Introduction

From inception to deployment, the Wait Time Information System (WTIS) project faced significant challenges associated with time, scope and complexity. It involved not only the creation and deployment of two large-scale province-wide systems (the WTIS and Ontario's Client Registry/Enterprise Master Patient Index) within aggressive time frames, but also the active engagement of 82 Ontario hospitals, scores of healthcare leaders and several thousand clinicians who would eventually be using the new technology and its data. The provincial WTIS project team (see Figure 1) also had to be able to adapt and evolve their planning in an environment that was changing day-by-day.

This article looks at the factors that allowed the team to take the WTIS out to the field and shares the approach, processes and tools used to deploy this complex and ambitious information management and information technology (IM/IT) initiative. (More information about Ontario's Client Registry/Enterprise Master Patient Index can be found in "Building a Sustainable System: The Making of the WTIS".)


[Figure 1]

Leverage the Beta Experience

The WTIS project began with a Beta test in October 2005 as Phase I. Unlike a Pilot, which tests whether or not to proceed with a solution, a Beta uses the first iteration of an identified technology to run a "live" trial of the initial system requirements and functionality. This phase also helped the project team identify the support and processes required for deployment of the product.

As they seek to uncover obstacles, Beta experiences are expected to be difficult and bumpy. To capture a range of scenarios and challenges, five hospitals representing a cross-section of hospital variables - small and large, urban and rural, adequate and fewer resources - were selected to participate in Beta/Phase I. These hospitals were willing to face the risks associated with being part of a Beta in exchange for the opportunity to get a higher level of support from the WTIS project team and the chance to help shape the system and its future deployment. Both the project team and Beta hospitals were learning in a just-in-time manner, requiring much patience and trust on both sides.

Through Beta/Phase I, the project team was able to discover and apply some valuable lessons that eventually turned out to be critical success factors in the broader implementation of the WTIS. These included the need to provide "high-touch" support to hospitals throughout the deployment, a strong communications plan to keep all stakeholders informed and involved, and a central information repository as a way to ensure all hospital staff working on the WTIS project and other stakeholders had access to the same pertinent information.

Secure Experts, Create One Team

Even while leveraging its existing infrastructure and experienced resources, Cancer Care Ontario (CCO) knew that additional capacity would be required to support a large-scale initiative such as the WTIS project, particularly within the tight time frames, and took the necessary steps to augment the project team.

Sarah Kramer, the Wait Time Information Strategy Lead, began by building a team of experts with proven delivery and change management experience, including some non-traditional choices with experience outside healthcare (e.g., financial services). Drawing on "best in field" resources not only opened up the resource pool to specialized expertise, but also brought technology development and deployment best practices from a range of industries into consideration. Leads were identified for each of the project work streams (Deployment, Privacy, Project Management Office, Stakeholder Engagement and Technology) to form the project leadership team.

Although it would have been simpler from a procurement and ongoing management perspective to work with a single vendor, the leadership team decided that the complexity and timelines of this project required a variety of subject matter experts in order to create the highest probability of success. A broad set of skills and knowledge was assembled through resources from six core vendors, multiple smaller vendors and independent consultants. Drawing from different resource pools also gave CCO the flexibility to quickly scale up or down in line with shifting requirements at various stages of the project.

With an array of resources pulled together from multiple areas, strong partnership and collaboration became cornerstones in the deployment of the WTIS. The project leadership team knew from experience that success depended on the ability to create a "one team" mentality. Unlike corporate projects, where individuals are part of one organization and share a corporate culture, the complexity of our healthcare system requires participation of multiple stakeholder groups, making consistency, collaboration and cohesion more difficult to achieve. To address this challenge, the project team made significant efforts to create a unified team with the understanding that

• project teams become high-performing teams when all members are committed, aligned and working toward shared goals;
• achieving a high level of stakeholder engagement requires consistent and coordinated activities and messages that can exist only when the project team's culture and attitude reflects "one voice," regardless of their parent organization.

