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Agile management is an approach that has become popular in many business circles, but it is only now gaining more attention in healthcare. Some Agile experts say quality leaders should consider this management method for the strengths it can offer in improving patient care and safety.
First created for use in software development, Agile is a project management methodology built around short development cycles called “sprints” that typically last four weeks. These sprints are used to focus on continuous improvement in the development of a product or service. Some healthcare leaders are finding applications for QI.
Agile is based on 12 principles, such as, “At regular intervals, the team reflects on how to become more effective, then tunes and adjusts its behavior accordingly.” (Editor’s Note: The principles are available online at: .) A key tenet of Agile is implementing changes quickly but acting on feedback so that each iteration of the improvement is better than the last.
Although based on software development, the principles can be adapted for other fields, including healthcare QI, says Leigh Burson, senior advisor with Impact Advisors, a consulting company in Naperville, IL.
“Agile project management around software or applications development has been around for a long time. Healthcare, which is behind in technology compared to other industries, has been trying to get on board for a while. We are seeing more success in using Agile in operational or clinical process improvement projects in healthcare,” Burson says. “It’s very new to healthcare.”
The idea behind Agile project management is based on breaking down a large project (e.g., improving patient care) into smaller chunks that are addressed easier and faster, says Arti Bedi Pullins, founder and CEO of Pundit Consultantz, a healthcare consulting company in Chicago. Healthcare organizations are likely to adopt Agile more in the near future after seeing examples of its success in the industry, Pullins predicts.
“Not all healthcare institutions are using it, but the ones that have embraced it are seeing massive amounts of improvements, efficiencies, and cost savings,” Pullins reports. “It’s becoming a newer management phenomenon within the healthcare industry. I think we’re going to see this management methodology take on a bigger role in healthcare.”
Agile may sound a lot like Rapid Cycle improvement using Plan-Do-Study-Act (PDSA) and Lean projects, Pullins notes. Although their names imply fast iterations in project or program management, those approaches both focus on much longer-term process improvements and adoptions, she says.
“Agile, on the other hand, requires constant iterations, changes, and implementations of those changes for faster learn-test-try and then re-calibrate and try again. Agile is more efficient and overtime yields better process and reduction of over-runs on cost,” Pullins explains. “Lean, at times, can be instituted on top of Agile, as Lean is looked at for continual longer-term improvements. Healthcare and quality improvement professionals can use Agile to break down the Lean project into smaller chunks at a task or business priority level, and deliver that specific task in a more efficient time-frame, sometimes in weeks vs. months. Agile, in a way, is about concentrating on solving smaller and specific tasks in relation to a larger project.”
With Agile project management, there is a sponsor for each project. Since they are defining that iteration’s work and the work is planned in short sprints, it allows the sponsor to see continuous improvement sooner rather than later, Burson says.
“Agile incorporates continuous feedback from users, and you build on lessons you learn. It’s an iterative approach so that you see [more] returns on investment than you do with many other project management methodologies like waterfall,” Burson says. “It is a simple methodology, but it takes time and education to get people all on the same page about it.”
Agile is different from other project management approaches in which no one sees the results until the end of the project, Burson says. With Agile, the methodology is quick and participants get to see pieces of the project effects along the way, she says. Healthcare quality professionals may find Agile useful when focusing on smaller, short-term improvements rather than the larger end goal, says Angela R. Tiberio, MD, physician executive and clinical performance solutions leader at Impact Advisors.
“The enemy of good is perfect, so Agile allows you to incrementally improve on something and recognize that while it’s not going to be perfect right out of the gate, nothing is,” Tiberio says. “Our constant striving for perfection can paralyze us. Agile can help combat that tendency if, culturally, the organization can get comfortable with implementing change, even if it’s not perfect. Then, you watch closely and make improvements as necessary.”
The healthcare landscape has changed to adapt to customer needs. The industry has become more competitive than it was in the past, Burson notes. Agile allows organizations to move forward and innovate more quickly than they might have with other methodologies.
“There are some early adopters in healthcare. I’ve worked with organizations that have a pretty robust Agile methodology they’ve been using for five or six years,” Tiberio reports. “Largely, it’s used for post-implementation of a system after you have it live. It can be used in an implementation framework, but that is not the more common situation we see. When you’re doing the primary implementation of an electronic health record, the vendor will have their own methodology, and you can’t do a wholesale swap.”
But after a system is live, then the healthcare organization can use Agile to advance the tool to be more usable and provide the utmost value, Tiberio offers.
The Agile framework could be used in a similar way with the implementation and optimization of regulatory or compliance efforts, Burson suggests. “If you have a project in which the solution options, the scope, or the requirements change frequently, then Agile can be a good [tool],” Burson says. “If it’s a really simple solution, Agile may not be the best approach. But for complex problems, one of the strengths of Agile is the cross-functional collaboration.”
With the short sprints, stakeholders see a return on investment quickly, which results in good buy-in, Burson explains. People also tend to stay involved with the improvement longer because they are seeing results rather than losing interest as they wait a year or longer for the final results of a different project, she says.
An Agile methodology requires the organization to use good oversight for identifying potential needs, prioritize what problems should be addressed, and establish measures of success, Tiberio says.
