'The cardiologist paused, then whispered to the mechanic..."Try fixing it while the engine is running".'
This punch-line of an old joke perfectly illustrates the greatest challenge of medicine – keeping the patient alive while fixing the problem. Incidentally, this challenge is not restricted to physicians. One of the greatest obstacles healthcare managers face is keeping their departments productive and on track, while implementing huge disruptive changes throughout their facility.
Advances in medical practices and technology coupled with changes in regulatory and competitive environments drive hospitals to continually reinvent the way they deliver services.
Most hospitals are involved in implementing projects such as computerised physician order entry systems and electronic medical records, initiatives to improve patient safety and satisfaction, programmes to become employers of choice or implement centres of excellence, and ventures such as surgical centres, birthing centres and walk-in clinics. Many of these initiatives are so costly that organisations risk their future on their success.
Yet as managers try to execute these critical projects, problems are the rule, not the exception. The most conservative estimate is that six out of ten major initiatives fail, and in some areas such as IT the failure rate may be as high as 91%.
The research team at VitalSmarts has used interviews, focus groups and surveys to identify and track these project successes and failures. The conclusion is that most of the problems that cause projects to fail are recognised well in advance of failure – early enough to have been remedied. The project manager and often a majority of the project team knew the project would fail and why, but failed to speak up and inform others.
In a study called Silence Fails, the team identified five challenges that are very common; 91% of the managers surveyed regularly experience at least one of them. These challenges do not mean the project is doomed, so long as they are recognised, addressed and resolved. But what turns these five challenges into project death sentences is that they are the 'elephants in the room' – people recognise them but rarely address or resolve them. Consequently, these challenges become ‘undiscussables’ and cause the project to fail.
The first of these challenges is known as fact-free planning. It occurs when budgets, schedules or deliverables are set without considering what is realistic. A member of a project team described what can happen in this scenario: "We have a very detailed, rigid project-planning process. But 'garbage in-garbage out' still applies. I was designated to lead the project team implementing our electronic ICU, but the timeline, budget and details were dictated by our parent system. They were impossible to meet, so all I could do was do my best, then take my punishment when the dust settled."
Fact-free planning is incredibly common, with 85% of leaders experiencing it in one form or another. Sometimes, as in the example above, the team has no input into the objective at all. At other times the team is asked for a detailed feasibility assessment, but then their input is either ignored or arbitrarily reduced.
Fact-free planning is quickly recognised by the hospital personnel who are working on the project. It becomes a hot topic for discussion, and can destroy the team's morale. But it can be solved if dealt with quickly. So, how should it be handled?
The project leaders in the study knew it was their job to speak up when faced with a fact-free plan, with 61% going to their administrator or the project's sponsor to try to make their case. But once in conversation, nine out of ten leaders described making their concerns known as 'between difficult and impossible'.
Nearly all backed down before explaining their full concerns. In fact, when asked whether the other person had understood their full concerns and showed respect for their opinion – even if they disagreed with it – the percentage dropped from 61% to 14%.
When the person leading the project either fails to bring up concerns or backs down before fully describing the issues, the problem continues. In fact, the most common description heard was that the project became 'a train wreck waiting to happen'. When a concern wasn't discussed and resolved, then 85% of the time the project failed to meet its budget, its schedule or its deliverables. The team's morale suffered 73% of the time.
The team in the above example did eventually meet their deadline, but not to full success. The electronic ICU was declared 'up and running', but nearly half of the physicians refused to use it. It took the hospital more than a year to mend the hurt relationships caused by lack of discussion. In the meantime, none of the quality, safety or cost benefits were truly achieved.
Absent without leave (AWOL) sponsors occur in a hospital when a project's sponsor fails to provide the leadership, political clout, time or energy required. One respondent described an AWOL sponsor scenario: "Our projects move forward fairly smoothly so long as the challenges are strictly technical. However, if we run into policy or political issues – perhaps with a physician group or with the union – then senior leaders disappear from the scene. They leave the project to its own devices."
Of the leaders surveyed, 65% experienced AWOL sponsor problems. As with fact-free planning, these problems were easy to see but difficult to address. Only one in ten leaders were able to discuss their need for greater support with their manager or the project's sponsor. When these concerns were left unresolved the project failed. Three quarters of the projects missed their budget targets, 85% missed their deadlines, 74% missed their deliverables or specifications and 69% of the time team morale was damaged.