In order to develop a unified team, the WTIS project would require an operating model that incorporated both vertical and horizontal team management. Vertically, work stream leads were accountable for managing their teams in the detailed planning and execution of their specific areas of focus. The interdependence of the work streams often meant a change in one area would impact another, necessitating a horizontal management view in which no change would be accepted without cross-functional approval. On at least a weekly basis, work stream leads would meet to bring forward the priorities, challenges and risks from their respective areas, sharing, weighing and discussing them at a program level. This was also critical to ensure that business needs and potential risks were identified and addressed proactively.

Cross-functional Relationships Demonstrate their Worth The value of the cross-functional relationship was put to the test and underscored in the weeks leading up to one of the "go-live" periods. In this instance, the Technology work stream discovered issues during the testing period that required additional investigation and testing time and could result in a delay to go-live. In many projects, decisions around how to manage this type of situation would have been left to the technology team, but, for the WTIS project, it was important to weigh the risks and impacts cross-functionally. Using this approach, the leadership team was able to identify the ripple effects of a delay through subsequent activities and milestones, including a significant risk to project credibility among stakeholders. The team concluded that while there were risks to face and additional work efforts required, it would be more prudent to delay go-live rather than compromise system performance. Through the cross-functional analysis, the team was prepared for the impact and able to proactively manage the issue and support hospitals through the change. Despite the delay, the project maintained credibility and hospital engagement.

Communications - A Fundamental Component

As with any new initiative, the buy-in of the target stakeholders for the WTIS was dependent upon their understanding the reason for the change and its impact. Often overlooked in technology projects, communications became integral in creating awareness for the WTIS, demonstrating its value and engaging stakeholders.

While the communications function can serve to develop and deliver messages, the strategic value for the WTIS project was in communications having a broader role, with a seat at the leadership table and communications specialists embedded in individual work streams. In this way, communications helped the project team monitor the "pulse of the field" and ensure that messages were relevant, coordinated and aligned across activities. The team used an open, two-way communication model to create transparency and ensure stakeholders were always up-to-date on the project's progress. The two-way model encouraged feedback from the field and helped to actively address stakeholder concerns, manage expectations and support adoption efforts.

Ready-Set-Go At the start of the project, Hospital Project Managers (PMs) assigned to the WTIS were concerned about the complexity of the initiative and the amount of information they would have to absorb. To help them, the communications team developed the Ready-Set-Go program - a series of toolkits that clearly identified what needed to be done, why, when and by whom. Ready-Set-Go was effective because it approached the project from the hospital's point of view. Along with a simplified high-level project plan created for hospitals, the toolkits provided step-by-step instructions, guidelines, resource requirements and deliverable dates for each major project activity that the hospital needed to complete (see Figure 2). [Figure 2] The program had three major sections: Get Ready - an overview of the project and high-level plan, along with an outline of preparatory activities that would be important for hospitals to complete in order to set the groundwork for meeting project milestones. Get Set - a summary of the various toolkits (by major deployment activity) and an outline of the tasks hospitals would complete in order to be prepared for deployment by the set date. Go - an overview of the go-live process, including a checklist and guidance on what to expect during go-live and the subsequent transition to the operational state. Many Hospital PMs indicated that this program was valuable in helping them plan their activities and resources more effectively. The ability to provide toolkits by subject matter took an overwhelming amount of information and made it more digestible and easier to use. The Ready-Set-Go toolkits were introduced to Hospital PMs at WTIS project kick-off workshops (described later in this article) and were designed to be used as the primary "go-to" reference through all stages of deployment (see Table 1.) The toolkits were modified for greater clarity and ease of use based on feedback and lessons learned from each phase. They eventually evolved to become re-usable operational materials, re-packaged as "Practical Guides" that would serve as a reference as the WTIS continued to expand. The guides are now also used as part of the orientation for new WTIS hospitals and project managers. The communications strategy and approach is discussed further in "An Integrated Approach to Stakeholder Engagement".

