Painfully Moving From Paper: IT Failure Caused by Lack of Change Readiness and the Impact on the “Innovators to the Laggards”
(Note: This paper was written by a clinician who is a student in my healthcare informatics certificate program. It is based on ‘in the trenches’ experiences in health IT. Used with permission.)
Across all areas of healthcare today, organizations are setting their sights on the successful implementation and diffusion of information technology that will provide improved quality, safety and improve financial performance across their organizations. The need to achieve this shift from a paper to electronic paperless health care delivery system within an environment where data standardization has not yet been fully accomplished to support a fragmented industry; it can be very difficult to demonstrate healthcare information technology’s return on investment. But some suggest that “IT adoption is 5 percent technology-related issues, and 95 percent sociocultural issues, such as change management, political process, leadership, commitment, risk tolerance and finances”. 1 Although technology related factors will be covered throughout this paper, so will the impact to this healthcare organization of the existing culture within the organization that was affected by the issues raised. Worldbook Encyclopedia defines “culture” as people’s whole way of life. It consists of all the ideas, objects, and ways of doing things. Culture includes arts, beliefs, customs, inventions, language, technology, and traditions.2 The impact of these culturally ingrained beliefs and the practices that result can be a major cause of change resistance. In addition to the individual stakeholder’s resistance; the technical, project management and organizational “people” skills that were inadequately addressed throughout the project implementation will be highlighted in relation to their impact on the “innovators to the laggards”.
According to The Standish Group’s CHAOS Report, a survey of general IT failures, healthcare IT projects were equally as likely to fail about 35% of the time; while fewer than 40% of large systems purchased from vendors met their goals”. 3 Traditionally, past research has shown that of the failed information systems, very little attention was paid to the topic of organizational and people issues. When these issues were considered at all, they were limited to the hands-on-users and ignored by the many other stakeholders within the organization. Their concerns were treated as “a last minute thought” and the too little too late mentality resulted in a lack of ability to make changes due to unbudgeted expense.4
Certainly challenges of motivating individual organizations constrained by budget constraints need to be addressed by the federal and state governments going forward and many have suggested an incentivized payment methodology be continued in greater degree to ensure that all facilities have an incentive toward IT Adoption to improve the benefits of the information exchange at the core of these projects. As for this IT Implementation, although the system was not an outright failure it did not meet user and organizational expectations; perhaps due to system limitations and lack of customization and interoperability which may of course been due to the budget constraints of this not-for-profit healthcare organization. This Healthcare Organization was a member hospital of a larger Regional Healthcare Organization and was therefore mandated to implement an “off the shelf” product and follow the corporate timeline of implementation. The system chosen by corporate allowed for very little customization resulting in reduced interoperability. Whatever the shortcomings, they most certainly caused added stress and resistance to change by the stakeholders and end-users, not to mention additional expense to the organization. What wasn’t known at the onset was that many questions that were assumed resolved, were in fact overlooked by the implementation team leaving a negative impact from the innovators to the laggards on future implementations.
If one looks at the necessary system components to ensure a successful health informatics implementation, the traditional focus in healthcare organizations has been first on hardware, then on software and the final and least prioritized component has been the peopleware. 5 A definite case of “seeing is believing” occurred with staff not “buying in” to the coming changes that were being announced. Significant delays in the implementation of the entire project were caused by a delay in the installation of conveniently located “hands on” hardware devices for use in accessing the newly implemented system. This lack of “visible” devices contributed significantly to the “painfully moving from paper” attitude of the end users causing the resistance to change that followed. Although the hardware has the advantage of its’ physical presence, even if viewed in a catalog or written on a purchase order; the organizational issues don’t have this luxury, with these factors typically being taken for granted due to an “it’s just common sense” attitude that can prevail over the “warm and fuzzy” peopleware issues. After all healthcare is the business of life or death; however remembering that the behaviors of the peopleware and their attitude toward what those systems can provide in terms of quality and support to that providers workday are critical and were not the initial focus of this project plan. It is obvious that these organizational issues tend to be a challenge to measure and predict success due to differences of impact level to the individuals and organizations involved. While hardware and software remain more visible components of success and may be easier to capture and statistically present fewer challenges in measurement, this still does not accurately tell the story as to whether the quality of the programs being used are sufficient to meet their organizational needs on a day to day basis or if “the people involved” needed in fact to create complex “work-arounds” in order to achieve the overall success that may have been attributed to those technical hardware and software improvements. This was most likely a contributing factor in this IT Failure.
