Exploring  Project  Management  Governance  as  a  Means  to  Create  Sustainable  Improvements  to  Patient  Safety  Through  Accreditation  

Lorraine Zimmermann APRJ-699, Applied Project April 27, 2013 Coach: Dr. Janice Thomas Word Count: 18,321

 

Table of Contents

Abstract ....................................................................................................................................2 Introduction..............................................................................................................................4 Research Purpose and Topic .................................................................................................5 The Statement of the Problem...................................................................................................5 The Opportunity .........................................................................................................................5 Literature Review.....................................................................................................................6 Section 1: Healthcare Accreditation...........................................................................................6 Section 2: Project Governance ..................................................................................................9

Enterprise Governance ........................................................................................................12 Section 3: Project Critical Success Factors .............................................................................14

Managing Projects ...............................................................................................................15 Leading Change...................................................................................................................18

Projects, Programs, and Portfolios in Healthcare ..............................................................20 Research Design....................................................................................................................21 Case Study Overview ............................................................................................................21 Discussion..............................................................................................................................28 Case Study Discussion............................................................................................................28 Overall Discussion ...................................................................................................................36 Recommendations and Conclusion.....................................................................................38 Moving Forward .......................................................................................................................39 Definitions ..............................................................................................................................41 Bibliography...........................................................................................................................42

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Abstract Every year an astonishing number of Canadians experience preventable harm while in our healthcare system. Patient safety is a growing concern in many countries and for over a decade healthcare organizations have struggled to identify and reduce patient harm across the continuum of care. As part of their challenge to be accountable for their financial and nonfinancial performance, Canadian healthcare organizations have developed clear objectives and invested significant resources to improve patient safety. Despite a growing body of knowledge and expanding communities of practice dedicated to patient safety improvement, medication errors, hospital acquired infections, and harm from falls continue to be experienced by our patients in alarming rates. If the data demonstrates that our patients are experiencing unacceptable levels of avoidable adverse events and we have the project management tools to reduce harm, why do so many of our patient safety efforts continue to fail to meet our expectations? The purpose of this report was to explore the role of project governance in the accreditation process as a means to create sustainable improvements to patient safety. Using a case study approach of one consultant’s experience with accreditation, combined with a review of the literature, the following topics were explored: Healthcare accreditation as a means to achieve improved patient safety; the value of an accreditation project governance framework that supports successful accreditation outcomes as well as organizational strategy; and top management support as a critical success factor that supports project success. As our understanding of project success has evolved over the past decades, from well-managed projects to sustainable changes in operations, we are beginning to understand that accreditation offers greater value when approached as part of continuous improvement rather than an exercise. The results support the use of a project governance model for accreditation, where processes, roles, responsibilities, and accountabilities are clearly defined and understood by all team members. The following recommendations are intended for leaders seeking to achieve greater value from their organization’s accreditation efforts: • Healthcare organizations should seek opportunities to strengthen stakeholder engagement

and improve performance by adopting an agile pragmatist paradigm for their project governance paradigm. This approach fosters organizational learning and sharing, and supports integration and standardization.

• Healthcare organizations should invest in Step 1 of a project governance framework where

their accreditation teams have a basic understanding of project management methodologies. This approach delivers an acceptable return on investment for accreditation related activities.

• Healthcare organizations should adopt a hybrid approach for their governance style in order

to maximize both effectiveness and efficiency with their accreditation efforts. A hybrid approach helps ensure that an organization’s accreditation efforts demonstrate alignment between organizational goals and operational goals.

• Healthcare organizations should seek opportunities to create an accreditation governance

model that enables top management support to help team members understand the

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connections between strategy and operations and achieve both strategic and operational objectives.

When accreditation is approached as a project, effective project governance can play an important role in ensuring that structure becomes an enabler for leadership rather than a substitution for leadership. Furthermore, when approached as part of an organization’s enterprise governance framework, project governance has the potential to create sustainable improvements to patient safety through accreditation, allowing healthcare organizations to be of greater service to those they serve.

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“Processes without results are useless, and results without processes are unsustainable.” - American Society of Quality

Introduction In (2000), the Institute of Medicine (IOM) published its groundbreaking report, To Err is Human: Building a Safer Health System, which broke the silence about the avoidable harm occurring to patients every year within the American healthcare system. A year later, the IOM followed with Crossing the Quality Chasm, a report designed to help healthcare organizations take their first steps towards building the organizational supports required to redesign a healthcare system that would foster an environment of patient safety (2001). In 2004 the Canadian Adverse Events Study provided data on patient safety in acute care settings and set the stage for Canadian healthcare organizations to identify and reduce patient harm across the continuum of care (Baker, et al., 2004). The study challenged healthcare leaders to become accountable for not only their organization’s financial performance but also for nonfinancial performance such as patient safety. Although the study was limited to twenty hospitals in five provinces, the data reflected similar findings in the UK, Australia, and the United States. The study suggested that of the approximately 2.5 million annual hospital admissions in Canada, 185,000 (7.9%) were associated with at least one adverse event of which approximately 70,000 (37% - 51%) were likely preventable (p. 1678). In the following decade, healthcare organizations around the world, including Canada, incorporated patient safety as part of their corporate strategy, directed resources to patient safety initiatives, and set clear goals for reducing avoidable harm to patients across their organizations. Healthcare improvement organizations, such as the Institute for Healthcare Improvement (IHI), the Canadian Patient Safety Institute (CPSI), and Accreditation Canada have developed evidence based standards, supported a growing body of knowledge, expanded communities of practice, and developed patient safety campaigns with project tools for organizations to adopt as part of their improvement projects. “Yet despite clear goals and considerable investments to improve patient safety, the gains have been limited” (Baker, 2012, p. 8). Patient safety issues continue to plague our healthcare system as medication errors, hospital acquired infections, and harm from falls continue to be experienced by our patients in alarming rates. If the data demonstrates that our patients are experiencing unacceptable levels of avoidable adverse events and we have the project management tools to help us create changes within the healthcare system to reduce harm, why do so many of our patient safety efforts continue to fail to meet our expectations? The problem may lie in our failure to ensure that governance frameworks are in place at the project, program, and portfolio levels of organizations to ensure that project managers and senior leaders deliver successful projects that remain sustainable in operations. This applied project will explore the role of project management governance in the accreditation process as a means to achieve sustainable improvements to patient safety in the Canadian healthcare system.

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Research Purpose and Topic

The Statement of the Problem Hospitals across the country recognize that patient safety is an issue but struggle with how to reduce preventable harm. “In only a decade, patient safety has been transformed from the esoteric interest of a small number of champions to an essential component of healthcare performance across Canada” (Baker, 2012), yet improvements are often made in the form of poorly executed projects that focus on changing processes but not the minds and hearts of our healthcare teams. Change efforts are often viewed as management issues involving planning, executing, and controlling, when they also need to be viewed as leadership issues involving strategy, empowerment and inspiration (Gill, 2003). In short, despite our best intentions to transform the quality of healthcare service delivery, success with improvement projects such as hospital accreditation rarely meet our expectations.

The Opportunity Hospital accreditation programs focus on quality through a patient safety lens, and offer healthcare organizations opportunities to improve their healthcare services. The accreditation process consists of the coordinated quality improvement activities of specialist teams undertaking a process of self-assessment, review, and remedial activity. Lack of sustainability of the improvement work related to accreditation can be perceived as project failure. This report assesses one Canadian healthcare organization’s project management approach to accreditation and how it is using the accreditation process to improve operational performance. As the organization completes its first accreditation cycle with Accreditation Canada, an opportunity exists to evaluate the success of the project, and apply lessons learned to ensure that improvements made to patient safety are sustained. The purpose of this report will be to provide practical guidance to healthcare leaders in their efforts to “implement sustainable systems and processes that improve operational effectiveness and advance positive health outcomes” (Accreditation Canada, 2012, p. 2) through the accreditation process. Using a case study approach based on this author’s experience leading accreditation for her healthcare organization combined with a review of the literature, the following topics will be explored: • Healthcare accreditation as a means to achieve improved patient safety; • The value of an accreditation project governance framework that supports successful

accreditation outcomes as well as organizational strategy; • Top management support as a critical success factor that supports effective project

governance. The paper begins with a review of relevant healthcare accreditation and project management literature. Next the accreditation process in one organization is described in some detail followed by a discussion of how the concepts in the literature help us understand the case experience. The paper concludes with recommendations for healthcare leaders looking to use project governance as a means to realize greater value from their accreditation efforts in the form of sustainable improvements to patient safety.

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Literature Review The literature review examines three areas that provide insight into why there are sustainability issues related to accreditation. The first element involves healthcare accreditation as a means to achieve improved patient safety. Accreditation provides healthcare organizations a framework to improve the quality of their services and demonstrate greater public accountability. The second element involves the value of project governance as a means to realize strategic benefits from successful accreditation projects by providing a consistent approach to achieving organizational goals. The third element explores the role of top management support, which is comprised of managing projects and leading change, and is likely the most significant critical success factor required for effective project governance. As primary data will not be collected, and only publically available organizational information shared, ethics approval is not required. Sources for this literature review will be gathered through the following sources: the Athabasca University Library for online access to journal articles; the Athabasca University MBA Program for course related textbooks and digital reading room materials; IHI Open School course materials; and personal books on relevant topics. The time frame for the literature review will cover materials published between 2000 and 2013, except where older sources are still considered relevant as indicated by their reference in the current literature.

Section 1: Healthcare Accreditation It is common for healthcare organizations to evaluate the quality of their healthcare services through external accreditation programs such as Accreditation Canada, a not-for-profit organization, which offers an external peer review process to help healthcare organizations assess and improve the quality of their services (Accreditation Canada, 2012). According to Wendy Nicklin, CEO of Accreditation Canada, “Accreditation is an internationally recognized evaluation process used to assess and improve the quality, efficiency, and effectiveness of health care organizations” (Accreditation Canada, 2012, p. 1). Accreditation Canada serves over 1000 Canadian and international healthcare organizations, drawing on the expertise of over 600 surveyors working within healthcare (Accreditation Canada, 2012). Through its Qmentum program, Accreditation Canada utilizes a cyclical process involving self-assessments, peer surveyor on-site visits, and quality improvement. Accreditation encourages organizations to meet compliance of evolving national standards of excellence by adopting a philosophy of continuous quality improvement. For organizations that include quality improvement as a strategic priority and demonstrate an ongoing commitment to patient safety, some commonly recognized benefits of accreditation include (Accreditation Canada, 2012): • Improves communication and enhances interdisciplinary team effectiveness; • Ensures an acceptable level of quality across the continuum of care and improves health

outcomes for patients and residents; • Promotes capacity-building, professional development, organizational learning and sharing

of leading practices between organizations; • Codifies policies and procedures and decreases variance in practices; • Stimulates sustainable quality improvement efforts and mitigates risk of adverse events; • Contributes to employee engagement and promotes a positive patient safety culture. The accreditation process begins with an inventory of services that an organization delivers and the scope of those services. This process involves determining which services are

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offered at each site and the volume of those services. This information is used to determine which Accreditation Canada Standards are applicable at both the site and organizational levels. Next the accreditation schedule is determined. Accreditation involves a cyclical process that begins with accreditation planning and self-assessment, followed by implementation of action plans and concludes with external peer assessment, an accreditation decision, and progress review (Figure 1). The timeframe for the accreditation cycle depends on the accrediting organization but is typically either three or four years.

