FOCUS:Process Improvement/Project Management …s3.amazonaws.com/rdcms-himss/files/production/public/HIMSSorg/... · ... Christiana Care has observed significant and sustained

FOCUS: Process Improvement/Project Management

54 Journal of Healthcare Information Management — Vol. 21, No. 1

It was May 16, 2005, and the bed management projectreached a critical juncture. The project team had encoun-tered a showstopper issue and had to present a recom-mended course of action to the project steering committee.

The bed management system, as designed, would not meetfuture state process requirements. The system could beimplemented on top of current state process by the targetgo-live date of June 30, 2005, but to get to the expected

Showing “What Right LooksLike”—How to ImprovePerformance through aParadigm Shift around

Implementation ThinkingDonna James; Steve Hess; Jacob E. Kretzing, Jr., MBA; and Mark E. Stabile, JD, PMP

A B S T R A C T

During a three-year period, Christiana Care has observed significant and sustainedimprovements in technology-enabled project outcomes. Just in the patient throughput area,

Christiana Care has seen an 11 percent reduction in length of stay in the emergencydepartment (ED), a 23 percent reduction in patients leaving ED without treatment and a

28 percent reduction in bed-clean turnaround time, all while accommodating patientvolume increases of 7 percent.This performance is directly related to a broader view of

implementation embraced by the organization. By looking at more than just traditionalproject management, Christiana Care has shifted their implementation paradigm, focusing

on benefits planning, user adoption, value realization and goal delivery within the portfolio.This has been a result of a journey that has included a subtle but deliberate introduction ofthe new implementation thinking, primarily marked by an experience-driven approach ofdemonstrating the benefits of good implementation practices. Christiana Care has created

the environment and process to get the greatest value for its IT-related investments and to show “what right looks like.”

K E Y W O R D S

■ Implementation ■ Project management ■ Portfolio management ■ Change management


Journal of Healthcare Information Management — Vol. 21, No. 1 55

future state benefits, the software had to be re-architected,and the team would miss the published go-live date.

“The decision was easy,” said Gary Ferguson, executivevice president and chief operating officer of Christiana CareHealth System. “Even though implementing the bed manage-ment system by June 30 was an organizational and manage-ment goal, the project team clearly showed how the benefitswe were hoping to achieve would not be delivered. Weagreed to accept the recommendation to delay the imple-mentation, our IT team worked with the vendor to recon-figure the system, and we implemented successfully lessthan four months later. We are now achieving outcomes forbed turnaround that exceed national standards.”

In the past, this decision—and the process to get to thisdecision—would not have been so easy. Most likely, thesystem would have implemented the system to meet the go-live date, and Christiana Care probably would not havereceived the greatest value out of the implementation. Or it would not have done enough of the process andplanning work to understand the full potential benefits that could be attained.

Christiana Care has experienced a true paradigm shift inits perspective of implementation. It has embraced a broaderview of implementation that combines process improvement,project management, portfolio management, organizationalchange management and risk management. These disci-plines, when integrated into project thinking, enabled thesystem to plan for and achieve maximum benefit realization.However, it did not happen overnight.

The Impetus for Change

Based in Wilmington, Delaware, Christiana Care HealthSystem is one of the largest healthcare providers in the Mid-Atlantic region, serving all of Delaware and portions ofseven counties bordering the state in Pennsylvania, Marylandand New Jersey. The not-for-profit, privately ownedChristiana Care family of services includes two hospitals—Christiana Hospital, on a suburban campus south ofWilmington, and Wilmington Hospital, in the downtownbusiness district of the city. Christiana Care has nearly 1,100licensed hospital beds, a major regional center for heart andvascular health, and the only Level I trauma service on theEast Coast corridor between Philadelphia and Baltimore.

