THE IMPACT OF STAKEHOLDER POWER AND
INTEREST CHARACTERISTICS TOWARDS THE
EARLY ADOPTION OUTCOME OF WORKFLOW
MANAGEMENT SYSTEMS
A Case Study Research and Critical Reflection of a Workflow Manage-
ment System Adoption Project in the Clinical Supply Chain
Master thesis
MSc Supply Chain Management
University of Groningen, Faculty of Economics and Business
Marc Binder S2873362
Table of content
Abstract ... 3
1
Introduction ... 4
2
Literature Review ... 7
2.1
The Health Care Sector ... 7
2.2
Workflow Management Systems (WfMS) ... 8
2.3
Early Adoption Outcomes of Information Systems ... 9
2.4
Stakeholder and Stakeholder Analysis ... 10
2.5
Stakeholder Interest and Power Factors ... 11
2.6
Conclusion and Research Question ... 13
3
Research Methodology ... 16
3.1
Research Design ... 16
3.2
Research Setting ... 17
3.3
Data Gathering ... 18
3.4
Data Analysis ... 20
4
Case Study Findings ... 24
4.1
Stakeholder Overview ... 24
4.2
Stakeholder Interest Findings ... 26
4.3
Stakeholder Power Findings ... 28
4.4
Case Study Outcome ... 30
5
Discussion ... 33
5.1
Critical Reflection of the Case Study Findings ... 33
5.2
Power and Interest Impact on the Early Adoption Outcome ... 34
6
Conclusion ... 38
6.1
Concluding the research question ... 38
6.2
Theoretical Implications ... 39
6.3
Managerial Implications ... 39
6.4
Research Limitations ... 40
6.5
Acknowledgements ... 40
Reference List ... 41
Appendix ... 49
Appendix 1: Interview Guideline ... 50
Appendix 2: Coding Tree Excerpt ... 56
Appendix 3: Coding Scheme, Stakeholder Interest Perspective ... 58
Table of figures
Figure 2.1: Conceptual Framework ... 14
Figure 3.1: Stakeholder Interest Factors ... 19
Figure 3.2: Stakeholder Power Factors ... 19
Figure 3.3: Coding Tree Excerpt (Open and Axial Coding) ... 22
Figure 3.4: Coding Tree Excerpt (Level 2 Coding) ... 22
Figure 4.1: Stakeholder Identification ... 24
Figure 4.2: Stakeholder Analysis ... 30
Figure 4.3: Case Study Findings ... 32
Figure 5.1: Adoption Workload Challenge ... 35
Figure 5.2: WfMS Incompatibility Challenge ... 35
Figure 5.3: Stakeholder Expectations Challenge ... 36
Figure 5.4: Adoption Leader Responsibilities Challenge ... 36
Abstract
1 Introduction
Managing the health care sector can be regarded as a widely-accepted phenomenon of interest now- adays. Due to an over-aging society and the economic rise of emerging countries, provoking new challenges, this phenomenon seeks to gain even more importance. In order to effectively cope with those challenges, increased emphasis needs to be put into the introduction of new innovations. Health care professionals are more and more concerned with balancing economic costs, quality and access to health care services (Chiasson & Davidson, 2004). The fragmented nature of the health care sector, its large volume of transactions, and its need to integrate new scientific evidence into practice are intuitively limiting the applicability of paper-based information management (Chaudhry et al., 2006). Increasing productivity and reducing costs, without affecting patient care quality, remains a big chal- lenge (Manias et al., 2016).
Rapidly changing environmental influences are calling for more in-depth understanding on suitable solution approaches, making the health care sector an important area for examining the strategic use of information technology (IT) (Kim & Michelman, 1990). Efficient and effective applications can help to improve cost-effectiveness, quality, and accessibility of health care (Chiasson & Davidson, 2004). However, it is of utmost importance that IT is not limited within organizational borders, but manages the information flow between all involved stakeholders in the clinical supply chain. The integration of effective and transparent information flows among stakeholders in the health care sector can be seen as a crucial necessity for performance and is directly associated with the quality of patient care. Infor- mation sharing across departmental boundaries is becoming self-evident, with stakeholders and pa- tients calling for more process visibility and transparency.
(WfMS) are software systems that support the specification, execution, and control of business pro- cesses (Reijers et al., 2010). When it comes to the health care sector, WfMS veil high potential in cost and service quality improvements (Dwivedi et al., 2001). Lenz and Reichert (2007) stressed the changing health care environment towards continuous treatments, involving multiple healthcare pro- fessionals and institutions. Linking different units within hospitals, knotting ties to other healthcare organizations, and organizing the information flow between those thus becomes paramount. While complex administrative procedures are being automated, clinical staff is left with more time for crucial,
potentially life-saving, clinical processes.
