a strategy for empowerment: the role of midwives in computer systems implementation

ELSEVIER Computer Methods and Programs in Biomedicine 54 (1997) 101- 113

.A strategy for empowerment: The role of midwives in computer systems implernentation

Tony Carroll *

Department of Ififorrnation Techrlology, Rotunda Hospital, Dublin 1, Ireland

Abstract

The procurement and implementation of patient administration systems has been done on numerous occasions in the past. The Rotunda project however encompassed major bespoke clinical developments which were going to impact upon large clusters of midwives. and medical staff to a lesser extent. A broad based four level structured methodology was used to implement the project which is significantly ahead of schedule. This methodology together with its strengths and weaknesses is comprehensively discussed. The empowerment of midwives, their roles in systems analysis and design, software testing and organisational re-engineering is described. The importance of undertaking comprehensive computer training is highlighted and a compact 10 h information technology course coupled with ongoing educational and related activities which could be adopted by any organisation is documented. The seven deadly sins of project management are mapped out. An update on benefits realisation is provided. Gender issues are also discussed. 0 1997 Elsevier Science Ireland Ltd.

.K~Jwo~&: Midwives; Empowerment; Training; Project Management; Gender; Re-engineering

I. Introduction

The Rotunda Hospital is one of the oldest maternity hospitals in the world. The hospital h,as 200 beds, delivers 6000 mothers annually and treated 1000 neonates in 1996.

The Eotunda has been exposed to computerisa- tion for quite some time. In the mid 1970s the Rotunda was one of the first maternity hospitals

*Tel.: + 353 1 5730700; fax: + 353 1 S733857; e-mail: [email protected]

to use computers for obstetrical data collection. Like most organisations, the Rotunda Hospital’s exposure to information technology (IT) grew with corresponding advances in computer technology, particularly following the birth of the microcomputer. By the late 1980s most departments had micro systems while the main patient a.dministrative areas were linked -through a first generation design patient administration system. The limitations of essentially stand alone systems a.re obvious. In the early 1990s the hospital drew up a strategic IT plan, the main recommendations

0169-2607/97/$17.00 0 1997 Elsevier Science Ireland Ltd. ,111 rights reserved PZZSO169-2607(97)00039-4

102 T. Cawoil/ Computer Methods nnn Programs in Biomedicine 54 (1997) 101-l 13

Table 1 PAS project implementation timetable

Milestone/module Planned start Planned Go Live Actual Go Live

Pre-implementation Patient master index and casenote tracking Outpatient management Inpatient management Waiting list Pathoiogy link Obstetrical management Neonatal tnanagement Clinical Information Services Casemix and audit Management information services Interfaces Team training/programming Eespoke developments

1st Jun 1994 1st Sep 1994 1st Nov 1994 1st Apr 1995 1st Apr 1995 1st act 1995 1st May 1994 1st Jan 1996 1st Jhl 1996 1st Nov 1996 1st Nov 1996 1st Jul 1997 1st Nov 1997 1st Apr 1998

1st Ott 1994 1st Jan 1995 1st Mar 1995 1st Jul 1995 1st Jul 1995 1st Dee 1995 1st May 1995 1st Apr 1996 1st Ott 1996 1st Jun 1997 1st Jul 1997 1st Ott 1997 1st Apr 1998 1st Jun 1998

1st Sep 1994 1st Mar 1995 1st Mar 1995 1st Mar 1995 1st Mar 1995 !st May 1995 1st Sep 1995 1st Apr 1996 1st Ott 1996 1st May 1997 1st May 1997 1st Jun 1997 1st .4pr 1997 1st Jul 1997

of which centred upon the procurement of a state of the a.rt patient administration and clinical information system (PAS). Funding was provided for the project by the Irish Department of Health (DoH) in 1994.

The AT&T TOTALCARE solution was chos- sen. The system module and implementation timetable are shown in Table 1. The implementation placed heavy emphasis upon end user involvement particularly at midwifery level where the highest concentration of end users was found.

2. Metlnsdolsgy

2.1. Structure

The project objectives are shown in Table 2. A broad based four level structured methodology was used to implement the project. The implementation team consisted of twelve personnel, four midwives, four implementors, two secre- taries, the project manager and a part time clini- cian. The midwives represented the majority of end users throughout the hospital.