In early 2004, a lot of change was occurring at ChristianaCare. Within the previous eight months, there had beenchanges at the CEO, COO and CIO levels. With new leader-ship came new strategy and an appetite for change. Thenew leadership team saw the need to accelerate perform-ance improvement initiatives and targeted five strategic focusareas—improving patient safety, clinical excellence, patientsatisfaction, physician and employee engagement, and finan-cial strength.

While Christiana Care’s performance was good in all ofthese areas, greatness was the goal. The IT department was

no different. The IT application and technical infrastructurewas sound; however, with many systems and good connec-tivity, the organization was not using the systems, data andinformation to its ultimate potential effectiveness. Whilecustomer satisfaction with the IT department was high andthe service orientation of the department was strong, thefocus and ability to deliver on projects was not where itneeded to be. The IT department and infrastructuresupported the organization, but it did not enable the organization. The new leadership of the health system was looking to change that.

“Both quality initiatives and financial conditions willcontinue to exert pressure on hospitals to improveprocesses, be more efficient and be more nimble. What we wanted to do with information technology projects wasto take a look at how we are doing things, how we shouldbe or need to be doing things, and use the technology-related projects to get us to where we needed to be,”Ferguson said. “In the past, we probably implemented a lotof systems and software on top of existing processes. Weneeded to change that. We looked to the technology-relatedprojects to drive the change and enable the change acrossthe organization.”

The Structure for Success

The approach was to have the technology-related projectsplay a greater role in enabling change and improvements.Software and systems no longer would be implemented ontop of existing inefficient work flows. Instead, work flowsand processes would be analyzed to identify opportunitiesfor improvements. Project teams would be expected tounderstand the potential clinical and business value to createachievable and sustainable solutions. Projects also wouldneed to be well planned, executed smoothly and evaluatedto ensure actual benefits matched expected benefits. Thesechanges would enable the healthcare system to be moreefficient, deliver better quality of care and make everyone’sjob easier.

But in 2003, the IT department was not positioned todeliver successfully. The department would set go-live datesbefore the appropriate level of planning was done, and itsubsequently missed the dates. It would manage scope and

“Software and systems no longer

would be implemented on top of

existing inefficient work flows.

Instead, work flows and processes

would be analyzed to identify

opportunities for improvements.”



risk inconsistently and encounter project surprises. The ITdepartment did not always do the appropriate levels ofbusiness process analysis, or it only focused on current stateand therefore did not understand, and missed opportunitiesfor future state benefits. Its success was a result of individualheroics rather than collective focus and structure.

While the department was aware of these shortcomings, itis hard to change the culture, focus, skills, maturity andother organizational dynamics in a single day, or even in asingle year. This included introducing traditional improve-ments in project management maturity (see OPM3), but thatwas not the focus. The strategy deployed was to introducedifferent ways of thinking, different roles into the environ-ment, different ways of working and different ways ofwatching performance. The idea was to continue to build on

a solid, sustainable foundation rather than trying to intro-duce and implement an overwhelming amount of change atonce. This approach has been used during the past threeyears, and it is continuing to be built upon.

In 2004, the department spent significant time assessingthe environment and creating a foundation for futureimprovements. Before it could determine where it needed togo, the department had to better understand where it was.The assessing phase included conducting an assessment ofthe current state project management process using a gener-alized capability maturity model; identifying and assessingother integral processes related to organizational changemanagement and resource management; assessing the readi-ness of the IT department and the overall organization forthe change required; and developing courses of action tomove the organization forward, including developing astandardized project management methodology.

The assessment and findings led to specific activity toinitiate the change. The IT department established a projectmanagement office led by an experienced leader with anorganizational dynamics background, not a certified projectmanagement professional. It also defined internal oversightcriteria for projects—managed, guided and monitored—forprojects based on their complexity and value. Projects weremanaged by resources in the project management office;guided projects received oversight and mentoring from theproject management office leader; and monitored projectsreceived minimal oversight.

The department created a foundation of project manage-ment capability to reduce the risk associated with theprocess of project management. For example, it usedexisting vacancies to hire experienced project managers;developed methods and templates within a standardizedproject management methodology; developed projectmanagement and methodology training; and developed aproject management Web site as the central repository forproject management methods, tools and lessons learned.

