As health care grows in scope and complexity, operational excellence increasingly is defined by value. To meet the challenge, innovative leaders adopt this team approach.
ABSTRACT: As U.S. health care grows in scope and complexity, operational excellence increasingly is defined by value. Adopting methods from the worlds of industrial and systems engineering and project management, such as Lean and Six Sigma, has become important for process improvement and optimizing efficiency in large health systems. The Agile framework of project management allows for seamless and simultaneous innovation and evolution, given health care’s reliance on information technology.
Project management is the deployment of resources and strategy to complete a project (a temporary operation undertaken to accomplish a defined goal). The traditional project management method has been referred to as “waterfall” project management. The term is derived from a description provided by Royce in 1970, in which he outlined sequential steps displayed in a downward flow like a waterfall: “generate system requirements, software requirements, perform analysis, program design, coding, testing, then operations.”1
Waterfall project management uses fixed, sequential steps to complete processes and projects.2-5 It requires considerable planning before execution, which is constrained by predetermined project scope, scheduling and budget. Schedules can be lengthened if input from the clinical areas is requested. Despite being thought to be rigid and not considered innovative, it still remains a highly used method of project management.
An example of a waterfall project in health care: A hospital needs to construct a new cardiac catheterization laboratory suite, and nearly all of the requirements are known and were used on construction of a separate surgical suite just years ago. This project description lends itself to waterfall project management because of the similarity to previous projects and the need to complete the build in a previously defined sequence.
Rooted in total quality management of the 1980s and subsequently popularized in the software industry in the 1990s, Agile project management was developed in response to the ever-increasing and evolving demands of the information technology industry.6-8 Several Agile frameworks, including Scrum and Kaizen Kanban, have emerged over the years.9,10 For the purpose of this article, the focus is primarily on Scrum.9
Agile project management involves flexibility and continuous project process improvement using a team approach. Even though Agile project management is still constrained by project scope, schedule and budget, responsibility for the constraints is shared, a component that makes team composition and dynamics extremely important for Agile projects. In the most basic sense, Agile is an iterative form of project execution. Trust among team members is critical, and a solid understanding of Agile project management by the project leader is necessary for success. Table 1 lists some of the key components of a successful Agile project team.
Agile project management can be viewed as team experiential learning. The iterations, termed “sprints,” have durations of one month or less and commonly are two weeks. This schedule allows project teams to stay focused on their work and to deliver a portion of the project to the appropriate stakeholders at the end of each sprint. This process also allows testing and feedback to occur early and often during the project — features that increase quality and ensure that expectations are met.
Creativity is encouraged and flourishes, and innovation becomes the byproduct. Although the upfront time constraints required by waterfall project management are no longer present, considerable time is saved, and teams are allowed to provide value to the customer throughout the entire life of the project, a characteristic that lowers risk for all stakeholders. Table 2 compares key components of Agile and waterfall project management, and Figure 1 provides a visual comparison.
An example of an Agile project in health care: A health care system is developing a website for which all of the requirements are not yet known. However, the key requirements have been identified, and there is a basic understanding of them. There is also a strong need to publish a usable website in a short time, prioritized components of which are provider directory information and the ability for patients to pay a bill. This project is suited for Agile project management because not all requirements have been identified and time constraints are tight. With the Agile approach, the team can initiate sprints to deliver the provider directory and bill-pay functionality first.
Emergence of Agile Project Management
Health care delivery systems became more operationalized in the 1980s with the emergence of cost-containment efforts and medical practice consolidations, mergers and acquisitions. Project management practices using traditional waterfall methods soon found their way into the health care industry. Examples include revenue cycle management, early electronic medical record implementation, surgical and procedural patient scheduling, and patient flow in examination offices and emergency departments.
Although efficiency improved through waterfall project management, its predefined characteristics often posed a challenge when fluid, highly variable health care workflows were used.
Currently, operational efficiency is critical for clinical practices and large health care systems. Unlike many manufacturing processes, however, health care projects and processes consist of myriad changing and sometimes-unknown variables. This complexity, meshed with the challenge to maximize value, volume and margins, created the need for more versatile and nimble project management methods. Innovative health care leaders are using Agile project management to meet this challenge.
Rather than abandoning traditional project management in health care, some health care systems are beginning to adopt Agile project management alongside the traditional waterfall methodology. Given the vast amount of information about Agile project management available in non-health care fields, it can be difficult to understand what it is, where it should be used, and how to use it within industries and firms that predominantly use waterfall project management.11,12
Mayo Clinic is undergoing an enterprise practice convergence of its three destination sites and large health system while cumulatively transitioning to a new, customized electronic health record. Using the Agile framework within the integrated health care system is helping its information technology department position itself to adequately fulfill diverse needs faster than ever and with increased quality using this iterative process.
For example, the existence of Agile teams within the information technology department allows for production of highly customized software with a faster development time, ensuring that patient care is not compromised while minimizing resource use. Metrics of success include implementation and integration while not sacrificing patient safety, patient experience and net operating income.
