Agile Project Management and its Application in Medical Practice

Originally Published by Data Driven Investor

A contemporary insight into managing today's Medical Practice

Realistically speaking, “Medical practice” is one big complex project. It is becoming even more complicated and intricate by the day. Unlike what typically pertains to a technology field, healthcare is riddled with numerous determinants and variabilities. Therefore, having a robust management methodology in the past decade has become furthermore crucial.

With the fast-paced technological evolution all through the last couple of eras, we have learned from the tech industry that the healthcare business is lagging behind all others. Medical practices, in particular, are typically behind by all means in adopting a practical yet efficient tool to stay ahead of the 21st-century millennial expectation while concomitantly sustaining a competitive edge.

Therefore, in my opinion, physicians’ practices, and not just large organizations, must adopt a form of project management methodology and tools that will pave the road on the way to what they do best; that being said, patient care.

Midst the spectrum of project management apparatuses, we can name the nine most common methodologies: Agile, Scrum, Kanban, Scrumban, Lean, eXtreme Programming (XP), Waterfall, PRINCE2, and PMI’s PMBOK. One can also note hybrids of one or more of the latest methodologies applied by various organizations.

I, for my part, don’t see myself as proficient in project management; still, I intend to present another perspective towards solving common medical practice challenges of our time.

This article solely focuses on the Agile practice and its potential value in healthcare and by no means favors one method over another.

Definition and Critical Characteristics of a Project in Medicine

Understanding the correct definition and the vital characteristics of a project takes individual standing because the execution of a project or task is beyond just finalizing a job. But through project management, the development serves as an opportunity to achieve some anticipated outcome or product. Therefore, an individual or organization tangled in any given project necessitates understanding how to solve the complexity of intricacies through project management.

The project provides an opportunity for organizations and individuals to achieve their business and non-business ambitions more efficiently through implementing transformation. Projects support our desired changes in an organized fashion and with a reduced likelihood of fiasco.

The typical project is usually impermanent. It invariably has a point of start and a finish utilizing a set of unique deliverables or a single product.

Every project requires progressive elaboration, including continuous investigation and improvement, as it becomes available, and all this allows constructing more accurate and comprehensive plans.

Any deliverable should address a problem or need analysis before the project start. Likewise, a standard project must be purposeful as it has a rational and measurable purchase, logical as it has a specific life-cycle, structured as it has interdependencies between its tasks and actions. A project may entertain conflict as it attempts to resolve a problem, restricted by available resources, and may go together with risk as an element.

A Project is distinguishable from others based on the work they aim to do, such as task, process, procedure. In the meantime, through a wide-ranging sense, a project is defined as a precise, predetermined activity that produces a visible and measurable outcome under exact predetermined specifications.

Let's consider the patient clinic visit as one out-of-the-way project, based on that assumption and by considering the complexity of the present healthcare system. We will be confident that some form of project management methodology is supportive of any medical practice.

Project Management Triangle

Irrespective of what project management methodology we chose for a given medical practice, one thing unanimously applies to all projects, regardless of the industry- all follow the rule of “Project Management Triangle.”

The project management triangle, also called the triple constraint, iron triangle, or only the project triangle, is a model of the limitations of project management.

According to the triangle, the quality of work is restrained by the project’s funds, deadlines, and scope. (Figure 1.)

Fig 1.

In a typical scenario, any given project manager has to make decisions between the three constraints while keeping the triangle as equilateral in shape as possible. Shifts in one restraint compel modifications in others to compensate. Otherwise, the quality will suffer. For instance, We can complete a patient visit faster by increasing the budget or cutting the scope of work.

As we know, insurance companies are not going to adjust compensation based on the financial requirements of a project; therefore, under such circumstances scope; hence the quality of care will suffer. Similarly, the increasing amount of work or deliverables may require corresponding increases in budget and schedule, something that is doubtful to achieve without utilizing essential technology, strategy, and human resources.

In short, cutting a budget without adjusting the schedule or scope will prime lower quality.

Fundamentals of Project Management and its Medical Application

Every Project management comprises a set of individual tasks or activities, including initiation, planning, execution, control, and closing the work of a crew to realize precise goals and meet specific success measures at the particularized timeframe.

