Because many aspects of health care operations are changing, health care adminis
ID: 352124 • Letter: B
Question
Because many aspects of health care operations are changing, health care administrators oversee a wide variety of projects. These can include logistical projects such as moving a department to a new facility, technology-related projects such as introducing a new system or piece of equipment, or process-related projects such as initiating new procedures for patient discharge. If the project has any degree of complexity, it will benefit from a project management approach. Administrators and managers in health care need to have a working understanding of project management: why it is important, what it accomplishes, and the repercussions on the organization if its basic tenets are ignored or not followed. Within project management, the project plan is the cornerstone of successful execution of a project. The project plan is designed to guide the process and execution of a project.
For this Assignment, you will develop a project plan, using as your focus a work-related project you are doing now or will be doing in the future.
Part 1: Service Level Agreement
It is suggested that the project you select be manageable in scope and not overly complex. You will assume that the objectives and scope of the project you have selected have been vetted and approved. The next step is to develop a project plan. You will develop a project management plan that will walk through key steps of the project management process. The objective of this Assignment is not a deep dive into the full intricacies of project management. Rather, it is to ensure that as a health care administrator, you have a solid theory and practical knowledge of key aspects of the project management process.
For Part 1 of this Assignment, you will create a Service Level Agreement (3–5 pages) which includes the following:
Project Description, Purpose, and Objectives: The project description delineates key aspects of a project. In 1–2 pages, your project plan should:
Describe the project and explain the purpose and justification for the project.
Explain the goals and objectives of the project.
Describe the requirements for the project.
Explain the tangible measures for acceptance criteria used to achieve project success.
Project Scope: The project scope defines the scope of the project and how the scope will be managed. In 2–3 pages, your project plan should:
Summarize, in detail, the expected deliverables for the project.
Explain the acceptance criteria for the project.
Explain the project assumptions, risks, and constraints.
Roles and Responsibilities: By definition, a project is a unique undertaking with a beginning and an end point. One responsibility of management is to determine who will be a part of the project team (including designation of a project manager). Ask yourself, “Who needs to be on this team to ensure that project goals are successfully met?” Consider as well the importance of communication among team members. What communication needs will each individual have? With whom will they communicate and how?
Note: For privacy purposes, please use pseudonyms.
Using the Project Roles and Responsibilities Matrix template in the Learning Resources, list the names* and titles of all individuals or entities involved in the project. Indicate whether each stakeholder is internal or external to the project organization.
Identify the internal and external stakeholders for a project.
Distinguish the roles and responsibilities of the project stakeholders.
Explain how to communicate with project stakeholders.
Part 2: Project Schedule
There are many different methodologies for planning and scheduling a project. For this Assignment, you will develop a Gantt chart that depicts key project activities, time allotted for each activity, and when each activity is scheduled to begin. To do so, you will need to consider dependencies. Some activities will be sequential, others may be simultaneous, and some may overlap.
Note: You may create your own Gantt chart using Excel, or search for and download a Gantt chart template.
Using a Gantt chart, construct a project schedule.
In 2–3 paragraphs of your project plan, explain the estimating techniques used to develop your project schedule. Provide rationale for why these techniques will be effective.
Part 3: Strategies for Maintaining the Project Budget
A project begins with an approved budget. Too often, however, unless the budget is meticulously managed, budget overruns occur. Health care administrators must ensure that the project management process includes careful oversight on spending. In 2–3 pages, describe the project budget key success factors including the following:
Analyze at least three strategies that can be applied for due diligence and maintaining oversight of the project budget.
Explain at least two challenges each of these strategies might present and identify opportunities for improvement.
Compare the positive outcomes that might result from each strategy.
Part 4: Risk Management, Quality Management, and Sustainability
Even the most straightforward and well-planned project can be impacted by unexpected circumstances. Anticipating risks is a key part of project management, and one that a health care administrator or manager must ensure is taken into consideration by the project team. Additionally, If not carefully monitored, budget and time constraints can take a toll on the quality of a project. Create a 2–4 page risk management and quality management plan, which includes the following:
Describe how you plan to manage risks for your project.
Analyze strategies for managing quality within your project.
Analyze strategies for sustainability of your project.
Describe at least two tools and/or techniques you plan to use to manage quality and defend why you chose those tools.
