Project management in the health sector

THE CONTENTS OF OUR WORKSHOP

1. How good is the health sector?

2. Examples of problems: health care

3. Examples of problems: project management

4. What causes problems?

5. How can we improve? The diagnosis phase

6. How can we improve? The treatment phase

7. What you can do: rules for project management

MY ARGUMENT

o The health sector has lots of good individuals

BUT

o Teamwork is usually bad and therefore efficiency and quality are unsatisfactory

o There are some useful ideas and techniques for project management

BUT

o Teamwork is usually bad and therefore efficiency and quality are unsatisfactory

o The solutions are the same for good routine management and good project management

o Both require good teamwork

1 HOW GOOD IS THE HEALTH SECTOR?

o It should be good. In most countries:

It gets 8% of GDP (a lot of money) It gets some of the best students It has long and expensive training programs It gets high levels of citizen support Its staff are highly respected It spends a lot on research and development Accreditation, licensing, and auditing

o But it’s actually very bad

2 EXAMPLES OF PROBLEMS: HEALTH CARE

A. Celje Hospital (Slovenia)

B. King Edward Hospital (Australia)

C. Bristol Royal Infirmary (UK)

D. Winnipeg Clinical Center (Canada)

I studied 11 legal enquiries in 7 countries

Because there was a chance that the truth had been found.

Here are four of them:

o Problems for 8 years

o 2500 path reports not produced or not returned

o Nearly everyone knew but no-one acted

o Story broke when patients got together and told the newspapers

o Hundreds of patients injured

o Some died from undiagnosed cancer

2A:CELJE HOSPITAL, SLOVENIA

“We are all to blame. We are all prisoners of a system that is good in its parts and bad in total.”

Newspaper headline: “Health Minister blames the system for poor care at Celje”

o Longtime rumors of bad obstetric care

o 3 enquiries, but AMA said they were faulty

o Legal enquiry after patients formed a committee and told the mass media

o Legal enquiry found that bad care in 47% of cases (23% serious) junior doctors made errors in 76% of cases midwives made errors in 60% of cases

senior doctors in 34% of the cases.

“Give me a fraction of the $7 million, I’ll find as many mistakes elsewhere, and you can pick the hospital”

2B: KING EDWARD HOSPITAL, PERTH

o Bad cardiac surgery for 8 years

o Anesthetist did statistical analysis and found: serious injury rate 10 times national average

mortality rate 20 times national average

o Other doctors called him a troublemaker

o No-one would speak to him

o Story broke when patients (and a few doctors) told the mass media (and Private Eye)

“I was the first doctor ever to make a formal complaint about another doctor to the General Medical Council”

2C: BRISTOL ROYAL INFIRMARY, UK

o New cardiac surgeon appointed

o 7 perioperative deaths in six months

o Nurses complained but were told to be quiet or leave

o Anesthetists went on strike, demanding independent enquiry

o Enquiry found no problems, surgery started again

o 5 more OR deaths in 3 months

o Parents went to mass media, Coroner’s enquiry said care had been ‘unbelievably bad’

2D: WINNIPEG CLINICAL CENTER, CANADA

WinnepegBristol

Celje

Perth

… and so on (more enquiries around the world)

Royal Melbourne

TuzlaPorto

Camden and Camberwell

Prague

Southland

Boston

Glasgow

Dr Death

UB

COMMON CONCLUSIONS OF ENQUIRIES

o Care was unbelievably bad

o Most staff (doctors, nurses, managers) knew the care was bad

o Data everywhere that proved care was bad

o None of the formal ‘quality assurance’ processes worked, such as: Accreditation and licensing

Peer review and clinical audit

o These were not “… stories about bad people”

3 PROJECT MANAGEMENT FAILURES

o Most failures are hidden: people don’t like to admit mistakes.

o But some mistakes are hard to hide. For example, we know that The Titanic sank The US Army lost in Vietnam The Challenger space-shuttle crashed.

o In the USA, most software projects are failures. EG, 84% exceed budget 30% are cancelled 45% are seriously behind schedule.

(www.stsc.hill.af.mil/crosstalk/1998/07/causes.asp)

Are health sector mistakes hard to hide?

PROBLEMS WITH DEVELOPMENT PROJECTS

o Asian Development Bank: Consultants can only come from the Region Study tours can only go to member countries

o World Bank: Officer who writes ToRs then supervises the Project WB officers only talk with Client (not consultants)

o European Union: Consultants only from EU countries

“Only one in ten internationally supported projects achieve their objectives to a satisfactory degree.”

Chinese Government, 2004.