Figure  1:  Accreditation  3-­year  cycle  (Accreditation  Canada,  2012)

Where accreditation involves a three-year cycle, year one involves forming Service Excellence Teams for each of the Accreditation Canada Standards. The Service Excellence Team begins its work by coordinating the self-assessment process in order to gather information from staff about their perceptions of compliance to the standards in their areas. The feedback information is compiled in a Quality Performance Roadmap and used to help guide the team’s improvement work. Action plans are developed based on the information in the roadmap and changes are implemented to ensure that the program is compliant with the applicable standards and Required Organizational Practices. This phase typically continues well into year two and three of the cycle. At the end of year three, Accreditation Canada surveyors visit the organization and assess the applicable service areas. Surveyors are chosen to assess an organization based on their clinical and administrative experience. During the on-site visit, surveyors assess the organization’s compliance to Accreditation Canada standards using a tracer methodology, which involves a surveyor following either an administrative process through the organization or a patient experience through the continuum of care. Administrative tracers involve a review of an organization’s human resource, finance, governance, and leadership practices while a clinical tracer follows a client’s journey through the healthcare system. Tracers involve the review of administrative or patient records, direct observation, and interviews with staff, physicians, patients/residents and their families, and external stakeholders (for example community partners). The information gathered helps the surveyor determine if the organization demonstrates compliance to criteria outlined in the Accreditation Canada standards and Required Organizational Practices. Individual programs across sites are evaluated as a single program and the organization is evaluated as an aggregate of all of its

Accreditation Planning

Self-Assessment

Implement Action Plans

On-Site Survey

Accreditation Decision

Progress Review

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programs. However, an organization is only as successful with accreditation as its poorest performing program or site. At the end of the on-site visit, surveyors present their initial findings to the organization, then the surveyors report their findings to the Accreditation Decision Committee, which then determines the organization’s accreditation status as follows (Accreditation Canada, 2012): • Accredited with Exemplary Standing: The organization attains the highest level of

performance, achieving excellence in meeting the requirements of the accreditation program. Met 95% or more of high priority standards in each service standard and all major tests for compliance for all Required Organizational Practices. • Accredited with Commendation: The organization surpasses the fundamental requirements

of the accreditation program. Met 85% or more of high priority standards in each service standard and did not meet one major test for compliance for Required Organizational Practice. • Accredited: The organization succeeds in meeting the fundamental requirements of the

accreditation program. Met 70% or more of high priority standards in each service standard and did not meet two or more major tests for compliance for Required Organizational Practices. • Not Accredited: The organization needs to make significant improvements to meet the

requirements of the accreditation program. Met less than 80% of all standards and met less than 70% of high priority standards and Required Organizational Practices.

If any Required Organizational Practices or high priority standards are deemed noncompliant, the organization must submit evidence that it has implemented the necessary changes to meet compliance as well as its plan to monitor success. Once Accreditation Canada has reviewed the additional evidence, it either accepts the new evidence, removes the conditions, and grants accreditation certification, or it rejects the new evidence, determines a new deadline for the organization to complete additional work, and again submits evidence. In some cases, Accreditation Canada will request a Focus Visit, which involves an additional on-site visit at the healthcare organization’s expense to evaluate the specific unmet criteria. An organization that fails to achieve accreditation certification potentially risks losing funding. It is therefore to the organization’s advantage that it invests in its initial accreditation efforts and contains costs by sustaining improvements. Despite the generally accepted belief within healthcare that accreditation certification is an indicator of an organization’s commitment to quality and patient safety, there is relatively little literature to support strong claims about the effectiveness of accreditation (Hinchcliff, et al., 2012). In looking at specific thematic categories of the benefits of accreditation, Hinchcliff et al. found inconsistent relationships between accreditation status and quality measures, organizational impacts (i.e. patient safety culture), change mechanisms, attitudes towards accreditation, financial impact, patient satisfaction, and surveyor issues (2012). The study does not reject the validity of accreditation, but challenges healthcare leaders to adopt outcome measures that assess the processes, effectiveness, and financial value of their accreditation program. A topic worth exploring is the underlying reason for this variation within the literature, specifically if it is related to an organization’s approach towards accreditation. When approached as an exercise, the goal of accreditation is to demonstrate compliance to the

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standards, but when accreditation is approached as a strategic priority it is likely an organization’s demonstration of its commitment to patient safety. Supported by an effective governance model with clearly defined roles and responsibilities, there may be potential for organizations to create a linkage between its accreditation efforts and strategic efforts that result in sustainable improvements to patient safety and improved organizational performance. Organizations should not limit their view of accreditation to a single, short-term goal but rather consider the potential impact accreditation has on the organization’s ability to become a high performing healthcare system that demonstrates an enhanced patient safety culture, high client satisfaction, and financial success. With greater accountabilities between Service Excellence Teams and operational teams, improvements to patient safety accomplished through accreditation should transition seamlessly to operations and become firmly embedded in practice and culture. If we consider accreditation as a strategic project, then project governance may provide the framework needed to link the accreditation project activities to the organization’s strategic priorities related to patient safety.

Section 2: Project Governance What does a successful project look like? At this point it is important to distinguish the difference between project management success and project success. Project management success is realized when a project meets its objectives of time, cost, and quality while project success is realized when a project meets its business benefits (Young & Jordan, 2008). Understanding this difference allows leaders to view projects from both a tactical and strategic perspective and to appreciate both aspects. According to Jugdev and Muller (2005), as our understanding of project management has become more refined, so has our understanding of project success. Looking at four distinct periods between1960 and 2005, our understanding of project success has evolved since project management was first recognized as a distinct discipline. Project success in the first period (1960-1980s) focused on implementation and handover (Jugdev & Muller, 2005). Success was measured by short-term goals, and failed to consider the value of the project after handover. In the second period (1980s-1990s), project success began to focus on the conditions that supported successful project outcomes (2005). While stakeholder satisfaction, change management, and project management soft-skills were identified as critical success factors (CSFs), these conditions were informally recognized and project success continued to focus on the project itself. In the third period (1990s-2000s) critical success factor frameworks began to emerge that considered the socio-cultural dimension of project management rather than solely on the technical dimension (2005). Project mission, stakeholder consultation and feedback, and management support were some of the critical success factors gaining acceptance as requirements for project success. Still, project success was limited to project lifecycle and did not fully appreciate the potential projects contribute to organizational strategy (2005). Only recently has our understanding of project success expanded to include long-term goals and achievement of organizational objectives, some reaching far beyond the original scope of the project itself. Given our current understanding of project success, project management governance may provide the framework necessary to ensure that projects deliver strategic results. Project governance provides the line of sight between projects and strategy, helping to connect the little dots to the big dots. Muller (2009) defines governance within the project management context as follows:

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“Governance, as it applies to portfolios, programs, and project management, coexists within the corporate governance framework. It comprises the value system, responsibilities, processes and policies that allow projects to achieve organizational objectives and foster implementation that is in the best interests of all stakeholders, internal and external, and the corporation itself” (p. 4).

Effective governance at the project, portfolio, program, and strategic levels of an organization creates an environment that supports the conditions required for project success. If project goals are to support organizational goals, then it seems reasonable that a project governance matrix be fundamental to a project governance framework. One such matrix described by Muller (2009, p. 11) relates shareholder and stakeholder governance theories to project management theories: Governance Theories • Shareholder Orientation - maximizes shareholder return, usually short-term objectives • Stakeholder Orientation - balances the interests of internal and external stakeholders,

including society

Project Management Theories • Behavior Orientation – follows a strict project management process • Outcomes Orientation – allows tailoring of the project management process to fit the desired

outcome The resulting matrix offers four possible Project Governance Paradigms (Figure 2): • Flexible Economist – focuses on Return-on-Investment (ROI) for shareholders, guided by

tactical Project Management Office (PMO) (minimizes cost) • Versatile Artist – balances qualitative and quantitative measures of project success, guided

by strategic PMO (maximizes benefits, balances diverse needs) • Conformist – maximizes shareholder return, strict use of project management techniques

(minimizes variation) • Agile Pragmatist – maximizes collective benefits for stakeholders, strict use of project

management techniques maximizes value (maximizes technical usability)

Outcome Orientation

Flexible Economist

Versatile Artist

Shareholder Orientation

Conformist Agile

Pragmatist

Stakeholder Orientation

Behavior Orientation Figure 2: Project governance paradigms (Muller, 2009, p. 11)

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Organizations will likely need to adopt different project governance paradigms depending on the objectives of its projects (Muller, 2009). Because a healthy population rather than profitability is the purpose of a publically funded healthcare system, stakeholder rather than shareholder theory is the predominant governance theory. Most Canadian healthcare organizations are publically funded to serve the communities in which they operate and are accountable to a broad range of external and internal stakeholders. Having such a broad stakeholder group requires that leaders are skilled in balancing the sometimes conflicting needs of governments, funders, suppliers, clients, and employees. In addition, healthcare is a highly regulated industry with strict standards and practices intended to optimize patient outcomes and mitigate risk. While some may balk at standardization of policies and procedures as cookie cutter medicine, standardized approaches to patient safety initiatives are intended to result in healthcare service deliver that consistently meets patient’s/resident’s expectations of quality. Patient safety initiatives consequently consider both process and outcome measures, depending on the phase of implementation. In the initial stages of implementation, process measures are used to gauge adherence to the new processes and procedures. Once the processes and procedures are firmly embedded in practice, the emphasis shifts to outcome measures, which are used to gauge operational success. Similarly, accreditation projects initially benefit from a behavior orientation as the focus is on adherence to new processes and procedures. As the accreditation work is handed over to operations, then measurement of long-term success shifts to an outcome orientation. Therefore accreditation projects undertaken by Canadian healthcare organizations are likely to benefit from following an agile pragmatist orientation, which is both stakeholder focused and outcome oriented. As we have gained a deeper understanding of the relationship between project management success and project success, so too has our understanding of project management maturity as a means to optimize project success. Larson and Gray (2011) explain the Project Management Institute’s Organizational Project Management Maturity Model as follows: The first level demonstrates project management immaturity with informal project management practices, and subsequent levels develop increasingly superior project management capacity (knowledge, experience, skills, and attitudes), until the fifth and final level is reached where project management becomes an organizational capability. The goal of this model is for organizations to reach level five. Muller (2009) offers another perspective in the form of a governance framework for project management. The framework consists of a three-step process where education, management demand, and economic pressures are addressed through increasing organizational focus on project management capabilities (2009). In this governance framework, the Project Management Institute maturity model does not come into play until Step 3 nor does it assume that all organizations should aspire to reach Step 3. Rather, Muller cautions organizations “[] to balance financial investment in project management capabilities against return – that is measuring (ROI) for project management” (Muller, 2009, p. 31). Muller’s framework for project management includes the following elements (Figure 2) (2009): • Step 1 requires a relatively minimal investment, is suitable for use with the Conformist or

Agile Pragmatist paradigm, and allows organizations to improve their project management goals of time, cost, and quality, by incorporating basic project management training, steering committees and sponsors, and formal and informal reviews and audit.

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• Step 2 requires a greater investment, is suitable for use with the Flexible Economist or Versatile Artist paradigm, and allows organizations to focus beyond the basic goals of time, cost, and quality, to broader critical success factors such as customer satisfaction and follow-up projects. Step 2 incorporates project management certification, project management offices, and mentorship programs for project managers.

• Step 3 requires the greatest investment and is suitable for use with the Flexible Economist

or Versatile Artist paradigms and allows organizations to use project management as a competitive advantage, incorporating advanced project management training, benchmarking, and project maturity models.

