Case study answer questions
Include a paragraph or two summarizing the key points of the case. Answer the following questions:
1. Who is part of the project management team? What is the role of the different committees? What is the role of the TSO manager?
2. Who are the key stakeholders? What are each stakeholder’s objectives and interests in reference to this project? What has to be done to bring them in the “same” project?
3. Evaluate the risks of each option using the following criteria:
Benefits form the project investment
Deployment strategy for WiFi
Cost of training programs
Security in drug administration
Impact on resources
Impact on time.
4. What is your recommendation to the decision-making committee for the preferred volumetric pump implementation strategy?
110 Project Management Journal DOI: 10.1002/pmj
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S Dealing with Uncertainty and Ambiguity
in a Complex Project: The Case
of Intravenous (IV) Pumps in a
Healthcare Center
Monique Aubry, School of Business and Management, Universit du Qubec Montral,
Montral, Canada
Madeline Boulay-Bolduc, Project Manager, retired, McGill University Health Center (MUHC)
Marie-Claire Richer, Associate General Manager, CIUSSS de lOuest de lle de Montral
Mlanie Lavoie-Tremblay, Ingram School of Nursing, McGill University
A University Hospital for the 21st Century
In 2008, the Quebec government approved a CAD$2.3 bil-
lion budget to build a modern academic healthcare facil-
ity that would provide state-of-the-art, highly specialized
healthcare services to the Montreal population and to a
broader community of 1.7 million Quebecers scattered
from Nunavik to the U.S. border. The new facility would
house a great part but not all of the McGill University
Health Center (MUHC) activities.
The opening of the Glen site in 2015 was the con-
clusion of a multifaceted project involving hundreds of
workers, over a period of close to eight years. The physical
architecture conveyed only a glimpse of the complexity
and magnitude of this redevelopment project, much of
which resided within its walls, where clinical teams from
different hospitals needed to prepare to work together day
one after the move. The programs and activities of the
two larger general hospitals, the Royal Victoria and the
Montreal General, had to be reconfigured and redeployed,
which required many teams to merge and many clinical
practices to be harmonized. In addition, throughout the
organization, many major clinical and administrative pro-
cesses had to be streamlined and optimized to meet the
expectations set for the new MUHC.
The physical move to the new Glen site of the MUHC
took place between April and June of 2015 and represented
the largest hospital move in Canadian history. A total of
273 patients were transferred, a very complex task. The
Royal Victoria Hospital, the Montreal Childrens Hospital,
and the Montreal Chest Institute sites closed down, while
the reconfigured Montreal General Hospital, the NEURO,
and the Lachine Hospital remained on their existing site.
A Turning Point: The Creation of the
Transition Support Office
In preparation for this redevelopment project, MUHC
executives visited hospitals in Europe and in the United
States that had undergone similar redevelopment projects.
What they learned was alarming: close to 50% of managers
had resigned from their position in the months follow-
ing the move. Testimonials pointed to a lack of dedicated
resources to support clinicians and managers in preparing
this major transformation. Typically the time needed to
prepare for the transformation was scheduled very late in
the process, as part of the move planning activities. This
situation led to operational disruptions and disconnects,
raising the level of stress and distress among clinical
teams. In other words, bricks, mortar, and IS/IT consid-
erations represented just the tip of an immense iceberg.
First and foremost, the success of a redevelopment project
would lie in preparing the people to transition seamlessly
to a radically new work environment, while maintaining
a high quality of care and uncompromised patient safety.
It was with this in mind that the MUHC created the
Transition Support Office (TSO) in 2008. This project man-
agement office was intended to support teams in harmo-
nizing practices and processes across sites as well as to
facilitate the merger and the move. The TSO had to act on
the following three areas to facilitate the merger:
1. Harmonization of clinical practices;
2. Review of all processes; and
3. Consolidation of work teams that would be merged
with the move.
Suzan was appointed as head of the TSO. She played
a strategic role on projects under her responsibilities
by linking with senior management when needed. She
held a doctoral degree in nursing and had proven strong
Project Management Journal, Vol. 49, No. 1, 110121
2018 by the Project Management Institute
Published online at www.pmi.org/PMJ
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February/March 2018 Project Management Journal 111
leadership qualities, fueled by an inspiring vision of the future
of the new MUHC. She firmly believed in project management
as a philosophy of management to lead the overall organiza-
tion transformation for the benefit of patient care.