Due to the distinct and service-centred nature of the health care domain, dividing the order, consumer, and payer role among different individuals, the number of stakeholders involved in system develop- ment and use is far greater than in traditional organizational systems (Pouloudi & Whitley, 1997). Therefore, the use of sophisticated measures to identify and evaluate stakeholders participating in information system implementation is of utmost importance. According to Boonstra and de Vries (2008), identifying stakeholders is an important activity towards achieving a broader goal, that is the management of stakeholders. Eslami Andargoli et al. (2017) further stressed this need to shift from the what (information technology) towards the who and why (stakeholder identification and analysis) as primary focus of evaluating IT in the health care sector. Several approaches have been made towards stakeholder identification in inter-organizational healthcare systems, including those of Lyytinen and Hirschheim (1987), Pouloudi and Whitley (1997), and Mantzana et al. (2007). However, Pouloudi and Whitley (1997) noted that most approaches failed to provide a practical technique for identifying stakeholders. Boonstra and de Vries (2008) criticized the lacking practical application of extant stakeholder identification frameworks. Mantzana et al. (2007) called for the consideration of power, control, and legitimacy issues of stakeholders when exploring their influence towards IT adop- tion.
Revealing stakeholder interests may therefore facilitate the early adoption of IT. Furthermore, WfMS often deals with connecting a multitude of stakeholders with differing power perceptions. Analysing the impact of stakeholder power towards the early adoption of this technology may be a further step
towards more successful adoption outcomes.
Performance assessment in health care organizations often evokes results that are multidimensional, thus easily paradoxical (Sicotte et al., 1998). This is based on the fact that stakeholders within the organization often established their own individual goals, preferences, and aims (Champagne, Con- tandriopoulos & Pineault, 1986). The stakeholders involved in the clinical supply chain are of both medical and managerial nature. A certain performance aspect that may evoke positive reactions for one stakeholder may therefore hold the opposite for another one. Both Quaglini et al. (2001) and Lenz and Reichert (2007) recognized the absence of WfMS in the health care domain, which may be partly repatriate to the fact of divergent stakeholder interests and power perceptions. This situation calls for innovative approaches regarding the early adoption of WfMS into the health care sector, while taking stakeholder power and interest into consideration. The research of Boonstra and de Vries (2005) could serve as a starting point towards approaching this goal. The authors proposed a framework to analyse inter-organizational systems from a power and interest perspective. Still, they motivated that further research should treat the operationalization of the constructs and give more in-depth insights by applying it to specific economic sectors. Therefore, this research seeks to address the various stakeholder power and interest attributes and their impact on the early adoption outcome of WfMS in the health care sector more profoundly. The following sub-topics will be conducted throughout this research:
a) The implementation and early adoption of WfMS into the health care sector
b) The identification and analysis of the power and interest characteristics of stakeholders in-
volved in the early adoption process
c) Finally, combining a) and b) towards discussing the underlying reasons for the outcome of a
WfMS adoption project in a real-case setting
2 Literature Review
2.1 The Health Care Sector
Being constituted mainly on paper-based documentation, the health care sector was confronted by a considerable amount of challenges and will continue to do so in the future. In particular, the area of oncology care was affected by these challenges: Driven by an aging society, population growth in emerging countries, and improved survival rates, the number of cancer patients was expected to rise rapidly throughout the next years (Erikson et al., 2007). In the German health care sector, the annual amount of new cancer diagnoses reached 460’000 cases in total in 2010 and seek to rise by a rate of 2-3% every year (Hohenberger, 2010). Simultaneously, oncology professionals were also aging, leading to considerable amounts of retirements throughout the next years. As a result, the gap be- tween demand and supply of oncologic care is ever-rising.
section, a possible solution approach for cross-organizational information interchange (WfMS) is pre- sented.
2.2 Workflow Management Systems (WfMS)
In order to gain deeper understanding of the underlying principles of WfMS theory, a proper definition of the workflow term is key. Georgakopoulos, Hornick and Sheth (1995) defined workflows as a col- lection of tasks, performed by one or more systems or humans, organized to accomplish a business process. Workflows are concerned with the automation of procedures, passing documents, infor- mation or tasks between participants according to a pre-defined set of rules, contributing to an overall business goal (Hollingsworth, 1994). Workflow management deals with enhancing the efficiency, adaptability, and flexibility of organizations when applying workflow technology (Han, Sheth & Bussler, 1998). In particular, WfMS serve to create, direct, and monitor the execution of these workflows (Yan, Yang & Raikundalia, 2006). They completely define, manage, and execute workflow processes by execution of workflow-driven computer software, representing the logic of the workflow process (van der Aalst, van Hee & Houben, 1994). WfMS tends to introduce formality and structure into organiza- tions (Stohr & Zhao, 1997). However, as work allocation decisions are made by computer systems rather than people, WfMS was perceived to limit work empowerment and the freedom to design own
work processes (Vanderfeesten & Reijers, 2005).
