The U.S. healthcare system is faced with considerable challenges, including funding healthcare for an aging population, pricing pressures on providers to lower reimbursements, assimilating new technologies, effective and efficient use of EHRs, integrating virtual and digital communication practices, and regulatory and legislative uncertainty. Integrated healthcare systems, hospital systems and medical group practices, in their search to enhance the value they provide to patients, employers, insurance companies and other stakeholders, need efficient mechanisms to introduce changes to the clinical practice. Effective change strategies are needed to transform the clinical practice and achieve operational excellence to enable high-value care and mission-advancing financial performance.
Provider teams that provide patient care are increasingly being asked to innovate and adhere to new ways of thinking and interacting, especially with new or updated information technology (IT) components within their workflows. One of the most challenging aspects of change management is addressing the increasingly complex, integrated and interfaced IT systems. Part of the leadership toolbox in engaging colleagues and driving results is the use of informal and formal project management skills to drive these change management initiatives.
What follows are best practices of a large radiology department in a large academic medical center that integrates a unique combination of IT and clinical practice project management capabilities, following six strategies to optimize the value proposition (see Figure 1) associated with IT change.
Strategy 1. Embrace the matrix organization
Within large academic medical centers, IT teams are often used to help clinical areas take on complex IT implementations and provide ongoing operational support and maintenance. However, it can be difficult for clinical leaders to effectively lead and manage change within this type of matrix. According to Harvard Business Review, “Influence and conflict management capabilities help leaders to build consensus around a common purpose and deliver the collaborative solutions that the matrix requires.”1 It is crucial to develop leaders who can embrace and lean into a matrix organization and take on these challenges.
A project management office (PMO), which provides a disciplined approach to IT implementation as well as clinical IT domain knowledge, can be helpful in a matrix organization. A PMO is typically staffed with program managers, project managers, and business and systems analysts. These roles help clinical leaders effectively and efficiently manage large IT change. In addition, a PMO can help a clinical area bridge its strategic goals and help create tactical business results.
Strategy in action
Over the years, our radiology department has developed a trusted partnership with our clinical IT PMO due to size, complexity and imaging informatics architecture requirements of radiology IT systems. The PMO provides a dedicated radiology IT program manager, three dedicated radiology IT project managers, and contracted IT project management staff to meet radiology IT strategic goals. This IT program is also supplemented with project managers from radiology to ensure that all facets of project scope are carefully considered and managed, including workflow changes, communications and transition to operations tasks for impacted clinical staff areas.
Strategy 2. Engage clinical leaders in IT projects
Establishing governance structures, identifying and creating processes, and advocating for clinical leaders in project sponsorship roles is another strategy to navigate change. A committee can provide governance, streamline processes and complete tasks efficiently. Well-appointed committees are composed of physician leaders, allied health clinical leaders and other key roles from a matrixed organization. Often, a committee is designed to have multisite membership, meaning that all geographic sites across a medical center are represented.
One of the first things a committee can do is identify and create processes for IT requests that minimize time demands from physician leaders. This helps save time and cost to clinical departments. Although not required, it is beneficial when all IT projects and maintenance tasks are tracked in one system. This allows for program-style reporting of project toll gates, length and cost of all projects and tasks.
It is critical to have clear roles and responsibilities defined for larger IT projects. One of the most important roles on an IT project is a project proponent, which helps the committee obtain a clear understanding of the problem(s) being addressed and helps to sponsor and champion the change(s) brought about by the project. If a project request is brought forward without adequately identifying a problem, further vetting with the proponent should be done before moving forward.
Project managers should use a common playbook, which helps to set clear and consistent expectations for clinical leaders, project proponents and key stakeholders. As part of that playbook, project managers should adopt a stakeholder identification and analysis tool [e.g., a RACI Matrix (Responsible, Accountable, Consult, Inform)] to identify all major impacted stakeholders and groups of stakeholders up front and before changes are introduced to clinical practice.
Strategy in action
Our radiology IT projects are overseen by a single informatics committee, which is responsible for the development of the strategy and outcomes for the following focus areas:
- Radiology architecture and standards
- Radiology artificial intelligence
- Radiology data analytics and reporting
- Radiology IT systems.
Each of the above focus areas has a dedicated committee, including a physician leader and a clinical administrative partner, to oversee the execution of projects and work. Because we are geographically dispersed, enterprise subspecialty and operational groups have been created to ensure all site perspectives are included in decisions to endorse or deny a project request.
We define roles and responsibilities to support each program’s objectives, to drive ownership and accountability for informatics security and standards, and to establish clear points of responsibility and accountability for key steps, tasks or activities mapped out in our playbooks. Our roles and responsibilities tool is an ARCIVD matrix (see Table 1), which defines six types of assignable roles: Accountable, Responsible, Consulted, Informed, Veto Power and Devil’s Advocate.