Explanation / Answer
Describe how you plan to manage risks for your project.
Risk is a probability/threat of damage, injury, liability loss that is caused by vulnerabilities and that may be avoided through pre-emptive action/s. Interaction of humans with health systems pose a threat to them mainly because of the; complex technology, intensely complex procedures, high demand on services, time pressure, high expectations from the service users, hierarchical by nature of training and responsibilities. W.H.O estimates show that in developed countries as many as 1 in 10 patients is harmed while receiving hospital care [1]. According to AHRQ national health disparities report 2013, rate of harm associated with hospital stays in U.S hospitals is 25.1 per 100 admissions [1]. Major contributors to these hospital-acquired conditions (HACs) were; adverse drug events, catheter associated urinary tract infections, patient falls, pressure ulcers, surgical site infection, central line associated infections, venous thrombo-embolism and ventilator associated pneumonia [2]. According to Institute for Healthcare improvement (IHI), medical errors have become the third leading cause of death in the United States each year, behind cancer and heart disease [1]. A 13.5 percent rate of harm was identified within the US Medicare population by the Office of Inspector General using the Institute for Healthcare Improvement’s Global Trigger Tool [3].
Predominantly the underlying causes of medical errors are; communication problems, inadequate information flow, human related problems, organizational transfer of knowledge, staffing patterns and work flow, inadequate policies and procedures and technical failures [2].
Hospitals are a common setting for hospital acquired conditions in part because of the clinically compromised state of many patients admitted to the hospital and high volume of care transactions and interventions that take place during a hospital stay. Investigations into incidents frequently stop with identifying the human error and designating the practitioners as the “cause" of the event [1]. Hindsight bias occurs when the investigators work backward from their knowledge of the outcome of the event. This linear analysis makes the path to failure look as though it should have been foreseeable or predictable, although this is not the case. Often this determination is made without any evaluation of systems or processes that might have contributed to the error [4].
Organizational leaders must become “systems thinkers" who demand in-depth analyses of safety concerns, replace punitive reactions to mistakes with an open environment and proactively address any risks; there will be an opportunity to build safer health care organizations. However there is no room for reckless behavior in the healthcare environment.
Probability is the measure of the likelihood that an event will occur. Threat is any activity that represents a possible danger. Vulnerability is a weakness. Loss results in a compromise to functions, life or assets. HACs are Hospital Acquired Conditions. Incident is an undesired outcome or occurrence, not expected within the normal course of care or treatment, disease process, condition of the patient, or delivery of services. Near miss is an event or process variation that could have resulted in injury but did not, either by chance or timely intervention. Sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, not related to the natural course of a patient's illness or underlying condition.
Risk Management can be Beneficial in the Following Contexts
Five Basic Steps of Risk Management [1]:
The five basic steps of risk management are outlined below and also in Figure 1.
Establish the context: Context is very important in risk identification and management. ICU (Intensive care unit), O.R (Operation room), E.R (Emergency room), blood transfusion services, CCU (coronary care unit), medication management including medication administration are contextually high priority areas for risk management in relation to patient care.
Identify Risks: Risk identification is the process whereby the healthcare professional and the healthcare employees become aware of the risks in the health care services and environment. The risks identified are entered in the Risk Management Tool (RMT) as depicted in Figure 2, also sometimes known as the Risk Register.
Sources of risk identification
Analyze Risks: Risk analysis is about developing an understanding of the risks identified. It includes the following:
Existing controls: When examining the existing control measures, consideration should be given to their adequacy, method of implementation and level of effectiveness in minimizing risk to the lowest reasonably practicable level. These include all measures put in place to eliminate or reduce the risk and may include:
Root Cause Analysis (RCA) represents a systematic approach to identifying the underlying causes of adverse occurrences so that effective steps can be taken to modify processes and prevent future losses. Brain storming with a team of relevant and informed people still remains the best method to do Root cause analysis.
Evaluate risks: The purpose of risk evaluation is to prioritize the risks based on risk analysis score and to decide which risks require treatment and the mode of treatment. Risk evaluation can be classified
Risk Treatment: (Also known as Risk reduction, Risk mitigation): The decisions in risk treatment should be consistent with the defined internal, external and risk management contexts and taking account of the service objectives and goals. Risk treatment plan should have:
ANALYZE STRATEGIES FOR MANAGING QUALITY WITHIN YOUR PROJECT
A regional or national hospital quality strategy is a long-term (2-5 year) programmed to increase patient and personnel safety and improve hospital quality. This synthesis searched for evidence about the nature, implementation and results of both specific strategies in one hospital and strategies to improve quality in many hospitals.