Parkes (2002) labelled the earlier phases of WfMS implementation as most critical to the overall pro- ject success, with most problems being related to end user and process design issues. In this stage, management commitment was labelled as most important success variable in WfMS implementation. Due to their dehumanizing effect by reducing resilience of daily work in process automation, WfMS were reported to be often difficult to implement. However, they held potentials in improving the quality of work life, by eliminating and digitalizing repetitive and boring tasks. Several hypotheses on the effects of WfMS on organizations were stated by Küng (2000). On overall, job satisfaction was per- ceived to increase under a WfMS, due to more speedy and accurate information exchange. Besides receiving responses who reported their jobs to become more interesting and challenging, Küng (2000) also reminded that certain jobs may become rather monotonous and uninteresting under the WfMS. Furthermore, dis-empowerment of middle management was observed as possible outcome of a
WfMS integration.
medical care processes and organizational structures, however, stressing the high level of customi- zation required in the health care context. Campbell et al. (2009) discussed several resistance factors towards computerized provider order entry systems in health care, including the fear of technology failure, clinical resistance and the inability of integration into existing health care systems. Performing an iterative alteration of the workflow system until a satisfactory solution is achieved has been con- cluded as a possible countermeasure. Given the knowledge on WfMS in general, the following section discusses the implementation and outcomes of the early adoption of this technology (and information systems in general).
2.3 Early Adoption Outcomes of Information Systems
The early adoption phase of IT is marking a critical phase towards overall system performance. Surry (2009) defined IT adoption as the taking and execution of a conscious decision to use a particular technology from both an individual and organizational perspective. Adoption involves rational and po- litical negotiations to get organizational backing and a decision to invest resources into the solving of organizational problems or new opportunities (Sharma and Rai, 2003). Hu et al. (2000) described the adoption of information systems as an organization’s decision to acquire technology and pro- vide it to its users. However, the implementation of information systems into existing organiza- tional structures was quite difficult to achieve due to various factors. It was complicated both from a technical point of view and due to various other contexts, such as strategic, organizational, political, or cultural viewpoints (Boonstra & de Vries, 2008). Accepting the central role of human, social, and organizational contexts in the implementation of information systems has been iden-
tified by Coakes (2002) and Aarts et al. (2010).
Parkes (2002) noted that the early phases of workflow implementation projects are most critical to the overall adoption outcome. The early adoption of WfMS is often facing a set of challenges within the organization, including the fear of losing flexibility, job losses, the need to relearn new technology or resistance to process automation (Kobielus, 1997). When it comes to the health care sector, Cresswell and Sheikh (2013) argued that the sector is usually quite slow in adopting new technology. Introducing technology within health care organizations was not a straightforward process, but dynamic in terms of several technological, social, and organizational factors. Boonstra and Broekhuis (2010) mentioned several reasons that caused barriers in the adoption of information systems in the health care sector, such as: Limited time resources in data entry, lack of interconnectivity with existing systems, lack of customizability, or lack of leadership moti- vation.
for a successful implementation. Kobielus (1997) presented the scalability of the WfMS to other or- ganizational situations as another outcome from a technological perspective. Management and hu- man categories are taking support or resistance from both management and staff into account. An application might be particularly suitable to a specific adoption situation from a technological view- point. However, shifting perceptions of the affected stakeholders may break the adoption outcome, or at least lead towards postponing the decision-making. Top management support and end-user ac- ceptance (Poelmans, 2002) have been mentioned as outcomes of a WfMS adoption from a human perspective. Hu et al. (1999) also recognized user acceptance as a human critical success factor for IT adoption. They further operationalized user acceptance as consisting of individual, technology, and organizational characteristics. From a process perspective, cultural aversion towards the process de- sign has been elucidated as a potential adoption outcome (Sinur & Thompson, 2003).
Jokonya, Kroeze and Van Der Poll (2012) acknowledged that most recent studies on IT adoption were based on a positivist paradigm, taking primary focus on the perception of individual usage but disre- garded to give attention to multiple stakeholders within the organization. Bernroider (2008) criticized that literature on IT adoption was paying too much attention on hard factors such as efficiency and effectiveness, without taking the complexities of the organization into account. This one-dimensional view led to the failure of many IT adoption projects, due to unclear responsibilities, lacking formal structures or other strategic limitations. In fact, a successful IT adoption requires a holistic approach through empowering and enabling equal participation of stakeholders in decision-making (Waddell, 2005). Checkland (1990) elucidated information systems as being social artefacts that can be affected by people according to their interests. Doing so, the adoption process should not only address the functionality of the information system, but actively converge all differing stakeholder interests in order to opt for optimum early adoption outcomes. The impact of the IT adoption will vary significantly among different stakeholders, hence, the identification of who affects or may be affected by the adoption is very important for its implementation performance (Jokonya et al., 2012). Given this reason, the way how stakeholders can be properly elucidated and analysed is discussed in the next section.
2.4 Stakeholder and Stakeholder Analysis
vided by Pouloudi (1997), defining stakeholders as all participants (groups, individuals or organiza- tions) that influence or are directly or indirectly influenced by the development and use of the system. Several stakeholder identification approaches could be retrieved from literature: Sharp, Finkelstein and Galal (1999) built their framework around a set of baseline stakeholders that are surrounded by a network of satellite, supplier, and client stakeholders. Pouloudi and Whitley (1997) proposed a four- step stakeholder identification procedure (identification of generic groups, conducting in-depth inter- views with initial stakeholder groups, revealing further stakeholders from interviews, revising the initial stakeholder map). Lyytinen and Hirschheim (1987) presented another systematic approach (nature of information system, type of stakeholder relationship, depth of impact, level of aggregation). Mantzana et al. (2007) distinguished between static and dynamic ways to identify healthcare stake- holders in the adoption of information systems, however, limiting the applicability of their model due
to its inability to identify sub-actor groups.
