An Oregon Health System’s IT Project Governance Success: Lessons Learned

While complex in itself, developing a formal IT project governance process can also prove to be a key step in a patient care organization’s efforts to optimize its processes around healthcare IT development and management. With four hospitals and 220 employed providers, St. Charles Health System, based in Bend, is the largest provider of medical care in central Oregon.

Last year, Laura Kreofsky, vice president, advisory services, at the Brentwood, Tennessee-based Pivot Point Consulting firm, worked with Jenny Boyer, director of infrastructure, and her colleagues at the St. Charles Health System, as they were developing a formal project governance process. Late last year, Editor-in-Chief Mark Hagland interviewed Kreofsky and Boyer about their experience. Below are excerpts from that interview.

Tell us about the origins of this initiative.

Laura Kreofsky: St. Charles recently finished a remarkably successful on-time, under-budget Epic implementation. And Jenny was director of the Enterprise Project Management Office, or EPMO. Jenny and I worked there on a number of endeavors. The one thing that Jenny and I worked on particularly closely—about eight months prior to go-live—was to get the organization ready to shift from go-live-based governance to a sustainable ongoing governance model. That’s something that most organizations don’t think about far enough in advance. Meanwhile, simultaneous to the deployment of Epic, they were also deploying an enterprise-wide ERP [enterprise resource planning] system, and building and getting ready to open, a new hospital tower. As a result, it required incredible project governance to move from a project-based governance model to an enduring governance model.

How did the ongoing governance model development emerge organically?

Jenny Boyer: Actually, Laura helped us with that while we were preparing for the Epic deployment. That was our fourth EHR [electronic health record]; it’s a very integrated system, and there are several third-party systems that attach to Epic. So consistency and standards were important. We did hardly any customizations, so that we could keep it a pristine, out-of-the-box system. Our goal was to minimize customization as much as possible. And in that regard, it was important to get the stakeholders together to discuss any customization needs—thus, the need for project-based governance.

How long did it take to create and implement the governance structure?

Probably eight months prior to go-live.

Kreofsky: Yes, and we started with the question, what’s working in our project structure that we want to sustain? And how do we take the best parts of our project management structure and project governance processes, and transition them into that enduring model? That was our starting point, and St. Charles had a really good start there. But it took months to work through some of those scenarios: what if something changes one group but not the other, how should something be handled? So, many discussions, and it was definitely a journey.

Boyer: And since we had used that governance structure during the implementation project, we knew it would work long-term.

What were the biggest challenges involved in developing this process?

Boyer: Developing the process went really well. We presented it to several people and got their signoff. When we started rolling it out, it took a while for people to remember to be disciplined, because they hadn’t been that disciplined in the past, they hadn’t done that level of integration before.

Kreofsky: Being their strategic advisor in areas of the Epic implementation, one of the things I had to nudge them to do while they were in the throes of the Epic implementation, was to step back and think about post-implementation conversations. To their credit, Epic, the IT leadership, and the operations leadership, all saw the value of and need for this sustained governance.

What have the biggest lessons been that have been learned so far in all of this?

Boyer: We paused the governance structure during the first 30 days of post-go-live so that we could focus on what had just been implemented and not get sidetracked by new requests.  This caused some confusion  about how and where to communicate the change you want to request and who to request it to.  In hindsight, we should have kept the governance structure in play, but possibly modified it a bit for the first 30-60 days post-go-live.

Kreofsky: Either you might not have paused it, or might have more clearly communicated to the stakeholders the importance of taking that pause, and making sure there was a clear process within the support desk, to catalog the change requests. The pause allowed you to focus on your end-users during what turned out to be a hugely successful go-live, but yes, some things could have been communicated more effectively.

What advice would you offer to CIOs, CMIOs, and other senior healthcare IT leaders, based on your experiences?

Kreofsky: I’ve got three thoughts. One is, if you’re moving from implementation to sustainment, you should start months in advance of go-live. The second piece is to be holistic: look at each “tier” of governance, and make sure you have the right stakeholders appropriately engaged. And the third piece is to look at the whole life cycle of a change or “governance need,” from the time it’s conceived either at an end-user level or an advisory board or committee level—to run it through your emerging governance structure several times, to sort of “bomb-test” your governance structure. That’s something that they’ve done very well at St. Charles.

Boyer: Yes, and I would absolutely have that governance structure in place in advance. That’s an absolute must.

Kreofsky: And the key point is to evolve it: it looks different during pre-implementation, during go-live, and afterwards.

Boyer: And I think that having that governance structure in place did lead to a wildly successful go-live.

Do you think that many HIT leaders underestimate the importance of IT governance?

I think that’s probably true. I feel very fortunate that that was not true here at St. Charles. But yes, the amount of time and discipline it takes to put a governance structure in place can be overwhelming from a time and resource standpoint.

Kreofsky: I would say yes, but I would add that there’s a growing awareness of how important it is. It’s like a lot of things, you either do it now or you pay for it later. You’re seeing it in various organizations where they’re basically doing a rebuild of an EHR that had been put in nine years ago with no governance structure, or in organizations with 491 EHR change requests in the cue, and no governance structure. So I think it’s becoming a very timely subject for discussion.

Boyer: I just cannot stress enough the importance of putting in a governance structure and sustaining it.