The four level model encompassed some of thl: following key elements:-

Level 1: Central to the implementation was the project plan which specified the organisational structures, timescales, resources and other factors

necessary to implement the project successfully over the 48 month period. Prior to project commencement, sponsors, champions and owners w’ere identified and were tied into the fabric of the plan through membership of the IT Steering C80mmittee, or as system implementors. This elim- inated the need to establish a user group in the ea.rly stages.

The vendor was also represented on the Steer- ing Committee by the company’s managing direc- tor. In this way a considerable amount of red tape

Ta.ble 2 Project objectives

Criteria StatUS

Quality patient information available 24 h ,) Better quality management information J Reduction in administrative chores a

Unified approach to data collection J Im,proved communication b

Easier access to patient information J More efficient use of resources c

M’ore personal service to patients/staff Good public relations j

Better education base for research and decisions / Enhanced skills for workforce :/ -

a Considerable improvement but also some displacement with new tasks. b Not always exploited. Time management weakest link. “Very good response but old habits hard to eliminate.

T. Car-roll /I Computer Methods ma Program m Biomedicine 54 (1997) 101 -I 13 103

was short circuited when problems arose which could not be satisfactorily resolved at lower management levels.

Level 2: This level covered the main implementation phases which always centred upon four sub phases the most important aspects of which included the following: (II Design phase-heavy end user involvement. o Construction phase-prototyping used exten-

This workbook was very important because each member of the team knew exa’ctly their tasks and roles. As a result a lot of the technical and supervisory elements were removed.

sively with mandatory sign off. (D Implementation phase-extensive training and

educational support to end user and rigorous software testing.

The project manager viewed his role in a supporting capacity. The team members were already highly skilled in their own spheres and it was really the function of the manager to harness these skills to one common purpose. The project manager viewed the team as a partnership agreement.

ID Review phase-development of pragmatic quality assurance programme. Level 3: The problems of bottlenecks and po-

tential remedies fell into this category. The mai.n problems were in the area of design changes and product enhancements requested by end users. These matters are discussed in detail later but the primary restraining tool was a comprehensive change control procedure agreed between the hospital and the vendor which ensured that only the project managers had the power to author&e changes and such requests had to be extensively documented and signed off.

The project was managed around team meet- ings which took place for short periods once a week. As the project progressed the manager gradually withdrew to a purely supportive role. There is no one best style of leadership, but is a combination of tasks and relationship behaviours depending on the circumstances [I].

In the final stages, the project manager’s role therefore was to co-ordinate the efforts of each team member so that the end product was produced on time and within budget where possible.

The project organisational structure is shown in Fig. 1.

2.2. Metimdological considerations Level 4: This level was primarily concerned

with post implementation support. The project made significant progress in the early stages and consequently the implementation of some modules were accelerated. While this was good, the down side was that the systems coming on stream had to be managed. The implementation team Twas appointed primarily to implement software, not manage systems as such, so new structums had to be devised. The appointment of applic.a- tion managers from the population of end users considerably eased the pressure.

Prior to the 1990s the implelmentation of systems at the Rotunda was done on a sporadic basis with heavy emphasis placed upon early roll out while little or no regard was given to organisational issues.

Their briefs also included quality assurance and training. aspects of which are discussed elsewhere in this paper.

With the implementation of financial systems in the early 1990s this situation changed. Because of the complex nature of the implementation, structured methodologies were used and considerable cognisances was given to organisational re-engineering. These techniques were subsequently adopted and expanded for other software projects and have become the hallmark of IT philosophy at the Rotunda. In addition the PAS project d.esign influences include the following.

2.1. I Maanagel~~erz t style 2.2.1. Midwijby evolution Prior to project commencement the project The Rotunda has a long tradition in research.

manager produced a workbook document which Since its foundation by Bartholomew Masse in documented the tasks and timescales with had to 1745, a number of significant contributions have be adhered to for the life of the project. been made to obstetrical practice, neonatology

104

rBFsyILTs To ON

STEERING COMMITTEE I I I

ADVISORY GROUP /

/” i---l

Fig. 1. Organisational structure-PAS project

and human assisted reproduction. The evolution of midwifery education has taken place against this background [2].

Today midwives are no longer clinical surro- gates for medical staff but are slowly becoming clinical leaders in their own right. Significan.t projects in areas such as smoking, occupational health, casemix and clinical audit, risk management and health services administration are testi- mony to this fact. In addition many hospital midwives are undertaking university courses and higher Bevel training to supplement existing qual- ifications. In other words the time was right for the Rotunda midwives to harness IT.

