Healthcare system improvement project management: making a big team work

It's tough chairing meetings, tougher chairing a big meeting (10-15 people), and tougher yet chairing a big meeting that's supposed to last an 8-hour day, one day a week for 6 months. A lot of planning goes into making such a day work with team members varying from the analytical kind to the "feeling" kind, from the surgical kind to the managerial kind. I'm slowly to get a hang of it having done it for a couple months now. The following is a lot of common sense, but if one doesn't have the chance to go through this kind of work with big teams, one may not think it so obvious as an approach. Thought I'd share for whatever it's worth.

• Make sure everyone is doing something - feeling of usefulness in the group, or else people will feel disengaged.



• Assuming natural progress of project is from problem discovery, to analysis, to design and implement, and assuming that everyone in a team needs to participate in all phases, then keep telling self that as soon as we get through to design, things will become more exciting. Analysis phase is not everyone's cup of tea, even though geeks like me find it most interesting.



• Spend the time and create a big poster out of rolling parchment paper. It becomes a live document of all work done on the project to remind team in every meeting of key aims and work accomplished so far. It is a pat on the shoulder for work well done, as well as always showing the direction for the team. Sometimes, one can't see the forest for the trees.



• Big team, big scope - recipe for getting lost or losing sight easily; remind team of aims frequently; relate how current tasks contribute to the aims.



• Identify one lead for each main task to be done in the implementation phase. Give team members enough time to develop own plans on how to implement, and write the document themselves to instill ownership from the start (do not use admin resources to do this). Sometimes it takes 2-3 days just to write and re-write the implementation plans, but the time is worth while, not because we need to have a perfect plan as that is unrealistic, but because it forces people to think of all nitty gritties of how get things done and how they would get around specific change management problems. Provide a good example from a colleague of theirs (real examples from real people = trust), but encourage and give them room to be creative. Then everyone on the team should peer review each other's plan with specific review criteria.



• Once you have all of the above done, engagement level should be pretty high by now, as a healthy amount of sweat and tears will have gone into the implementation plans. I bet anything that you won't be able to hold people back on actioning out those implementation plans.
  

There you have a much happier and motivated team. There is no sure recipe. This isn't one by any means, but it is working for me so far.

Healthcare system improvement project management: how not to manage projects

Lately, I am finding it difficult to not do the work myself in the projects I'm leading/managing. The excuse I've been using is "well, it's just easier to do it myself than asking someone else for it". However, I end up paying for it with way too many late nights working around the clock. I'll be the first to admit: this is the wrong way to manage projects. I end up feeling burned out and tired doing work that should have been done by others in the team, leaving me without enough energy or time to actually 'manage' the projects. Ultimately, if I continued this way, it would be both bad for me and the projects.


However, I used to lead projects like this before, and it worked charmingly. What changed?

Well...

Here I talked about the Master of Management in Operations Research program that trained me as an OR professional (great program by the way). During this master's program, each student is a project lead on a 4-6 months project with a real company doing real projects. The students are fully capable of carrying out all tasks within the project, but have data analysts to help out, because there is just too much analysis work for one person usually. A project lead in this scenario is both the leader and largely the doer - what I'm used to do at work both before and after the master's program.

Why isn't it working now? In my humble opinion, leading 2 projects with relatively large project teams is quite a busy job. One simply doesn't have the time to both lead and do. I did, so I paid for it. Then I learn. I guess in this case, it would probably be overall easier to ask someone else to do it than doing it myself.

Got any tips to share with me? Comment here or email me at dawen [at] thinkor [dot] org

Healthcare system improvement project management: what's the right balance?

I now live in London, UK, and work for a rather famous hospital, renowned for its medical reputation internationally. My role is a project manager on 2 system improvement projects. Such projects are also labeled as "transformation" or "modernisation" projects, depending on where you work. The idea is to work with doctors, nurses, managers, clerical and administrative staff, as well as patient families, who live and breathe the hospital, so that this group of people take ownership of the problems and solutions. We meet one day a week for a full day, and project managers like me and lean improvement facilitators are thrown into the mix to try to help the projects move along. The key is all about implementation, which may make some external management consultants jealous, since they almost never get to implementation. It is a luxury as one can see one's work flourish.

Great idea, isn't it?

Is the team too big?

