Project management in the health sector

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Project management in the health sector
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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

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MY ARGUMENT

• The health sector has lots of good individuals
• BUT
• Teamwork is usually bad and therefore efficiency
  and quality are unsatisfactory
• There are some useful ideas and techniques for
  project management
• BUT
• Teamwork is usually bad and therefore efficiency
  and quality are unsatisfactory
• The solutions are the same for good routine
  management and good project management
• Both require good teamwork

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1 HOW GOOD IS THE HEALTH SECTOR?

• 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
• But its actually very bad

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EXAMPLES OF PROBLEMS HEALTH CARE
I studied 11 legal enquiries in 7
countries Because there was a chance that the
truth had been found. Here are four of them

1. Celje Hospital (Slovenia)
2. King Edward Hospital (Australia)
3. Bristol Royal Infirmary (UK)
4. Winnipeg Clinical Center (Canada)

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2A CELJE HOSPITAL, SLOVENIA

• Problems for 8 years
• 2500 path reports not produced or not returned
• Nearly everyone knew but no-one acted
• Story broke when patients got together and told
  the newspapers
• Hundreds of patients injured
• Some died from undiagnosed cancer

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Newspaper headline Health Minister blames the
system for poor care at Celje
We are all to blame. We are all prisoners of a
system that is good in its parts and bad in
total.
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2B KING EDWARD HOSPITAL, PERTH

• Longtime rumors of bad obstetric care
• 3 enquiries, but AMA said they were faulty
• Legal enquiry after patients formed a committee
  and told the mass media
• 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, Ill find
as many mistakes elsewhere, and you can pick the
hospital
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2C BRISTOL ROYAL INFIRMARY, UK

• Bad cardiac surgery for 8 years
• Anesthetist did statistical analysis and found
• serious injury rate 10 times national average
• mortality rate 20 times national average
• Other doctors called him a troublemaker
• No-one would speak to him
• 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
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2D WINNIPEG CLINICAL CENTER, CANADA

• New cardiac surgeon appointed
• 7 perioperative deaths in six months
• Nurses complained but were told to be quiet or
  leave
• Anesthetists went on strike, demanding
  independent enquiry
• Enquiry found no problems, surgery started again
• 5 more OR deaths in 3 months
• Parents went to mass media, Coroners enquiry
  said care had been unbelievably bad

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and so on (more enquiries around the world)
Glasgow
Prague
Winnepeg
UB
Bristol
Celje
Boston
Porto
Tuzla
Dr Death
Camden and Camberwell
Perth
Royal Melbourne
Southland
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COMMON CONCLUSIONS OF ENQUIRIES

• Care was unbelievably bad
• Most staff (doctors, nurses, managers) knew the
  care was bad
• Data everywhere that proved care was bad
• None of the formal quality assurance processes
  worked, such as
• Accreditation and licensing
• Peer review and clinical audit
• These were not stories about bad people

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3 PROJECT MANAGEMENT FAILURES

• Most failures are hidden people dont like to
  admit mistakes.
• 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.
• 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.a
  sp)

Are health sector mistakes hard to hide?
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PROBLEMS WITH DEVELOPMENT PROJECTS
Only one in ten internationally supported
projects achieve their objectives to a
satisfactory degree. Chinese Government, 2004.

• Asian Development Bank
• Consultants can only come from the Region
• Study tours can only go to member countries
• World Bank
• Officer who writes ToRs then supervises the
  Project
• WB officers only talk with Client (not
  consultants)
• European Union
• Consultants only from EU countries

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DESIRABLE COMMUNICATION CHANNELS
Host government
Consultant Team
World Bank
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WORLD BANK COMMUNICATION CHANNELS
Host government
Consultant Team
World Bank
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4 WHAT ARE THE CAUSES OF FAILURE?

• Too little money?
• Poor training?
• Lack of access to information?
• Health care is too complicated?
• Or are there other reasons?

