Tre NZ 4
Tre NZ 4
Tre NZ 4
Brown K, Clarke D, Percy F & Kent K : Facilities Modernisation Project South Auckland Health. IPENZ treNz 2002-4
3) An experienced competent project sponsor (business 5.3. Five essential “soft skills”:
manager(s) who work well with the PD/PM/leader). On
a large project it is also necessary to arrange supporting 1) An ability to control and minimise the negative
project owners from within the business organisation. impact of unconstructive team members. It is important
to create a positive atmosphere and to recognise, listen A sense of calm, focussed urgency is critical and
to and reward (or acknowledge) in some way those who repeated messages are needed to reinforce changes in
challenge or criticise in a constructive way. culture and process. The management of change is
critical for the entire organisation throughout and
2) Intelligent and pragmatic risk identification and beyond the project phase and into the future. As a
mitigation processes. The project needs pragmatic starting point, a generic process or structure for
systems and the application of a sensible risk mitigation managing the acceptance and implementation of new
process, blending experience, intuition and common service procedures must be agreed and established. The
sense, and including operational and business risks, and acceptance of change, which requires communication to
in particular change management issues. It is useful to bring about understanding of the organisation’s vision
have the risk system critiqued externally on a regular and direction, is however the key.
basis to check its effectiveness.
The actual “line diagram” process and disciplines used
3) Leadership (of the overall programme and each of the to manage the change process is important, though
sub-projects) that takes account of project-specific secondary.
systems and the people and groups involved. In other
words, “horses for courses”. Projects do not just happen The development and agreement of processes between
– they must be made to succeed through leadership the operations and project teams is a good way to gain
under each set of circumstances! Leaders need to mutual understanding of change requirements, and thus
approach every element of the project with a passionate buy-in; and it can form a “contract” determining how
and healthy urgency, bringing people along through people will work through issues.
involvement and input. They should look to find where
leadership and passion are missing, and coach and Once these processes or basic team rules and behaviours
encourage those struggling with the change process. have been set up to manage organisational and project
change we can then move on to develop and consolidate
4) A project culture should be developed to reflect and the details of the new business operations and master
complement the business culture of the organisation plans.
undergoing change. Business managers require regular
engagement on project issues – especially the 5.5. Communicating the plan to external
nominated project sponsors, to ensure they are organisations
managing organisational change and keeping up. Treat
the project as a change management opportunity. Once all the decisions on existing and new clinical
services have been made the multitude of service
5) Make it a growing and rewarding experience for all deliveries must be communicated to the designers.
involved. Sell the big picture and real social benefits to Managers, clinicians and nursing staff need to do robust
motivate them. Keep the patient and clinical work prior to the involvement of the external project
performance in focus. Emphasise the purpose of the delivery team. The PD must make sure this happens,
development – to provide a facility, processes and possibly using experienced outside consultants.
technology to enhance the already respected
performance of clinical staff, and to provide a better It is advisable as part of this phase to document an
health service for the people of a region or community. approved-by-management project-team brief, based on
agreed internal business plans for sub-projects, and
5.4. Change Management reconciled with the overall business direction. The
briefs are subsequently developed into an overall
For many of the clinical services new processes, diagrammatic master plan. This master plan, combined
procedures and policies will be developed for with a milestone timeline for the programme, is a very
implementation in the new facilities. The Project powerful tool for selling the vision to everyone
Director, by maintaining communication with the CEO, involved. It helps encourage and consolidate change
can ensure that General Managers and clinical leaders organisation wide, and discourages “silo” thinking.
take responsibility for developing and implementing
change management plans in their departments. A Communication, feedback and confirmation of shared
philosophy of organisational “cross pollination” of ideas knowledge ensure that the whole team becomes greater
and benefits is needed, as opposed to “silo” thinking. than the sum of its parts.
Real skill is required in change – it is an art; so make
sure experienced people manage it for or with you. The Once this high-level understanding is reached, it must
most effective approach is often learnt only through be converted into a project scope with an associated
experience. For example, letting people describe the budget. Remember that a lot of work will already have
current organisational position to you, rather than been done on broad-brush scoping and budgeting during
assuming or telling them where it sits, can help open the preparation of the business case; consolidation and
people up to change and provide a factual starting point. refining is now required. This will require input from
external experts and consultants. All work streams must perfection in design and working within time
progress in parallel, and must be continuously constraints.
reconciled so that new processes and designs are fully
co-ordinated. Without losing sight of detail, don’t sweat the small
stuff.