Stakeholder analysis has been elucidated by Crosby (1991) as a set of different methodologies to point out stakeholder interests. Being an approach towards conducting organizational policies, stake- holder analysis is concerned with the distribution of power and the role of interest groups in the deci- sion-making process (Brugha & Varvasovszky, 2000). Due to the obscurity in terms of actors involved and a growing need for process standardization using IT, stakeholder analysis is of particular im- portance when it comes to hospital settings. Rouse (2008) recognized the large number of players and sub-sectors involved in health care, attempting to both serve their own interests and to provide high quality care. Several studies have been performed in the field of stakeholder analysis, including those of Bunn, Savage and Holloway ( 2002), Prell, Hubacek and Reed (2007), or Elias et al. (2002). With regard to information systems, de Vries (2011) stressed the dynamics of stakeholder coalitions, sharing different mindsets and responsibilities. However, Brugha and Varvasovszky (2000) argued that most studies were restricted to eliciting the stakeholder views, not taking into account the influence of their roles, relationships, and interest on the decision-making process. Therefore, the following section introduces how stakeholders can be further characterized by the power and interest factors they possess.
2.5 Stakeholder Interest and Power Factors
of discontent or feeling of urgency’ towards actions or changes in a focal organization. Within this particular term, Fox (1973) distinguished between unitary and pluralist perspectives of stake- holder interest. From a unitary angle, the structure of social relations within organizations is per- ceived to incorporate rational efforts to develop the most efficient and effective means of achieving common interests and objectives (Willmott, 1987). The unitary viewpoint implies that managers are responsible to transform diverging stakeholder interests into the creation and realization of
common goals. Making use of constructive negotiation as a mean to influence stakeholders to-
wards shared interests can be an effective tool in order to strive towards a more unitary direction (Frooman, 1999). However, Willmott (1987) mentioned that the complexity of the technical divi- sion of labour in modern organizations led to conditions of specialized training, motivating individ- uals to form coalitions for the pursuit of sectional objectives. The emerging conflict among different
individual and group interests that start vying for power led to the evolvement of the pluralist
viewpoint. Different stakeholder perceptions and attitudes might lead individual stakeholder inter- ests into a more pluralist direction (Frooman, 1999). Boonstra and de Vries (2005) argue that the notion of potential users that the system does not bear sufficient economic or strategic ad-
vantages might be an interest-related barrier.
Stakeholders retaining higher power than others may be able to claim their individual interests in the early adoption process of WfMS more thoroughly. Buchanan and Badham (2007) defined stakeholder power as possessing the capacity to exert one’s own will over that of others in order to realize certain intended benefits. In this paper, the phenomenon of stakeholder power was further operationalized by using the individual power factors of Whetten and Cameron (2010) and Hardy (1994)’s dimensions of power. Whetten and Cameron (2010) further conceptualized their theory into four different types of power: Positional power indicates that a power holder is legiti- mately conferred with the formal power going along with the occupation of a managerial position, allowing to persuade and influence the actions of others more thoroughly (French & Raven, 1959). Furthermore, stakeholders are able to acquire knowledge power through accessing knowledge or by active participation in its production or dissemination (Gaventa & Cornwall, 2001). Being expert in a specific field or accessing information, and being able to derive connections from them more effectively, enables stakeholders to express their interests in a more powerful manner. Per-
sonality power is related to the centrality of the power holder, its behavioural variables and its
individual perception of power (Brass & Burkhardt, 1993). Stakeholders that are more aware of their individual power position may express their interests in a stronger manner. Finally, network
power is closely related to centrality, defining the number of network participants the power holder
cess and meaning power. Resource power indicates the degree of having access to scarce re- sources within the organization. Mannix (1993) further operationalized these resources, dividing them into more tangible (funding, personnel) and more intangible ones (access to information, knowledge, trust). Process power defines the execution of control on formal decision-making ar- eas and agendas within organizational boundaries. An example of process power is the ability to include or exclude a significant item from a discussion agenda (Cawsey et al., 2011). Finally,
meaning power is related to the ability to define the meaning of things, using symbols, rituals or
a powerful language. According to Boonstra and de Vries (2005), power-related barriers might occur in situations where potential users are not able to sufficiently convince other stakeholders to establish their individual interests, or have the power to ignore other’s opinions. Boonstra and de Vries (2008) further argued that power and interest are subject to change over time, meaning that their identification and assessment should be a repeating process rather than a static proce- dure.