• 20% of 8-12 people's time is huge! On paper, the staff are 'back filled' for that 20% of work, but in reality, finding the right people with the right skill mix to do 1 day's work is quite difficult. Therefore, these people often end up working 120%. Commitment to the team starts high but then lacks off a bit.
• With the amount of time invested, people outside the group have very high expectations. They want to see things getting churned out from the team quickly, and often ask "when are you going to deliver what". When in reality, such projects have a research nature to them. There may be the best of project plans, but research will always take as long as it does until you can move onto solutions.
• Keeping 8-12 people 'entertained' and interested in the same topic is challenging. Some people are very detailed. Some want to talk big concepts. Some just want to start getting into the issues and start tearing it apart. Keeping everybody happy is never easy.
  
• Big groups also suffer from democracy. It takes time for everybody to have their say, and one person can dominate the whole discussion and shut others up. The good facilitators will still find this difficult.

But is the team too big? I've definitely experienced the same group, but with fewer people, and we were very productive for the small group days. True, everybody in the team should be there because of their functions within the hospital, but perhaps they don't need to all be there every week.

Ideas on how to tackle the big group:

• We are now trying to break the team into smaller groups to be efficient, and to break the group dynamic. Each sub group also has a sub lead, so more people can feel true ownership within the team. We then reconvene after half a day to update each other on progress. It seems to be working so far.
• Send team members out to the hospital to observe, collect information, shadow someone else, and then update. It breaks the 'classroom' feeling when in a meeting room.
• Of course there are many facilitative ways to deal with it as well when they are all doing this: :)
  

I find these projects are shaping like way more people talking than actually doing the work. It is especially frustrating for the ones who actually joined up for doing the work. I've definitely done successful projects in the past that didn't involve such an elaborate set up. This way of working should make implementation easier. I am waiting and seeing.

Introducing variability, flow and processes in a funny video to anyone

I'm leading on two variability & flow management projects at the hospital right now, and the terms "variability" and "flow" are certainly not something the medics hear much about. I needed a quick way of explaining what the projects are about, what these terms mean, and what kind of problems we are trying to resolve. A colleague suggested this video from the ever popular "I Love Lucy" TV series, episode "Chocolate Factory". It does a wonderful job of making people laugh, as well as acting out some strong parallels to a process, and the variability and flow within the process. Take a look at the video (it's a funny one!) and read on for the parallels to the operation of a hospital. The doctors, nurses and patients on my team all found the video not only hilarious but also made it clear to them what we are trying to do in the variability & flow management project.



The parallels:

• Process: the chocolates can be patients coming into the hospital 'conveyor belt'. Lucy and her friend Ethel can be the nurses, for example, (or the various clerks, doctors, pharmacists, radiographers, etc.) handling the patients, 'dressing' them up or giving them care to make them better so they can go on to the next hospital professionals, i.e. the pharmacists to receive medications in the next room down the conveyor belt. The patient traveling through the conveyor belt is a process. Similarly, Lucy and Ethel picking up the chocolate from the conveyor belt, taking the wrapping paper, wrapping up the chocolate nicely, placing the wrapped chocolate back onto the conveyor belt, and returning to the position to be ready for the next chocolate, is a process. Lucy and Ethel are the 'servers' within the process. The things they do to the chocolate are 'steps' within the process. The girls feeding the chocolate onto the conveyor belt for Lucy & Ethel in the previous room are the servers of the upstream process to Lucy & Ethel's wrapping process. Similarly, the girls boxing the chocolates in the next room, perhaps, are the servers of the downstream process.
  
• Flow: The chocolates going through the Lucy & Ethel's wrapping process is a flow.
• Variability: The speed the chocolates are placed onto the conveyor belt is a source of variability, because the speed changes, and so is the speed that Lucy & Ethel wraps the chocolate, as they have very different styles of wrapping. This results in the variable speed of the wrapped chocolates flowing out of the Lucy & Ethel wrapping process.
• Queuing & waits - When Lucy & Ethel were running behind and when they started to collect the chocolates in front of them and in their hats, so that they can wrap them later, that's queuing the chocolates, and those chocolates are experiencing 'waits'.
  
• Mis-communication: When the supervisor meanie lady shouted to the upstream girls to "let it roll" and nothing happened so she had to go to the previous room to sort it out, that's mis-communication or signal failure. :)

The video also shows some classic examples of problems around processes:

• Isolated processes and working in silos – what is going on 'upstream' and 'downstream' is absolutely unknown to Lucy & Ethel.
  
• Lack of issue escalation procedure - when the chocolates are coming too fast for Lucy & Ethel to handle, they had no way of letting the upstream or the manager know (but of course, the meanie supervisor lady didn't allow them to leave one chocolate behind).
  
