Clinical Informatics

Leadership models guides that suggest specific leadership behaviors to use in specific environments or situations
Leadership/Managerial Grid model Blake & Mouton (1985); questionnaire --> classify in one of four quadrants: authoritarian (highly task oriented but hard on workers), country club (uses reward power to maintain discipline), impoverished (delegate and disappear) or team leader (strong on task and people skills)
Situational Leadership Hersey & Blanchard (1977); level of direction and level of support depends on worker's skill and knowledge; leadership styles are matched to maturity level. Directing = high direction low support; Coaching = decreased direction and increased support; Supporting = further decreased direction and similar support; Delegating provides direction and support as needed
Servant Leadership SL timeless; 'first among equals'; a servant-leader focuses primarily on the growth and well-being of people and the communities to which they belong; shares rather than exercises power, puts the needs of others first and helps people develop and perform.
Action-Centered Leadership Model Adair (1973), functional leadership model in which leadership is thought of as a set of behaviors (rather than as an individual person) that help a group of people perform their task or reach their goal. Leadership function meets the needs of Task, Team, and Individual.
Functional Results-Oriented Healthcare Leadership Model builds on Adair + 4th element: results, that builds on the foundation of Individual, Team, Task. "Results" emphasizes leadership responsibility for achieving measurable outcomes in healthcare setting. (where we're moving in informatics)
Healthcare Quality Professional Leadership Development Model (2008) focus on professional leadership development. Pyramid buidling from 1. Professionalism/Professional Values upward to self-development & self-management, communication, performance improvement, organizational awareness, fostering of postiive change (achieving good outcome). Published by NAHQ
National Center for Healthcare Leadership Competency Model NCHL (2008) Venn diagram of Transformation activities, Execution activities, and People considerations to be addressed by health leadership. 26 competencies within the three domains
American College of Healthcare Executives ACHE
Healthcare Leadership Alliance Model published by ACHE (2013): overlap of four domains with leadership in the middle : 1 Communication and Relationship management, 2 Professionalism, 3 Business skills and Knowledge, 4 Knowledge of the healthcare environment
ACHE Healthcare Executive Competencies Assessment Tool Captures multiples areas of competencies with the four domains; part of leadership model for leaders
Center for Creative Leadership Six-Part Model for Transformative Change six part model for adapting and thriving during a time of collaborative transformative change: collaborative patient-care teams, resource stewardship, talent transformation, boundary spanning, capacity for complexity / innovation / change, engagement and well-being

Dimensions of effective leadership ability to mobilize an effective team; create an environment that removes barriers to success; 'character with competency' (integrity); coping with change: depict clear vision for the future, present strategies to attain the vision; alignment of people and vision
Five dimensions of effective leadership (McKinsey) #1 meaning (finding meaning in work); 2 positive framing (converting stress into opportunity); 3 connecting (leveraging connections); 4 engaging (acting in the face of risk); 5 managing energy (sustaining energy)
Reeves leadership dimension theory leaders need not be every dimension themselves; but the effective leader must ensure that every leadership dimension (visionary, relational, systems, reflective, collaborative, analytical, communicative) is provided by some member of the leadership team
Strategic thinking a deliberate and systematic process for making decisions and long-term planning for sustained growth; the goal is to seek innovation and imagine new and very different futures that may lead the company to redefine its core strategies and even its industry. Must have a systems perspective, be intent-focused, think in time, hypothesis-driven, intelligent opportunism
Strategic planning to realize and support strategies developed through the strategic thinking process and to integratre these back into the business
Tactical thinking more immediate , often safe and conservative and status quo maintaining; looks for the immediate payoff and involves automatic and routine execution of a task - 'what to do and how to do it'
Analytical thinking break down complex bits of information, thinking step-by-step to develop an overall conclusion or solution; uses facts to support conclusions or a train of thought.
Critical thinking takes facts and uses them to form an opinion or belief; evaluates and interprets data
Kipling Method who what where when why how to help trigger ideas and solve problems
Brainstorming 4-8 people; write a well-defined clearly stated problem, review ground rules, facilitate discussion, generate idea, clarify and conclude
Imaginary Brainstorming form problem statement, substitute key ideas with silly replacements, generate ideas to address imaginary problem, extend ideas back to original problem statement
Brainwriting 6-3-5 6 participants supervised by a moderator who are required to write down 3 ideas on a specific worksheet within 5 minutes; the outcome after 6 rounds, during which participants swap their worksheets passing them on to the team member sitting at their right, is 108 ideas generated in 30 minutes.
Reverse brainstorming a way to bring a new perspective to idea generation that can be especially helpful when a team is cynical about a project or lacking energy. If you have members of your team who are hostile or worn out, this approach can take advantage of the hostility or fatigue. Asks the negative questions - what could we do to make target worse
Visioning imagine desired future and describe it to others in dynamic and emotive words to paint a picture; test it against others to ensure vision works for them as well

