Copyright © 2000 Artemis Management SystemsCreating The Wo.docx

Copyright © 2000 Artemis Management Systems
Creating The Work Breakdown Structure
By Kim Colenso, Managing Principal, Artemis Management
Systems
The Work Breakdown Structure (WBS) is the foundation for
project planning and control. It is the
connecting point for work and cost estimates, schedule
information, actual work effort/cost expenditures,
and accountability. It must exist before the project manager can
plan these related and vital aspects of the
project, and they all must be planned before the project manager
will be able to measure progress and
variance from plan. In order to perform this vital function, the
WBS is at its core a hierarchy of
deliverables or tangible outcomes. This article describes a
proven approach for creating and implementing
a WBS.
Before we get started, lets establish some terms to facilitate
communication within this article1.
• Phase – The Phase is a major component within the project
life cycle. When creating a process-based
WBS, the Phase is the highest level within the WBS. When
creating a deliverables-based WBS, the
term is probably not appropriate. For the purpose of examples,
the Phase is at Level 1.
• Activity – The lowest level within the WBS. Activities are
where deliverables are assigned to an

individual. The individual will perform a work process to
create the deliverable. Therefore, the
Activity is a combination of deliverable and process. For the
purpose of examples, the Activity is at
Level 3.
• WBS Entry – A generic term for any level within the WBS,
but always representing a deliverable.
WBS Entries are decomposed into other WBS Entries, and at the
lowest level, are decomposed into
Activities. For the purpose of examples, the WBS Entry (at
Level 2) will fall below the Phase and
above the Activities at Level 3. In actual practice, there can be
as many levels of WBS Entry as
needed.
The WBS As Hierarchy
Before looking at how to build a WBS, it is generally a good
idea to create a mental model for what we are
going to build. The mental model I have used many times in the
past is the Outline. If you go back to your
time in grade school (and if you’re as old as I am, that can be a
challenge), you will remember that your
teacher always wanted you to create an outline as the first step
in writing a report. The outline had some
very specific characteristics and rules, and if you didn’t follow
them, the teacher would apply ‘corrective
discipline’, and you would make the necessary changes. Well,
the Work Breakdown Structure has many
aspects in common with the outline.
Topic Project Level 1 Level 2 Level 3
I. Phase 1
A WBS Entry 1-1

1 Activity 1-1-1
2 Activity 1-1-2
B WBS Entry 1-2
1 Activity 1-2-1
2 ...
II. Phase 2
A WBS Entry 2-1
1 Activity 2-1-1
.. ...
1 Note: the naming of levels within a WBS is not standardized
within the project management discipline,
nor is it standardized within many industries. The terms I am
using in this article are often used, but within
your organization you may have different terms for these same
concepts. Other terms that are often used to
represent WBS entry levels include stage, step, task, and work
package.
The Outline
The outline begins with a topic. It is the subject that the rest of
the work will describe. The outline is a tree
structure, and at its highest level the sections are numbered with
Roman Numerals. Within each Roman
Numeral heading, there are sub-headings with capital letters.
Within each of the capital letter sub-
headings, there are sub-sub-headings identified by Arabic

numbers.
The rules for outlines are as follows:
• At any level, if you have one entry at that level, then you
must have two or more, otherwise the level
itself is meaningless.
• At any level, the content of the lower level entries is
conceptually equivalent to the higher level entry
that they are a part of.
The WBS
Like the outline, the WBS is also a hierarchical tree structure.
At the highest level is the project. The
project is not part of the WBS, just like the topic is not part of
the outline. Within the project is a
hierarchical structure that defines the content of the project, just
like the outline defines the content of the
topic. Therefore, the following general statements are valid:
• Although the WBS content does not have to roll-up
conceptually like an outline does, this is a very
good idea as it provides the project manager with the ability to
validate the WBS before committing to
a completion date.
• Any WBS entry, when decomposed into components, should
have two or more components defined,
otherwise the decomposition itself is meaningless.
• For any WBS entry that is decomposed into components: the
content of the lower level entries should
be conceptually equivalent to the higher level entry that they
are a part of. In other words, the higher

level entry should be a deliverable, and the lower level entries
should be components of that
deliverable.
Like the outline, when not done properly there will be
corrective action applied, only you won’t have to
stay after school. In all likelihood, the project will be late, over
budget, and not meet expectations…
Creating the Work Breakdown Structure
The WBS can be structured in either of two ways. The first
approach structures the WBS primarily from a
deliverables perspective, in that the highest level (Level 1)
entries represent the major deliverables that the
project is committed to create. The second approach is from a
life cycle perspective, in that the highest
level entries in the WBS correspond to the major phases of the
life cycle.
Steps to create a deliverable-based structure:
1. Take the committed deliverables from your project charter,
statement of work, or other project concept
documentation. This list of deliverables becomes your Level 1
(highest level) entries within the WBS.
All WBS Entries that directly correspond to deliverables should
be named as noun deliverables or
adjective/noun deliverables. Examples include “Specification”
or “Design Specification”.
2. Take each of these highest level entries, and decompose them
into their component parts (each
becoming a WBS Entry). Each component must be logically
distinct, as everyone who sees the WBS
needs to understand what the deliverable or outcome will be

from each WBS Entry.
What logically distinct means is that the breakdown of a higher
level deliverable to its lower level components must make
sense. Each of the lower level components musts be
distinguishable as unique, and they must be recognizable as part
of
the higher level deliverable.
Continue the decomposition until you reach an appropriate level
of detail.
This last very vague statement is intentionally so, as the level of
detail in a WBS should be based on the complexity of the
project, the level of risk in the project, and the level of control
that the project manager needs to plan and manage the
project. However, a general guideline in many IT organizations
is that each lowest level entry in the WBS should be
assigned to a single individual, and that individual should be
able to complete it in 1 to 10 working days. This lowest level
of decomposition is the Activity level. Activities should be
named as active verb / adjective / noun deliverables. Examples
include “Create Design Specification” or “Update Design
Specification”. By adding the active verb, you better
communicate to the assigned team member not only what the
outcome is (the deliverable) but you also communicate what
kind of process the assigned person is going to perform (create
or update). Note: You should never use terms like
“perform”, as they do not communicate what is expected.
3. When all committed deliverables have been decomposed to
the appropriate level of detail (becoming
Activities), examine each WBS Entry and Activity to see if

there are required deliverables that are not
already in the WBS but that will be needed to create something
that already is in the WBS.
As an example, you may have a deliverable defined for a
software component (system, subsystem, or function).
However,
to deliver this into the production environment, you may also
need preceding deliverables such as test results, compiled
code, design documentation, and requirements documentation.
These preceding deliverables, even though they haven’t
been committed to, still must be created and therefore must be
in the WBS.
Take all these required deliverables, and decompose them to the
appropriate level of detail, just as you
did for the committed deliverables.
4. Level the hierarchy to the extent that it is possible. At this
stage of development, the WBS may have
some Activities at level two, some at level three, and so on.
See if the hierarchy can be modified so
that the number of levels that Activities fall into is reduced to a
short range.
One way to do this is to examine the number of Activities
falling within a single WBS Entry. If the number is less than
three to five, see if these Activities can be merged with another
WBS Entry’s Activities. If the number is more than 10, see
if the WBS Entry can be split into two logically distinct
components, each with its appropriate Activities. The general
idea
is to attempt to have each WBS Entry that decomposes into
Activities have approximately 7 plus or minus 2 (5 to 9)
Activities.

Do this for every WBS Entry, attempting to get each entry in
the WBS to decompose into 5 to 9 lower
level entries. This should be considered as a nice to have, and
not a requirement. You should never
make these changes if the merger or split of a WBS Entry does
not make logical sense.
• When evaluating whether to merge two WBS Entries, the
question to ask is, “are these two
deliverables really part of one deliverable, and is that
deliverable distinct from all others?” If the
answer is yes, then you should combine them, otherwise don’t.
• When evaluating whether to split a WBS Entry with too many
components, the question to ask is,
“does this WBS Entry deliverable have two or more major
components, and can the already
defined lower level deliverables be combined into these
proposed higher level ones?” If the
answer is yes, then you can split the WBS Entry. If the answer
is no, then leave it as is.
5. When you think you have a completed WBS, validate it using
a bottom-up approach. A bottom-up
validation works like this:
• For each WBS Entry that decomposes into Activities, ask
yourself the question: “If I had all the
deliverables from each of these Activities, would my WBS
Entry deliverable be complete?” If the
answer is yes, move on to the next WBS Entry. If the answer is
no, add in the missing Activities.
• Once the evaluation of the lowest level WBS Entries and
Activities is complete, examine the next
higher level of WBS Entries. Keeping with our three-level

