ORIGINAL ARTICLES

Project management for hospital accreditation: a case study 

Elana Maria Ramos Freire¹, Renata Cristina Rocha Batista¹, Maria Regina Martinez²

¹Federal University of Minas Gerais
²Federal University of Alfenas

ABSTRACT
Aim: describe the implementation of Project Managing techniques, based on the propositions of the Project Management Body of Knowledge (PMBOK), which was used on a Sterilization Central Supply, to help it meet the quality standards needed to get accredited.
Methods: a descriptive case study. Participant observation, document analysis and a structured questionnaire were used to collect data.
Results: the development and management of the project actions were based on eight PMBOK knowledge areas - Project Integration, Scope, Time, Quality, Human Resource, Communications, Risk and Stakeholder Management.
Conclusion: project management made it possible to implement the project at the expected time and scope, meeting the quality standards, and allowing the team to better engage and compromise to the project.
Descriptors:   Quality Management; Accreditation; Nursing.  

INTRODUCTION

In a globalized scenario - defined by easy access to information, constant changes, technological advances and growing competition in several activity fields - quality becomes essential when talking about attracting customers and customer loyalty. This is even more important in health care institutions, where surviving the market has become a challenge.    

In an attempt to familiarize themselves with social and technological changes and meet the requirements of increasingly demanding customers, Health Care Managers have begun taking new approaches to implement increasing "quality" standards in the services they provide.      

Quality is essential in healthcare, as it impacts greatly on society and in others systems of the field⁽¹⁾. However, meeting expectations and assuring the rights of the customer, and assuring a safe and qualified assistance during the present healthcare scenario, permeated by the continuous increase in care costs, a shortage in investments and an ineffective use of the available resources, is challenging.    

Due to this situation, hospitals have been investing in new care and management models, in order to achieve satisfactory results and be able to optimize resources, promote humanized care and improve the services provided and their outcomes⁽²⁾, while focusing on patient safety.    

It is noted a growing movement of hospitals seeking certification and quality assessment programs that demonstrate its results, improve the application of resources and expand the productivity and satisfaction of internal and external customers⁽³⁾.

The hospital accreditation lies amongst major healthcare quality assessment programs, establishing interdependent standards that must be thoroughly met to enable the healthcare facility reaches the pre-established quality levels. 

According to the approach used by the Brazilian Accreditation System (Sistema Brasileiro de Acredição - ONA), accreditation is a process of evaluating institutional resources; it is an unforced, recurrent, private and confidential practice used to assure care assistance, based on previously approved standards. The standards could be either be minimal or more elaborated, establishing different levels of satisfaction and qualification: level I or accredited, level II or fully accredited and level III or excellence accredited⁽⁴⁾. An accredited healthcare institution distinguishes itself from others by the quality and safety shown in by its services, obtaining, therefore, more trust from its clients and social credibility⁽⁴⁾.   

Furthermore, being an accredited healthcare institution makes it possible to promote organizational changes, as it encourages habits and behavioral changes, enforcing the interruption of mechanized care, therefore improving quality and providing a top quality organizational environment.

Healthcare Institutions that do not meet the desirable standards for accreditation have incongruities that need to be corrected through improvement projects, to fulfill established requirements and meet required quality standards.  

Given that, healthcare projects are developed to improve infrastructure, management and organizational processes. 

A project works like a plan or temporary undertaking, presented to meet a proposed target, using resources in order to create a unique result in a limited time period⁽⁵⁾.  Projects are important change makers in healthcare institutions, as they provide the possibility of turning goals and strategies into real results.  

Their creation goes beyond merely documents and reports; projects are linked to day-to-day company activities, and are therefore an import management tool for achieving good results. Yet, for this to happen, the steps of the project need to be well performed⁽⁶⁾.  

In this context, managing the steps of a project is a marketplace challenge, as most companies do not have a proper organizational structure to do so.

Their management processes are based on traditional models, which limit the projects to their functional areas; these, in turn, may not always include the skills and capacities required to manage a project, once everyday activities have been prioritized⁽⁷⁾.

Applying methodologies oriented to project management motivates employees to achieve strategic organizational goals, increasing the competitive edge. However, these measures are still rare when it comes to healthcare organizations^(8,9).