2.6 Conclusion and Research Question
In this section, a review of relevant literature revealed the main scientific framework of this re- search. Initially, the pattern of WfMS has been defined and its particular practicability for the health care sector has been acknowledged. Furthermore, the early adoption of information systems was discussed, particularly emphasizing on the adoption of WfMS. In doing so, several outcomes could be observed: An early adoption project could miss its expectations due to missing interfaces or other technological shortcomings, stakeholder resistance, or lacking awareness and process knowledge. Recognizing the impact of organizational actors on the early adoption phase of WfMS, further research accentuated the concept of stakeholder analysis, and observing the power and interest attributes that these stakeholders possess. The early adoption phase of information sys- tems is often accompanied by high levels of obscurity and ambiguity in decision-making. In this phase, different power and interest relationships among stakeholders become relevant factors that form or derail the performance of a system adoption.
hence the outcome of the WfMS adoption. Accelerating significant performance improvements might be particularly achievable in the health care sector, where varying power positions of stakeholders concur with the alignment of wide-spreading interests. Providing scientific and managerial audience with accountable results may enhance existing knowledge on WfMS adoption outcomes within the health care supply chain. Having established the scientific framework, this paper thus treats the fol- lowing research question:
What is the Impact of Stakeholder Power and Interest Characteristics on the Early Adop- tion Outcome of WfMS in the Clinical Supply Chain?
A more thorough operationalization of the stakeholder power and interest factors known from literature has been performed by observing their interaction in a real-life case. Knowledge was acquainted on these characteristics and how they were used by stakeholders to influence the decision-making process. Ultimately, the way how these characteristics affected the outcome of the early adoption process were intended to be observed. The following conceptual framework
(Figure 2.1) serves to summarize the main constructs this research is based on, aiming to con-
ceptualize the empirical direction of the further procedure.
Figure 2.1: Conceptual Framework
3 Research Methodology
3.1 Research Design
3.2 Research Setting
In order to answer the research question, empirical data needed to be gathered. In the previous paragraph, a single case study was considered as reasonable research method to accomplish this data collection. In order to detect a setting that facilitated this data extraction, several case selection criteria applied: A case had to be found within the health care sector in general, specifi- cally depicting a clinical supply chain. Within this supply chain, several stakeholders possessing different power and interest attributes had to be apparent. Finally, the intention of adopting a WfMS within this clinical supply chain was a necessary condition in order to discuss the underlying rationalities of the early adoption outcome. Based on these selection criteria, a suitable research setting could be retrieved.
The empirical part of this research was conducted by performing a single, in-depth case study in the health care setting, analysing a WfMS adoption project in the oncology supply chain of a hospital. The setting of this research took place at the oncology department of a mid-sized hospital situated in Germany. The department was specialized in offering a wide range of treatments of different cancer disorders, including inpatient and ambulant outpatient care. The department was found in 1996, setting its focus on the interdisciplinary treatment of cancer patients. Working closely together in multidisciplinary teams, the organization was able to perform much more intri- cate treatments that heavily improved the quality of cancer care and the survival rate of patients. The hospital consisted of 41 beds for inpatient care and 13 outpatient care spots. Making use of its highly-specialized facilities and a dedicated team of physicians and clinical staff, the hospital was able to process more than 2500 cancer patients per year. In order to maintain this high med- ical status, organizational processes must go along with these high-performance expectations. However, the current process of entering and distributing medical data of patients alongside the clinical supply chain still incorporated a quite manual, thus very complex procedure.
adoption of this WfMS within the organization. An adoption project group was inaugurated, con- sisting of all stakeholders that will be affected by the WfMS. Compared to the selection criteria, the depicted case setting was perceived suitable in order to properly conclude on the research question.
3.3 Data Gathering
In order to operationalize the stakeholder power and interest attributes from the research frame- work, different kind of data was gathered. This research used data triangulation in order to realize construct validity and lead towards convergent findings. Out of the six sources of evidence in case study research (Yin, 1994), this paper made use of a document analysis, semi-structured inter- views and direct observation in order to retrieve generalizable results.
Direct observation of the current patient data distribution process was used in during the kick-off meeting. In this stage, direct observation was seen suitable to point out all stakeholders of the clinical supply chain that were affected by the early adoption of the WfMS. An initial kick-off meet- ing with the adoption project group leader led to the awareness of the single stakeholders that were affected by the early adoption project. Furthermore, the adoption leader provided insights into documents that followed this WfMS adoption process. Analysing documents that emerged from the adoption project was seen suitable to understand how the organization itself perceived the appearance of power and interest of each stakeholder. A document containing a stakeholder analysis from a power and interest perspective towards the WfMS that has been performed in the beginning of the project could be retrieved. This assessment was used as a starting point to fur- ther explain the impact of stakeholder power and interest on the early adoption outcome. In the
next chapter, these findings will be presented and further discussed.
by the term influence throughout the interview questions. In performing the interviews, an opera- tionalization of the pre-existing power and interest constructs in literature was achieved. Within the organization, stakeholder interest was characterized by the level of enthusiasm and engage- ment of organizational actors towards pushing decision-making and the adoption of the WfMS. According to the conceptual framework, the unitary and pluralist viewpoints of Frooman (1999) were intended to be further operationalized from a stakeholder interest perspective. (Figure 3.1).
Figure 3.1: Stakeholder Interest Factors
Additionally, the organization characterized power as the level of influence and impact that a stakeholder had on the decision-making process and the outcome of the early adoption. Accord- ing to the conceptual framework, the power attributes of the interviewed stakeholders were ana- lysed by using the knowledge of Hardy (1994) and Whetten and Cameron (2010) (Figure 3.2).