example, for each Phase ask: “If I had
the deliverables from the WBS Entries that are part of this
Phase, would the Phase deliverable be
complete?” If the answer is yes, move on to the next one, if the
answer is no than add in the
missing WBS Entries or go back to step 4 and rebalance the
hierarchy, or both.
Note: Validating the completeness of the WBS if extremely
important, as a major reason for projects
being late and over budget is the originally planned scope of the
project was incomplete, and there was
a significant amount of unplanned work that had to be done.
Since this unplanned work was not part
of the original plan, and it consumed resources that were
originally scheduled for other project work,
the schedule inevitably slips.
6. When you have completed your bottom-up validation, it is
now appropriate to re-evaluate the entire
WBS one last time by comparing the currently defined WBS
deliverables to the originally defined
objectives for the project. Ask yourself the question, “If I had
all these deliverables, would I achieve
the planned objectives for the project?” If the answer is yes,
you can move on to the next step. If the
answer is no, you still have a lot of work to do.
An Example WBS
The following example has the terminology used in this article
in the leftmost column. In the middle

column, is an example numbering system that is typical of many
that are used, and the far right column
provides the names of the entries as they would appear in your
project plan.
Phase 1 – WBS Level 1 1.0 Requirements Phase
WBS Entry - WBS Level 2 1.1 Business Objectives
Activity – WBS Level 3 1.1.1 Create Draft Objectives
Activity – WBS Level 3 1.1.2 Review Draft Objectives
Activity – WBS Level 3 1.1.3 Update Objectives
Activity – WBS Level 3 1.1.4 Approve Objectives
Milestone – WBS Level 3 1.1.5 Business Objectives Complete
WBS Entry – WBS Level 2 1.2 Draft Requirements
Activity – WBS Level 3 1.2.1 Interview Stakeholders
Activity – WBS Level 3 1.2.2 Write Draft Requirements
Activity – WBS Level 3 1.2.3 …
WBS Entry - Level 2 1.3 Final Requirements
…
Phase 2 – WBS Level 1 2.0 Design Phase
…
Phase 3 – WBS Level 1 3.0 Development Phase

…
Phase 4 – WBS Level 1 4.0 Test Phase
…
This example is a typical waterfall type of project plan. Each of
the Phases are major process steps, and as
such usually also happen to be major deliverables.
Steps to create a life cycle-based structure:
1. Take each of the major Phases from the life cycle, and use
them as the highest level entries in the WBS
(Level 1).
2. Take the committed deliverables (as in the deliverables
approach) and use them to create the next level
WBS Entry (Level 2) under the Phases. Place these committed
deliverables within the Phase where
they will be created.
3. Decompose the rest of the WBS just as in the deliverables
approach.
Templates
Both the deliverables-based and the life cycle-based approaches
can take advantage of using standard WBS
structures and standard project templates. There is considerable
time savings for the project manager when
he or she does not have to spend the time to develop a WBS
from scratch, not to mention all the additional
planning information that gets attached to the WBS like
estimates, dependencies, and generic resource

assignments.
Completing The Work Breakdown Structure
Once the deliverables hierarchy has been established, detailed,
and validated, it is time to move on to the
final steps in completing your WBS. First up is compensating
for the uncertainty that exists in your
project. This is usually referred to as Risk Planning. My
favorite technique to compensate for uncertainty
within the WBS is as follows.
Contingency Planning
1. Take those risk events that have a schedule or cost impact
from your project charter, statement of
work, risk management plan, or wherever you have risk events
documented, and create a contingency
activity that is named for the risk event.
2. Examine the WBS, and determine which Activity or
Activities would be impacted by this risk event,
should it occur. If there is only one Activity that will be
impacted, insert the contingency activity
immediately after the impacted Activity in the WBS. If there is
more than one, insert the contingency
activity immediately after the impacted Activity that you think
will be scheduled first.
3. Using the documented risk event impact and probability,
calculate the duration of the contingency
Activity. As an example, if the risk event had an estimated

impact of four weeks, and an estimated
probability of 25%, then the scheduled duration for the
contingency Activity would be 1 week. (25% x
4 weeks = 1 week).
4. When you define your dependency network, you will want to
create a finish – start dependency link
from each impacted Activity to the appropriate contingency
activity. The normal successor to the
impacted Activity should be defined as a successor to the
contingency activity. When scheduled, you
will have incorporated a compensating factor for the schedule
uncertainty in your project.
5. As for compensating for the cost uncertainty, that is even
easier. Assign to each contingency Activity
the type of resource that reflects the cost in the impact, and the
estimated amount. As an example: if
the impact of the risk event is $100,000, should it occur, and
the likelihood is 40%, then you would
assign a budget resource to the contingency activity, and plan
for a value of $40,000. (40% x $100,000
= $40,000).
Milestones
The final step in completing your WBS is the inclusion of
Milestones. Milestones are major events that
occur during the course of the project, and should have the
following characteristics:
• They are a point in time, and therefore have no duration. In
most project management software, you
define a milestone by setting the duration of an Activity to zero.
• Milestones represent major points of progress within the
project, and will provide a high level means

of communicating. Therefore they should represent events that
have significant importance for project
stakeholders. As an example, if the project charter or statement
of work included committed
deliverables that the stakeholders felt were important to the
success of the project, then each of these
committed deliverables should have a milestone representing its
completion.
• Milestones should be named as past tense events. As an
example, “Acceptance Test Completed”. This
communicates two facts: the life cycle phase or the major
deliverable, and the fact that it is completed.
Milestones can also represent the beginning of a process, as in
“Acceptance Test Started”, but the
completion milestones should always be included in the WBS
whereas the start milestones are
optional.
Conclusion
This process for creating a Work Breakdown Structure is a
major, but not the only, planning deliverable a
project manager needs to complete when planning a project. It
is true that you can’t complete your project
planning without a WBS, but it is not true that the WBS is the
only planning you must do. Once the WBS
is completed, you must develop a dependency network, estimate
Activity duration, acquire and assign
resources, calculate and refine the schedule, and baseline the
plan. Many of these steps can be performed
somewhat in parallel, but it is absolutely true that you cannot
complete the dependency network, the
estimates, the work assignments, or the schedule until the WBS
is complete.

Author
Kim Colenso is the Managing Principal of the Methodology and
Project Management Process consulting
practice with Artemis Management Systems, with over 20 years
experience in IT and over 15 years
experience in project management. He is PMP certified by the
Project Management Institute (PMI), and is
a Certified Software Quality Engineer by the American Society
for Quality (ASQ). Currently he is serving
as the volunteer project manager for PMI’s Practice Standard
for Work Breakdown Structures project,
which will provide guidance to project management
practitioners worldwide on using the WBS as a project
management tool.
Creating The Work Breakdown Structure
The Effects of Hospital-Level Factors
on Patients' Ratings of Physician
Communication
Mona Al-Amin, PhD, assistant professor, Healthcare
Administration Department,
Sawyer Business School, Suffolk University, Boston,
Massachusetts; and Suzanne C.
Makarem, PhD, assistant professor, Marketing Department,
Virginia Commonweath
University, Richmond
E X E C U T I V E S U M M A R Y

The quality of physician-patient communication influences
patient health outcomes
and satisfaction with healthcare delivery. Yet, little is known
about contextual factors
that influence physicians' communication with their patients.
The main purpose of
this article is to examine organizational-level factors that
influence patient percep-
tions of physician communication in inpatient settings. We used
the Hospital Con-
sumer Assessment of Healthcare Providers and Systems
(HCAHPS) survey and
American Hospital Association data to determine patients'
ratings of physician
communication at the hospital level, and to collect information
about hospital-level
factors that can potentially influence physician communication.
Our sample con-
sisted of 2,756 hospitals.
We ran a regression analysis to determine the predictors of poor
physician
communication, measured as the percentage of patients in a
hospital who reported
that physicians sometimes or never communicated well. In our
sample of hospitals,
this percentage ranged between 0% and 21%, with 25% of
hospitals receiving poor
ratings from more than 6% of patients. Three organizational
factors had statistically
significant negative associations with physician communication:
for-profit owner-
ship, hospital size, and hospitalists providing care in the
hospital. On the other
hand, the number of full-time-equivalent physicians and dentists
per 10,000 inpa-

tient days, physician ownership of the hospital, Medicare share
of inpatient days, and
public ownership were positively associated with patients'
ratings of physician
communication. Physician staffing levels are an understudied
area in healthcare
research. Our findings indicate that physician staffing levels
affect the quality of
physician communication with patients. Moreover, for-profit
and larger hospitals
should invest more in physician communication given the role
that HCAHPS plays
in value-based purchasing.
For more information about the concepts in this article, contact
Dr. Al-Amin at
[email protected]
28
mailto:[email protected]
Patients' Ratings of P hysician Communication
I N T R O D U C T I O N
Patient-physician relationships, and
communication specifically, influence
patient outcomes, patient satisfaction,
recall of information, and adherence to
treatment regimens (Chang et al., 2006;
Roter, 1989; Schneider, Kaplan, Green-
field, Li, & Wilson, 2004; Zachariae et
ah, 2003). Evidence also indicates that
physician communication is associated
with a shorter length of stay and fewer
complications (Trummer, Mueller,