A quality strategy differs from a quality tool in being an overall approach an organization takes over a period of time, rather than a specific method for a particular purpose. Thus, a programmed for external inspection of hospitals is a strategy. A particular method for carrying out inspections is referred to by quality specialists as a tool. It is possible to pilot-test a tool, but not a strategy. Benchmarking is both a tool and a strategy. A separate WHO policy synthesis of research into quality tools is under work
Many strategies are reported in the literature, and are listed below. The research referenced refers to descriptions of the approach rather than to studies of effectiveness, which are considered later. Increasing resources: increasing the financing, personnel, facilities or equipment used in a hospital or health system, with the aim of treating more patients or treating the same number faster, better and at lower cost-per-person. Large-scale reorganization or financial reform: changing the structure of a hospital or health system so as to facilitate better decision-making or use of resources. Changes in financing methods are made as a way of improving quality. Strengthening management: improving quality by increasing management responsibilities, authority or competencies. It is sometimes used as part of other types of strategy. Standards and guidelines: formulating standards of what is expected from health providers, communicating, providing training in, and enforcing the standards.
Examples are the United Kingdom’s national standards frameworks, the Zambian national technical standards, and clinical practice guidelines for various health conditions. Most medical and clinical audits fall within this category, as well as some approaches called “quality assurance” and “clinical pathways”. Patient empowerment and rights: giving patients a voice, for example through complaints systems or patient satisfaction questionnaires, as well as publicizing what patients have a right to expect. There may also be methods to strengthen patient power through legal entitlement, advocacy or other institutions, such as a right to treatment within 30 minutes of arriving at an emergency room, and the United Kingdom “patient’s charter” of the early 1990s. A number of Nordic countries have patient guarantees as well as patient rights in law, and ombudsmen and other schemes to strengthen patient power.
ANALYZE STRATEGIES FOR SUSTAINABILITY OF YOUR PROJECT.
Why doesn’t sustainability occur when you just focus on it after launching the initiative? Let’s face it: after a launch, a certain amount of momentum simply gets lost. I call it initiative fatigue. Everyone works intensely to get to that launch point, and then the reaction tends to be, “We made it! Now we can ease up on our pace a bit.”
If you don’t have the structure and processes already in place to sustain, the stakeholders involved in the initiative tend to disengage or are pulled to other projects. Many factors are involved in this loss of momentum and focus, but the most important are:
The alignment of organizational resources I outline below addresses these issues. It establishes permanent teams, clearly designates accountability, includes analytic and clinical resources, and involves every level of the organization to ensure broad understanding and support for the change.
The three basic tiers of this structure are:
1. The Clinical Implementation Team (CIT)
Once a clinical work process (for example, pregnancy) has been prioritized for improvement, the clinical implementation team is assembled. The team includes individuals who represent every major step in the care process (for example, fertility; prenatal; L&D; postpartum). This is a broad sampling of stakeholder groups who will be affected by a data-driven improvement initiative. The clinical implementation team is led by a physician, a nurse subject matter expert, and a clinical operations leader; what I call the “leadership triad.”
Involving a physician, a nurse, and someone in operations on the CIT is very important. A physician could propose a plan that optimizes a process for physicians without realizing that it doesn’t fit the nurses’ workflow. Or a nurse could suggest a change that raises red flags for the operations team member. Engaging the entire triad ensures that an improvement works for the entire care team, not just one or two groups. This leadership triad extends beyond the CIT and, in fact, should flow through the entire structure of organizational improvement.
Each CIT member represents a group of peers who fill the same role in the workflow. The team member communicates planned improvement targets to this larger “constituency” in regular staff meetings and relates their concerns and suggestions to the clinical implementation team. In this way, every stakeholder affected by a change is aware of it and has the opportunity to provide feedback. I call this process fingerprinting.
The result of this iterative process is the establishment of a shared baseline—the agreed-upon protocol or standard for how clinicians and other staff will execute any particular clinical process.