Step 1 2 3 Education Basic project

management training Project management certification

Advanced Project management training

Management demand

Steering committee Project management office

Benchmarking

Perceived economic pressure

Audits Mentorship Maturity model

Figure  3:  Governance  framework  for  project  management  (Muller,  2009,  p.  32)

Following Muller’s governance framework for project maturity, Step 1 is likely sufficient for a successful accreditation decision but may not be sufficient to sustain the gains to patient safety and maintain momentum for further improvement.

Enterprise Governance Healthcare has become increasingly complex and complicated. As programs within hospitals became more specialized, individual programs became more fragmented, creating silos within individual hospitals. Over time, this fragmentation has resulted in disparate information systems, uncoordinated strategic planning, and variations in practice that resulted in inconsistencies with the quality of healthcare service delivery. This issue has been amplified as Canadian healthcare has evolved from independently operated hospitals, to groups of hospitals within regional health authorities, to large provincial healthcare organizations where greater economies of scale are achievable. Healthcare organizations are often tasked with prioritizing multiple strategic initiatives within this fragmented and resource-limited environment. Project value is maximized when both stakeholder and shareholder objectives are achieved (Muller, 2009). As noted above, publically funded healthcare is stakeholder focused, but because governments are funders, it could be argued that they have a dual role as stakeholder and shareholder. Project selection is governed by balancing effectiveness (doing the right projects) and efficiency (doing projects right). Healthcare organizations must select projects that will make the greatest contributions to healthy populations and demonstrate financial stewardship of their publically funded budgets. Strategic project management can therefore be described by the common phrase, “doing the right projects right”. Individual projects can be combined into portfolios to optimize their contribution to strategy or into programs where their aggregate effects contribute to a common objective (Muller, 2009). Depending whether project resources are shared or not and whether objectives are related or not, there are four possible governance structures available for organizations to adopt (Figure 4) (2009):

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• Portfolio of Projects – Individual projects share common objectives to maximize efficiency • Hybrid Organization - maximize effectiveness and efficiency through a blend of program

and portfolio projects • Multi-Project Organization – unrelated projects contribute independently to strategic

objectives • Program of Projects – maximizes effectiveness through common skill sets to achieve

strategic objectives

Sha

red Portfolio of

projects

Hybrid organization

Res

ourc

es

Not

sha

red

Multi-project organization

Program of projects

Unrelated Related Objectives

Figure  4:  Project  Governance  structure  (Muller,  2009,  p.  47)

Project portfolio management provides objectives based on strategy, optimizing project selection by considering value maximization, choosing a balance of projects, and ensuring strategic alignment (Muller, 2009). Project program management, also provides objectives based on strategy but seeks to maximize value through project synergies. Healthcare organizations have attempted to deal with fragmentation by imposing structure, hoping that hierarchies will result in order and create greater value. Unfortunately, we often impose structure without fully understanding what the issues are or what we hope to achieve through structure (MacLeod & Davidson, 2013). An enterprise governance model, however, adds value to the various structures within organizations by clarifying the linkages between project management, governance paradigms, and governance of projects, programs, and portfolios (Muller, 2009, p. 90). Applying Muller’s enterprise governance model to the healthcare environment, individual projects may be undertaken by programs such as Surgery, Medicine, or Palliative Care, where team members share similar clinical skills and are able to maximize project effectiveness. Portfolios such as Urban Health Services, Rural Health Services, or Seniors’ Health Services may also undertake projects where team members with varied skill sets are able to contribute to broader objectives, maximizing efficiency. Where an organization’s accreditation efforts are strategic in nature, having both a program and portfolio approach helps ensure that teams are able to leverage individual clinical program successes and create synergies between programs that result in successes across portfolios that in turn contribute to organizational success. With enterprise governance, there is an interface between projects and operations (Muller, 2009). It is here where conflicts can arise, especially if projects and functional areas are not aligned. It is also here, however, where there are tremendous opportunities for project governance to contribute significantly to strategy. Project sponsors are ultimately responsible for ensuring alignment between projects and strategy. Where the project is large, complex, or

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carries a high degree of risk, steering committees are able to help the project sponsor create linkages between the project as a temporary organization and the parent organization by maintaining two opposing perspectives (Muller, 2009): • Parent organization towards the project – project governance, strategic focus, define goals • Project towards the parent organization – support, project focus, remove barriers As an agency for change, resource utilization, and risk, project sponsors and steering committees can successfully manage conflict and maintain alignment between projects, operations, and strategy (Muller, 2009). Because an organization’s accreditation success depends on both effective program and portfolio governance, enterprise governance may best support an organization’s accreditation efforts through a hybrid model where objectives related to patient safety standards are accomplished through shared resources, including knowledge, research, and best practices. Accreditation Canada encourages organizations to standardize practices as much as possible to help ensure a consistent level of quality for its clients. It also recognizes that some variation exists between programs and consequently some customization of practices may be required to meet the needs of various populations of patients/residents. Although Accreditation Canada has developed specific standards for the various administrative and clinical programs, there are common threads running through all programs. For example, a particular Required Organizational Practice may be found within the Leadership Standards. It may also be found within the Surgery, Medicine, and Mental Health Standards. Required Organizational Practices such as falls prevention and medication administration safety are best achieved when both resources and objectives are shared across the organization because these initiatives typically involve large and complex change initiatives. Using falls prevention as an example, reducing harm from injurious falls may be a strategic priority that initiates the implementation of a corporate falls prevention program. Policies, procedures, and education are standardized across all clinical programs as much as possible, but also allow for some customization in order to better serve those populations identified at greatest risk to experience harm from falls. This example illustrates how enterprise governance contributes to the achievement of both operational and strategic objectives by ensuring alignment of activities between projects, programs, and portfolios, which “[] are designed to bring consistency, structure, accountability, and improvement to the management of projects” (Larson & Gray, 2011, p. 565) and their operational sustainability. With the understanding that project governance offers organizations a framework for their accreditation projects, we must consider the most significant barriers that prevent successful accreditation project outcomes. Once we are able to identify the barriers to our effective use of a project governance model, we are then able to reframe the problem and transform barriers into critical success factors.

Section 3: Project Critical Success Factors As our understanding of project success has evolved, so too has our understanding of the relationship between success factors and project outcomes. Critical success factors can be found in an organization’s internal or external environment (Jugdev & Muller, 2005). While an organization must consider external factors such as demographics, economics, politics,

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environment, social, and technology (DEPEST), these factors are beyond the control of the organization. Some critical success factors, which contribute to either a project’s success or failure, however, are found internally and are therefore within an organization’s control. There are ten commonly cited critical success factors, which can be categorized into the following themes (Young & Jordan, 2008): 1. Project Management Methodologies • Clearly defined requirements • Adequate project planning • Achievable project milestones

2. User • User involvement • User ownership

3. Top Management Support 4. High-level Planning

• Realistic expectations • Clear vision and objectives

5. Project Staff • Capable and willing • Dedicated

Of all the factors listed above, top management support has been found to be the most important critical success factor for project success (Young & Jordan, 2008), yet “[] practitioners and researchers alike, have focused their attention on factors they can more directly control and appear to only pay lip-service to top management support.” (Young & Jordan, 2008, p. 713). Perhaps if leaders have a better understanding of what top management support looks like and what factors need to be in place to support it, they will be more willing to embrace this softer side of project management and consequently be better able to contribute to project success. In addition, having a corporate perspective has long been recognized as the most important critical success factor for managing and leading change (Jugdev & Muller, 2005). For the purpose of this report the above top management support will be explored through these two project management dimensions: managing projects and leading change.

Managing Projects There are two opposing dimensions of project management. The first side represents the science of project management, “[] the technical side of the management process, which consists of the formal, disciplined, purely logical parts of the process” (Larson & Gray, 2011, p. 15). This dimension is concerned with the project lifecycle (defining, planning, executing, and closing), and involves the statement of scope, work breakdown schedules (WBS), resource allocation, budgets, and status reports. This is the dimension in which project managers control costs, time, and scope in order to manage quality (2011). When patient safety initiatives are approached as purely technical projects, however, they fail to address the socio-cultural dimension of project management and consequently result in varying degrees of success, which may achieve short-term compliance but rarely achieve long-term commitment. Despite the efforts of healthcare organizations to ensure that policies and procedures are in place that address hand hygiene, safe medication practices, and safe surgeries, patients and residents continue to experience avoidable harm (Institute of Medicine, 2001).

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The second side represents the art of project management, and “[] centers on creating a temporary social system within a larger organizational environment that combines the talents of a divergent set of professionals working to complete the project” (Larson & Gray, 2011, p. 15). This socio-cultural dimension consists of the elements related to organizational structure and culture, such as leadership, problem solving, teamwork, negotiation, politics, and customer expectations (Larson & Gray). Just as there are two dimensions to project management, project managers need to be skilled in two roles: manager and leader. They must be able to manage project scope, cost, and time and they must be effective leaders who are able to inspire, guide, and support their team while building and nurturing relationships with internal and external stakeholders. Jim Collins describes a level 5 leader as one who “builds enduring greatness through a paradoxical blend of personal humility and professional will” (Collins, 2001, p. 20). In the case of accreditation projects, effective leaders are able to influence their team’s behaviors and attitudes in a way that enables permanent change and creates the conditions that support continuous improvement. Effective leaders positively influence the organization’s patient safety culture. Whether project teams are organized within functional areas, as dedicated teams, or in a matrix arrangement, the project team’s structure must provide the framework necessary to “[] balance(s) the needs of the both the parent organization and the project by defining the interface between the project and parent organization in terms of authority, allocation of resources, and eventual integration of project outcomes into mainstream operations” (Larson & Gray, 2011, p. 65). Where project managers have limited formal authority over operational areas, having the appropriate project team structure is essential. According to Connor (1999), in order to ensure project accountability and successful implementation, project sponsor, implementer, change agent, and advocate roles need to be clearly defined so that members understand their roles and responsibilities and are able to contribute to the project’s success (Figure 5).

Figure 5: Project Mapping (Adapted from Connor, 2009)

While top management support has been identified as the most important critical success factor for success projects, these individuals cannot carry the burden of project success alone. Connor (1999) goes on to explain how structure is key to enabling project teams to

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effectively manage change. Applying Connor’s project team structure to healthcare accreditation, roles within the service excellence teams might appear as follows: Executive Sponsor: Senior leader who has operational authority within administrative or clinical programs or portfolios, and possess the social skills required to lead others (Connor, 1999). The project sponsor should be the risk-owner, the person who has the most to gain through the project’s success (Kloppenborg, Manolis, & Tesch, 2009). Project sponsors are accountable for creating the vision for the project, which includes setting goals, performance measures and expectations, managing priorities, and creating linkages between the project and strategy (Connor, 1999). Effective project governance enables project sponsors by ensuring that they have formal reporting relationships within the operational area and the authority to hire and fire individuals. Common attributes of effective executive sponsors include (Helm & Remington, 2005): • “Appropriate seniority and power within the organization; • Political knowledge of the organization and political savvy; • Ability and willingness to make connections between project and organization; • Courage and willingness to battle with others in the organization on behalf of the project; • Ability to motivate the team to deliver the vision and provide ad hoc support to the project

team; • Willingness to partner with the project manager and project team; • Excellent communication skills; • Personally compatible with other key players; • Ability and willingness to provide objectivity and challenge the project” (p. 57). Implementers: Project team members who understand the day-to-day operations within the program area and are able to carry out the necessary changes to process, while staying in constant dialogue with the sponsor (Connor, 1999). These individuals are the program content experts, able to carry out the direction of the project sponsor and able to bring forward issues. Implementers may have formal authority in the program area but may also be informal leaders who are able to influence their colleagues and consequently the team’s norms and behaviors. Within the context of accreditation, implementers can include middle managers, physician leaders, supervisors, educators, or front line champions. While senior leaders create strategy and high level plans, effective implementers influence culture and are therefore able to convert strategy into operational reality. Change Agent: Project team member who contributes to project success by guiding and supporting the team and helping each member perform to their best ability (Connor, 1999). Where a centralized project team leads organization-wide projects such as accreditation, the clinical quality consultant (project manager) is the change agent, and must be capable of building relationships based on trust and credibility within the project team and consequently able to influence the project team and help facilitate the required changes. Operating within a matrix structure, the clinical quality consultant strives to balance the needs of what needs to be done with how the work is to be accomplished (Larson & Gray, 2011). Advocate: Individual who brings forth ideas and issues that may present as barriers or opportunities but have not received formal sponsorship (Connor, 1999). The sponsor, implementers, or change agent may at any time assume the role of advocate, or another project stakeholder may assume this role (for example client or community member).