World Bank

Host government

Consultant Team

DESIRABLE COMMUNICATION CHANNELS

World Bank

Host government

Consultant Team

WORLD BANK COMMUNICATION CHANNELS

4 WHAT ARE THE CAUSES OF FAILURE?

o Too little money?

o Poor training?

o Lack of access to information?

o Health care is too complicated?

o Or are there other reasons?

Let’s look at some simple problems in the health sector.

Picture #1: back entrance to large hospital in Mongolia

Can you see any problems?

Can you see solutions?

Who’s responsible?

Simple and wrong answer“We need the stone to avoid falls in the dark”

Picture #2: a teaching hospital in Tokyo, Japan

Can you see any problems?

Can you see solutions?

Who’s responsible?

Simple and wrong answer“It's too difficult to get everyone to agree”

Gambar #3: Klinik Gigi suatu Rumah Sakit di Indonesia

Adakah masalah yang tampak?

Apakah anda lihat solusinya?

Tanggung jawab siapa?

Simple and wrong answer“It's too expensive to run a multi-skilling program”

Picture #4: anywhere in Vietnam

Can you see any problems?

Can you see solutions?

Who’s responsible?

Simple and wrong answer“Children don't travel as far as adults”

Slika 5: laboratorij v eni izmed bolnišnic na Kitajskem

Ali vidite kakšen problem?

Ali vidite rešitve?

Kdo je odgovoren?

Simple and wrong answer“We can't supervise everyone all of the time”

Slika 6: Sarajevo

Vidite li ijedan problem ?

Vidite li rješenje ?

Ko je odgovoran ?

BoR = 47%

BoR = 44%

Simple and wrong answer“We won't save much. Infrastructure costs are only a small component”

Good people working hard BUT …… not always working together

5 HOW TO IMPROVE: THE DIAGNOSIS PHASE

o It’s important to diagnose the illness

o Several methods have been used, such as: Audits by independent government agencies Ongoing monitoring by the Medical Association Soft systems methods Hire consultants Ask consumers

o Let’s look at one useful and easy-to-use diagnostic tool

1Ideas for change are very welcome, especially from junior staff.

2The most senior staff usually arrive first at meetings.

3All staff wait for change to be suggested by the most senior staff.

4

It is easy to make change: if you have a good idea, you do not have to wait for lots of formal approvals. You can go ahead immediately.

5Powerful people often go to meet junior staff where they work, and have an informal chat.

6 People are often praised for their work.

7Supervisors encourage junior staff to talk about their problems.

Yes ?? No

SOME DIAGNOSTIC RESULTS

60

70

80

90

100

110

120

130

140

150

1 3 4 10 15 2 5 8 11 12 13 14 6 9 19 20 21 22 7 16 17 18 23

Doctors Nurses

Generating ideas Building juniors Building teams Solving problems

Comparison of senior and junior staff views, RS

Wahidin

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

1 3 4 10 15 2 5 8 11 12 13 14 6 9 19 20 21 22 7 16 17 18 23

Question

Rating

SOME DIAGNOSTIC RESULTS

Junior

Senior

“It’s the first time we ever talked about these things except within our own tribe”

RATINGS OF ORGANIZATIONAL CULTURES

1

2

3

4

5

0 1 2 3 4 5 6 7 8Germany UK Slovenia VietnamBosnia MongoliaIndon

GolnikTabanan

3rd Hospital

“We’re good in spite of the Ministry and the insurers”

6 HOW TO IMPROVE: TREATMENT PHASE

o Lots of ways of trying to improve. EG,

Write more policy documents

Increase total spending on health care

Change the education curricula

Increase salaries of health professionals

Get a loan from the World Bank

TREATMENT

Your rating

Mentoring

Giving each junior staff member a senior person they can trust for support.

1 We do it, it works well 2 We do it but not well 3 We tried it, it doesn’t work 4 OK, but it won’t work here 5 Not tried, we should try it 6 Not tried, we shouldn’t try it

TREATMENT

Your rating

Multidisciplinary induction

Using a multidisciplinary team to welcome and advise new staff members.

1 We do it, it works well 2 We do it but not well 3 We tried it, it doesn’t work 4 OK, but it won’t work here 5 Not tried, we should try it 6 Not tried, we shouldn’t try it

7 IDEAS ON PROJECT MANAGEMENT

1. Know the common mistakes

2. Get planning right

3. Fix up ways of talking

4. Fix up meetings

5. Pay for outputs from team members

6. Improve teamwork

7. Improve organizational culture

1 KNOWING COMMON MISTAKES

o Here are a few examples that I’ve often seen:

Terms of Reference are nearly always poor The parties have different objectives (but don’t realize

it) Recruitment processes are crude People don’t know how to talk Bureaucracy kills innovation People forget the non-technical aspects Meetings are usually run badly Team leaders don’t understand their role

OTHER LISTS OF COMMON MISTAKES

o An internationally famous expert in project management says: Failure to LEARN Failure to ANTICIPATE Failure to ADAPT.

