Project management
We generally argue that knowledge gained from the business literature can easily be transformed to the medical domain. In this Executive summary we have made comments arguing why we we think the advice given by the authors is equally applicable to the medical domain. Hopefully we have transform the messages from the literature to meaningful advice also for the medical domain.
We have written an Executive summary of an article authored by M. Keil and R. Montealegre ( "Cutting Your Losses: Extricating Your Organization When a Big Project Goes Awry", Sloan management review, 41 (3), 2000, p 55 – 68)
When a Project Goes Awry
When a project is no longer on track and the project escalate the executive needs strategies and tactics to turn the project around (if possible) or to stop it (if necessary).
This is as much an issue in the medical domain as in the business in general. The question raises is the projects different in nature or will the strategies have to bee different due to the fact that it exist in a medical environment.
Generally the problem of escalating projects is particular common in technologically sophisticated project with a strong information technology (IT). The special nature of these projects – high complexity, risk and uncertainties makes them particular susceptible to escalation. The very nature of medicine is based on technology and information and the projects are often mission critical. It seems evident that we are talking about the essentially same kinds of projects (developing and implementing new HIS systems, building new Hi Tech wards etc)
The problem is that in many cases, executives become so strongly wedded to a particular project, technology or process that they find themselves continuing when they should pull out. Resulting in accelerated pouring in more resources
- Escalation of commitment to a failing course of action -
Since the problem is escalation the focus should be on strategies to de-escalation
The process has four phases:
1. Problem recognition
2. Reexamine the previously chosen path
3. Searching for an alternative course of action
4. Implementing an exit strategy
The authors give seven ways to de-escalate commitment to failing projects
1 Don’t ignore negative feedback or external pressure
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Statement by paper |
Comment for the medical domain |
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"Executive need to be aware of bias toward escalation and pay close attention to negative feedback and external pressure, because these present warnings signs that can aid in problem recognition. It is common for executives to delude themselves into thinking that a project will pull through – that success is just around the corner." |
Professional bureaucracies such as in the medical profession, is normally very resistant to change and high techs projects is consequently meet with resistance, whether it is negative feedback or merely resistance to change is the question. The tendency is to consider high tech changes resistance and not real negative feedback. There is a tendency to discount negative feedback with remarks in line with " users must use their head, the system is simple.. ". The gab is often bigger in the medical world since reinvestment in a public system is often not continuous, but happens in big leaps, which makes informed leaders tending to see negative feedback as ignorance and not real objections. |
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"External pressure may be lacking in projects that are internal to an organization an do not involve external parties". |
Many projects in the medical domain are "internal" in nature with few external reference persons. It is therefore important for the managers to realize that External pressure might not be very obvious, therefore the awareness of negative feedback become the prime warning signal. Proactive attitudes by the executives are imperative. |
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Over commitment to a course of action is likely to make executives miss certain warning signs or misinterpret them when they do appear |
IT project are often "flagships" and therefore very prestigious resulting in an attitude completely denying that the "ship" may not be floating. |
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External pressure may be lacking in projects that are internal to an organization and do not involve external parties |
Since the medical domain is a world of experts the projects are often initiated and managed within the organization. Few external persons will have the knowledge to put an intelligent question to the relevance of the project. |
2 Hire an external auditor to provide a more objective assessment
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Statement by paper |
Comment for the medical domain |
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Executives often sense that the project is not going well or that things could be better, but they do not have the objective evidence needed to translate their vague feelings into concrete action. |
Again this is mainly an issue of the internal nature of IT project in the medical world. |
3 Don’t be afraid to withhold further funding
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Statement by paper |
Comment for the medical domain |
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It seems only natural that executives are inclined to keep pouring more resources into the escalating project |
Again IT project are often "flagships" and therefore very prestigious resulting in an attitude completely denying that the "ship" may not be floating. A common statement could be something like this "The problem encountered just now is temporally since our project is a killer in the long run …" |
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By refusing to spend more money on the project, not only minimizing further investment |
Not only minimizing further investment, it also highlights that a serious problem exits. |
4 Look for opportunities to redefine the problem
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Statement by paper |
Comment for the medical domain |
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Visibility of project costs can play an important role in promoting problem redefinition |
At least in public organizations the costs are usually embedded. The executives dare not expose the cost (IT is expensive) since the medical world generally is under pressure to reduce their cost substantially. Exposure usually draws the attention of external forces making simple cost benefit calculations. |
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Implement project review procedures that encourage creative thinking |
The medical world is generally known to be robust and stable which is an asses for the patients thus avoiding new – non-proven treatment. In the review process this however is a drawback since the opposite is required – creativeness and courage. |
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Creating a culture that encourages individuals to openly question wether an IT system solution is the bedst (or even viable) approach toward a given problem |
The medical world is an very authoritative world an power is often build on not shearing knowledge making it extremely difficult to get enough information on the project not to mention the unlikelihood of a critique to be in a position to be heard. |
5 Manage impressions
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Statement by paper |
Comment for the medical domain |
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One of the most powerful forces that can promote escalation is the human need to save face. Nobody wants to be associated with a failing course of action. There is a natural tendency to want to continue a failing project in the hope of turning it around and vindicating oneself |
Again the authoritative nature of the medical world makes it inevitably that loosing face is unacceptable. |
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The executives are more likely to extricate themselves and their organizations from failing courses of action when conditions allow them to manage impressions and save face in the process. |
Obviously this is also true in a medical world |
6 Prepare your stakeholders
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Statement by paper |
Comment for the medical domain |
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Large and complex projects often take on life of their own and involve multiple stakeholders. It is important to recognize the importance to prepare stakeholders. |
Obviously this is also true in a medical world |
7 Look for opportunities to deinstitutionalize the project
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Statement by paper |
Comment for the medical domain |
| Patterns of escalation are more difficult to break when projects become institutionalized. Ross and Staw describe deinstitutionalization as removing a project "from the core of the firm, either by moving it physically away from the central location of the company or by emphasizing is peripheral nature" | This ought to be the easiest part in the medical world. If it is not possible to give an unambiguously positive answer to the question "does it benefit the patient?" the combined forces in the institution will tend to go for a closure of the project. |
The summary is based on:
Keil M.; Montealegre R. Cutting Your Losses: Extricating Your Organization When a Big Project Goes Awry. Sloan management review, 41 (3), 2000, p 55 – 68