2.2.2. Nursing and midwifery practice At a global level many changes are taking place

throughout the profession. The work of the following are relevant in this regard.

Roberts argued that once nurses recognised the dynamics of oppression, liberating actions were possible, including grassroots leadership, reclaim- ing nursing’s culture and heritage, and engaging in dialogue with ather nurses to develop consensus on values and priority in nursing practice [3]1. The importance of nurses and midwives acquiring

new skills has been underlined by Fleck and Fyffe [4]. Documenting clinical performance accurately can be used as a repository from wh.ich others can learn and develop their skills [5]. Polit and Hun- gler [6] point out that nurse researchers using the scientific paradigm face a number of major obsta- clues, one of which is primarily related to the complexity associated with investigating humans. The EVINCE Project showed how nurses and others used information [7]. The Heathrow debate sets out the eight strategic issues for nursing and midwifery in the 21st century [8].

While technology may challenge the founda- tions of nursing, nurses do not expect technology to have a negative effect on practice, and in some cases computers for example were thought to have a beneficial impact by improving speed, efficiency and flexibility [9- 111.

2.2.3. Health services management The Irish Department of Health’s Strategy for

Effective Health Care in the 1990s states that managers at all levels will have clearly defined responsibilities and will be fully accountable for achieving targets [ 121.

T. Carroll /Computer Methods ana’ Programs in Biomedicine 54 (1997) 101-I 13 105

In an era of limited healthcare resources and increasing demand for healthcare services, it is imperative that those involved in the care of patients use treatment strategies based on evidence which has proven those treatments to be effective [13].

Lorenzi and Riley [14] point out that over the past decade many organisations have felt pres- sures fo:r megachange and our healthcare systems are now been drawn into this high stress arena. Many European healthcare systems, facing figura- tive, if not literal bankruptcy, are looking at ways to slash costs. The US healthcare system is facing huge unknown changes. Hospitals in the US are already merging at near frantic rates.

2.3. Participation of midwives

The project midwives were involved in all aspects of the implementation including the follow- mg.

2.3.1. Systems development The vendor was unable to provide a maternity

system (off the shelf. As part of the contract the vendor agreed to build a maternity system to the Rotunda Hospital’s specification. The Rotunda and the National Maternity Hospital (which w.as its partner for the procurement phase) appointed a small team to write the functional specification for the maternity system. This team included a midwifery sister, consultant obstetrician/gynaecol- ogist, systems analyst and clerical support. The specification was drawn up over a three month period.

Input from the wider community of staff was seen as crucial to the success of the project. T:he greatest number of end users would be pupil and staff midwives. To ensure their involvement the project midwifery sister organised lectures, seminars and workshops in addition to maintaining one to one contact with key end user colleagues. .A prototype was built and demonstrated throughout the hospital on a lap top computer. Following feedback the prototype was revised. This process was done on several occasions before the prototype was signed off by end users. A broadly structured methodology was used for the systems

analysis and design while prototyping was done through Filemaker Pro which is a proprietary semirelational database package.

The empowerment of midwifery end users through key representation continued for the implementation phase of the bespoke development. In addition to the secondment of the original midwifery sister, three midwives from key loca- tions also joined the project. Their specific involvement in systems development centred around software testing, software enhancements and wider quality assurance matters.

Although the vendor had worked closely with the maternity rewrite team following contract signing, a considerable gap had to be bridged between their interpretation of our requirements versus the hospital’s understanding of what the finished product would look like. While close co-operation existed between both parties the project team members failed to document additional precise requirements which had allegedly been agreed with the vendor representatives.

There was no malice in either parties’ interpretation of events but the situation demonstrated the need to keep careful notes and to ensure that the comradeship which is often cemented with tieam members on both sides is kept in perspective particularly in terms of commercial realities.

The task of testing the software proved extremely daunting and time consuming. The maternity system consisted of four sub systems- ante-partum, labour/delivery, post-partum and anaesthetics, containing hundreds of fields spread over as many screens.

The testing procedure included checking the physical design for look and feel inadequacies, matching the contents of each of the sub modules against the hospital’s specification and finally checking the system’s functionality.

Discrepancies in each process were noted and advised in writing to the vendor. The amendments were done, a revised version released and the same checking procedure was undertaken again. This process continued over a six. month period until the hospital signed off on the software. In addition to the project midwives leading the testing programme, their colleagues throughout the hospital also became involved in the process

through parallel training on the module. By intro- ducing training during software testing the greater training requirement was accelerated while valuable feed.back could also be channelled into the testing phases.