At this point the project team would generally include
the Project Director acting for the client (including
clinicians and hospital staff), the master planner, the 6. USEFUL TIPS ON PROJECT
architect, the functional space adviser (who may be the
architect as long as they are experienced in this area), PHASES & IN-HOUSE
the services concept engineer and the client financial PROCESSES
adviser, who may be an independent QS.
6.1. Developing clinical streams, models
Before moving on to the detail or developed design
stage (of any project) the full gamut of needs must be of care and operating philosophies
reconciled with budgets robustly, taking into account all
costs. I suggest strongly that experienced people should It is essential that a strategic plan be developed prior to
be involved here. The project succeeds or fails the detailed planning of a project. The strategic plan
depending on how well this is done. This is where an serves as the high-level reasoning or foundation stone
effective Project Director must engage with for a project. Each projects should implement the
management (and clinical staff) on the client's behalf to relevant part of the strategic plan, and should be a
help them see the real picture, and to facilitate rational outcome of the strategic planning process. The
communication through to the project team. justification for adopting particular project alternatives
should include the following:
Above all, make no assumptions about costs; and ensure
that the following costs, which should be obvious but • service area population
are often forgotten, are covered: internal resources (for • demographic characteristics
internal Project Management, site facilities and • health status characteristics
equipment purchased internally for the project); IT, • analysis of current hospital services
including management and implementation; testing of • financial & resource constraints
systems; equipment procurement; internal procurement;
infrastructure upgrades; security; road and parking re- Once service delivery requirements and capacity are
alignments; staff training prior to moving into new confirmed, the model of care for each service needs to
facilities; commissioning and set-up; and of course re- be confirmed rigorously prior to concept design, and
current operational costs, including building life-cycle reconciled with the operating philosophy of the service.
costs. For example, the SAH philosophy is to separate adult
and paediatric A&E care; this done, a central nurse
Cost control of every one of these items must be set up, station or a race-track model of care may be adopted,
consolidated and reconciled. This cannot be emphasised depending on staffing, technology and clinical issues.
enough! It is advisable to set up an organisation-
standard template for business cases at the outset, to Critical operating philosophies and models of care must
include or at least account for all facets of cost, taking a be led and communicated internally to be effective long-
“triple bottom line” or “balanced scorecard” approach. term. The process can be externally facilitated, though
to be successful the outcomes must be internally driven.
Unforeseen costs arise, especially in a fast-track or
volatile environment, and often changes are beyond a All the information, when collated, must be moulded
single organisation's control. The secret to containing into a master-plan. This document serves as a great
change and minimising the resultant risk is to have an communication tool, but more importantly establishes
effective system for considering flexibility and cost- disciplined milestones for progress.
benefit options strategically on the basis of excellent
information, through clearly established decision 6.2. Master Plan
mandates.
The Master Site Plan should represent the most current
Keep the system simple; and above all get the right thinking regarding the ultimate development of the
information to the people with a mandate to sign-off on Hospital site, in line with the clinical strategic direction.
change. This instills accountability early on. Don't be This Plan includes the current land use (buildings,
afraid of change and consequent re-prioritisation – just roads, and access), and projected use. Future plans
be prepared to manage it and mitigate the risk! By all should include proposed building developments,
means spend time if you have it on crossing the t’s and expansions and demolitions, parking, land acquisition.
dotting the i’s, but there is generally a trade-off between The Master Site Plan should also indicate such physical
constraints as flood plains and retention ponds, and the consequences clear in your mind and anticipate this
availability of utilities. The Plan should: discussion). Help the board with contingency ideas and
1. Provide a road map for the future development of the give them realistic latest dates for decisions. Avoid
site to ensure that any particular development plan will rushing to a wrong answer!
not be precluded by the limitations of the campus.
By supporting the information chain at every level,
2. Identify the site, zoning, building, and land use accurately and in a timely way, you have done your part
constraints and other legal restrictions that could limit or in promoting good decision-making.
affect proposed development, so that site or programme
alternatives can be evaluated. 6.6. Project Set-Up
Allowing for the change-management constraints An internal business Project Execution Plan can be
discussed earlier, only once the master plan (or key drafted at this stage of the project. It should be kept very
parts thereof) is signed off should the team move into short. Only critical and realistic systems and lines of
concept and developed design and procurement for the communication need to be included. If kept succinct, it
physical execution of the project. actually forces critical thinking and draws out effective
processes worth embedding into the project. It is a good
6.3. Pilot new processes strategy to get the team members to draft this document
themselves, with external help if required.
