Project management provides a structured approach that can help keep projects within budget and on time. There are several methodologies and approaches that can be used and tailored to fit specific projects or industries. Regardless, many projects fail, and part of the reason is that every project is different, with a different scope and variables like environmental, budget, and time constraints. Therefore, using the same approach may not result in the same outcome. The stage-gate approach is one project management approach that has demonstrated positive results over a long-term period. Public health projects can be large in scope, and it can take a long time to develop, implement, and before outcomes become clear. This paper aims to discuss the stage-gate process, its benefits and problems, and whether it could be a suitable approach for public health projects.
Project management is a systematic and structured approach that is often used to keep projects within budget and on time, while allowing for flexibility and adaptation to suit specific industries, environments, or projects (Newton, 2016; Passenheim, 2020). Project management is based on principles of accountability, diligence and providing value, amongst others (Biafore, 2019). Different project management methodologies have been developed by several associations and institutes, including the Association of Project Management (APM), Harvard Business School (HBS), International Project Management Association (IPMA), Project Management Institute (PMI), the UK government (PRINCE2), and a Project Management Association in Serbia (YUPMA) (Jovanović & Berić, 2018). Project management involves certain processes, knowledge, skills, tools and techniques (Biafore, 2019), and these differ between different methodologies (Jovanović & Berić, 2018). Processes generally include initiation, planning, execution, monitoring and control, and closing (Biafore, 2019). PMI knowledge areas include communication, cost, integration, procurement, quality, resources, risk, schedule, scope, and stakeholders (Project Management Institute, 2017). Skills refer to technical, business, problem-solving, interpersonal, and leadership skills (Biafore, 2019). Tools can be used for scheduling, communication and for other tasks, and can include GANTT charts (scheduling), Slack (communication), etc. (Michalak & Rysavy, 2020; Project Management Institute, 2017). Certain techniques can reduce workflow variation and waste, resulting in reduced cost and time (Gubinelli, Cesarotti, & Introna, 2019). Agile, Lean, and Six Sigma are some of these techniques (Gubinelli et al., 2019). There are several approaches that can be followed such as a traditional waterfall approach which is suitable for simple, low-risk projects where the cost, quality and time is determined by the scope; and agile, which is suitable for complex projects requiring high involvement and a more iterative approach and where the deliverable features will depend on the cost, time and quality invested in the project (Biafore, 2019; Petersen, 2020). Following a traditional approach provides directions for which steps to follow during project management, while techniques such as Lean and Six Sigma provides direction on “how to perform these steps” (webpage) in the most efficient way (Gubinelli et al., 2019).
Despite applying project management processes, skills, tools and techniques, most projects still fail (Passenheim, 2020). Projects fail if one or more of the three constraints (cost, quality, and time) is not met (Passenheim, 2020). Part of the reason for failure is differences and variation between projects. Other factors that can contribute to failure are poor communication, coordination, performance, planning, execution, inadequate risk assessment, management, and leadership (Passenheim, 2020; Petersen, 2020). According to one source, the stage-gate approach “is the only approach that has ever been shown to work long-term” (p. 74) (MA Ajam & bookboon.com, 2019). Forty-five percent of the Net Present Value (NPV) of a project can be eroded by not following the stage-gate approach (MA Ajam & bookboon.com, 2019). In contrast, effective use of the stage-gate approach can reduce the project life cycle (i.e., duration) by 25% because of better planning and risk management, and a reduction in the amount of work that must be redone (MA Ajam & bookboon.com, 2019). The following sections provide a review of the stage-gate process, its benefits and problems, and whether it is a suitable approach for public health projects.
