Score: 0 (0/7/0)
Ventura County Grand Jury • 2014-2015

County Project Management – a Case Study

Published: June 04, 2015 22 pages
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Findings and Recommendations 25 findings

F01
The Grand Jury found that project management across the County is inconsistent in its use of ISO/PMI best practices even though the expertise and resources to employ those practices are available through ITS. The EHR project governance, as defined by PMI, should have begun with a qualified project manager and a County project plan as early as 2009, when the search for a qualified vendor began. It did not. (FA-01, FA-02, FA-04, FA-05, FA-06, FA-07, FA-08, FA-13, FA-14, FA-15)
No recommendations for this finding
F02
The Grand Jury found that the County maintained a website with PMI- compliant forms, policies, and procedures during the EHR project. Not all project managers were aware of the website’s existence and those who knew were not required to use any of the recommended procedures or documents. As of May 2015 no Countywide policy, applicable to all agencies, identifies required project management standards. Merely posting recommended templates and documents on a website is not a clearly stated policy. (FA-04, FA-05, FA-06, FA-07, FA-08)
No recommendations for this finding
F03
The EHR is an enterprise-level project based on its cost and its effect on other departments and agencies. Such effects include the integration with the County data network and the interface with the Auditor-Controller’s office. Enterprise projects require formal risk assessments prior to a project start date. The risk assessment documented and approved on the APAQ did not meet the level of detail expected for an enterprise-level project. By limiting risk assessment to federal incentive reimbursement and fines, the County ultimately failed to address the impact the system could have on patient safety; the daily workflow of doctors, nurses, lab technicians, pharmacists, billing, and registration; and the effect on VCHCA’s efficiency and profitability. (FA-01, FA-02, FA-12, FA-13, FA-14) 8 County Project Management – A Case Study
No recommendations for this finding
F04
Scheduled quarterly ITC status reports for the EHR project were infrequent and inadequate, allowing the project to expand in both scope/size and cost. Failure to have quantitative project status and Estimate at Completion (EAC) reports caused ITC, the governing group, to miss opportunities to identify problems and take corrective action throughout the EHR project. (FA-09, FA-10, FA-11, FA-13, FA-14, FA-23, FA-24)
No recommendations for this finding
F05
Information contained in the EHR project and plan documentation provided to the Grand Jury was incomplete and inaccurate and did not reflect effective project management. These documents did not accurately allocate or report the amount of time needed or spent on projects by County employees. They did not track the progress and cost of the individual tasks assigned to County resources. (FA-13, FA-14, FA-15)
No recommendations for this finding
F06
The Grand Jury found that County labor required for the EHR project, as documented in the APAQ, was severely underestimated and ultimately proved more costly than originally proposed. The Grand Jury could not accurately verify the labor hours and cost due to the tracking methodology employed during the project. (FA-13, FA-14, FA-15, FA-17, FA-19, FA-22, FA-23)
No recommendations for this finding
F07
VCHCA knew from its research and the ITC knew from its status reports that there was a shortage of County personnel assigned to the project, but both failed to take the necessary and timely corrective action. (FA-14, FA-25)
No recommendations for this finding
F08
VCHCA failed to develop a project plan to reflect the hours and resources necessary to integrate with the Cerner production schedule. (FA-01, FA-15, FA-16)
No recommendations for this finding
F09
The ITC allowed the adoption of an APAQ that gave priority to meeting a “Meaningful Use” date. Setting this priority distracted from establishing a PMI-compliant project plan. VCHCA adopted the vendor’s “Event Driven Methodology,” which covered Cerner’s production but did not integrate into any County plan. (FA-12)
No recommendations for this finding
F10
The ITC had no way to quantitatively measure successful completion of the APAQ goals. The project cannot be called complete until all outstanding substantive issues related to satisfaction of the APAQ goals are resolved and accurate project performance data is produced. (FA-12, FA-20, FA-23, FA-24)
Related Recommendations (2)
R05
The Grand Jury recommends that the Board of Supervisors assign to the ITC the responsibility and authority to regularly: monitor achievement of stated project goals; ensure compliance with the approved project process; enforce utilization of quantitative data to measure project progress; identify problems; and assure that prompt corrective action is taken. (FI-03, FI-04, FI-07, FI-08, FI-09)
R06
