Financial and Business Management for the Doctor of Nursing Practice: Project Management

Prioritizing Communications: Power/Interest Grid

The power/interest grid is a method to prioritize communications and is essential to the communication plan.
High power/high interest stakeholders: Require regular engagement from the DNP project manager.
Low power/low interest stakeholders: Do not require frequent contact.

Stakeholder Analysis

The information gathered from the power/interest grid is used to develop a stakeholder analysis (Figure 13.4).
The stakeholder analysis summarizes how to involve and communicate with stakeholders throughout project implementation.

Gantt Chart

Definition: A bar chart used as a project scheduling tool during the project monitoring phase.
Breaks down the project into activities with start and finish times (Larson & Gray, 2020; Figure 13.5).
Effectiveness: Most effective when the responsible party’s name is displayed, the responsible members of the team can then report their progress with the deliverables.
Function: Provides a visual display of time and scope; other tools may be used to monitor progress.

Project Evaluation and Review Technique (PERT)

Definition: A statistical analysis tool used to analyze and represent project tasks.
Identifies the critical path, which is the longest possible continuous pathway from the initial event to the terminal event (Larson & Gray, 2020).
Impact of delays: A delay along the critical path will create an equal delay in project completion. A series of delays along the critical path will have a cumulative effect on the delay.
Helps show the project team’s progress along the critical path (Figure 13.6).
Essential elements:
- Optimistic Time (OT): Minimum time required to accomplish the task.
- Pessimistic Time (PT): Maximum possible time required if everything goes wrong.
- Most Likely Time (MT): Normal estimate of time required to accomplish a task.

Stakeholder Analysis Example

Director of Quality Improvement: Responsible for Deliverable Arch Best Practices, Draft Policy, Revise Policy.
Hospital Chief Medical Officer: Responsible for Obtain Medical Staff Feedback.
Hospital Chief Nursing Officer: Responsible for Obtain Nursing Dept. Feedback.
Teaching Facility Medical Officer: Responsible for Obtain Teaching Facility Feedback.
Chief Operating Officer: Responsible for Hospital Admin. Approval, Announce in Full Staff Meeting, Implement Policy.

PERT Projections

Help the DNP project manager model potential project completion scenarios.
Provide the ability to determine the float or slack, which is the amount of time a project task can be delayed without impeding subsequent tasks.

Risk Breakdown Structure (RBS)

Larson and Gray (2020) recommend developing an RBS based on the WBS and risk profile.
Function: Identifies general risks (e.g., personnel shortages) and explains why/when they may occur to develop contingency plans.

Risk Profile

Includes structured questions designed to identify risks, actions to mitigate risks, and means of averting subsequent costs.
Risk Evaluation Questions:
- Are customer and developer expectations aligned?
- Is staff assigned only to this project, or are their responsibilities divided?
- Are financial resources allocated specifically to this project or contingent on other variables outside the project manager’s control?

Risk Severity Matrix Diagram

Used by the DNP project manager to display the impact and likelihood of risks related to the project.

Preparation for Changes: Contingency Plan

Project managers must prepare for unusual conditions that require adjustments via a contingency plan.
Example: A request to reduce project duration and bring it ahead of schedule.
- Scenario: A new oncology drug protocol is scheduled to take 6 months, but physicians approve it 2 months early and want immediate implementation.
The DNP project manager would consider the need to compress the project schedule and its clinical and financial implications including the cost of staff overtime.

Project's Crash Time

The greatest time reduction possible under realistic conditions (Larson & Gray, 2020).
DNP project managers prepare for contingencies, such as projecting crash times, by preparing documentation in advance to demonstrate the implications of the change.

Team Dynamics

Projects require collaboration among diverse individuals to bring a project to completion.
The group process fosters optimal decision-making due to the members' diverse experiences and backgrounds.

Synergistic Effect

The group produces more knowledge than each member working alone (Lasker & Weiss, 2003).
Group processes also increase the likelihood that the project will gain acceptance throughout the organization.
Increased general awareness of the project’s value and importance when more people are involved.
Managing projects in a complex adaptive healthcare setting requires DNP project managers to have a good understanding of how teams develop and function.