With the knowledge of evolving examples of unsuccessful implementation making the healthcare and IT industry news headlines, “the role of people and organizational issues was heightened when it appeared that people issues were more responsible for implementation failure than the technical abilities of the system”.6 In the case of this Healthcare Organization a strategic decision was made to move beyond technology acquisition to the next level of technology assimilation; unfortunately there was more of a financial incentive driving the assimilation goals in the area of capturing charges, compliance with regulatory governing bodies and revenue enhancement than on the area of provider delivery of quality of care and efficiency by ensuring stakeholder and end user communication, involvement and satisfaction. This may have been due to the organizations’ politics among leadership which in this case was more of an “Anarchy Model” with corporate dictating that a system purchase decision must be made between two available corporate-blessed systems; the result being that the more affordable system was chosen by the organization out of budget constraints and the knowledge that there was an ever present need to move forward and sooth the hunger of the practitioners demanding better quality and timelier data. With no perceived unified model or leadership confidence by the departments and subunits, which had in the past been forced to manage their own information challenges due to an unresponsive overworked IT department, they set out from beginning to end of the project to “control” their data and became the greatest obstacles to success. Perhaps the “Reactive Leader” behaviors of the administration which carried through to the CIO running the project had a major impact on the lack of empowerment over the “big picture” that the department heads perceived. The perception of the stakeholders, (department heads, line supervisors and end users), was that the decision was made personally by someone in high level administration (without a medical or an information technology background), and then delegated the “change agent” and project manager role to the CIO, Chief Information Officer, (who also had no medical background).
The CIO was given the mandate of pushing the organization toward results as opposed to pulling it toward a shared vision. The project became problem oriented out of a need to keep control and self-protect this project managers’ reputation. The dictating continued and listening became minimal, in fact the ego displayed was obviously a sign of fear of loosing control and evoked more of a sporadic commitment of activity toward the individual project goals than a lasting commitment which should have occurred if the stakeholders and end users were involved and had “buy-in” along the way. This Reactive vs. Proactive Leadership behavior described above that occurred in this organization developed into a definite disconnect between this designated change leader and the stakeholders, including the physicians who blamed the CIO for their lack of involvement by not including their medical informatics liaison to the degree desired by the medical staff.
“The support and participation of upper management in every level of this process is critical. Executives must be willing to move to a shared-leadership model that involves all employees in developing and enabling a common vision. They must be comfortable receiving constructive feedback from employees about what’s working and not working within and commit the time required for teams of employees to work on improving internal communications.” 7 This being said, in order to be fair, although the approach to leadership may not been ideal, in addition to a solid IT solution the organizational goals needed to have become part of a common thread woven through the organization prior and during the planning stages, not announced simultaneously with the go live. This situation most certainly rendered the CIO “incapacitated” without the supportive organizational issues resolved there was little chance to create mindful end users who were committed to the project and the change leader.
At this point of the project, it was evident that the discovery and planning phase had gotten off to a rocky start. Without Senior Leadership’s willingness to acknowledge the importance of communicating a clear vision to the entire stakeholder and end user group, a shared vision that was not only in line with Corporate view for the individual Healthcare Organization, but also that met the needs of all stakeholders’ within the individual organization and the patients served challenges heightened. This error in not recognizing that there is no “magic bullet” in IT-enabled transformation and that for successful change to occur, the hard reality is that “change is everyone’s job”. 8 It is also important to point out that when there has not been adequate involvement of these stakeholders and end users, it places the organization at risk for users to blame the IT technology for poor performance or their lack of involvement as an excuse to render the new system “worthless” in their eyes. This is what occurred with this healthcare organization and the end users blamed the technology instead of the lack of planning, communication or involvement that was more the cause than the “off-the-shelf” hospital information system and clinical data repository. Another issue that occurred was the waning of support from the department heads that had been charged with supporting the change leader. One might ask if the leadership wasn’t proactive in developing a shared vision, why didn’t those at the department head level who were also empowered as decision makers ensure that a proactive approach to a shared vision and project implementation was achieved.