The primary challenge of development management is to reach all of the outlined goals within the given constraints, as described by the project triangle. This information is usually specified in project documentation, created at the start of any development process. From the time a patient contacts the doctor’s office until discharged with a plan and follow-up on the program, a medical practice must have a well-defined goal provided the prevailing constraints. Therefore, It is fair to state that the objective of project or practice management is to yield complete patient care in compliance with the physician’s and patients’ goals and expectations. In many cases, such patient encounter management aims to shape or reform the physician’s claim to address objectives feasibly; and endure optimal patient satisfaction.

Once the objectives of the medical practice are precisely introduced, they should be able to influence all fortitudes made by others involved in their plans, such as managers, consultants, contractors. Poorly defined project management objectives are damaging to decision construction.

Project management is often tailor-made to a specific type of project based on size, the scope of the scheme, nature, and the type of the industry.

The Four P’s of Project Management

The ultimate triumph of any project is conditional on how adequately four critical aspects of the management are aligned with its dynamic environmental forces. These critical factors are also referred to as the four Ps. The latter includes Planning and forecasting activities, the Project development by which overall strategy to all operations and project governance is applied, People and the dynamics of how they collaborate and communicate, and finally, Power lines of authority, decision-makers, policies for implementation.

How to Approach a Project

There are many methods for designing and completing projects, including phased, lean, iterative, and incremental. There are also different branches to project forecasting, based on outcomes (product-based) or activities (process-based).

Regardless of the methodology engaged, overall project objectives, timeline, cost, and the roles and responsibilities of all members and stakeholders, need careful consideration.

What is a Project, and how it Applies to Patient Care?

In an organization, a project is a scrupulous piece of work planned for implementation within a given business ecosystem. Within that project management realm, one must make a distinction between different parts of creation. For instance, a Program usually pertains to a broad, long-term goal that We can often break down into sequences of projects and subprojects. Or a Task where denotes an identifiable and measurable activity that involves carrying out a small portion of work for a related project.

Other parts to mention concerning a project are work packages related to a division of a project task. Consequently, the Work unit is a division of that work package.

Imagine; patient care as a project within its spectrum and sequences of the said process of patient care arises tasks, work packages such as scheduling, evaluating, and follow-up after discharge.

The principal benefits of using project administration exercise within a medical practice environment can accelerate the perfection and strengthening of the physician’s practice management by achieving the concepts of hands-on supervision. The latter approach also helps deal with risks resourcefully by accomplishing distinct variations linked to the clinic’s strategies.

Project Management Tools and their Significance

Earlier in this article, I pointed out the prime “4 P” approaches to typical project management. I also delineated the outcomes (product-based) or activities (process-based) applications. Regardless of the methodology applied, particular attention needs to be furnished to the overall project objectives. That includes paying special attention to cost, timeline, and the roles and duties of all stakeholders, such as nurses, managers, physicians, and clerks.

Within the assumed domain, we can also find various focus points and approaches to the project, including Benefits realization management, Critical chain project management, Earned value management, Iterative and incremental project management, Lean project management, Phased approach Project production management.

Choosing the Right Methodology for a Medical Practice

In the modern project management globe, managers don’t typically stick to a single methodology. Instead, a contemporary medical practice must be well-versed in a variety of project management means, know how to blend several techniques concurrently. It must be able to adapt based on the individual practice requirements. Eighty-nine percent (89%) of the project experts surveyed in 2019 proclaimed that their institution executed hybrid project management schemes.

Today, one can find abundant project management methodologies used in one way or another, nine of which I outlined earlier in this article. Nevertheless, to better understand, all popular methods are the scheme of exercises, techniques, procedures, and rules used by those in a domain. Nonetheless, We must select the methodology based on performing things in a certain way, like applying various principles, themes, frameworks, processes, and standards. So, for the sake of conversation, let us pick the “Agile methodology.”

Agile Management is the Application of Healthcare Values

Agile management is the application of the values established primarily for the technology domain as Agile software development. Today the methodology is becoming more prevalent in various management techniques in other industries. Trailing the appearance of the Agile Software Development domain in 2001, Agile systems began to scatter into other areas of activities.

Because Agile methodology values are based on experience throughout the delivery process, it can be a valuable model for small medical practices.

Evolution of Agile Methodology

Agile methodology encompasses many strategies to patient management under which requirements and solutions unfold through the collaborative exertion of self-organizing and cross-functional teams and their patients. It upholds “adaptive planning,” evolutionary growth, early delivery, and continual transformation. Agility motivates a rapid and flexible response to change, which is very familiar for today’s medical practice sphere.