Lets look at some simple problems in the health
sector.
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Simple and wrong answer We need the stone to
avoid falls in the dark
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Simple and wrong answer It's too difficult to
get everyone to agree
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Simple and wrong answer It's too expensive to
run a multi-skilling program
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Simple and wrong answer Children don't travel as
far as adults
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Simple and wrong answer We can't supervise
everyone all of the time
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Simple and wrong answer We won't save much.
Infrastructure costs are only a small component
BoR 44
BoR 47
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Good people working hard BUT not always
working together
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5 HOW TO IMPROVE THE DIAGNOSIS PHASE

• Its important to diagnose the illness
• 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
• Lets look at one useful and easy-to-use
  diagnostic tool

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Yes
??
No
?
?
?
?
?
?
?
?
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SOME DIAGNOSTIC RESULTS
150
Doctors
Nurses
140
130
120
110
100
90
80
70
60
1
3
4
10
15
2
5
8
11
12
13
14
6
9
19
20
21
22
7
16
17
18
23
Generating ideas
Building juniors
Building teams
Solving problems
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SOME DIAGNOSTIC RESULTS
Junior
Senior
Its the first time we ever talked about these
things except within our own tribe
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RATINGS OF ORGANIZATIONAL CULTURES
Were good in spite of the Ministry and the
insurers
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6 HOW TO IMPROVE TREATMENT PHASE

• 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

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TREATMENT
Your rating Your rating Mentoring
Your rating Your rating 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 doesnt work ?
4 OK, but it wont work here ?
5 Not tried, we should try it ?
6 Not tried, we shouldnt try it ?
?
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TREATMENT
Your rating Your rating Multidisciplinary induction
Your rating Your rating 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 doesnt work ?
4 OK, but it wont work here ?
5 Not tried, we should try it ?
6 Not tried, we shouldnt try it ?
?
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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

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1 KNOWING COMMON MISTAKES

• Here are a few examples that Ive often seen
• Terms of Reference are nearly always poor
• The parties have different objectives (but dont
  realize it)
• Recruitment processes are crude
• People dont know how to talk
• Bureaucracy kills innovation
• People forget the non-technical aspects
• Meetings are usually run badly
• Team leaders dont understand their role

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OTHER LISTS OF COMMON MISTAKES

• An internationally famous expert in project
  management says
• Failure to LEARN
• Failure to ANTICIPATE
• Failure to ADAPT.
• (http//members.aol.com/AllenWeb/failure.html)
• 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
  )

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2 GET PLANNING RIGHT

• You need to use good planning methods
• You need a plan for the whole Project
• You also need detailed personal plans for all
  team members
• The personal plans must be shared among all team
  members
• The personal plans must match with the plan for
  the whole Project
• People must be accountable for their plans

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THE MANAGEMENT CYCLE
Was Plan successful? Why or why not?
Is work being done according to Plan?
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EXPERIMENTAL DESIGNS
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THE HIERARCHY OF PERFORMANCE MEASURES
Cost-effectiveness
Equity of health
Equity of costs
Equity of health care
Equity of health service use
Health outcomes
Efficiency
Health outputs
Consumer satisfaction
Quality of care
Level of inputs
Equity for health care providers
Type of inputs
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TRICKS AND TECHNIQUES

• SWOT analysis
• (strengths, weaknesses, opportunities, threats)
• SMART goals
• (specific, measurable, attainable, realistic,
  timely)
• Nominal group technique
• Delphi technique
• Grounded theory
• Soft systems method
• Gantt charts
• etc

Theyre all useful sometimes IF you assume
people are rational, honest, and open
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BRAINSTORMING
Idea
Idea
Idea
Decision
Idea
AIMS
Idea
Decision
Idea
Idea
Convergence
Expansion
Idea
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ENSURING PERSONAL ACCOUNTABILITY
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3 IMPROVE WAYS OF TALKING

• Talking is the main way that ideas are created
• Talking is the main activity before decisions are
  made
• BUT
• Most of us never have formal training (especially
  in talking in project teams)
• Most of us dont have any formal evaluation of
  our ways of talking

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SOME BAD WAYS OF TALKING

• Ponceing (unfair criticism of new ideas)
• Stereotyping
• Giving false explanations of why you disagree
• Transfering your opposition to someone elses
  mouth
• Giving poor excuses for delay
• Claiming the high moral ground
• Making unfair use of history (we tried it before,
  it didnt work)
• etc

We talk the sacred language in meetings, and
only tell the truth over a Guinness
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• PARTIAL OR NON-COMPARATIVE EVALUATION (PONCEING)
• Partial evaluation only referring to costs or
  only to outcomes
• Your idea of scheduling of elective patients
  will not work because of the cost.
• 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
• Your idea is poor.
• We are using an excellent method already.