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Appropriate project team structure and agreed upon code of conduct ensure that project teams have clear lines of authority and ownership, support direct communication and collaboration, and that all members understand their roles and responsibilities. Projects without an appropriate team structure in place may never realize their full potential as dysfunctional conflict, infighting, stress, and delays threaten the project’s success (Larson & Gray, 2011). An organization’s accreditation structure needs to be congruent with its organizational structure in order to ensure successful handover of projects from their temporary project environments to their permanent homes in operations. To help facilitate that transfer, sponsors must be able to successfully manage projects and lead the required changes.

Leading Change Structure enables effective top management support, which in turn, enables change. Healthcare improvement projects are based on evidence based medicine and best practice guidelines yet “[] the variation in the success of different teams in adopting these practices makes it evident that knowledge of effective practice alone is insufficient to improve performance” (Baker, 2012). As project leaders, we are asking our staff and physicians to become vulnerable and adopt new practices that challenge their beliefs and attitudes, which can sometimes result in feelings of shame or inadequacy (Brown B. , 2012). Leading successful and sustainable patient safety initiatives can be accomplished through effective change management, in which the project sponsor is able to win the hearts, minds, and souls of everyone involved in the change (Gill, 2003). “Great sponsors of change have three roles: participate actively and visibly in the project; build a coalition of sponsorship and manage resistance from mid-level managers; and communicate directly with employees about the need for change” (Creasey & Hiatt, 2008). Project software can help manage the technical side of a project, while an effective change management model can help manage the socio-cultural side of a project. One of the most familiar change management models is John Kotter’s eight-stage process (Kotter, 1996). Kotter’s Leading Change model, based on patterns found in successful change efforts, includes the following linear process: Establish a sense of urgency, create the guiding coalition, develop a vision and strategy, communicate the change vision, empower employees for broad-based action, generate short-term wins, consolidate gains and produce more change, and anchor new approaches in the culture (1996). The premise of Kotter’s approach is that each step is carried through with intention, solidifying the foundation for subsequent steps. When prior steps are not firmly in place, the foundation is weakened and the entire project is put at risk of failure. While Kotter’s eight-stage process may seem prescriptive, its methodical approach may be helpful to organizations in the early stages of project management maturity and looking to develop their project management capacity, particularly where projects are disruptive to current policies and procedures or a strong organizational culture. Conscious Transformation (Ackermann & Ackerman Anderson, 2001) challenges project leaders to consider three thinking orientations: Project thinking which focuses on the technical dimension; systems thinking, which focuses on nonlinear and interconnected processes; and conscious process thinking, which focuses on a dynamic multi-dimensional process that spills past the borders of the current project and into the entire organization (2001). Depending on the situation, each thinking orientation is associated with a corresponding change in

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leadership styles: Controlling, facilitating, and self-organizing (2001). While conscious process thinking and self-organizing is thought to maximize human potential and organizational performance, it assumes that leaders are capable of nurturing the conditions required for change and that organizations have the capacity to design and facilitate the change process (2001). It also assumes that organizations have progressed from a mindset of management of project management systems (Level 5 Project Maturity) where time, cost, and quality are the focus to one that focuses on a culture of continuous improvement that is organic and fluid (Larson & Gray, 2011) (Ackermann & Ackerman Anderson, 2001). The most obvious benefit of the Conscious Transformation model is that it is closely aligned with situational leadership, which is a well-known model for developing others based on their level of competence and commitment (The Ken Blanchard Companies, 2003). A significant constraint with Conscious Transformation, however, is that in order to maximize its potential project leaders should be competent change leaders, capable of catalyzing significant system-wide change and building organizational capacity for continuous improvement. Unless all leaders possess Level 4 or Level 5 leadership (Collins, 2001), the burden for transformational change will fall on the select few who may not be able to overcome the inertia and resistance to change. Another model for change is based on the Switch model, proposed by the Heath brothers (Heath & Heath, 2010). Rather than prescribe a sequence of events or stages of enlightenment, the Switch model supports a practical approach to change management that is based on an analogy of a rider, an elephant, and the path. The rider represents the rational side and must be directed. Directing the rider requires that we “follow the bright spots” by researching successful practices and adapting or adopting them for our own industries and organizations (2010). An example is how healthcare has created safe surgery checklists based on aviation preflight checklists. Directing the rider also requires that we “script the critical moves” where we translate lofty strategic goals into practical and specific behaviors with clear expectations (2010). Finally, directing the rider requires that we “point to the destination” so that everyone understands what we are trying to achieve and why the struggle will be worth it (2010). The elephant represents the emotional side and must be motivated. Motivating the much larger and stronger elephant requires that we “find the feeling” (Heath & Heath, 2010). In healthcare, we have the data that supports the need to reduce patient harm, but we need to help people connect emotionally to the data in order to shift mindsets. One way to present data with meaning is to share patient stories about the harm they experienced while in our care because “stories are data with soul” (Brown B. , 2010). Motivating the elephant also requires that we “shrink the change” by breaking down the change into smaller sets of changes which are less emotionally overwhelming to people (Heath & Heath, 2010). Lastly, motivating the elephant requires that we “grow our people” by establishing a sense of identity and fostering an environment that supports growth (2010). In healthcare, we have a common calling to help those in need and through effective coaching and mentorship, we are able to help our teams reaffirm their sense of purpose as healthcare professionals. The path must be shaped for the rider and elephant to travel in the correct direction (Heath & Heath, 2010). Shaping the path requires that we “tweak the environment” in a way that makes the new direction seem more attractive or makes the status quo uncomfortable or difficult to maintain (2010). Shaping the path also encourages us to build habits that will support the norms and behaviors that we are trying to create. Finally, shaping the path requires that we “rally the herd” by supporting change champions (2010). It is so easy to be reactive with

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change efforts and to focus the majority of our time and effort on the resistors. Rather than focusing our efforts on the laggards, we should focus on creating environments that support the innovators, and early adopters so that they are able to successfully influence the early and late majorities. Laggards eventually adopt new practices or they move on to other organizations. With the introduction of safe surgery checklists, for example, some healthcare organizations are shaping the path by keeping the checklists simple and enforcing that surgical teams initiate the process prior to surgery or risk cancellation of the procedure. The Switch model challenges project managers to address both the rational and emotional sides of change and to clear the way for challenging change efforts to succeed. Because it addresses change from technical, socio-cultural, and broad system perspectives, it supports both project management success and project success, which will result in sustainable performance for projects such as accreditation. There are pros and cons for the change management models presented above, each offering a different approach to leading change. Rather than limiting our thinking by choosing one option while rejecting the others, there may be value in adopting elements from all three models for accreditation. Kotter’s Leading Change model supports the connection between vision and sustainability, with each step providing the foundation for the next one. Where Kotter’s model may appear rigid, Conscious Transformation provides flexibility for change management, depending on the organization’s capacity for change leadership and tolerance for innovation. Finally, the Switch model complements both Kotter’s model and Conscious Transformation by clarifying the connections between strategic issues and operational solutions. Using all three models to assess accreditation efforts may contribute to effective project governance framework by providing both the approach and the means to achieve sustainable change, regardless of an organization’s change management capacity.

Projects, Programs, and Portfolios in Healthcare At this point in the paper, it might be helpful to clarify how projects, programs, and portfolios are classified in healthcare organizations and how they are related to governance frameworks in the literature. For the purpose of this paper accreditation will be referred to as a project, even though in practice, it could be argued that it is simply a cyclical audit process (similar to a financial audit) that evaluates compliance to standards. Accreditation is approached as a corporate project created to deliver a specific product (accreditation certification) within a specified timeframe (a three or four-year life cycle) that happens to repeat. Within the healthcare setting, programs exist either as areas with common clinical processes (for example Critical Care, Emergency Department, Surgery, or Medicine) or administrative processes (for example Finance, Human Resources, or Emergency Preparedness). Programs are formed around common objectives that are best achieved by grouping projects. For instance, Finance may include Accounts Receivable, Accounts Payable, and Payroll. All three areas follow different operational processes but share common objectives related to financial accountability. A Surgery program on the other hand, may include Orthopedics, Gastroenterology, and Cardiac but share a common goal of successful surgical outcomes without complications. Even though there is some sharing of resources (for example operating rooms, post operative patient care units), skill sets vary greatly between the subspecialties. In this regard, the Surgery program can be considered to share objectives but not necessarily all resources.

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Portfolios also exist within the healthcare setting where clinical or administrative areas are grouped based on similar resource or skill set needs. For instance Rural Health Services, Urban Health Services, and Seniors’ Health Services receive their budgets based on different funding models. Projects within each of these portfolios are prioritized based on their anticipated contribution to strategy. Within portfolios it is not imperative that objectives be related to each other as long as individual’s skills maximize contributions to strategic objectives (Muller, 2009). For instance a falls prevention project, hand hygiene project, and a safe surgery checklist project may be implemented throughout Rural Health Services. While objectives for each patient safety initiative are very different, all three projects contribute to the organization’s harm reduction strategy for rural populations.

Research Design This paper explores the relationship between project governance and sustainable improvements to patient safety through accreditation. Using a case study approach based on this author’s experience with leading accreditation for her organization, project governance may offer a lens to help us understand why some clinical and support programs were more successful than others during the same accreditation cycle. This insight may also help us better understand the linkages between project, and program portfolio governance as well as the linkage between project management success, project success, and organizational performance. The purpose of this paper is to develop a healthcare accreditation project governance model that will help guide healthcare leaders to maximize the benefits of accreditation and bring about sustainable improvements to patient safety within their organizations.

Case Study Overview Established as part of a provincial healthcare restructuring strategy, this healthcare organization has facilities located in communities across the province. Its team of over 10,000 employees, physicians and volunteers provide a range of healthcare services through its urban health services, rural health services, and seniors’ health services portfolios. Although the organization’s facilities had previously participated in accreditation with their former Regional Health Authorities (RHAs), the expectation became that it would seek accreditation status, independent of its funder. With support from its board of directors and senior leadership team, the organization began its accreditation journey with Accreditation Canada using a sequential model dividing its service standards over a three-year cycle (Figure 6).

