Hospital Topics, 88(1):10–17
Copyright
C Taylor & Francis Group, LLC
ISSN: 0018-5868 print
DOI: 10.1080/00185860903534182
Evaluation Methods for Hospital
Projects
JANET R. BUELOW, KATHRYN M. ZUCKWEILER, and KIRSTEN M. ROSACKER
Abstract. The authors report the findings of a survey of hos-
pital managers on the utilization of various project selection
and evaluation methodologies. The focus of the analysis was
the empirical relationship between a portfolio of project evalu-
ation1 methods actually utilized for a given project and several
measures of perceived project success. The analysis revealed
that cost–benefit analysis and top management support were
the two project evaluation methods used most often by the
hospital managers. The authors’ empirical assessment provides
evidence that top management support is associated with over-
all project success.
Keywords: hospital, project management, project selection,
project success
H ospitals presently face intense demands to
lower costs, improve quality, and expand
access to the nation’s growing uninsured
population. Although these complex demands often
result in critical consequences to millions of Ameri-
cans, healthcare managers are frequently challenged
to address these demands due to their lack of knowl-
edge of management best practices. Fundamental
management scholarship in healthcare is often lack-
ing for healthcare managers to call on (Knight 2005;
Austin, Homberg, and Shmerling 2000; Carden
and Egan 2008). Hospital organizations are qual-
itatively different from other business organizations
for many reasons. Changing reimbursement poli-
cies as well as private and public quality and access
regulations constantly challenge the ability of a hos-
pital manager to competitively thrive (Langabeer
2008). Although medical treatment has made
Janet R. Buelow, PhD, is an associate professor of health services administration at the College of Health Professions at Armstrong
Atlantic State University. Kathryn M. Zuckweiler, PhD, is an assistant professor of management at the University of Nebraska at
Kearney. Kirsten M. Rosacker, PhD, CMA, is an assistant professor of accountancy at the University of Wisconsin–La Crosse.
10
astounding advances in recent years, “the packaging
and delivery of that treatment are often inefficient,
ineffective and consumer unfriendly” while concur-
rently being quite costly (Herzlinger 2006, p. 58).
It has been projected, for example, that spending
on healthcare-related activities may account for ap-
proximately 18% of the U.S. gross domestic product
in the 2009 fiscal year. This number is expected to
continue to rise in coming years, increasing to 20%
in 2018 (Elmendorf 2009). Although our “nation’s
aging hospital infrastructure attempts to meet an
increasing demand for services, deciding how to
spend scarce dollars has never been more difficult”
(Butcher 2007, p. 7).
Modern project management techniques have
been increasingly utilized in a broad variety of busi-
ness environments (Project Management Institute
2009). The adoption and successful application of
these management support tools within hospital set-
tings would certainly lead to reductions in costs
and enhanced quality (Sa Couto 2008). “Project
management is a set of management disciplines
and practices that, if executed well, raise the likeli-
hood that a project will deliver the desired results”
(Glaser 2004, p. 34). A review of the healthcare
and project management literature reveals that few
empirical studies have considered the application
of project management concepts within healthcare
settings. Additionally, prior empirical research has
not identified which project evaluation methods
are commonly used within a hospital environment.
HOSPITAL TOPICS: Research and Perspectives on Healthcare
Hospital administrators responsible for oversee-
ing projects within their organizations cannot and
should not assume that effective project selection
and evaluation methods in other industries apply
within the hospital industry. Even if believing this
assertion to be true, such a hypothesis should be
empirically assessed.
This article has four primary purposes. First, we
used a survey to determine whether hospital man-
agers utilize standard project methodologies in se-
lecting among various project opportunities and
controlling the projects selected for implementa-
tion. Second, the survey documented the preferred
project analysis methodologies utilized by a cross
section of project managers in evaluating and con-
trolling recently completed projects within health-
