Project Management in Psychiatric Nursing: An Interdisciplinary Approach

Psychiatric nursing demands time-sensitive information and coordination in order for administrative actions and caregiver interventions to be effective. Project management is a tool that can be used in the field of healthcare to plan, organize, direct, and control human and company resources in order to accomplish “specific” “relatively short-term” “goals and objectives” (Kerzner 1.7.2). “Project management utilizes the systems approach to management,” by assigning “functional personnel (the vertical hierarchy)…to a specific project (horizontal hierarchy),” this means that both staffing and necessary objectives can be coordinated together effectively by using the tools of project management. (Kerzner 1.7.2). Ideally, project managers can form a coalition of staff members who each have a unique role and skill set to engage toward the ends of accomplishing specific, agreed-upon goals.

In order to address staffing, budgetary, time, and focus concerns, project management must include ongoing measurements and evaluations of a project’s state of quality and completion. Broadly, project success can be described as “the completion of an activity within the constraints of time, cost, and performance;” more specifically, success demands “acceptance by the customer/user” and does not disrupt the “main work flow” or “culture” of a company (Kerzner 2.2.3). In psychiatric nursing, our customers are our patients, their families, insurance companies, and government healthcare benefits providers. The company culture of any psychiatric care provider is necessarily therapeutic and sensitive to issues of privacy, dignity, and respecting a patient’s spirituality and holistic needs. Thus, when developing goals for a potential project, medical, and legal or ethical concerns are vitally important to consider along with traditional evaluation metrics such as staff and budget allocation and percentage of completion. A similar situation can be found in the project management at “Disneyland and Disneyworld,” which “had six constraints: time, cost, scope, safety, aesthetic value, [and] quality,” the last three of which, including safety, first and foremost, were considered “locked-in constraints that could not be altered during trade-offs,” whereas time, cost, and scope can have trade-offs and concessions as long as the project is completed successfully (Kerzener 2.10-11).

“The true definition of failure is…unmet expectations,” and there are three types of failure: perceived, planning, and actual, the levels of which depend on discrepancies between planned and measured outcomes (Kerzener 2.11). Basically, success means a project accomplishes its goals within a planned, achievable, and reasonable, time, cost, and scope; while failure means a project has not performed according to expectations in any or all of these areas.

Continual assessments of a project’s goals and the costs incurred by pursuing them are vital to project implementation. Just as nurses have a scope of practice that provides a framework within which to operate safely and effectively, each project has its own scope which should not be drastically altered throughout the course of a project’s progress. There are many different methodologies of project management, which have their own benefits and drawbacks. These methodologies apply to projects of different time-frames, scales, directions, and levels of managerial involvement and thus have varied approaches to completing the goals of effective project management. Software development utilizes some important models which psychiatric nursing could also follow, as it enters an age of information systems and evidence-based practices that demand high-quality access to data and building a cohesive product (Mason, Leavitt and Chaffee 444).

In the case of psychiatric nursing, the product is the provision of holistic mental health care. The “Waterfall” method is a “used across all industries” (Successful Projects). It is a hierarchical methodology with linear steps: “requirements specification,“ “design,” “construction, (…or coding),” “integration,” “testing and debugging…(validation),” and ending with “installation” and planning for future “maintenance” (Successful Projects). There are other, more dynamic methods that can be used to manage projects, such as the “Agile” method or “Scrum” method. The Agile method is more non-linear, with “no clearly defined end product at the onset,” instead focusing on providing “rapid, continuous delivery of product to the customer” (Successful Projects).

The Agile method emphasizes “non-static requirements,” which include “flexibility” and “communication” (Successful Projects). The Scrum method is also structurally fluid; its main requirements are “30-day ‘sprints’ and monthly ‘scrum sessions’” which analyze “project deliverables” (Successful Projects). Instead of a formal project manager, there is a “Scrum Master,” who is in charge of coordinating between team members and resolving problems or “distractions” (Successful Projects).