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 Figure  6:  Sequential  Accreditation  Cycle

The Quality and Patient Safety Team (Patient Safety Team) facilitated the accreditation project and its related quality improvement efforts, including educating and providing support to the service excellence teams. The Patient Safety Team also coordinated the logistics associated with the accreditation process, including self-assessments and planning the on-site surveys by Accreditation Canada surveyors. Functioning within a project matrix environment, each Service Excellence Team was assigned a clinical quality consultant who provided education, guidance, and support to the team for the entire process. For each service standard (for example, Effective Governance, Leadership, Infection Prevention & Control, Managing Medications, Long Term Care, Hospice & Palliative Care, Emergency Department, Critical Care, Surgery, Obstetrics & Perinatal Care, Medicine, and Mental Health) Service Excellence Teams were tasked with coordinating the self-assessment process and applicable functioning tools (Governance, Patient Safety Culture, Worklife Pulse) developing action plans, and implementing changes to ensure that each program was compliant with Accreditation Canada’s standards, including applicable Required Organizational Practices. Service Excellence Team membership was comprised of an executive sponsor, team lead, clinical quality consultant, and a mix of frontline managers, supervisors, educators, frontline staff, and physicians. The exact team composition and level of performance varied greatly between portfolios and programs. It was suggested that teams meet at least monthly, depending on the amount of work identified through the self-assessment processes. Some teams met biweekly, while others met less frequently. Team size ranged from ten to twenty individuals, depending on the size of the administrative or clinical program. The senior leadership team functioned as the accreditation steering team, responsible for approving the overall accreditation plan and resolving high-level issues.

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While senior leaders are responsible for operations within their specific portfolios (Urban Health Services, Rural Health Services, or Seniors’ Health Services), there was considerable overlap of their accreditation responsibilities. For example, a senior leader with operational responsibility for the Surgery program in Urban Health Services was also responsible for the Surgery program in Rural Health Services, and a senior leader with operational responsibility for the entire Rural Health Services portfolio was responsible for Emergency Department services in both Rural Health Services and in Urban Health Services. In both examples, the senior leaders were expected to be effective sponsors in areas that they had operational responsibility and for areas that they did not. Each year during the three-year cycle, Accreditation Canada surveyors visited the organization to assess compliance to Accreditation Canada’s standards with each year resulting in successful accreditation decisions and overall scores consistently greater than 95%, yet some programs appeared to experience greater success than others within the same accreditation cycle. For example, some programs successfully met all or nearly all Required Organizational Practices and standards, while others struggled to implement basic patient safety practices or failed to address unmet standards altogether. One reason for this discrepancy between accreditation score and actual performance is because the on-site visit merely provides a snapshot within narrowly defined confines of space and time, and as such cannot possibly adequately assess organizational performance within the larger scope. It can be easy to find fault in the on-site visit but rather than disregard the value of accreditation all together, organizations should appreciate its value as an integral part of its quality improvement efforts. For example, following the final on-site survey of its first three-year cycle, this organization was awarded Accreditation with Exemplary Standing, the highest accreditation decision level possible. As long as the benefits and limitations of accreditation are recognized, expectations can be managed. As a project, accreditation has proven to meet its objectives, yet the real challenge will be to sustain its improvement efforts and ensure that best practices associated with patient safety are consistently demonstrated throughout all areas of the organization. Only when this challenge is met will accreditation deliver its full value to the organization: “sustainable improvements in quality improvement and organizational performance” (Accreditation Canada, 2012, p. 2). When an organization’s accreditation efforts are linked to operations and performance measurement, monitoring of quality improvement efforts is possible. The case studies presented below are representative of ‘typical’ Service Excellence Teams that may be found within organizations. Case Study 1 represents two individual service excellence teams while Case Studies 2 and 3 are consolidated representations of several different service excellence teams. From a system’s perspective, they illustrate some of the challenges that teams may experience in the absence of an effective project governance framework as well as some “bright spots” that may give us insights into what effective project governance might look like and if it might have a role in supporting sustainable improvement. Case Study 1 – Administrative Service Excellence Team with Effective Project Governance and Top Management Support The Effective Governance Team was comprised of the board of directors and the Effective Organization Service Excellence Team was comprised of the chief executive officer, chief medical officer, as well as senior leaders from Human Resources, Finance, Ethics, Quality, Communications, and Strategic Planning. Quality and patient safety is a strategic direction for

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this organization and accreditation certification is considered a strategic priority. At the beginning of their accreditation journey, members from both Service Excellence Teams participated in an on-site introductory accreditation education session facilitated by Accreditation Canada. The board of directors and senior leadership team completed a self-assessment survey. In addition, the board of directors completed a Governance Functioning Tool to evaluate the existing governance structure and processes (Accreditation Canada, 2010). Completion of both the tool and self-assessment survey was nearly 100% for both teams. The self-assessment survey results generated a Quality Performance Roadmap from which each team was able to evaluate its performance against the Accreditation Canada standards, prioritize issues based on risk, and develop action plans to resolve issues. For each of the support areas (for example, Human Resources, Finance, Ethics, Quality, Communications, and Strategic Planning) working groups were formed to address any unmet criteria in the specific departments. Because many of the administrative areas of the organization already had systems and processes in place to meet best practice standards (for example: GAAP in Finance; Workforce Planning, Contract Negotiation, and Employee Engagement in Human Resources; Ethics Team and Ethics Guide in Mission, Ethics, and Spirituality; Balanced Scorecard in Strategic Planning), there were very few issues identified through the self-assessment process. These teams required very little guidance in terms of team size and meeting frequency. When issues were identified, they were addressed immediately and completely. When assessed during the on-site survey, Accreditation Canada surveyors reviewed documents and files, and interviewed board members, senior leaders, staff, and community stakeholders. The meetings with the surveyors took on a variety of forms. In some cases the surveyors met with senior leaders privately or with leaders and their teams to learn more about their programs, their successes, and their challenges. In other cases, the meetings involved discussions with staff from different program areas as surveyors toured facilities. The surveyors also met with community board members and community stakeholders from local school boards, universities, colleges, municipalities, government, and partner healthcare organizations. The surveyors commended the organization for its commitment to patient safety. The surveyors noted that the organization’s strategy is well articulated and that its values were evident throughout. In addition, Accreditation Canada recognized the organization’s Mission Discernment Tool as a Leading Practice. The Mission Discernment Tool is a guide to ethical decision-making in healthcare and is now receiving international interest. Case Study 2 – Clinical Service Excellence Team with Neither Project Governance nor Top Management Support This Service Excellence Team had over twenty team members from a single clinical program that was present across multiple sites within different portfolios (Urban Health Services and Rural Health Services). The executive sponsor had operational responsibility within one of the portfolios but not in the other. In order to support the organization’s integration strategy, which involved standardizing processes and practices across the organization, team members from the two different portfolios were encouraged to collaborate wherever possible. It was also anticipated that the larger sites could offer greater support to the smaller, more isolated sites within the program. As noted earlier, senior leaders were assigned responsibility for each service standard, based on their clinical experience rather than operational authority. By having one executive sponsor who encouraged collaboration across sites and between

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portfolios, it was anticipated that the Service Excellence Team would be able to leverage the strengths of successful areas and create synergies that would result in an improved level of quality of healthcare service delivery that was consistent across all sites. The Service Excellence Team members were expected to participate in an Introductory Accreditation Education session facilitated by the organization’s accreditation specialist but participation at the sessions generally poorly attended. The poor attendance may have been because individuals had experience with other forms of accreditation and thought that the same principles and process would apply, or they perceived accreditation as a threat to their autonomy over their clinical program or site, or they did not understand the benefits of accreditation as a means to improve operational performance. Regardless of the reason, attendance was likely poor because the perception was that accreditation offered little value. Team members facilitated self-assessment surveys in their program areas within their respective sites and used the resulting Quality Performance Roadmap to evaluate their performance against the Accreditation Canada standards. Over the next twelve months, the Service Excellence Team met at least monthly and developed action plans and implemented changes to meet unmet criteria based on their Quality Performance Roadmap and program specific standards. Not all sites participated equally, however, as participation was lower in sites where site leaders failed to make these meetings or the resulting improvement work a priority. For a multitude of reasons, related to governance, leadership, and communication issues, status updates to the executive sponsor or senior leadership team reported that there were no issues with unmet criteria when in fact, there were significant issues around Required Organizational Practice compliance. Either individuals did not understand the significance of the issues or did not want to present issues that might reflect poorly on themselves or their programs. Unfortunately this Service Excellence Team struggled to stay on track with its accreditation related work and for the most part, viewed accreditation as an exercise rather than a means to contribute to the organization’s strategy. The executive sponsor did not have formal authority for the program across portfolios or technical knowledge of the program and consequently delegated some responsibility to other members, taking a hands-off approach. While in some instances Service Excellence Team members had formal accountability for their site’s program, in others responsibility was delegated to front line managers or staff with little or no formal authority. In both instances, the delegates may have had formal authority within their narrowly defined clinical program areas but not within the larger Service Excellence Team and certainly not across portfolios. This structure included a wide range of individuals from across the organization, each bringing their knowledge and experience to the team. This structure was intended to leverage individual strengths, create synergies, and support collaboration between programs, sites, and portfolios. However, because sponsorship was ineffective, the benefits of accreditation certification and its linkage to the organization’s strategy were not actively communicated, resulting in under communication about emerging issues regarding unmet criteria, ambiguous accountabilities, and in some cases resistance to quality improvement work, putting the entire organization’s accreditation status at risk. Despite the challenges this Service Excellence Team faced, the on-site visit contributed to a favorable accreditation decision for the organization with minimal conditions. All conditions of accreditation were lifted once additional patient safety work was done and evidence submitted

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to Accreditation Canada for review. It is important to note that even with executive sponsorship issues, overall most sites that made up this Service Excellence Team performed very well with regards to improving quality within their sites and with the surveyor visit. In these cases, executive sponsor responsibilities were delegated to managers who had strong leadership skills and technical ability, and who used the accreditation process to meet operational objectives within their scope of influence. Case Study 3 - This last case study represents two Service Excellence Teams from two different portfolios, but within the same clinical program and led by one executive sponsor. One service excellence team represents the clinical program from Rural Health Services while the other represents two large urban community hospitals (Urban Health Services). The major difference between the two Service Excellence Teams was that the executive sponsor had formal authority for the program in only one of the portfolios. She was, however, highly involved at the beginning of the process and continued to be visible and supportive throughout for both teams. As with the other Service Excellence Teams, members were encouraged to participate in an Introductory Accreditation Education session facilitated by the organization’s accreditation specialist. Service Excellence Teams were expected to facilitate self-assessment surveys in their program areas and use the resulting Quality Performance Roadmap to evaluate their performance against the Accreditation Canada Standards. Participation with both the education session and self-assessments was inconsistent between the two teams, likely for the same reason mentioned in the previous case study: The perception was that accreditation offered little value for operational improvement. In the beginning, the plan was for these two Service Excellence Teams to work together to develop action plans through knowledge sharing. Case Study 3a – Clinical Service Excellence Team without Project governance but With Top Management Support This Service Excellence Team was comprised of less than twenty members from sites across the province (Rural Health Services) and a team leader was chosen from one of the sites to coordinate the accreditation process for the team. Some of the team members were site leaders while others were front line managers or staff. Each member was expected to facilitate the self-assessment survey at their site so that any site-specific noncompliant standards could be addressed locally, while portfolio related noncompliant standards could be addressed either through this team or through collaboration with other Service Excellence Teams. Overall participation in the self- assessment process was poor and at least one site did not participate in the self-assessment process at all, making it very difficult to identify noncompliant issues as well as any successes with patient safety. This Service Excellence Team struggled the most with accreditation. These smaller sites are typically not as well resourced as larger ones and often the same people were involved in multiple Service Excellence Teams, contributing to work burden. Even after the initial merger, these sites operated quite independently and continued to have close operational ties with their former Regional Health Authorities. Site leaders continued to remain autonomous, and for the most part continued to place site priorities ahead of organizational priorities, including accreditation. One of the first signs that the team was having difficulties was that this team was late in forming, at least four months later than its Urban Health Services counterpart. Because of this delay, it was impossible for the two Service Excellence Teams to collaborate as much as was originally anticipated. In order to support this team it was decided that given the significant amount of work required, the team would meet at least biweekly, Unfortunately