The stage-gate approach is a structured process that was introduced in the 1980’s by Cooper as a faster way to control, direct, and manage product innovation and development(Cooper, 1990; Smolnik & Bergmann, 2020). It is a conceptually simple but operationally complex model that provides a plan or framework for process management to efficiently and effectively take a product “from idea to launch” (p. 44) (Cooper, 1990). This approach involves determining major milestones (stage gates) where progress and quality is checked (Van Der Schouw, 2015). Work on specified deliverables is done during the stages, and the quality of the deliverables is checked at the gates – typically, the number of stages and gates can range from 4 to 7 depending on the product, project, or industry (Cooper, 1990). Each subsequent stage becomes more expensive to execute, and therefore more, and better quality information is required at each subsequent stage to manage risk better (Cooper, 1990). Each gate consists of inputs (deliverables), criteria to judge quality on, and outputs or decisions which can include go (proceed to next stage), hold and recycle (rework), or kill (terminate the project) (Cooper, 1990). An action plan has to be approved for the next stage, and resources are allocated before moving on (Cooper, 1990). The gatekeepers who decide to proceed or not can be senior managers, but some have included project managers and the project management office (PMO) to help drive progress through the stages (Cooper, 1990; Gumede, 2016). In healthcare, gatekeepers can include senior managers with project management and relevant clinical skills, PMO directors, quality assurance managers, six sigma practitioners, or other internal and external assessors (Mattucci & Goldsmith, 2010). Similarly, it would be important to have a range of multidisciplinary experts serving as gatekeepers for public health projects. Figure 1 provides a visual presentation of the stage-gate approach. However, it may look different depending on the industry, product, project, or other variations.
Sources: Adapted from Ajam 2015 (M Ajam, 2015); Cooper 1990(Cooper, 1990); Mattucci & Goldsmith 2010 (Mattucci & Goldsmith, 2010); Smolnik & Bergmann 2020 (Smolnik & Bergmann, 2020); Tolan 2017(Tolan, 2017); and Washington 2018(Washington, 2018)
Stage-gate is part of the waterfall approach, which includes the following: defining deliverables and assigning resources to them, creating a detailed estimate of work that must be done, initiating and developing the requirements, and testing the deliverables before deploying the service (Van Der Schouw, 2015). There are also other names for stage-gate, including phase-gate and go-no-go (Van Der Schouw, 2015). Following this approach, the project is managed both “at the stage level, and across the stages” (p. 52), i.e. managing the whole life cycle (M Ajam, 2015; Basu, 2006). A project life cycle generally consists of starting, preparing/organizing, execution, and ending/closing phases (Project Management Institute, 2017). A major advantage of the stage-gate approach is that it should be easy to answer whether tasks have been fulfilled and required progress achieved (yes/no), and if not, to quickly address any misalignments and work on shortcomings (Van Der Schouw, 2015). Progress is monitored and quality checked, so that mistakes can be detected and changes made accordingly (Van Der Schouw, 2015). The waterfall and stage-gate approach follow a linear process, and work on a new deliverable cannot start until the preceding deliverable is completed to the desired quality (Van Der Schouw, 2015). Stage gates are therefore part of the monitoring and controlling process during a project’s life cycle (but applied throughout the life cycle), and ensures consistency and alignment with project objectives (MA Ajam & bookboon.com, 2019; Wuest, Liu, Lu, & Thoben, 2014). Reviews at each gate are conducted according to standardized criteria by appropriate stakeholders or gatekeepers (Basu, 2006). By standardizing criteria and processes and performing frequent quality checks, the timeline of the life cycle can be shortened by using resources optimally, preventing work duplication, and reducing downtime, waste and redundancy (streamlining) (Basu, 2006). The quality of deliverables are evaluated according to detailed checklists and compared to documents, plans, reports or studies before a critical decision is made about continuing or altering course (M Ajam, 2015; Basu, 2006; Project Management Institute, 2017; Wuest et al., 2014). If used effectively, this approach could result in consistency in quality, and cost and time savings. A limitation is that this very linear and structured approach may not lend itself well to quickly adapting to a changing environment, but it can help prevent damage to capabilities and implementation due to errors or inadequate completion of deliverables (Van Der Schouw, 2015). Waterfall and stage-gate approaches are feasible for projects with well-known, pre-defined, stable requirements, while the project team may be inexperienced or unfamiliar with working with each other (Van Der Schouw, 2015). However, there are some problems that can make the Stage-Gate approach ineffective. The stage-gate approach works well for cross-functional team collaboration, but does not encourage timely customer feedback (only episodic customer feedback), which can cause delays due to having to redo some work (Kozarcanin & Mohamed, No Date; Paluch, Antons, Brettel, & et al., 2020). Two other critical issues are where in the project or process the gates are positioned, and how well the quality checklists are developed (Wuest et al., 2014). The gates must be positioned before stages or processes that require large investments or many resources, or where failure could result in the most harm (Wuest et al., 2014). Checklists for quality review must be based on gate positioning and fundamental quality features (Wuest et al., 2014). It is advisable that external experts critically review the content of the checklists to see if it would ensure that the quality is up to required specifications (Wuest et al., 2014). Some of the problems of the stage-gate approach may be overcome through automated gates or “virtual quality gates” (p. 37) (Wuest et al., 2014). Table 1 presents several of the benefits and problems of the Stage-Gate approach.
