Project Governance

Governance is the architecture which describes how an organization delineates the rights and responsibilities of decision making. In a health system, governance can be defined as “the arrangements of... relationships by which authority and function are allocated and obligations established and regulated and through which clinical policies and practices are effected.”(1)

Introduction

Most large companies have an IT governance structure to help align the investments in technology with the strategic vision of the company. This delineated system of reporting and accountability prevents, for instance, a CIO from committing the organization to IT purchases that do not meet the long-term business plan of the hospital. Other instances of governance exist in healthcare. Increased involvement of nursing in high-level organizational decision-making is often referred to as "shared governance."

Why focus on governance of CPOE?

Governance of clinical systems in the healthcare industry is becoming an increasingly recognized need. A well-respected CIO at Beth Israel Deaconess Hospital and Harvard Medical school, John Halamka blogged, “I’ve committed to make 2011 the year of governance.”(2) The mounting interest in governance is caused by many converging forces on health care organizations. Halamka cites three specific reasons: increasing stress on systems to meet “meaningful use” under the Health Information Technology for Economic and Clinical Health (HITECH) Act, the increasing focus on accountable healthcare systems and reporting of data, and new regulatory or compliance mandates in the pipeline, like roll out of the ICD-10. In these tough economic times, a hospital system can’t afford not to invest in health information technology (HIT), nor can they afford a failed implementation of CPOE or an electronic health record.(2) The presence of clinical systems committees are often seen as an "important success factor" for CPOE implementation.(3, 4)

Supporting the mandate: top-down and bottom-up

The primary source of the power and responsibility given to a health system's CPOE governing body stems from upper level management. Without high level support, committing "unwaveringly and visibly" to the project, it is only a matter of time before the governing body is undermined.(5) This commitment can be demonstrated by a direct presence of executive members on the committee or by inclusion of leadership of the CPOE governing body in executive meetings.

But support also has to come from the institution as a whole. To garner this support, a key ingredient is a well-communicated, shared vision of the importance of CPOE adoption, its benefits and also an honest appraisal of the difficulties and challenges it brings.(5)

Composition of a governing body for CPOE supervision

The structure and people involved in CPOE governance will vary amongst health systems. Some strong suggestions from the literature include:

• Obtaining broad representation of all those affected by CPOE. Failure to include an involved party is a very difficult situation from which to recover.
• Reliance on more than just the IT management and staff for project management.(6) CPOE implementation has profound effects on clinical workflow. The IT department alone will not have sufficient clinical experience nor garner enough respect of the clinical staff to facilitate change.
• Involving stakeholders with a wide range of skill sets, including "leadership, peer-relationship skills, [and]... technical expertise"(4)
• Including individuals with clinical experience who champion the use of the CPOE across all disciplines and clinical areas(5)
• Inviting "curmudgeons," individuals with contrarian opinions or concerns regarding the system.(4)

Organizational needs addressed by governance

Communication

Governance allows for effective communication of the organizational vision surrounding CPOE adoption and maintenance. Maintaining a clear goal is essential to CPOE implementation. Also, a governing body can create formal, dedicated channels of communication through which accurate information regarding the CPOE project will be passed. Such channels might involve reporting mechanisms from the members of the group to their clinical areas, the publication of a quarterly flyer, or a web presence with continual updates. Governance requires two-way communication, and a governing body also exists as a forum for dialog on ongoing concerns or suggestions. This promotes greater transparency of the process, and helps to manage expectations and relieve the fears associated with change.

Addresses threats to autonomy

The autonomy of medical providers is threatened by the implementation of an electronic health record, yet they more than any group in a healthcare system determine the success or failure of CPOE adoption.(7) Involvement of physicians and nurses in the governance of CPOE implementation helps ease these concerns.. "Some technologies that get into hospitals don’t affect workflow much, like telephones. No one pays much attention to what kinds of phones get purchased."(8) The technology of CPOE is not like this: "they’re [health IT products are] much more like the real tools of the trade, the bronchoscope or the catheter that the cardiologist uses... Computers are now tools that affect the way we work every bit as much as that, and we don’t have a model or structure that has the people who use those tools engaged in specifying what the tools are or how they should be used."(8)

Healthcare providers are very often wary of those in managerial positions and vice versa.(9) Only 39% of doctors in one study knew the educational degree of their manager, and 71% of those that knew the degree felt it was inadequate for effective hospital management.(10) With such contentiousness, any mandate from administration can feel like a specific imposition. Providers, however, are more willing to participate in activities that limit or restrain their clinical choices if they themselves are involved in the process that creates those restraints. One author summarized this by saying of physicians, “I am being regimented if you give algorithms to me, but I am being systematic if I develop algorithms for myself.”(11)

Power Issues

Governance formalizes and to some degree exposes the power structures in an organization regarding decisions of CPOE implementation. It serves to “specify people responsible for establishing business process, data, and technology standards and for dealing with requests for exceptions to those standards.” (12) Many hospitals are "underbounded system[s]... organization[s] where the lines of authority are not well drawn and where the decision-making process is ill-defined.(6)

“Governance should surface and institutionalize natural tensions.”(12) For instance, providers feel increasingly that their clinical autonomy is being threatened by instruments such as practice guidelines, performance measures, and clinical decision support tools. Institutions are faced with the growing pressures to address ballooning healthcare costs and poor quality. Without a setting to address these kinds of enduring tensions, they will often spill out in conflicts and confrontations between entities. Handling them in a transparent manner will aid the health of the organization.