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the Service Excellence Team meetings were sporadic at best and cancelled for the summer to allow for summer vacations. An additional support was arranged in the form of monthly meetings between the team leads from the two portfolios where they could discuss issues and share knowledge and resources. These meetings also rarely occurred. Policies, processes, and procedures varied greatly across the organization, as did clinical practices and compliance with standards. Again accreditation was viewed as an organizational priority but not a site priority. While the organization often spoke of clinical program integration as a strategic priority and accreditation was viewed as a means to help achieve greater standardization, there was little evidence that integration or quality improvement was an operational priority across all sites, further adding to the resistance of all sites to participate fully in the accreditation process. Significant issues with noncompliance were not communicated in a timely manner to the executive sponsor necessitating significant last minute education and training for staff to ensure that policies and procedures were in place and clinical practices were current prior to the on-site survey. Again despite the challenges this Service Excellence Team faced, the last minute improvement efforts to prepare for a “test” seemed to pay off as the on-site survey resulted in a favorable accreditation decision. However, without an effective governance structure that supports operational accountability there is a significant risk that the quality improvement work accomplished will not be sustainable. Case Study 3b - Clinical Service Excellence Team with Effective Project Governance and Top Management Support This Service Excellence Team represented one large program within a single portfolio. Spanning two urban acute care sites, the executive sponsor had formal authority over the program, as did the team leader who managed the program at both sites and reported directly to the executive sponsor within operations. The team was comprised of members from both sites and represented formal and informal leaders from the program’s interdisciplinary care team, some of which were included in the team lead’s reporting structure, while others reported to superiors within their own departments. The team also included some physician representation, typically a group difficult to engage in patient safety initiatives. Team members were chosen with intent. They all demonstrated a high level of performance and an ability to influence others within their specific areas. This team was highly engaged, competent, and demonstrated strong teamwork abilities. Although there was significant work associated with accreditation, the team understood the benefits of accreditation and committed to meeting every two weeks for over a year. Both the executive sponsor and team lead were extremely effective leaders who controlled the program’s resources and were the principle risk-owners. They understood the value of accreditation as a means to achieve operational and strategic objectives and were able to inspire those around them to want to work towards a common goal of safer patient care. They made patient safety meaningful to their teams and clearly linked the accreditation work with program objectives to achieve integration of service delivery and standardization of best practices across the sites. The self-assessment surveys were completed and an action plan was developed based on the Quality Performance Roadmap and on a gap analysis of the standards. Team members were assigned sections of the standards and compiled evidence of compliance for each standard including policies, procedures, reports, meeting minutes, management action plans,

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and education/training materials. A subsequent gap analysis included observational audits, chart audits, and mock tracers to identify any discrepancies between policies/procedures, training/education, and practices at the bedside. Audit tools were developed by the team and intended to evaluate common patient safety issues while the mock tracers were based on questions from the initial Accreditation Canada self-assessment surveys. Both the audits and the mock tracer processes were designed to be objective, systems-focused, and allow for just-in-time education. The various audits were less about checklists and more about meaningful conversations with staff and physicians about patient safety success and challenges within their areas. The team lead also interviewed patients to assess the quality of healthcare services from the client perspective. The results from the audits, mock tracer, and interviews were somewhat sobering. While there were many successes highlighted, there were also some surprising gaps in quality identified. Again, strong leadership prevailed and quickly turned the gaps into opportunities for improvement. Clinical nurse educators developed an education plan to address issues and delivered a patient safety refresher to nearly 600 program staff and physicians within a few weeks. Audits and mock tracers were again completed to evaluate effectiveness of the education sessions, this time with much greater awareness and compliance to the Required Organizational Practices and other standards. The Service Excellence Team was ready for the on-site visit. With such a large program, communication and engagement were paramount to leading the improvement work. While the smaller Service Excellence Team was actively engaged from the early stages of the accreditation work, once the work related to the action plans was well-underway, engagement plans spread to the much larger leadership team within the program and finally to the rest of the program and related areas. Given the size and complexity of this program, not to mention the lack of dedicated resources to complete the required work, this team’s accomplishments were remarkable. Not only did the team’s efforts contribute to an outstanding accreditation on-site visit, but it also used the accreditation process to develop the program’s capacity for future quality improvement work.

Discussion The above case studies offer a glimpse of the accreditation process at one Canadian healthcare organization through a strategic project management lens. Limited by the personal experiences and observations of the author, the information provided in the case studies are likely somewhat biased and lacking in the breadth and depth that only multiple perspectives can bring to life. As limited as these results may be, the case studies are meant to give living, breathing examples to the literature so that others may consider how the case studies may relate to their organizations as they embark on their own accreditation endeavors. If the findings in this case study analysis support project governance as a means to achieve a successful accreditation decision and sustainable improvements to patient safety, then it may be worthwhile for healthcare leaders to further explore project governance within their own organizations.

Case Study Discussion Case Study 1 – What Does Project Governance Look like? This case study gives us a glimpse of what effective enterprise governance might look like. Although formal project governance was never officially adopted by either of these two service excellence teams, they demonstrated several project governance attributes, including

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an accountability framework and top management support. Both of these service excellence teams were committed to accreditation. With team members being either board members or members of the senior leadership team, these two groups were directly involved with the organization’s strategy development and subsequently became risk-owners. Accreditation certification not only contributed to strategy, but because it was government mandated, accreditation was also mission-critical and had direct consequences for these senior leaders. As a newly formed organization focused on growth, the organization was beginning to develop its project management capabilities and consequently had just begun to develop a project management office. At Step 1 of the governance framework for project management, project management processes were beginning to evolve from previously established technical practices (Muller, 2009). Functional programs such as Finance, Human Resources, and the Board of Directors already followed sound business practices and had some experience with project management processes, albeit on an ad hoc basis. The organization had created learning opportunities for some employees to participate in basic project management training. The board of directors, its various subcommittees (example Quality, Finance), and the senior leadership team functioned as steering committees, defining project goals, providing the means to achieve these goals, and supporting the project as part of a larger picture (Muller, 2009). Besides being at the interface between projects and strategy, these Service Excellence Teams were also at the interface between the organization and its external stakeholders, including the Minister of Health, its strategic partner and funder, post secondary education institutions, and community health boards. Being able to balance the diverse needs of its many stakeholders was already central to their existing business practices, and so these two teams naturally approached accreditation from a stakeholder orientation. Although this organization had developed a robust strategic planning process, it had yet to develop its capacity for strategic and tactical project management, which was being driven through a newly established central project management office. These teams utilized basic project management methods to stay on track with their accreditation efforts, demonstrating an agile pragmatist paradigm. Beginning with education about accreditation, these teams used the quality improvement roadmaps and Accreditation Canada Standards to develop action plans within a multi-project framework. Again, because this organization had only begun to develop its strategic project management capabilities, its various administrative programs embarked on independent projects as part of a larger, fragmented Canadian healthcare system. For example, Finance, Human Resources, Quality, and Ethics implemented projects independently of one another, and although each area was successful in its contribution towards strategy, collectively they may have missed an opportunity to create synergies through shared resources and learnings found in a hybrid organization. From a project governance perspective, these service excellence teams were leaders within the Board or within their administrative areas and had the most to benefit directly from accreditation. Additionally, whereas most projects rely on the executive sponsor for top management support, these service excellence team members were top management. Not only did they have “appropriate seniority and power within the organization” (Helm & Remington, 2005; Kloppenborg, Manolis, & Tesch, 2009), but they were also able to create linkages between accreditation and strategic objectives related to patient safety and articulate

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to their teams why changes were necessary. As risk-owners within their own functional areas, change management was related to localized improvement and was accomplished by leaders actively participating in the change process, they were able to manage resistance through a blend of formal authority and influence, and they were able to communicate directly with their teams, enabling their entire programs for change. In summary, these Service Excellence Teams were successful for two reasons: Members had direct responsibility and accountability for the necessary changes; and the change effort itself included a smaller number of people who were directly involved. Overall, these two teams illustrate elements of effective governance and give us a glimpse of what effective project governance might look like as well as enterprise governance that allows successful projects to spill over into sustainable operational successes. Case Study 2 – Why is Project Governance Important? This case study illustrates why effective project governance is necessary for organizations seeking to achieve their strategic directions related to patient safety. Although in the end this service excellence team contributed to a successful accreditation decision, a poorly designed service excellence team structure and lack of effective top management support prevented this team from using accreditation to achieve sustainable improvements across all sites. This team was hampered by two issues: the executive sponsor did not have operational authority of all of the sites within the clinical program or technical expertise of the program, resulting in a general lack of accountability; and the historically independent sites continued to place site priorities over organizational priorities, resulting in low commitment to accreditation and patient safety. The organization as a whole was beginning to develop its capacity for project management but individuals with project management capabilities were seen mainly in administrative and strategic areas. Clinical areas, on the other hand relied heavily on technical expertise of its staff and physicians. This reliance on clinical knowledge, skill, and technology to improve healthcare service delivery may have resulted in improvements to clinical programs in the past but it has also contributed to a fragmented healthcare system and lost opportunities to create improvements that are reproducible, adaptable, and sustainable. While there was some informal knowledge of project management processes, formal project management processes were inconsistently utilized. The areas that understood the value of accreditation demonstrated commitment towards their improvement efforts, while areas that viewed accreditation as drain on valuable program resources struggled to meet compliance. As a single Service Excellence Team, this team had not made the conscious shift from technology based quality improvement to Step 1 of the governance framework preventing this team from using accreditation to achieve both program and organizational objectives across the organization. Because this clinical program was inexperienced with project management methodologies let alone project governance, it was no wonder that its members struggled to work within a project governance paradigm. A fundamental issue this team had was to correctly identify its key stakeholders, which created one of the most significant barriers that this team faced. At the heart of patient-centered care is the relationship between caregivers and patients. Applying this philosophy to an organization’s commitment to accreditation, it is about our promise to those we serve and to those who serve. The goal of accreditation is to ensure that patients receive care that meets their expectations, and staff and physicians are enabled by a

