“Preparedness prevents peril.” – Chinese proverb

“Be prepared.” - Boy Scout motto

“I have a plan!” – Dr. Strangelove

A fundamental principle of project management is that the more complex the
project, the more detailed the plan for mitigating risk. Transforming a health
care organization to more integrated, technology-enabled, cost-competitive clinical
processes is a complex and risky endeavor. Yet, the wreckage of over-budget
and delayed IT implementations throughout the health care industry makes the
case for proper planning at the onset of these projects. Often, organizations
fail to appreciate just how vast and complicated a clinical transformation project
is. Sometimes, a sense of urgency to cut to the chase can give short shrift
to the planning process. Perhaps it’s the perception that planning isn’t really
taking action. After all, when the government commissions a study, we don’t
expect decisive action anytime soon. To the cynic, planning connotes inaction
or even procrastination.

In reality, project planning is essential to project success. Far from a passive
endeavor, planning is a time for the most active and talented people to focus
their multiple fields of expertise on a plan that will guide the project through
system implementation and beyond. The considerable time and effort spent planning
and organizing a clinical transformation are well invested. Measured against
the very real risk of failing at a mission-critical initiative, an implementation
team soon realizes that project planning pays off handsomely.

One health care system, for example, took the time up front to identify the
right staff to participate in the implementation and then trained them to use
the chosen products so that they knew the functionality and capabilities of
the applications before the project began. This organization also identified
the skills that were essential to the project’s success and interviewed consultants
and IT vendors to acquire those skills. They insisted on the right to exclude
from the project any personnel proffered by vendors who didn’t bring to the
table desired attitudes or skills. This organization invested in meticulous
pre-implementation planning. It should come as no surprise that the subsequent
implementation was a recognized success.

Fast or Right?

The philosophy behind project planning is that doing it fast is less important
than doing it right. By the time a clinical information system goes live, a
methodical approach to project planning always proves its worth by assuring
a product that’s well worth the investment in time and money. While there are
legitimate, methodical ways to accelerate a project’s timeline, these methods
must not cut short the necessary steps of planning or stakeholder involvement.

Plan the Work to Work the Plan

A proper project plan will provide a level of detail that is appropriate for
the work that needs to be done. It will keep everyone involved in the implementation
focused on what needs to be done — and not distracted by features or functions
that are beyond the scope of the project. How much planning is enough? More
than what’s required for an average construction project. A useful rule-of-thumb
estimate is that approximately ten percent of the duration of the overall clinical
transformation should be devoted to detailed project planning. It is not uncommon
for IT vendors writing proposals for systems that will cost upwards of $50 million,
and will occupy implementation teams of hundreds of people for several years
to schedule just a few short weeks for intensive planning. Such an approach
fails to appreciate the magnitude of complexity that a proper implementation
plan must address.

A project plan must set up an infrastructure for the implementation and develop
the wide-ranging sponsorship that assures the system will be adopted by physicians,
clinicians, and others throughout the enterprise. An incomplete or sloppy plan
can multiply many-fold the unpredictability and risks associated with a project
as complex as implementing an advanced clinical information system. A lack of
planning will undoubtedly lead to overruns and delays over the course of the
project. Proper planning will never fully eliminate delays or overruns, but
it will minimize these factors.

Charters and Work Plans

The project charter provides the foundation for the project by defining its
scope, objectives, and overall approach. The charter contains key information
required to initiate a project, such as high-level project plans, the organization,
and staffing approach. Most importantly, a charter provides the project team
with a clear definition of the project direction, expectations, and the approach
to managing changes to the project.

The work plan, like the charter, provides an opportunity to get things right
up front, which prevents delays, budget overruns, and systems that don’t deliver
promised benefits. The intersection of complex technologies with varied organizational
structures, different interrelationships among clinicians, and unique clinical
processes makes for an extremely complicated system implementation project.
These complexities translate into unpredictable implementation results, which
translate into disappointed executives. Tackling such an undertaking that is
both extremely complicated and mission-critical requires a cogent and detailed
plan.

Work plans provide a level of detail that helps to visualize and identify the
elements of a project, and the interdependencies among various software applications.
With this information, the level of effort and resources needed can be estimated,
and budgeted appropriately. A work plan is a map for moving forward. Inevitably,
that map will change, but the map provides a consistent track to which adjustments
can be made.

Sample Work Plan Activities

Planning and Evaluation

• Develop program structure
• Identify and secure sponsors
• Complete the project charter
• Confirm project scope
• Structure the team
• Confirm skills required and develop plan for project team training
• Develop workplan
• Define meeting schedules
• Develop status reporting tools
• Develop communications plan
• Develop database to log and manage issues
• Plan for integration of process improvement opportunities and technology
  system design

Analysis

Support education team responsible for training

Implementation

• The project team will support the following implementation activities:
  
  • Conversion
  • Device deployment
  • Final testing
  • Preparations for live use
  • Cut-over activities
  • Dress rehearsal
  • Go-live activities
  • End-user support
  • Issue management
  • Continue to implement process improvements
  • Conduct post-conversion support and evaluation
  • Monitor and report on expected benefits

Integrated Approach

Clinical transformation results from concurrent improvements in IT, organizational
change, and process improvement. No part of the equation can occur in isolation.
Workable applications require close collaboration between clinical and technical
teams. For example, teams implementing process improvements need to be mindful
of the strengths and constraints of the enabling technology. Each order set
or clinical process designed by the clinical team must be within the capabilities
of the chosen applications. Getting processes right requires close communication
and coordination among clinicians and IS technicians. Managing these collaborations
is in itself a complex process.

More complex still is the integration of multiple, individual workplans —
perhaps dozens of them — into a comprehensive project workplan. For example,
there must be workplans for testing and training an interface, or data integration,
workplan; a technology support workplan; and a communications workplan. There
are workplans to address process improvement, and workplans for each individual
application. In a clinical information system, there may be workplans for
order management, clinical documentation, medical records, patient access,
pharmacy, radiology, and laboratory applications. All these individual workplans
need to be integrated into one project workplan, so that the appropriate resources
can be brought to bear on them, and interdependencies coordinated. Planning
and productivity applications such as MicroSoft Project and other web-enabled
tools help hospitals track a project’s progress, milestones, and interdependencies
on a weekly or daily basis. Many organizations are beginning to use the Web-enabled
enterprise-wide planning tools to manage and update multiple projects, as
well as track resources and benefits on a real time ongoing basis.

Building a Plan

It is a useful exercise to compare the planning requirements of a major system
implementation such as an enterprise-wide clinical information system to a
major construction project, such as building a new hospital wing. The financial
investments are similar. Yet, in spite of the fact that no reasonable person
would begin to erect steel beams without an architectural blueprint, system
implementations are often begun with only rudimentary planning. The planning
comparison becomes even more lopsided if the enormous complexity of a CIS
implementation is considered. For example, in a construction project, the
building components interact in predictable ways. Design challenges are based
on vast prior experience and can be foreseen. In system integration projects,
individual applications are constantly evolving and interactions among them
can be unpredictable. These complexities make planning a clinical transformation
potentially more demanding than planning a construction project. Where there
is risk, there needs to be robust and knowledgeable planning to address and
mitigate that risk. Viewed from this perspective, health care providers would
do well to heed their own medical experience regarding the worth of “an ounce
of prevention.”