Given that, professional project management, backed by scientific literature, becomes the key for developing and executing healthcare projects. Managing projects means applying knowledge, skills, tools and technique to project activities, with the aim of reaching or exceeding project requirements and expectations⁽⁵⁾. 

Project management goes from planning to subsequent implementation, in order to meet a particular purpose. Its primary focus is planning the scope of a project, so it can be finalized according to the established schedule and budget.     

The finalization of the overall scope of a qualified project, within the planned schedule and without exceeding the budget, brings a sense of satisfaction to the client and to everyone involved in the project. 

Amongst the existing Project Management procedures and guidelines, the Project Management Body of Knowledge (PMBOK) can be found. It consists of a guidebook containing facts about Project Management. The Project Management Institute (PMI) developed it, and it is recognized worldwide as a base reference in the field.   

PMBOK compiles a set of project management tools and techniques, categorized in process groups or knowledge areas, which are recognized as "good practice" in the field, following the idea that a project is accomplished through a series of steps or actions to reach its goals and meet its requirements⁽⁵⁾.  

PMBOK uses five process groups and ten field areas to explain project management. 

The process groups are initiating, planning, executing, monitoring/controlling and closing. The ten knowledge areas are project integration, scope, time, quality, human resource, communications, risk, procurement and stakeholder management⁽⁵⁾. Project Management makes projects faster, more organized, dynamic and interactive, therefore helping healthcare managers when developing projects.

Scientific studies using project management are justified, as they provide an excellent opportunity to improve and motivate the managing of projects in the healthcare field. So, helps nurse managers and other healthcare professionals to achieve autonomy and governability, using their competencies, specific health care skills and knowledge about project management. In addition, there are still very few scientific studies in literature, which approach this subject.  

Given all the above, this present study aimed to describe the implementation of Project Management Processes, based on the PMBOK propositions. The Project Management Processes were used to develop an adaptation project to help a Central Sterile Supply (Central de Materiais e Esterilização – CME) meet the standards established to get level I accreditation.  

METHODS

A descriptive study was carried out, which deeply analyzed and described an atypical situation, which occurred in a healthcare institution. A case study seeks to explore a particular situation, which takes place in contemporary real life. It is well defined and contextualized in space and time, allowing the investigator to perceive the holistic and significant aspects of the events⁽¹⁾.

The study was held in a small private hospital, located in a town in the southern part of the state of Minas Gerais.  

The hospital has room for 50 beds, which are allocated to ambulatory, adult ICU, NICU and observation beds in the Emergency Department. The facility also includes a surgical wing, image and laboratory diagnostic services and medical offices. Since the hospital was visited by a certified accrediting institution (CAI) in 2006 and received its organizational diagnosis, it has been pursuing its accreditation.  

Ever since, the establishment has been investing in continuous improvements of procedures and infrastructure, receiving accreditation from the National Accreditation Organization (Organização Nacional de Acreditação - ONA) in 2013, reassuring its commitment to quality and patient safety. The present case study includes the CME of the aforementioned hospital; the object of analysis was the management of the CME Adaptation Project, which was based on the requirements for project management, prescribed by the PMBOK. 

The study took place from May 2011 to May 2012, and it was conducted with approval from the institutional ethic committee at the Universidade Federal de Alfenas (Code 085/2011). Due to ethical and privacy reasons, the research field was named Hospital X.

The CME was chosen as the study case, based on the premise that it is a hospital area that needs help to eliminate nonconformities and bring it up to standard to meet the requirements for hospital accreditation, all within a year.    

Participant observation, document analysis and a structured questionnaire were used to collect data.   

The participant observer was the researcher, who was not employed by the hospital, but joined the working team as the project manager. The observer was responsible for planning and managing the projects, acting as a team member in the organizational environment and partaking in the situations analyzed, therefore being an essential decision maker in the activities that were carried out⁽¹¹⁾.   

The observation was carried out during the entire research process; the data, registered without a structured script, was documented in a field journal. 

During the project planning and implementation, daily activities and the behavior of the CME professionals and others involved in the project were observed. This was done to obtain information, in order to manage the team's engagement and embracement of the suggested activities.    

The analyzed document consisted of the organizational diagnosis report, which provided essential information to evaluate the adequacy needs of the CME. 