Nowak, Stidl, & Pelikan, 2006). As
Windish and Olson (2011, p. 44)
pointed out, the "patient-physician
relationship is the cornerstone for
quality of health care." The ll.S. Medical
Licensing Examination and Accredita-
tion Council for Graduate Medical
Education emphasizes the importance
of patient-physician communication
through the evaluation of residents'
communication skills (Zolnierek <&
DiMatteo, 2009). The Hospital Con-
sumer Assessment of Healthcare Provid-
ers and Systems (HCAHPS) survey has
provided publicly available data pertain-
ing to patients' hospital experiences.
HCAHPS results were first reported
publicly in March 2008 (Rothman, Park,
Hays, Edwards, & Dudley, 2008).
HCAHPS contains measures of interper-
sonal communication, specifically
quality of communication with physi-
cians and nurses. In 2009, 1 year after
HCAHPS scores were first released,
hospitals witnessed a modest improve-
ment in their overall ratings and patient
ratings on all dimensions, with the
exception of physician communication
(Elliott et al., 2010).
Clever, fin, Levinson, and Meltzer
(2008) argue that physician commu-
nication is significantly associated with
patient satisfaction and with patients'
overall ratings of their hospital experi-

ence. Therefore, physician communica-
tion is not only important for its impact
on patient outcomes but also is impor-
tant because of its role in influencing
overall patient ratings of the hospital
(O'Malley et al., 2005). Patient percep-
tions and overall ratings of the inpatient
experience have emerged as important
indicators of hospital performance.
Value-based purchasing (VBP) provides
financial incentives for hospitals to
improve HCAHPS scores and to main-
tain good scores (Elliott et al., 2010).
Hence, patient ratings of the hospital
experience are an aspect of care that can
potentially influence the hospital's
livelihood. Among the care dimensions
that influence patient perceptions of
quality of care, physician communica-
tion is one of the most important. In
fact, pay-for-performance initiatives will
become tied less to technical competen-
cies and more to the quality of patient-
physician interactions (Safavi, 2006b).
While ample literature exists regard-
ing the impact of patient-physician
communication on patient satisfaction,
clinical outcomes, and organizational
outcomes (Hammerly, Harmon, &
Schwaitzberg, 2014), limited research is
available on the organizational factors
that shape this communication. Physi-
cian behavior, including physician
communication, does not occur in a
vacuum, but is influenced by organiza-

tional structure, environment, and
culture. Physicians' attitudes about
healthcare organizations may influence
their cooperative behavior, and these
attitudes are shaped by the degree to
29
Journal of H ealthcare Management 61:1 January/F ebruary
2016
which physicians identify with the
organization (Dukerich, Golden, &
Shortell, 2002). Furthermore, Ham-
merly et al. (2014) argue that organiza-
tional efforts to improve physician
alignment should take into consider-
ation physicians' emotional intelligence,
including their communication and
interpersonal skills.
The main purpose of this study is to
examine organizational-level factors that
influence physician communication
with patients in inpatient settings.
Physicians operate in an organizational
context and, although communication
skills vary at the individual level, organi-
zational structure, culture, staffing levels,
availability of electronic health records
(EHRs), and other organizational-level
factors affect physicians and, in turn, the
time, commitment, and incentives they
have to provide better patient experi-

ences. This study contributes to our
understanding of how organizational
factors may affect physician communi-
cation, as measured by HCAHPS scores.
Given patient expectations, the potential
for financial penalties, and the negative
impact that poor physician communica-
tion can have on a hospital's public
image, this understanding is crucial for
hospital leaders.
Physician ownership of hospital
shares, defined by the American Hospi-
tal Association (AHA) (2009) as a
hospital "owned in whole or in part by
physicians or a physician group," is one
factor that influences physicians' align-
ment and identification with the hospi-
tal and, thus, their attitudes toward
hospital performance and success, their
subsequent behavior, and its effects on
organizational performance (McCarthy,
Reeves, & Turner, 2010). The organiza-
tional theory literature contains ample
research on the role of employee owner-
ship and its influence on organizational
performance, especially for professional
service firms such as hospitals (Klein,
1987; Long, 1980). Physician ownership
has also been examined in previous
healthcare research about the effects of
organizational factors on the quality of
physicians' services (Conrad & Chris-
tianson, 2004) and on patients' satisfac-
tion, as evidenced by HCAHPS ratings

(Makarem & Al-Amin, 2014).
In addition to ownership, which
might influence physicians' attitudes,
operational variables (such as physician
staffing levels and number of full-time-
equivalent [FTE] physicians available for
a certain number of inpatient days) are
likely to affect quality of care, the
amount of time the physician has to
take care of patients, and the quality of
physician communication. Although the
effect of nurse staffing levels on patient
satisfaction has received a lot of atten-
tion from researchers (Aiken, Clarke,
Sloane, Sochalski, & Silber, 2002; Vahey,
Aiken, Sloane, Clarke, & Vargas, 2004),
the relationship between physician
staffing levels and quality and patient
experience is understudied. Shanafelt et
al. (2012) found a prevalence of burn-
out among physicians in the United
States, which can have detrimental
effects on quality of care, but their study
did not take physician staffing levels
into account.
Given the critical role that physician
communication plays in patient out-
comes and satisfaction, it is important
to explain the variation in patient
ratings of physician communication not
30

Patients' Ratings of Physician Communication
just between patients, but also between
hospitals. To that end, we take a step
back from understanding how to
improve physician communication to
focus on establishing a clearer picture of
the effects of organizational-level factors
on patient perceptions of physician
communication.
C O N C E P T U A L F R A M E W O R K
The conceptual framework by Donabe-
dian (1980) has been used frequently in
health services research on quality.
According to this framework, there are
three categories for assessing quality:
(1) structure—organizational character-
istics or attributes, such as staff-to-
patient ratio, that influence care delivery;
(2) process—protocols, practices, and
the actual steps followed in delivering
the service; and (3) outcomes—measures
such as survival and mortality rates,
readmission rates, and patient satisfac-
tion and number of complaints (Blies-
mer, Smayling, Kane, & Shannon, 1998;
Davis, 1991). Both structure and process
influence outcomes.
Donabedian differentiates between
two domains of quality: (1) technical, the
medical and clinical dimensions of care
such as mortality and survival rates, and
(2) interpersonal, the sociopsychological

features of physician-patient communi-
cation (Cleary & McNeil, 1988). We focus
on physician communication, an inter-
personal dimension of quality, which
also influences technical quality because
poor physician-patient communication
can result in patients' not understanding
their treatment regimen and in not
complying with physicians' orders and
recommendations (Cleary & McNeil,
1988). Our main objective is to
determine how structural dimensions
influence physician-patient communica-
tion. We hypothesize that a higher
physician staffing level, a key structural
attribute, is associated with higher ratings
of physician-patient communication.
Using HCAHPS data, Kutney-Lee et al.
(2009) found that nurse staffing levels
were significantly related to patients'
ratings of nurse communication. We
predict a similar relationship between
physician staffing levels and patients'
ratings of physician communication.
M E T H O D S
Data Sources
We used two sources of secondary data
to determine patients' ratings of physi-
cian communication at the hospital
level and hospital-level factors that
could potentially influence the quality
of physician communication. We used
2009 HCAHPS survey data, which are
publicly available on the Centers for

Medicare & Medicaid Services Hospital
Compare website. The HCAHPS survey
was developed to assess patients' experi-
ences of their hospital stay, and its
validity and reliability are supported by
several studies (Goldstein, Farquhar,
Crofton, Darby, & Garfinkel, 2005;
O'Malley et al., 2005; Rothman et al.,
2008). The publicly available data adjust
for patient-mix factors such as age,
education, health status, and method of
suivey administration (Elliott et al.,
2009; Jha, Joynt, Orav, & Epstein, 2012).
Physician communication, one of the
eight dimensions in HCAHPS, is mea-
sured by asking patients to rate how
often their doctors communicated well
with them. The final results are then
31
Journal of H ealthcare M anagement 61:1 January/ F ebruary
2016
reported as the percentage of patients in
a hospital who responded (1) always,
(2) usually, and (3) sometimes or never.
For our analysis, we merged the
AHA annual survey database (2009)
with HCAHPS data. All organizational-
level variables were derived from the
AHA database. Specifically, we retrieved
information about hospital size, FTE

physicians and dentists per 10,000
inpatient days, hospitalists providing
care at the hospital, physician owner-
ship, for-profit ownership, public
ownership, teaching status, specialty
status, Medicare share of admissions
(i.e., Medicare admissions divided by
total admissions), EHRs, and high
technology index.
V a ria b le s
Dependent Variable
Because we were interested in organiza-
tional factors that could impede the
quality of patient-physician communica-
tion, we defined our dependent variable
as the percentage of patients in a hospital
who reported that physicians "sometimes
or never" communicated well. This
variable was reported in HCAHPS.
Independent Variables
The AHA database includes data regard-
ing part-time and FTE hospital staff.
However, the data do not distinguish
between inpatient and outpatient
settings, and they report FTE medical
doctors (MDs) and dentists as one
measure; hence, we were unable to
exclude dentists from our staffing vari-
able. From the AHA database, we
included one staffing measure in our
model: FTE MDs and dentists per 10,000
patient days. Several studies have used