care environments. We expected an ordered ranking
of project methodology usage to flow directly from
the survey results. Third, we developed a description
of the rationales employed by hospitals in ranking
and ultimately selecting among multiple project op-
portunities. Fourth, we present empirical findings
surrounding the relationships that exist between the
project evaluation methods chosen and perceived
project success. The success measures evaluated were
those reported in prior empirical research regard-
ing project methodologies and measures of project
success (Belout and Gauvreau 2004). This research
adds to the literature on project management and
ultimately its findings should be of assistance to
hospital administrators as they select among various
projects and manage their selected projects through
to successful implementation.
PROJECT EVALUATION METHODS
Lasting success for an organization is frequently
determined by the effectiveness of its project eval-
uation process (Sun, Zhi-Ping, and Wang 2008).
Organizations formally appraise their project invest-
ments to justify their investments, enable and sup-
port a decision between alternative projects, control
expenditures, improve the investment selection pro-
cess, and facilitate project management (Garrison,
Noreen, and Brewer 2010; Ghasemzadeh, Archer,
and Lyogun 1999; Olson 2004; Sun, Zhi-Ping, and
Wang 2008).
Two broad categories of project appraisal tech-
niques—quantitative (financial) and qualitative—
commonly used in evaluating and selecting among
investment opportunities have been identified
(Ghasemzadeh, Archer, and Lyogun 1999). Al-
though financial evaluation is important and
relatively straightforward, qualitative metrics are
11
equally essential. This latter focus may be in recog-
nition that projects involve group-oriented activ-
ities subject to the benefits and issues associated
with group interactions and communication. Thus,
qualitative approaches often override quantitative
approaches, which may require more detailed data
than is reasonably available.
Quantitative Project Evaluation Methods
Several quantitative project evaluation method-
ologies have been reported in the research litera-
ture. These methods are directed at and focused
on evaluating project investments using financial
criteria. They include cost–benefit analysis (CBA),
budgetary constraint, payback, net present value
(NPV), internal rate of return (IRR), net project
execution cost (NPEC), and net project operation
value (NPOV).
CBA involves determining the anticipated costs
and benefits of investing in a project. In general,
for a project to be acceptable under this technique
its benefits should exceed its costs. When utilizing
the budgetary constraint method, an organization
simply selects the number of projects that can be en-
tertained within its present budget—an extremely
simplistic methodology. The payback approach to
project investment analysis measures the time it
takes to recover the initial investment and ranks the
projects based on this criterion (Boyle and Gutherie
2006). Although “the payback method ignores both
the time value of money and cash flows that oc-
cur subsequent to payback” (Boyle and Gutherie
2006, 1), the literature reports widespread use re-
vealing that 40%–90% of U.S. firms use payback as
a project evaluation technique (Gilbert and Reichert
1995; Gitman and Vandenberg, 2000; Stanley and
Block 1984; Visscher and Stansfield 1997).
Advanced financial analysis techniques view a
project as a series of primarily, although not exclu-
sively, initial cash outflows and future cash inflows
composed of two important components: (1) the
recovery of the initial investment and (2) income
(Garrison, Noreen, and Brewer 2010). The NPV
method, also referred to as the discounted cash flow
method, employs financial evaluation formulas to
compute the values for all cash flows—inflows and
outflows—that are expected to accompany a poten-
tial investment based on an organization’s expected
minimum rate of return at a stipulated common
point in time. Effectively, all cash inflows and out-
flows are discounted for presentation at a fixed point
in time. The use of NPV in projects has been widely
addressed and reported in the literature (Flaig 2005;
12
Mullen and Donnelly 2006). The NPV method
evaluates the present value of estimated future cash
flows on the assumption that future benefits are sub-
ject to a discount factor that takes into account the
cost of money and project risk. “While the NPV
measure is theoretically valid, it lacks the intuitive
appeal of the IRR in communicating the value of