There instead was a division of department heads who met outside of the nursing initiatives and then a stand alone nursing task force that met outside of the division of department heads and both met outside of the medical informaticist physician sessions. There were no “in common” focus groups. Perhaps the leadership was concerned that too many requests for customization and too much empowerment of a combined leadership group would render too many expensive customizations and they wanted to solely make the decision as to where the resources would be spent. As a result individual department meetings resulted in a negative environment where line managers were witnessed at backstabbing, gossip and disregard for organizational values. These symptoms were surely the early warning signs of a lack of readiness on the part of the organization for a system that by definition, must capture data from multiple sources to be used in critical decision making at the point of care. The organization did not establish up front a multifunctional team committed to working with leadership, the CIO, the IT Department and each other to establish their own and a common hospital wide vision and goal. Delivering the highest quality care to the patients we serve along with reducing errors in an environment cognizant of best use of financial resources must be the ultimate goal that everyone in the organization needed to embrace. Although the CIO was empowered to lead the change, he fell victim to the organizational structure of the past that had been a rigid structure that had gone unchanged as an anarchy for over 5 years. The cynical attitude of mid line managers due to a lack of feeling of empowerment from past projects carried over from the mentality of “too many hats” to take another project seriously. The issue here was, without those stakeholders involved and communicating to their staff the project was doomed to some level of failure from the start.
After several productivity consultants had made serious reductions in staffing and what some employees and managers determined, “another waste of money that could have brought medical technology or the staff to run it”, the consultants came and went about four times to no avail. The employees did not see an improvement in overall operating performance of the organization as a result of these “experts”. This attempted culture change had caused distrust and had in some cases caused low self esteem among workers who felt threatened that they would be next among the “reorganized FTE’s, full time employees”.
It caused not only distrust among management and staff, but also among departments vying for financial resources and negative competition for capturing productivity volumes to make their departments shine in the eyes of administration. Although leadership had made efforts to introduce a values in practice recognition program; many employees felt that it was just another attempt at a method to render them “not worthy” and an excuse to cut staff since it involved being recognized by a patient or family and many employees organization wide do not have access to this direct patient contact such as laboratory or pharmacy staff.
Add to the existing lack of trust culture and the old saying “pay me now or you can pay me later” rings true. The lack of time spent on the planning, communicate and involve phase; although many technology projects are outcomes focused, must be realized in this situation which results in months on end post go live of duplicative documentation and a memory of “painfully moving to paperless”that many will not soon forget. Another area of downfall was the decision to hold all “conflict issues” until after the go live. This decision was handed down by corporate in the form of a mandate to wait for “system enhancements” to save this individual hospital money. However when these “conflict issues” involve your primary customer, the physicians, and their pride and joy of “ customized flow sheets” created over several years across medical department sections; the results can be catastrophic to all end users. The proposed assumption of paperless charting of vital signs resulted in double documentation for the nursing staff, and a nightmare of retraining needed for those who would have been early innovators turned laggard due to disappointment that their issues and priorities were not being heard.
understand the situation in the organization with respect to the technology
diffusion among the individual organization, an academic medical center, one
can point to the Diffusion of Innovations (DOI) theory which began to be
developed in the 1930’s and was defined by Everett Rogers, who published his
volume in the 1960’s as “the process by which an innovation is communicated
through certain channels over time among the members of a social system”.
With innovation being defined as “an idea, practice, or
objective perceived as new by an individual, a group, or an organization”.
9 The time element in
If one follows the time element of the project there was a definite lack of diffusion of information causing a delay in the diffusion of technology. What should have been a project planned for a period of approximately 2 years was rushed into a 9th month implementation plan which did not allow for the adequate persuasion of the broad spectrum of stakeholders. Hospitals are presented with a special challenge in dealing with the wide variety of needs, desires and attitudes of their stakeholders which can potentially create many conflicts. The varying group of stakeholders can be quite diverse and potentially include: the public, the owning entity, various government agencies and payors, vendors, professional staff, physicians, patients and their families or even area employers. Managing these conflicts as they occur is essential to empowerment of the project and the change leader.