 

Table 1. "Ready-Set-Go" program toolkits
Guidance (introduction and overview)	Provides a brief introduction to the WTIS project and answers frequently asked questions about the WTIS and overall strategy.
Stakeholder Engagement Toolkit (adoption, training and communications)	Presents an overview of all the tools and support available during the project for communication, adoption, impact to workflow, training and priority assessment tools
Surgeon Connectivity Toolkit	Provides step-by-step guidance on what Hospital PMs and other hospital team members need to do in order to work with the Smart Systems for Health Agency to establish Internet connectivity in surgeon's offices
Hospital Connectivity Toolkit	Provides information needed to successfully establish the different types of connectivity to the WTIS and Client Registry/EMPI environments
Integration Toolkit	Helps Hospital Project Managers and their teams prepare for the integration and interfacing requirements of the WTIS-EMPI (Client Registry) project
Procedure Mapping Toolkit	Provides guidance in completing procedure maps, including important information concerning the types of procedures that should be included for reporting and how they should be mapped
Registration Toolkits	Outlines the different types of registration required, including information explaining the registration process, job aids and registration tools
Testing Toolkits - Client Registry/EMPI and User Acceptance Testing (UAT)	Client Registry/EMPI - Provides the components to assess applicable hospital network and systems to identify appropriate type and number of testing resources UAT - Provides information required to facilitate user acceptance testing of the WTIS application to ensure key objectives are met
Privacy Toolkit	Includes six informational tools for hospitals that describe the collection, use and disclosure of personal health information via the WTIS and EMPI, and an EMPI Data Protection Requirements Checklist
Legal Toolkit	Includes legal agreements used to describe hospitals' and Cancer Care Ontario's responsibilities as they relate to the use of the WTIS and Ontario's Client Registry/EMPI
Go-Live Toolkit	Helps hospital teams through the days pre- and post-Go-Live, as hospitals switch from an implementation phase to an operational one

Establish Single Points of Contact

The Beta/Phase I experience demonstrated that hospitals would need a strong level of individual support throughout the deployment effort. The project team also recognized that it would not be possible to reach all stakeholders directly. The balance came from an approach that identified individuals from the project team and from each hospital who would become the single points of contact for all WTIS-related information and support.

Being able to turn to an individual dedicated as the conduit for information helped establish the necessary relationships and provide the high-touch support that became so valuable in instilling confidence and building trust throughout the project. The approach also proved highly effective in making the best use of resources for the hospital and the project team and created efficiencies in the ability to fulfill requests for information and support.

Provide a "Single Source of Truth"

As the scope of the project grew beyond Beta/Phase I and expanded to more hospitals and clinicians, the project team anticipated the need for a more effective and efficient means of sharing and exchanging information that could serve as the "single source of truth" for all current project information.

While email communication is convenient, it is ineffective as the sole vehicle for delivering information for complex, large-scale projects. With many activities to track and new information to be relayed on an almost daily basis, email can become unruly. One Site Lead reported receiving 900 email messages during Beta/Phase I alone.

Using an online collaboration tool, the project team developed a secure central information repository from which project and hospital team members could access the same up-to-date information. The repository also included a robust question and answer database to record questions from all hospitals and store updated answers as more information became available. All communication updates and revised support materials were also housed on this site as they were released, to be downloaded by hospitals as needed.

Keep Clinicians Top of Mind

Getting clinicians to buy into new healthcare technology initiatives continues to be a challenge (Canadian Medical Association n.d.). Clinicians are often sceptical of new technology and understandably concerned about new initiatives that could result in competing priorities or increased workload.