Yin (1994) stressed the use of a case study protocol to accompany the case study project. This protocol contained the main instruments, procedures, and general rules that are followed during the case study project. Accordingly, an interview guideline was designed, containing a brief de- scription of the research project, defining the aim of the data collection, and introducing the ques- tions that were asked during the interview. The interview guideline was provided to the participants in advance, accompanying the scheduling of time and setting to conduct the conversation. Doing so ensured the interview partners to be properly prepared for the questions posed and offered opportunities to consult the interviewer prior to the session in case of ambiguity.
Runeson and Höst (2009) proposed the interview to be split into a number of phases. Based on this conceptualization, the first questions aimed to unfold the tasks and responsibilities of the stakeholders. The next phases intended to reveal the challenges of the status quo and interests of the stakeholders in the WfMS. The stakeholder power characteristics and their impact on the decision-making process were subject of the following interview phases. Finally, the last phase asked for the opinion of the stakeholders about the expected outcomes of the early adoption. The interview guideline can be retrieved in the appendix of this paper. Tape-recording the interview was recommended in order to capture all details of the discussion and to be used as backup for the field notes taken during the interview (Runeson & Höst, 2009). Participants were asked for permission to record the conversation prior to conducting the interview session. The time frame of the interviews was unbounded, but interaction was intended to last at least one hour. As Ger- man was the mother language of the participants, the interviews were conducted in German. This, in terms, encouraged the active participation of interview partners and facilitated the generation
of more enlarged and enriched data.
Finally, direct observation of an adoption group meeting was performed as last measure of data gathering. In this final stage, direct observation was seen suitable to reveal the outcome of the early adoption project. From taking an observer role, it could be discovered how the stakeholders used their power and interest attributes in order to fulfil their own interests and to persuade others with their opinion. This observation, in terms, facilitated the understanding of how the outcome of the early adoption project was affected by the stakeholder power and interest characteristics. The correlations between stakeholder power and interests and the adoption outcome will be discussed later in this paper.
3.4 Data Analysis
during the data analysis phase in order to achieve internal validity. Miles and Huberman (1994) requested the data analysis procedure to consist of data reduction, data display, and conclusion
drawing. In this section, the operationalization of these steps is introduced.
Being the initial step after the data has been gathered, the documentation process enabled the transcription and archiving of the gathered data. Transcribing the recordings of the interviews was performed as soon as possible after the case visit, as recommended by Voss, Johnson and God- sell (2016). The prompt transcription served to both maximize recall and to facilitate follow-ups if gaps in the data were detected. Ideas and insights that emerged during the field visit were also taken into consideration in the transcription procedure.
After the interviews were successfully transcribed, coding the data marked the next step towards data reduction and category building (Miles & Huberman, 1994). The data analysis of this re- search was performed by using the classic coding scheme of Strauss and Corbin (1990), being comprised of open, axial, and selective coding. Making use of computer software (MicrosoftâEx- cel) facilitated the coding and data analysis procedure. In first instance, open coding was used to highlight and collect useful fragments from the transcribed data. The transcribed interview text was reviewed for relevant quotes that could be related to one of the power and interest concepts from the conceptual framework. Those quotes were highlighted and adopted into an Excel coding template. Narrowing down the interview transcripts into useful coding fragments served to achieve
data reduction.
Moreover, axial coding was used to disaggregate several core themes within the coding frag- ments. The quotes were checked for relationships in order to relate them to one of the stakeholder power and interest factors from the conceptual framework. In category 1, each quote was appro- priately related to stakeholder power or interest (column 6 of the Excel template). In category 2, each quote was appropriately related to one of the interest views (unitary/pluralist) or power fac- tors (dimensions of power/individual power factors). This was performed in column 7 of the Excel template. Finally, each quote was appropriately connected to its suitable stakeholder interest or power factor from literature retrieved from the conceptual framework (column 8 of the Excel tem- plate). Aligning the codes into categories served to achieve a data display of the gathered infor- mation. The coding tree excerpt in Figure 3.3 may expound the open and axial coding procedure
Figure 3.3: Coding Tree Excerpt (Open and Axial Coding)
Finally, selective coding was used to pick out certain key variables to explain the impact of the stakeholder power and interest attributes on decision-making. While analysing the quotes of each attribute, certain sub-categories (main concepts) of each attribute became apparent. Accordingly, each quote was related to its appropriate main concept (column 4 of the Excel template). Within the main concepts, a further operationalization of each concept took place. Based on the obser- vation how interviewees experienced the emergence of power and interest attributes in the early adoption project, several conclusions could be deduced. Operationalising the main concepts was necessary to conclude the underlying rationalities, from a power and interest perspective, that determined decision-making and the early adoption outcome of the WfMS. The operationalization of the main concepts was performed in column 5 of the Excel template. Drawing several main categories and further operationalising them served to facilitate conclusion drawing from the gath- ered information. The coding tree excerpt in Figure 3.4 may expound the selective coding proce- dure in a more objective way.