At its peak, the TSO was staffed with 26 full-time equiva-
lent persons, who collectively managed a portfolio of no fewer
than 100 projects, a third of which focused on supporting
clinicians across the different sites to harmonize their clini-
cal practices based on the best available evidence from the
scientific literature. Nearly half of the TSO employees had an
education in project management, either a masters degree in
project management or a PMO certification.
Maggie was a former Associate Director of Nursing,
responsible for the Clinical and Professional Staff Develop-
ment Service at the MUHC from 2004 to 2011, and had devel-
oped a large network of contacts within the organization over
the years. One of her departments numerous responsibilities
included the harmonization of clinical practices. In 2012, she
was recruited as a project manager by the TSO to manage proj-
ects related to the harmonization of clinical practices, befitting
her background. In this role, she would be supported by a proj-
ect management specialist and the results would be a winning
combination of clinical and project management expertise
One early morning in 2012, Suzan met with Maggie to inform
her that the TSO had just been asked to provide support for the
selection, implementation, and use of a new float of IV pumps.
The Intravenous (IV) Pumps Project
IV pumps known as infusion pumps were commonly used to
provide care in a variety of clinical settings. Nurses used them
to administer intravenous fluids and medications to patients.
There were two basic kinds: a volumetric pump for continu-
ous infusion and a syringe pump for intermittent infusion.
Maggie referred to them as an essential, everyday tool for
nurses. Patients often had more than one IV pump at a time
for the administration of multiple medications; for example,
premature babies might need up to 14 pumps at any given
time. Infusion pumps were manufactured with software that
could alert users to potential errors. The pumps with this
additional software were often referred to as Smart Pumps
or Intelligent Infusion Devices. This software allowed an
organization to create a library of medications that provided
medication dosing guidelines, by establishing concentrations,
dose limits, and clinical advisories.1 This security feature was
called the Dose Error Reduction System (DERS) or drug library
and when not used, pumps were referred to as being dumb.
Before the move and consolidation to the Glen site, IV
administration procedures varied across MUHC hospitals,
and there were as many as eight different types of pumps
being used. As Maggie recalled it, There were always pumps
missing, in fact through our investigations, we found out that
there was a lot of hunting and gathering by staff members.
This situation meant that staff spent much time looking for
pumps because they were not readily available to them.
Biomed Engineering was responsible for the acquisition
and maintenance of medical equipment for the MUHC. In
2012, it was time to renew IV pumps contracts and, given the
impact this type of technology would have on clinical prac-
tices, the TSO was asked to assist with the process.
The goal of this project was to address the long-standing
clinical and operational issues surrounding the use of IV pumps
at the MUHC. It would be a system-wide, inter-departmental
project that needed to be conducted before the move to the
Glen site. Not only would it include the harmonization and
optimization of practices, but it would also encompass the
selection and implementation of IV pumps. For the project
to truly meet clinical needs, clinicians needed to be involved,
which posed a challenge since, traditionally, clinicians involve-
ment in the decision-making process was limited. As Maggie
put it, clinical was going to drive the project.
Project Organization
The first thing Maggie did was to put in place the project plan
and governance structure. The project sponsors would be the
Director of Nursing and the Pharmacist-in-Chief. The core proj-
ect team consisted of the two sponsors plus a clinical practice
consultant (Nicole) and a knowledge broker (Martha). Many ad
hoc membersclinicians, experts in process review and evalua-
tion as well as representatives from different departments, such
as Quality, Patient Safety, and Performance, Biomed, Finance,
Logisticswere solicited as needed for their expertise at differ-
ent junctures during the project (see Figure 1).
The objective was to engage the multiple stakeholders
around strategic decisions that would have to be made, and at
the right level. She, therefore, created two committees: one at
the executive level and another at the operational level. The
first was the Harmonization of IV Practices Steering Committee
that would include director-level representatives from Nursing,
Pharmacy, Biomed, Information Technology (IT), Finance,
Quality, and Logistics. The operational committee consisted
of a group known as the Harmonization of IV Practices Work-
group. The committee represented inter-professional clini-
cians from all MUHC sites (adult and pediatric care) and
various clinical settings. All these representatives were brought
together to guide the clinical decision process regarding the
selection of IV pumps, the elements to support their use, and
the harmonization of IV practices.