Following going live the system was monitored on an ongoing basis during the first 12 months of operation. Despite vigorous testing some changes had not been done. It is important however to remember that with the breath and complexity of software of this nature it is virtually impossible to guarantee its correctness to the last percent. Some shortfalls only become apparent when all the functionality of the system is used on a continuous basis over a relatively long period. This prob- lem coupled with the inevitable enhancement:; which end users often require ensures that the process of software revisions will continue.

The involvement of key end users in both this process and also in system monitoring is crucial. The system cannot be left unaided following implementation but equally so the approach to these matters rnust be undertaken in a pragmatic way. The continuous involvement of end users should also encompass some aspects of the commercial negotiations with the vendors so that the end users can appreciate the costs of misjudging the testing phases and the cost implications of enhancements in general.

2.3.2. Process mappirzg One of the major goals of the project was to

streamline organisational procedures. Although milestones had been identified in the project plan for this process the amount of time involved and the complexity of the tasks had been underesti,- mated. The process was undertaken in a number of phases as follows:

Phase 1 involved a general review of organisational processes throughout the hospital.

o Phase 2 concentrated it’s review specifically upon those departments as a block which would be directly affected by the implementa,- tion. Phase 3 examined the processes within each department and the likely impact of the implementation.

The tools used throughout these phases included work studies, special surveys and feedback techniques. The investigations had been largely designed by the project midwives who played a key role in their success especially in clinical areas.

The level of co-operation received from colleagues would not have been as forthcoming if the investigations had been conduct.ed by non-midwifery staff. Once the purpose of the studies were clearly explained midwives were eager to partici- pa.te.

In many departments throughout the hospital no such studies had ever been undertaken before and consequently the role of the midwife had evolved through custom and practice.

The studies revealed the following: 1. Much duplication existed in supporting man-

ual systems. 2. The organisation and management of clinical

records fell far short of best practices. 3. Midwives were involved in a wide range of

non midwifery duties. 4. The absence of ward clerks placed a huge

clerical burden upon routine midwifery functions.

5. The overall work flows for task completion were inefficient.

The project midwives worked with their ward colleagues to draw up systems and procedures which would eliminate or at least reduce such problems. The methodology was revised and subsequently repeated for the implementation of each of the modules in the suite of software. The project team was anxious to ensure however that change was not driven by the demands of the software and the midwifery members of the team made sure that the focus was clinically driven.

Arising from the reviews numerous initiatives were prompted some of which include the following: 1. The clinical records and the obstetrical and

neonatal case folders were redesigned. 2. Changes in patient flow through outpatients

resulted in additional new patients being seen at each visit.

3. A comprehensive book of definitions for clinical and operational statistics was compiled and agreed by all senior staff.

T. Carroll/Computer Methods and Programs in Biomedicine 54 (1997) 101~ 113 107

4. Ar, inventory of documents was established and procedures put in place to manage all clinical documents.

.5. Data quality checks were introduced.

2.3.3. Training The four midwives who joined the team had no

background in IT nor had they received formal computer training in the past. Some of the midwives had used hospital computer systems elsewhere but their proficiency was scant and limited to end user exposure on second generation systems, The IT Department organised a one week course on project management which key team members attended. This was conducted by exte.r- nal specialists and formed the basis for determin- ing roles, responsibilities and the overall project philosophy.

A basic 10 h ‘IT Introductory course’ was designed in-house by the IT Department. All staff using the system throughout the hospital were required to undertake this course. In addition 3- 6 h training on each of the ten modules was provided to end users. The contents of the basic course is shown in Table 3.

The project midwives undertook all of these courses initially and through the cascade approach, delivered the courses to two hundred colleagues and forty clinical end users. They became subsequently responsible for training new hospital staff in these departments.

The level of assimilation by the project midwives was remarkable. The core training was undertaken over a one month period and within that time the midwives had fine tuned their material, prepared their own lecture notes and established training accounts to aid the teaching process for colleagues. This pattern of assimilation remained throughout the implementation and all training opportunities both internally and externally were exploiteld.

Although considerable resources were required to provide all end users with the basic 10 h traiqing programme, the benefits in core module traiti’jng and the outlook of staff to IT in general were- enormous. While project midwives became the catalysts for empowering colleagues, the ex-

tensive training gave additional confidence and ultimate authority to end users.