Once a particular process or model of care is developed
it is wise to pilot the scheme, if possible, before roll-out The required systems and processes will fall into place
in a new facility. Electronic discharge summaries from if the project culture is right. As external third parties
an A&E department is a good example. Pilot trials iron become involved they can be integrated into a project
out teething problems and facilitate staff buy-in. execution plan. Projects tend to collapse when basic
systems, disciplines, leadership and or experience is
6.4. Feasibility and recommendations overlooked at critical stages of a programme’s life-
cycle.
Once analysis and consultation is complete, the business
case should be submitted for approval by the board (or A key concept is unity of command and
board representatives) for each recommended sub- communication. This knits all the processes and systems
project option within the agreed master plan. This together, and survives the hard times when the systems
should be co-ordinated by the Project Director, who are under pressure. It should be the responsibility of one
must ensure that the management and the board are person with an able assistant or “vice president”
involved and informed throughout the process. If this is
done well, approval becomes a formality. Put simply, this requires single points of accountability
and a single line or “clearing house” for ALL
6.5. Board approvals information.
The approval of many projects is delayed because There should be one person who makes decisions at
insufficient or wrong information is passed to the each specific level of command. The types of decision
decision-makers. The solution is simple – ask them allowable, delegated authorities and communication
what they need to enable them to make any particular channels once decisions are made must be clear.
decision. Take the attitude that their ability to make a
decision is directly proportional to your good work. On This “frees up” the project team to lift the level of their
the financial front, painting a pessimistic or optimistic performance.
picture too early helps nobody and creates re-work and
frustration later. An accurate account of the realities is 6.7. Project-related decision mechanisms
what people need, and some detailed research will be and mandates
required to ensure that this is delivered in a robust form
early the process. The CEO and Board will be the ultimate decision-
makers on policy and final project expenditure, within
Remember that managing the process of referring the integrated master plan and budget.
decisions progressively up the management chain is the
key here. You must be flexible, courteous and Recommendations will come to them from the project
intelligent in your approach; and above all, do your steering group, having already been approved by project
homework before presenting anything for approval. sponsors and their governance teams. This
decentralisation of project decisions is good for change
If you have done all that is possible and a decision is management.
still not reachable, point out to the board the
consequences clearly and calmly (you must have these
The quality of information is critical, and decision- So research and find a top-quality master-planning and
making teams at every level should be asked for their concept architect, who listens and has good ideas. The
requirements in detail well before a recommendation is more work done at this stage of the process the better,to
to be made. ensure a steady, robust and inclusive process.
A “warm-up” paper in advance of an approval is well The ultimate project and long-term operational risk
worthwhile. profile of the organisation will be determined during
this phase.
The report work of the Project Management team needs
robustness and accurate. It is a good idea to develop a 6.10. Engineering systems analysis at
comprehensive checklist to make sure that all aspects of concept design
a sub-project are covered. Most cost over-runs come
from omissions of scope or associated works (as a result Make sure the on-site engineering systems such as
of misunderstanding rather than deliberate) and fewer stand-by power are considered very early in the design
from grossly wrong initial estimates. The message is to process. Involve the maintenance and facilities team in
be thorough and comprehensive in costings. analysing the life-cycle options and ongoing
maintenance requirements of new facilities. An
Finally, allow plenty of time for decisions; don't put inevitable conflict will arise here: the tendency of the
undue pressure on the Board because you have not facilities engineering department will be to standardise
planned ahead. everything to facilitate ongoing replacements, while the
design team will want to upgrade everything, exercising
6.8. Project Control Groups/Processes flair and ingenuity. So this relationship must be
(PCG) developed early in the project. Be prepared to manage
this natural mis-match of cultures between engineering
The PCG is extremely important in the day-to-day, departments and project teams.
week-to-week execution of a project. It deals mainly
with project and contractual issues. It would typically 6.11. Developed design and construction
include the Project Director, the architect and
consultants, the contractor, internal project resources Once concept design is complete the developed design
and the financial QS. Regular monthly meetings are process may begin. This phase is often overlapped with
normal, but information should flow freely within this concept design to accelerate the programme as stages of
group both formally and informally, and continuously. work are confirmed step by step. This is fine if it is
managed well and the risks of change are mitigated.
Good formal communication systems are needed.