investment alternatives” to an organizations man-
agement (Kennedy and Plath 1994, p. 38). The
IRR method, although based in NPV techniques,
returns a metric that may be more understandable
for some project managers. The outcome of an IRR
analysis is the rate of return that equates project cash
inflows and outflows to a NPV of zero. An organi-
zation’s management determines the minimum ac-
ceptable IRR for a project—generally referred to as
the hurdle rate. Those projects that exceed the min-
imum hurdle rate remain in consideration, whereas
those that do not are eliminated from the evaluation
process. Kennedy and Plath (1994) explained that
IRR is easily understood by organizational decision
makers.
NPEC and NPOV differ from the other two
quantitative methodologies in that they overtly
consider opportunity costs (Yu, Flett, and Bowers
2005). NPEC is the excess of all project costs over
the project benefits incurred during the execution
phase of a project. NPOV considers all the benefits a
client obtains from the project during operation and
reduces these by any related operational costs. More
advanced financial analysis variants have been pro-
posed in the literature (Patton and Shechet 2007;
Liesiö, Mild, and Salo 2007); however, although
theoretically appealing, these advanced techniques
have not been reported as widely utilized.
Qualitative Project Evaluation Methods
Qualitative attributes represent business or
project characteristics, issues, or concerns that can
be identified but are not easily quantified (Klein and
Beck 1987). Qualitative characteristics include but
are not limited to such things as instinct, gut feel,
mandatory requirements, past experience, proba-
bility of completion, and top management support.
Essentially, they represent anything that impacts the
desirability or feasibility of a project from the broad
perspective of any of the project stakeholders. The
project management literature provides evidence
that managers occasionally base investment deci-
sions on instinct (Powell, 1992). Instinct is a subtle
form of reasoning that takes into account how the
world really appears rather than merely “relying on
what the spreadsheet says” (Bannister and Remenyi
Vol. 88, no. 1 2010
2000, p. 237). Instinctive behavior is widely dis-
cussed in biological settings and its presence is so
well known and defined that it simply cannot be
ignored when making most decisions.
A legal requirement, demands of an external cus-
tomer or supplier, and competitive pressures may
mandate an organization to undertake an invest-
ment (Fitzgerald 1998). Past experience provides
an initial decision framework for projects that fol-
low. It is often from this starting point that project
techniques are selected for use in future manage-
ment decision making. Many projects may not be
permitted to proceed without the presence of top
management support (Jacobsen 2008). The project
management literature indicates that top manage-
ment support is mission critical and that the degree
of its presence significantly influences project suc-
cess (Jha and Iyer 2008; Young and Jordan 2008).
Additionally, only those projects that have a high
probability of reaching completion are to be under-
taken.
METHOD
In the present study, we used a survey method-
ology, incorporating a standardized survey instru-
ment that has been widely used in project man-
agement research (Rosacker and Olson, 2008)
and, to our knowledge, has never been used in
healthcare organizations. Survey participants were
identified using snowball sampling with the au-
thors identifying hospital chief operating officers
(COOs) in 11 Midwestern and Southern states (Al-
abama, Colorado, Connecticut, Georgia, Kansas,
Michigan, Minnesota, Missouri, South Carolina,
South Dakota, and Wisconsin). Hospital COOs
were contacted via e-mail and asked to either com-
plete the online survey themselves or forward the
e-mail containing the survey link to individuals in
their organizations who were in charge of a hospital
project. Hospital managers in all 11 states partici-
pated in the survey.
RESULTS
Managers and Hospital Project Sample
A total of 199 hospital managers answered the
survey link, providing 186 usable responses. Nearly
half (48%) of the managers identified themselves
as senior hospital administrators, 29% identified
themselves as department managers, and 23%
identified themselves as various clinicians (e.g.,
physicians, nurses). Table 1 presents the breakdown
of responding hospital managers.
HOSPITAL TOPICS: Research and Perspectives on Healthcare 13