Governance (eg processes; responsibility versus authority) puts structure around how organizations align HIT with business strategy, ensuring they stay on track to achieve their strategies and goals, and implementing good ways to measure HIT performance. Processes and decisions that seek to define actions, grant power, and verify performance: the rules and actions used to produce, sustain, and regulate an organization or group
HIT governance confers legitimacy on decisions, standardizes processes, shapes expectations, ensures benefits are achieved, aligns strategy, provides input to capital budget process, provides HIT demand mgmt, provides HIT portfolilo mgmt
Governance goals 1. demonstrates value for staff, 2. builds consensus, 3. minimizes resistance. Addresses the following needs: managing change, clinician-focused benefits, clinical knowledge-based content, care process, communication, training and support, vendor system design
Portfolio management establish and maintain portfolio of new and exisiting HIT capabilities; build portfolio; align portfolio with strategic direction; have evaluation criteria in place; implement a decision-making process to prioritize allocation of resources for operations, maintenance and systems development
Governance considerations Who sets priorities, decides what problems to tackle? How are efforts aligned with organizational mission? Who designs, selects, imlements processes/procedures/systems? What determines and constitutes success? How do outcomes of an effected change further improve healthcare delivery and quality? Who is accountable for maintenance and future updates?
Governance benefits transparency/consistency, alignment of decisions with the strategic direction of the organization, risk mitigation, collaboration, reduced duplication, better stakeholder involvement
Governance elements A defined structure (ie committees, reporting lines); responsibilities for committees; personnel that are aligned with the principles associated with the governance framework; infrastructure for communication
Steering committee should govern all HIT projects
Governance key factors strong leadership, invites and leverages clinical provider input on the governance team; anticipates resistance and has strategy to overcome; aligns with organizational mission and other business drivers (eg TJC, MU)
Physician Advisory Group PAG for example, established by medical executive committee for the purpose of HIT governance; would have its own charter, document roles, standing and ad hoc committees; communicates with other medical executive commitees.
Responsibility vs Authority governance structures have both authority and responsibility to effect positive change for the organization. Fulfilling the responsibility requires skills in negotiation, conflict mgmt, collaboration, motivation and deicison-making. Authority is not a skill: it is bestowed upon you by virture of your position or something you command

Negotiation Collaborative better; prepare alternatives; both sides should know non-negotiables; earn trust; effective communication; transparency; be prepared to compromise; use innovation and creativity
Best Alternative to a Negotiated Agreement BATNA the likely course you will take if you \cannot come to an agreement with the other party; you should know what it is before entering into negotiations and you should not accept anything less
Distributive negotiation hard-bargaining negotiation: negotiations looked at as a process for distributing a fixed amount of value
Integrative negotiation principled negotiation: more trust and relationship forming; can involve creating problem solving o achieve mutual gains. Win-win negotiation

Conflict management Address early; unresolved conflict has ongoing negative consequences; conflict well handled lead to improved outcomes, increased team cohesion, increased understanding of important issues
Constructive conflict when a group agrees to disagree in a way that promotes the goal of the group; vs negative conflict which results in hostility and prevents the group from moving forward
Sources of conflict schedules/deadlines, priorities, resources, technical opinions, administration, cost/budget, personality
Conflict types concern for the group vs concern for the individual: G+I+: Collaboration G+I-: Accommodation (parties concentrate on what they agree on rather than differences; allows other party to satsify their concerns while negecting ones own concerns) G-I+ Competition (win-lose) G-I- Avoidance
Conflict resolution comfortable setting, adequate time, prepare ahead, work to establish common ground. Establish dialogue and negotiate: agree on what the problem is! Good communication; abandon prior assumptions in order to hear the other side; problem solve together; acknowledge emotion but dont let it drive you or decision-making.
Collaboration parties discuss their differences and develop potential solutions that lead to agreement : win-win (preferred)
Compromise parties find a solutions that satisfies both to some degree; lose-lose, second preferred

Collaboration Leadership tool that considers and attempts to meet the needs of all parties involved in a process; based on premise of cooperation to achieve effective outcome; good when you need to consider variety of viewpoints, when there have been previous conflicts, when multiple stakeholders also have responsibility to meet the needs of their own subgroups

Helzberg's Two-factor (motivators and hygiene) theory motivators align with intrinsic factors (eg importance, achievement, recognition, responsibility). Hygiene factors align with extrinsic factors and help avoid demotivation (salary, office space, supervision, policy)
Motivation Internal and external factors that stimulate desire and energy in people to be continually interested and committed to a job, role or subject, or to make an effort to attain a goal
Intrinsic factors come from the work itself as well as the goals and aspirations of the individual (achievement, possibility for growth, social relationships, etc) More effective motivators
Extrinsic factors depend on the surrounding environment or basic human needs (salary, office space, responsibility, etc)
Maslow's hierarchy of human needs Higher level needs become motivators only after lower level needs are satisfied. Physiological (salary, office space, facilities) --> Safety (security, pension, health insurance) --> Social --> Self-Esteem --> Self-actualization (realization of the full potential of the individual)
McClelland's Human Motivation Theory (theory of needs) People have one dominant motivator of achievement, affiliation, or power. Which motivator is dominant is dependent on an individual's culture and life experience; knowing what motivates a person allows you to communicate with them, and leverage their talents more effectively
Sirota's Three-Factor Theory of Human Motivation Equity/Fairness; Achievement; Camraderie. Organizational goals are not in conflict with workers' goals; organization should try to meet workers' basic needs; enthusiasm of your staff an organizational advantage