Variation control and signoff is an example of a critical Continual contact with user groups is important during
control system, and probably the most important. Link developed design, but they should not be able to hijack
the systems to business decision mechanisms so they the process once key decisions have been made. They
can be effective at governance level to close the loop in need to be fully aware of the agreed concept and
terms of organisational accountability. Keep them associated budget. If the concept is at risk of change,
simple and easy to use and have a top-quality filing and higher management must become involved
retrieval system. immediately.
7.1. Transitioning facilities in today’s On the SAH project, two additional meetings, similar
health sector but larger, were scheduled six weeks in advance, as a
general communication forum for the wider
Is it possible in today's environment to have a clinical organisation.
facility occupied and operational within 48 hours of its
being handed over by developers? The answer is yes, as Transition Budget
long as the transition documentation, communication
network and clinical/project team involvement is Additional costs that sat outside the operational and
inclusive and co-ordinated so that it is accepted by those project budgets included additional staff required to set
at the “shop floor” level. up the clinical areas, and relief staff to cover user
familiarisation tours and preparation of documentation
The transition phase consists of a pre-commissioning prior to “going live”. When “going live” additional staff
period, (recommendation three months), along with were required to ensure patients’ safety, while staff got
commissioning (recommendation two weeks) and post- used to working in a new environment, with new
commissioning (recommendation three months) periods. technology, processes etc. Catering, signage, cleaning,
It is important to recognise that the transition period waste management & security requests justified a
requires additional resourcing and that these costs need separate transition budget.
to be identified and agreed to many months in advance.
Procurement Meetings
The core transition team is recommended to consist of
“occupiers” of the facility, representing managerial, These vital meetings were held weekly to develop
clinical and clerical staff, to ensure that the transition processes for ensuring that equipment, furniture or
period is progressed by like-minded individuals. The fittings were bought and/or installed (by vendor, client
expectation is that the “occupiers” know the business or supplier) efficiently and quickly.
best and that each core member will take responsibility
for setting-up, familiarisation with, and management of Transition period support documentation
their designated areas during the transition period.
Working along with this core group will be individuals • Equipment relocation lists, giving old and new
or “users” of the facility, representing materials locations
management, pharmacy, sterile supplies, security, linen, • Asset register of existing equipment
communications and hotel services etc. This group is • Notification/communication checklists – who
supplemented again by an Information Systems support to inform of what, when
team, which is charged with installing the computers • Device relocation lists – old and new locations
and phones to user specifications. and networking requirements for computers
and telecoms devices
7.2. Operational Perspective • Equipment plans, showing new equipment, and
its cost and location within facility
Gantt Chart • Floor plans indicating areas for clinical clean,
sealing etc,
The Gantt chart assists in the programming of tasks by • Imprest lists for stocking
helping identify the critical milestones of the project, • Buy-in lists
• Variation lists, stipulating owner, supplier or
vendor An organisational discussion is needed to decide the
• Equipment/furniture/fittings supply and length of the transition period, because there are some
installation lists, clarifying parties’ opportunity costs associated with both longer and
responsibilities shorter transitions.
• Phone lists indicating individuals involved in
the relocation Some design issues were overlooked when documents
• Clinical memos detailing timeframes, were signed off, because users lacked understanding of
deliverables, responsibilities, contacts etc. the process implications.
during the transition period. For example,
materials management was required to stock
shelves to previously determined imprest Another issue is compliance. Decisions made to meet
levels. fire regulations etc. directly impacted on the operational
• Communication group exchange memo, flow of the facility, resulting again in rework in
informing the organisation of changes response to requests from users. Compliance regulations
need to be in the forefront of the users’ mind as they
Note: The usefulness of the lists varied, depending on consider traffic flows and security measures etc.
who used them, for what purpose and how much rework
was required to make them useable. This is an area Site visits need to be controlled and used to of
where efficiencies can be made across multiple projects. encourage and inspire users of the facility only. Banning
Knowing how to complete the lists and when the site visits in the final months of construction proved
information needs conveying and to whom is vital. detrimental to the transition process, as it prevented
staff from imagining what it might be like to work in the
User familiarisation area.