The concerns around the WTIS were no different, and the project team knew that it had to keep the clinician's perspective top of mind through every step of deployment. A comprehensive stakeholder engagement program, which included a focused effort on driving adoption of the WTIS among clinicians, became an integral part of ensuring the WTIS could be successfully deployed. Adoption efforts involved demonstrating clear value of the program for clinicians, solutions and tools to help remove barriers that stood in the way of implementing the technology and the use of "clinician champions" to serve as advocates of the program among their peers. Further details on the project's stakeholder engagement program can be found in "An Integrated Approach to Stakeholder Engagement".

Set the Pace from the Start

Time was of the essence for the WTIS project. The government had publicly committed to have the WTIS deployed across the province by June 2007, and everyone understood that this deadline was immovable. The project team used the timing challenge to their advantage, recognizing that speed of activity can be used to ensure priority and drive urgency. It was important to set the pace from the start and get momentum going as quickly as possible.

At the start of each deployment phase, a WTIS kick-off was organized in the form of a one-day orientation workshop that brought all Hospital PMs together with the WTIS project team in Toronto. The workshop was effective in reinforcing the mandate and urgency of the WTIS project and, more importantly, helped establish relationships that were integral to setting the foundation for the hospital and project team to work together. By providing an opportunity for everyone to hear about timelines and expectations at the same time, the team ensured that all parties were at the same starting point and understood their role in helping to meet the public commitments for wait times. (See Figure 4 for overall timing and sequence of activities for deploying a phase of the WTIS.)

 

[Figure 4]

Create Opportunities to Learn as You Go

The project team used a phased approach to deploy the WTIS to hospitals. With the input and agreement of LHIN and hospital executives, hospitals were assigned to a phase. Some facilities were keen to be early adopters and participate in Phase I for the opportunity to help shape the deployment program and the system. Others preferred to take a "wait and see" approach and participate in a later deployment so that they could benefit from lessons learned in earlier phases. Technical factors such as technology experience and challenges, resources, integration level and past experiences with similar initiatives were primary considerations when determining which phase a hospital would be ready to deploy. Once hospitals were assigned to a deployment phase, they were slotted into rollout waves for go-live. Phases II and III each had three waves of go-lives staggered a few weeks apart.

This phased approach heightened the complexity of the project. The many levels of interdependent and overlapping activities and resources required a rigorous and highly coordinated planning effort. At the same time, it provided tremendous payoff in terms of hospital preparedness and the opportunity to apply lessons learned throughout the project. It allowed hospitals that needed it the time to get their systems and resources ready to support the WTIS, as well as the opportunity to learn from others' experiences. In addition, it gave the project team the opportunity to learn from each rollout and make changes and improvements for the next.

Single Points of Contact Working Together On the hospital side, the PMs assigned to manage the deployment of the WTIS at their respective sites became the single points of contact that all hospital staff could turn to for up-to-date information on WTIS deployment activities and requirements. The PMs also provided the channel through which clinicians could voice questions and concerns. In turn, Hospital PMs were given a single point of contact within the WTIS project team, referred to as Site Leads. These Site Leads worked with between four and seven hospitals to provide ground-level support, and served as the primary channel for getting answers and guidance on all deployment activities. With access to the various subject matter experts within the project team, they were able to get the right information to the hospitals in a timely manner. Figure 3 shows the single point of contact model used by the WTIS project team. [Figure 3] Site Leads were assigned hospitals based on similarities in infrastructure, vendor partners, type of hospital or information systems. Where possible, hospitals in the same LHIN were kept together and allocated the same Site Lead. Grouping hospitals in this manner provided the opportunity for facilities to create an informal support network through which they could work together to find solutions to common concerns and issues. In some cases, Hospital PMs within an assigned group arranged their own regular meetings to exchange information, advice or best practices. This helped create the opportunity for "role modelling" among hospitals and also decreased the level of reliance on the project team. (Hospital PMs' responsibilities are shown on Table 2.) Although the single point of contact approach proved to be highly effective in making the best use of limited resources, the project team still needed to address the diverse experiences and skill sets among Hospital PMs. Some had more project management experience, while others had more clinical or technical knowledge. To supplement the range of knowledge, additional tools and support were provided, including orientation workshops conducted at the start of implementation phases and the Ready-Set-Go toolkits described in this article.