Decision making Process/skill, not an outcome (leads to an outcome). Unilateral decisions may have crippling consequences; shared decision making takes more time and effort but has enormous payoffs in the long run.
Decision making styles decisive (little information, one course of action); flexible (little information, many options); hierarchical (lots of data, one course of action); integrative (lots of data, many options)
Decision making process Defining/analysing the problem (agree on objectives or process, agree on process, collect data) --> developing alternative solutions --> evaluating the solutions --> select the solution (communicate, get buy-in)--> implementing --> follow up/evaluate
Cynefin framework sorts all issues into five contexts defined by the nature of the relationship between cause and effect: obvious (sense-categorize-respond), complicated (sense-analyze-respond), complex (probe-sense-respond), chaotic (act-sense-respond), disorder
Problem solving as opposed to decision making, which requires coming to a conclusion or judgment, problem solving is more concerned with developing a plan for solving a problem and is often part of the decision making process

Human resources management (eg hiring, performance reviews and feedback, professional development, termination) technical skills, clinical expertise (clinical champions, critical for workflow considerations, critical to preserve healthcare delivery outcomes, critical to represent the intended user group); consider expertise in workflow analysis, user training, implementation, troubleshooting, follow through
HR resources process HR planning -> Staffing -> Development -> Evaluation -> Compensation -> Maintaining the workforce ->
Job analysis the systematic study of a job to determine what tasks and responsibilities are expected, the qualifications required to successfully meet those expectations, the conditions under which the work is performed, and who the position is accountable to
Job description the fruit of a job analysis; facilitates training, safety, compensation, performance evaluation, devleirables, responsibilities
Exempt status federal wage and hour term meaning not elibible for overtime pay over 40h. Nonexempt: is eligible for overtime
Performance reviews should relate to prestated performance expectations; expectations should align with organizational goals: review and set goals at least annually; make mid-course corrections early and often
Specific, Measurable, Attainable, Realistic, Time-Oriented SMART framework for performance goals
Feedback give feedback more frequently than formal perfomance reviews; focus on behavior, performance, and process (not personality traits); significant individual concerns? Address in person and privately; build in feedback loop- employee response is important; provide resources for improvement where needed)
Professional development provide orientation to organization and team; leverage or create relevant internal/external education and training opportunities; tailor individual professional development with written individual development plans or learning plans: employee is the driver, but plan should benefit both employee and team or organization; team may identify professional development needs as the team progresses through its mission
Value proposition the value that an organization can deliver to customers and other constituent groups within and outside the organization
Employment Branding the process of positioning an organization as an 'employer of choice' in the labor market

Team productivity and effectiveness (eg articulating team goals, defining rules of operation, clarifying individual roles
Team goals the team (not administrative leadership) sets and endorses team goals based on team mission; clarify goals and approach to achieve them (specific, timeline/deadlines, who on team is responsible); realistic goals and timelines based on resources; identify and conduct measures of success (otucome measures); revisit goals periodically; effect mid-course corrections
Team rules Document in writing: team members, roles, reporting lines; approach to decision making; resources, timelines, deliverables; meeting schedule and requirements for independent work.
Explicit norms written or discussed, eg silence phones in meetings, treat team members equally. All group members should agree
Implicit norms not discussed; dont talk behind each others back, dont complain
Team charter document that defines the purpose of the team, how it will work, and what the expected outcomes of the team are. 1. Purpose 2. Stakeholders 3. Membership 4. Responsibility 5. Decision making 6. Team name 7. Life expectancy 8. Communication 9. Financial resources
Tuckman model of group development Forming, Storming, Norming, Performing (Adjourning)

Group decision making define the question-analyze options-decide: diversity in groups may generate wider variety and higher quality of decision alternatives than individual or homogenous groups; greater collective understanding of the eventual course of action chosen; improve buy-in and adoption. However group decision making is slower
Groupthink individuals pressured to conform to dominant view in group; dissenting views suppressed; alternative courses of action not fully explored; group polarization: tendency of a group to entertain more risky or extreme solutions to a problem
Nominal group technique group members individually develop ideas or proposed solutions in writing; then each group member in turn shares one item from their list until all ideas are publicly recorded; group engages in discussion; conclude with group members ranking all options; highest ranking chosen. Can be conducted without face to face meetings; can accommodate opinions from a large number of people; can be conducted anonymously; minimizes bandwagon effect. Range of opinions are only as diverse as the experts in the group; best written opinions may sway group opinion. Best example is single problem.
Consensus mapping facilitator and group reach consensus about how best to arrange or sequence multiple inter-related activities into a useable plan of action. Best example: multiple issues eg implementing new information system department or facility-wide; based on expectation of compromise. Begin by creating a master list of all ideas/projects 2. Form small groups (2-4 task groups, each 5-9 people) 3. Large group review and re-evaluation of original ideas 4. faciliator work with large group to create 'strawman' integrated map 5. map reconfiguration by small group 6. large group presentation 7. map consolidation. Each team member has the opporutnity to provide input and opinions; solution predicated on the agreement or acceptance of all team members; works best with a trained experienced group
Delphi method Originally developed by RAND in the 50s to forecast impact of technology on warfare: systematic interactive forecasting method which relies on a panel of experts. 1. experts answer questionaires 2. faciliator provides anonymous summary of the experts forecasts and reasons 3. experts are encouraged to revise their answers in light of replies of other members 4. goal is that during this iterative process the range of answers will decrease and the group opinion will move toward a final answer 5. process stops when a predefined criterion is reach (eg number of rounds, consensus) 6. mean or median scores of the final round determine results. Can be conducted without face-to-face meetings; can accommodate opinions from a large number of experts, can be conducted anonoymously; minimizes bandwagon effect. Range of opinions only as diveres as the experts; best written opinions may sway group opinions

