2. Identifyandbriefly describethestrengths andweaknessesobserved inboththe Alphaandthe Beta cases.
4. Identify and discuss two dimensions/types of challenges/barriers related to the technology implementation observed in the two cases and provide specific examples to illustrate and support your answer.
6. Describe whether the challenges/barriers that you identified in the previous question were consistent throughout the process of planning and implementation of the new technology. Provide two examples of actions that alleviated or contributed to these challenges.
8. Identify three lessons learned from these two cases (you can refer to any or both of the two sites). Explain how these lessons relate to IT implementation practices and may be leveraged bymanagers inthecontextofimplementationofdifferenttechnologiesinotherhospitals.

InnovatingMindfully:TwoStories,TwoEnding

Innovating Mindfully: Two Stories, Two Endings

Description of the Alpha case

The Alpha case took place from 1995 to 2001 in an acute care hospital in a suburb of a large Canadian city. The budget estimate for the project was $3.5 million. Before it acquired the PACS, the medical imaging department used film for all the images made with its various imaging devices. The department received a budget envelope to cover the cost of supplies and hospital management made it responsible for managing the budget. However, large budget cuts in the 1990s made the department responsible for providing the same quality of service with a much smaller budget. This led them to consider a PACS implementation as a potential response to the budget cuts. In February 1995, the film supplier organized a PACS demonstration for the hospital's general management and its unit heads. The hospital then asked the supplier to make a submission to have an approximate cost for such a system. In the Fall of 1995, the head of the medical imaging department and the technologist in charge of administrative services for the department attended the annual meeting of the Radiological Society of North America, at which there were several PACS activities (such as seminars, lectures, system demonstrations). Participating in these activities gave them a better understanding of how the system worked and how it could be beneficial to their medical imaging department and the hospital as a whole. This meeting reinforced the hospital's interest in acquiring a PACS system and led them to develop the idea further, including an examination of Alpha's longstanding relationship with its film supplier. The department heads then sought a second opinion from another supplier in order to compare the two proposals. In April 1996, a formal acquisition proposal was presented to the hospital's administration. The proposal was prepared by a team consisting of the two department heads who attended the annual meeting as well as a clinical radiologist. The proposal included several deployment phases and was designed to minimize interference with hospital operations. In addition, in order to meet the requirements of hospital management, a detailed budget was prepared of the projected direct gains (e.g., reduced costs through the elimination of film purchases) and the projected indirect gains (e.g., PACS' impact on the length of hospital stays) associated with the PACS acquisition. In July 1996, Alpha conducted a study of the path taken by a radiology request in order to develop a better understanding of the operational flows that the system would need to support. The tendering process began in January 1997. Since the team was unable to determine the optimal system configuration that would best meet the organization's needs, the decision was made to prepare the document in a way that would transfer this responsibility to the supplier. The tendering document, which only covered the organization's general expectations (95% reduction in the use of film, rapid access to images, a user-friendly system and full integration with the existing radiology information system), was sent to six carefully selected potential suppliers. From February to May 1997, the team visited four hospitals located in the United States, Canada, Australia and Germany that had been using PACS for some time. These visits provided a better understanding of implementation strategies, potential challenges and the savings realized by health care organizations. This period was also used to conduct a survey of habits in the use of radiological film. The survey was sent to all the members of the hospital's board of physicians, dentists and pharmacists. Following these visits and an analysis of survey responses, the decision was made to change the preliminary deployment plan from two phases to a single phase, which would allow the hospital to start realizing savings earlier. A new, detailed action plan was presented to the hospital's administration in May 1997. The administration identified key problems for each of the groups that would be affected by the change (radiologists, physicians, employees and unions) as well as key individuals in these groups who could promote the project, find sources of funding and develop an operational plan. The action plan convinced the hospital's administration to invest in the project, and a supplier was selected based on the quality of the proposed hardware (e.g., the monitors) and software as well as compliance with the initial project criteria. The successful bidder had already provided 70% of the hospital's medical imaging systems, and the organization hoped that by working with this supplier it could minimize integration problems. Before the supplier was officially selected, the organization took some time to inform the employees who would be affected by the changes about the imminent re-organization, including the abolition and transformation of certain positions. Some employees decided to leave before the system was deployed, which greatly helped the transition. Shortly after the successful bidder was announced, it installed some work stations and invited future system users to experience the quality of the images for themselves. This gave users an opportunity to discuss their reactions and concerns. The supplier took these comments seriously, since it was keenly aware that user dissatisfaction can hinder the implementation of IT solutions. In early 1998 the organization struck two committees for the PACS implementation. The first committee, which would plan, coordinate, control and implement the project, consisted of the initial project team, the technician who would be responsible for the system's future management, a member of the administration and the supplier's project manager. The committee met once a week. The second committee was charged with developing a communications plan that would foster appropriation of the system by the targeted users and keep the medical community informed of progress made in the project. The second committee consisted of the members of the first committee as well as representatives from various interested groups (management, the finance and technical department, etc.). Before the PACS was rolled out, the supplier updated the existing radiology information system (RIS) so that the two systems would be able to communicate with each other. Employees in the imaging department and physicians received individual training; the employees were trained according to a pre-established schedule, and the physicians were offered training by appointment, given their busy schedules. In addition, a small but professional-looking journal, "PACS in a Nutshell," was distributed to all employees. This communications tool included several sections, including "PACS for Dummies," which was generally used to give simple explanations of the technology, but also to provide answers to frequently asked questions about how the implementation would unfold. The system was deployed in the Fall of 1998, and the deployment took less than two weeks. User reactions to the deployment were positive overall: the system made access to images easier and reduced the number of required tasks. Six months after deployment, a postmortem was carried out. It revealed that six weeks of technical adjustments were required before the system became fully functional, and that productivity gains could be seen after three months. A survey conducted six months later revealed that all the users preferred PACS to the former system and that the system provided easier access to images, which saved time and enhanced productivity.