Christiana Care saw year one as a critical stage of thetransformation. This is the year the IT department and theorganization would and should begin seeing a change,although probably a subtle one. It was also the year withthe greatest risk of failure. Many process improvements dieor lose momentum before any value is attained.

Thus, those seeking the change took a risk. Instead ofstanding in front of the organization and stating, “Here iswhat we are going to do,” and showing diagrams, organiza-tional charts and other pictures and words, the IT teamwanted to use a visible project to begin changing theenvironment. In essence, it wanted to “show what rightlooks like” instead of just talking about what right shouldlook like.

The project selected was an emergency departmenttracking system implementation. The Christiana Careemergency department, like many others, is a complex andsometimes chaotic environment, providing care for morethan 138,000 emergency visits each year. With many staffmembers, many patients and many pieces of equipmentconstantly moving around a large physical area, the ability totrack where everyone and everything is at any given time isnot a simple task. The department needed a passive trackingtool that would enable efficiency and not add yet anotherburden to the staff.

This project had many of the variables that would help to demonstrate the shift in implementation thinking. It had visibility within the organization; departmental-levelscope with enterprise-level implications and benefits; potential impact for measurable outcomes; engaged businessand clinical leadership; known technical solution in themarketplace; and a complex process with known currentstate gaps.

“Often, we would not know where a patient was,” saidLinda Laskowski-Jones, vice president of trauma, emergencyand aeromedical services. “The patient may have been takento radiology, but the front desk was unaware of that. Wedesperately needed something that would help us managepatient flow and patient care flow better. We knew thetechnology could help us, but we also knew that this was an operations issue, and we needed help to change the waywe worked.”

To pursue this opportunity, the IT department organizedteams differently, defined and refined roles (both IT andorganizationally), put more emphasis on the upfront process

“…the IT department focused

on introducing project and portfolio

management processes as a

natural part of the project work it

was initiating.”



work, did the appropriate level of planning before settingthe go-live date, managed the scope with the appropriategovernance and communicated project status in a newstandardized way. More importantly, the project teamensured the clinical staff of nurses and physicians partici-pated in the process-design and problem-solving meetings,and ensured the clinical leaders were there every step of theway, providing vision, support and barrier resolution.Although individuals were playing vastly different roles thanthey ever played previously, they could see their role hadvalue and their input was being heard, and the results ofthese efforts were evident.

The IT department not only delivered a successful projecton time and budget, but it developed a new process for theemergency department to care for patients. Shortly after go-live, the department was experiencing positive outcomesdirectly attributed to the implementation. For example, theaverage length of stay in the emergency department foradmitted patients was reduced by 36 minutes, an 11 percentreduction; the average length of stay in the department fortreated and released patients was reduced by 14 minutes, or5 percent; the percentage of patients who left without treat-ment was reduced by 24 percent; and there was a statisti-cally significant improvement in wait times and overallpatient satisfaction.

The effort also provided a picture of the new way ofimplementing systems at Christiana Care.

“We embraced the technology and system because wesaw how it could help us manage a chaotic ED environ-ment. But, what we did differently with this project wasembrace the necessary business process changes prior to thetechnology implementation,” Laskowski-Jones said. “The ITdepartment and their implementation approach helped usposition the initiative for mutual accountability and ultimatesuccess. The new approach engaged our department in theproject differently than we had ever experienced before—wewere all involved in building a solution, not just imple-menting a system. I never want to take on another IT-relatedED project without following the same process.”

Defining the Implementation Framework

This created the impetus to build on the year one foundation. In year two, a more formal IT framework andstructure was created to help capture work, resourcerequirements and focus. The IT department made changes to people, processes and tools within what was called itsDefining Phase.