Ensure quality with quality control checkpoints at every gate
If gates are not rigorously developed, they can present a weak point
Ensures success through alignment with goal and termination of irrelevant projects at any gate
Gatekeepers may not feel empowered to make the right decisions
Reduce cost and time by reducing waste, rework and duplication - allocate resources effectively and efficiently
Enough resources may not be assigned to allow progress
Can allow for information exchange between team members and guide project prioritization
Critical information may not be shared with the project team
Provide a road map with objectives, processes, guidelines, and inputs for the project team (discipline and structure)
Lack of focus on stages due to excess focus on gates
Reduce risk by improving the process and removing tasks that do not add value (improve focus)
Gates may be bypassed or decisions made on opinion or hidden agenda rather than evidence (lacking appropriate criteria)
Structured project management and standardized planning and control, no scope creep
Gate meetings may be canceled because gatekeepers or other important stakeholders do not show up
Documentation is monitored at each gate and information is easily accessible
Inadequate quality checklists
Improve coordination and early error or issue identification and adjust accordingly
Quality gates may not be in the right position
Supports stakeholder collaboration, communication and coordination
The process, product and requirements must be well understood by everyone to be effective
Can be customized to facilitate risk assessment and decision-making
There can be several unknowns during the early stages that make the stage-gate approach weak early on
Make working in cross-functional teams easier and harmonize working
Lack of alignment and shared understanding between team members may result in different use of guidelines and information between team members
In summary, stage-gate involves macro-planning and deterministic logic, follows a mostly linear directionality from idea to launch, and focus on quality and risk (Paluch et al., 2020). In contrast, agile type approaches involves micro-planning and stochastic logic, follows an iterative directionality for development of a product and testing, involves continuous customer feedback, and focus on speed and learning (Paluch et al., 2020). Depending on the product or task (moderate innovation and task uncertainty), a hybrid agile stage-gate approach may be beneficial (Paluch et al., 2020). Agile provides flexibility, whereas stage-gate provides efficiency, simplicity and reduced uncertainty (Paluch et al., 2020). The stage-gate approach is well suited in predictable environments with well understood and stable requirements, incremental innovation and a finite time horizon; whereas agile is better suited in fast-changing environments with changing requirements, radical innovation and a finite or infinite (hyper-agile) time horizon (Paluch et al., 2020). The stage-gate approach is better for managers that want more control, whereas a hybrid or agile model may be better suited to those that are comfortable giving up some control (Paluch et al., 2020).
