prevalent issue within healthcare organizations. One cannot ignore the impact of change on the healthcare sector during project management implementation.
The field of project management has evolved from its origins and spread beyond engineering, construction, and information systems (Kloppenborg & Opfer, 2000). Project management practices have now been integrated into government organizations, as new hires from such vocations have brought with them their project management expertise and practices. Managing change in a healthcare environment comes with the challenges with managing projects that are contingent on stakeholder support.
Through a meta-analysis process, three themes were identified as project management success factors during integrated health changes. The following factors were identified as indispensable to managing change and leading to project success: a demonstrated competency in project management; a clear articulation of the project benefits, supported through data or evidence-based research; and the need to integrate facets of change early in the project lifecycle, either through the initiation or planning phase.
Considering the health sector is not a static environment, projects must be approached through iterative planning cycles. Based on the results of this study, there is a definitive need for organizations to commit to fulfilling the project success factors and utilize an agile approach to their projects. In doing so, the facets of change and project management can be blended to increase project results.
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Aaron Gordon is an Assistant Professor in the Department of Business & Economics at Algoma University, in Sault Ste. Marie, Ontario, Canada. Equipped with a Masters of Business Administration (MBA), he has also earned a Doctorate of Philosophy (Ph.D.), which specialized in Project Management. Most recently, Aaron was the project management and integration lead for Ontario’s northeast region, where he led various healthcare integrations. In addition, he has advised project teams, within government, private, and non-profit, to better align their practices with PMBOK® Guide principles. Aaron’s research interests focus on aligning project management and change management, with strategic human resource planning.
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