The Grand Jury recommends that the Board of Supervisors direct the ITC to conduct post-mortem project reviews to determine “lessons learned” and publish the results in support of continuous process improvement. (FI-06, FI-07, FI-08, FI-11) Responses Responses required from: Board of Supervisors, Ventura County (FI-01, FI-02, FI-03, FI-04, FI-05, FI-06, FI-07, FI-08, FI-09, FI-10, FI–11) (R-01, R-02, R-03, R-04, R-05, R-06) Auditor-Controller, Ventura County (FI-01, FI-03, FI-04, FI-05, FI-06, FI-08, FI-10, FI-11) (R-03, R-04) Responses requested from: County Executive Officer, Ventura County (FI-01, FI-02, FI-03, FI-04, F-05, FI-06, FI-07, FI-08, FI-09, FI-10, FI–11) (R-01, R-02, R-03, R-04, R-05, R-06) Chief Information Officer, Ventura County (FI-01, FI-02, FI-03, FI-04, FI-05, FI-06, FI-07, FI-08, FI-09, FI-10, FI–11) (R-01, R-02, R-03, R-04, R-05, R-06) 10 County Project Management – A Case Study
F11
From October 2011 through December 2014, the BOS authorized in excess of $71,000,000 for the EHR. County labor hours and other expenses not charged to the project, reimbursement for Cerner travel expenses, and losses from uncollectable billing ultimately will increase total costs to an amount not currently known. (FA-17, FA-20, FA-21, FA-23, FA-24) County Project Management – A Case Study 9 Recommendations
No recommendations for this finding
F12
The October 3, 2011 APAQ for the Cerner EHR project presented to the ITC identified three goals, one measurement for success, and a minimal risk assessment. County Project Management – A Case Study  Goal 1: To replace VCHCA’s clinical record system with a single system which complies with the HITECH provision of ARRA  Goal 2: To automate and integrate the patient accounting and supply chain management with the new clinical record system  Goal 3: To automate and integrate billing and claim management for leveraging information across the enterprise  Measurement: The single measure of this project’s success would be achieving its first attestation in accordance with federal requirements under the “Stage 1 Meaningful Use” (MU) criteria by September 1, 2013.  Risk assessment: Risk would be limited to the loss of federal reimbursement allocations and the issuance of fines if the project was not started by January 1, 2012, and completed by September 1, 2013.
No recommendations for this finding
F13
As indicated in its agenda, status reports on open projects need not be provided at ITC meetings unless requested by the ITC. Of those reports given, a quantitative assessment is not required. The reports reviewed for EHR were qualitative and thus could not be monitored with any metrics. They also failed to provide status for goals stated in the APAQ.
No recommendations for this finding
F14
Project status reports for Cerner presented to the ITC on October 18, 2012, January 9, 2013, April 11, 2013, and October 9, 2013, were primarily qualitative; i.e. no quantitative progress was provided which would support a performance-based prediction of total project costs at the completion date and a performance-based prediction of the completion date. All reports stated that there was a shortage of County labor and thus milestones would not be met.
No recommendations for this finding
F15
The Grand Jury requested all project files that demonstrate how the Cerner project was conducted, including activities that cover the pre-Cerner- installation plan, the Cerner integration efforts, and the planned post-“Go- Live” maintenance tasks. The Grand Jury only received and reviewed the following project plans created by Cerner:  Project file number one (submitted to the Grand Jury on January 21, 2015, as a Microsoft Project plan file), spanned the period from October 24, 2011 to September 30, 2013, and represented Phase 1 of the EHR System project implementation.  Project file number two (submitted to the Grand Jury on January 21, 2015, as a Microsoft Project file), spanned the period from August 26, 2013, to March 18, 2014, and represented Phase 2 of the EHR System project implementation.  Project file number three (submitted to the Grand Jury on January 21, 2015) spanned project period from “9/11/14 to 2/13/2014” [sic] and represented the project tasks to be completed, achieving “Federal Core Measures.” County Project Management – A Case Study 5  Project file number four (submitted to the Grand Jury on January 21, 2015) spans the period from March 1, 2014, to December 27, 2019, and includes Cerner implementation of the Cerner Remote Hosting option and maintenance. The plans reviewed did not have the PMI-required data for County labor needed to perform specific tasks. Resources such as equipment and labor for the project milestones were missing. The Grand Jury did not receive a County PMI-compliant plan for the Cerner project that was referenced in the BOS response to a 2013-2014 Ventura County Grand Jury report: “HCA did use a formal structured policy management plan for the Cerner System Implementation. The plan presented was the project plan required of Cerner in their contract with the County. This plan followed an Event Driven Project Management methodology.” The project plans presented to the Grand Jury were developed by Cerner and covered only Cerner tasks. [Ref-01, Ref-07, Ref-08]
No recommendations for this finding
F16