The “Kanban” method involves posting project work onto a board, with tasks divided into three general categories: “’in queue’, ‘in progress’ and ‘recently completed’” (Successful Projects). As the project is completed, items move from left to right and demonstrate in a visual manner the specific and total progress accomplished. There are many other methodologies which can be employed for effective project management, depending on context, these include: “DMAIC (…Define, Measure, Analyze, Improve, and Control),” “PRINCE2” (used widely in the U.K.), and “Outcome Mapping” (used for charitable projects) (Successful Projects). All of these methodologies take three important actions: set goals and outcomes, plan and implement tasks and deliverables toward completing these goals, and evaluate the cost and level of accomplishment of the planned objectives.

Section 2: Project Planning

As in the general corporate world, in the world of healthcare, “the stated mission should be visible or it is only rhetoric” (Mason, Leavitt and Chaffee 440). That is, the results of a project must be defined, measured, and pursued continuously in order to fulfill the underlying mission of the project and the organization. This project will be planned using a hybrid of the Waterfall and Kanban styles. The main tasks will be defining requirements, presenting the project to stakeholders, designing the software interface, creating a training program for nurses to utilize this new program and product, testing and evaluating staff and patient outcomes, and finally, rolling out the program for use amongst a subsection of the care population. Thus, the waterfall method will be effective in organizing the capital, information, and human resources needed to accomplish these many tasks and their sub-tasks. In order to plan time, the Kanban method will allow members of the project team to manage time by demonstrating how they are progressing on each task and re-evaluating to plan meetings and discussions about how to overcome any potential obstacles or conflicts.

There are many risks to the on-time completion of this product, including intrinsic and extrinsic factors (Frey and Osterloh). Internal risks include skepticism lack of employee and patient understanding of the reasons behind this new program or the software itself; this can be considered a problem of morale. This risk can be assessed by applying questionnaires that rank attitudes about a hypothetical program such as the proposed one. The most obvious risks are that of exceeding the planned budget or not implementing the program at all. These can be assessed by checking daily, weekly, and monthly expenditures and percentages of tasks accomplished during the yearlong pilot phase. Other internal risks include an inability to create an effective software solution in-house that works with our existing charting system and abides by all legal and technical standards required. This is harder to assess without conducting extensive research and holding a recruitment program within the ranks of the company. Raw numbers can be pulled which look at how many employees are certified in electronic charting, which is now required to be 100% of licensed nurses, (though many have varying, quantifiable, levels of expertise). Paraprofessionals should be familiar with the consequences of using detailed electronic charting to predict effective interventions for improving patient outcomes, even if the actual charting is outside of their scope of practice. Thus, this risk can be mitigated through internal training programs that are already in place.

External risks include not being able to acquire grants or other external funding which could balance out the heavy initial costs of this project. Other external risks include trying to compete with other psychiatric facilities which already utilize similar programs, the so-called keeping up with the jones effect, which means our company will have to pay commensurate salaries for workers skilled in the deployment of case-management software and if called for, prices for third party solutions.

In order to effectively communicate this project plan to the relevant stakeholders, a report will be prepared which gives a SWOT analysis of the proposed software and care style project based on the information contained in this proposal. In the case of this project, standing in contrast to a general business proposal, the stakeholders will necessarily include patients and their families, insurance representatives and policymakers, in addition to the usual management, supervisory, and front-line employee involvement. In the case of psychiatric nursing, customers are generally insurance companies and government benefits programs such as Medicare, while the clients are the patients themselves. The services provided by a psychiatric facility position it economically as the vendor of a health product to multiple stakeholders.