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healthcare system to deliver quality healthcare services. Not only was the team unable to successfully balance the diverse stakeholder needs, but it was unable to agree upon quantitative and qualitative measures of project success. Had the Service Excellence Team adopted an agile pragmatist paradigm, where stakeholder focus and behavior orientation are key, it would have realized that accreditation had the potential to help them create standardized and sustainable improvements to their clinical program so that patients and residents consistently receive healthcare that is appropriate, accessible, acceptable, effective, efficient, and safe (Health Quality Council of Alberta, 2004). As with most clinical programs, this service excellence team approached accreditation in isolation of other clinical programs as part of a multi-project organization. As healthcare organizations have become more sophisticated over the years, specialization of tasks has largely kept different programs in isolation of one another. While specialization has fostered innovative advances in medicine, it has also contributed to our fragmented healthcare system and resulted in lost opportunities for knowledge sharing between programs and portfolios. The multi-project approach may have been appropriate when hospitals operated independently of one another but in the current environment, this approach is neither effective nor efficient in multi-site healthcare organizations where standardization is the key to quality and resources are limited. Hybrid organizations offer the best of resource sharing and achievement of related objectives by fostering an environment that encourages organizational learning, development of shared competencies, and economies of scale (Muller, 2009). An effective project sponsor can be the difference between project success and failure, and even though this senior leader demonstrated many attributes of an effective sponsor, this executive sponsor “failed to engage personally in the project” (Creasey & Hiatt, 2008), believing that the technical experts within the clinical program would be able and willing to make the connections between organizational objectives and site objectives. By not being directly involved in defining goals and expectations (technical and socio-cultural), this team experienced a “crisis of silence” (Grenny, Maxfield, & Shimberg, 2007). In some cases, team members failed to honestly assess progress with action plans, while others failed to participate in meetings and complete tasks. Agency issues resulted in an imbalance in how well prepared sites were for the accreditation survey. The sites that adhered to the accreditation process were able to successfully meet all Required Organizational Practices and standards, while other sites scrambled near the end to implement basic practices. Without the presence of an effective sponsor, team members felt awkward about bringing forward concerns about their colleagues, instead focusing narrowly on the program within their specific sites. When issues were raised with the executive sponsor, little could be done except to work intensely with the problem sites to ensure that compliance was addressed through informal audits and education. The problem with this reactive approach was that the focus was on accreditation as an exercise rather than a means to achieve sustainable improvements in quality for our patients and residents. For this particular service excellence team, accreditation may have provided the burning platform for improving quality but ineffective project sponsorship resulted in inconsistently sustainable results, illustrating why project governance is vital to project success. Case Study 3a – Who is Responsible for Effective Project Governance? This case study helps us understand the importance of an effective project governance framework that clearly defines key roles and individuals. Although this Service Excellence

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Team also contributed to a successful accreditation decision, it had a poorly designed structure that empowered but did not enable top management support, preventing this team from using accreditation to bring about sustainable improvements to patient safety. There were three key issues with the leadership structure of this Service Excellence Team. First, it was difficult for the executive sponsor to effectively lead this team without having any formal authority over operations in the portfolio. Second, it was difficult for the team lead to coordinate activities as she only oversaw operations at one site. Third, it was the portfolio leader not the executive sponsor who was the primary risk-taker and ultimately responsible for the team’s success, yet the portfolio leader was not a member of the Service Excellence Team. Although the executive sponsor and portfolio leader worked closely to resolve emerging issues, the Service Excellence Team structure did not enable effective project governance. Until recently, formal project management processes were not a priority for smaller, independently operated healthcare facilities. With a strong focus on clinical expertise for localized quality improvements, these smaller sites could approach projects without considering project methodology processes, project oversight, and optimization. However, as healthcare organizations become considerably more complex, and smaller autonomous sites merge into larger health regions and organizations, project management is becoming increasingly crucial to achieving system-wide objectives. While some elements of Step 1 governance measures were evident with this team, this service excellence team largely overlooked project management as a disciplined approach to achieve accreditation objectives. Without clearly defined roles and responsibilities, accountabilities and expectations were misinterpreted, resulting in misaligned priorities and resistance from some team members to follow the accreditation process to achieve program, portfolio, and organizational objectives. The lack of a governance framework for accreditation also contributed to Agency problems. Information imbalance and information asymmetries resulted in the team lead managing the executive sponsor and limiting information to the sponsor, potentially putting the entire organization at risk for failure (Muller, 2009). This Service Excellence Team also struggled to work within a project governance framework, largely because of a lack of experience with project management methodologies and understanding of project governance. Principal-agent issues arose, as the team lead was unable or unwilling to meet the expectations of the executive sponsor, who was trying to meet the needs of a diverse stakeholder group. Because the majority of this Service Excellence Team failed to adequately identify key stakeholders and their diverse needs, it perceived the standards as a checklist, rather than a rich source of opportunities to better meet the needs of its patients and residents. The team approached the standards as an exercise, as in present or not present, rather than asking, “how are we meeting this standard and how can we do this better?” The root of the issue was a principal-agent conflict as information asymmetries developed disruptive and passive aggressive behaviors creating friction within the team (Muller, 2009). It is important to note that the team members who demonstrated Step 1 attributes were more willing to identify stakeholders and did use the standards to add value to their programs. Unfortunately there was little interest by team members to learn from these bright spots. Had the team correctly identified stakeholder needs, its members would have seen the value in adopting an agile pragmatist paradigm and used accreditation to drive system-wide improvements to patient safety.

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A common misconception about accreditation is that it is a project in isolation from ongoing quality improvement work, which has the detrimental effect of creating the perception that it is an add-on activity for individuals. Instead, the accreditation standards provide guidance to organizations seeking to develop their own patient safety frameworks. Accreditation standards are essentially best practice standards that are evidence-based and should be integrated into daily operations and continuous improvement planning. When accreditation is perceived as add-on work within a multi-project mindset, organizational learning becomes limited and presents as a lost opportunity to leverage successes and create synergies that accelerate quality improvement. This Service Excellence Team had not yet made the transition from a group of independently operated facilities within isolated communities to a team of interdependent healthcare facilities striving to achieve portfolio and organizational objectives. Part of the issue was that this team had some difficulty making connections between organizational objectives, program objectives, and site-specific objectives. This affected collaboration within the team as team members became focused on what they perceived to be unique issues requiring unique solutions. The other part of the issue was that it was physically very difficult for team members to share resources such as policies and procedures. Without a fully developed corporate suite of policies and procedures and information technology infrastructure, sites relied on a variety of resources, reducing the potential to standardize the quality of care. As with the previous case study, the multi-project approach may have been appropriate when the sites operated independently but a hybrid approach would have better enabled this multi-site clinical program to better meet client expectations within a rapidly evolving and resource limited environment. In creating this Service Excellence Team, a critical success factor was overlooked: Top management is not the same as top management support. While the executive sponsor was a senior leader with operational ownership of a segment of this program within a different portfolio, the sponsor did not have appropriate power over this particular segment of the program. Consequently, the sponsor was not the risk-owner. The risk-owner was a different senior leader who did have operational responsibility for this segment of the program, but was not part of this service excellence team. While both the executive sponsor and the operational leader are talented and experienced leaders, the Service Excellence Team structure failed to support their success with accreditation. While it is true that structure cannot be a substitute for leadership, it is an enabler that makes top management support possible. Without an effective project governance structure for accreditation, seniority was powerless, political savvy became game-playing, connections between project and organization were lost in translation, objectivity was misinterpreted as criticism, and the willingness to battle on behalf of the project became a battle on behalf of the organization. To further add to the issues around top management support for the service excellence team, the team leader only had appropriate power within her site and struggled to consider how the clinical program at her site fit into the larger portfolio and beyond to the organization. This lack of perspective hindered the team’s collaborative efforts to address system wide issues in a timely manner, putting the entire program and the organization at risk. In order to resolve significant emerging issues with compliance to the required organizational practices, the operational leader assigned extra resources in the form of educators and administrators to ensure that the sites were given adequate support to complete their accreditation action plans. There were highly engaged individuals within this team, but there was also a general lack of commitment, illustrating that the cost of forcing compliance is greater than the cost of commitment.

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Although this service excellence team had top management support, an ineffective project governance structure did not enable the executive sponsor to perform effectively. This case study illustrates how fragile top management support can be if it is not adequately supported by an effective governance framework. Case Study 3b - How is Project Governance Supported? This case study serves as an example of what effective project governance looks like when project structure enables top management support. Not only did this Service Excellence Team follow the organization’s accreditation plan, but it also aligned its accreditation objectives with its clinical operational objectives. Team members were chosen with intent from a large bi-site interdisciplinary healthcare team. They were knowledgeable, skilled, experienced and possessed attitudes that demonstrated their commitment to patient safety. In addition, they were all talented influencers, able to connect accreditation with the work their teams do every day. The executive sponsor had operational authority, the team lead had a formal reporting relationship with the sponsor, and the clinical quality consultant was the change agent, working within a balanced matrix project structure. This clinical program still relied heavily on technical expertise to drive improvement, but also recognized the value of project management methodology for business improvement and was receptive to the clinical quality consultant as the change agent. At Step 1 of the governance framework for project management, this interdisciplinary Service Excellence Team served as the implementer group and its members were the clinical content experts, while the clinical quality consultant served as the technical expert for the accreditation process. Both the sponsor and team leader were well respected for their willingness to partner with others and for their excellent communication skills. Although they had not worked on a project before, the team leader graciously accepted the clinical quality consultant as a valuable part of the service excellence team, and accreditation subsequently became a partnership: accreditation objectives became the clinical program’s objectives and both supported organizational objectives. Because the executive sponsor and the team lead already had a trusting and credible reporting relationship through operations, the development of an effective accreditation accountability framework developed quite organically. Similarly, the team leader fostered positive, collaborative relationships within her clinical program’s interdisciplinary team, which were also evident in the Service Excellence Team. Team members held themselves and each other accountable and were open to challenging the status quo, constantly striving to improve the quality of care. Through a series of gap analysis exercises, chart audits, observational audits, and mock tracers, the team honestly assessed their clinical program, and used each review as an opportunity to improve practices. The team leader took audits one step further and sought feedback from patients about their care experience and incorporated those observations into action plans, leading one to wonder if this team was on the brink of Step 2. With an appreciation for the accreditation process and an intentional approach to stakeholder orientation, this Service Excellence Team operated within an agile pragmatist paradigm. There was a healthy principal-agent relationship between the executive sponsor, team leader, and clinical quality consultant that contributed to objective and transparent information sharing within the team, and between the executive sponsor and the senior leadership team (the accreditation steering group). While some Service Excellence teams may have been reluctant to share issues with noncompliant standards, this team did not hesitate to candidly share its challenges and successes with the senior leadership team. The executive sponsor and team

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leader were skilled at balancing the needs of a diverse stakeholder group and fostered collaboration within the team. Being new to the accreditation process, this team relied on guidance from the clinical quality consultant and adopted a project management approach that included, defining, planning, executing, and closing phases that followed a work breakdown structure (WBS), timelines, and deliverables. The Service Excellence Team began its accreditation related activities early on and included an introductory education session, biweekly accreditation meetings, a clinical program leaders’ retreat, and closing celebration. Moving forward, this team plans to meet biannually to review and update its evidence demonstrating compliance to the Accreditation Canada standards and will be presenting a poster highlighting its success with audits and education at a national conference. This team was also received internal recognition for its collaborative approach towards accreditation. While working largely within a multi-project organization, this Service Excellence Team demonstrated evidence of a hybrid approach to project governance style. Again stemming from its ability to create synergies within its multi-disciplinary teams, the team was able to successfully create significant change efforts across its bi-site program. The team was able to align its accreditation efforts with its operational objectives, leveraging accreditation as a driver of quality improvement, rather than a separate exercise. An interesting observation should be shared at this point: When most teams begin their accreditation cycle, it is almost always viewed as a work burden; something separate from daily operations. There is a point, however, where a switch seems to turn on and the team understands the benefits of accreditation, becoming actively engaged in their accreditation work. Some teams reach this point early in the process while other teams never fully understand the value of accreditation. This team was no different. Skeptical in the beginning of the accreditation process, the team quickly became engaged with their accreditation work with members contributing their talents to the benefit of the clinical program. Early on, the team’s leaders made the connection between accreditation and the work people do everyday, and consequently did not have the challenge of forcing compliance because their people were already committed to achieving their best through accreditation. By balancing clinical and organizational objectives, this team was able to implement corporate patient safety initiatives and local program objectives that were meaningful to those who provide care at the bedside. This Service Excellence Team was able to find the balance between strategic and clinical program objectives and collectively had the knowledge, skill, experience and attitude to make those objectives a reality. This case study supports the idea that top management support is the most important critical success factor for successful projects. It also illustrates the importance of an effective project governance framework as an antecedent. Both the executive sponsor and the team leader possessed most, if not all of the common attributes known to contribute to successful project outcomes and were also the primary risk-owners within operations of this clinical program. The executive sponsor was highly visible at the beginning of the process and although her physical presence diminished over time, her commitment to the team was unwavering throughout. Leading with a blend of courage and grace, both the executive sponsor and the team leader were able to inspire team members to want to be part of this worthy struggle, to motivate them to keep moving forward despite the workload and resistance, and to direct them confidently despite ambiguity with the process. They were also exceptional change leaders, who were able to help their team members understand the connections between strategy and operations and how accreditation was merely the catalyst to transform quality improvement. Not only did they appeal to their team’s intellect, but they ignited a shared sense of purpose, and made the future state much more appealing than the present.