Maggie hoped that the involvement of clinicians from
the very onset of the project would ensure that the selected
pumps would suit the needs of the many clinical settings
in which they would be used. She also hoped it would help
the TSO obtain buy-in from participants across the MUHC.
Moreover, if they supported the initiative, she believed that
1Proceedings from the Institute for Safe Medication Practices (ISMP) summit on use of smart
infusion Pumps: guidelines for safe implementation and use.
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Dealing with Uncertainty and Ambiguity in a Complex Project:
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112 February/March 2018 Project Management Journal
it would be easier to achieve the required behavioral change
and shift.
Project Kick-off Meeting
Eager to get the stakeholders involved, Maggie held the project
kick-off meeting of the Steering Committee on 20 March 2012
(see Table 1). The objective of the meeting was to arrive at a com-
mon vision of the project; agree on the scope, major elements;
and timetables for the project and establish the next steps. The
main goal and objectives of the project were to:
1. Harmonize all the practices linked to the administration
of IV medications based on the best available evidence;
2. Acquire IV pump equipment based on the best technology,
in a sufficient number that met all the clinical needs of the
MUHC;
3. Improve the safety of use of IV pumps across the MUHC; and
4. Improve the management of the pump fleet across the
MUHC.
A fifth objective was added as a result of the kick-off meet-
ing, and that was to ensure sustainability by putting in place
a decision-making structure to address and communicate
issues promptly. This exemplified the importance of the com-
munication needed across departments and professions to
ensure ongoing involvement and cooperation from all parties
throughout the project.
See Table 2 for the Project Charter. The project scope was
defined as The Harmonization of IV Practices across the
MUHC sites, and the renewal of the pump fleet for the adult
sites, excluding the Lachine and the MCH sites. These sites
were to be involved in identifying the selection criteria for
the pumps, but would not renew their pump fleet until later.
The MCH site had recently purchased pumps and would not
benefit from the project until the expiration of that contract,
but it was important for them to have a say in the decision-
making process.
Next on the agenda were the proposed timetables.
The tight deadlines along with the budget needs of the project
Figure 1: The organization and governance structure for the harmonization of IV practices project.
Source: Diagram designed specifically for this case
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February/March 2018 Project Management Journal 113
Items Discussion/Decision/Action
1 Review of the agenda Maggie explained the agenda and the objectives of the meeting:
Arrive at a common vision of the project (see if the expectations are similar and address the divergence)
Agree on the scope of the project, its major elements, and the timelines
Agree on the next steps
Maggie explained that Julie would be with the project until the end of April 2012. She will be able to assist on
moving certain aspects of the project, such as the needs assessment.
2 Context of the project The harmonization of IV practices project is supported by the Transition Support Office. It is a system-wide inter-
professional, inter-departmental project that needs to be addressed before the move to the Glen. In addition to the
harmonization and optimization of practices, selection and implementation of IV pumps are integral parts of this
project.
3 Definition of the project 1. Goal and objectives of the project:
A document called Needs statement had been circulated to the group members before the meeting and was
discussed. The main goal was presented as well as the four main objectives of the project. The group agreed
on these and asked that a fifth objective be added and that is: Put in place a decision-making body that would
address and communicate issues related to IV practices and pumps post implementation as a strategy to ensure
sustainability. Therefore, part of the sustainability plan of this project is to recommend to senior administration the
appropriate structure needed to ensure ongoing quality improvement related to IV practices post implementation.
The importance of communicating explicitly the need for inter-professional and interdepartmental ongoing
involvement and commitment in this project was also mentioned. The group agreed with this.
2. Scope of the project:
Harmonize IV practices across the MUHC sites and renew pump fleet for the adult sites excluding Lachine
(proceeding currently with call for tender but will participate in identifying selection criteria) and the MCH (who
will participate in identifying selection criteria only because they purchased the pump a few years ago). It excludes
pumps used for pain management (PCA pumps). The available budget is 3 million dollars for the first year
(20122013) and up to CAD$9 million. Colin explained that this amount was determined based on historical data and
market references. It is a onetime capital investment required to create, sign, and get the contract running in order
to have access to the pumps that we need. This would permit 1.5 IV lines/patient. The CAD$9 million will pay for the
equipment, the professional support to implement, educate, and deploy. It was suggested to include the notion of
partnership with the vendor.