Since its establishment the IT department has remained pro-active on other educational fronts. Walk-in tutorials are provided on one evening per week for all end users. Short courses on propri- et.ary packages, the Internet and specialised software together with regular seminars on IT related topics are also provided. An annual IT conference is held and the department provides a newsletter on a regular basis. The contribution by the project midwives to these activities is significant.

2.3.4. Quality assurance A quality assurance programme for testing soft-

ware had been introduced at an early date in the irnplementation process. Quality concepts were therefore established in the mindset. Following the implementation of the system a number of data quality initiatives were esta’blished. These centred upon project midwives reviewing clinical data entries in the system on a daily basis for logical and general accuracy. Type of errors revealed included the following:

Table 3 IT program contents

Session 1 IT overview K.eyboard Mavis Beacon

Session 2 IT overview Video

Session 4 Software PSF Works Works WP

Session 5 Works WP

Session 7 Works chart Informatics Video

Session 8 Works DB Informatics

Session 10 Informatics Housekeeping Video Wrap up

Session 3 Software Mavis Beacon Video

Session 6 Works spreadsheets

Session 9 Informatics Data protection Video

Video material: Compututor Introduction and Guide to Per- sonal Computers (Technology Productions), Beyond the The- ory (British Computer Society), Introduction to Computing Video by L.K.K. Lian and Dr R. Jones, University of Glas- gow, 1989.

108 T. Carroll/Computer Methods ami Progrunzs ir, Biomedicine 84 (i997) 101 -I 13

1. Printouts not signed. 2. System updated but revised printouts not

pulled off for inclusion in notes. 3. One end user inputting data but colleague

signing off on printout(s). 4. Password violations.

After several months of system usage and fol.- lowing an extensive education programme these errors were greatly reduced.

However, no amount of visual checking can identify all possible weaknesses. It is only when trigger mechanisms are introduced that short comings can be identified. The trigger mecha.- nisms in the project’s case were provided by the implementation of information services which followed shortly after the main implementation had been completed. Clinical statistics and other outputs pointed to general data errors. The interfaces between the main system and subsidiary systems also highlighted more serious errors. This type of tracking is particularly beneficial and easy to operate because some of the interfaces automatically reject records which are irt- complete. The greatest number of errors are rnade by clerical staff recording basic administrative data, midwifery staff who fail to always notify the system of inpatient movements and doctors entering clinical information. A recent independent study on data quality throughout the labour/delivery notes revealed that midwives in the delivery suite were extremely accurate in recordirrg relevant delivery information in both the patient’s medical record and on the system cu.

The Rotunda is in the process of designing a comprehensive data quality assurance programme. the corner stone of which will be the appointment of a manager for each of the ten rnodules in the system. In addition to having responsibility for module training, each of the managers will also have specific responsibility for qualhty assurance. With respect to the obstetrical management and neo-natal information s,ystems, which are the two key clinical module,s, a combination of status reports, cross checks and random sample record abstraction will be undertaken on a regular and in some cases, daily basis.

Each clinical module will be managed by a midwife, a process which will also validate ownership and maintain empowerment.

3. Results

By using the above methodology the project targets were achieved and the overall project is scheduled for completion six months ahead of the original schedule.

3.1. Advan tczges

The advantages of using this type of methodology include the following: l Most efficient use of hospital resources. 0 Central focus for communication, planning

and control. l Early identification of problems. o Single point of leadership from beginning to

end. o Written and agreed upon objectives. e A system for review of potential changes. o Early warning of potentially late tasks. e View of dependencies for timely task comple-

tion. l Elimination of duplication of effort. o Ensures the inclusion of senior management

and clinicians in key decisions effecting the project.

e Ensures end user input at the highest level.

3.1.1. Disadvm tages The disadvantages included the following:

o Over indulgence on system modification. e Naive expectations and inexperience of end

users working in the commercial world. 0 Significant staff implementation costs.

The salaries and conditions of employment for the implementation staff were fixed. Salary in particular was relatively low. The Irish computer industry is rapidly expanding and abounds with job opportunities at considerably higher salaries than the public sector. Consequently the team lost most of its members during the implementation phases which added considerable strain to those who stayed. The fixed nature of the contract

T. Carroll / Computer Methods and Programs in Biomedicine 54 (1997) 101-I 13 109

proved to be a considerable indirect disadvantage which was not initially anticipated. Also the du,al nature of some team posts whereby members retained their original job in addition to working on the project caused problems on two specific fronts. Heavy cyclical workloads often coincided ,with similar work patterns on the project and thus .led to a conflict of interest. Secondly the systems management functions which had to be done fctl- lowing rapid implementation progress, did not always suit the skills base of the team members concerned.