The Manifesto for Agile Development

Agile methodology values are Based on their combined experience of delivering a project such as patient care and helping others do the same. The agile philosophy declared the importance of transparency and prioritizing:

● Individuals and interactions; over processes and tools

● Working service operation; over comprehensive documentation

● Clientele Collaboration; over contract negotiation

● Responding to change; over following a plan

Tools and processes are vital in agile methodology, but it is even extra critical to have qualified staff effectively working together. Adequate documentation is valuable in helping people to understand how the operation and patient care distribution is constructed and how to utilize a system, including technology and service delivery. Still, the project's central theme is to take care of the patient, not document or follow a set of strict protocols.

A pact is relevant but is no substitute for working closely with physicians and patients to discover their desires.

A project strategy is essential, but it must not be excessively stringent to acclimatize alterations in technology or the setting, stakeholders’ priorities, and people’s understanding of the problem and its solution.

The Agile Movement is not Anti-Methodology.

Some believe the quick scheme, by itself, is against the methodological principle. On the contrary, many expect to restore credibility to the word methodology by restoring a balance. That is why Agile project management schemes embrace modeling, but not for the sake of filling some model and policy in a dusty corporate repository. But, It is necessary to clasp documentation, but not hundreds of pages of never-maintained and rarely-used tomes. Agile helps plan but also recognizes the thresholds of planning in tumultuous settings.

The Philosophy of Agile Methodology

The agile methodology primarily targets complicated systems with dynamic, non-deterministic, and non-linear properties. In situations like medical practice and healthcare delivery, precise estimates, firm plans, and forecasts are often hard to get in the early stages, and confidence in them is likely to be very low. Hence, Agile users will solicit to lessen the trust that is needed before We can achieve any proof of value. Requirements and design are held to be up-and-coming while accepting that any significant up-front stipulations would perhaps cause a lot of waste in such cases, like economically unsound. These basic arguments and previous industry practices learned from years of triumphs and failures have helped form Agile development’s support of adaptive, iterative, and evolutionary advancement.

Physician and patient satisfaction by timely and consecutive delivery of valuable service is the core target of any medical practice. Therefore, acknowledging altering requirements, even later in the process, is essential to its project management. The methodology must be able to deliver services frequently, tightly within daily teamwork amid staff. Agile offers that kind of management system.

Projects built around the Agile structure encourage individuals who should be reliable; it affords a face-to-face discussion as the best form of communication.

Patient and physician satisfaction is the primary measure of growth in the Agile system. It offers unstainable development, can bear a steady pace, presents uninterrupted awareness of excellence and ethical practice model. Simplicity is essential.

Best architectures, rations, and designs emerge from self-organizing teams. Within the latter, regularly, the crew weighs on how to become more productive and adjusts accordingly.

Most agile development methods break project work into small increments that minimize up-front planning and design. Iterations, or sprints, are short duration frames that commonly last from one to four weeks.

Each redundancy comprises a cross-functional team working in all duties, including planning, analysis, operation design, surveying, and approval testing.

At the end of the project, a working system is demonstrated to participants. That minimizes the overall risk and allows the outcome to adapt to changes swiftly.

Adopting Agile Principles in Health Care

The constant escalation of pacing technological headways, rising costs, and new player emergence in the healthcare marketplace have created challenges for healthcare stakeholders, particularly independent physician practices. Therefore, healthcare organizations and physician practices must find practical ways to embrace reform, which we outline as the passage of new patient and clinician values. Most modern developments in the healthcare realm, together with governance, business planning, and information technology implementation, are designed to minimize risk to medical practices. Yet, they are often inflexible to adapt quickly to new changes, making incremental changes that fail to deliver much-needed transformation.

A core principle of agile methodology in healthcare is that for every innovation, from inception, it establishes an Agile team comprised of clinicians, engineers, managers, data scientists, and user representatives. Each group organizes a project cycle to improve results and raise the value to patients, health professionals, and the overall system.

While the core team covers not many employees, several hundreds of people from member health care systems have participated in Agile projects. By implementing Agile principles in the integration process, medical practices can integrate changes and iterate quickly, thus online mechanisms for clinical deliverables from behavioral health, diabetes management, patient engagement, campus wayfinding, practice compliance, and remote monitoring.