Description of the Beta case

The Beta case was a regional hospital located in the suburbs of another Canadian city. The budget for this project was close to $2 million, and it ran from 1997 to 2001. In the 1990s, the hospital's management decided that the hospital should be a state-of-the-art facility in order to retain the region's client base and facilitate the recruitment of medical specialists. Before this vision could be achieved, the hospital was already known as one of the first to acquire new technology. This included being the first hospital to buy a computer-controlled axial tomodensitometer in 1980, and one of the first hospitals in this area to acquire a magnetic resonance device in 1990. At Beta, the idea of adopting PACS came out of two parallel projects. First, the hospital wanted to replace the obsolete tomodensitometer using funds from the device's maintenance budget. Then the hospital received funds to replace a fluoroscopy room and add two other rooms: a fluoroscopy room and a magnetic resonance room. The problem was that this equipment would have increased the facility's treatment capacity, which would have increased the number of films to be developed, since films were used to view and store radiology images. Another result was that new laser cameras would be needed. These various acquisition projects were bundled into a single project to reorganize the medical imaging department for a price of close to $7 million. Given the size of this expense, in the Fall of 1997 four members of the project committee attended the annual meeting of the Radiological Society of North America to learn more about new devices on the market. It was at this conference that the team came up with the idea of acquiring a PACS, since this system would eliminate the need to develop films and sidestep the need to procure additional development cameras, which cost $150,000 each. Upon their return from the meeting, the committee members in charge of the project met to evaluate whether PACS could both meet the organization's needs and become part of the current reorganization project. Six managers of different departments joined the committee. This larger group made the decision to make a PACS acquisition part of the medical imaging department's reorganization, since it could be tied in to over half of the department's equipment, thereby reducing the use of films. Beta also expected that, in the years to come, PACS would begin appearing in other hospitals in its region, and it wanted to be one of the first to acquire a system. Since the organization was operating in an environment where financial resources were becoming harder to come by, it needed to demonstrate that the project could be self-funded. In November 1997, with this economic analysis underway, the tendering process for acquiring a PACS and the other equipment began. The committee developed a series of documents to define all the characteristics of each project. The call for tenders was launched in January 1998. As the submissions were being reviewed, particular attention was paid to the two least expensive bids, since they met the project's needs. In February and March 1998, the committee visited the two shortlisted suppliers as well as clinical sites that were using their PACS. After these visits, the committee met to review the two bids one more time. Based on several factors (e.g., PACS integration with the new equipment and image quality), the committee decided to accept the second bid, which was judged superior due to the quality of the monitors, the customization options, the supplier's reputation, a lower price, etc. As it turned out, the same supplier had been selected to furnish the new medical imaging equipment. The committee therefore hoped that this would ensure better integration between their new PACS and the new equipment. The economic arrangements and the committee's selection of a supplier were submitted to hospital management in April 1998 and approved a month later. The project was expected to pay for itself in eight years. Following this decision, a contract was signed by the supplier and hospital management, and the mandate of the management committee came to an end. The stakeholders who had initiated the project saw the implementation phase as a period of operational challenges. They abandoned the file and