To determine the team's satisfaction with the project and its results, structured scripts were used during the quality control stage. Two questionnaires were elaborated; five CME staff members answered one and two members of the Hospital Coordination Unit - the Hospital Coordination Unit Nurse Manager and the coordinator of the Hospital Infection Control Committee, answered the other. 

The questionnaires consisted of 12 closed questions (Likert Scale) and an open question, which was used for criticisms and suggestions. Opinions regarding the changes made to the techniques and infrastructure of the CME, as well as the evaluation of the project management, considering time, scope, quality, communication, risk management, the relationship between the manager and team members and the achievement of desired outcomes, were all topics included in the questionnaires. During this particular research stage, only the workers who were directly involved in the execution and/or planning of the project were allowed to participate.  

The investigation was divided into three phases. In the first phase, an organizational diagnosis of the CME was made, with the purpose of identifying nonconformities that could prevent it getting a level I accreditation.

The second phase consisted of elaborating the CME Adaptation Project, carried out in partnership with the hospital administration, establishing the goals and targets to be met.  

Finally, the third phase - and the main point of this article - included the execution of the project and its follow up, with the help of free software called OpenProject and based on the propositions of the Project Management Body of Knowledge (PMBOK).  

The data found was analyzed and presented in a descriptive manner, using a chronological approach⁽¹¹⁾, following the sequence in which the events occurred throughout the study. It was divided into two phases: CME Situational Diagnosis presentation⁽¹²⁾ and elaboration/execution of the CME Adaptation Project. 

RESULTS

Situational Diagnosis
Situational diagnosis was conducted to identify existing inconsistencies, related to both the quality standard required for level I accreditation by ONA⁽⁵⁾ and also to the current legislation, ANVISA RDC 50⁽¹³⁾ and RDC 15⁽¹⁴⁾ resolutions. The situational diagnosis made outlining a profile of the CME possible; this profile provided the necessary information for developing the department’s adaptation project^(1,2).  

CME Adaptation Project
The CME Adaptation Project formally started after a meeting between the researcher, a member of the hospital administration, the nurse coordinator and the CME nurse. At this meeting, they determined the actions that would take place, taking in account their priorities and the resources available (human, material and financial resources).  

The project was managed based on the five PMBOK management process groups, taking into consideration seven knowledge areas (CHART 1).

Cost and acquisition management were not explored in this research, as the hospital had a functional and organizational structure, defined by a lack of specific funds for developing the project and limited resources - which were controlled by senior management - resulting in restricted authority for the project manager. Consequently, a non-involvement policy regarding the cost and acquirement areas was created for the project manager.   

Initiation Processes
Performed in order to define a new project, initiation processes identify the project needs, goals and targets, also defining its team and manager⁽⁵⁾.  
During the CME Adaptation Project, the following initiation processes were performed:

• Development of the project’s opening form: a document that formally authorizes the execution of the project and includes the stakeholders’ needs and expectations. Thanks to the situational diagnosis, it was possible, not only to display the project demands and necessities, but also to elaborate the organizational chart of the project, which holds information such as the demands that brought the project to life, its purpose, propositions, organizational constraints, the assigned manager and team.
• Stakeholder identification: identifying people or organizations that somehow could be influenced by the project, in a negative or positive way, and information related to their interests, involvement with the project and the type of impact on it (Figure 1). 

In Figure 1, the positive rating refers to the stakeholders who are likely to benefit from the project’s successful conclusion, while the negative rating refers to those who are inclined to be damaged or inconvenienced. 

The level of interest is equivalent to the level of concern with the results; the subjects' active participation in developing and executing actions is comparable to their engagement with the project, while the ability to make changes in the project planning and execution matches the project impact.    