3.2. Cost benejt analysis

The project was funded on the understanding that benefits would be realised. During the implementation phase the monitory value of benefts was pegged reasonably low, but post implementation the return on investment was expected to .be significant. In bygone days the package of benefits associated with health care computer systems ‘were always attractive enough to ensure funding. Benefits were largely seen as a paper exercise which rarely materialised for sponsors. Most benefits tended to be in the area of intangibles while t.angibles and net savings were rare. This approach to benefits realisation has changed and today IT sponsors and champions are interested in obtaining a return on their investment at an early date.

The Rotunda Hospital’s IT Steering Committee was anxious to see proof of system benefits. An independent study was conducted by an external expert into benefits realisation. Arising from t!his study a Benefits Realisation Committee was established. This committee consists of key end users and module owners who meet with IT staff on a regular basis to document benefits, exchange success stories and highlight wastages. The original implementation objectives outlined in Table 2 provide a background for measuring system performance and goal focusing.

To date the most significant monitory benefits have been in the area of cost avoidance. During the first 18 months of the project additional ser- v&es funded through staff savings of 80000 ECU’s have been realised. Intangible benefits and

soft savings are numerous but the benefits committee tend to discount their impact.

Because of the composition of the Committee and its level within the organisation, Committee members are honest about the successes and the failures of the implementation to date. The identification of failures or wastages is as equally as important as the success stories and by using brainstorming techniques significant progress has been made by addressing shortcomings. Neither the Hawthorne effect or assessment bias has been encountered. The Committee members are credi- ble witnesses who have nothing to gain by either exaggerating or withholding information. Struc- tured measurement techniques are not used.

There are a number of barriers which inhibit IT in hospitals and which in turn effect the rate of return on investment. In the first instance the incentives from economic and non-economic perspectives are relatively poor. Secondly clinicians tend to resist external independent reviews of their working practices, jealously guarding internal ac- countability only. In the third instance the amount of resources made available for IT in Ireland is relatively limited. Finally in the past healthcare applications have not been designed to a satisfactory level and tended to be implemented on a traditional basis although the next generation of systems will be more robust and appropri- ate.

While the IT Department acts as a facilitator for benefits realisation, it cannot be held responsible or accountable for delivering benefits. This job rests with the department managers and key users who exercise ultimate control over the system and their staff using it.

3.3. Lessons learned

A considerable amount of knowledge has been gained from the implementation to date. The lessons learned have a number of interesting par- allels with the biblically labelled Seven Deadly Sins. These include the following.

3.3.1. Sponsohip Sponsors are critical to the success of a project.

They must be identified and taken on board at an

110 T. CamAl / Computer Methods and Progmms it? Biomedicine 54 (1997) IOl- 113

early date. However sponsorship in the commercial sensle usually means pay back and hospital sponsorship is no different. Key sponsors may expect greater efficiencies within their departments, passibly staff savings and so forth.

Sponsors may also wish to have direct involvement in the management of the project particularly if their staff are involved in the implementation phases. In these circumstances the price of sponsorship may be to high in which case more benign sponsors with less organisational clout may have to be identified. Therefore the deadly sin of greed may pose a real threat to progress.

Ownership implies a willingness or a desire to have something. In every day life mortal man has to choose between that which he wants versus those which he can afford. System owners should be faced with the same dilemmas. They must be involved with the acquisition of the system from the outset. They must be part of the process of procurement and implementation. Too often ownership is forced upon the parties after the system has been implemented and instead of the system being accepted as a family member, it is regarded as an adoption with no blood links to the organi.. sation. The deadly sin of wrath may be exacted upon the project when system owners realise that the system falls short of expectations.

3.3.3. Pdlic relations For the project to succeed everyone in the

organisation must know about it. The right climate has to be created through whatever means may be necessary to get the message across. From this process champions may be identified and if the momentum is maintained, everyone throughout the organisation may seek to have the system.

There is a danger however that the deadly sin of envy rnay permeate throughout the organisation to the point where those who work on the project may become outcasts because they will be perceived to be working in the ultimate leading ed.ge arena.