In this phase, the department focused on building ashared understanding of the separation of work (projectsversus productional support), work priorities and roles. Itdefined resource roles and allocated staff assignments basedon those roles. It also created a leader’s analysis method tobridge the gap between organizational goals and projectsuccess, with the intent of engaging sponsorship early in the

process to provide clear guidance to the project team.As part of the defining phase, cross-team planning

meetings within the IT department were introduced toexpand the participation of formal and informal leaders inthe fiscal year planning process. Extended leadershipmeetings were established to highlight progress and createaccountability for team and project leaders in reportingstatus against departmental goals. The organization usedexisting vacancies to hire additional project managers, and itcreated a portfolio database tool to capture project work andkey information related to project progress.

Continuing the philosophy of showing the changes ratherthan talking about the changes, the IT department focusedon introducing project and portfolio management processesas a natural part of the project work it was initiating.

To accomplish the experience-driven change approach,the IT department used a clinical system upgrade project tobegin introducing the new implementation thinking to abroader audience. The project involved a major upgrade ofcore clinical systems and electronic medical records, and ithad many of the attributes sought in a demonstrationproject—visibility within the organization, enterprise-levelimplications and benefits, broad reach into the IT organiza-tion, involving many IT staff members and leaders, andknown vendor and vendor relationships.

The purpose of the upgrade project was to begin intro-ducing new implementation paradigms to the greatestaudience possible, within both IT and the organization;create a better vendor management structure with the coreclinical vendor; drive functional benefit to the business; and set the stage for a more complex clinical project. In the past, this would have been strictly viewed as an “ITproject.” Instead, the IT department had departmentalleaders from nursing, pharmacy and surgical schedulinginvolved in defining success around current operational and system issues.

All goals were achieved, including rectifying 68 percent ofthe outstanding issues from the previous software version,providing end users with greater functionality and intro-ducing a more refined structure for vendor management.The project also met the goal of exposing the project teamstructure and roles to a broader audience, within both ITand the healthcare system. The upgrade project was used toraise the comfort level of those involved in clinical systemimplementations. This experience set the stage for a muchlarger and more complex clinical initiative to implement theelectronic medications administration record and bar codingat the point of care the following year.

Simplifying Complexity

The new way of working, while not perfect, was deliv-ering focus and results effectively. With a more formalframework in place, the IT department began havingintegration discussions, pulling projects, processes and infor-



mation architectures together. More than ever before, manyIT leaders had to reach out into the clinical and businessareas to understand the environment and set the context forpriority discussions and decisions.

Year three was called the Learning Phase. It included:• Engaging senior organizational leadership with more

formal roles and expectations, more than ever before,through IT steering committees with a focus on usingsteers for business driver, project success guidance, escalation resolutions and resource assignments.

• Directly linking organizational and departmental goals toIT focus and goals.

• Introducing staff planning, including the assessment oflevel-of-skill proficiency for specific roles, and identifyingconflicts and gaps as development and augmentationopportunities.

• Identifying and discussing integration points betweenprojects, including dependencies and prerequisites, link-ing projects to programs within the portfolio.

• Focusing on planning and go-live milestones within theportfolio process and creating the accountability to meetexpectations.

• Introducing a project complexity model to guide scalabili-ty and use of the project management methods and tools,recognizing not all projects are equal, and certain projectsrequire more oversight and focus than others.

• Instituting biweekly portfolio review meetings to provideactive portfolio oversight and to create a shared under-standing of projects, issues and focus areas.

• Utilizing priorities to determine resource conflict resolutions.

• Creating a formal process for introducing new work intothe portfolio.

• Implementing a formal production change managementprocess for introducing changes into production.

• Modifying the portfolio database tool and process, moving it away from a project management status tool to a true higher-level portfolio tool.

With previous successes to learn from and lean on, thenew way of implementing systems was becoming more thenorm than the exception. One of the focuses of the organi-zation was to improve patient throughput, includingreducing the length of stay. This not only helps improvefinancial strength but it also increases patient safety andclinical excellence, creating the capacity for the healthcaresystem to function more efficiently.