Functional vs. Dysfunctional Conflict

Functional Conflict: Supports the group’s goals and is a productive part of the group process (Park et al. 2020).
Dysfunctional Conflict: Hinders group performance and requires intervention to get the group back on course.
The DNP project manager may need to establish ground rules for the team and state that personal attacks are not allowed.

Five-Stage Model of Group Development (Tuckman & Jensen, 2010)

Forming: Group members are unclear or disagree on the purpose of the project.
- DNP Role: Offer guidance and support and clarify project goals.
Storming: Members struggle for power and experience conflict.
- DNP Role: Coach members through the conflict to keep the group moving toward goals.
Norming: Members experience role clarity.
- DNP Role: Reinforce roles during this part of the group process.
Performing: Group members focus on performing tasks associated with the goals.
- DNP Role: Monitor group member performance.

Adjourning

Group members are satisfied with completing their tasks and meeting the goal.
DNP Role: Recognize accomplishments and acknowledge member contributions.

Group Work Considerations

Group work takes more time, and not all decisions and tasks benefit from group discussion.
The DNP project manager monitors group interactions and tasks and, when appropriate, asks group members to work on their own or in subgroups and report their findings to the full project team to expedite project completion.
Work needs to be distributed based on what's best for the group

Groupthink

Definition: Members of a group strive to agree with each other even though, in their private analysis of the problem, they do not agree (Janis, 1972).
Impact: Limits the adequacy of the decision made by the group and puts the project in jeopardy; members fail to solve problems or select the best alternatives because all just agreed without question.
Contributing Factors: A strong sense of group cohesiveness in the presence of high stress or recent failures, which makes group members afraid to make incorrect decisions.

Addressing Groupthink

Devil’s Advocate: Appoint someone to criticize and test group recommendations (Holley, 2019).
Leader Absence: If a leader’s power-based presence is the source of the group’s unwillingness to make decisions, discuss the situation with the leader and suggest that the leader not attend critical decision-making meetings.
- Nominal Group Techniques: Ask members to anonymously document their opinions (Mullen et al., 2021). The ideas are then listed on the whiteboard for the group’s discussion, free of influence due to judgments about the comments’ source.

Organizational Culture

Schein (2017) described culture as patterns of shared assumptions that inform actions and beliefs of members of a group.
Culture may arise from organizational values, beliefs, and assumptions or across the organization, as in occupational communities.
Occupational Communities: Have shared assumptions that come from outside the organization, based on common educational backgrounds, professional requirements, and interactions with colleagues from the same field.

Operator vs. Executive Culture

Operator Culture: Composed of people who perform work, such as clinical work (nurses and physicians).
Executive Culture: Constitutes people who focus on efficiency and productivity.
When management and operator goals are aligned around a shared goal, projects, and innovations progress in support of organizational goals (Schein, 2017).

Managing Conflict

When environmental conditions change (e.g., budget crisis or staffing shortage), occupational communities experience conflict and impaired coordination that inhibits the progression on project goals.
DNP Role: Monitor conflict within the group and determine when intervention is needed to realign members around a shared goal.
Realignment can be accomplished by reinforcing the team member’s shared goals, communicating how these goals relate to the project, and emphasizing how they will benefit from the team’s collaboration and coordination.

Appreciative Inquiry

A method to realign member goals to the project goals (Harris et al., 2018).
Four Phases: discovery, dreaming, designing, and delivering the project.
Confirms team member collaboration and alignment on the goal by beginning with a focus on the project’s mutual goals and potential benefits.
DNP Role: use is to align staff to core values and motivate team members to stretch to higher performance levels.

Sociocultural Dimension of Project Management

Reflects the dynamic nature of collaborating on projects.
The DNP project manager may use negotiating skills that promote the win-win approach.
Successful negotiating rules encompass the technique of principled negotiation.
Focus: shared interests and separate the people from the problem.
The DNP project manager is prepared to invent mutual-gain options and use the best alternative to negotiated agreement (BATNA) technique when dealing with individuals hesitant to compromise.

The Change Process (Lewin, 1948)

Unfreezing: An essential precipitating factor for a change in established practice or status quo.
- Requires a significant amount of disconfirming information delivered in an informed manner when working primarily with evidence-based practitioners.