End users must be given the tools of empower-

ment through training courses and other medi- urns. However empowerment must also be tempered with realism. The fact of the matter is that hospital systems are lagging somewhat be- hind developments taking place in the commercial sector. Although the human race is living on the ed.ge of the information superhighway. end users may be disappointed with the look and feel of hospital systems when they are compared with the type of technology they use on a day to day basis outside the hospital environment. Consequently end users may commit the dead.ly sin of lusting after the ultimate system to the point where empowerment becomes uncontrollable.

3.3.5. Cormacting After the specification of requirements, the con-

tract with the vendor is the most important document. While honesty and trust play a vital role in any partnership a clear statement of the ground rules and the exceptions will eliminate a lot of the dissatisfaction which may arise between both parties after the project commences. It is a good idea to try and incorporate the specification of requirements into the contract just in case some aspects of functionality are not present in the final product. The area of reports and system outputs in particular are often neglected.

It is imperative that a comprehensive change control agreement is included in the ffnal contract. In addition to addressing the obligations of the vendor it also helps to focus upon what the hospital can and cannot expect. All to often buyers feel that any amount of enhancements and customisations can be done and they then become bitterly disappointed when this does not transpire. The obligations of the vendor and the buyer in change control must clearly be studied and fully understood before the contract is signed. Escrow arrangements by a reputable agent must also be incorporated into the contract. In tihe process of contracting however the parties may commit the deadly sin of pride by failing to compromise.

3.3.6. Costs it is rare that a project will come in on time and

within budget. It may be possible to achieve one goal but not both, The question of budgetary

T. Cuuroll i Computer Methods anal Program in Biomedicine 54 (1997) 1 Ol- 113 111

overruns can occupy a lot of the project manager’s time especially if budget arrangements are rigid. There are two possible options. The first is to create the right climate throughout the organisation, ensuring that end users are happy with the system and gamble on spending outside the budget in the hope that the information systems board may be sympathetic if end users are happy and the organisation can see that over expenditure was well spent. The second approach is to seek additional funding approval first on the basis of what has been achieved. This may not be forthcoming as the board may not be fully aware of the achievements to date and may be more sympathetic to other competing resources.

In the final analysis it is really a judgement call which the project manager has to make. Over indulgence on the project budget however can take over from wise budgetary controls and can Kead to the sin of gluttony.

3.3.7. IT benejfs The realisation of benefits from the systems in

.terms of hard cash may be difficult. Most system implementations realise a wide range of intangible ‘or soft benefits but tangible benefits and net savings are difficult to trap. The establishment of a Benefits Realisation Committee consisting of key stake holders and key end users will focus upon this issue. Benefits workshops may also be helpful. Most importantly all users must be trained not ,just on the system itself but on the organisational changes which will arise. Training must be provided on time management in order to ensure that any savings are channelled into productive tasks. IIowever the organisation may not take benefns seriously and may regress towards the deadly sin of sloth.

4. Discwsicm

The introduction of new technology represents a potent force for change. In addition to impact- ing upon the nature and management of work, technolsogy implementations will touch the very culture of the organisation and change its folklore forever.

Hospitals have become sociotechnical organisations driven by people, complex adaptive patients and complex adaptive workers.

The most common type of category error or incorrect assumption made by managers is that they fail to recognise people as complex adaptive systems, open both externally and internally, ca- pable of generating an internal environment. ca- pable of possessing thought, imagination and the ability to hypothesise. Tapping people potential in sociotechnical organisations requires innovation in management. People who are most likely to be poor managers of innovation are those who do not posses the skills which are necessary to manage empowerment and the powerless in their organisations. Senge’s [16] skills requirement of managers point to intellectual and emotional skills. Intellectually, management requires an understanding of the role of the organisation and its mission, identifying the sub goals to fulfil this role and mission, a clear perception of strategies, an understanding of resources to facilitate strategies, good communication skills, the ability to identify category errors and the ability to understand the key concepts and issues of technology, produc- tion, administration and other areas in so far as they impact upon the viability of the organisation. Emotionally, leadership requires, the ability to dis- tance ones self from one’s ego, to share ownership of ideas, a tolerance and patience regarding indi- vidual differences in work styles, consensus making and the abilities to inspire, be assertive and give clear direction. In many organisations staff potential is often overlooked, particularly where large groups of the same occupations such as white or blue collar workers are found. A hospital environment is no different. Midwifery and nursing groups often occupy the majority of the workforce and are predominately female.

