Much has been written about the pros and cons of leadership teams composed of senior healthcare administrators and clinicians, but there is little debate that active involvement by both parties is essential to the successful management of the hospital organization.
This is particularly true with regard to the strategic planning for and management of large scale projects; in no area is this truer than in the planning, selection, and implementation of an electronic health record (EHR). Given the increasing conversion of hospitals to an EHR, this article attempts to summarize a number of items which optimize the likelihood of this endeavor proceeding in an effective manner.
It is tempting for both administrative and clinical groups to view conversion from paper to electronic records as an information technology (IT) project. In fact, the optimal approach recognizes the integral role played by IT but recognizes such activity as an operations effort supported by IT and lead by Project Management. The most successful EHR initiatives will concentrate on project management governance first. The most common groups to look to for this governance will be a formal enterprise project management office or the IT department. There is no single governance structure that fits all organizations; rather, it is imperative for the Program Director to facilitate a process of aligning roles & responsibilities based upon the idiosyncracies of the specific organization. With this caveat in mind, what are the keys elements to ensuring the highly functional and successful EHR team?
First of all, how do we define the EHR Steering Committee? Can this be defined as a committee or as a task force? The former is generally applied to an entity with a common purpose and function but without a foreseeable end date. Conversely, a task force generally has a specific task to accomplish and may cease to exist once that is completed.
The EHR Steering Committee is often a hybrid of both because of its relatively long-term nature and the possible morphing into an entity with a temporally indefinite function. Regardless of how defined, the team needs to initiate its existence with a clearly defined goal and timeline. This necessity is apparent both from the standpoint of buy-in by the team's membership but also to put the activities in a context which is relevant to the organizations senior most governing body for the purposes of budgetary, resource allocation, and strategic planning.
There are numerous requirements for the ideal EHR Steering Committee's membership. As with all large projects, the optimal size of the Steering Committee is less than 12. The membership should include executives from the key areas being impacted by the project with well defined alternates. As would be expected, the membership will be tailored to the individual organization. Although there is a trend to use more teleconferences and/or videoconferences, the value of a face-to-face Steering Committee should not be underestimated. From a frequency perspective, the EHR Steering Committee will realistically only be able to meet monthly. One consideration to keep in mind is doing off-site full day meetings. One typical issue experienced by EHR projects is waiting a month for EHR Steering Committee's to meet to make key decisions can introduce significant delays into the project.
To guard against the natural constraints of the EHR Steering Committee, identify four individuals as Project Champions from the Steering Committee. We'll consider this the second key leadership team. The four individuals should be capable of representing physician, nursing, administration, and IT. This sub-committee of the EHR Steering Committee needs to commit to attending reliably and being active participants in the team's activities - we suggest meeting weekly so as to not allow a decision to stall beyond 1 week. Critical to this groups effectiveness is there being championed by senior most administrative leadership (e.g. Officers) who give the team decision making power.
Successful implementation requires that these individuals be "link-at-the-hip" since success is evidently dependent on both. Without such ability, critical decisions become delayed and potentially damaging. Consideration of individual members who "get along," while seemingly evident, can too often receive inadequate attention; lack of attention to this requirement can lead to interactions influenced excessively by personality and which distract from the teams primary purpose. Important to the overall process is the need for the members to consistently relay information gleaned from the team's activities widely among their constituents in the organization. The importance of this communication cannot be overstated as it not only serves to allay fears which occur as a natural consequence of such a large scale project, but avoids frustration resulting from individuals concerns and issues being not being heard and addressed.
In addition to the Project Champion's key role of making decisions for the project, this key Executive team should have the responsibility for being evangelists of the project and thus setting the right tone for the initiative. Ultimately an EHR implementation is a large exercise in change management. The Project Champions are in a unique position to start managing the change with early and often communications to all employees. A series of town hall "roadshow" sessions are valuable to explaining the end product that is coming, progress being made, and how it will impact every stakeholder. These sessions should also be used as an opportunity to ask the important question "what are you concerned about." What you will typically find is the participants may flag items that were not considered in the scope, requirements, and workplan of the project.
The third leadership team for the EHR initiative should be a strong Project Management Committee. The Project Management Committee will vary by the specific modules being implemented; however, there are some key components of this committee that should be in place regardless. The key roles includes: project metrics lead, project administrator for documentation, and the vendor's Program Director. Beyond that, a Project Manager should exist for each key workstream on the project based completely on the scope of your project. The Project Managers are the leaders focused on making sure tasks are being completed on time and on schedule. They are also focused on addressing the constant onslaught of changes, issues, and risks. A common thread between the Steering Committee, Project Champions, and Project Management Committee should be the Program Director. Ideally, this role is leading both teams.
Finally, Program Director is a critical leadership appointment and needs to be identified at its outset and can be the most difficult position to staff because of the idiosyncracies of organizations. The most important item to keep in mind when selecting the Program Director is finding someone that can be closely aligned with the Officers on the Project Champion's Committee. This position must be an employee and fully dedicated to the EHR project. When selected, the initial role of the Program Director may best be described as that of a facilitator. Labeled as such in the early phase of the team may be less intimidating to the senior most members of the organization; more specific expectation of the Program Director's role generally comes as a natural consequence of time and greater confidence in the process.
Ideal functioning of the Program Director is best supported by a strong set of project governance processes. At a minimum, the project governance processes should include the following:
- scope management – defines how the scope is protected and managed
- communication management – defines content, target audience, communication channel, and frequency
- meeting management – defines rules of meetings such as agendas, meeting minutes, timelines, and logistics
- resource management – defines roles/responsibilities and appropriate staffing
- schedule management – defines how changes to the project schedule will occur
- change management – defines how changes to budget, schedule, scope, and requirements will occur
- issue management – defines how issues will be triaged and addressed
- risk management – defines how risks will be mitigated
- quality management – defines the plan to ensure the highest quality in the end product and resulting processes
- budget management – defines a process for ensuring the project is delivered on or under budget
- records management – defines where the enormous volume of project artifacts will be stored and easily accessed
- performance management – defines reporting of key metrics regarding the project performance such as earned value
- defect management – defines expectations around defects
These pre-defined processes provide a process framework to the EHR initiative that have important implications to the success of the team. You will find that the most successful Program Directors, Steering Committees, and Project Management Committees manage the process around the project versus the content. Whereas the details of these pre-defined processes ultimately are strikingly similar from one organization to another, it is critical for the Program Director to work with the Steering Committee, Champions, and Project Management Committee to define organization specific processes. For no other reason, this builds buy-in into the governing processes that are used day-to-day for a very long endeavor.
In addition to the above actions helping to ensure that the team succeeds in meeting its goal(s), functioning as described has a number of secondary benefits. These benefits include building a strong sense of camaraderie among team members. A highly effective EHR team has addressed one of the most challenging projects in health care today; such a team is likely to be similarly successful in a number of health care endeavors.