Our complex matrix extends beyond project management and into support systems. Because we have well-defined processes and roles for project intake, project management and maintenance, activities are streamlined and resources are used to their fullest potential. Systems can then be supported by several different areas, internal and external to our department. Different IT teams within our organization — network, hardware, purchasing and other technical teams — can then be part of our infrastructure support. There are also biomedical teams, as well as external vendors, that can be used for specific hardware, equipment and application support. Lastly, departmental teams should also be engaged for application support, report writing, project management and training.
Strategy 3. Manage projects within life cycles
Most projects follow a project life cycle. For example, IT-vended system implementations often employ a waterfall approach. This approach tracks project progress through well-defined stages of initiating, planning, executing and closing. Requirements and design are completed before development and testing. Other types of projects, such as IT custom development projects, tend to adopt more agile, iterative approaches for project completion. No matter the life cycle methodology, project managers need to work hand in hand with proponents, committees, team members, and other stakeholders to ensure that scope, schedule, and financial plans are developed and delivered. To help increase value to large, multisite clinical practices, unique approaches can be implemented to ensure projects are prioritized, resourced, and sustain forward progress to achieve the project deliverables.
Another effective tool is to develop a common playbook for project managers, which helps to set clear and consistent expectations for project proponents and stakeholders. Because IT projects impact many areas of clinical practice, it is important for all project managers to have a common set of tools and techniques, and to flex those tools and techniques depending on the scope of the project and the needs of the clinical practice. Sometimes, agile methodologies work best for projects; other times waterfall works better. Often, a mixed/iterative approach is taken to achieve goals faster.
When a project is being executed, teams are actively implementing key elements of the project plan and achieving various milestones to meet the project schedule. A well-formed transition plan for a select few project elements from the project team to department operations is also vital to successful change and sustainability. Transition planning should begin in the execution phase to be most effective. Individuals most likely to assume these long-term responsibilities should help the project team develop the transition plan.
Conducting a lessons-learned session with project team members as one of the closing activities is also extremely effective. These lessons learned should be documented in the project portfolio management (PPM) software tool or in a team-accessible location and reviewed by individual project, program or the entire portfolio when new IT requests are approved to begin.
Strategy in action
Recent implementations of a new EHR system, a new primary image viewing system, and an updated radiology reporting system have simplified the systems architecture of our radiology department. However, complexity and substantial interdependencies remain. As a result, thorough architecture and security reviews for all new and modified IT projects are started immediately to ensure adequate and timely planning reviews occur by key stakeholder groups.
Robust planning is critical to ensure that scope, schedule and cost parameters are well developed, integrated, and communicated, regardless of the project’s life cycle.
As projects are ready to move to execution, the committee is provided with an extensive review of key planning activities, including a refined scope definition, a proposed training and implementation schedule, and an overall budget for the project. These project elements are provided in a standard presentation template, which helps ensure that consistent information is presented for each project.
Depending on the size, complexity, and risk levels of our projects, discussing and reviewing change requests can consume valuable time for committees. To improve the speed and agility of our decision-making, we implemented a “right-sizing” approach for reviewing and approving changes.
Small change requests are characterized by a less than 10% change in scope, schedule or cost. A medium change request falls between 10% to 25% and a large change request is more than 25%. Small change requests do not require a formal change request or formal approval from the committee. They are simply documented as a decision made by the project manager and proponent. Medium change requests are sent to an executive group of the committee and are included on the consent agenda at the next full committee meeting. Review and decisions are made in real time, and then documented as a decision by the project manager. Only large change requests need to be reviewed by the committee for approval. For example, if a one-year project went over schedule by one quarter, this would represent a 25% change in schedule and would need to be reviewed by the committee before moving forward to implementation.
Strategy 4. Apply a robust prioritization process
Project prioritization in a large academic medical center can be very complex. Reviewing related IT projects as a program helps the committee establish processes for funding, prioritization and maintenance activities. Developing a scoring rubric will help clinical leadership select the right projects to assign resources.
Strategy in action
Identifying criteria and scoring like the matrix (see Table 2) can assist in matching a strategic plan and can help with decisions about what projects to move forward on.
Strategy 5. Leverage systemic change management
Many change management models are available for use during an IT project implementation. This is a key strategy for clinical leaders in which to pay close attention. Large IT projects can often have dedicated change management practitioners for consultation and development of plans.
The Awareness, Desire, Knowledge, Ability, and Reinforcement (ADKAR) Model from Prosci Research is a popular and effective change management model used in large academic medical centers. Jeff Hiatt describes the ADKAR model as a tool to systematically approach significant changes in personal, professional, organizational or community life. According to Hiatt, individual change must first be understood and managed effectively to achieve organizational change.2
Strategy in action
Our initial key step is to create awareness (A) of changes being proposed as part of a project. Key stakeholder groups need an opportunity to hear about changes they are likely to experience in the future.