3. The preliminary timeline:
The proposed timeline was presented. We are facing a tight timeline linked to the call for tender. Colin needs
the selection criteria and plans to have a detailed call for tender document by the end of July 2012 and he plans
to organize an evaluation workgroup thereafter. He plans to proceed with the call for tender at the beginning of
August 2012, followed by the evaluation of the call for tender thereafter and finish this by the end of 2012. A needs
assessment with front line staff regarding IV practices, pump storage, and management is planned. The nurse
managers have been solicited to identify their current pump situation and forecast future needs. She should receive
all the information by the end of March 2012. Colin mentioned that there are internal and external factors that
might impact on the project and that is the ministry is thinking about selecting a pump system that would be used
provincial-wide. Internally, the fact that we aim to ensure each patient has at least one pump is a big change and
will greatly impact the logistic aspect (storage, maintenance, cleaning). We discussed also the infrastructure needed
to support the smart pump technology like setting up drug library and needing Wi-Fi technology to update the library
in a safe manner. There will be Wi-Fi at the Glen and at the MGH, it will not be for another five years. This means
that we will purchase smart pumps, but not use the library for two to three years until we move to the Glen and it
could be for five years for the MGH if we do not have access to Wi-Fi technology. We will need to include this in
our risk management analysis when we look at the different scenarios. It was clear from all present that as senior
person from IS/IT needs to be a member of this coordinating committee.
4 Next steps 1. The members present agreed to be a member of the harmonization of IV practices coordinating committee
knowing they are a decision-making body for this project. It was mentioned that a senior person from IS/It also
needs to be a member. We informed the group that we have solicited IS/IT to delegate someone to join our group.
Some of the next steps are:
1.1. Proceed with the needs assessment
1.2. Form the harmonization of IV practices workgroup and the management of IV pumps workgroup as well.
1.3. Set the next harmonization IV practices Coordination Committee meeting
Table 1: Minutes of the kick-off meeting.
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Dealing with Uncertainty and Ambiguity in a Complex Project:
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114 February/March 2018 Project Management Journal
Project Identification
Project Name:
Harmonization of practices linked to the administration of IV medications
Department:
Nursing, Pharmacy, Logistics, Biomedical, Finance, Information Services,
Quality, Risk and Performance
Site:
RVH, MGH, CHEST, Neuro, MCH, and Lachine
Project Start:
January 2012
Project Completion (expected):
July 2014
Project Governance
Requester:
Pharmacy/Nursing
Sponsor(s):
Director of Nursing
Pharmacist-In-Chief
Clinical or Other Leader(s):
Assistant to the Director of Nursing
Pharmacist
Project Manager(s):
Maggie, Transition Support Office
Clinical Practice Consultant: Nicole
Project Environment
Strategic Justification:
Within the context of the redevelopment project, it is imperative to optimize and harmonize the practices related to the administration of IV
medications, based on best evidence and supported by state-of-the-art technology.
Project Context:
Across the MUHC we find:
Diverse IV administration practices
Different IV administration systems (different pump system and tubing) obtained from different vendors (different contracts and end of contract
dates)
Shortage of IV pumps and time constraint related to renewal of pump contract
Absence of a comprehensive system of pump management (tracking system and central management and rotation of stock), preventative
maintenance and cleaning
The above elements are contributing to:
Having a negative impact on quality and security of patient care by contributing to an increase of infection risks, medication errors
Increasing caregiver stress due to pump not being accessible when needed
Increasing the risk of errors and inefficient use of human resources
Difficulty in providing adequate servicing to pumps, difficulty in keeping track of inventory, and depletion of IV inventory due to loss of the pumps
Difficulty in ensuring appropriate level of training for the different types of pumps in circulation, often done by word of mouth, contributing to
increased risk of errors
Lack of confidence in the system in being able to provide the equipment needed in working order when it is needed, thus contributing to hoarding
and stashing and also tension between caregivers
Problem/Opportunity Statement:
Engaging in the harmonization of IV practices must be done before 2015, opening of the new Glen site
As part of the redevelopment plan, a budget has been reserved for the purchase of new equipment such as IV pumps
IV pump contracts are coming to an end, creating the sense of urgency to look at purchasing new pump technology to support the harmonized IV
practices
(continued)
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February/March 2018 Project Management Journal 115
Key Stakeholders:
Pharmacy
Nursing
Biomedical
IS/IT
Finances
Logistic
Infection control
Quality risk and performance
Patients
Union
Anesthetists
Respiratory therapists
Project Definition
Aim:
Within the context of the redevelopment project, it is imperative to optimize and harmonize the practices related to the administration of IV
medications, based on best evidence and supported by state-of-the-art technology
Project Description:
The purpose of the project is to identify, optimize, and harmonize IV practices, based on best practices, and support these practices with the state-
of-the-art technology that best meets the clinical needs of the MUHC in order to improve the quality and security of the patient care linked to the
administration of IV medications.