The “decision” for system selection was made by a corporate entity irrespective of the individual needs of the member hospital. These enterprise entities with their mergers and acquisitions of hospitals resulted in this case as a perception that the for-profit hospitals were only interested in services that impact positively their bottom line vs. not-for-profits whose efforts in pursuit of excellence have largely had to come from within their organization. The lack of involvement of the stakeholders and end users in the decision for implementation of systems and methodology played a role in the failure. The “early adopters” or individuals that an organization reaches out to before implementation, were in many cases not involved to the level of detail and therefore the component systems and representative mid line managers of these departments were unaware that issues would crop up as a result of them “not knowing what they didn’t know”. These role models needed to be at the core of the planning phase not brought in at the time of implementation as was the case in some instances. As a result the “early majority” was delayed in their acceptance of the innovation and diffusion was further delayed. These two groups of early adopters and early majority can represent almost half of the total population of stakeholders and end users. “The early majority’s unique position between the very early and the relatively late to adopt makes them an important link in the adoption process.11
A major lesson learned as a result of the implementation phase was that the involve and communicate methodology had not been followed as recommended by many change management models. Had the ‘train the trainers’ been more directly involved in the communication channels, they would have learned that there were major delays to the system implementation. As a result many staff members were trained too far in advance of the “go live” date and were no longer competent users of the system by the time they would actually have access to it. In fact, the training program was inactivated at least 2 weeks before the go live, when there was to only be a 2 day down period initially planned. This caused issues with self esteem among staff and resulted in fear or embarrassment of incompetence if they were to request the retraining offered, instead they would “just help each other” and get by. This made the job of the trainers even more difficult and presented multiple challenges in determining whether there was confirmation of competence among the core and end users whose ability to be proficient in the system was a vital aspect of patient care while “moving from paper to paperless”. Of course with the staff clinicians experiencing difficulty and delays the physician population, who were the last to be trained since the idea was that the positive energy from the staff recognizing the tremendous benefit to their workflow would “sell” the system to the physician, there was no chance of success with physicians and their was initially refusal to use the system followed by a validation of reasons daily as to why their resistance to change was validated in the name of “patient quality of care”. Those who should have been the “change agents” as successful staff end users were to have calmed the fears of the physicians that the data would be there for them when they needed it without wading through the paper chart. Instead the physicians lost faith in the project and insisted on duplicate documentation sending the nursing staff into overload resulting in overtime expense and employee dissatisfaction to the greatest extent.
In order to encourage these individuals to adopt the innovation that was being implemented it became important to uncover to what change the employees and physicians were resisting to ? Was it the technology itself that they were resistant too due to a lack of self confidence because they did not initially possess the skill to feel competent and the delay in the roll out had caused even stronger issues of insecurity on user competence. Was it the specific system of software, in this case a new hospital information system that had moved the organization from a DOS to a Microsoft Windows environment where many users had not yet become proficient in feeding the “mouse” some cheese and getting it to behave so they could get their tasks accomplished in an acceptable time frame. Was the resistance the result of outside factors such as environmental issues that were growing in the nation and causing physicians and clinicians to ask themselves, “what kind of a healthcare world is this becoming?” I am being mandated to use a system that I haven’t even been represented in the implementation stage. Who went to medical school anyway ? Resisting the change in one’s own environment in some cases was the only power these providers could exert with the limited information they were given at the time. Actually in the end, there was the greatest resistance to the original “change agent” who was perceived as senior leadership and their designee CIO, who by this time had been exposed to both “judge and jury” by the staff and been voted guilty by his title and the fact that he had neglected to “involve and communicate” the project and plan to them in the way they felt they were deserving of. In the end a complete change in leadership was introduced including a middle line manager who had become the “champion” of the project through the creation of “focus groups” that had so significantly redirected the project to an end user centered “change team” that they were able to save the go live date within days along with only a 2 week follow up training timeframe before all end users were deemed competent and equally as important part of the “change team” and accountable for both the quality, productivity and efficiency of the new system moving forward.
This Healthcare Organization is not alone in its lack of readiness for change. It is my opinion that although there are many significant challenges that face organizations like this one. The challenges continue to grow in the areas of ownership enterprising, rising acuity and aging of patients, rising costs of treating patients due to exploding technologies and legal issues, a wiser public with a declining trust in healthcare, a diverse personnel and customer base in its’ employees, clinicians and physicians and a unique payment structure that results in many patients never seeing the costs of their care received. It has been clear throughout the points made on this topic, that the real key to success is user involvement, involving them every step of the way to gain trust and buy in on the redesign of their work practices and ensuring that their priorities have been met as part of a larger team effort to prioritize patient care and public safety. Equally as important is the adherence to the organizational aspects of change management and to pay close attention to the support and structure given to the empowered “change agent” ensuring that the person designated to this role stays as the perceived champion of the project and does not become the detriment unknowingly through poor decision making and management strategies.
Ensuring a positive working environment that respects people and encourages the high level of team work and collaboration is the result of focus on these important attributes to be included in the process and the project. Both individual and organizational goals can be attained from following the best practices recognized in this paper and through plans to seek out the most current research on the topic such as “Avoiding the F-Word: IT Project Morbidity, Mortality, and Immortality”, a workshop being planned at the American Medical Informatics Association Annual Meeting in 2006. Focus on customer and common goals for collaboration, along with a sharing or “morgue” of data on outcomes for failed systems is the goal of such a forum, and those who want to avoid a similar failure as occurred at this institution, which may have been partially or completely preventable, should consider heeding the advice of those experts in the field of medical informatics who have walked in the shoes in both domains and are focused on the “sharing” and collaboration needed to move individual organizations to their needed platform of success so that the national incentives for patient quality of care and efficiency can be realized.
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