the number of FTE registered nurses
(RNs) per 1,000 patient days as a mea-
sure of RN staffing levels (Kane, Shamli-
yan, Mueller, Duval, & Wilt, 2007; Mark,
Harless, McCue, & Xu, 2004). We created
a similar variable for physician staffing
level by dividing the number of FTE MDs
and dentists by inpatient days and
multiplying the quotient by 10,000; we
used 10,000 instead of 1,000 because the
number of MDs and dentists at a hospi-
tal is often much smaller than the
number of RNs. While studies tradition-
ally have examined the impact of nurse
staffing levels on quality and patient
satisfaction (Aiken et al., 2002; Bond,
Raehl, Pitterle, & Frank, 1999; McCue,
Mark, & Harless, 2003), ours is among
the first studies to examine the role of
physician staffing levels. Pharm, Raehl,
and Pitterles (1999) were among the few
researchers to investigate the relationship
between physician staffing levels and
quality of care, but they used hospital
mortality rate, a technical measure of
quality of care, as their outcome measure
and found the relationship to be insig-
nificant (White & Glazier, 2011). We also
included a dummy variable indicating
whether hospitalists provide care at the
hospital. Previous research indicates no
difference in patient satisfaction between
those treated by hospitalists and those
treated by primary care providers (Seiler
et al., 2012). However, given the growth
of hospitalists in the past decade, it is

important to compare hospitals that have
hospitalists with those that do not in
terms of physician communication
ratings.
Previous research findings indicate
that physician ownership has a positive
association with patients' overall ratings
3 2
of the hospital experience (Makarem &
Al-Amin, 2014). According to Long
(1980), ownership results in increased
involvement and commitment. In fact,
when their incomes and reputation are
tied to hospital performance, physicians
are more driven to help the hospital
enhance its performance and achieve its
goals. Therefore, we included a dummy
variable—"hospital owned in whole or
in part by physicians or a physician's
group"—in our model to investigate the
effect of physician ownership on physi-
cian communication.
We also created a high-technology
index, which is the total number of
technologies or services in a hospital
that are considered to be high technol-
ogy. The AHA database contains a list of
technologies and services available in

hospitals. Here are the high-technology
services, which we modified from
Landon et al. (2006):
1. Adult cardiac surgery
2. Adult diagnostic/invasive
catheterization
3. Certified trauma center
4. Extracorporeal shock-wave
lithotripter
5. Bone marrow transplant services
6. Heart transplant
7. Kidney transplant
8. Liver transplant
9. Lung transplant
10. Tissue transplant
11. Other transplant
12. Robotic surgery
13. Computer-assisted orthopedic
surgery
We controlled for organizational
characteristics that have been found to
influence HCAHPS ratings (Jha, Orav,
Zheng, & Epstein, 2008; Lehrman et al.,
2010). We classified hospitals as teach-
ing hospitals if they belonged to the
Council of Teaching Hospitals and
Health Systems. Other organizational
factors included as predictors in our
model are hospital size (measured as
the number of beds in a hospital),

for-profit ownership, public ownership,
presence of fully implemented EHRs,
specialty hospital, and Medicare share of
inpatient days. Specialty hospital is a
dichotomous variable indicating
whether the hospital is a limited service
hospital, on the basis of the AHA
database. We included these organiza-
tional variables in the model because of
their documented influence on patient
ratings of hospital experience or quality
of care (Jha et al., 2008; Makarem &
Al-Amin, 2014).
R e g r e s s i o n A n a l y s i s a n d S a m p l e
D e s c r i p t i o n
We ran the regression analysis using
statistical software (Stata 13, StataCorp)
to determine the association between
ratings of physician communication and
organizational-level predictors. Outliers
or extreme values influence regression
parameters and, therefore, are of con-
cern in any regression analysis. High
leverage refers to data points that have
extreme values on a given predictor
(Bobko, 2001). High leverage is of
specific concern to this study because
one of the main independent variables—
FTE MDs and dentists per 10,000
inpatient days—has not, to our knowl-
edge, been validated in the literature.
33

2016
Therefore, we paid specific attention to
this variable. After removing hospitals
with missing data, we found a mean of
5.92 FTE MDs and dentists per 10,000
inpatient days, with a standard devia-
tion (SD) of 17 (75th percentile = 5.71
and maximum value = 625). Clearly,
there were points with high leverage.
Therefore, we used the extremes com-
mand in the statistical software, which
reports the top five cases with extreme
values, and we eliminated these cases
from the data set (values ranged from
203 to 625 FTE MDs and dentists per
10,000 inpatient days). Our final sample
consisted of 2,756 hospitals.
In our sample of hospitals, 9% have
teaching status, 14% are for-profits, 18%
are public hospitals, only 5% are par-
tially or fully owned by physicians, 3%
are specialty hospitals, 68% have hospi-
talists providing care, and 23% have
fully implemented EEIRs (77% had
either partially implemented EHRs or no
EHRs). The average hospital size is 210
beds, the average number of FTE MDs
and dentists per 10,000 inpatient days is
5.5, and the average Medicare share of
admissions is 50%. The hospitals in our
sample have an average of 2.4 services or

technologies out of a maximum possible
high technology index score of 13. Table
1 provides details about characteristics
of the hospitals. After testing for multi-
collinearity, we found a significant
correlation between hospital size and
high technology index (r = 0.74).
Therefore, we dropped the high technol-
ogy index variable from the model.
Given the recommended threshold of 10
for variance inflation factors, we found
no further evidence of multicollinearity
in the regression model (Hair, Tatham,
Anderson, & Black, 2006).
T A B L E 1
C h a ra c te r is tic s of H o s p ita ls in th e S a m p le
N o . (%) of H o s p ita ls
C h a ra c te r is tic s N = 2 ,7 5 6 M e a n (SD)
Teaching Hospital (Belongs to COTH) 256 (9 ) —
For-Profit Ownership 386 (14) —
Public Ownership 493 (18) —
Physician Ownership 136(5) —
Specialty Status 91 (3) —
Hospitalists Provide Care 1,879 (68) —
Fully Implemented Electronic Health Records 637 (23) —
Number of Beds — 210 (212)

Full-Time-Equivalent Physicians and Dentists per — 5.48
(10.96)
10,000 Inpatient Days
Medicare % of Inpatient Days — 50.5 (16.88)
Note. SD = standard deviation; COTH = Council ofTeaching
Hospitals and Health Systems.
3 4
T A B L E 2
E ffe c ts o f O rg a n iz a tio n a l F a c to rs on P a t ie n ts ’
R a t in g s of P h y s ic ia n C o m m u n ic a tio n
P re d ic to r
R e g re s s io n
C o e ffic ie n t t /7 V a lu e *
Teaching Hospital (Belongs to COTH) 0.0922 0.53 .596
For-Profit Hospital 1.2775 9.24 «* .000
Public Ownership -0.3917 -3.53 « .000
Specialty Status -1.1109 0.48 .630
Physician Ownership -1.5118 -6.85 « .000
Electronic Health Records 0.1204 1.22 .223
Num ber of Beds 0.0027 10.57 = .000
Full-Time-Equivalent Physicians and
Dentists per 10,000 Inpatient Days -0.0084 -2.22 .026
Hospitalists Provide Care 0.7252 7.73 =» .000
Medicare % of Inpatient Days -0.0066 -2.6 .009

Note. F( 10,2756) = 53.75 (p < .001); adjusted R2 = 0.16; N =
2,756.
Note. Dependent variable: physician communication =
percentage of patients who rated "physician communicated
well" as
"sometimes or never."
*p value significant at < .05.
R E S U L T S
In our sample of 2,756 hospitals, an
average of 4.65% (SD = 2.32%) of
patients reported that physicians com-
municated well "sometimes or never."
In the best-performing hospitals, no
patients reported that physicians some-
times or never communicated well,
whereas 21 % of patients in the worst-
performing hospitals reported that
physicians sometimes or never commu-
nicated well. In 25% of the hospitals,
more than 6% of patients reported that
physicians communicated poorly.
The regression analysis results
indicate that the regression model is
significant with F = 53.75 (p < .001),
and that the predictors in our model
account for 16% of the variance in
physician ratings (Table 2). The results
also show that all but three hospital-
level factors have a statistically signifi-
cant association with patient ratings of

physician communication at a .05
significance level. The hospital's spe-
cialty status, teaching status, and avail-
ability of fully implemented EHRs had
no significant association with ratings of
physician communication. Hospital
size, hospitalists' providing care at the
hospital, and for-profit ownership were
significant predictors of, and positively
associated with, the percentage of
patients who rated physician communi-
cation poorly (p < .01). For-profit
hospitals and larger hospitals received
poorer patient ratings of physician
communication. Also, the percentage of
patients who reported poor physician
communication was higher in hospitals
35
2016
in which hospitalists provided care (p <
.01). To investigate this further, we ran a
single-factor analysis of variance fol-
lowed by a Tukey Honest Significant
Difference post hoc test to compare
physician communication ratings
between (1) hospitals in which hospital-
ists did not provide care, (2) hospitals
that contracted with independent
hospitalists groups, and (3) hospitals
that employed hospitalists. The results