TABLE 1. Respondent and Project TABLE 2. Hospital Characteristics

Characteristics
Characteristic n %
Characteristic n %
Size
Job title 6–24 beds 41 21
Senior hospital administrator 95 48 25–49 beds 16 8
Department, unit, or floor manager 59 30 50–99 beds 22 12
Physician, RN, allied health professional 45 23 100–199 beds 26 14
Project description 200–299 beds 19 10
Facilities construction or renovation 69 24 300–399 beds 14 7
Process improvement 50 17 400–499 beds 17 9
Information technology 44 15 500 or more beds 37 19
Efficiency or financial improvement 41 14 Ownership
Quality improvement 37 13 Proprietary 13 7
New service development 28 10 Not for profit 145 81
Human resource development 15 5 Public 22 12
Other 6 3 Critical access
Project budget Yes 60 34
Less than $100,000 56 29 No 119 66
$100,001–$500,000 45 23 Urban or rural
$500,001–$1,000,000 16 8 Urban 104 59
$1,000,001–$5,000,000 40 21 Rural 72 41
$5,000,001–$10,000,000 8 4
Greater than $10,000,000 27 14

Hospital managers were asked to identify the
types of projects that provided their framework for
completing the survey. Managers, although select-
ing only one project as their frame of reference,
were permitted to characterize projects under more
than one project type. For example, one respondent
identified her chosen project as involving infor-
mation technology, process improvement, quality
improvement, and efficiency/financial. Another re-
spondent identified his chosen project as involving
facilities construction or renovation and new service
development. This multiple-classification method-
ology permitted managers to more fully describe
projects without having to choose between equally
applicable project types. Through the use of this
project-type classification, the managers were able
to provide data for 290 project types. The project
types were categorized as facilities construction or
renovation (24%), process improvement (17%), in-
formation technology (15%), efficiency/financial
improvement (14%), quality improvement (13%),
new service development (10%), human resource
development (5%), and other (2.07%). A summary
of the project types is provided in Table 1.
Project budgets ranged from less than $100,000
to greater than $10,000,000. Half of the budgets fell
within the lowest two categories (less than $100,001
and $100,000–$500,000). In all, 27 projects had
budgets greater than $10,000,000.
Hospital Characteristics
Table 2 shows characteristics of the hospitals the
surveyed managers represented. In terms of urban
and rural facilities, the hospital sample was similar to
the distribution of American Hospital Association-
registered U.S. hospitals, including 59% urban and
41% rural facilities (American Hospital Association
2009). The majority of the sampled hospitals were
of not-for-profit status (81%), with 7% proprietary
and 12% public hospitals. In total, 26% of the hos-
pitals were critical-access hospitals. The bed size of
the hospitals differed considerably from U.S. hos-
pitals. The present sample had more large hospitals
with 400 or more beds (28% vs. 8%) as well as
more small hospitals (6–24 beds), at 21% versus
10% nationally.
Project Type and Evaluation Methods
Hospital managers were asked to select the
methods used to justify their project. Over-
all, managers reported using an average of 3.88
evaluation methods per project (SD = 2.17).
CBA was used most frequently (76%). Other
project evaluation methods commonly used in-
cluded top management support (64%), bud-
getary constraints (40%), mandatory requirements
(39%), IRR (33%), payback method (28%), NPEC
(29%), NPOV (29%), probability of completion
(29%), and instinct (28%). For about 9% of
projects, managers identified another evaluation
14
method not listed on the survey instrument and
entered their method. No additional quantitative
methods were recorded by the managers. Additional
methods used included alignment with mission and
strategic vision, community need, equipment ob-
solescence, increased productivity, market compe-
tition, physician support, rate of patient satisfac-
tion, space issues, and quality improvement. For
only three projects did managers not know the type
of evaluation used. Table 3 presents a summary of
project justification methods used by type of project.
Success Metrics
For purposes of the present study, a successful
project was defined as satisfying five objective mea-