According to the BOS response to the 2013-2014 Grand Jury Report, Cerner uses a management method it calls “Event Driven Project Management Methodology.” This methodology cannot be found in the standard ISO or PMI management literature. It is used by Cerner as its own production planning tool because Cerner’s work is driven by the customer’s response (known as an “event”) to its requirements. Cerner has no authority over the customer’s workforce. Therefore, Cerner cannot predict when the customer will respond to its requests or how complete the response will be. The VCHCA, by contrast, was being driven by a very firm scheduled due date, the “Go-Live” date of July 1, 2013. Issues arise when event-driven methodologies are used on schedule-driven projects. A Federal Aviation Administration case study concludes that scope creep/project expansion and budget overruns are a consequence of this mismatch. (Ref-01, Ref-07, Ref-08, Ref-09, Ref-10, Ref-11, Ref-12)
No recommendations for this finding
F17
As of May 1, 2015, the total cost of the EHR system had not been publicly disclosed. The Grand Jury requested audit data from the Ventura County Auditor-Controller in order to evaluate implementation performance. At the time of the request, no audit had been completed. However, the Grand Jury received the following information:  County employee project time was not always charged to the project.  Equipment purchased had not been inventoried or not charged to the project.  Payments to vendors could not always be tracked to the project.  The true cost of EHR could not be ascertained.
No recommendations for this finding
F18
Audits are routinely conducted where cash is used in daily transactions or where there might be a propensity for theft. Audits may also be initiated at the request of agencies, submittal of a public complaint, or, if requested, at the completion of a project. County Project Management – A Case Study
No recommendations for this finding
F19
The EHR funding process began with a VCHCA letter to the BOS dated October 4, 2011, that recommended the purchase of an EHR system with the vendor Cerner for $32,466,000. The recommended project had an 18- month duration with a set of activities as follows:  Month 1. Contract Execution  Month 2. Hire Implementation Team  Month 3. Project Kickoff  Month 4-5 Training, Design  Month 5-12 Build, Validate  Month 13 Integration Test 1, Integration Test 2, Go-Live  Month 14-18 Post Live System Check, Begin Production Maintenance Activities [Ref-14, Ref-15]
No recommendations for this finding
F20
The BOS gave approval of and authorization for EHR expenses to be increased from the initial $32,466,000 on October 4, 2011, to over $71,000,000 as of May 7, 2015. [Ref-13, Ref-14] The history of BOS authorizations is as follows:  April 10, 2012 for $5,110,980 Cerner charges for services [Ref-15]  July 24, 2012 for $5,748,500 for staffing services, computerized physician order entry software and 5% contingency; $4,450,000 to NovaCoast Corp. for staffing support during EHR (July 24, 2012 to June 30, 2013); $125,000 to Zynx Corporation for physician order set creation services (July 24, 2012 to June 30, 2013) [Ref-16, Ref-17]  May 21, 2013 for $6,337,196 for medical equipment, end user equipment, licenses and software necessary to integrate patient care into EHR [Ref-18]  June 24, 2014 for $19,160,788 Cerner Remote Hosting [Ref-19]  September 23, 2014 for $514,560 not to exceed $599,880 for annual hosting of the Health Portal, portal reporting database, and Helping Hands Level 1 support [Ref-20]  November 4, 2014 for $99,900 with the ability to expand to $570,000; second amendment to contract with Barnard Howard LLC [Ref-21]  December 2, 2014 for $379,000 for first amendment to contract with Luminous Technology Group (January 3, 2014 to June 30, 2015) [Ref-22]
No recommendations for this finding
F21
The Cerner contract estimated Cerner’s travel expenses at $346,000. As of December 31, 2014, the County had reimbursed Cerner Corporation over $834,000 for travel expenses. [Ref-13] County Project Management – A Case Study 7
No recommendations for this finding
F22
As of the July 1, 2013 “Go-Live” date, over 100,000 County employee hours had been used for Phase 1 of the EHR implementation.
No recommendations for this finding
F23
The Ventura County Star, citing the EHR as a contributing factor, reported an $8,550,000 loss at the Ventura County Medical Center (VCMC) in fiscal year 2014. [Ref-23]
No recommendations for this finding
F24
Problems stemming from the implementation of the EHR system affected the VCHCA’s ability to bill correctly, resulting in an operational loss. These problems created a large volume of uncollectable patient billing (estimated at $40,000,000) that, even after being corrected, still left a substantial portion unrecoverable.
No recommendations for this finding
F25
Both before and after selection, County employees visited other hospitals that were either in the process of implementing a Cerner EHR “Solution” or had already completed their implementations. Their research revealed that other institutions employed more people with the necessary skill sets (e.g., informatics) to support their EHR system than the VCHCA had allocated during its Cerner EHR implementation. The VCHCA’s current level of EHR support remains below that of comparable institutions. Findings
No recommendations for this finding

Commendations 4

Agency Responses 1

Government agencies' official responses to this report's findings and recommendations. Click on a response to see the structured breakdown.

No Responses Found 3

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County of Ventura Agency
Ventura County Auditor-Controller Elected County Office
Ventura County Board of Supervisors Elected County Office