Healthcare organizations and medical practices are innately complex adaptive systems, with many clinical and non-clinical disciplines working in tandem using technology to serve the needs of patients, within an invariably shifting administrative and reimbursement policy, besides rapidly expediting medical information.

Cultural appropriation of Agile and similar theories is predominant to both expediting the delivery of reform and obtaining reception of methods that are not traditional within healthcare. To that end, medical practices must focus on spreading a culture of innovation throughout their organizations.

Efficient and face-to-face Communication

Co-location is one of the characteristics of the Agile methodology. As the principal, co-workers of the team typically align collected to launch their identification as a team better, then to improve communication. Co-location allows face-to-face intercommunication, ideally in front of a whiteboard, that diminishes the cycle time typically taken when queries and answers are mediated through various communication portals such as phone, Slack, Microsoft Teams, or email. Irrespective of the type of progress method selected, every team should include a client representative, recognized by stakeholders to act on their interest and makes a personal obligation to be obtainable for developers to answer questions throughout the emphasis. At the end of each repetition, stakeholders and the customer representative review progress and re-evaluate priorities to augment the return on investment (ROI) and ensure alignment with client needs and practice goals.

The Agile System requires a very Concise Feedback Loop and Adaptation Cycle.

A common characteristic in the agile scheme is the daily stand-up or scrum in the Scrum framework. The latter pertains to brief sitting, team members reporting to each other what they did the previous day toward their team’s iteration goal and what they plan to do now in the direction of the goal, and any barriers or impediments they can see to the target.

The Quality focus in Agile Methodology

Various tools are often used to improve quality and enhance products or services in Agile. That includes specific tools and techniques, such as continuous integration, automated unit testing, pair programming, test-driven development, design patterns, behavior-driven growth, domain-driven design, and other methods. That is signified; designing and building quality from the beginning and demonstrating solutions for physicians, staff, and patients at any point, or at least at the end of every iteration.

Adaptive vs. Predictive Method

Every project management tool occupies a spot within the perpetual spectrum from adaptive to predictive. Agile methods employ the adaptive side of this continuum. One key feature of the adaptive process is the “rolling wave approach” to schedule planning, which identifies milestones but leaves flexibility in the path to reach them, providing leeway for the pillars themselves to change in the future.

Adaptive systems concentrate on readjusting swiftly to shifting realities. Thus, when the needs of a project change, the adaptive team changes too. But, at the same time, an adaptive organization is restrained in predicting what will happen in the future.

An adaptive team cannot outline what responsibilities they will have in the coming week, nonetheless only which features they plan for the following month. The further away from a date, the vaguer will be an adaptive method is about what will happen on that date.

On the other hand, predictive methods tend to focus on analyzing and planning the future in detail and cater to established risks. In the climaxes, a predictive team can communicate precisely what features and tasks are scheduled for the entire length of the management process. Predictive methods rely on active early-stage analysis, but on the downside, if the aforementioned fails, the project may have a shifting course towards complication.

Predictive teams repeatedly institute a change control board to ensure what they consider only the most valuable variances. Therefore, to help managers choose between adaptive and predictive models, they implement a risk analysis.

Project Life-Cycle in Agile Methodology

Agile methods support a broad range of development or implementation life cycle. Some focus on the practices, while some focus on managing the flow of work. Few support activities for requirements and expansion, while others seek to cover the entire development life cycle.

Situation relevance should be acknowledged as a differentiating attribute between Agile methods. Nonetheless, in practice, provisions can be tailored using various gears.

Agile development has been broadly recognized as highly suited to specific environments, including small teams of experts working on undeveloped projects.

In response, an assortment of strategies and outlines has grown for overcoming challenges with large-scale development efforts amongst other problems; and there are now several recognized frameworks that seek to mitigate or avoid these difficulties.

Agile Methodology; in the highly Regulated Domains

Agile methods were seen initially as best suitable for non-critical service and product domains, thereby barred from use in regulated fields such as medical devices, pharmaceutical, financial, nuclear systems, automotive, and avionics sectors, etc. However, recently, there have been some drives for the adoption of agile methods for non-technology domains.

