Getting from A to B : Project Management for Clinical Leaders

 Hi fellow CMIOs, CNIOs, #HealthIT, and #Informatics leaders and friends,

Change is important. As a clinical leader, you'll want to know how to make workflow changes, either to help fix a workflow that's not ideal, update a workflow that needs updating, or build a new workflow. (As long as there are new journal articles and conferences, there will be necessary updates to clinical practice to stay current.)

So this week, I thought I'd write about a topic that can help a clinical leader to feel comfortable with making changes in their area: 

"How to get from Point A to Point B"

I once alluded to a problem with making changes back in 2016, when I blogged about the Red Sneaker Problem - And How To Fix It. To help avoid frustration for you and your team, it's helpful to understand 'How does anything change?'. Without understanding the change process, it can be hard to make change. 

Although clinical leaders often need to focus primarily on clinical services, functions, and expertise - it's still helpful to know the basics about two important things, related to 'how things get done' : 

1. Project Intake / Scoping - Helps you secure necessary people, time, and resources before you start a change project.
2. Project Management - Helps you effectively use those people, time, and resources to get things done (accomplish the change)

Without understanding these two steps, it can be very hard to accomplish much change. And without regular, smooth, and predictable changes, clinical leadership can seem more daunting than it needs to be. 

So as a brief introduction for new clinical leaders, let's review these two items in a little more detail. Borrowing some slides from a recent presentation I did for a group of clinical leaders, I present some high-level overview below. 

1. PROJECT INTAKE / SCOPING - 

Making change is work. It takes people, time, and resources, to move your CURRENT state (Point A) to your desired FUTURE state (Point B). 

Ideally, to make sure you have the 'gas' needed to drive your 'car' to where you want it to go, you'll first need to understand the scope ('size') of your project. Conceptually, think of this as collectively driving your car (with your team inside it!) from :

• Your CURRENT state (Point A)
• Your desired FUTURE state (Point B)

This is why I always advise people to formally map the current and future states. The distance between these two points is what will determine the scope (size) of your project,  and the work effort (and resources) needed to accomplish your goal.

• If you have the time, people, and resources necessary to get from Point A to Point B - Great! 
• If you don't... Then you may feel frustrated.

So to make sure you have a thorough, well-documented analysis that you can share with your project team - it's very helpful to formally document, in a folder, your CURRENT state, and also formally design your ideal FUTURE state, one that is formally signed off by the clinical leaders who oversee the clinical staff who will live in this new future-state workflow. 

People sometimes ask me : "Do I need to do this much for every change I want to make?" My advice : You only need to apply as much rigor as you need to get the change accomplished. E.g. : 

• For small changes (e.g. making some small changes to a documentation template) --> Usually, less rigor is required
• For large changes (e.g. implementing electronic med reconciliation at all transitions of care) --> Much more rigor is required

This exercise will not only help you scope your project, and identify the people, time, and resources you will need to secure - It will also help you formally plan a project, estimate the return on investment (ROI), and secure the necessary approvals before beginning your project. 

2. CLINICAL PROJECT MANAGEMENT

Once you have secured the necessary people, time, and resources, and have the approvals of your leadership to move forward - It's helpful to identify a formal, trained, and experienced project manager to plan, orchestrate, and lead your project. For a high-level overview, you can see the Wikipedia piece : https://en.wikipedia.org/wiki/Project_management 

For planning purposes, many experienced project managers might develop a Gantt Chart ( see https://en.wikipedia.org/wiki/Gantt_chart ), a sort of ordered series of steps, with time estimates and dependencies, that will be needed to finish the project and achieve the desired outcome. Similar, but also helpful is a Responsibility Assignment Matrix, sometimes called a RACI Chart. 

Experienced clinical leaders, especially those who have worked with good project managers, can often help a project by anticipating steps and helping to answer questions before they arise. While there are different types of project management (from the more traditional waterfall model, to newer agile methodologies), I've stripped down some bare essentials that are helpful to think about before starting any clinical update or improvement project : 

These are the ten steps (above) that I commonly plan and follow for clinical projects, where the rigors of step two (2) above are often necessary to help adequately scope and plan clinical projects, and help ensure that there are no unanticipated surprises later in the project. Note: Clinical Informatics professionals often work in steps 2, 4, 5, 6, and 9 above, working closely with end-users, analysts, educators, and project managers.

As a clinical leader, you will want to help champion change and updated practices. While there is much more to be said about project intake, scoping, planning, and execution, I hope this little introduction will help my friends in clinical leadership see the value of good project managers, and good project planning, and the role they play in getting things done.

Remember, this blog is for educational purposes only - Your mileage may vary. Always ask your local Project Management and Clinical Informatics professionals for guidance, and work closely with your clinical leadership to review, prioritize, and approve your projects before initiating any changes.