Managing meetings be clear about why team is meeting; determine if a meeting is the best way to accomplish a specific task; determine venue; choose meeting frequency that can be achieved; develop and distribute clear agenda based on desired goal and outcomes; identify stakeholders; distribute prework needed to accomplish agenda. Follow up! generate minutes, document decisions, tasks, deadlines, next steps; make arrangements to handoff assignments
Types of meetings Information Distribution (eg presentations), Information Collection (breifing senior leaders); Teaching/Learning (learning about a new EHR module); Problem-Solving (determining requirements for a new software)

Managing group deliberations meeting leader makes clear which decisions are being made by team versus when input is being solicited by final decision not being made by team; make all needed information available for discussion and decision making; beware of analysis paralysis; encourage participation; follow rules of operation
Group size Ideally 5-7 people
Robert's Rules of Order provide a framework for discussion, debate, voting; eg must stand before speaking to group, debate begins after chair states motion, no speaking twice on same topic until all others have had the opportunity; courtesy; silence means consent

Effective communications Creating understanding
Transmission model (standard view) message transfferred from sender to receiver via a channel; simple model, depicts a complex process. Sender encodes message which is sent to receiver (decoder): information source produces message (eg natural language); transmitter encodes message into signals; message transmits via a channel; receiver decodes message from signal; message arrives at destination
Successful communication intended meaning is preserved from sender to receiver: communication is a process of transmitting information. Information is the message, what is being communicated. Communication can have an effect on the message itself and on the message effectiveness
Premiere mistakes in communication making the assumption that what i said is what you understood. Failing to understand that miscommunication carries costs and consequences - sometimes BIG.
Methods of communication Oral, Written, Non-verbal (body language, facial expressions, vocal intonation)
Media Richness Theory MRT A framework to describe a communication medium's ability to reproduce the information sent over it. Channels may be more or less rich or lean: rich a/v face-to-face in person or via video ---->audio but nonvisual (eg telephone, voicemail) --> lean (email, memos, posters)
Lean communication Pro: inexpensive, good for routine communication, mass mailings. Cons: 1-way communication, difficult to individualize or personalize the message, no real-time feedback from receiver, no opportunity to alter message as communication unfolds; no quick way to know who saw/understood message, difficult to retract or rectify errors
Rich communication Pros: personal; can tailor same message to appeal to specific individuals/groups; 2-way communication; can alter message during communication; best for complex messages or ideas. Cons: More expensive, more time-consuming.
Effective communication strategy WHAT is the message (clearly identify the message, what has brough about the need for the message, identify primary point you want to communicate, what is the outcome you want to effect with the message, educate your implementation team to be consistent with core message), WHY are you delivering the message, WHO do you want to receive the message (identify and characterize the target audience), HOW will you deliver the message (choose a communication channel suited to type of message and target audience)
Information overload results in decreased communication, eg alert fatigue, erroneous documentation due to indisicriminate copy and pasting

Effective presentations to groups Who is audience? Setting appropriate to size, allow adequate time; look for ready-made venues; cultural issues, use a rich channel of communication; practice with feedback

Effective one-on-one communication Who is recipient? Setting convenient for the recipient; use rich channel of communication; eye contact; 'on the fly' vs appointment

Writing effectively for various audiences and goals choose wording, style appropriate to mesasge and audience; simplicity, utility, purpose; error check; field test; lean channel

Mid-course corrections involve stakeholders in crafting solutions to problems that arise and communicate the solutions as you make corrections
Stakeholders who will benefit and/or who is affected by (losses) the implementation; recipients of your communication message may be heterogenous (staff, admin, patients); commit to a program of continuous communication throughout the implementation process
Crafting messages involve stakeholders early; tailor message to stakeholder, stage of implementation. Select branding (logo/title) for implementation! Before implementation assess and communicate impact of implementation on workflow; be honest and realistic: forecast anticipated discomforts, negative impacts (and solutions) as well as forecast anticipated benefits
Stakeholder feedback Understand that not all stakeholders will share your enthusiasm; look for champions early to help communicate message; create channels for feedback; respond to feedback
Education and Training Plan and deliver education/training for stakeholders/users; training availability should be at convenience of user with least disruption to their workflow; plan back-up coverage where needed; make it worth their time and interest (food, CME, comforts!) timing of training is key: not too early not too late
Post roll-out Provide capable accessible technical support; continue feedback loop; use rich channels of communication when feasible: encourages sense of stakeholder unity, provides best opportunity to close the feedback loop. Within the implementation, use redundancy in communication channels to maximize effectiveness of communication in daily work