DNP Role in Planning Phase

Thoroughly evaluate evidence, both positive and negative.
Discuss the evidence in a forthright, informed, and deliberate manner to establish trust, authority, and credibility with other team members.

Psychological Safety

Occurs when individuals believe that change can be made without harming their values or integrity (Schein, 2017).
Individuals are more likely to participate in change if they feel that they will not experience failure.
DNP Role: Guide, mentor, and support others through the change process.

Refreezing

Occurs when individuals involved in the change process have thoroughly incorporated new attitudes or behaviors into practice.

Force Field Analysis and SWOT Analysis

Tools used to evaluate conflicting factors involved in the change process (Harris et al., 2018).
Force Field Analysis: Weighing pros and cons to see which has more influence.
SWOT Analysis: Focuses on the internal strengths and weaknesses and the external opportunities and threats.
Both methods can provide the DNP project manager with insight into ways to reduce the opposing forces’ impact and strengthen supporting forces.

Rogers's Decision Innovation Process (2003)

Describes how individuals' networks go through phases before adopting a practice change.
Five Stages: knowledge, persuasion, decision, implementation, and confirmation.
The DNP project manager promotes the project’s adoption by spreading knowledge on the project’s needs, goals, strengths, and limitations.
Persuasion helps others on the project team accept the project plan and agree to complete their assigned deliverables at the specified time.

Acting as A Change Agent

To drive behavior, attitudes, and, ultimately, practices (Rogers, 2003).
Change Agents’ Functions:
- Developing the need for change in others
- Establishing a relationship to exchange information
- Assessing problems with the exchange of information
- Creating the intent to change in others
- Establishing similarity
- Building credibility
- Working with the influential
- Evaluating the change in practice

Communication and Change

Organizations expedite the adoption of new projects by assigning skilled change agents, such as DNP project managers, to lead the change process on new initiatives (Harris et al., 2018).
Rogers (2003) formulated a model to show how change agents use effective communication skills during the change process.
Because they mediate others’ understanding of the change throughout the project, change agents play an important role in the diffusion of a change throughout an organization.
Individuals who do not engage in negotiating understanding through communication and debate will not promote innovation (Forrestal, 2016).

The Concluding Phase

The DNP project manager brings the team together to reflect on the project, performs an evaluation, and produces documentation to inform future projects (Larson & Gray, 2020).
This determines whether the project delivered met the project’s goal expectations.
Considers the efficacy of the management of the project.
Reviews deliverables and time frames to provide more information on how smoothly the management process went.
Interviews or surveys can help the DNP project manager obtain feedback from stakeholders and customers to reflect on the process and determine what worked well and what could have been done better.

Executive Summary

The DNP project manager develops an executive summary listing the project’s history, activities, and learning opportunities (Larson & Gray, 2020).
Effective executive summaries: Succinct, clear, and forthright in discussing the project’s strengths and weaknesses.
Includes the project goals, how the goals were met, and quality and satisfaction with deliverables.
A summary of the procedures and systems used, recommendations, and lessons learned is also included.
Appendices are attached for those who want to review supportive information more thoroughly.
The documentation provides a historical record of the project for use by others who lead future projects.

Agile Project Management

Chris Argyris's (1993) conceptualization of double-loop learning, in which organizations shift paradigms by questioning the norm associated with linear thinking.
In contrast to the traditional model, agile project management does not progress in a linear direction (Larson & Gray, 2020).
There are times when there is a need for a design with incremental phases in which the end product evolves through multiple iterations.
Ideal for phased testing: This is most beneficial in the microsystem level.

Traditional Project Management Characteristics

Premised on developing a perfect prototype during the analysis and design phase.
The project has a finite scope, with little or no change after the design phase.
Minimizes stakeholder feedback during the project life cycle.
Relies on fixed deliverables and milestones during the project, with evaluations performed postimplementation.
The project is designed once and completed.

Agile Project Management Characteristics

Consists of multiple iterations that are designed and implemented as new information about the project evolves.
Based on flexibility, response to stakeholders’ feedback, and concurrent development during the project’s iteration phases.
Short design phase with a broad scope.
Works with teams of rotating stakeholders who are often the end-users.

