Physicians have traditionally been individual thinkers and doers. Healthcare in general has been generally slow to adopt proven successful methods of processes and technologies employed with success in other sectors of society. Medical training from medical school through post-graduate education has been traditionally focused on the individual. Hospitals these days are driven by regulatory issues surrounding patient care. In reading about project management (PM), I have noticed that much of what I did as a practicing physician fit into standard PM teaching. However, it helps to frame a discussion around PM today in the context of healthcare, because of how fragmented care delivery is.
1. Collaborative interaction is a key component to success. It fosters constant and open communication, multidirectional input, and conflict resolution as it occurs, not when it is too late. Team management of patients is something which is catching on, but is not universally practiced. Multidisciplinary hospital rounds including pharmacy, nursing, discharge planning are important to identify patients at high risk of readmissions, improve the relay of consistent and accurate information to the patient and caregivers, improve documentation, and indirectly improve patient satisfaction and efficiency. Collaboration and communication among personnel in the operating room is especially important and in one study “Communication failures in the OR …occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.” Electronic health records and their interoperability are being implemented to facilitate collaborative interactions among different technologies and providers. There are even intra-office communications problems which have negative outcome implications for patients. There is a long way to go on that front, mostly due to non-technical issues.
2. Planning, execution and management are other important fundamentals of PM. Key to this is the project manager. ‘Ownership’ of the patient from a supervisory standpoint is important. A patient with multiple co-morbidities and chronic diseases (especially in ED and ICU patients) might commonly have multiple physicians and other providers involved in care. Communications among team members in the ICU is important to not only resolve conflicts among ICU team members, but to improve care at the time of discharge from the ICU. Reevaluation of the patient at certain milestones (on admission, important relevant tests, significant change of clinical status, pre-discharge, etc) with the entire team is important for clinical decision-making, communications to family members, and transfer of the patient to an outside facility.
3. Sharing a vision is paramount in any team project. Goal alignment and vision as well as support from the managers all constitute part of the foundation for ongoing good morale and thus execution. If the hospital, physician, and others have different visions, the patient will not be receiving the best possible care. I always surprised people by saying that my biggest decisions were based on what would benefit the patient. They were invariably the right decisions.
4. Technology today plays a role in all project management; however it is never a solution. Project management uses technology as tools in projecting costs, keeping track of personnel, timeline milestones, efficiency and budgets. Hospitals and providers are using more and more technology to collect, analyze and reference information. Technology in all instances needs to be considered and utilized as a tool and not a solution. Though the implantation of a pacemaker might be a solution to a patient’s problem, the monitoring of that device wirelessly for evaluation of device system function and the patient’s arrhythmia status are tools to support that solution. Good medical apps are potential tools which can be used for reference, patient self-monitoring, and disease management. They do not serve as a substitute for a physician or other healthcare provider.
5. Costs matter. Hospitals and others are today looking more at costs and less at the revenue side of budget planning. Bundled payments, decreasing reimbursements, and the dissolution of fee for service models have all driven this shift. The purchase of medical equipment and devices has seen a drastic shift in processes as well as players. Project management preaches minimizing scope creep (which invariably raises costs). In the same vein, healthcare must minimize cost creep. In order to do so might mean examining some (the less clinically impactful and more regulatory-laden) provisions of the ACA.
I did not intend to give a seminar in PM, but merely to frame a discussion around the idea that healthcare changes can come about without fundamental changes. Some are accomplished with institution of principles of PM, and some require cultural shifts in education, roles of providers, relative emphasis of technology, and most importantly with who is most important, the patient which should be at the center of all major healthcare PM decisions.