• Performance management - the meanie supervisor lady did not have realistic expectations on Lucy & Ethel's performance, or maybe she simply didn't have any clue about the variability of the sometimes very high demand placed on Lucy & Ethel from the upstream.
  
• Reactionary management - When the supervisor lady came into the room and saw that Lucy & Ethel had no chocolates on the belt and therefore ordered the upstream to feed faster is very reactionary. She simply made the decision based on one observation / data point, and did not ask any questions about why it is that way.

Hope you find the video useful in your work as well. I'm sure you can draw parallels to other industries aside from health care. Please feel free to share it with me. Things are often best explained by humour.

Decision Making Model on Stroke Prevention: Warfarin or not

An interesting talk I attended at the CORS 2008 conference in Quebec City was by Beste Kucukyazici from the Faculty of Management of McGill University. The topic of the talk was “Designing Antithrombotic Therapy for Stroke Prevention in Atrial Fibrillation”.

Beste Kucukyazici showed the study of stroke patient data to see if a decision model could be derived to systematically decide on the commencing of warfarin treatment for stroke patient and its intensity. Now my question is: will OR decision models take a bigger and bigger foothold in the future of medical arena as we start to gather more useful patient data in well-planned studies? Medical doctors tend to argue that each patient has a different case, and need to be examined on an individual basis. However, if a model such as Kucukyazici’s can prove the accuracy of its decision given real patient data, then it would probably start to weaken the doctor’s argument and favour a more systematic approach. At least, such models might help reduce the complexity of doctor’s decision making process, or even reduce chances for human errors in diagnosis.

Atrial fibrillation, which is a common arrhythmia particularly common among the elderly, is one of the major independent risk factors of stroke. Several randomized control trials have shown that long-term antithrombotic therapy with warfarin significantly reduces the risk of stroke, however, it also increases the risk of suffering a major bleed. Given the potential benefits and risks of warfarin treatment, the decisions that need to be made by the clinicians are two-fold: (i) whether to start the therapy, and (ii) the intensity of warfarin use. The objective of this study is to develop an analytical framework for designing the optimal antithrombotic therapy with a patient-centered approach. The approach seeks to create a rational framework for evaluating these complex medical decisions by incorporation of complex probabilistic data into informed decision making, the identification of factors influencing such decisions and permitting explicit quantitative comparison of the benefits and risks of different therapies.

ORAHS 2008 in Toronto Canada

The 34th annual conference on Operations Research Applied to Health Services will be held in Toronto, Ontario, Canada, on July 28 - Aug 1, 2008. 

The ORAHS was formed in 1975 in Europe, and it is usually held in Europe as well. This year, however, Canada has the honour of hosting it.

Check here for more details on the ORAHS 2008 conference.

Mike Carter on New Challenges for OR Applications in Health Care

I had the pleasure of meeting Professor Michael W. Carter at the Canadian Operations Research Society conference (CORS) in Quebec City, and listening to his plenary talk on "New Challenges for Operations Research Applications in Health Care" - the kick-off talk for this year's CORS conference on May 12th, 2008.

Professor Carter is one of the Canadian leading experts in healthcare and operations research, with over 17 years of experience in OR applications in healthcare. He currently leads the Centre for Research in Healthcare Engineering, Mechanical and Industrial Engineering, University of Toronto. Click here for more information on Professor Mike Carter.

Mike has been very kind to allow me to publish his talk here on ThinkOR.org. Here are some key points to take away:

• Healthcare is North America's single largest industry; Canada spent $142 billion CDN in 2005; US spent $2 trillion.


• Canada's per-capita spending ($3,326 USD) was half of US ($6,401 USD), and this is how it's been growing:


• US & Canada are about the same in terms of quality of health care, access, efficiency , and equity (based on the Commonwealth Fund 2004 International Health Policy Survey)


• A new way of looking at the healthcare system's stakeholders (no wonder it's difficult to make decisions in a hospital):
  
• Challenges in healthcare system can be viewed as operations research challenges:
  
  
  
  • Patient flow - supply chain
  
  
  • Surgical wait list - better scheduling
  
  
  • Infectious diseases - logistics
  
  
  • Health human resources - forecasting

Mike also demonstrated the application of O.R. techniques in his own practice:

• Ontario Wait List Management


• Colorectal cancer screening


• Cancer treatment centre locations


• Health Human Resource Modelling

Thank you Mike for allowing me to write about your talk. It was delightful to see OR in action in the Canadian healthcare. We look forward to seeing the 30% potential waste of money spent in healthcare to shrink fast.