The potential benefits and drawbacks to implementing this project will be presented with different scopes and angles to the various stakeholders: patients will be informed of the ways it will improve their treatment and lead to a recovery outcome, insurance representatives will be informed of increased access to valuable data and cost savings due to smart application of interventions and the time patients spend in treatment, policymakers will be made aware of the production of valuable evidence to guide future regulations, management will be informed of the ways it will relieve staffing issues and become highly cost-effective after initial technology expenditures, nurses will be informed of the ways it makes the role of nursing interventions known and measures their effectiveness, and paraprofessionals will be informed of the ways these new tools can help them do their job of maintaining the floor and assisting with day-to-day patient care tasks easier.

Section 3: Project Management

Project Initiation Document

1. PURPOSE

The purpose of this project will be to implement a software-based client-centered recovery approach model which utilizes project management theory and practice to bring together patients, paraprofessional staff, licensed and registered nurses and the interdisciplinary team under a new paradigm of treatment in order to transform the current care process at our long-term psychiatric care facility toward a recovery based effort centered on quantifiable improvements in cost, care outcomes and staff knowledge and confidence (Woods and Kettles 132).

2. BACKGROUND

This project proposal comes as a result of a pressing need for the use of data analytics to ensure that evidence-based best practices are followed in mental health care. In order to maximize the effectiveness of this experimental pilot project, a multidisciplinary leadership team will be formed which will choose the segment of the patient population and staff who will be involved in this project.

3. PROJECT OBJECTIVES

The objective of this project is to change the way nurses, unlicensed caregivers, and their patients’ understand the goals and outcomes of psychiatric treatment. The deliverable product will be an innovative software product that allows nurses, doctors, and the patient's therapeutic alliance to view the interventions applied to a patient, desired outcomes, and progress toward those outcomes. The software can also allow patients to view some of this data, as is therapeutically beneficial, such as when administering nursing education regarding medication usage and dose over time. Thus this project will contain within it a microcosm of patient case management which echoes the goal-oriented and evaluation driven mission of the larger project. There will be a steep initial cost for implementation due to the software and hardware acquisition, technical and training aspects of this project. If the project can stay within +or-50% of its pre-planned budget, time, and staffing demands, while accomplishing its goal of a working software implementation, then it should be expected to provide increased patient outcomes, increased safety through effective documentation, decreased costs due to ineffective interventions being avoided, and other benefits such as improved knowledge and morale among patients and staff.

3.1  METHOD OF APPROACH

The defined method of approach for this project will be to assess the potential for “in-house” development of a “made-to-fit” software package by recruiting project members from our existing IT department or others who show interest or potential skills in integrating electronic charting into a holistic, information-based and patient-centered care method. Full assessments of stakeholders will be done during the planning phase (Eskerod, et al.).

This project will be based on technologies that can be easily integrated into our current IT landscape, which includes mainly Windows PCs and Tablets, and is starting to incorporate more support staff (such as doctors) who utilize Smartphones such as iPhone and Android. The best way to deploy this project's product may be a web-based solution that is served securely from a local server, to ensure security and privacy concerns such as HIPAA compliance, are followed (Luxton, et al.).

3.2  PROJECT DELIVERABLES

The main deliverable will be an occupational education program and a software product which will enable patients and their care team to review and plan care information based on codes entered for electronic charting and thus incorporating a standard terminology. The desired outcomes include increased positive patient behaviors, decreased negative behaviors, increased confidence and knowledge among patients and staff regarding individual objectives, and lower overall operating costs after an initial up-front investment in the software and curriculum. Psychiatric care provides a high level of nursing interventions (Ryan 90) and will benefit from these deliverables because interventions that are not working can be recognized more quickly and avoided.

3.4. PROJECT SCOPE

The scope of this project is to develop and introduce this pilot project amongst a roughly 25% subset of the psychiatric facility's current population. It will have dependencies ranging from quality of charting and specificity of patient's stated and actual goals. If the program and the software it uses gain acceptance among patients and caregivers because of their efficacy in empowering psychiatric patients to help guide their recovery from mental health symptoms, then its scope may expand to include more interdependency following its installation. For this specific project, it will take place over one year with daily, weekly, and monthly evaluations regarding any modification to the scope of the project in its many dimensions.