2. The Clinical Workgroup
Once the clinical implementation team leadership triad has been selected, a small workgroup is formed. The workgroup is comprised of the leadership triad and best practices, analytic, and technical experts. This small, smart group does the legwork for the larger team by assembling and analyzing data and drafting tools like order sets, treatment protocols, and value stream maps. Additionally, the workgroup has primary accountability for studying the impact of the improvement effort and bringing forward that information to the CIT. The clinical implementation team will use that information to adjust the tools and process to foster ongoing improvement.
The team hears the workgroup’s findings and makes recommendations about which ideas to prioritize and how to roll out a best practice. This kind of participation and feedback cements each participant’s investment in quality improvement decisions and ensures that all participants understand the implications of any initiative on their clinical workflow.
3. Hospital Senior Executive Leadership
Of course, this structure and improvement methodology requires executive sponsorship. Understanding of a need for a different approach and being willing to make the necessary cultural changes must start at the top. It is difficult to surmount the challenge of involving clinicians on the frontlines of care in the process of improvement if executives aren’t completely on board with the approach. Executives who don’t embrace cultural change management may still drive some improvement by implementing analytics technology, but they will not achieve what they might have with a structure for continuous improvement.
DESCRIBE AT LEAST TWO TOOLS AND/OR TECHNIQUES YOU PLAN TO USE TO MANAGE QUALITY AND DEFEND WHY YOU CHOSE THOSE TOOLS.
Plan-Do-Study-Act (PDSA)
Quality improvement projects and studies aimed at making positive changes in health care processes to effecting favorable outcomes can use the Plan-Do-Study-Act (PDSA) model. This is a method that has been widely used by the Institute for Healthcare Improvement for rapid cycle improvement. One of the unique features of this model is the cyclical nature of impacting and assessing change, most effectively accomplished through small and frequent PDSAs rather than big and slow ones, before changes are made systemwide.
The purpose of PDSA quality improvement efforts is to establish a functional or causal relationship between changes in processes (specifically behaviors and capabilities) and outcomes. Langley and colleagues proposed three questions before using the PDSA cycles: (1) What is the goal of the project?
(2) How will it be known whether the goal was reached? and
(3) What will be done to reach the goal?
The PDSA cycle starts with determining the nature and scope of the problem, what changes can and should be made, a plan for a specific change, who should be involved, what should be measured to understand the impact of change, and where the strategy will be targeted. Change is then implemented and data and information are collected. Results from the implementation study are assessed and interpreted by reviewing several key measurements that indicate success or failure. Lastly, action is taken on the results by implementing the change or beginning the process again
Six Sigma
Six Sigma, originally designed as a business strategy, involves improving, designing, and monitoring process to minimize or eliminate waste while optimizing satisfaction and increasing financial stability. The performance of a process—or the process capability—is used to measure improvement by comparing the baseline process capability (before improvement) with the process capability after piloting potential solutions for quality improvement.53There are two primary methods used with Six Sigma. One method inspects process outcome and counts the defects, calculates a defect rate per million, and uses a statistical table to convert defect rate per million to a (sigma) metric. This method is applicable to preanalytic and postanalytic processes (a.k.a. pretest and post-test studies). The second method uses estimates of process variation to predict process performance by calculating a metric from the defined tolerance limits and the variation observed for the process. This method is suitable for analytic processes in which the precision and accuracy can be determined by experimental procedures.
One component of Six Sigma uses a five-phased process that is structured, disciplined, and rigorous, known as the define, measure, analyze, improve, and control (DMAIC) approach. To begin, the project is identified, historical data are reviewed, and the scope of expectations is defined. Next, continuous total quality performance standards are selected, performance objectives are defined, and sources of variability are defined. As the new project is implemented, data are collected to assess how well changes improved the process. To support this analysis, validated measures are developed to determine the capability of the new process.
Six Sigma and PDSA are interrelated. The DMAIC methodology builds on Shewhart’s plan, do, check, and act cycle.The key elements of Six Sigma is related to PDSA as follows: the plan phase of PDSA is related to define core processes, key customers, and customer requirements of Six Sigma; the do phase of PDSA is related to measure performance of Six Sigma; the study phase of PDSA is related to analyze of Six Sigma; and the act phase of PDSA is related to improve and integrate of Six Sigma