sures developed by Belout and Gavreau (2004).
These measures included timeliness, cost, use by
clients, impact on users, and overall project success.
Each success metric was evaluated using a 7-point
Likert-type scale against a statement representing
the success construct (1 = strongly disagree; 7 =
strongly agree).
Timeliness referred to whether the project was
implemented in a timely manner. This was ad-
dressed with the statement, “The project will come
in on time.” The cost measure evaluated whether
the project’s overall cost was within budgetary con-
straints. This was assessed with the statement, “The
project’s cost objectives will be met.” The next two
measures, although addressed separately, were com-
bined into one construct regarding whether the
project’s implemented solution contained the fea-
tures and functionality requested by the end user(s).
The two measures for this construct were tested with
a statement for intended use—”The project will be
used by its intended clients”—and a statement for
positive impact—”The project will have a positive
impact on those who make use of it.” Finally, overall
project success expectations were assessed with the
statement, “All things considered, this project will
be a success.”
Responses to the success metrics were analyzed in
combination with the project evaluation methods.
Analyses of variance were used and the results are
reported in Table 4. It should be specifically noted
that the results for the project evaluation method “I
don’t know” should be interpreted with great cau-
tion because this cell contained only three responses.
This cell size is well below the guideline of a mini-
mum 20 observations recommended by Hair et al.
(1998). All other cell sizes exceeded the minimum
number of observations recommendation.
Vol. 88, no. 1 2010
Success metric 1—Time. Four project evaluation
methods (IRR, NPV, payback, and top manage-
ment support) were statistically significantly (p =
.05) associated with the time dimension of project
success. IRR, NPV, and payback represented quan-
titative project evaluation measures. Top manage-
ment support was a qualitative project evaluation
methodology. No other project evaluation method
displayed a statistically significant relationship with
the time success metric.
Success metric 2—Cost. Cost–benefit analysis
and payback, quantitative project evaluation meth-
ods, were significantly related (p = .05) to positive
project cost performance (or expectations). There
were no other statistically significant relationships
between project evaluation method and the cost
success metric.
Success metric 3—Use. Two project evaluation
methods were statistically related to the use dimen-
sion for project success. Although NPV, a quantita-
tive project evaluation method, was not widely used
(see Table 3), when it was utilized projects tended to
perform well on use with a weak statistically signifi-
cant relationship (p = .10) between success and the
use of this evaluation method. Top management
support, a qualitative project evaluation measure,
revealed a highly significant association (p = .01)
with the use success metric. There were no other
statistically significant relationships between project
evaluation method and the use success metric.
Success metric 4—Impact. Project impact dis-
played a statistically significant relationship (p =
.05) with top management support, a qualitative
project evaluation method. There were no other
statistically significant relationships between project
evaluation method and the impact success metric.
Success metric 5—Overall success. Overall ex-
pected project success was weakly associated (p =
.10) with the use of the payback method, a quanti-
tative project evaluation method. Top management
support, a qualitative project evaluation measure,
was significantly associated (p = .05) with over-
all project success. There were no other statistically
significant relationships between project evaluation
method and the overall success metric.
TABLE 3. Type of Hospital Project, by Evaluation Method (N = 290)

Top man- Mandatory Probability

agement Budget require- of I don’t
Project type n CBA support constraint ments IRR NPOV NPEC completion Instinct Payback NPV Other know

n 222 187 116 114 97 85 84 83 81 80 41 27 3

Facilities construction 69 47 50 29 23 22 14 18 20 24 24 14 4 2
HOSPITAL TOPICS: Research and Perspectives on Healthcare