The stage-gate approach has been used in several industries (Wuest et al., 2014). Basu included it as one of the building blocks for excellence in developing products for healthcare (Basu, 2006). Public health interventions present a unique situation. These interventions attempt to address population-based health issues, and can range from interventions directed at the individual, to interventions aimed at communities, or policies and regulations aimed at a societal level. Examples include vaccinations, school exercise and meal programs, and taxes on products that may affect health negatively such as alcohol, tobacco or sugary drinks. Project management is applicable to the development of public health interventions, but the scope tends to be large and the duration of the projects tend to be long. Politics and the political climate can have a big impact on public health interventions. For instance, a government that is sympathetic to business needs and the economy may not want to focus on public health interventions that would be good for the health of citizens, but bad for businesses – for example, by banning smoking and drinking alcohol. Political influence can therefore impact public health interventions to a great extent, especially considering that it is possible to have a new government with a new focus in power every four years or less. Additionally, it is very difficult to evaluate the effectiveness of public health interventions, because there are a large number of variables at play at the population level, making it difficult to prove causality and evaluate deliverables. These factors and others can make managing a public health project extremely difficult. However, if public health projects are not managed effectively and efficiently, it may result in large amounts of resources being wasted in addition to having a negative influence on the health of the public (which may result in additional costs to taxpayers and organizations in terms of increased healthcare resource utilization, absenteeism and presenteeism as a result of poor health).
The author has contributed to two largely unsuccessful public health research projects that could have been improved if project management principles, processes and tools were successfully applied. One of these projects failed because it was not aligned with the organizational (health authority) goal. The health authority spent a large amount of money on an ineffective intervention, but wanted research conducted to prove that they spend the money well. If they applied the stage-gate approach, they would have investigated the intervention first, and conducted a study/research and pilot test before committing to implementing the intervention. This project was small and simple enough for the successful application of the stage-gate approach.
The other project the author worked on was a much larger national research project to investigate why certain regions implement public health interventions successfully while others do not. Some project management tools like GANTT charts were used for this project, but the project still fell behind schedule. Although the stage-gate approach was not applied to this project, problems similar to that found in the stage-gate approach were encountered. As mentioned in Table 1, gate meetings may be cancelled because gatekeepers or other important stakeholders do not show up. This happened on several occasions with this particular public health project, and progress was stalled for months at a time as a result. Even when stakeholders did show up for meetings, they were unprepared and a lot of time was wasted in bringing people up to speed. Meeting objectives were rarely accomplished. This project could have benefitted from project management in general, and the stage-gate approach in particular by making deliverables time-bound and having a project manager to drive progress. Problems with getting gatekeepers/stakeholders to attend meetings could have been overcome with the use of some technologies. Some examples are tools for collaboration, communication and information sharing like Slack (Mustonen, 2020; Veroya & bookboon.com, 2020), tools that can help teams work together like Trello, or project and time management software like Teamwork (Veroya & bookboon.com, 2020). RACI (responsible, accountable, consult, inform) charts could also have helped in clarifying roles and responsibilities and holding people accountable for achieving goals in a timely manner (Project Management Institute, 2017).
These two public health projects would have benefited from the structured procedures and processes of project management and the stage-gate approach. Governments can help achieve public health intervention goals by committing the necessary resources for a sufficient period of time to achieve the proper development and implementation of these interventions. It is important to keep in mind that traditional approaches like waterfall and stage-gate are more suitable for simple, low-risk projects. Public health projects can be very complex and risky. However, the author posits that using agile approaches where deliverables can change on a continuous basis would be highly inefficient for public health interventions. These large, long-term projects require stability, structure and a finite time horizon for implementation. When more flexibility is required, a hybrid approach or some of the newer approaches that were discussed earlier could be tried.
A limitation of this paper is that it provides a very high-level overview of project management, the stage-gate approach, and public health. Future research could compare different project management approaches for public health projects by first applying different approaches to small public health projects, and ensuring sufficient homogeneity to make a comparison of results feasible, before scaling up and using the more successful approaches in larger projects.
This paper provided a brief overview of project management, the stage-gate approach, and public health projects. In the author’s experience and opinion, public health projects can benefit from project management, particularly with regards to ensuring alignment with objectives, applying better planning and executing processes, better leadership skills and principles such as accountability and diligence, and better use of tools to improve communication and teamwork. Public health projects can also benefit from the structure provided by the stage-gate approach, as well as from project managers that can drive progress. However, the wider context also needs to be taken into consideration. Without the political will to provide the necessary resources and commitment for the development and implementation of effective public health interventions, even the best project management approaches and skills will be in vain.
Author: Adinet Lock
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