of our analysis show a significant
difference between the three groups in
the mean percentage of patients who
reported poor physician communication
(p < .001). Hospitals in which hospital-
ists did not provide care had the lowest
percentage (3.8%) of patients reporting
poor physician communication, fol-
lowed by hospitals that employed
hospitalists (4.8%). Hospitals that
contracted with independent hospitalist
groups had the highest percentage of
patients (5.2%) reporting poor physi-
cian communication.
In contrast, FTE MDs and dentists
per 10,000 inpatient days, physician
ownership, public ownership, and
Medicare share of inpatient days had
statistically significant negative associa-
tions with the percentage of patients
who rated physician communication
poorly. In our sample, hospitals with
more FTE MDs and dentists per 10,000
inpatient days had a lower percentage of
patients reporting poor physician
communication (p = .026). In other
words, lower physician staffing levels are
associated with poorer patient ratings of
physician communication. Also, hospi-
tals that are fully or partially owned by
physicians had a lower percentage of
patients reporting that physicians
communicated poorly (p < .01). Simi-
larly, public hospitals and those with a

higher share of Medicare inpatient days
had a lower percentage of patients
reporting poor physician communica-
tion (p < .01).
D I S C U S S I O N
The healthcare system in the United
States has moved toward VBP, which
rewards or penalizes hospitals on the
basis of their performance on patient
experiences, clinical processes, patient
outcomes, and, in the future, hospital
efficiency (Ryan & Damberg, 2013).
Moreover, patients' ratings of hospital
stays and outcome measures are now
publicly available. Given the impact that
VBP could have on hospital financial
performance and the impact that public
reporting could have on patients' choice
of hospitals, patient satisfaction with
physician communication is a key
improvement area for hospitals. An
organization's contextual factors influ-
ence employee behavior, yet research is
scarce regarding how hospital-level
factors affect physician performance and
behavior. Understanding hospital-level
variables that influence physician
performance is important, especially in
relation to physician communication
and interpersonal skills (Glick, 1985).
This study offers a better understanding
of organizational factors that impede
physician performance in an inpatient
setting by examining the effects of
various hospital characteristics on

patient perceptions of physician
communication.
In addition to considering multiple
organizational factors commonly
examined in healthcare quality research,
3 6
Patients' Ratings of P hysician C ommunication
this study sheds some light on the role
of factors, such as physician staffing,
that have been overlooked in previous
research. To the best of our knowledge,
no other studies have specifically
investigated how these organizational
factors predict poor patient-physician
communication. Our model shows a
statistically significant association
between many organizational factors—
7 out of 10 considered—and physician
communication. Consequently, organi-
zational factors should be included
when studying patient perceptions of
hospital performance and more specifi-
cally physician performance. Our study
findings have important implications for
physicians, hospital managers, and
policymakers.
One main and novel finding is the
significant role of physician staffing
levels, which is associated with patient

perceptions of physician communica-
tion. Given the prevalence of physician
burnout in the United States (Shanafelt
et al., 2012), this is an important finding
that sheds light on an underexplored
hospital-level factor that potentially
could influence quality of care and
patient experiences. Driven by hospitals'
interest in increasing market share and
aligning incentives with those of physi-
cians, hospitals have been employing
full-time physicians at a quick pace since
the passage of the Affordable Care Act
(ACA) (O'Malley, Bond, & Berenson,
2011). As hospitals rely more on physi-
cian employees, we need to be aware of
how physician workload or physician
staffing levels affect patient experiences.
By focusing solely on nurse staffing,
which is not directly linked to patient
ratings of physician communication,
most studies have overlooked the
influence of physician staffing on health
outcomes and patient satisfaction. A
smaller number of FTE MDs and den-
tists per 10,000 patient days indicates
higher workloads and, consequently,
less time and energy to spend with
patients. Because this can have a detri-
mental effect on the quality of patient-
physician communication, hospital
managers should pay special attention
to physician staffing levels. Another key
factor related to physician staffing is the
association between hospitalists and

patient ratings of physician communica-
tion. Our findings indicate that hospi-
tals that contract with independent
hospitalist groups had the poorest
ratings of physician communication.
Thus, it is important to differentiate
between the various arrangements
hospitals have with hospitalists provid-
ing inpatient care.
Another key hospital-level predictor
of physician communication ratings is
physicians' full or partial ownership of
the hospital. Our findings indicate that
hospitals in which physicians own
shares receive a lower percentage of poor
physician communication ratings than
hospitals in which physicians do not
own shares. This finding is not surpris-
ing given that ownership influences
employee attitudes, commitment, and
performance (Klein, 1987; McCarthy et
al., 2010). In line with the literature, our
study found that physician ownership is
likely to influence the quality of
patient-physician communication and,
thus, patient experiences, satisfaction
levels, and ratings.
Consistent with previous research,
our findings show that for-profit
37

2016
hospitals and hospitals that are larger in
size receive poorer patient ratings of
physician communication. In fact,
studies have reported lower patient
ratings of their overall hospital experi-
ence in for-profit hospitals (Jha et al.,
2012). The main goal of for-profit
hospitals is to generate profits for
shareholders. This goal is usually
achieved with a focus on efficiency,
which might come at the expense of the
patient experience. Also, research
findings indicate that size is negatively
associated with patients' overall ratings
of their hospital experience, with
smaller hospitals reporting better ratings
(Jha et al., 2008). Therefore, for-profit
hospitals and larger hospitals should
pay special attention to the quality of
physician communication and imple-
ment strategies and incentive systems for
improving it.
C O N C L U S I O N
S tu d y L im i t a t io n s
This study has a number of limitations.
First, the cross-sectional nature of the
data, limited to HCAHPS ratings 1 year
after the survey's public release, does not
allow for observing changes in physician
communication over time or how these
changes may have been affected by

organizational-level factors. Second,
although we considered organizational
factors that are commonly examined in
healthcare research, other factors—such
as organizational culture, physician job
satisfaction, and physician training—
could have significant effects on physi-
cian communication. Our findings
indicate that a fully implemented EHR
has no significant association with
patient perceptions of physician commu-
nication; however, our study did not take
into account whether physicians have
been trained to effectively communicate
with their patients using EHRs.
Finally, there are limitations associ-
ated with some of our measures.
Although we created a physician staffing
level variable that is similar to the
commonly used measure for nurse
staffing, this measure, to our knowl-
edge, has not been tested or validated in
other studies. Also, our outcome
variable—patients' ratings of physician
communication—is measured in
HCAHPS by means of a frequency scale
ranging from "sometimes or never" to
"always," rather than by asking patients
to rate the quality of communication
using scale points such as "poor" or
"excellent." This can limit the validity of
the measure because "always" is not
necessarily the same as "excellent"
(Reeves, Binder, & Grida, 2008).

P r a c t ic a l Im p l ic a t io n s a n d F u tu r e
R e s e a r c h D ir e c t io n s
With the exception of the teaching and
specialty status and the availability of
fully implemented EHRs, all remaining
seven hospital-level factors examined in
this study were significant predictors of
patient ratings of physician communica-
tion. Thus, organizational-level factors
should be considered in future research
aimed at examining different aspects of
healthcare quality, especially patient
perceptions and ratings of hospitals.
Hospital leaders should be concerned
about public reporting of data and how
this may affect their bottom line. The
results of this study indicate that hospi-
tals may be able to improve the patient
3 8
experience, evidenced by HCAHPS
ratings, by paying attention to organiza-
tional factors such as staffing, the
hospitalists model, physician workload,
and physician engagement and align-
ment with organizational goals.
Specifically, hospitals need to pay
attention to physician staffing levels.
Moreover, hospitals that rely on hospi-

talists need to consider the benefits and
disadvantages of employing hospitalists
versus contracting with independent
groups. Doing so is important, not only
with regard to patient ratings, but also
with regard to outcomes and efficiency.
While offering physicians shares in
the hospital is not a feasible option after
the passage of the ACA, different mecha-
nisms are available through which
hospitals can provide physicians with a
sense of ownership and, hence,
strengthen the incentive to provide a
better patient experience. An example is
participating bond transactions (PBTs),
which tie physician income to hospital
performance. PBTs are tax-exempt bonds
that carry a high yield of about 11% to
14%, and the interest payment depends
on hospital performance; thus, these
bonds result in strong alignment
between physicians and hospitals
(Al-Amin, Weech-Maldonado, & Prad-
han, 2013; Safavi, 2006a).
In an increasingly competitive
market, public reporting of patient
ratings can push hospitals to perform
better to sustain their market share
(Chou, Deily, Li, & Lu, 2014). Research
is needed to further understand organi-
zational changes that can lead to
improved physician communication
over time. Researchers should examine
the long-term effect of public reporting

on physicians' behavior, especially their
communication with patients. In
addition to longitudinal studies of
secondary HCAHPS and AHA data,
researchers could benefit from using
different methodologies, such as case
studies and matched control designs, to
compare hospitals with similar capabili-
ties and target markets to gain a deeper
understanding of how organizational
factors affect the quality of physician
communication.
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41
Journal of H ealthcare M anagement 61:1 January/F ebruary
2016
P R A C T I T I O N E R A P P L I C A T I O N
Jeffrey Canose, MD, FACHE, chief operating officer, Texas
Health Resources,
Arlington, Texas
B efore the terms Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) surveys and value-based
purchasing (VBP) became part of our vocabu-
lary, healthcare organizations focused on patient perception,
satisfaction, and experi-
ence. The relationship of a physician's (and other caregivers')
interpersonal skills and
quality of communication with patient outcomes and
satisfaction has long been
recognized.