Merging the results from all interviews led to the creation of two coding tree frameworks, both from a stakeholder power and interest perspective. Further analysis of the research results is based on those frameworks, which can be consulted in appendix 3 and 4 of this paper.
4 Case Study Findings
4.1 Stakeholder Overview
After having set the methodological frame this paper is based on, further research dealt with the findings of the data collection. Initially, a kick-off meeting was scheduled, including a meeting and introductory conversation with the adoption leader. During this meeting, it became apparent that an adoption team has been formed after deciding on the early adoption of a WfMS. This adoption team was formed out of the operating supervisors of each stakeholder affected by the adoption task. In gathering and documenting the interests of every stakeholder, the adoption team had the task of managing the operational issues that aroused during the early adoption of the WfMS. A member of the administration office has been affirmed as adoption leader and project representa- tive of this adoption team. Doing so provided a guidance of the decision-making process that was unbiased by medical professionals. The field visit also expounded the single stakeholders and their roles and responsibilities within the organization. Making use of the hub-and-spoke model of Freeman (1984), the involved stakeholders were depicted in figure 4.1.
Figure 4.1: Stakeholder Identification
The stakeholders were comprised of both medical and non-medical nature. It was recognized that nurses represented the biggest group of stakeholders in the organization (20 employees), fol- lowed by the administration and the accounting. Physicians represented a smaller, however very important fraction of stakeholders involved in the process. Relatively small stakeholder groups were further detected in the tumour documentation, psycho-oncological care, and the oncologic laboratory. The pharmacy consisted of only one individual professional.
WfMS adoption
Nurses Physicians Pharmacy
In conducting the interviews with the single stakeholders, their roles and responsibilities in the organization became more explicit. The nurse supervisor was mainly responsible for the care processes within the oncology department. Nurses were dealing with preparing and providing intravenous drugs for cancer patients. The nurse supervisor was also culpable for quality moni- toring and setting safety boundaries. It was recognized that nurses were collaborating closely together with many other actors in the hospital organization: ‘In general, we have close contact
to all health care stakeholders participating in the oncology supply chain. This includes care ex- perts, as the wound management or physiotherapy, in particular. But we also interact closely with physicians, the pharmacy, or the psycho-oncological care. We are exchanging information on a regular base with these stakeholders, for example by having regular meetings’. Physicians were divided into a stationary and an ambulant department. Doctors at the stationary department were working closely together with the hospital’s pharmacy, as the requested thera- pies needed to be customized for each patient. In comparison, doctors from the ambulant depart- ment were slightly less interacting with the pharmacist, as drugs could be ordered by the patient at any pharmacy on receipt. On overall, physicians were responsible for treating their patients in an accurate, timely and safe manner. This also included the credibility of their diagnoses and
therapy plans for subsequent stakeholders in the oncology supply chain.
Being responsible for the constant replenishment of the requested medication, the pharmacist occupied a central role in the oncologic supply chain. Receiving orders from the administration office, after approval by a physician, the pharmacist either prepared the therapy or ordered it from an external supplier. Regarding the ordering procedure, the pharmacist stated: ‘Generally, we
receive a pre-plan from administration, entailing type and amount of medication, two days in ad- vance. We can then start to prepare the therapy. One day prior to delivery, we receive the final order. However, it sometimes occurs that orders arrive too late, leaving us no possibility to prepare the therapy for the next days’.
Being responsible for a timely and accurate ordering process, the administration office formed the junction between the medical professionals and the pharmacy. Their position was reported as followed: ‘In our daily business, we perform a continuous, close information exchange with those
with the nurses in post-treatment. Finally, the accounting department had close ties with all above- mentioned stakeholders and external ones like insurance companies, in order to guarantee proper accounting of the therapies.
4.2 Stakeholder Interest Findings
Making use of the data gained from the interviews, the interest variables from the research model were further operationalized. In presenting quotes from the data analysis procedure, the distinct stakeholder interest variables and their impact on the WfMS adoption were expounded more thor- oughly. The entire coding scheme from a stakeholder interest perspective can be consulted in appendix 3 of this paper.
After performing the interviews, the realization of the common WfMS adoption goal could be further operationalized into the definition of the adoption strategy and goals, and the preparation of stakeholders towards the WfMS adoption. The adoption team had the joint task to actively
preparing the organizational stakeholders towards the WfMS adoption, as a doctor stated:
‘We as departmental leaders share the responsibility to actively promote our employees that the
WfMS will be implemented soon’. In order to do so, the adoption strategy and main goals
needed to be defined according to the adoption leader: ‘It is our main task as project group to
make those care processes visible that need to be tailored in order to adopt the WfMS’.