3.5. CONSTRAINTS

There are unfortunately many constraints planned into on this project. The facility is willing to spend around 10% of its budget, a relatively large amount, on research and development, which would include projects such as this one. However, software development is costly, and quite labor and time-intensive; additionally, our in-house IT staff may not have the skills necessary to complete this project in a timely and cost-effective manner. There will also be constraints placed on the number of staff available to participate in this program and the number and type of patients that will be acceptable to work with on this project. There are also technological constraints because the system will need to piggyback onto our current IT landscape.

3.6. INTERFACES

This program can directly interface with the informal network of information sharing among doctors and researchers, who could use their smartphones to access relevant medical information and use private or anonymized data from this project to share and evaluate patient's behavioral therapy interventions and outcomes. The actions of the intake department, medication department, and the unit itself will be integrated and better coordinated following the implementation of this program.

4. PROJECT ORGANISATION STRUCTURE

This project will be organized from the middle-out, with nurses leading the way due to their close relationship to patients' plans of care. They will act as the interface between management and doctors, and the IT staff and paraprofessional team members. A dynamic, egalitarian structure will be utilized, that stresses communication and change management (Schifalacqua, et al.).

5. COMMUNICATION PLAN

The communication plan will make use of the Kanban method of product management, in which staff will hold meetings in front of the large planning board which has all the tasks of project implementation laid out and categorized according to time and level of completion. Nurses will be the main communicators, acting as intermediaries for patients and upper management as well as delegators to paraprofessional workers.

6. TOLERANCES

Time and cost tolerances can be flexible, up to a point. If deadlines begin to approach a two week lag-time, then exceptions and contingencies must be looked at as potential options. If costs run over budget by more than 20% or do not hit planned estimates for more than four weeks, then those tasks will have stricter controls set and team members involved will be admonished accordingly.

8. PROJECT CONTROLS

Highlight reports and the Kanban board will both be controls utilized to control the project throughout its development and enaction. Daily, weekly, and monthly goals will be set and evaluated according to how close actual outcomes were to planned ones, thus rating the project’s success and failure on three different scopes of time.

9. EXCEPTION PROCESS

If there is a substantial deviation from accepted limits for the time, cost, or scope of this project, exception processes will engage which allow for a rapid exit from an extremely poorly performing dimension of the project. For example, if the software development is simply not meeting its deadlines according to the Kandan chart, the software aspect of this measurement program may be substantially reduced or eliminated, and a process of personalized reports of varying levels of detail depicting a patients progress toward recovery which are prepared by staff may be implemented in its place.

8. CONTINGENCY PLANS

There are many contingency plans which can be put in place to mitigate the aforementioned risks. Contingency tables can be set up to show different possible scenarios in binary form, allowing further analysis (Woods and Kettles 51-51). Consultants can be hired to provide emergency assistance with managing software rollouts and obtaining outside funding for technology-oriented health projects. If certain staff members are not working toward the shared mission goals, they can be reassigned or dismissed from the project.

Section 4: Project Outcomes

The outcomes of this project can be easily presented to the various stakeholders involved: by measuring decreased levels of negative patient behaviors, and increased self-reported measures of patient knowledge about their treatment plan because of the new software interface, then the main goal of the project has been accomplished. In order to convince administrators and managers of the fiscal importance of this project, financial data such as expected and actual ROI planned and actual budget, ongoing maintenance operating expenses, and other comparative outcome figures can be presented. My project will spend around $10,000 ($7,500 in up-front purchasing and development and $2,500 in operating costs) but should save the hospital at least $1,000 per week after being in place for six months due to an increased ability to redirect the right resources to the right patients. That is an overall savings of $2,000 in the first year, with a projected savings of around $45,000 in its second year: an ROI of 20% and 200%, respectively.