Experience and Adoption of the Agile Tool

Although We can use Agile designs with any paradigm or language in practice, they were initially closely associated with object-oriented environments. As stated earlier, the initial adopters of Agile methods were customarily small to medium-sized teams working on unique systems with requirements that were hard to clinch and likely to change as the system was being developed.

Measuring Agility

There are many immeasurable practices and tools for gauging the performance of agile products and teams, a few of which I will describe in this section.

Internal Assessments

The Agility measurement index, amongst others, rates project progress against five dimensions of project development—the latter include; risk, duration, newness, effort, and interaction. Supplementary techniques are instituted on those measurable goals as one study implies that swiftness can be used as a metric of agility. There are also agile self-assessments to settle whether a team is using agile practices.

Public Surveys on Agile Methods

One of the early studies reports gains in quality, productivity, and business satisfaction using agile schemes.

Surveys also increasingly account that the Agile system helps them deliver faster, improves their ability to manage changing client priorities, and increases their yield. Studies have also consistently conferred better results with agile development approaches compared to classical project management. In opposition, there are also reports that agile management methods are still too young to qualify for extensive academic research on their success.

Common Agile Development Pitfalls

Organizations and teams implementing agile methodology often face obstacles transitioning from more traditional methods such as waterfall methodology, also referred to as Agile anti-patterns or, more commonly, Agile smells.

Lack of Sponsor supports Agile System.

Agile methodology is often implemented as a “grassroots” effort by teams trying to optimize their development processes and ensure a consistent project life-cycle. By not taking sponsor support, teams may face difficulties and resistance from business partners.

Insufficient Training with the Agile

Insufficient training seems to be the most significant cause of unsuccessful Agile project management. Teams have fallen into the trap of assuming the reduced processes of Agile development compared to other methodologies.

Poor Engagement of the Project Owner with Agile

The product owner is responsible for the business in the development activity and is often the most challenging role. A common misconception is to have the product owner role occupied by someone from the project team. That requires the team to make its individual decisions on prioritization without real feedback from the business. The team attempt to solve business matters within or delay work as they scope outside the team for direction. That often leads to disruption and a breakdown in collaboration.

Lack of Focus by the Team Members

The agile methodology requires teams to meet project obligations, which means they should emphasize only work for that objet d’art. However, team affiliates who appear to have spare capacity are often expected to take on other activities, making it difficult for members to help complete the work their team had committed.

Excessive Preparation/Planning for Agile Methodology

It is not uncommon for teams to fall into the trap of spending too much time preparing or planning. The latter is particularly prevalent for those less accustomed to an Agile system where the teams feel obliged to understand entirely and specification of all legends. We should prepare units to move forward only with those stories in which they have confidence, then, during the emphasis, continue to discover and develop work for subsequent iterations.

Problem-Solving in the Daily Stand-up

A daily stand-up should be a focused, timely meeting where all team members disseminate information. If problem-solving transpires, it often can only involve specific team members and potentially is not the best use of the entire team’s time. If, during the daily stand-up, the team starts dipping into problem-solving, it should be set aside until a sub-team can talk, usually immediately after the stand-up completes.

Assigning Tasks in an Agile System

One of the intended benefits of Agile methodology is to permit the team to make choices, as they are most familiar with the problem. Additionally, they should make selections as close to implementation as possible to use a timelier report in the judgment. If team affiliates are assigned tasks by others or too early in the process, We can lose the benefits of localized and rapid decision-making. Moreover, 3rd party work assignment also compels team members into specific roles, which confines prospects for cross-training. Through the Agile approach, team members can take on responsibilities that stretch their skills and provide cross-training opportunities.

Scrum Master as a Contributor

A scrum master is an enabler for the agile action team. Scrum is a methodology that enables a group to self-organize and make modifications rapidly, according to agile doctrines.

The scrum master brings about the process of how information is swapped.

Another standard Agile method deadfall is for a scrum leader to act as a contributor. But, the scrum master needs to ensure they can move in the role of scrum master first and not working on development tasks. A scrum master’s part is to facilitate the process rather than create the product.

Absence Automation of Testing

Due to the reiterative nature of agile development, different cycles of testing are often required. Automated testing helps reduce the influence of repeated shame integration and regression tests and frees originators and validators to focus on higher-value work.

Test automation provisions constant restructuring. It allows a manager to quickly run trials to confirm that the refactoring has not altered the system's functionality. It may reduce the workload and increase confidence that cleanup efforts have not introduced new defects.