Table 2. Hospital WTIS Project Managers' roles and responsibilities

Manage the overall project including coordination of all hospital WTIS tasks Follow good project management practices such as keeping sponsors informed, managing and resolving issues Attend and participate in status calls and report on your hospital's status Develop detailed working knowledge of WTIS Liaise with the WTIS project team Site Lead

Commit to a "No Surprises" Approach

No project plan is ever perfect. Even the most carefully crafted plans encounter some variances along the way and require adjustments. What cannot change, however, are the project's confirmed objectives and end goals. The WTIS project was clear about its objectives from the start and worked to ensure the expectations on what it would take to achieve them were understood by everyone involved. If the project began to steer off course and additional tasks or changes were required, all parties were advised so that no one was caught off guard. This level of transparency in objectives, expectations and issues management ensured there were "no surprises" along the way. In order to clearly monitor assigned activities, the project team relied on a couple of key tactics described below.

Indicator Report

With numerous activities to manage in a short time, the project and hospital teams needed a way to easily track the status of deliverables over the course of the project. Although the hospital go-live dates were staggered, they were close enough that any change would significantly impact project resources and the sequencing of activities. A delay with any one hospital had the potential to jeopardize overall deployment goals.

Based on CCO's experience in managing previous provincial healthcare projects, the WTIS project team understood how valuable an "Indicator Report" (Figure 5) could be in helping keep the project on track. The team made significant efforts to identify the actions that would indicate progress against every critical project task. Through the report, the status of each critical task ("indicator") against deployment milestones was tracked on a weekly basis. With each phase, the indicators grew more sophisticated and effective in assessing status.

 

[Figure 5]

Shared both internally and externally, the Indicator Report was vital to the "no surprises" approach and demonstrating transparency across all stakeholders.

A key feature of the report was its ability to be forward-looking. Many other approaches tend to report on what has already happened, providing little opportunity for corrective interventions. The WTIS project's Indicator Report also tracked the number of units completed against an expected result over time, at a fairly granular level. This enabled the team to predict which deliverables were likely to be late and make the necessary escalations to ensure schedules could be maintained.

The project team reviewed the report at weekly meetings to monitor status and determine if any areas required intervention to head off potential problems. Similarly, Site Leads used the report as a project management tool with their Hospital PMs. During weekly status reviews, Hospital PMs and Site Leads discussed upcoming deliverables and identified areas requiring additional support well before they became issues. For example, getting clinicians set up with an Internet connection so that they could access the WTIS required a long lead time. From the Beta experience, this proved to be a challenging milestone to meet. To avoid these difficulties in subsequent phases, the project team identified several points throughout deployment at which hospitals could measure progress against this activity. Hospital PMs were asked to keep count of the number of clinicians that had established Internet connections at each point, helping keep the activity top of mind for both the project and hospital teams.

Every other week, the Site Lead and Hospital PM would confirm the status against the designated indicators and an update would be provided to hospital and LHIN executives. This ensured project and hospital teams were working with the same agenda and could maintain the level of trust that was so crucial in the success of the project.