Another advantage of using the Agile framework includes increased transparency both within the project and externally to project stakeholders. Mayo Clinic’s Knowledge Content Management System within the Knowledge and Education Systems Support section uses the Agile framework. This group has four main stakeholders:
- Knowledge Management (Office of Patient Education, AskMayoExpert, MayoExpertAdvisor and Provider Relations).
- Global Business Solutions.
- The platform (Sitecore/TopBraid).
- Sitecore nonclinical systems (IT Connect/Mayo Clinic Health System websites).
Figures 2 and 3 show the reduction in Knowledge and Education Systems Support incidents as a result of the iterative framework found within Agile. The use of iterations creates an environment for stakeholders to prioritize the incidents and focus attention appropriately. The definition of incidents in this case is defects in the product (for example, a lack of testing and clearly defined requirements).
The benefits of the Agile framework have resulted in increased requests for Mayo Clinic’s IT department to have Agile teams “rescue” projects that have used traditional waterfall methodology. Given the overwhelming success with regard to IT productivity and quality, the number of practicing Agile teams within the health care system is expected to increase.
Change and uncertainty continue to loom over the future of health care. More than ever before, delivery systems must be committed to efficient and effective change management to be successful. Despite widespread use of waterfall project management, adoption of novel Agile methods will be important to mitigate risk, prevent losses, and thus ensure continued positive returns, both clinically and financially.
One sign of a successful organization is its ability to innovate and manage change. Health care systems are currently challenged to do this daily in various forms. The Agile framework of project management provides the necessary tools to seamlessly and simultaneously innovate and evolve.
These goals are clearly important in health information technology, but Agile methods can be used throughout other departments and functions within health care systems. A recent article in Harvard Business Review demonstrated the application of Agile methodology in many firms.8 Without iterative planning, self-managing teams, and multiple releases of usable products delivered earlier and with higher quality, the likelihood of success of any project diminishes.
The systemic adoption of Agile project management can help improve collaboration, communication and team dynamics — all of which are signs of a successful organization. In addition, early adopters of Agile project management stand to gain a competitive advantage when introducing changes into their practices by adopting this project management method.
Eric Pool, Ed.D., PMP, CSM, is a senior project manager in information technology at Mayo Clinic in Minnesota. He also teaches project management at the University of California at Berkeley.
Kenneth Poole Jr., MD, MBA, chairs the health information coordinating subcommittee, which oversees informatics policy for Mayo Clinic in Arizona and Florida. He also is medical director of patient experience and sits on its clinical practice committee for Mayo Clinic Arizona, and is an assistant professor of medicine for Mayo Clinic College of Medicine and Science.
David Upjohn, MS, is the operations manager of the Otorhinolaryngology and Audiology Department at Mayo Clinic in Arizona. He also is an instructor of health care systems engineering in the Mayo Clinic College of Medicine and Science.
James S. Hernandez, MD, MS, FCAP, FASCP, is the immediate past chair of the laboratory medicine division and past laboratory medical director for Mayo Clinic in Arizona. He is an associate professor of laboratory medicine and pathology in the Mayo Clinic College of Medicine and Science.
- Royce WW. Managing the development of large software systems. Proceedings of IEEE WESCON. 1970;26:328-338. www-scf.usc.edu/~csci201/lectures/Lecture11/royce1970.pdf.
- American Society for Quality. What is total quality management (TQM)? 2017; https://asq.org/quality-resources/total-quality-management. Accessed Oct. 30, 2018.
- Project Management Institute. A Guide to the Project Management Body of Knowledge (PMBOK Guide), 4th ed. Newtown Square, PA: Project Management Institute, 2008.
- Project Management Institute. About us. 2017; https://www.pmi.org/about. Accessed Oct. 30, 2018.
- Project Management Institute. A Guide to the Project Management Body of Knowledge (PMBOK Guide), 5th ed. Newtown Square, PA: Project Management Institute, 2013.
- Rico D. The History, Evolution and Emergence of Agile PM Frameworks (Part 1). 2013; https://www.projectmanagement.com/articles/277013/The-History--Evolution-and-Emergence-of-Agile-PM-Frameworks--Part-1-. Accessed Oct. 30, 2018.
- Harvard Business Review. A Quick Introduction to Agile Management. [Video]. 2016; https://hbr.org/video/4846148015001/a-quick-introduction-to-agile-management. Accessed June 26, 2018.
- Rigby DK, Sutherland J, Noble A. Agile at scale. 2018; https://hbr.org/2018/05/agile-at-scale?autocomplete=true. Accessed June 26, 2018.
- Schwaber K, Sutherland J. The Scrum Guide: The Definitive Guide to Scrum: The Rules of the Game, 2016: https://www.scrumguides.org/docs/scrumguide/v2016/2016-Scrum-Guide-US.pdf. Accessed 2017 Aug 30.
- Bouchereau F. Kaizen Kanban: A Visual Facilitation Approach to Create Prioritized Project Pipelines. Milwaukee, WI: ASQ Quality Press, 2016.
- Hernandez JS, Aderton J, Eidem L. The role of project managers who assist physician leaders at Mayo Clinic. The Physician Exec. 2011;37(4):62-5.
- Hernandez JS, Mustapha M. Systems engineers working with physician leaders. The Physician Exec. 2010;36(6):44-6, 48.