Project management the application of knowledge, skills, and techniques to execute projects effectively and efficiently; the discipline of planning, organizing, motivating, and controlling resources to achieve specific goals
Project temporary endeavor with a defined beginning and end undertaken to meet unique goals and objectives, typically to bring about beneficial change or added value. Finite in length, usually one-time pieces of work invovling a number of activities that must be completed within a given time frame, and often on a fixed budget
Business operations repetitive, permanent, or semipermanent functional activities to produce products or services

Basic principles Plan first (define the work to be done in detail before starting); put together the right project team; estimate time and costs; break the job down into smaller manageable chunks; establish a procedure by which you will manage change; communicate to stakeholders; agree on acceptance criteria which defines project end
Triple constraint scope (objectives that will be accomplished), time (duration), cost (budget); 4th dimension: Quality. A project can define two and the third is constrained.
Project traits unique, most often part of a larger program; specific deliverable, specific due date, require multi-disciplinary talent, problems, conflicts
Project Management Institute PMI the governing body for project management
Project Management Body of Knowledge PMBOK widely referenced project management resources (bible)
Process groups Initiation, (Planning & Design, Executing, Monitoring & Controlling), Closing
Project management lifecycle analagous to project process groups; collection of generally sequential and sometimes overlapping project phases; can be mapped to lifecycle structure
Project phases not the same as process groups: describe a project in time (initial, intermediate, final); each project phase happens only once in every project VS process groups are a means of grouping project management processes (may repeat in each phase)
Cost and staffing bell shaped curve; lowest at start of project, most expensive when carrying out the work, tapers off as project comes to close
Level of uncertainty highest at start of project; decreases as work progresses and goals are accomplished then declines steadily toward project close
Cost of changes lowest at start of project, then increases steadily as planning and work progress
Project initiation clarify goals and requirements, align project with organization, develop project charter which is approved at end of initiation
Project charter final product of product initiation: formally authorizes the existence of a project, a 'blueprint': team requirements, goals & objectives, assumptions, business case (why this project needs to be done), stakeholders, budget, deliverables
Project planning WHAT (what needs to be done, ie project charter), HOW, HOW MUCH (cost)
Project planning steps 1. Define problem 2. Identify project requirements 3. feasibility study (is outcome able to be achieved?) 4. product/project scope
Feasibility study determine if organization has sufficient economic, technical, and human resources to execute project successfully; cost/benefit analysis?
requirements the end products, not the same as resources!

Identifying resources part of project planning; human/material/financial; requirements dictate what resources are needed; consider time constraints

Resource allocation part of project planning; feasibility study as part of planning helps clarify resources needed; be efficient but relaistic

Brainstorming generate ideas, goals, approaches; useful at project initation and to solve midcourse problems; use project team SMEs, focus groups
Subject Matter Expert SME
Mind Map take information that group produces and group by themes
Fishbone Diagrams aska Ishikawa, Cause and Effect, Herringbone; identifies multiple possible causes; begin with identificaiton of problem then work backwords; consider where process may be changed; useful for failure analysis, project planning
Work Breakdown Structure WBS Hierarchical decomposition of the total scope of work; subdivides major project deliverables into smaller, manageable achievable components. Defines all the work (first step - identify the major tasks needed to complete the scope); can be used to estimate task duration, assign resources, manage costs. FIVE components: 1. Project title 2. Project subsystems (subprojects) 3. Major devlierables 4. Subdeliverables 5. Work packages
Program Evaluation Review Technique PERT tool used to schedule, organize, and coordinate tasks within a project (clearly illustrates task dependencies); particularly useful when time is critical (but details of tasks less clear) and may be used in conjunction with CPM; project milestones/events represented as circular numbered nodes; directional vectors represent sequential tasks required to achieve project milestones; dependent (serial) tasks must be completed in the sequence specified; nonsequential tasks = concurrent tasks = parallel tasks. Critical path is longest continuous pathway from initial milestone to terminal milestone; Float is amount of time a particular task may be delayed without resulting in delay of subsequent tasks (Free float) or delay of the whole project (total float); tasks with float have no temporal dependency
Critical Path Method (activity on node diagram) CPM the series of sequential steps with the longest duration (i.e. the shortest time possible to complete the project - good when late finish has serious consequences). Uses three elements to calculate three variables: project activities, time to complete, dependencies --- calculate (1) critical path, (2) earliest each activity can start, and (3) latest each can finish without making the total project longer. Critical activities are those on the longest path. Float activities are not on critical path and can be altered without altering total amount of time. Subcritical paths possible. Used to prioritize activities for time management and 'prune" critical path activities; "fast track": perform more activities in parallel; 'crash the critical path' = add resources to shorten duration of critical path activities
As Built Critical Path ABCP post mortem analysis after project; analyzes causes and impacts of changes between planned schedule and resulting actual schedule as the project was implemented
Gantt Chart Bar chart used to represent project activities/tasks/phases on a timeline (ie shows overlap and order / predecessor/successor relationships); facilitates scheduling and resource allocation. Fixed and flat nature offers little room for uncertainty: does not place schedule variations in a meaningful context, does not reveal implications of one activity being delayed verus another, does not represent variations in workload of one activity versus another, does not lend itself well to a project with many tasks