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Modeling servant leadership, they made accreditation less about an exercise and more about our promise to those we serve and to those who serve. All through this process, they were not simply leading twenty individuals through the accreditation process; they were coaching and mentoring twenty new leaders to continue their work. The combination of effective project governance structure and top management support helped this service excellence make the connection between project management success and project success creating the potential for sustainable improvements to patient safety through accreditation. Still, with a burden of conflicting priorities and limited resources, only time will tell if this Service Excellence team will be able to sustain its successes and continue to seek new opportunities for improvement.

Overall Discussion The sequential accreditation model allowed the organization to spread out its accreditation efforts in a way that was manageable. This was especially sensible given that the organization was a novice with accreditation and provided its diverse healthcare services over a large geographic area. It was also wise to align its accreditation efforts with those of its provider. Not only would this better ensure that funding requests for accreditation related activities were aligned but this would also help ensure that collaborative efforts could be realized through formal and informal clinical networks. Basic tools and education resources were developed to assist Service Excellence Teams understand the accreditation process and to help them develop and implement their action plans. Terms of reference were developed to define roles, expectations, and project deliverables but seemed to be rarely followed. Although the Quality office led accreditation and was responsible for all aspects of the accreditation process, it appeared on the accreditation structure map as an afterthought (Figure 6). Project governance was simply not considered during project planning, instead relying on influence and relationships to support project deliverables. This approach was not completely flawed. After all it is not uncommon for project managers working within a matrix project structure to lead projects successfully without being able to rely on formal authority. In these cases, however, clear guidelines help define roles and expectations between the project manager and the functional manager, as well as for other project team members. The issue was not that the Quality office had no formal authority within any of the administrative or clinical programs. It was that Service Excellence Team member roles and responsibilities were not clearly understood which resulted in a general lack of accountability. Considering that this healthcare organization scored greater than 95% every year of its three-year cycle, one could assume that this was possible because of a perfectly designed accreditation process. This would be an incorrect and dangerous assumption. Incorrect because as we have discovered, project management success and project success are only loosely related and that the real value of accreditation is realized not as an audit exercise but as a means to enhance patient/resident safety and minimize risk, and that improvements made to patient safety because of accreditation need to be sustainable after the on-site survey. Dangerous because a score of 95% might lull a healthcare organization into a false sense of security that it has achieved a sustainable level of excellence, and this puts the organization at risk. Still, we might be tempted to consider our job done - but we know better. Declaring victory too soon encourages complacency and allows the resistors to undermine improvement efforts that prevent the changes from being firmly anchored into culture (Kotter,

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1996). Operating within a “just culture” framework, where there is shared accountability between the organization and employees, accreditation is about keeping our promise to those we serve and to those who serve. It is about improving the quality of care for our patients and residents, and it is also about enabling our teams to provide safe care. Referring to Figure 7, the case studies are analyzed in this discussion paper from the perspectives of their governance framework, governance paradigm, governance style, top management support, and significant challenges. Through the analysis, Case Study 1 and Case Study 3b were deemed the most successful accreditation projects, while Case Study 2 and Case Study 3a were considered less successful. The Service Excellence Teams from Case Studies 1 and 2 shared many similarities, including an appropriate governance paradigm and governance framework for accreditation that enabled their programs to successfully achieve their accreditation objectives. They also differed in a way that illustrates an important point about top management support. The teams in Case Study 1 were small and had its members benefitted directly from the strategic accreditation work, whereas the team in Case Study 3b was very large and its members were largely removed from strategy. Both teams, however, demonstrated a high degree of user involvement and user ownership, challenging the idea that the benefits of accreditation must be direct and significant. A key attribute of top management support is the ability to make the connections between projects and the organization. It was easy for the teams in Case Study 1 to make those connections because they were top management but it was through intentional effort in Case Study 3b to win over the hearts and minds of the team members and give purpose to the accreditation work. A key element of accreditation is to promote continuous improvement, and it is the responsibility of the organization to enable itself to be open to assessment, review, and improvement. An important characteristic of learning organizations is the ability to assess performance and to be willing and able to use that information to improve (Institute of Medicine, 2001). Through their self-assessments, gap analysis, and various audits, the team in Case study 3b is a potential “bright spot” from which the organization could learn. With significant issues related to governance paradigm, governance framework, and governance style, the teams in Case Study 2 and Case Study 3a did not have the necessary antecedents in place to support top management support or organizational learning. With both teams affected by Agency issues, sponsors struggled to force compliance when the appropriate structure could have alleviated at least some of the issues.   Case Study 1 Case Study 2 Case Study 3a Case Study 3b Governance Paradigm

Agile pragmatist Absent Absent Agile pragmatist

Governance Framework

Step 1 Pre-step 1 Pre-step 1 Step 1

Governance Style Multi-project Multi-project Multi-project Hybrid Top Management Support

Effective Ineffective Ineffective Effective

Challenges • Governance style

• Governance framework

• Governance paradigm

• Governance style

• Governance framework

• Governance paradigm

• Governance style

• No significant challenges identified

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• Top Management support

• Top Management support

Figure  7:  Case  study  analysis  summary  

The individual case study analysis as well as the above overall analysis provides the platform for the recommendations noted in the next section.

Recommendations and Conclusion The case study analysis presented in this discussion paper does not insinuate that individuals are to be blamed for an organization’s challenges with its accreditation efforts. Sometimes good people are simply put into impossible situations. Rather, healthcare organizations should heed the phrase coined by Paul Batalden, “every system is perfectly designed to get the results it gets” (2007, p. 25), and ensure that their systems are designed to support their people for successful accreditation outcomes. The first step is for leaders to understand that accreditation is not an exercise but a framework that provides guidance to organizations seeking to improve the quality of their healthcare services. Through the accreditation process, organizations are able to identify their strengths and weaknesses with the quality of the services they provide clients as well as to identify opportunities and threats within their local environment. Not to be pursued separately from operational improvement, accreditation provides standards based on current best practices (Accreditation Canada, 2012) that organizations should be striving to achieve, regardless of accreditation. All healthcare leaders wishing to improve their organization’s patient safety performance should consider adopting a governance framework for accreditation. As part of an overall enterprise governance framework, effective project governance defines an organization’s project management capacity and supports top management support, thereby creating greater value from their accreditation efforts. Healthcare leaders should consider evaluating their organization’s current project management capacity and establish plans to develop organizational capabilities that will help achieve strategic objectives, with the understanding that the goal of this exercise should be to achieve a reasonable return on investment. Based on the lessons learned from one organization’s accreditation efforts this section provides recommendations intended to support the development of an effective project governance framework that will result in sustainable improvements to patient safety. In order for healthcare organizations to utilize project governance as a means to create sustainable improvement to patient safety, their accreditation governance models require the following: • Governance Paradigm – Agile Pragmatist Paradigm With an emphasis on public accountability, healthcare organizations should seek opportunities to strengthen stakeholder engagement and improve performance by adopting an agile pragmatist paradigm. With limited resources and conflicting priorities, the behavior control focus of this governance paradigm can help healthcare organizations achieve their strategic objectives in a way that fosters organizational learning and sharing, and supports integration and standardization. This approach ensures that healthcare organizations are consistently able to meet the needs and expectations of their patients and residents. • Governance Framework – Step 1 While organizations may benefit from a greater investment in their governance frameworks overall, Step 1 is likely sufficient for their accreditation efforts. A basic understanding and

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appreciation of project management methodologies will help ensure that the Service Excellence Team is able and willing to accept direction from the executive sponsor and guidance from the clinical quality consultant, who will be expected to receive some formal project management training. • Governance Style – Hybrid In order to maximize both effectiveness and efficiency with its accreditation efforts, healthcare organizations should adopt a hybrid approach. This approach may be especially helpful for organizations that have included integration of programs and services as a strategic priority. By sharing resources to achieve related objectives across, programs, sites, and portfolios, healthcare organizations are able to leverage their strengths and create synergies that build upon isolated successes and accelerate change. A hybrid approach helps ensure that an organization’s accreditation efforts demonstrate alignment between organizational goals and operational goals. • Top Management Support – Critical Success Factor Effective project sponsors demonstrate a blend of courage and humility, and are willing and able to devote their time and effort to the project in order to review project progress and resolve issues on behalf of the project. As an integral part of an accreditation Service Excellence Team, the executive sponsor is able to help team members understand the connection between strategy and operations in a way that is meaningful and purposeful to them. In order to be an effective sponsor, however, the accreditation governance model must be structured in a way that supports top management support and removes barriers that prevent the sponsor from achieving both operational and strategic objectives.

Moving Forward In order to maximize the value of accreditation, healthcare organizations should adopt an accreditation governance model that helps provide the line of sight between strategy and operations for their employees and physicians such as the one in figure 8.

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Figure  8  Accreditation  Governance  Model

Not only does this model support a sequential approach for accreditation but also provides a structure that enables top management support. Where the previous accreditation model attempted to create alignment between operations and the service Excellence Teams, this proposed model overlays the existing operational organization structure with the accreditation organization structure, creating an accountability framework that defines an organization’s accreditation structure, roles, and accountabilities in a way that promotes congruency between accreditation, strategic, and operational objectives. Once an organization understands that accreditation and its related patient safety initiatives offer the link between strategic and operational objectives, it is more likely to rely on enterprise governance “[] to provide a balance between what could be done with what should be done in order to ensure long term sustainability” (Muller, 2009, p. 93). This proposed accreditation governance model serves as a starting point from which healthcare leaders can begin to formulate their own accreditation governance models in which structure becomes an enabler for leadership, rather than a substitution for leadership. When approached as part of an organization’s enterprise governance framework, project governance has the potential to create sustainable improvements to patient safety through accreditation, allowing healthcare organizations to be of greater service to those they serve.

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Definitions Adverse Events - Adverse events are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from healthcare management (Baker, et al., 2004). Patient Safety Culture - Patient Safety Culture is “[] an integrated pattern of individual and organizational behaviors based upon shared beliefs and values, that continuously seeks to minimize patient harm which may result from the processes of care delivery” (Canadian Patient Safety Institute, 2011) Required Organizatonal Practice (ROP) – “[] an essential practice that organizations must have in place to enhance patient/client safety and minimize risk” (Accreditation Canada, 2012). Leading Practice – “[] noteworthy examples of high-quality leadership and service delivery. These practices are worthy of recognition as organizations strive for excellence in their specific field or contribute to health care as a whole (Accreditation Canada, 2012). The practices must be linked to Accreditation Canada Standards, be sustainable and adaptable to other organizations, and offer creative and cost efficient means to improve quality through knowledge sharing. Just Culture – There is a shared accountability between healthcare organizations and their employees and physicians to provide safe patient care: Organizations are responsible for ensuring that systems are in place to support safe patient care; and employees and physicians are responsible for choosing appropriate best practices and safe behaviors.

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