Unpacking the Gains in HCA Healthcare’s HIT Governance Evolution

July 3, 2018
At the Health IT Summit in Nashville, Karen Thompson and Dr. Edmund Jackson of HCA Healthcare shared with attendees the learnings that have been gleaned so far in their organization’s progressive health IT project governance and prioritization model

On Friday, June 29, during the Health IT Summit in Nashville, sponsored by Healthcare Informatics, two executives from the Nashville-based HCA Healthcare shared their learnings and perspectives around their organization’s streamlined project governance model.

Speaking at the Sheraton Hotel Nashville Downtown, Karen Thompson, associate vice president, strategy and innovation, and Dr. Edmund Jackson, vice president and chief data scientist, both based in the organization’s Nashville headquarters, told Summit attendees about the complex but successful path forward through healthcare IT project prioritization that they and their colleagues at HCA are pursuing these days, as the demands on everyone’s time and resources accelerate in the current healthcare operating environment, in a dual presentation entitled “Govern Not Squash: The Road to Building a Flexible Clinical IT Governance Model.”

To begin with, Thompson and Jackson referenced the fact that HCA Healthcare is a huge organization, one that encompasses 179 hospitals, 1,800 total sites of care, 240,000 employees, 37,000 active physicians, 80,000 nurses, and 27.1 million patient encounters every year, across 20 states.

That alone has made for a complex, challenging journey. “Many people, when they think of governance, think, ‘hall monitor,’” Thompson said. “But that’s not what this is about. In this space, we’re always talking about innovation; we want to go faster. Governance is not something that helps you do that.” But what it does do, she said, is to help everyone in the organization get on the same page. What’s more, she said, “No, we don’t have it all worked out; it’s an ongoing journey.”

Meanwhile, Jackson said, “The data science” that supports innovation in patient care organizations “moves quickly, fails frequently, and is expected to fail. So the challenge Karen and I took on was, how do we get an agile space built into the business structure?”

As a result, Thompson, Jackson, and their colleagues came up with a three-phase conceptual solution. From 2008-2011, the focus was on standardizing and scaling the project prioritization and authorization process. From 2011-2012, the focus was on “exploring and innovating.” And, since early 2017, the focus has been on accelerating and on measuring innovation and progress.

“I’ve been at HCA a little over 12 years, the formal governance process has been in place about 15 years, and it has ebbed and failed,” Thompson said. “At first, it was like a franchise model, everyone was doing their own thing. We had to create a standardized foundation,” he reported.

Karen Thompson (r.) and Dr. Edmund Jackson (l.), during their presentation on Friday in Nashville

And, Thompson added, “Edmund and his colleagues came up with great idea, and they said, hey, we’re going to save babies’ lives. How can you say no to a baby?? But what challenged everyone was, OK, what was the priority? What if you have 15 ideas and they’re all about safety and quality? And beyond the clinical, there are other aspects of our business that we also have to pay attention to—things like registration. And things like providing physicians and nurses with the technology they need to do their jobs.” Looking at what faced them, she said, “Since we’ve been able to prioritize more, it’s been, what about quality, speed, and efficiency? How can we get faster and better, but also do it cheaper? Can we do something in 18-24 months? So you’ve got this great idea to integrate a sepsis tool. Well, we’ve got 179 hospitals. But we’ve got this great idea. OK, so pilot it. You want me to go slower? No, pilot it.”

And in that regard, Thompson noted, “We have a gate review committee. It’s like ‘Shark Tank’ with 20 of your closest colleagues! We need to be sure that we’re acting as good stewards with your money. Because sure, you’ve got a great idea. But there are 20 other colleagues who’ve got great ideas, too. So our gate review committee makes sure we prioritize our projects appropriately, and pace them correctly. And people will say as a result of going through this, they end up with a better project. And you can’t keep going to the same markets to test things,” so pilots are launched in a variety of different facilities and local healthcare markets. And, she notes, “Testing is great for us.”

Of course, Jackson said, “That was kind of a hard lesson for the innovative side to take on. Because we operate in silos, though I hate that word. And I might want to take on some kind of innovation project, and I can’t understand why Karen says she’s not ready for my project; but then I find out that there are 20 other projects like mine, and she knows that, and I don’t. and that took me a while for me to onboard and fully understand.”

Indeed, Thompson said, “We are shifting from an annual prioritization process, involving clinical, hospital operations, IT, etc.; and we have x millions of dollars to fund projects this year, and so we look at such elements as breadth, impact, and time and intensity of projects, and then we draw a line after a certain amount. But are we leaving anything on the table that it’s a priority for our company? And so now we’re doing what we call our ‘Evergreen’ prioritization process. You prioritize and integrate across strategies as opposed to just business areas. So we’re trying to look across strategies and not just business areas.”

Thompson said, as a humorous note, “So, someone will show the ‘baby’ slide” in a presentation proposing a project, “and we’ll say, hey, we’ve got three projects saving babies already. And we need to have a bit of a sense of humor around this, too. But it’s about balance and composition. So this is why we have this evergreen portfolio process. But sometimes, someone happens to pass Sam, our COO, in the hallway. And the hallway hit-up is real.”

“Karen’s being humorous, but the issues are real,” Jackson said. “And you have to stick to process. The move to the Evergreen Process was real. And yes, most projects are 18-24 months in terms of their timeframe. They had been of various lengths, with some only three months long.” But innumerable short-term projects had become impossible to govern, he said. “So Karen and I and the CEOs and COOs got together and asked ourselves, how do we work this out? And the Evergreen Process emerged. For many years, we had lived on a yearly funding process, and it wasn’t working.”

What’s more, Thompson said, “The time and amount of energy it would have taken,” would have been overwhelming, had the Evergreen Process not been developed. “We couldn’t give units their own pools of money. So we would test ideas within individual areas. That’s how Edmund and I worked this out. We said, yes, you do need to go faster. And it’s more about an iterative build.” As a result, she said, it’s worked out well to work with the innovation team on specific pilots and tests, while maintaining an overall governance structure.

In that regard, Jackson noted, he and Thompson and others created a Lean Oversight Committee, which meets quarterly for 60 minutes, and includes group presidents, CFOs, and senior vice-presidents across the nationwide organization. “It’s a group of people who understand the full scope of the company’s strategies and work,” he explained. “We review potential projects. And we do a forced ranking. We don’t promise we’ll fund the projects, but we do force-rank them. And designing that process took a little bit of time. We actually had to get some friends to support us.” That approach is working well, he reported. “HCA is big and doesn’t move particularly quickly. So one of the keys to success in this was gathering people and aligning support.”

“What I love about what Edmund’s done is the fact that it’s about educating people and letting them know what’s going on; and not everybody needs to know what’s going on all the time,” Thompson said. “So the composition of that committee was important. We wanted some people from the strategic planning committee. But we also wanted the naysayers, because otherwise they’ll throw rocks from the side. And so the more closely you collaborate with people and build trust over the years. Those are the conversations you want to have. What’s going well and what’s not, and why not? And the lessons we’ve learned here, we’re going to apply to the rest of the portfolio. And we’re going to manage ourselves. And the honesty of those conversations really begets trust among people. When you’re honest about what doesn’t work, you beget trust.” “And Karen’s point about getting the naysayers on the committee is exactly right,” Jackson added, “because those people will buy into the process.”

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