Why projects fail poor project communication, failure to recognize uncertainty/risks, demands exceeed realities, difficulties in stakeholder management. Scope creep (scope exceeds originally defined boundaries); managing expectations; balancing competing priorities --- handle with good project planning

Scope define during planning: extent of the work involved to complete the project; knowing boundaries is important; use project charter as guide to define project scope; scope planning results in scope statement, scope management plan, WBS
Scope statement common understanding of the project, objectives and deliverables, formas basis of project planning processes, contains justification, description, deliverables, time and cost estimates, success crtieria, assumptions, constraints
Scope management plan documents procedures that wil be used to manage proposed changes to project scope during any point in the project lifecycle (invoked during monitoring & controlling process group)

Managing expectations define and agree on project scope during project planning; consult project charter and scope with WBS early and often. If change is needed (eg regulatory change), evaluate and plan within context of project scope; communicate effectively

Balancing competing priorities be realistic about needed resources and resource allocation during project planning; evaluate 'competiion' within context of project scope; use project tools to assess effect on success; can use tools to identify strategies to mitigate risk imposed by competing priorities; allow some flexibility in how you accomplish project tasks while remaining steadfast in staying within project scope and commited to project goals

Strategic and financial planning for clinical information systems Align CIS with the mission/vision/goals of the health organization as a whole
Organizational Pull Model Priority of organization's business objectives drives IT requirements
Technology Push Model Evolving IT enables organization to expand its business scope beyond its current state, e.g. wireless communication within a network gives clinicians immediate access to patient information & ordering ability independent of location; promotes care across continuum; time-efficiency; may decrease costs, increase guideline compliance and staff satisfaction
Component Alignment Model Identifies 7 components to be kept aligned: external environment, emerging IT, org mission, org infrastructure, IT infrastructure, org business strategy, IT strategy
Strategic planning Long-range (3-5 yrs, vs project planning). Revisions may be required, e.g. because of regulatory issues; managed by a team led by CIO or CMIO. Steps are: 1. Assess current state including organizational & health IT/CIS structure; perform an environmental scan; 2. Describe/develop desired future state which will drive strategy: the embodiment of your goals; resolve weakness from SWOT or other analyses; get input and agreement all around 3. Devise plan from 1 to 2 - formulate strategy and action plan including financial planning. Start with a vision statement, a mission statement, objectives, strategies

Vision Statement defines your organization's purpose in terms of its values; likely to include statements that are meant to inspire and convey a sense of higher or overarching purpose
Mission Statement defines the purpose and primary objectives (business goals) of organization, facility, department or division; intended to communicate your purpose to others; an embodiment of the vision; Action-Oriented; addresses your main function, reason for existence as it relates to your customers; should align with organizational strategic plan
Objectives (core principles or goals) statements of tangible actions, activities, services, and programs that operationalize the organizational mission and vision; describe how you will fulfill your mission and vision; top-down (from execs or subset sets pace) versus bottom-up goal setting (less usual but may be necessary)

Environmental scanning collecting information and data about external and internal influences that will affect mission, vision, objectives and strategies for the future of your organization's CIS. Use information/analysis to revise vision, mission, objectives, strategy
Internal categories human resources, financial resources, facilities, organizational culture
External categories collaborators and affiliates, regulators, vendors, contractors, competitors, professional organizations, current industry standards... Survey other entities similar to yours in size/vision; current and predicted industry standards and regulations; get data from publications, focus groups, leaders, gather data
Environmental scan components what does this organization do, what are its activities/prodcuts; who are the customers; who benefits; how well is organization doing? # of beds, counts of patients, trainees; organizational chart? Physical plan. Where does information management fit in facility's current organizational structure ? Is there a current information management plan in place?
Strengths, Weakness, Opportunities and Threats analysis SWOT
Political, Economic, Socio-cultural, Technological factors PEST for external environmental scanning, may be richer than SWOT

Strategy formulation select the right architectures/solutions to operationalize target state, resolve weaknesses and mitigate threates (determined from environmental scan); specify any process reengineering that needs to be undertaken before and during implementation of new IT capabilities; employ workflow analysis techniques; specify type of roll-out (ie incremental vs enterprise-wide for each component)
Flexibility specify a process for evaluating possible need for 'change of plan' due to unpredicted occurrences; specify a process for effecting change to the Strategic Plan when required
Financial Strategic Planning Account for costs related people, process, technology: workflow analysis, reengineering health processes, integrating & mataining IT into the reeengineered processes; training staff and patients