Planning Processes
Planning processes are applied to planning actions and define the path or course of the project, in order for it to meet its established goals and targets. 
The planning processes used in this research were:

• Gather Requirements - using situational diagnosis, it was possible to raise some project demands that were secured after a meeting with the hospital administration, the nursing coordination and the CME nurse. The CME workers were also informally interviewed, in order to confirm the necessity of the defined changes, and, if needed, to add or eliminate determinations.   
• Scope definition - consists of making an elaborate report of the project and the services provided by it, describing its goals, the project base, acceptance criteria, time estimated to execute it, project constraints and deadline dates. Creation of a work breakdown structure - is an oriented decomposition of the project into smaller components for easier management, resulting in a hierarchical decomposition of the total scope of work, organizing and displaying it, in order to achieve better control and supervision of the project.
• Activities definition and sequencing, activity resources estimation and development of the project calendar - actions were determined, in order to reach the project handover phase. The activities were arranged according to their connection with the project, while estimating the number of materials, equipment and people required for developing each project activity. The work time necessary to conclude each activity, using the available resources, was also estimated, as shown in Figure 2. 
• Project Quality Management⁽⁸⁾ - there were defined ways to demonstrate when and how the quality range would be measured throughout the project. Signing off the project in the established time, respecting 90% to 100% of the scope, the CME employees' satisfaction and acceptance of the project outcomes, and the organization's satisfaction with the project were established as standards to measure the project quality.   

• Human resources planning - used to determine who would be responsible for each work package, establishing roles, responsibilities and hierarchical relationships.      
• Communications Planning - used to define each stakeholder’s need for information, as well as to establish when it should be passed on, the best methods to do so and a person responsible for reporting the information for each method chosen.       
• Risk identification, quantitative risk analysis and risk response planning - the identified risks were classified, taking in account the probability of occurrence, the time impact and the impact they would have on the project scope (Figure 3). For each risk, a response or action was developed: mitigate it, eliminate it or ignore the risk factor. Both the identified risks and the determined actions were defined during management meetings between the Functional Manager, the researcher (the Project Manager), the CME nurse and other stakeholders.   

Executing Processes
Consist of developing the scheduled activities, in order to conclude the project in accordance with the established requirements. The Executing Processes used were:

• Project Execution Managing and Directing – consists of doing the activities according to the schedule, aided by activity monitoring, schedule control and team management, conflicts management, communication management and risks and changes management, aimed at achieving a better work environment and greater accomplishment of the project requirements. Mobilize, develop and manage the project team - assigning professionals for each activity, so the project can obtain the adequate resources for its execution, as proposed in the human resource planning. 
• Team Training, doing periodic performance evaluations, establishing direct contact by the Project Manager with the staff while the activities are being executed.  
• Distributing Information and managing the expectations of the stakeholders - distributing information according to the communication management plan. Group or individual meetings were held to give the stakeholders unexpected information. The manager sought to have a positive relationship with all stakeholders, which made establishing trust relationships, resolving conflicts and accepting changes easier for both parties.   

Monitoring and Controlling Processes
Responsible for monitoring the activities to make sure they are concluded as scheduled.  The Monitoring and Controlling Processes used were:

• Project Scope Verification - a meeting was held between the Functional Manager and the hospital administration to review the delivery of the project’s goals and to make sure the scheduled scope was delivered.
• Schedule Control - weekly meetings between the Project Manager and the Functional Manager were held to compare the planned schedule with the actual project status. These meetings were also used to distinguish the finalized activities from the delayed ones.  Next, responses were elaborated, in order to correct possible delays encountered or even to postpone delivery dates. The schedule was updated after discussion between the concerned parties. 
• Quality Control⁽⁸⁾ - used to ensure that the project met the quality standards established in the Quality Planning process. The aims described in the scope and also the deadlines were verified to check if they had been met according to the schedule. Structured questionnaires were given to the CME staff, nursing coordination and the Hospital Infection Control Committee, in order to evaluate their satisfaction level with the project outcomes. Consequently, the quality standards were positively evaluated, meeting the hospital workers’ expectations.  
• Risk Monitoring and Control - the process of following and monitoring risks that have already been identified, identifying new risks, and executing the plan for identifying and controlling them.   

Closing Processes
These are done in order to bring the project and all planned activities to a close. 

• Project Closure: during this process, all the planned work was checked to make sure it had been concluded and that the objectives that were predicted before the project started had been fulfilled; all the resulting paperwork was filed. Finally, a meeting with the Functional Manager was held, in order to formalize the closure of the project activities and to confirm all the aims of the project were delivered.  The Project Manager went through the remaining executed processes, verifying if the planned requirements had been fulfilled. The aims that were not concluded were included in the hospital’s strategic planning. 