Expected Benefits:
Improve the quality and security of the patient care linked to the administration of IV medications
Optimized and harmonized practices, contributing to decreasing medication errors
Increasing ease of providing appropriate training to pump users
Accessibility of the IV pumps when needed, functional and clean
Optimal use of human resources
Increased caregiver satisfaction
Demonstration of effective inter-professional and inter-departmental collaboration
Efficient management system of pumps, contributing to decrease expenditure related to continual crisis management because of pump shortage
Objectives:
1. Harmonize all the practices linked to the administration of IV medications based on the best available evidence
2. Acquire IV pump equipment based on the best technology, in sufficient number, that meet all the clinical needs of the
MUHC
3. Improve the safety of use of IV pumps across the MUHC
4. Improve the management of the pump fleet across the MUHC
5. Ensure sustainability by putting in place a decision-making structure to address and communicate in a timely manner
issues linked to the IV practice and pumps
Evaluation Indicators:
1. Percentage of IV
practices harmonized
Scope (Inclusions):
Harmonization of all practices linked to IV practices across all sites
Identification of selection criteria for IV pump selection to meet the needs of clinical areas across the MUHC
Renewal of the IV pump fleet for all MUHC sites except MCH (purchased IV pumps not that long ago) and Lachine
(carrying own call for tender)
Estimated budget: first yearCAD$3 million (20122013), the remaining funds about CAD$6 million for a total of
CAD$9 million (includes purchase of equipment, professional support to implement, educate, and deploy)
Scope (Exclusions):
MCH and Lachine for
the call for tender
Pumps for pain
management such as
PCA pumps
(continued)
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Constraints:
Sense of urgencymove to the Glen in 2015
Urgent need of pumps
Having to manage different IV pump contracts
Diverse IV practices across the different sites
Wi-Fi technology not available for many of our current hospitals except for the Neuro and certain units. Although, the Glen will have WI-Fi, the
installation of Wi-Fi at the MGH is not forthcoming (lag time of possibly five years or more)
Lack of confidence in the process from the users due to previous failure of previous initiatives
Culture of hoarding and stashing equipment in order to meet the urgent needs of pumps on the units and lack of confidence that the caregivers will
have easy access to the equipment they require to provide safe care.