Action planning and strategy implementation develop a plan that moves you from current to future state using your defined strategy; produce a project portfolio with planne d measures, priorities, timeline, costs; dont underestimate complexity of underlying healthcare processes
CIS Strategic Plan Implementation issues follow steps/timeline in your strategic plan; strong leadership required, even in setting of change in leadership, environment, or budget; during implementation, evaluate all potential changes in light of your defined target state; engage stakeholders actively in the implementation process.
Risk during implementation stray from planned path: the more tightly your strategy is linked to your organizational strategic plan the more likely you will stay on course during implementation; manage your implementation according to sound change mgmt and project mgmt principles

Capital budgeting Planning process for expenditure of relatively large sums on long-term assets such as replacing worn out assets with new ones and developing new business opportunities; eg licensing fees, hadware, consulting fees
Operating budgeting A detailed projection of all estimated income and expenses based on forecasted revenue during a given period. A complete operating budget consists of not only a projected profit and loss statement but also a supporting cash flow statement, as well as a balance sheet
Depreciation To lower the price or estimated value of, particularly of a long-term asset that has diminishing value over time
Net present value The difference between the present value of all cash inflows and the present value of all cash outflows; used to determine whether or not a project is an acceptable investment. NPV(i,N) = SIGMA (t=0--> N) Rt/(1+i)^t

Managerial accounting concerned with providing information to internal managers; includes accounting information (budgets, performance reports), tools for organizing and directing and decision making; more emphasis on the future, non-monetary data, more emphasis on segments of an organization rather than the whole; not governed by generally accepted accounting principles (conventions for how accounting information is expressed)
Financial accounting concerned with providing information to stockholders and others outside an organization
Profit and Loss statement P&L
Operating leverage describes the amount of money you spend on fixed costs and what is gained beyond is profit
Cost-volume-profit analysis plot cost, volume, profit
Budget types Statistical (what-if scenarios); Revenue (for government expenditures); Cash (prediction of future cash receipts and expenditures); Expense (includes spending data items); Operating; Capital
Balance Sheet Assets ((Current eg cash, Fixed eg buildings) = Liabilities (short and long-term debt) + Equity
Income Statements Operating earnings = Gross Profit - (Operating Expenses + Depreciation)
Cash flow Amount of cash that changed hands during an accounting period
Health Information Communication Technology HICT Costs divided between implementation (support, training, build processes, admin), maintenance (support, most of the costs), RDTE
Research, Development, Training, Evaluation RDTE
Hospital Expenses salaries/benefits: 50%
Total cost of ownership Hardware/software (computer, network, purchasing research, migration, risks); Operations (infrastructure, electricity, diminished performance, security); Long term expenses (replacement, future upgrade, decommissioning); consider life cycle of system not just initial purchase/licensing cost
Cost reduction optimize work processes eg eliminating searching for charts; facilitate optimal choices; remind clinicians to perform appropriate preventative health services; reducing errors; checks reminders alerts; summarization; advance directive notice

Evaluation of planning process How well we did: develop as part of strategic plan: validate and justify your plan design and deicison making; demonstrate value and impact on patient care delivery and outcomes; informs future strategic planning and project planning efforts; industry standard; often required if receiving supplemental funding.
Evaluation plan 1. description of your strategic plan 2. statement of goals of your plan 3. evaluation goals (evaluation audience, purpose) 4. evaluation metrics
Evaluation metrics choose metrics appropriate to project; must be able to be realistically measured; may use mix of quantitative and qualitative measures; consider one-time measures and ongoing measurements (eg clinical outcomes, provider adoption & attitudes, patient access and satisfaction, workflow impact & financial impact); be efficient - look for measures already being done for other reasons such as QI efforts or regulatory compliance

Change Management A process that evolves over time that considers factors that make up the culture, structure, and behavior of the organization (People & Process) which are as important to consider as technology factors. An approach to transitioning individuals, teams, organizations from a current state to a desired future state. An organizational process aimed at helping the stakeholders of change to initiate, facilitate, accept and embrace changes in their environment. The application of the set of tools, processes, skills, and principles for managing the people side of change to achieve the required outcome of a change project or initiative
Change To become different, make different, make radically different, give a different position/course/direction, to undergo modification, transformation, transition, switch, replace
Natural history of change Change will happen but the outcome is not always predictable; change is neutral but the response may not be; no change is without consequence; context matters
Change management life cycle Current state - Identify (Assess & Analyze) - Engage/Plan (Strategy) - Implement - Desired State (iterative process: implement - identify (take stock again))

Organizational culture Cultural change required (people always resist!); people can make any system fail; what is current organizational culture: leadership (integrity, consistency, mindset, openness to change); personnel (numbers, talent, history of reaction to change); financial state and resources
Organizational Behavior leadership (focus of recent actions, readiness for change); human resources (morale, collaborative behaviors, readiness for change); current major organizational projects that may align or not with proposed system change; unresolved organizational or systems crises?
Organizational Assessment Place the information and data you collected in your assessment into context to inform next step of the change management cycle, strategy development; seek external and internal feedback which can form the basis of potential options for the planning stage; involve stakeholders!