“If we can reduce our length of stay by two-tenths of aday, it equates to a 40-bed unit,” said Ferguson, COO,Christiana Care.

With the new implementation paradigm as a framework,Christiana Care initiated a bed management project. Afterdoing the current state-future state process work, the organization laid out a framework for a multi-faceted, multi-phased approach. The first phase involved bed turnover,

which means cleaning beds as efficiently and effectively aspossible to enable the next patient to be admitted in atimely manner.

The existing process for turning around beds was fairlyreactive, with staff cleaning beds when the next patient wasready to be placed. It also did not allow time for environ-mental service assistants to be dispatched to hospital areasthat had high demand. If three beds were lined up to becleaned in one unit, the service assistant assigned to the unitwould clean them all, one at a time, creating delays withbed placements.

The organization needed a new way of processingcleaning requests, distributing the workload appropriatelyand providing service-level accountability to the organiza-tion. While all the process changes were defined and withthe environmental system organizational structure changesmade, the system was implemented successfully, but not on time.

This is where the learning has come in. Conducting thecurrent state-future state process work, mapping to organiza-tional goals and really understanding the fundamentalchanges that were necessary to drive maximum successbecame the basis for the technical solution. While, this mayappear to be a basic requirements definition, this funda-mental understanding was extended to the entire team.

During unit testing, the project team recognized a failurepoint and that the system needed to be reconfigured toattain operationally defined success. Because the organiza-tion had started to adjust its definition of success and shiftedits implementation approach and thinking, it was able toinvolve appropriate stakeholders and make the rightdecision for the organization to delay the project, re-architectthe system, enabling it to implement it with a much greaterchance of success.

The results were and continue to be remarkable. “We areturning around beds in about 32 minutes, while industrystandards are in the 50-minute range,” said Rick Olivere,director of environmental services, Christiana Care. “Theovernight shift used to average 40 to 50 beds cleaned eachnight; now, they are down to six. This is a result of less bedcleans being carried over from shift to shift. These dramaticoutcomes are a result of making significant changes to ourprocess and work flow, and we used the project implemen-tation to introduce those changes.”

In addition to turning around beds more quickly, theprocess for requesting beds to be cleaned is moreautomated, and the status of bed requests are more visibleto everyone in the hospital. This efficiency gain was not loston the nursing team.

“Our recent technology-related implementations havereally been collaborative efforts between nursing, IT andother service departments. The focus on nursing efficiency is understood by all and is really driving benefit to thehospital,” said Diane Talarek, senior vice president of patient



care services and chief nursing officer. “When the nurses areon the phone calling for beds and trying to track downhousekeepers, they can’t be with the patient. This is notabout the IT department pushing systems on us; this isabout looking at the patient-care work flow and usingsystem implementations to help nurses do what they dobest—take care of patients.”

Continuing the Paradigm Shift

Now, in year four, a sustainable structure and process forplanning and executing the IT project portfolio has beencreated, but it continues to grow and mature in how theportfolio is managed. The current phase is called theManaging Phase. It involved:• Introducing goals for each enterprise and department

level project.

• Aligning all goals to Christiana Care’s annual operatingplan and ensuring goals are measurable.

• Shifting accountability for planning to directors and their teams.

• Introducing change-control process for goal changes and approvals.

• Conducting portfolio risk assessment and developing arisk-management plan for portfolio.

• Identifying key integration areas related to process, application, platform and developed formal integrationactivities.

• Instituting organizational structure changes to better alignpeople to roles that leverage their skills and provide focusand clarity for work deliverables.

• Increasingly using the project management Web site forproject information management.

• Creating a project phase duration tool to provide betterestimates to guide project planning.

• Formally communicating expectations for early escalationof issues.