Many healthcare leaders complain that people try to work around or avoid the project-management process. This concern is known as 'skirting'. One of the leaders interviewed described this issue: "We have a really powerful group practice – a large group of paediatricians – who can pretty much get anything they want. If they don’t like some aspect of an initiative, they stop speaking to you. Your calls and emails go unanswered, and they go straight to the CEO, who gives them whatever they want."
Skirting was experienced by 83% of the leaders surveyed. But only 13% were able to successfully address it when it happened. When these concerns were left unresolved the project failed. Almost 80% missed their budget targets, 87% missed their deadlines, 80% missed their deliverables or specifications and 66% of the time the team's morale was damaged.
The idea of 'playing chicken' – where two teenagers would point their cars head on and speed toward a collision, with the driver who flinched first to avoid crashing being the chicken – was also applied during this study. A similar kind of risk-taking behaviour was found among healthcare leaders, especially during project review meetings.
A leader would know their team was behind schedule, but would keep quiet, knowing that others were also behind. The leader who spoke up first would take the heat and everyone's schedule would be delayed. Those who failed to speak up benefited from the extra time and no one ever realised they were behind.
One respondent described project chicken's worst case scenario: "We were working on a major initiative, a part of our CPOE. It had a lot of moving parts and a very tight schedule. If you read the progress reports, you'd think it was right on target, but after everything crashed and burned we found out people were just telling us what they thought we wanted to hear. I guess they were hoping everything would magically come out all right, but it didn't."
Project chicken was experienced by 55% of the leaders surveyed. Only 13% were able to successfully confront their peers when they saw it happening. Those who didn't deal with this saw their projects fail. More than three quarters of projects missed their budget targets, 86% missed their deadlines, 74% missed their deliverables or specifications and 54% of the time the team's morale was damaged.
This caused huge problems for the facility in the example above: "The hospital took a huge step backwards. CPOE got a reputation for being a big failure nobody wanted to be associated with. It must have set us back at least three years."
Team failures refer to problems within the project team, such as team members who miss meetings, fail to deliver on assignments or undercut the team in other ways. Sometimes the team member does not have the right skills for the job. Other times they have too many competing priorities.
One survey respondent described a typical scenario for this problem: "Sometimes you'll get a resource for your team, but in the resource's mind all they are doing is attending your meetings; they are not really doing any work. At some point in the project they have to do some work, and that is when they get their head around the project for the first time."
Team failures were experienced by four out of five of the leaders surveyed. When they failed to solve these team issues, then the project failed. Budget targets were missed by 73% of teams, 82% missed their deadlines, 77% missed their deliverables or specifications and 69% of the time the team’s morale was damaged.
TACKLING THESE PROBLEMS
Based on the five challenges behind failing projects, what can you do to ensure your hospital, department or team overcomes these obstacles and salvages current and future initiatives? Senior leaders need to encourage the people leading projects to speak up and make sure they are heard by others.
More than half of the healthcare managers who tried to warn others about problems backed off because the decision-maker became defensive, failed to listen, would not take their concerns seriously, or because they feared retaliation. Leaders will not be able to drive out fear overnight, but there is an approach that can work:
- Build the case for change. Project failures are extremely costly, but are rarely documented. Track and publish project success rates and also rates of speaking up. This data will demonstrate the scope of the problem. Begin a listening campaign. Meet with administrators, physicians and project team members to learn what makes it difficult to discuss threats to project success.
- Invest in training. Most healthcare managers lack the skill and confidence required to succeed in politically risky conversations. Training in these kinds of conversations can yield strong results.
- Hold senior management accountable. Continue to collect data showing rates of speaking up. Set an ambitious improvement target. If 10% of your project managers can already speak up successfully, then set a goal to double or triple that figure. When results lag in one senior manager's area, work with him or her to determine why fear remains and how to reduce it.
The Silence Fails study shows that many, if not most, of a hospital's project failures can be averted if the people leading the projects can speak up and be heard. Those who successfully address one or more of the five challenges are 50–70% more likely to fully achieve project objectives.
However, success requires both 'top-down' and 'bottom-up' solutions. Senior leaders in hospital or healthcare systems need to make it safe to speak up and important to listen. The people working on projects need to make the choice to speak up and acquire the skills to do so effectively and respectfully. When both parties are able to discuss issues and resolve them together, then problems will quickly become the exception instead of the rule.