Creating the desire (D) to change among key stakeholders is the next step in effective change management and seeks to develop the desire within individuals to change. The need to describe anticipated improvements resulting from the project is vital to our stakeholder acceptance.
The knowledge (K) phase ensures our stakeholders know how to change and what needs to happen during the transition to the future state. Stakeholders need several opportunities to hear and learn about changes planned as part of the project. Smith and Osborne3 first described the Rule of Seven related to messaging and communications necessary for consumers. They suggested people need to hear information seven different times in seven different ways before purchasing products or services.
Ability (A) is the next phase and represents the application of new knowledge into action by use of the new tools, systems or processes during practice or simulation. Typically, training sessions for our stakeholders are an effective approach to ensuring they can use a new tool or process as part of the project implementation.
Reinforcement (R) is the final phase and is vital to changes being successfully sustained over time. Reinforcement can take many forms, including thank-you notes and expressions of appreciation from supervisors, direct observation of system/process use, and electronic audits of compliance.
Strategy 6. Optimize stakeholder communications
Project communications in a large, multisite matrix organization is challenging. As part of change management planning, developing a communications plan is a key component of IT projects. According to recent research presented at PMI Global Congress, this communication must “build or increase support (change attitudes), maintain or enhance existing relationships (build credibility for when support is needed), [and] deliver information (and therefore manage stakeholders’ perceptions).”4
One effective communication example is a monthly project status meeting. The intent is to bring a wide variety of stakeholders together for a status update on active projects. Templated status reports are updated by project managers and sent to meeting attendees. Another communication example is when a committee receives more frequent updates during a “two-minute drill” exercise conducted for the committee’s executive group. This rapid-fire review provides a brief overview of each project and surfaces any urgent risks or roadblocks that require leadership assistance or intervention. Other examples of communications are emails, blogs, websites, SharePoint sites, internal news articles and roadshow meetings.
Even establishing a few simple communication methods such as daily huddles, weekly update meetings, “two-minute drills,” and stage gate reviews can decrease confusion, reduce duplication of effort, and increase engagement with projects.
Strategy in action
One unique facet of our radiology and IT partnership is the very intentional approach to the relationship. The IT radiology program manager is considered a part of the radiology leadership team and participates in strategic planning efforts, operational discussions, and resource management planning. There is free-flowing communication between radiology and IT, ensuring alignment and transparency between the two teams. Any issue or area of concern is discussed openly and honestly, allowing all parties to be heard. Proposed solutions to issues are vetted to ensure buy-in by both parties. This successful partnership relies on trust and transparency, which were set out at the start of the relationship as our operating principles.
Important to this alignment is good change management and communication between teams and among stakeholders. Both teams have had input into the organizational structure, resources focusing on radiology, and on-going support structures. When there has been no alignment of ideas, we have successfully relied on the values of our organization: respect, integrity and teamwork to guide us to a mutually acceptable outcome, always focusing on the patient.
Conclusion
Organizational excellence is going to be achieved when a vision is operationalized with talented leaders who solve problems and facilitate change management while efficiently and effectively driving toward desired results. Developing and maturing project management capabilities can be an important part of the leadership development arsenal utilizing the strategies presented in this article. Effective project management is a powerful strategy that can be deployed by physicians, nurses, and other healthcare providers working in partnership with IT leaders to enable innovation, excellence, and stewardship, essential values for success.
In our organization, our primary value — or North Star — is “The needs of the patient come first.” This value anchors all decision-making and gives everyone in the multisite matrix organization a common point of understanding as the foundation of everything we do. In the relationship between radiology and IT, this primary value has provided alignment and focus for both parts of the team to work toward. By aligning to this value, we have been able to focus on business priorities for the clinical practice — centering on what our patients need.
Using program management, combining business agility with business decision-making, and using a matrix organization approach has allowed radiology and IT to optimize the value proposition in project management to achieve business results.
Notes:
- Malloy R. “Managing Effectively in a Matrix.” Harvard Business Review, August 10, 2012. Available from: bit.ly/3BXx4PZ
- Hiatt J. ADKAR: A model for change in business, government, and our community. Loveland, Colo.: Prosci Learning Center Publications, 2006.
- Smith T. and Osborne J.H. Successful Advertising. Its Secrets Explained. Smith’s Press, 1888.
- Bourne L. “Beyond reporting — the communication strategy.” Paper presented at PMI® Global Congress 2010 — Asia Pacific, Melbourne, Victoria, Australia. Newtown Square, Pa.: Project Management Institute.
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