“Without that strong structural support, the Agile methodology is just going to replicate some of the craziness that goes on today with everyone wanting something and wanting it now,” Tiberio cautions. “You still have to have all those things in place whether you’re using Agile, waterfall, or any other project management model. It also is crucial that you operational-ownership throughout the entire cycle, which forces you to get multiple disciplines together.”
All the stakeholders from multiple disciplines must actively participate with the Agile sprints, but that is more feasible because they are shorter than some project management approaches, Tiberio notes.
“If you get the ownership, you tend to push things out more quickly with Agile because they are seeing results. Their requests and their needs have not gone into the black hole of a long-term project,” Tiberio says. “They see us building this thing quickly, seeing how it works, adding and changing it as needed, and then we move on.”
A common scenario in which Agile could be applied is a requested change to the EMR, Tiberio notes. As with most changes or implementations involving technology, the biggest challenges will involve people rather than machines, she says.
For instance, when an EMR goes live or features are modified, it is common for clinicians to report that changes are needed to a rounding guide.
In that scenario, Agile management would call for gathering everyone involved with that aspect of the EMR. Then, the team discusses the needed changes and acts quickly to make the those changes, assess the effect, and tweak the EMR further if necessary, Tiberio explains.
“You come up with user stories that illustrate who, what, and why for the improvements. The why part is very important. A doctor may explain that she wants to optimize the rounding navigator so that her time is used better and she has fewer clicks per day,” Burson explains. “The Agile IT team will talk about the options for different solutions, and present those possibilities with an assessment of the time and resources required.”
Pullins is working with one of the biggest distributors of healthcare products, using Agile project management for simplifying supply chains and logistics for key medical equipment, pharmaceuticals, and supplies. The goal is to ensure products are delivered in a timely, consistent manner, with constant flow and in proper quantities, while keeping track of expiration dates and other factors.
The project involves the distributor working closely with healthcare organizations to develop systems that improve with each iteration based on feedback from customers, Pullins explains. At the end of each Agile sprint, participants conduct a sprint retrospective to determine what went well and what could improve.
Agile management can be particularly helpful with breaking down silos, a common problem in healthcare, says Jimmy Benani, federal industry practice lead at Excella, an Agile technology firm in Arlington, VA.
“As much as it’s a process, we think of it more as a mindset,” Benani says. “Before you adopt this approach, you have to be sure you’re aligned to what Agile is promoting in terms of collaboration, welcoming change, and adjusting those changes. The work is done by cross-functional team members who are self-managed as opposed to how projects sometimes are managed from the top down.”
Technology and data functions in healthcare will offer the most obvious opportunities for the use of Agile, notes Amanda Makulec, data visualization capability lead with Excella. The approach can help quality leaders manage system-level data all the way down to individual patient records, she says.
“Agile can have a great impact by making data more usable and accessible by managing and improving how physicians interact with the electronic medical record. It can help us better understand how the record is impacting patient care and how physicians interact with the technology,” Makulec explains. “Agile can help us pull together data from disparate systems, triangulating data from the financial and human resources systems, moving iteratively toward some kind of unified vision of how the entire hospital system is working.”
Speed is critical to the Agile approach, Makulec notes, with sprint teams implementing change in a short period.
But that does not mean that the work is performed hastily, sacrificing quality for speed. Rather, the goal is to put one iteration of the change in front of people quickly so that they can provide feedback to improve the ultimate improvement.
“It’s about speeding the development so that people have something they can see, feel, and touch. They can give you feedback incrementally,” Makulec explains. “That is as opposed to spending a year and a half working to try to make something perfect, and then handing over that final product. It’s not going to be perfect, and you’ll need to respond to feedback anyway.”
Makulec and Benani say they are seeing more interest in Agile from healthcare organizations, but the shift in mindset can be a challenge. Even nimble organizations can find it difficult to shift to Agile for large, enterprise-scale IT projects involving sensitive health data, she says. The healthcare components of the federal government are adopting Agile more rapidly than the rest of the industry, Benani says. The Veterans Administration and the Department of Health and Human Services are adopting Agile for data system implementation and are showing interest in expanding the methodology to less technical issues, Benani says.
Training in the Agile methodology is available from various sources, but to learn Agile, Makulec suggests starting small. “Find smaller-scale projects that could be used as demonstration cases for the value that an Agile management approach can bring, the faster speed to delivery and the user-centered design. The early project may be scalable in the future or show how the process yields results for the end user and gets them excited,” she says.
“We’re doing a project now with the CDC on designing a dashboard of community scorecard data for healthcare facilities in Uganda as our pilot country,” Makulec continues. “Later, [the solution can] be scalable to other country environments. In doing that, it wasn’t a huge piece of work that required cumbersome, complex enterprise-level data streams.”
Financial Disclosure: Author Greg Freeman, Editor Jonathan Springston, Editor Jill Drachenberg, Nurse Planner Jill A. Winkler, BSN, RN, MA-ODL, Consulting Editor Patrice Spath, MA, RHIT, Editorial Group Manager Leslie Coplin, and Accreditations Manager Amy M. Johnson, MSN, RN, CPN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.