Women have tended to be disadvantaged within society and traditionally have not been given the same access to education, employment and other opportunities which I-rave been afforded to their male counterparts. Because of the limited availability of science subjects for example in some colleges, female workers may be forced into a particular career path and within that environment may not be able to progress to greater job

112 T. Carroll/ Computer Methods and Programs in Biomedicine 54 (1997) 101-113

opportunities such as those found in senior management or within the ranks of the highly mobile knowledge based industries. Consequently profes,- sional staff in certain categories may be ignored and feel powerless. Powerlessness poses one of the greatest threats to innovation.

One deterrent against powerlessness is empowerment but to use this deterrent means that managers have to be trained in powersharing.

The traditional concept of the organisation must also change if the benefits of IT are to be realised. Benjamin and Levinson [17] point out that re-engineering an older process is much more complex than developing an initial process. Based upon a review of the change management literature they identified three analytical modules which managers can use to support IT enabled change. One model treats the systematic process of change, one deals with the need to mutually adapt technology, busi- ness process and organisational structure; and one deals with the politics of the organisation.

Croswell [18] points to the need to modif;{ organisational structures to reap the rewards 01 technology but indicates that this might be met with scepticism in government agencies and private companies where traditional top down arrangements exists. In changing organisational structures, Kramer [19] suggests that the switch over must be carefully planned and realised through investment in education and training of staff at all levels.

While .the implementation at the Rotunda Hos- pital did involve a considerable degree of process mapping, the traditional structure of the organisation which is a typical voluntary hospital matrix design did not change at all. This may be due to the fact that IT enabled change was led in a bottom u,p design where staff training at lower levels in particular was substantial. The development of information systems will impact upon line managers and the next revolution may be driven by those cat’egories of staff who will possess casemix and resource information.

5. Conchsions

The completion of the PAS project at the Ro- tunda will signal the end of a significant phase in

the hospital’s recent history. Prior to project commencement, experience had been gained using structured techniques but the current project has demonstrated weaknesses which need to be ad- dressed for future implementations. During the bespoke developments for example valuable time was lost because configuration management had not been undertaken at the outset. The recruit- ment of project staff within the organisation and issues relating to pay and conditions of employment will need to be examined in greater detail. The possibility of outsourcing for specific implementations may, in future, prove to be a better option.

The realisation of benefits frorn IT related projects are always hard to quantify. In many instances more benefits may be realised if the status quo had been maintained while in other cases there may be no option but to computerise. Sponsors may need to be more realistic in their approach to IT benefits realisation.

A better philosophy may be for them to use the salme criteria which they would apply to the acquisition of other major items of expenditure such as medical equipment, building construction or laundry services. While the rationale for such expenditure invariably centres around direct patient care, the provision of information through technology is equally critical to the well-being of the patient, his guardians and family.

The role which the midwives played in the implementation, their ability to assimilate complex skills rapidly and impart knowledge, em- polwer colleagues and in effect re-engineer the organisation through consensus, has proved to be a significant bonus to the hospital. In future implementations considerable emphasis will be given to end user empowerment. The four level model used to project manage the implementation can easily be adapted for projects in other domains.

Project management has huge benefits to offer over traditional management techniques and could greatly assist in helping to manage scarce resources more effectively throughout the health services. The seven deadly sins are a product of hu.man nature and can appear where more than one shares the same sidewalk.

T. Carroll / Computer Methods and Programs in Biomedici?ne 54 (1997) 101~ 113 113

Acknowledgements

The author wishes to thank the following for their support and enthusiasm: Senior management-Dr P. McKenna, Dr M.R.N. Darling, M.A. Kelly and N. Nelson. De- partment of Health-A. Enright, Dr R.J. Nolan, C. Costello, S. McCormack. Project Team-Sr M. Philbin, M. Williams, H. Young, K. Muldoon, M. Lavin, M. Holohan, P. Griffin, A.M. Aboukrhes, E. Kane, A. Casey, M. Farrell, C. Connole, J. Brady, E. McGrath, D. Loftus, E. Hutchins. A. Rafter, E. Drew, A. Grogan, G. Gray, P. Loughlin-Lunt. AT&T Istel staff-T. Tyler, A. Ridley, S. Scott, B. Osmonde, M. Man- gan and the technical/support staff at Sheffield, Redditch and Newcastle.

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