In order to realize the common WfMS adoption goal, the prevalent stakeholder interests needed to be somewhat adjusted to each other. This constructive negotiation was reported to consist out of three components: Constructive bargaining, collaborative decision-making, and main re- sponsibility of the adoption leader. Counselling the negotiation process was seen as main re-
sponsibility of the adoption leader. Accordingly, the adoption leader stated: ‘It is of utmost
importance to clearly formulate and align our own interests in first place, before contacting the WfMS provider and starting the adoption task’. In visualizing and negotiating different or some-
what conflicting stakeholder interests during the adoption group meetings, the goal of an accepted set of requirements was pursued. Regarding this constructive bargaining process, the adoption leader argued: ‘Within the adoption group, we need to accept the different viewpoints of stake-
holders and try to adjust the different perspectives to another. However, it is also my responsibility to decide whether expectations are reasonable or not’. Making use of their work experience,
stakeholders were actively negotiating the usefulness and plausibility of their interests. It was seen of utmost importance to integrate all stakeholders into collaborative decision-making in order to realize valid results, as a quote of the tumour documentation stakeholder expressed: ‘In
The expected WfMS adoption evoked different individual interests, which could be further dis- tinguished into process flexibility and adoption workload. Accounting reported that their depart- ment might lose some process flexibility, as the standardization of workflows prohibited their execution ad hoc or according to personal convenience. Furthermore, ambiguity occurred due to expected adoption workload, as a nurse reported: ‘There will be definitely conflict potential:
Conflicts will occur due to the different environmental conditions, that are leaving some stake- holders with more workload than others’. In order to overcome this ambiguity and to motivate all
stakeholders towards the WfMS adoption, interviewees called team leaders to collect individual interests within the stakeholder’s departments first, and then defending them within the adoption
team meetings.
Several measures were taken into account in order to enforce the group interest towards the WfMS adoption: Third-party consultation was introduced as one measure to drive the adoption performance. The adoption leader reported that external partners from the WfMS provider were intended to be integrated into the adoption group, in order to receive valuable technical support. Both doctors and the adoption leader agreed on the importance of performing field visits at or- ganizations dealing with similar adoption projects, in order to gain valuable experience. When confronted with the idea of integrating external project support, nurses however argued that this could disrupt the confidence of the adoption leader and undermine her meaning power. Second, the outlook of a significant process optimization should raise the group’s awareness and interest into the WfMS adoption. Accordingly, the adoption leader stated: ‘With the WfMS, we have a joint
documentation foundation, a medium which improves our operational processes in a significant manner’.
Finally, stakeholder perceptions and attitudes were stimulated in two ways. First, in enabling transparency by integrating all affected stakeholders into joint decision-making, as underpinned by the following statement from the laboratory: ‘In the past, we also experienced less successful
adoption projects. They failed partly due to unrealistic expectations. But mainly because not all affected stakeholders have been incorporated into decision-making in the way they should be’.
Second, in addressing the main focus of the WfMS adoption, as mentioned by accounting: ‘Sometimes, we should adapt conditions that are simplifying our work, but do not represent an
optimal state yet. The main reason of choosing the WfMS was the optimization of the therapy ordering processes. In my opinion, we should emphasize on this particular issue first’.
4.3 Stakeholder Power Findings
Making use of the data gained from the interviews, the power variables from the research model were further operationalized. In presenting quotes from the data analysis procedure, the distinct stakeholder power variables and their impact on the WfMS adoption were expounded more thor- oughly. The entire coding scheme from a stakeholder power perspective can be consulted in ap-
pendix 4 of this paper.
The artefact of resource power was further operationalised into the access to internal and finan- cial resources. Internal resources were comprised of training, interface linkages or the number of licences granted to each stakeholder. Regarding their resource power, nurses reported: ‘The
resource consumption depends on the group size. It is ubiquitous that we form one of the biggest stakeholders in terms of people employed. It should be known that nurses require more resources than other stakeholders. Whether these will be granted by management, is another issue’. Re-
garding financial resources, the adoption leader stated: ‘There are of course differences in the
access to financial resources among stakeholders. However, it is my task to set financial barriers and assess their compliance’.
Stakeholder process power was expressed by the degree of process complexity and ur-
gency, and the amount of workload during the WfMS adoption. Doctors defended their emi-
nence in the clinical supply chain: ‘We share the main responsibility for the patient in the process,
consequently our interests should be of high significance in decision-making’. Different viewpoints
existed regarding the significance of adoption workload towards stakeholder power. Nurses ex- pressed: ‘We don’t think that the adoption workload should be subject in decision-making. How-
ever, during our last meeting, doctors explicitly stated that they will be affected by an enormous workload when adopting the WfMS. Personally, I don’t think that this statement is helpful in order to reach consensus’. Doctors however responded: ‘As we will face the highest adoption workload in implementing the therapy plans into the WfMS, we really expect the system to outreach our expectations, in order to be worth the effort. In a prior IT adoption project, I remember one doctor to be busy for two weeks in order to implement all therapy plans into the system’.
Stakeholder meaning power was experienced in terms of persuasive skills, attentiveness, stake- holder position, and job tenure. While observing the project meeting, it could be detected that doctors or the pharmacist expressed their interest in a more thorough and powerful manner. Mak- ing use of their knowledge, persuasive skills and attentiveness, they were able to gain more attention than other stakeholders. Furthermore, the stakeholder position and job tenure deter- mined meaning power, as a doctor stated in the interviews: ‘The influence among stakeholders
on decision-making is very heterogeneous. It is defined by the position, knowledge, and job tenure of each single stakeholder’. It was perceived that the adoption leader should be equipped with a