Allowing Technical Debt to Build-up

Overemphasis on delivering new functionality may give rise to technical debt. The team must allow time for flaw remedy and refactoring. Technical debt hinders planning abilities. Increases the volume of unscheduled work as development breaks divert the group from further progress. As the system expands, it is essential to refactor as the entrance of the system logically increases. Over time the lack of constant care causes increasing defects and development costs.

Attempting to Accept excess Responsibility in an Iteration

A common misconception is that an Agile system allows constant transformation; however, a repetition backlog agrees on what work can be finalized during a recapitulation.

Having excessive work-in-progress (WIP) ends in wastefulness, such as context-switching and queueing. The team needs to evade feeling compelled to take on additional work.

Fixed Time, Resources, Scope, and Quality

Agile fixes time (iteration duration), quality, and ideally resources in advance, while the scope remains changeable. The client often pushes for a fixed range for an iteration. However, Agile teams should be reluctant to commit to the locked time, resources, and scope (the project management triangle). Efforts to add breadth to the fixed time and resources of Agile evolution may result in diminished quality.

Burnout of the Originator

Due to the focused pace and continuous nature of agile modes, there is a sharpened risk of burnout among associates of the delivery team.

Agile Management is Iterative and Incremental

The term agile management is applied to an iterative, incremental method of managing the design and build activities of discipline areas that aim to provide new product or service development in a highly flexible and interactive manner, based on the principles expressed in the Manifesto for Agile Development.

Agile X techniques may also be called extreme project management. It is a variant of the iterative life cycle where deliverables are submitted in stages.

The main difference between agile and iterative development is that agile methods complete small deliverables in each delivery cycle (iteration). In contrast, iterative methods evolve the entire set of deliverables over time, completing them near the end of the project.

We developed both iterative and agile methods to respond to multiple obstacles that set in more consistent forms of the project structure. For instance, as projects grow in complexity, end-users conduce having trouble determining the long-term requirements without viewing progressive ideals. But Projects that happen in iterations can continuously gather feedback to help filter those requirements.

Agile Business Management Model

Agile business management principles and values are expressed across five domains:

  1. Integrated client engagement involves embedding patients and physicians within any delivery process to share accountability for product or service delivery.

  2. Facilitation-based management or adopting agile management models, like the role of Scrum Master, to aid the day-to-day operation of teams.

  3. Agile work practices: ratifying specific iterative and incremental work habits such as Scrum, Kanban, test-driven development, or feature-driven development across all business functions.

  4. An enabling organizational structure with a focus on staff engagement, personal autonomy, and outcomes-based governance.

  5. DataOps or, Applications of the agile process to data analytics, business intelligence, big data, and data science.

Agile paradigms are flexible; hence they can be applied in other areas of life, such as raising children. Its success in child development might be founded on some basic management principles; communication, adaptation, and awareness.

Criticism of the Agile Project Management

Agile practices can be inefficient in large organizations and certain varieties of projects. That is why many organizations reckon that Agile methodologies are too frigid and, based on that assumption, adopt a Hybrid method that combines elements of agile development and plan-driven strategies. The increasing adoption of agile practices has also been criticized as a management style that simply describes existing good practices under a new idiom promoting a one size fits all mindset towards development strategies and erroneously emphasizes method over results.

The agile journey is particularly self-conscious. It continually checks its self-appearance in a mirror but is tolerant to few criticisms, lone attentive in being with its peers, rejecting en bloc all wisdom from the past, merely because it is from the past. It literally adopts fads and new dialects, yet, at times, cocky and arrogant.

Is the Agile Methodology the Right Option for Medical Practices?

There is no doubt that most modern project management tools are new and may take some time to be perfected. Nonetheless, if wisely selected, it will mature further, accommodating the needs of any medical practice. They will become more accessible to the outside world, more reflective, and, therefore, more effective.

Agile is a more reliable method for small medical practices because it is a grassroots movement and flexible. It can furthermore be hybridized for optimal adaptability.

Today, apart from large and most medium-sized healthcare organizations, most physician practices are alien to any kind of project management. But with the increasing volume of regulations and mandates, along with emerging value-based reimbursements, utilizing some form of project management, methodologies are becoming unavoidable and exceedingly necessary.

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