transferred responsibility for the project to a new team that consisted of the technologist responsible for managing the system as well as two technicians: one from the supplier and the other from the hospital's IT department. From the outset, this new committee naturally focused its efforts on technical issues. For example, it worked on the interfaces that would allow the PACS to communicate with the RIS that the hospital had already been operating for several years, as well as with existing equipment and devices acquired as part of the reorganization project. Generally speaking, little attention was paid to the human and organizational dimensions of the project. Once the contract had been signed, the supplier demonstrated how the system would work, and two standard memorandums on the innovation were sent to hospital employees to discuss the reasons for the acquisition and announce that the project had begun. At one point, the committee decided to give some gifts (allocating more work stations of a better quality) to the two specialties who were their biggest clients, the orthopedists and the pneumologists, as a way to prevent dissatisfaction with the system. The technologist responsible for managing the system had a week of training outside the hospital and then trained the other members of the team to act as super-users. The committee then sent out a letter that invited all future system users to attend their training sessions on a voluntary basis. These sessions were offered to large groups on a fixed schedule several days before deployment. Only 30% of the physicians attended. Despite the low attendance, deployment of the PACS began in the Fall of 1999, but things did not go smoothly. We should point out that Beta had decided to begin by digitizing fluoroscopy and their digital modalities instead of their analog modalities, yet no physician was looking at these images. The physicians thus had great difficulty seeing the usefulness of the system. When the digitization of exposure imaging began six months later, the physicians quickly started to express their dissatisfaction with the quality of the images. The head of radiology had to ask the hospital's administrative manager to intervene and impose system use on specific physicians. Then problems began to appear in the interfaces that had been developed to link the RIS to the PACS, and this interfered with the use of these systems. The situation seriously disrupted operations in the radiology department, where these systems were being used on a daily basis. With the problems still unresolved one year after system deployment, the decision was made to acquire a new RIS. The IT department was given responsibility for the process for acquiring the new RIS, since it would be assuming the costs. This time there was no call for tenders, and Beta acquired the RIS from the same company that supplied the PACS in order to ensure better integration. Some processes had to be reviewed before the RIS could be deployed in order to ensure that it would be fully compatible and integrated with the PACS. However, acquiring a new RIS did not resolve all the problems, since the system crashed on the very day it went into operation. In contrast to the former RIS, which was linked to the PACS by an interface, the new RIS was completely integrated with the PACS, such that when one system crashed, it paralyzed the entire department. The supplier's explanation was that this technical problem was the result of underestimating the amount of data that would have to be shared between the two systems. In order to ensure continuity in the department's operations, the former system was re-installed and used for another eight weeks, giving the technicians time to make the necessary changes to the new RIS. The project team then tried to install the new RIS a second time, but in a phased implementation. Fifteen months after the PACS was deployed, it was still not an integral part of the organization's operations. No productivity gains had been observed, but the main objective - the elimination of films - had been achieved. Furthermore, no official mechanism had been implemented to collect comments from users, but occasionally the staff expressed opinions about the system, especially at tactical intervention group meetings, responsible for the analysis of ambulatory services.