Process improvement 50 37 25 17 22 16 18 14 11 11 11 4 6 0
Information technology 44 41 31 18 15 11 12 14 15 10 9 8 7 1
Efficiency/financial improvement 41 31 23 23 18 14 14 12 11 9 12 5 4 0
Quality improvement 37 28 25 12 21 13 13 13 12 11 10 4 3 0
New service 28 23 21 11 9 15 8 7 10 11 8 6 1 0
HR development 15 13 10 5 5 5 5 5 4 3 4 0 0 0
Other 6 2 2 1 1 1 1 1 0 2 2 0 2 0
Percentage of projects using 76% 64% 40% 39% 33% 29% 29% 29% 28% 28% 14% 9% 1%
method

Note. CBA = cost–benefit analysis; IRR = internal rate of return; NPOV = net project operation value; NPEC = net project execution cost; NPV = net present value.
15
16 Vol. 88, no. 1 2010

TABLE 4. Significance (F ) of Evaluation Methods Compared with Success Measures

Success Metric
Success Metric Success Metric Success Metric Success Metric 5—Overall
Method 1—Time 2—Cost 3—Use 4—Impact success

CBA 1.01 3.91∗∗ 0.72 1.11 1.32

Top management support 5.46∗∗ 0.42 11.67∗∗∗ 6.53∗∗ 9.24∗∗
Budget constraint 0.06 0.24 0.27 0.10 0.60
Mandatory requirements 0.33 0.18 1.27 0.10 0.27
IRR 3.96∗∗ 1.71 0.00 0.01 0.02
NPOV 0.11 0.02 0.88 0.41 0.01
NPEC 0.00 0.38 0.95 0.12 0.15
Probability of completion 1.48 0.19 1.00 0.62 0.17
Instinct 0.11 0.55 1.92 0.16 0.06
Payback 6.90∗∗ 4.33∗∗ 0.60 2.39 3.61∗
NPV 5.72∗∗ 2.63 3.21∗ 2.54 1.95
I don’t know 3.01∗ 0.81 1.19 0.07 1.33
Other 1.13 0.39 0.00 0.74 0.13

Note. CBA = cost–benefit analysis; IRR = internal rate of return; NPOV = net product operation value; NPEC = net
project operation cost; NPV = net present value; df = 185 for every F .
∗
p = .10. ∗∗ p = .05. ∗∗∗ p = .001.

DISCUSSION results of this research effort suggest that hospital

Interestingly, a number of the project evaluation
methods showed no statistical relationship with any
of the five measures of project success, including
mandatory requirements, probability of comple-
tion, NPEC, and NPOV. The latter two quantita-
tive project evaluation methods, relatively new and
evolving, may not yet be well understood by present
project managers.
Given the statistical significance for four of the
project success measures relative to the qualitative
project evaluation method of top management sup-
port, we conducted further analysis. This assessment
focused on assessing whether job title moderated the
relationship between top management support and
these four measures of project success. Specifically,
this analysis considered whether top management
support was rated more highly by top managers or
if employees, regardless of job title, rated top man-
agement support important to project success. The
moderating effect of job title on top management
support and project success was evaluated using the
general linear model. This analysis indicated that
managers, regardless of job title, rated top manage-
ment support as important to project success.
Selecting projects from many worthy project pro-
posals is a crucial decision of hospital administra-
tors. Furthermore, seeing that selected projects are
managed successfully is a continual challenge. The
managers commonly use several project evaluation
methods, with CBA and top management support
representing the two most commonly used project
evaluation methods. In line with findings reported
for prior research efforts, the importance of top
management support to overall project success is
strongly supported.
There is a recognized trend toward project man-
agement education in academe, a trend that is too
late for many hospital project managers who may
be some years removed from their undergraduate
or graduate studies. A hospital manager’s primary
source of project management knowledge may well
be the anecdotal evidence shared by experienced co-
horts (Wood 2008) or studies similar to the present
study. The findings of the present study should serve
as a useful and practical guide for experienced and
new hospital managers, thereby supporting the im-
provement of hospital project management.
Note
1. We use the terms selection and evaluation interchangeably
throughout the article.
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Copyright of Hospital Topics is the property of Taylor & Francis Ltd. 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.