The HCAHPS surveys, which contain questions specifically
focused on how often
communication with patients occurs, has given us information
to challenge our
assumptions about how well we communicate with patients.
Healthcare organizations
and physicians have responded to the challenge of HCAHPS
surveys by enhancing
efforts around patient-centered behaviors and processes aimed
at improving the
quality of communication and keeping patients informed about
their care. While
these practices can be effective, their success in affecting
HCAHPS scores depends on
consistent and reliable execution. HCAHPS scores are also
sensitive to perceived or
actual barriers that make it difficult for caregivers to execute
performance consis-
tently. As healthcare leaders, we must support patients and
physicians by identifying
and removing or modifying barriers to effective communication.
Improving patient ratings of physician communication on the
HCAHPS survey
can be challenging. Al-Amin and Makarem look at an area that
has not yet had a
great deal of research: organizational factors that may influence
physician communi-
cation. The study provides insights into broad categories of
organizational factors
that can affect physicians' attitudes and their ability to
communicate effectively.
As organizations move from a medical staff model, composed of
community-

based physicians who have ongoing relationships with patients,
to an employed
physician and hospitalist model, healthcare leaders need to
better understand
organizational factors that may predict poor patient ratings of
physician communica-
tion. Physician engagement and alignment efforts are other
areas of needed research.
The most novel aspect of this study is quantification of
physician staffing and
workload as a predictor of patient ratings. More research on
staffing levels and
physician workload will be of value to administrators,
particularly in making deci-
sions to employ hospitalists or contract with groups to provide
patient care. Addi-
tional information will allow leaders to more adeptly balance
efficiency and cost
with quality, safety, and satisfaction of patients and physicians.
Many findings in this study validate what healthcare leaders
have empirically
observed. However, because the number of negative ratings is a
relatively small per-
centage of HCAHPS responses overall, further research to
identify organizational
4 2
P atients ' Ratings of P hysician C om m unication
factors that may predirt top box ratings of physician
communication would be valu-

able. Of particular interest are factors that move responses from
"usually" to "always."
Al-Amin and Makarem acknowledge study limitations, such as
its focus on
negative patient ratings provided in 2008—the first year of
HCAHPS surveys—and,
therefore, it does not take into account a multitude of efforts to
improve physician
communication in subsequent years. Moreover, in this initial
look at extenuating
organizational factors, the authors examine broad variables
(large versus small
organizations, for-profit versus not-for-profit organizations).
Research on organiza-
tional factors specific to each hospital category and their impact
on physician com-
munication would increase the relevance of the findings and
facilitate performance
improvement.
With the advent of VBP and public reporting, patients' ratings
of their experience
have the potential to affect an organization's reputation, market
share, and the
bottom line in ways that were not possible even a few years ago.
As healthcare
leaders, we have a responsibility to be aware of the factors that
affect the sustainabil-
ity and success of our organizations.
However, our larger obligation and the cornerstone of what we
do every day is
caring for people—body, mind, and spirit—in this special,
sacred, humbling, and
heroic ministry to which we have dedicated our careers. Timely

and thorough infor-
mation, communicated by physicians, nurses, and other
caregivers in a way patients
can understand, decreases anxiety, builds trust, and ultimately
leads to better out-
comes. Knowledge gained from studies such as this makes an
important contribution
to the literature that can lead to more successful partnerships
with physicians in
achieving this shared goal.
43
Copyright of Journal of Healthcare Management is the property
of American College of
Healthcare Executives and its content may not be copied or
emailed to multiple sites or posted
to a listserv without the copyright holder's express written
permission. However, users may
print, download, or email articles for individual use.
Module Four Worksheet
Every data collection and analysis method has limitations. For
this worksheet activity you will identify an article with a study
similar to that of your final project article. Identify all elements
of the article that you have studied in previous modules. In
addition, you will identify the limitations presented by the study
and the advantages and disadvantages of the statistical analysis
used.

To complete this assignment, complete the following steps:
1. Review the article you selected for the final project and
identify another article with a similar study in the references
list.
2. Obtain the article referenced by your final project article and
review it.
3. Download and complete this Module Four Worksheet
document. Address the following:
· Purpose, research question, and hypothesis
· Research methods
· Results or key findings
· Limitations
4. Upload and submit your completed worksheet assignment
Part I: Identify the Articles
1. What is the number of the article you have chosen from the
Final Project Articles document?
Article Number:
#4,5
Primary Article: Al-Amin, M., Makarem, S. C., & Canose, J.
(2016). The effects of hospital-level factors on patients’ ratings
of physician communication. Journal of Healthcare
Management, 61(1), 28–43.
2. What is the full APA style citation of the article you
identified from the references list of your final project article?
Al-Amin, M., Makarem, S. C., & Canose, J. (2016). The Effects
of Hospital-Level Factors on Patients' Ratings of Physician
Communication. Journal Of Healthcare Management, 61(1), 28-

43.
Part II: Purpose, Research Question, and Hypothesis
1. What is the purpose of the study?
2. What is/are the research question(s)?
3. What is/are the hypothesis(es) of the study?
4. What is/are the explanatory variable(s)?
5. What is/are the response variable(s)?
Part III: Research Methods

1. What population are the researchers interested in?
2. What is the sample? How did the researchers select their
sample?
3. How did the researchers collect their data?
4. What statistical analysis did the researchers use?
Part IV: Results or Key Findings
1. What was/were the result(s) of the research question(s)?
2. What were the differences in the groups that were being
studied?

3. Did the result support the researchers’ hypothesis or not?
4. List (with support) any other results that you found
interesting.
Part V: Limitations
1. What did the researchers state as the limitations of their
study?
2. Why are these limitations?
3. Please list a question you have about the study that was not
addressed in this article.

1
A Statement of Work (SOW) is typically used when the task is
well-known and can be described in specific terms.
Statement of Objective (SOO) and Performance Work Statement
(PWS) emphasize performance-based concepts
such as desired service outcomes and performance standards.
Whereas PWS/SOO's establish high-level outcomes
and objectives for performance and PWS's emphasize outcomes,
desired results and objectives at a more detailed
and measurable level, SOW's provide explicit statements of
work direction for the contractor to follow. However,
SOW's can also be found to contain references to desired
performance outcomes, performance standards, and

metrics, which is a preferred approach.
The Table of Content below is informational only and is
provided to you for purposes of outlining the
PWS/SOO/SOW. This sample is not all inclusive, therefore
the reader is cautioned to use professional judgment
and include agency specific references to their own
PWS/SOO/SOW.
Software Application and Web-based Service Interface Page 1
of 36
B.1 GENERAL DESCRIPTION
...............................................................................................
................................ 3
B.2 SERVICES AND PRICES/COSTS
...............................................................................................
..................... 3
B.3 INDIRECT / MATERIAL HANDLING RATE

...............................................................................................
.. 3
B.4 INCREMENTAL FUNDING LIMITATION OF
GOVERNMENT’S OBLIGATION ..................................... 4
B.5 CONTRACT ACCESS FEE
...............................................................................................
................................ 5
C.1 PURPOSE
...............................................................................................
............................................................ 5
C.2
BACKGROUND......................................................................
........................................................................... 5
C.2.1 AGENCY
MISSION................................................................................
........................................................... 6
C.2.2 CURRENT ENVIRONMENT
...............................................................................................
............................. 7
C.3 SCOPE
...............................................................................................
................................................................. 7
C.4
OBJECTIVE............................................................................
............................................................................ 7
C.5 TASKS
...............................................................................................