DISCUSSION 

Companies have been investing in methods and techniques to achieve desired results and answer clients expectations⁽⁶⁾ in order to maintain the competitive lead. Project Management is a powerful tool for this purpose.  

Management Processes are suitable for most projects, having an increasingly approval in the most diverse fields⁽⁵⁾.  

Companies of different fields have been using the PMBOK as a foundation to acknowledge its advantages in order to increase the success of their projects. It is also a vast field to be explored in studies proposing development of new products, services and/or systems for healthcare organizations⁽¹⁵⁾. 

In this present research, project management processes were of great importance for developing the CME Adaptation Project in a prompt and organized way, especially when it came to communication, engagement of the team with project activities and reaching the results within the time and scope predicted, meeting the institution expectations.   Supporting these results, in a hospital research during which PMBOK processes were used to the implementation of a Costs Center Project, communication and stakeholder managing were fundamental to the project success, as it enabled team awareness, decrease of internal resistance and a higher acceptance of the final deliveries. The identification and engagement of the stakeholders were designed in the planning phase and put into practice in the execution, monitoring and controlling phases, considering that, in an organization, change processes are very likely to cause resistance, which must be considered in its scope and planning.      

One of the main difficulties when managing this research project consisted of the fact the hospital is a functional structure organization, in which the workers couldn't dedicate themselves exclusively to the project or even had an hourly load dedicated to its activities, having to conciliate activities related to the project with professional routine. 

Besides, the Project Manager did not have autonomy to make decisions regarding costs and resources allocation. 

The fight for resources (material, financial, human) and the involvement of these in multiple projects inside one organization is a significant institutional projects problem, worsening in functional organizations, where the managers usually are responsible for certain decisions, but do not hold the authority over the company resources. Given that, it is necessary to invest in studies, researches and efforts to adapt management models that integrate innovation activities to the organizations daily activities.  

Regarding the viability of the implementation of PMBOK propositions in healthcare projects management, another study demonstrated that its application to the field was viable and promising to the project development. It also significantly contributed to the project performance in terms of communication, teamwork and experience, making it possible to deliver the project within the scheduled time and allocated budget and corroborating this present research. Implementing PMBOK can benefit both management processes and medical and healthcare scientific research results.  

Regarding Nursing, although Registered Nurses are not taught to manage during graduation school, there are many abilities and skills developed throughout nursing school and subsequent career that can be helpful in their work environment⁽¹⁸⁾.  Leadership, administration and management, communication, decision making and permanent education are some of the administrative skills learned during a Nursing graduation course.   

Based on the above considerations, the PMBOK application is viable and can contribute in the improvement of healthcare projects. More studies approaching this thematic are needed in order to encourage and stimulate Project Management in healthcare institutions. As soon as the CME Adaptation Project was over, the institution was submitted to the ONA certification evaluation, receiving the title of Accredited Hospital. Thus, it can be concluded that the project contributed to the CME adaptation to the quality standards, and, consequently, to its certification.   

Consisting evidences indicate that accreditation programs improve in a significant manner the healthcare outcomes, should then be viewed as an incentive tool to improve the quality of the services provided.   

CONCLUSION

The utilization of management techniques in healthcare projects can help healthcare managers improve the quality of the service they provide and obtain hospital accreditation certifications.    
In this study context, Project Management allowed for a professionalized management model, based on scientific literature, which contributed to achieving the project goals within the planned time and scope. It also allowed for an increase in the effectiveness of the communication and commitment of the professionals, seeking organization, agility and quality results. In healthcare institutions, nurses are responsible for managing health assistance and services, as they have a good knowledge of the hospital sectors and processes. They also work toward quality results.  
Given that, nurses have all the abilities and skills needed to take on Project Management in these organizations. 

ACKNOWLEDGEMENTS 
To Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – CAPES), for the financial support; and to Observatory Extension Program of Healthcare Management of the Federal University of Alfenas (Programa de Extensão Observatório de Gestão Hospitalar da Universidade Federal de Alfenas - Unifal-MG).

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All authors participated in the phases of this publication in one or more of the following steps, in According to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the version submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

Received: 02/10/2015
Revised: 01/25/2016
Approved: 01/25/2016