Change theories (eg precede-proceed, social influence theories, complex adaptive systems) Help us understand specific organizational behavior, and guide development of a successful change management strategy
Diffusion of Innovations Rogers (1961) frequently referenced; an innovation is an idea, practice or object that is perceived as new by an individual or other unit of adoption (eg EHR adoption); key elements: innovation, communication channels, time, social system. Diffusion is the process by which an innovation is communicated through certain channels over time among members of a social system.
Innovation adoption lifecycle innovators (2.5%) , early adopters (13.5%), early marjority (34%), late majority (34%), laggards (16%)
Transition Theory Bridges (1991): Phase 1: Ending, Losing, Letting go (dealing with loss; define what has ended and who is most affected). Phase 2: Neutral Zone - confusion, chaos, attempt re-alignment. Phase 3: The New Beginning (energy, purpose, unity, embracing change)
Lewin's Change Theory Three stage process: Unfreeze (preparation for change, overcome inertia, deal with individual and group resistance); Change (marked by the discomforts of confusion and transition); Freeze (the new circumstances and mindset are crystallizing, increasing comfort with the outcome of change)
Precede-Proceed Model Green (1980): Planning phase (assess current state) - Setting the Programme (implementation) - Evaluation Phase
Social influence theories People's behavior is intentionally or unintentionally influenced by others - and therefore affects acceptance of change or ability or willingness to participate in change, one way or the other; social norms exert influence and elicit a response of conformity; compliance, identification, internalization, conformity, self-fulfilling prophecy, reactance, obedience, persuasion
Complex Adaptive Systems First used to describe change in networks (neural, telecom), aka complexity science: complex systems are about relationships among members of a system. Complex adaptive behavior has multiple inputs and outputs. A system may be functioning with an underlying order/structure but is always poised to become unstable in that it may seek to change : 'Edge of Chaos". A flexible and adaptive system.
Kubler-Ross Grief Cycle Denial, Anger, Bargaining, Depression, Acceptance

Kotter's Eight Steps to Transforming Your Organization 1. Establish a sense of urgency 2. Forming a powerful guiding coalition 3. Creating a vision 4. Communicating a vision 5. Empowering others to act on the vision 6. Planning for and creating short term wins 7. Consolidating improvements and producing still more change 8. Institutionalizing new approaches
Kotter's Three-Phased Approach to Managing Change Phase 1: creating a climate for change (leadership establishes sense of urgency, builds a coalition, creates a vision); Phase 2: Engaging and enabling the organization (communicate future state, leadership empowers others to take action; plan for and create short-term wins); Phase 3: Implementing and sustaining the changes (focus on problems, solutions, behavior change; training, retraining, technical assistance, celebrate success). Gets you from current to future state: focus on people, process, technology
Critical Success Factors and Management Interventions for Managing Change Having a clear vision of the future state; creating and disseminating a plan of action; establishing a knowledgeable leadership (guiding) team; defining communication strategies; establishing and communicating where/how staff can get help; being prepared to train, retrain and provide technical assistance
Strategy Development for Change Management Develop a comminications plan regarding upcoming change; plan and effect process improvement/systems re-engineering prior to technical systems change; Involve stakeholders in the change management process; Develop strategy to help stakeholders move through resistance; Education/training/coaching of stakeholders who will be affected by system change
Implementing strategy Approach to implementation will be based on the strategy you have mapped out; be prepared to make mid-course corrections during implementation; use an implementation team
Evaluate and Restart the Cycle Evaluation: What was outcome (efficiency and effectiveness) of the change you implemented? Evaluation methods: survey stakeholders, focus groups, individual interviews, compare pre and post system performance or outcomes data. Restart change management cycle as indicated

Strategies for promoting adoption and effective use of clinical information systems Know your biggest risk areas for failure; Don't underestimate the potential impact of resistance to change, manage it; Apply change theories to your process; Assess and address people and process problems before investing in change to address technology problems; engage stakeholders early and often - identify early adopters; address later adopter fears, especially fears of clinical user staff
Resistance Resistance to change agents and champions; Organizational resistance to change / leadership issues; Resistance as a consequence of changes or uncertainty in the larger healthcare environment; Frequent change leading to resistance ('change fatigue'); False Starts: history of project effort that never resulted in useful production leads to resistance to repeat efforts; Resistance to specific information technology
Managing risk areas for failure: Culture and Communications Ineffective communication: ramp up from lean to rich communication if the lean communication was ineffective; Organizational culture - may need strategies to heal hostile or stagnating culture; Organizational behavioral issues: lack of clear vision, poor mgmt of uninteded consequences, staff turnover or competency issues, poor reporting structure, failure to address mgmt problems on the mgmt or leadership level
Managing risk areas for failure: Project Complexity Understimating project complexity: cost of missed deadlines, excess cost, loss of faith in project by stakeholders; prevent by diligent planning, mid-course corrections, communications. Scope creep. Technology issues: poor technology procurement; inadequate technology vs emphasis on technology to detriment of people & processes
Managing risk areas for failure: Training and Leadership Lack of training opportunity or lack of accessibility to busy staff; poor quality of training products; poor timing: too early or too late. Leadership issues: poorly prepared leader(s), poor skill set, not enough of time commitment