(http://members.aol.com/AllenWeb/failure.html)

o Another expert in IT project management says: poor user input skills that do not match the job hidden costs of under-resourcing failure to plan communication breakdowns lack of flexibility refusal to note signs of possible failure.

(www.stsc.hill.af.mil/crosstalk/1998/07/causes.asp)

2 GET PLANNING RIGHT

o You need to use good planning methods

o You need a plan for the whole Project

o You also need detailed personal plans for all team members

o The personal plans must be shared among all team members

o The personal plans must match with the plan for the whole Project

o People must be accountable for their plans

Evaluating Planning

Doing

Monitoring

Was Plan successful? Why or why not?

Is work being done according to

Plan?

THE MANAGEMENT CYCLE

O1 Experiment O2

O1 Control O2

SF-36 = 75 SF-36 = 84

SF-36 = 75 SF-36 = 77

EXPERIMENTAL DESIGNS

THE HIERARCHY OF PERFORMANCE MEASURES

Cost-effectiveness Equity of health Equity of costs

Level of inputs

Equity of health care

Equity for health care providers

Health outcomes

Health outputs

Quality of care

Type of inputs

Consumer satisfaction

Efficiency

Equity of health service use

TRICKS AND TECHNIQUES

o SWOT analysis

(strengths, weaknesses, opportunities, threats)

o SMART goals

o (specific, measurable, attainable, realistic, timely)

o Nominal group technique

o Delphi technique

o Grounded theory

o Soft systems method

o Gantt charts

o … etc

“They’re all useful sometimes IF you assume people are rational, honest, and open”

AIMS

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Idea

Decision

Decision

Convergence

BRAINSTORMING

Expansion

Activity Location Actual

1-J an Off duty Home As planned

2-J an Off duty Home As planned

3-J an Plan I nception Workshop Bucharest As planned

4-J an Plan I nception Workshop Bucharest As planned

5-J an Review translation of I R Bucharest As planned

6-J an Review translation of I R Bucharest Demo of DRG sof tware

7-J an Off duty Bucharest As planned

8-J an Off duty Bucharest As planned

9-J an Meetings, FHI H Bucharest Prepare I nception Workshop

Hindle J an-06

ENSURING PERSONAL ACCOUNTABILITY

3 IMPROVE WAYS OF TALKING

o Talking is the main way that ideas are created

o Talking is the main activity before decisions are made

BUT

o Most of us never have formal training (especially in talking in project teams)

o Most of us don’t have any formal evaluation of our ways of talking

o Ponceing (unfair criticism of new ideas)

o Stereotyping

o Giving false explanations of why you disagree

o Transfering your opposition to someone else’s mouth

o Giving poor excuses for delay

o Claiming the high moral ground

o Making unfair use of history (we tried it before, it didn’t work)

o … etc

SOME BAD WAYS OF TALKING

“We talk the sacred language in meetings, and only tell the truth over a Guinness”

PARTIAL OR NON-COMPARATIVE EVALUATION (PONCEING)

Partial evaluation: only referring to costs or only to outcomes

o “Your idea of scheduling of elective patients will not work because of the cost”.

o “Your idea of admission control (to avoid unnecessary admissions) will not work because mistakes will harm some patients”.

Non-comparative evaluation: not stating another solution

o “Your idea is poor.”

o “We are using an excellent method already.”

What bad talking behavior is being used?

“Hindle’s the last communist”

o People spend much time in meetings, and most meetings are inefficient.

o Define rules and make sure they are followed. EG,set an agenda in advance, with fixed times

appoint the best chairperson (not always the team leader)

give everyone a fair chance to speak

interrupt people who use bad habits

give everyone feedback on meeting performance

o Different meeting methods for different purposes:

Ideas meeting? Decision meeting? Info-sharing meeting?

4 IMPROVE MEETINGS

% time talking

Actual

Guessed by doctors

Guessed by nurses

Doctors

?

?

?

Nurses

?

?

?

o We recorded every meeting in an Australian hospital, where doctors and nurses took part.

o We analysed the talking patterns.

o One result was as follows:

13%

50%

10%

87%

50%

90%

A STUDY OF CLINICAL MEETINGS

5 PAY TEAM MEMBERS FOR OUTPUTS

o In most teams, there are members who don’t do their fair share of work

o It’s often difficult to take action, because team spirit is at risk

o Most team leaders are poor at giving criticism

o Here is one easy way: write rules into contracts from the start

make payment conditional on outputs

THE ACCOUNTABILITY CHAIN

Month plan submitted?