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Hindles the last communist
What bad talking behavior is being used?
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4 IMPROVE MEETINGS

• People spend much time in meetings, and most
  meetings are inefficient.
• 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
• Different meeting methods for different purposes
• Ideas meeting? Decision meeting? Info-sharing
  meeting?

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A STUDY OF CLINICAL MEETINGS

• We recorded every meeting in an Australian
  hospital, where doctors and nurses took part.
• We analysed the talking patterns.
• One result was as follows

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90
50
50
13
87
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5 PAY TEAM MEMBERS FOR OUTPUTS

• In most teams, there are members who dont do
  their fair share of work
• Its often difficult to take action, because team
  spirit is at risk
• Most team leaders are poor at giving criticism
• Here is one easy way
• write rules into contracts from the start
• make payment conditional on outputs

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THE ACCOUNTABILITY CHAIN
Month plan submitted?
NO
Reminder from TL
YES
Month plan agreed?
NO
Revision needed
YES
Month plan completed?
NO
Revision needed
YES
Payment claim can be submitted
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6 IMPROVE TEAMWORK

• Everyone wants good teamwork
• BUT
• It often doesnt exist because
• Poor teamwork is difficult to identify
• There are usually no ways of measuring it
• People dont like to talk about it.
• Here is one simple way
• Define the rules for teamwork
• Make assessments on whether rules are being
  followed.

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• KEY FEATURES OF GOOD TEAMS
• A clear purpose
• Adequate resources
• Specified tasks for everyone, within agreed Plan
• A good leader and the right team members
• Each team member understands himself
• Each team member is trusted
• Clear rules for decision making
• Good methods of communication between team
  members
• Ways to manage conflicts between team members
• Regular and fair evaluation of the teams
  performance
• etc

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• 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 A by B Yes / No Yes / No Yes / No
Yes / No Yes / No Yes / No Yes / No Yes / No
Self-rating by A Yes / No Yes / No Yes / No
Yes / No Yes / No Yes / No Yes / No Yes / No
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8 MANAGE ORGANISATIONAL CULTURE

• Culture is a set of ways of thinking and acting
  that
• are used by almost everyone
• are not based on logic
• are used automatically
• There are benefits
• for example, work can be undertaken continually,
  without having to undertake analysis from first
  principles
• There are also penalties
• in particular, it is difficult to implement
  changes.

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ORGANIZATIONAL AND PROFESSIONAL CULTURES

• People like to belong to tribes
• Tribes have their own beliefs, ways of talking,
  attitudes, and ways of behaving
• The tribes culture is reinforced, because people
  who think the same way prefer to talk only among
  themselves
• Each tribe builds enmity with other tribes it
  is good to have someone else to blame
• Often people dont recognise their own culture,
  and fail to see how it can be harmful

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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
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STUDY IN SIX COUNTRIES

• Five types of health workers in a survey
• doctor-managers
• doctor-practitioners
• nurse-managers
• nurse-practitioners
• lay managers (administrators)
• Countries were China, UK, Australia, Slovenia,
  New Zealand, USA
• There were over 100 questions to be answered

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SURVEY QUESTIONS OF TWO TYPES

• Should we work as teams, using shared knowledge
  and agreed standards?
• OR
• should we rely on own judgment and experience?
• Should doctors and nurses only worry about giving
  best possible care (not about avoiding waste)?
• OR
• Should doctors and nurses worry about both costs
  of care and quality of care?

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(No Transcript)
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THE CAUSES OF SUCCESSFUL PROJECTS
A successful project
depends on
Planning
Learning
Meetings
Flexibility
Leadership
Monitoring
Right staff
depends on
Teamwork
Communication
Respect
depends on
The right organizational culture
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QUESTION 1

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

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QUESTION 2

• In 2003, a WB officer wrote terms of reference
  for the Bosnian Hospital Rationalization Project
  in 2003.
• The project began in 2003 and was completed in
  2006.
• The project teams report was rejected as
  unsatisfactory because it did not fulfill all the
  terms of reference.
• The project is still not complete because the
  Consulting Company has run out of money.
• Acceptance of recommendations and their
  implementation are delayed pending completion of
  an acceptable report.
• Can you see any solvable problems? What would you
  advise to be done differently next time?

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QUESTION 3

• Select a health sector project that has been
  finished, and for which you can find good
  documentation.
• Write a summary of what has been stated about the
  method of conduct of the Project regarding
  problems of Project Management.
• What does the documentation tell you, in terms of
  lessons relevant to other projects?