Most importantly, my project should help patients to recover faster and return to the community, opening up more rooms and allowing for increased revenue from high patient turn-over. This program should see a 25% reduction in negative patient interventions such as seclusion and restraints, as well as a 25% increase in positive patient behaviors such as attending group sessions or taking part in healthcare team personalized planning exercises. Nurses and other caregivers will be assessed during and after the implementation of this project for their ability to recall specific patient goals and interventions used to achieve them. In order to improve this project, more refinements must be made to the presentation of patient data and the transformation of this wealth of information into actionable statements regarding the direction a patient is going toward achieving their personal and institutional outcomes. Specifically, a better interface, enhanced education for staff, and more patient inclusion, as well as adding any features that could help cut costs, such as data-based guidance on lowering staffing levels when low acuity is expected from a specific patient, group of patients, or time frame (Sockolow and Bowles).

Personal Statement

The main themes from this unit which have impacted my work role are the ideas of accountability, making trade-offs and concessions in order to reach a goal, and the utmost importance of teamwork and a customer focus when developing a new program or product. My strengths in the area of project management before this unit were my ability to voice my opinion as a patient advocate and keep a project focused on important goals. My weaknesses included not knowing the different methods of planning and managing a project efficiently, and being relatively unable to delegate roles and tasks effectively without looking to someone else for guidance. After taking this unit, I feel more confident in my ability to plan, enact, and evaluate any type of project. My work going forward will emphasize delegation, communication, and a dynamic system of accomplishing short-term goals among my staff. That way, long-term positive outcomes can be achieved for my career, my fellow staff, and most importantly, our patients.

Works Cited

E-Morris, Marlene, Barbara Caldwell, Kathleen J. Mencher, Kimberly Grogan, Margaret Judge-Gorny, Zelda Patterson, Terrian Christopher, Russell C. Smith, and Teresa Mcquaide. "Nurse-Directed Care Model in a Psychiatric Hospital." Clinical Nurse Specialist 24.3 (2010): 154-160. Print.

Eskerod, Pernille, and Anna Lund Jepsen. Project stakeholder management. Farnham, Surrey, England: Gower, 2013. Print.

Frey, Bruno S., and Margit Osterloh. Successful management by motivation: balancing intrinsic and extrinsic incentives. Berlin: Springer, 2002. Print.

Kerzner, Harold. Project management a systems approach to planning, scheduling, and controlling. 11th ed. New York: John Wiley, 2013. Print.

Loo, Robert. "Project Management: A Core Competency for Professional Nurses and Nurse Managers." Journal for Nurses in Staff Development (JNSD) 19.4 (2003): 187-193. Print.

Luxton, D. D., Kayl, R. A., & Mishkind, M. C. (2012). mHealth Data Security: The Need for HIPAA-Compliant Standardization. Telemedicine and e-Health, 18(4), 284-288.

Mason, Diana J., Judith K. Leavitt, and Mary W. Chaffee. Policy & politics in nursing and health care. 6th ed. St. Louis, MO: Saunders/Elsevier, 2012. Print.

Ryan, Tony. Managing crisis and risk in mental health nursing. Cheltenham, U.K.: Stanley Thornes, 1999. Print.

Schifalacqua, Marita, Chris Costello, and Wendy Denman. "Roadmap For Planned Change, Part 1 Change Leadership And Project Management." Nurse Leader 7.2 (2009): 26-52. Print.

Successful Projects. "PM Methodologies." Successful Projects. 2013. Web. 24 Mar. 2014. <http://www.successfulprojects.com/PMTopics/IntroductiontoProjectManagement/PMMethodologies/tabid/336/Default.aspx>.

Sockolow, Paulina, and Kathryn H. Bowles. "Including Information Technology Project Management in the Nursing Informatics Curriculum." CIN: Computers, Informatics, Nursing 26.1 (2008): 14-20. Print.

Woods, Phil, and Alyson Kettles. Risk assessment and management in mental health nursing. Chichester, U.K.: Wiley-Blackwell, 2009. Print.