Month plan agreed?

Reminder from TL

Revision needed

Month plan completed?

Revision needed

Payment claim can be submitted

YES

YES

YES

NO

NO

NO

6 IMPROVE TEAMWORK

o Everyone wants good teamwork

BUT

o It often doesn’t exist because: Poor teamwork is difficult to identify

There are usually no ways of measuring it

People don’t like to talk about it.

o Here is one simple way: Define the rules for teamwork

Make assessments on whether rules are being followed.

KEY FEATURES OF GOOD TEAMS:

o A clear purpose

o Adequate resources

o Specified tasks for everyone, within agreed Plan

o A good leader and the right team members

o Each team member understands himself

o Each team member is trusted

o Clear rules for decision making

o Good methods of communication between team members

o Ways to manage conflicts between team members

o Regular and fair evaluation of the team’s performance

o … etc

RATING YOUR BEHAVIOUR IN TEAMS

Work in a pair (with someone you know) Rate yourself (person A) and ask your colleague to rate

you too Compare your ratings

Behaviour

Do you listen carefully?Do you encourage others to speak?Do you support other people's ideas?Do you speak too much?Do you speak too little?Do people think you talk too fast?Do people usually understand what you say?Is what you say often negative?

Rating of Aby B

Yes / NoYes / No Yes / No Yes / No Yes / NoYes / NoYes / NoYes / No

Self-ratingby A

Yes / NoYes / No Yes / No Yes / No Yes / NoYes / NoYes / NoYes / No

8 MANAGE ORGANISATIONAL CULTURE

o “Culture” is a set of ways of thinking and acting that:

are used by almost everyone are not based on logic are used automatically

o There are benefits

for example, work can be undertaken continually, without having to undertake analysis from first principles

o There are also penalties

in particular, it is difficult to implement changes.

o People like to belong to ‘tribes’

o Tribes have their own beliefs, ways of talking, attitudes, and ways of behaving

o The tribe’s culture is reinforced, because people who think the same way prefer to talk only among themselves

o Each tribe builds enmity with other tribes – it is good to have someone else to blame

o Often people don’t recognise their own culture, and fail to see how it can be harmful

ORGANIZATIONAL AND PROFESSIONAL CULTURES

A WAY OF SEEING HOW ORGANIZATIONAL AND PROFESSIONAL CULTURES DEVELOP

X is true, I think

I disagree, goodbye

X is true, we think

I disagree, goodbye

X is true, because we all believe it

STUDY IN SIX COUNTRIES

o Five types of health workers in a survey: doctor-managers doctor-practitioners nurse-managers nurse-practitioners lay managers (administrators)

o Countries were China, UK, Australia, Slovenia, New Zealand, USA

o There were over 100 questions to be answered

o Should we work as teams, using shared knowledge and agreed standards?OR

o should we rely on own judgment and experience?

o Should doctors and nurses only worry about giving best possible care (not about avoiding waste)?OR

o Should doctors and nurses worry about both costs of care and quality of care?

SURVEY QUESTIONS OF TWO TYPES

1

2

Resources not my concern

Clinical and resource decisions can’t be

separated

Individual judgment

Teams

3

2

1

4

5

DW

NW

DM

NM

A

THE CAUSES OF SUCCESSFUL PROJECTS

A successful project

Teamwork Communication Respect

The right organizational culture

Planning Learning Meetings Flexibility Leadership Monitoring Right staff

… depends on

… depends on

… depends on

QUESTION 1

o Overseas and local consultants were recruited for a WB project in Bosnia.

Overseas consultants were nominated by the Consultancy Company, and approved by the WB and the Bosnian government on the basis of CVs.

Local consultants were nominated by the Bosnian government and selected by the Consultancy Company.

o What strengths and weaknesses can you see in this method? How would you recruit the consultants?

QUESTION 2

o In 2003, a WB officer wrote terms of reference for the Bosnian Hospital Rationalization Project in 2003.

o The project began in 2003 and was completed in 2006.

o The project team’s report was rejected as unsatisfactory because it did not fulfill all the terms of reference.

o The project is still not complete because the Consulting Company has run out of money.

o Acceptance of recommendations and their implementation are delayed pending completion of an acceptable report.

o Can you see any solvable problems? What would you advise to be done differently next time?

QUESTION 3

o Select a health sector project that has been finished, and for which you can find good documentation.

o Write a summary of what has been stated about the method of conduct of the Project regarding problems of Project Management.

o What does the documentation tell you, in terms of lessons relevant to other projects?