................................................................. 8
C.5.1 TASK 1 - DEVELOPMENT, MODERNIZATION AND
ENHANCEMENT (DME) ...................................... 8
C.5.2 TASK 2 – STEADY-STATE CORRECTIVE
MAINTENANCE ....................................................................
13
C.5.3 TASK 3 – MONTHLY STEADY-STATE OPERATIONAL
SUPPORT ........................................................ 17
C.5.4 TASK 4 – TRANSITION
SERVICES..............................................................................
................................ 20
C.6 SECTION 508 COMPLIANCE
...............................................................................................
......................... 20
D.1 DELIVERABLES MEDIA
...............................................................................................
................................ 21
E.1 PLACE OF INSPECTION AND ACCEPTANCE
...........................................................................................
21
E.2 SCOPE OF INSPECTION
...................................................................................... .........
................................. 22
E.3 BASIS OF ACCEPTANCE
...............................................................................................
............................... 22

E.4 INITIAL
DELIVERABLES....................................................................
.......................................................... 22
E.5 WRITTEN ACCEPTANCE/REJECTION BY THE
GOVERNMENT............................................................ 22
E.6 NON-CONFORMING PRODUCTS OR SERVICES
...................................................................................... 22
F.1 PLACE OF
PERFORMANCE.....................................................................
..................................................... 23
F.2 PERIOD OF
PERFORMANCE.....................................................................
................................................... 23
F.3 TASK ORDER SCHEDULE AND MILESTONE DATES
............................................................................. 23
F.4 PLACE(S) OF DELIVERY
...............................................................................................
............................... 27
F.5 NOTICE REGARDING LATE
DELIVERY.............................................................................
....................... 27
G.1 INVOICE SUBMISSION
...............................................................................................
.................................. 28
G.2 INVOICE
REQUIREMENTS....................................................................
....................................................... 28

G.2.1 INVOICING INSTRUCTIONS
...............................................................................................
......................... 28
G.2.2 TRAVEL
...............................................................................................
............................................................ 29
G.3 LIMITATION OF
COSTS....................................................................................
............................................ 29
H.1 GOVERNMENT FURNISHED PROPERTY (GFP)
....................................................................................... 29
H.2 GOVERNMENT FURNISHED
INFORMATION......................................................................
..................... 29
H.3 TRAVEL
...............................................................................................
............................................................ 30
H.3.1 TRAVEL REGULATIONS
...............................................................................................
............................... 30
H.5 SECURITY
REQUIREMENTS................................................................ ....
.................................................... 30
H.5.1 SECURITY
POLICY..................................................................................
...................................................... 30

H.5.2 SECURITY AND OTHER COMPLIANCE CONCERNS
.............................................................................. 30
H.6 KEY
PERSONNEL..........................................................................
................................................................. 31
H.7 ORGANIZATIONAL CONFLICT OF INTEREST AND
NON-DISCLOSURE REQUIREMENTS ............ 31
H.7.1 ORGANIZATIONAL CONFLICT OF INTEREST
......................................................................................... 31
H.8 TRANSFER OF HARDWARE/SOFTWARE
MAINTENANCE AGREEMENTS TO FOLLOW-ON
CONTRACTORS.....................................................................
......................................................................... 32
H.9 EARNED VALUE MANAGEMENT CRITERIA
...........................................................................................
32
I.1 FEDERAL ACQUISITION REGULATION (48 CFR

CHAPTER 1).............................................................. 33
I.2 FAR 52.217-8 OPTION TO EXTEND SERVICES (NOV
1999) .................................................................... 33
I.3 FAR 52.217-9 OPTION TO EXTEND THE TERM OF THE
CONTRACT (MAR 2000).............................. 33
J.1 LIST OF
ATTACHMENTS.....................................................................
......................................................... 33

of 36

Project Name & ID: ______________
May 1, 2011
NOTE: Paragraphs B.1 through B.3 of the offeror’s awarded
Alliant GWAC are applicable to this Task Order
Request (TOR) and are hereby incorporated by reference. In
addition, the following applies:
B.1 GENERAL DESCRIPTION
Consistent with Agency and Federal goals of enterprise, shared-
solution, and service-based approaches to
information technology: services may include a new systems,
consolidate and/or integrate systems, develop
interfaces with other systems/services, and expand the existing
systems to also support other program areas, and,
potentially, support data and requirements from other Federal
Government agencies.
The Contractor shall perform the effort required by this task
order on a Labor Hour and Firm Fixed Price (hybrid)
basis. The work shall be performed in accordance with all
sections of this task order and the offeror’s Alliant
GWAC, under which the resulting task order will be placed. The
Contractor must propose labor categories and
hourly rates that are contained within its Alliant contract, at
fully burdened rates that do not exceed the benchmark

rates established for each particular labor category in its Alliant
contract. Therefore, for the purposes of this task
order, the labor rates shall not exceed the benchmark rates
unless the Contractor proposes a specialized or rare labor
category not explicitly defined by any established labor
category description in the Alliant GWAC. If a highly
specialized or rare labor category is proposed, the Contractor
must provide the appropriate support rationale. Please
reference Section L.7(c) Price Supporting Documentation (Tab
C).
B.2 SERVICES AND PRICES/COSTS
The following abbreviations are used in this Task Order
Request:
(CLIN) Contract Line Item Number
(FFP) Firm Fixed Price
(LH) Labor Hour
(NSP) Not Separately Priced
(NTE) Not to Exceed
Note: An Indirect Handling Rate Or Other Overhead Charges
(Such As G&A) Shall Only Be Included If The
Underlying Contract Allows The Application Of Such A Charge

And Includes The Negotiated Rate/Charge.
The Nte Ceiling Amount Represents The Maximum Amount Of
The Government’s Liability. The Contractor
Exceeds The Ceiling At Its Own Risk.
*Transition-In Services (Clin 0004) Applicable To Base Year
Only
Transition-In Services Are Not Anticipated For The Incumbent.
Therefore, These Services Should Not Be Proposed
By The Incumbent.
All Other Offerors Shall Price Transition-In Services Separately
From The Total Price Of The Base Year.
B.3 INDIRECT / MATERIAL HANDLING RATE
Travel will be reimbursed at actual cost in accordance with the
limitations set forth in FAR 31.205-46.
of 36

Profit shall not be applied to travel costs. Contractors may
apply indirect costs to travel in accordance with the
Contractor’s usual accounting practices consistent with FAR
31.2.
B.4 INCREMENTAL FUNDING LIMITATION OF
GOVERNMENT’S OBLIGATION
(a) Contract line item(s) (CLINs) * through * are incrementally
funded. For these item(s), the sum
of $ * of the total ceiling is presently available for payment and
allotted to this task order. An allotment
schedule is set forth in paragraph (j) of this clause.
* To be inserted at time of award - after negotiation.
(b) For item(s) identified in paragraph (a), the Contractor agrees
to perform up to the point at which the
total amount payable by the Government, including
reimbursement in the event of termination of those
item(s) for the Government’s convenience, approximates the
total amount currently allotted to the contract.

The Contractor is not authorized to continue work on those
item(s) beyond that point. The Government
will not be obligated in any event to reimburse the Contractor in
excess of the amount allotted to the task
order for those item(s) regardless of anything to the contrary in
the clause entitled “Termination for
Convenience of the Government.” As used in this clause, the
total amount payable by the Government in
the event of termination of applicable contract line item(s) for
convenience includes costs, profit, and
estimated termination settlement costs for those item(s).
(c) The Contractor will notify the Contracting Officer in writing
at least ninety days prior to the date when,
in the Contractor’s best judgment, the work will reach the point
at which the total amount payable by the
Government, including any cost for termination for
convenience, will approximate 85 percent of the total
amount then allotted to the task order for performance of the
applicable item(s). The notification will state
(1) the estimated date when that point will be reached and (2)
an estimate of additional funding, if any,
needed to continue performance of applicable line items up to
the next allotment of funds. The notification

will also advise the Contracting Officer of the estimated amount
of additional funds that will be required
for the timely performance of the item(s) funded pursuant to
this clause, for a subsequent period as may be
specified in the allotment schedule in paragraph (i) of this
clause or otherwise agreed to by the parties. If
after such notification additional funds are not allotted by the
date identified in the Contractor’s
notification, or by an agreed substitute date, the Contracting
Officer will terminate any item(s) for which
additional funds have not been allotted, pursuant to the clause
of this contract entitled “Termination for
Convenience of the Government.”
(d) When additional funds are allotted for continued
performance of the contract line item(s) identified in
paragraph (a) of this clause, the parties will agree as to the
period of task order performance which will be
covered by the funds. The provisions of paragraphs (b) through
(d) of this clause will apply in like manner
to the additional allotted funds and any agreed to substitute
date, and the task order will be modified
accordingly.
(e) If, solely by reason of failure of the Government to allot
additional funds, by the dates indicated below,

in amounts sufficient for timely performance of the contract line
item(s) identified in paragraph (a) of this
clause, the Contractor incurs additional costs or is delayed in
the performance of the work under this task
order and if additional funds are allotted, an equitable
adjustment will be made in the price or prices
(including appropriate target, billing, firm fixed price, and
ceiling prices where applicable) of the item(s),
or in the time of delivery, or both. Failure to agree to any such
equitable adjustment hereunder will be a
dispute concerning a question of fact within the meaning of the
clause entitled “Disputes.”
(f) The Government may at any time prior to termination allot
additional funds for the performance of the
contract line item(s) identified in paragraph (a) of this clause.
(g) The termination provisions of this clause do not limit the
rights of the Government under the clause
entitled “Default.” The provisions of this clause are limited to
the work and allotment of the contract line
item(s) identified in paragraph (a) of this clause. This clause no
longer applies once the contract line
item(s) identified in paragraph (a) of this clause are fully
funded except with regard to the rights or

of 36

obligations of the parties concerning equitable adjustments
negotiated under paragraphs (d) and (e) of this
clause.
(h) Nothing in this clause affects the right of the Government to
terminate this task order pursuant to the

clause of the underlying contract entitled “Termination for
Convenience of the Government.”
Nothing in this clause shall be construed as authorization of
voluntary services whose acceptance is
otherwise prohibited under 31 U.S.C. 1342.
(j) The Government has allotted funds to this task order in
accordance with the following table:
CLIN DATE FUNDING
OBLIGATED
TOTAL TASK
ORDER
ESTIMATED
CEILING PRICE
AMOUNT OF
FUNDING
OBLIGATED
TOTAL FUNDED
ESTIMATED
CEILING PRICE
0001, 0002, 1001,