User familiarisation manuals were produced as a central Information resources should be made widely available
point of access to information regarding the new to help project managers in their work. They should
processes etc. required operating in the new include:
environment. A welcome letter introducing the facility
was also prepared, which could later be modified as an • Templates of operational plans, transition
orientation letter for new staff. plans, transition budgets, Gantt charts, issues
lists, equipment plans with virtual rooms and
Familiarisation of users with the facility included costs associated with the items in the room
rostering all staff into a fire evacuation training session, • Contact numbers of employees with project /
followed by a walk-through of the facility showing how change management expertise & experience
the new technology, equipment and processes worked in • Descriptions of the roles associated with the
the clinical environment. To add a personal touch, various titles held under project structure
members of the transition team should be available on • Definitions of terms such as scope of a project,
site for 48 hours to personally orientate staff members risk, signoff etc
and for trouble-shooting. • Textbooks for consultation by clinical staff
involved in decision-making.
Commissioning Period
Staff debriefs should be the norm and not the exception.
An issues list should be started on day one of opening,
detailing the issue, who has raised it, who has been For the benefit of users, clinical, hotel and materials
asked to resolve it, and the date of resolution. management, security etc. should be consulted to
establish a priority listing of products or finishes that
Transitioning recommendations operationally impact on quality, flexibility and cost over
time. This process should assist with budget allocations
The project group needs to make decisions that at the beginning of a project.
complement the operational aspect of the business. The
two groups cannot work in isolation. Therefore the
project manager should ideally have good operational 8. CASE STUDIES USING
management skills.
POST-OCCUPATION
To speed the decision-making process, the clinical REPORTS
sponsor/owner needs a high level of confidence in the
project manager. To engender this confidence good Lessons Learnt and Some Project Results
communication is needed during all project phases. A
philosophy of “no surprises” should be adopted.
The SAH Facilities Modernisation Project has been the implications of prevent this recurring.
dramatically successful. As each sub-project was two sites on staff
finished a Post Occupation Review was completed numbers
approximately six weeks after the transition. Lessons
Inadequate change Detailed change management
were learnt from earlier projects and incorporated into
management became a key component of all
all subsequent developments. allowed the basic projects.
project philosophies
The table below provides real examples of post-project to be diluted.
analysis. It lists some of the valuable lessons learnt
during the SuperClinicsTM and Kidz First projects. The project itself The methodology for
was under- calculating project resources
8.1. SuperClinicsTM resourced. was revised.
• The primary difference between the more Various procurement options must be considered.
traditional approaches and more recent forms Choosing between them involves thinking about your
of contract is the “fast-track” approach. This is risk, time requirements, where expertise lies, and how
where incomplete plans and specifications confident you are around the concept master plan.
(basic documents, schematics, preliminary Remember that whichever system is finally adopted it
structural drawings, etc.) are utilised in could fail if not managed well. Success depends entirely
contracting with the general contractor. The on the people involved, their leadership, experience,
advantage of this approach is that the time organisation and commitment. So spend more effort on
from the inception of the project to its the “type of people” factor than on the method of
completion can be reduced, since the design procurement, which is often decided well before people
and construction phases are overlapped. The are nominated.
incomplete construction package is usually
submitted to several contractors for preliminary The message is that once you have decided on a
estimates or proposals. The risks inherent in method, get on with it ! Certainly make contractual
fast track construction are as follows: modifications or negotiate to strengthen your position,
but focus more on the people. Don't think that because
• Because engineering is not co-ordinated at the time you have a great contract or methodology, success is
that the contract for the early phases of the work is guaranteed. It helps, but only if you get the chemistry
awarded, change orders during construction may be and project culture working ! I would argue that any
required. form of procurement can deliver outstanding results if a
great team is managed well.
• The potential for litigation is increased if the
completed plans and specifications represent a
change in scope from the preliminary drawings 10. SUMMARY:
(and, therefore, an increase in cost), or represent
completion and refinement of the preliminary The essence of our learning during this programme has
drawings (and, therefore, no increase in cost). been the discovery and use of effective links between
Hence, fast-track construction requires a certain business change and physical projects.
Business change unfolds continuously in the context of the wider picture of business change alongside capital
and trends of a particular industry and its wider projects will succeed, and provide real value to clients.
economy. Whilst processes and people within an
organisation must change to move with or influence
these change forces, they must be given time and
“room” to do so.
11. REFERENCES:
Capital projects of a large scale and intensity should be McKee & Healey, (2001)
consciously treated as an opportunity to develop and Changing role of the hospital in Europe –Causes and
embed new, better ways of doing things in the context Consequences. Journal of Clinical Medicine 1 No. 4
business and industry change. (July/August 2001): 301
Organisations that can bring to projects a mind-set, Braithwaite Vining & Lazarus (1994)
skills and systems reflecting an integrated understanding The Boundaryless Hospital. Aust NZJMED 1994: 565