HIT Project Request Form v9

Title of Request: [Title]

Section 1 - To Be Filled by Requestor
Business Unit (BU): / ☐ CHM ☐ COM ☐ CON ☐ HT ☐ RAD ☐ HIT
Requestor Name: / Department: / Date:
Problem Statement:
Currentapproach for solving this problem:
Proposedapproach for solving this problem:
RequestScope
(IN scope):
Request Scope
(OUT of scope):
Risks of not addressing this problem:
BU Sponsor Name: / Sponsor Approved: / ☐Yes
☐No
BU Sponsor Date:
Section 2 - To Be Filled by HIT in Collaboration with Requestor
PM Name: / Request Number:
Proposed Solution:
List Systems/Services Impacted: / Existing System:☐Upgrade☐Enhance☐New Module ☐Retire
1.
2.
3.
4.
☐New System Implementation
Resource Estimates:
(+/- 50%) / Resources / Hrs / $ Est / Resources / Hrs / $ Est
HIT Infrastructure / HIT Desktop
HIT Clinical / HIT PMO
HIT App/Web Dev / Business Unit
HIT Ed Tech / RAD Dev
HIT Service Desk / RAD Ops
Budget Estimates:
(+/- 50%) / Category / Capital Exp / Operating Exp
Hardware
Software
Internal Resources (does not include BU)
Professional Services
Contingency (10%)
TOTAL: Flag unbudgeted expense with *
Portfolio Impact Analysis:
Section 3 – To be Filled by HIT in Collaboration with Requestor
Project Prioritization Scoring
Project Security/Compliance/Expansion/Foundational Override
# / Legal/Regulatory Override / Scoring Factor / Override
1 / Required for Regulatory Compliance / Yes/No
2 / Required to support Unit Expansion / Yes/No
3 / Required to meet Security Standards / Yes/No
4 / Vendor mandated activity without which we lose support / Yes/No
If Override selected, skip to Project Scoring Summary
Project Value Assessment
# / Criteria / Scoring Factor / Score / Weight / Total
1 / Addresses Unit Strategy or Goal
Academic:
  • Increase student enrollment
  • Enhance and innovate education experience
  • Facilitate distance learning
  • Engage and manage organization constituents (students, faculty, and alumni)
Clinical:
  • Promote patient care
  • Enhance patient experience
  • Improve Physician/Patient interaction
/ Low = 1; Medium = 2; High= 3 / 20 / 20
2 / Improves Customer Satisfaction (Patients, Students, Faculty, Staff) OR
Supports Innovation in Learning and Patient CareOR Supports Research Opportunities / Low = 1; Medium = 2; High= 3 / 15 / 15
3 / Creates Monetary Savings OR
Generates Revenue (thru Federal Incentives, Grants, Increased Student or Patient Population) / None = 0;
$1K-10K = 1;
$10K-30K or Headcount Avoidance = 2;
>$30K or Headcount Reduction = 3 / 20 / 20
4 / Improve Organizational Effectiveness (Effectiveness is about doing the right things and achieving goals or intended results) / Low = 1; Medium = 2; High= 3 / 15 / 15
5 / Improves Operational Efficiency / Low = 1; Medium = 2; High= 3 / 10 / 10
6 / Stabilizes Core Services and Systems (Predictive Maintenance and Upgrades) / Critical Systems/Services = 3;
Ancillary Systems/Services = 2;
Low Priority Sys/Serv = 1 / 10 / 10
7 / Project Align with Technology Architecture / Low = 1; Medium = 2; High= 3 / 10 / 10
Total / 100
Project Risk Assessment
# / Risk / Scoring Factor / Score
1 / Have We Ever Done This Type of Project / Yes (Successfully) = 0; Yes (Challenges) = 1; No = 2
2 / Project Rely on 3rd Party Resource / Extensively = 2, Minimal = 1; No = 0
3 / Does this Project Have Project Dependencies or pre-requisites / Extensive = 2; Minimal=1; None = 0
4 / Will Multiple HIT Departments Need to Be Involved / Four or More Depts = 2;
Two or Three Depts = 1; One Dept = 0
5 / Business Resources Available to Execute & Support / Yes or N/A = 0; Spread Thin = 1; No = 2
6 / HIT Resources Available to Execute & Support / Yes = 0; Spread Thin = 1; No = 2
7 / How Much Combined Effort does this Project Require / >1040 Hours = 2; 400 to 1040 Hours = 1;
<400 Hours = 0
8 / What is the Impact to End User Community / Low = 1; Medium = 2; High= 3
Total

Project Scoring Summary (Please add them here and highlight the appropriate section):

  1. Security/Compliance/Expansion/Foundational Override =
  2. Yes = Project Must be Completed to Meet a Legal, or Regulatory Requirement(1st Tier)
  3. Yes = Project Must be Completed to Support Unit Expansion (1st Tier)
  4. Yes = Project Must be Prioritized for Completion to Meet a Security Mandate (1st Tier)
  5. Yes = Project Must be Completed to meet Vendor Mandated Activity (1st Tier)
  6. Project Value Score =
  7. 190-270 = Highly Aligned; High Priority – Must be Completed (1st Tier)
  8. 130-189 = Well Aligned; Medium Priority –Prioritize for Completion (2nd Tier)
  9. 90-129 = Fairly Aligned; Low Priority – Recommend Approval only if Low Risk and Resources Available (may be canceled as needed) (3rd Tier)
  10. 0-89 = Poorly Aligned, Recommend Denial (Denied)
  1. Project Risk Score =
  2. 10-14 = High Risk
  3. 6-9 = Medium Risk
  4. 0-5 = Low Risk

Project Request Approval

Requestor Name/Title:

Signature: Date:

Sponsor Name/Title:

Signature: Date:

HIT Intake Manager Name/Title:

Signature: Date:

HIT Subcommittee/Committee Approval

Required / Committee / Next Scheduled Date / Date Reviewed / Status / Signature
☐ / Administrative Technology
☐ / Clinical Informatics
☐ / Educational Technology
☐ / Financial
☐ / Executive Steering

Assumptions:

  • Requestor is keeping Business Sponsor in communication loop throughout Project Intake Process
  • Business Sponsor is communicating with Committee members regarding Project Requests prior to next committee meeting
  • Business Sponsors are (CHM-Barbara Forney, COM-Mark Notman, CON-Terry Viau, RAD-Suresh Mukherji, HT-Richard Ward, and HIT/Clinical-Tracey Holland; Hit/Academic –Tawnya McKinizie)
  • Project requests fully funded by Radiology will be forwarded to Committee for notification (Approval not required)

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