1002, 2001, 2002,
3001, 3002, 4001,
4002
month/day/year $ $ $
Total $ $ $
B.5 CONTRACT ACCESS FEE
The Contract Access Fee (CAF) is ¾ of a percent (i.e., 0.0075)
to be applied to the total price/cost for contractor
performance as billed to the Government.
The formula is: Total CAF = Total Price or Costs * CAF
Percentage.
On all Orders, regardless of Order type, Contractors must
estimate CAF in their proposals and OCOs may fund CAF
as a separate Contract Line Item Number (CLIN).
The Contractor remits the CAF to GSA in accordance with
Alliant GWAC Section G.9.5.
C.1 PURPOSE
The purpose of this task order is to obtain services related to the
Operations, Corrective Maintenance, and
Development/Modernization/Enhancement (DME), of the
Agency’s electronic grants management (eGrants) and

other related Information Technology (IT) systems. These
systems primarily support program offices.
The current IT systems within scope of this task order include
Integrated Disbursement and Information System
Online (IDIS OnLine), Performance Measurement System
(PERMS), and the Title V system. Consistent with
Agency and Federal goals of enterprise, shared-solution, and
service-based approaches to information technology:
services may also be required to develop new systems,
consolidate and/or integrate systems, develop interfaces with
other systems/services, and expand the existing systems to also
support other program areas, and, potentially,
support data and requirements from other Federal Government
agencies.
C.2 BACKGROUND
Offices under the Office of the Chief Information Officer
(OCIO) monitor most IT functions in the Agency.
Systems (applications) work is currently performed under the
OCIO Office of Systems Integration and Efficiency
(OSIE). Additionally, staff in the division serves as the focal
point in coordinating the technical activities involved
with other OCIO organizations including the Chief Information
Officer and Deputies, Investment Management,

Enterprise Architecture (EA), Policy and e-Gov, IT Operations,
and IT Security offices.
The Agency serves as the focal point for coordinating efforts
with external stakeholders including grantees, public
interest groups, citizens, White House Office of Management
and Budget (OMB), and Congress.
of 36

For purposes of this task order there is one clear distinction that
is validated by the Department’s organizational
structure. The people who work in OCIO respond to and

effectively manage all technical aspects of this task order.
The people who work in CPD respond to and effectively manage
all business aspects of this task order.
The business processes covered under this procurement include,
but are not necessarily limited to, the general
aspects of the Grants Management Lifecycle.
This Grants Management Lifecycle is consistent and compatible
with the benchmarks identified in the Federal e-
Grants initiative and the Grants Management Line of Business.
The IT systems within scope of this task order each
support one or multiple functions of the Grants Management
Lifecycle.
CPD’s vision for Electronic Grants Management is to:
Automate or increase efficiency of grant management and
administrative processes
Retire manual and/or paper-based processes
Increase use of single-sign-on so grantees have fewer points-of-
entry to grants systems
Increase integration among grants systems
Reduce reliance on stove-piped, single-purpose solutions
Streamline database design to increase performance and
reliability

Centralize data where feasible (single-source) and share via
services
Reduce overall data footprint
Increase accuracy and standardization of data
Reduce data entry burden for grantees and staff
Better utilize existing data for improved analysis, reporting, and
decision-making
Improve system design, interface, usability, and user-
friendliness
Reduce reliance on manual data corrections to reduce overall
operational costs
Improve quality of system releases to minimize need for
corrective maintenance
Enable additional grant programs to leverage the eGrants
systems for cost savings
Further enhance systems with stronger financial controls for
improved accountability
Develop public-facing interfaces for improved transparency
Utilize innovative web technologies for integrated and cost-
effective solutions
Rapidly and efficiently respond to legislative mandates
requiring system changes
Reduce overall costs to operate/maintain eGrants systems

CPD believes this vision will lead to more rapid award and
disbursement of funds to grantees, better execution of
grants, greater capacity of grantees, and better on-the-ground
performance of grants. Most importantly, the Agency
believes an improved and integrated spectrum of IT systems
will directly lead to improved access to affordable
housing, better neighborhood conditions, job creation, and more
targeted services to better meet the needs of low-
income families, the homeless, HIV/AIDS patients, and other
key beneficiaries of Agency’s grant programs. In
times of limited Federal dollars for grant programs, optimizing
use of IT systems can directly lead to improved
outcomes, i.e., reduced grantee time spent on administrative
paperwork frees up staff time to directly execute and
oversee grant activities.
Additionally, CPD believes that grant programs in other
program offices could benefit in terms of significant
efficiency gains and administrative cost savings if they
leveraged CPD’s grants management systems to administer
their grants, and abandoned existing stove-piped, legacy, and/or
paper-based solutions. CPD’s grants management
systems are poised to begin servicing other grant programs
around the Department.

C.2.1 AGENCY MISSION
The Agency seeks to develop viable communities by promoting
integrated approaches that provide decent housing,
a suitable living environment, and expand economic
opportunities for low and moderate income persons. The
primary means towards this end is the development of
partnerships among all levels of government and the private
sector, including for-profit and non-profit organizations.
of 36
The Agency seeks to empower local residents by helping to
give them a voice in the future of their neighborhoods;
stimulate the creation of community based organizations; and
enhance the management skills of existing
organizations so they can achieve greater production
capacity. Housing and community development are not
viewed
as separate programs, but rather as among the myriad
elements that make up a comprehensive vision of community
development. These groups are at the heart of a bottom-up
housing and community development strategy. The IT

systems identified in this task order request are dedicated
to supporting this mission.
Work outlined in this task order request is directly related
to the following Strategic Goals:
The Contractor shall provide innovative, integrated, EA-
compliant, and cost-effective IT solutions that increase
efficiency, reduce data entry, reduce IT system operations
costs, and reduce manual/paper-based administrative
burdens for staff and grantees in order to meet this
mission.
C.2.2 CURRENT ENVIRONMENT
The Technical Environment for each of the existing IT
systems is defined in Attachment 1 to this solicitation.
The Agency currently uses the following desktop business
applications: Microsoft Windows XP, Microsoft Access
version 2007, Microsoft Excel version 2007, Microsoft
PowerPoint version 2007, Microsoft Word version 2007,
Microsoft Project version 2007 and Microsoft Visio version
2007, but regularly upgrades the environment. The
current Technical Reference Model (TRM) can be found on

the website. All deliverables will be in a format
compatible with standards listed.
C.3 SCOPE
The milestones and deliverables in the following
requirements will be implemented and thoroughly discussed
with
the GSA Contracting Officer’s Representative (COR) and the
Agency Technical Points of Contact (TPOCs)
(Government Technical Representative [GTR]/Government
Technical Monitor [GTM]). This task order will be
performed for a five-year period with one base period, and
four option years.
The Contractor shall support the following functions:
IT System Steady-State Operational Support services
necessary to continue on-going operations of existing
IT systems.
IT System Steady-State Corrective Maintenance services,
including application bug fixes, fixes to reports
that are inaccurate, correcting business rules that contain bad
logic, and/or assistance in completion of
scheduled Enterprise Architecture (EA) and infrastructure or

software upgrades as identified by OCIO.
Systems Development, Modernization and Enhancement
(DME) services for each of the eGrants systems
and subsystems as budgets permit. DME typically includes
requirements analysis, design, development,
testing, and deployment of changes and enhancements to
existing systems to engender new or modified
functionality in response to regulatory and statutory
changes. DME may also include development of future
systems, consolidation of systems, integration of systems
for improved data sharing, and/or the expansion
of the existing systems to support other grant-making
program areas in the Agency or potentially from
other Federal Government agencies. All of these services will
include coordination with the infrastructure
support vendor(s) and, from the Contractor’s side, effective
project management in alignment with Project
Planning and Management (PPM) process.
C.4 OBJECTIVE
The Contractor shall be responsible for providing substantial
value to the Agency in the form of technical services to
ensure successful business operations, maintenance, and

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