Scrum Concept

Hirotaka Takeuchi and Ikujiro Nonaka coined the term scrum in 1986 when describing commercial product development, using a rugby team’s analogy of holding onto the ball while constantly changing its placement among team members (Larson & Gray, 2020).
Example: A hospital setting with a cross-functional team representing each hospital department meets to brainstorm the development of a portable cart that can quickly be converted into an isolation bed anywhere in the hospital. After the prototype is created, each week a new iteration of the product is developed and moved to a new department for its use.
The finished agile project is generally completed for less cost than traditional projects and is more likely to be successful in meeting the project specifications.

Project Implementation Sustainability

Projects require ongoing care and maintenance even after they are implemented, so any sense of complacency is a threat to the project’s ongoing sustainability.
DNP project managers include a sustainability plan in the initial project plan to control this threat.

Sustainability Framework (Lennox et al., 2020)

Sustainability is a project’s ongoing viability once the development is done.
Essentially the process of locking the project into routine operations.
Three Aspects: project design, factors within the organization, and factors outside the organization.

Project Design Sustainability

DNPs promote project sustainability by involving stakeholders to secure their commitment to the project’s value and success, ultimately laying the foundation for lasting support for the project.
Ensuring that project designs allow for modification makes those projects more likely to have lasting viability than those that cannot be adjusted for changing needs and conditions.
Developing a monitoring plan to demonstrate the project’s continued value.

Organizational Factors Regarding Sustainability

DNPs also assess factors within the organizational setting to determine the potential sustainability of the project.
DNPs verify that the project is aligned with the organization’s goals and changes operating procedures to ensure that projects have ongoing relevance.

External Factors

Analyzing external factors likely to affect the project’s viability, including:
- favorability of external economic factors
- the effect of market forces
- the constraints of legislation
- reimbursement availability that might influence the project.
- Thoughtful modifications may be necessary to make the project more effective, and the modifications should not impair the project’s core components. It is essential to (a) identify and support a program champion and (b) to take a leadership role in both initial program development and planning for sustainability.

Spread

The IHI defines spread as the dissemination of a successful project, practice, or knowledge to a different care setting (IHI, 2021b).
When the organization has made great strides in testing and implementing the project, it is time to consider replicating the gains from the initial work and initiating a spread plan.
The DNP selects projects that are strongly related to the organization’s mission and culture and are supported by upper management.

Three-Part Plan for Spread (IHI)

laying the foundation for spread
developing an initial plan for spread
refining the plan.

Laying the Foundation for Spread

The spread plan will be most successful with the support of leadership in the form of an executive sponsor accountable to the CEO and board of directors.
Appointment of a spread leader within the project team can be useful to manage the spread process.
Discussing the results will attract attention to the value of the interventions and their positive impact on patient care outcomes.

Developing the Initial Plan for Spread

The team works with senior leadership to put together the spread plan and monitor the goal’s progress.
The first step in developing the spread plan is formulating an aim statement.
It is essential that the plan account for differences in the new unit that might impact how the intervention is implemented.
Some attention should be given to how the project design should be adjusted for the new setting.

Communication Plan and Spread

The communication channels used in the initial project are a starting point to increase awareness about the project.
Hospital-wide meetings, newsletters, media coverage, and special events can build interest and motivation.
During the plan’s development, establishing a measurement system to track the adoption of the project over time is critical to success.

Refining the Plan

Adjustments in the spread plan may be necessary to accelerate the adoption of the project.
By monitoring reports, the spread team can identify the need for adjustments.

Project Management Integration

Project management is no longer delegated to one or two departments in an organization; rather, it is now integrated into every important aspect of organizational operations.
Complex adaptive systems often require agile project management managed through feedback and multiple design iterations toward the desired outcome.

DNP Competencies

The DNP project manager is prepared with the “essential” core competencies as defined by the AACN (2021): a practitioner, skilled in leadership, financial and organizational analyses, collaboration, communication, critical and creative thinking, team building, evidence-based research, negotiating, and informatics skills.