Lessons Learned Take calculated risks - In significant change initiatives, answers are not always readily available. Instead, leverage start-up momentum and use issues and risk-management processes to compensate for not having all the answers upfront. Establish single points of contact - Use dedicated Site Leads during deployment to work with dedicated project managers/coordinators on the hospital side. This allows the establishment of business relationships and better communication between project and hospital stakeholders. Employ a "no surprises" approach - Build a culture of trust and goodwill by being clear about what is needed by when and providing tools to measure progress along the way. Project plans are important in setting expectations, but a user-friendly tracking tool such as an Indicator Report can proactively identify issues and is an ideal partner to performance management. Secure communications support - The power of using communications strategically cannot be underestimated. Done well, it can ensure consistent and coordinated messages reach all stakeholders, keep them on the same page, and speed up deployment activities. Embrace issues and escalations - Issues are bound to arise in any project. The earlier issues are identified the better. Focusing on solutions and teamwork will minimize the fear of being blamed and encourage individuals to share issues and risks sooner. Make room for local solutions - Working with multiple stakeholders means dealing with diverse skill sets and needs. With overall timelines, milestones and expectations set upfront, give as much guidance as possible to allow individuals to adjust their plans based on local circumstances. Leverage all learning opportunities - Establishing a formal lessons-learned program ensures feedback is gathered from all stakeholders and helps to document and prioritize opportunities for improvement. Acknowledge the work effort of the field - Stakeholders in the field (hospital executives, project managers, clinicians) are critical to the success of any large-scale healthcare project. Their active engagement and involvement is required to support deployment efforts. Ensure their perspectives and concerns are heard and accounted for in your project plans and that their work effort and commitment in the initiative is acknowledged throughout.

Effective Issue and Escalation Management

Working with multiple levels of stakeholders and the unique needs of so many hospitals, the project leadership team needed a way to proactively manage risks. An escalation process was established that was embraced by both project and hospital team members.

Initially some Hospital PMs were apprehensive about calling out issues and the subsequent escalation. The Indicator Report and working relationship between Hospital PMs and project Site Leads provided the means to identify issues early. Early detection meant early resolution. Therefore, to alleviate the PMs' concerns, the project team needed to ensure that when issues were identified, the focus turned immediately to solutions.

Hospital PMs eventually came to rely on the issue and escalation process to highlight the need for further attention and support. For example, when a hospital milestone was in jeopardy, indicated by "red" status, the project team had a clear process and lines of communication to help PMs work with and gain the support of their CIO or director of IT. Some PMs began leveraging red status on the Indicator Report to rally support from their executives when all other means had been exhausted.

The specific escalation process depended on the situation; some were resolved through communications with the Hospital PM, and others involved the hospital CEO or LHIN. In all cases, regular status reporting meant that stakeholders were not surprised by any flagged issues.

The same approach was used internally by the project team and made CCO equally accountable for meeting project timelines. Internal and external escalation of issues, particularly at the earlier stages, meant that appropriate attention could be given before it impacted the schedule.

Results

With hundreds of project tasks and dozens of project milestones to meet, the WTIS project encountered only two instances where a go-live had to be delayed slightly due to system performance issues during testing. Using a highly coordinated vertical and horizontal management approach and consensus-based decision making, the project team was fully prepared to respond to the issues and communicate related amendments quickly to all stakeholders. While the delays meant additional preparation work for project and hospital teams, momentum remained intact and hospitals appreciated that system performance quality would not be sacrificed. In the end, the project team and hospitals were able to fulfill the original mandate for deployment of the WTIS and meet the government's public reporting commitment.

By the end of Phase III deployment in June 2007, the WTIS was being used in 81 hospitals and 1,700 clinician offices, and was capturing an estimated 1.2 million procedures, including 100% of wait time funded procedures. Two years later, it has been expanded to a total of 86 hospitals, is used by 3,300 clinicians, and is capturing approximately 2.2 million surgical procedures and MRI/CT scans, approximately 85% of all surgical cases in Ontario.

Work is now underway to leverage the system to capture what is referred to as "Wait 3" - the period between when a patient in an acute care facility is assigned to an alternate level of care (ALC) and the date of their discharge to the ALC. The WTIS also holds promise for capturing more of the continuum of care and supporting performance improvements in the broader health system. More information about the future of the WTIS can be found in "Transitioning Initial Success into Sustainable Results: The Future of the WTIS".

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