Have any stories to share about clinical leadership in supporting clinical projects? Have any tips or tricks to share from your own clinical project management experiences? Feel free to leave them in the comments section below!

Why You Should Always Map the Current State

Hi fellow CMIOs, CNIOs, #Informatics, and other #HealthIT leaders,

Today I'm writing to discuss a fairly common question in clinical change management, related to the practice of 'mapping the current state': Is it really necessary?

When planning a clinical improvement project, it may be one of the most common newbie mistakes: Thinking you can't, or don't need to analyze the current state : 

It has been said that Clinical #Informatics and #workflow engineering is a bit like 'rebuilding the plane while it is still in the air' - Healthcare is in business 24x7, and can't really shut down, even for a few minutes, without a potential impact on patient care. (This is one of the things that separates #HealthIT from #BusinessIT, #AcademicIT, and #ResearchIT.)

So in today's fast-paced healthcare environment, it's more important than ever to make sure that projects are executed well, on-time, on-budget, and according to plan. And this is where our discussion starts : How to make sure you're really planning well. 

First - Without mapping the current state, it looks something like this : 

... and then it becomes impossible to tell if your project is going to look like this : 

... or this...

... and so without a current-state assessment, it's easier to either under- or over-estimate the work it will require to get to Point B. 

Remember, smooth workflow change is not just about the configuration you need to do inside the EMR - It's the work you need to do outside of the EMR too, including development of staff education needed to get your clinical teams from Point A to Point B - See #7 in the grey box on the left-handed side below : 

Taken from my 11-18-2015 blog post, 

"The Informatics Domain and Workflow Management"

Again, in today's healthcare environment, having smooth, well-executed workflows and projects is more important than ever. As an example, Dr. Danielle Ofri recently wrote this very relevant opinion piece in the New York Times which really introduces the importance of well-designed, well-planned workflows :

"The Business of Health Care Depends on Exploiting Doctors and Nurses"

(June 8th, 2019)

... in which she writes, "With mergers and streamlining, [corporate medicine] has pushed the productivity numbers about as far as they can go." After she describes some real problems with the efficiency of some EMR documentation, she shares this insight, "But in health care there is a wondrous elasticity - you can keep adding work and magically it all somehow gets done."

While Dr. Ofri is quite right that this is a commonly-held belief, there's still a basic problem: Math is math. Healthcare should not plan to do 25 minutes of work in a 15 minute timeframe. So in the national discussion about physician burnout (#physicianburnout, or as ZDoggMD describes it, 'moral injury'), it's more important than ever to make sure workflows serve the needs of the patients, providers, nurses, pharmacists, and other clinical and administrative people working in #healthcare. To make sure we're not overloading our clinical teams, every data element needs to be well-analyzed, well-studied, well-planned, and serve a legitimate patient care or business function.

And this is why the current state is important. Without studying the current state, it becomes very challenging to answer questions like: 

• Which stakeholders need to be involved in this project?
• How much time will this project take?
• What training and support will we need to go-live with the planned future state?

Still, some people express concern about the work it takes to map the current state, or question the real benefits. Allow me to share some common arguments, along with my counter-arguments : 

ARGUMENT : "We don't have time or resources to map the current state." 

COUNTER-ARGUMENT : "Will we have time or resources to fix things that we didn't account for? How will we know the scope of the effort, who to invite to meetings, or how much educational effort we will need to plan for?" 

ARGUMENT : "It's not worth mapping the current state, last time it took us hours and we still couldn't figure it out." 

COUNTER-ARGUMENT : "Not being able to map the current state, despite best efforts, is still a really important factor to consider when scoping and planning a project." 

ARGUMENT : "We don't want to map the current state because we don't want to bring old habits into our new workflow." 

COUNTER-ARGUMENT : "Even though there may be parts of your current-state workflow worth keeping, it's not to bring old habits into your new workflow - It's to make sure we're covering all of our bases, and doing the best job planning, designing, and executing that we can."

ARGUMENT : "It takes too much work to map the current state." 

COUNTER-ARGUMENT : "It doesn't need to take a lot of work, and you don't always need Visio swimlane diagrams. For many workflows, a simple well-written procedure with each line written as [WHO] will/may [WHAT] will do the trick. Even if it's not documented - it's still important that whoever plans the project has ample access to someone with a good understanding of the current-state workflow(s)."

Fortunately, most experienced Clinical #Informatics and #HealthIT professionals know the importance of mapping the current state in planning clinical improvement projects, and how to map it quickly. So if you ever need help mapping the current state, ask your local Clinical #Informatics or #HealthIT experts for assistance!

Remember, this blog is for academic discussions only - Your mileage may vary. Seek expert advice from your leadership, legal counsel, clinical informatics, or project management teams before changing strategies. Do you have any questions, comments, or feedback? Leave them in the comments section below!