Maintenance of high-level/institutional goals

Governance surrounding the electronic health record and its use can ensure that the larger organizational goals and objectives are aligned with the continued improvements to the CPOE system. “Enterprise-wide objectives are often in conflict with subunit objectives... One role of IT governance is to encourage desirable behaviors that organizational and incentive systems cannot or do not motivate.”(12) A governance structure helps focus priority on an institutional goal. For instance, a hospital system may be notified of a new performance measure that it will be accountable to address. With a governance structure, changes to CPOE in support of this mandate might be assigned priority over other requests for improvement.

Promote behaviors of a learning organization

The governing body can serve as a center for institutional learning and innovation. “Governance should help firms learn so that they stop making the same mistakes over and over... [giving] them valuable experience in recognizing what goes right and wrong in delivering projects.” (12) Project management itself is a learned skill, and providing an working laboratory where that learning occurs in a visible way can help to streamline future projects. “Implemented appropriately, the governance groups become the fulcrum for innovation, and home to the change agents.”(13)

The goal is an organization that has empowered the right mix of people to work in concert on developing and sustaining CPOE under a well-supported mandate from the administration. Only with all the support structures in place can the work begin in earnest. This is not a utopian dream; a good foundation doesn't ensure smooth sailing. Dr. Halamka says his experience in leading governance organizations is to "expect conflict. Don't fear and fight it. Acknowledge it and work with it. Conflict can create a sense of urgency among participants to solve problems. Conflict can lead to stronger relationships and catalyze change."(14)

In a learning organization, "knowledge must not be seen as a product to be inserted into existing planning and decision-making processes but must be used to inform the way planning and decision-making takes place."(15) An unintended outcome of CPOE governance might be to facilitate a culture shift towards innovation and greater team orientation by breaking down fragmentation and interdepartmental competition.

References

1. Gray A, Harrison S. Governing Medicine: Theory and Practice. Maidenhead, England: Open University Press; 2004.
2. Halamka J. The Year of Governance. 2010 [cited 2010 Nov 16]; Available from: http://geekdoctor.blogspot.com/2010/10/year-of-governance.html
3. Ash JS, Stavri PZ, Dykstra R, Fournier L. Implementing computerized physician order entry: the importance of special people. Int J Med Inform. 2003 Mar;69(2-3):235-50.
4. Mellin A, MD, MBA. CPOE requires governance structures from organizational leaders to succeed. Performance Strategies 2010 [cited Nov 16, 2010]; Available from: http://www.strategiestoperform.com/volume4_issue4/docs/volume4_issue4_f.pdf
5. Ash JS, Stavri PZ, Kuperman GJ. A consensus statement on considerations for a successful CPOE implementation. Journal of the American Medical Informatics Association : JAMIA. 2003;10(3):229-34.
6. Massaro TA. Introducing physician order entry at a major academic medical center: I. Impact on organizational culture and behavior. Acad Med. 1993 Jan;68(1):20-5.
7. Ash JS, Sittig DF, Campbell E, Guappone K, Dykstra RH. An unintended consequence of CPOE implementation: shifts in power, control, and autonomy. AMIA Annu Symp Proc. 2006:11-5.
8. Ash JS, Anderson JG, Gorman PN, et al. Managing change: analysis of a hypothetical case. Journal of the American Medical Informatics Association : JAMIA. 2000;7(2):125-34.
9. Degeling P, Maxwell S, Kennedy J, Coyle B. Medicine, management, and modernisation: a "danse macabre"? BMJ. 2003 Mar 22;326(7390):649-52.
10. Vlastarakos PV, Nikolopoulos TP. The interdisciplinary model of hospital administration: do health professionals and managers look at it in the same way? Eur J Public Health. 2008 Feb;18(1):71-6.
11. Komaroff AL. Algorithms and the "art' of medicine. Am J Public Health. 1982 Jan;72(1):10-2.
12. Weill P, Ross JW. IT savvy : what top executives must know to go from pain to gain. Boston, Mass.: Harvard Business Press; 2009.
13. Gunasekaran S. A team approach. Rather than being the responsibility of one individual, EMR governance takes a village. Healthc Inform. 2007 Aug;24(8):62, 84.
14. Halamka J. Forming, Storming, and Norming. 2010 [cited 2010 Nov 16]; Available from: http://geekdoctor.blogspot.com/2010/10/forming-storming-and-norming.html
15. Scott C, Seidel J, Bowen S, Gall N. Integrated health systems and integrated knowledge: creating space for putting knowledge into action. Healthc Q. 2009 Oct;13 Spec No:30-6.

Dgelman dgelman2@nyc.rr.com