One of the most significant changes introduced this yearis how overall project success is measured. In years onethrough three, the organization had focused on schedule,budget and benefit, but in year four, it has introduced morequalitative measures to go with traditional quantifiable ones.Moving forward, it is measuring project success across threedimensions—goal delivery, quality and acceptance (SeeTable 1).

Each project will be measured against the three areas,with the quality and acceptance measures being scoredusing surveys. The new measurement tool provides a magni-fying glass into implementation delivery performance,enabling the organization to continue to focus on the areasthat need attention, and enabling the organization tocontinue to build on its success.

Future years and phases are expected to optimize theprocesses and structures that have been created. Initially,



that will involve spreading awareness and participation inthe implementation methodology into operational depart-ments. This will mean reinforcing the value of alignmentbetween IT projects and operational goals, as well asenabling departments to experience the benefits of increased leadership and participation in projects.

Enabling the organization will continue to involve acombination of structural project methods, excellence inproject delivery and organizational change management. For instance, the IT department has embarked on an enter-prise architecture project that will help make architectureand integration discussions and decisions more efficient. By improving the communication with departmentsregarding technology, IT can team with operations to deliver better value.

One important element will be to continue to raise thelevel of knowledge of the IT team, not only about standardindustry methodologies and approaches, but also aboutbusiness and clinical processes. The roles of individualsinvolved in IT projects will continue to be fine-tuned, notonly within IT, but within the business and clinical areas aswell. The department also will continue to put portfoliomanagement tools, communication tools and leadership andstaff structures in place to provide the oversight andmanagement needed to ensure progress is being made inthe most efficient manner possible. All together, these tacticsand continuous improvement of the processes and structuresenabling implementation will optimize the ability of IT todeliver high value to the healthcare system.

All the changes made to the people, processes and toolsin the past three years have become a fairly natural part of

the way business is done. The level of thinking, the integra-tion of discussions across projects, and the ability to see andmanage conflicts proactively have all improved steadily.There is a real appreciation for the organization’s strategy,an understanding of goals and a growing culture of account-ability toward achieving those goals that is becominghardwired into the department.

“We have had a lot of organizational success over the pastseveral years,” Ferguson said. “The IT department has beentransformed from a support organization to an enablingorganization, and with that change, Christiana Care hasreaped the benefits.”

Conclusion

The maturation of an organization does not happenovernight. It takes not only a vision, but also a steadyapproach to be executed and difficult decisions to be madeto ensure progress is foundational and sustainable, and thatfuture success builds upon past learning (See Table 2).Success is not achieved by implementing industry standardmethodologies alone. Rather, success is achieved byadopting a broader view of implementation that will deliverorganizational benefits.

In this case, the concept of implementation combinesprocess improvement, project management, portfoliomanagement, organizational change management and riskmanagement. However, adoption of this implementationconcept involved a paradigm shift for the organization. It isa slow process that has involved establishing a structuralframework, demonstrating the benefits of that model,integrating operational performance focus with projects and



then enabling the organization to operate in a new goal-oriented implementation environment.

No two healthcare organizations are alike, and eachorganization’s structure and culture must be understoodbefore embarking on major IT change initiatives. ChristianaCare executives still believe it has a long way to go. It plansto continue to use a subtle and sustainable approach toimprove implementations. It will continue to use importantIT-enabled projects to change the way it thinks and works,helping to “show what right looks like.”

About the Authors

Donna James is the director of the project managementoffice at Christiana Care. She has been with the organizationsince 2002.

Steve Hess is the vice president of IT and chief informa-tion officer at Christiana Care. He has been with the organization since 1991 and has been CIO since 2003.

Jacob E. Kretzing, Jr., MBA, is a senior partner atGreencastle Consulting, where he leads solution implemen-tation and engagement delivery.

Mark E. Stabile, JD, PMP, is a senior partner atGreencastle Consulting, where he leads client solution development.

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FOCUS:Process Improvement/Project Management …s3.amazonaws.com/rdcms-himss/files/production/public/HIMSSorg/... · ... Christiana Care has observed significant and sustained