Multiple projects that will impact on this project and where alignment is crucial such as OACIS, CPOE, Pharmacy system
Missing important stakeholder presence and involvement such as IS/IT
Preliminary Project Planning
Working Hypotheses:
The plans and models that are developed will guide the implementation
The users and various stakeholders will take active part and assume accountability in the different phases of the project
The result of the user needs assessment will be adequately integrated in the project and will help in shaping and choosing the different scenarios
for the harmonization of practices, the selection criteria for the pump selection and the pump management model
The identified risks will be taken into consideration and addressed throughout the project
Risks:
Gap between the chosen scenarios and the user needs
Inability to put in place the needed infrastructure to support the full use of the smart pump safety features
Absence of allocated budget post implementation to ensure daily operations
Absence of a department willing to take on the management and upkeep of the IV pumps
Lack of coordination between related projects such as equipment, harmonization of IV practices
Absence of full-time dedicated resources to the project
Key Milestones and Deliverables:
1. Needs assessment with front line caregivers regarding the IV practices and IV pump
Milestone 1: Completed needs assessment
2. Analyzing different scenarios:
(a) practices requiring harmonization, (b) model for continuous infusions and intermittent IV medication administration,
(c) pump management model
Milestone 2: Chosen and validated scenarios
3. Develop selection criteria for call for tender for IV pumps
Milestone 3: Selection criteria chosen and validated as well as the call for tender needed
4. Call for tender for IV pumps
Milestone 4: Choice of equipment and validated
5. Development of detailed plan to:
harmonize the IV practices (a), pump logistics (b), deployment and communication (c)
Milestone 5: Detailed implementation plan for the three aspects
6. Operationalization of the plan, deployment, follow-up of the harmonized practices, pumps (with or without library),
training, pilot project, full-scale implementation and monitoring of indicators
Milestone 6: Established targets met
7. Development and implementation of sustainability plan
Milestone 7: Quality indicators reviewed, transfer to daily operations completed, and IV pump decision making
structure in place and functional
Expected Completion:
1. End of June 2012
2. End of August 2012
3. September 2012
4. December 2012
5. February 2013
6. February 2014
7. July 2014
(continued)
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Resources Needed:
Resources from Transition Support Office needed:
Project manager 2 days a week for 2 years
Process expert (IV pump management workgroup)
Knowledge broker
Change management expert
Clinical practice consultant
Evaluation consultant
Resources Needed from Other Departments
Risk and performance expert
Pharmacist
IT/IS
Biomed
Estimated Number of TSO Hours:
15 hours/week for 2 years 5 2,000 hours
14 hours/week 12 months 5 670 hours
15 hours/week 6 months 5 360 hours
14 hours/week for 12 months 5 670 hours
15 hours/week for 2 years 5 1,800 hours
Ad hoc 100 hours
Total hours 5 5,600 hours
Steering Committee:
Director of Nursing and Sponsor
Pharmacist-in-Chief and Sponsor
Director of Biomedical Department
Director of Purchasing
To be named, IT/IS Department
Clinical lead pharmacy
Clinical lead and Assistant to the Director of Nursing
Associate Director, Quality, Risk, and Performance
Purchasing sector of Finances Department
Project Manager
Clinical Practice Consultant (TSO)
Project Authorization
Sponsor’s Signature:
Clinical Leader’s Signature:
Project Manager’s Signature:
*In the absence of signatures, electronic approval is required
Date:
Date:
Date:
Table 2: Project charter for the IV pump project.
were presented to the Steering Committee. The Biomed
department representative informed the committee that he
would need a detailed call for tender by the end of July 2012.
He would then set up an evaluation group that would be in
charge of evaluating specifications as the project evolved.
A project management student intern would be in charge of
soliciting input from the pump users to identify their current
pump situation and forecast future needs.
The Biomed representative was concerned that some
internal and external factors might pose challenges to the
project. He informed the group that the Quebec Health Min-
istry was considering selecting a pump system that would be
used province-wide. Internally, the fact that the project aimed
to ensure a ratio of one pump per patient was a significant
change that would greatly impact the logistics department
regarding storage, maintenance, and cleaning.
The infrastructure needed to support the smart pump
technology was discussed. This required setting up a drug
library with the names of all medications and dosages that
could be administered through the pumps. A Wi-Fi network
was also needed to support and update the drug library safely
for all sites and all departments at all times. This new tech-
nology minimized the risk of medication administration and
dosage errors. At that time, Wi-Fi was to be available at the
Glen site in 2015 as well as at the MGH by 2017. It would hence
have precluded the use of the drug library for two to three
years until the Glen site opened. This situation represented a
major risk for the project and would require the assessment of
several scenarios to select the best options. From then on, a
senior representative from IS-IT needed to be involved in the
coordination committees decision-making process.
It was already clear after the first meeting that the main
challenges to address were going to be:
1. Budget, as the funding was not finalized and the number
and types of pumps needed had yet to be determined. It
was important to (a) ensure that clinicians had the num-
ber of pumps needed and (b) eliminate the hunting and
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118 February/March 2018 Project Management Journal
gathering phenomenon. A challenge would be to obtain
the budget approval in a timely manner to post the tender
according to the set timeline.
2. External pressures from the Ministry would be an issue,
since the implementation of a province-wide tender
system would prevent hospitals from posting tenders
individually. This situation represented a risk with regard
to the feasibility of meeting the tight timelines and the
organizat
