A Bilateral, Double Motive Perspective on Stakeholder Management in Healthcare for IS Projects
Master’s Thesis Erik Nijmeijer (1640704)
University of Groningen
Faculty of Economics and Business
Business Administration Department
Supervisor: Albert Boonstra
Second Assessor: Marjolein Achterkamp
Abstract
Introduction
Implementing information systems (IS) is known as a tedious, complex and hard task. A task which too often leads in failure. A study in 2003 revealed that fifteen percent of the IS projects failed (Standish Group, 2003). The adoption of IS in healthcare is facing similar adversities as most commercial organizations. A non-optimal implementation of IS in
healthcare, however, can result in the deterioration of the health of the people being treated. A successful adoption of IS can, on the other hand, result in positive results for human health, for example: an increased ability to find and subsequently apply the data of a patient for a physician (PCAST, 2010). Similarly, the European Commission’s (2009) report shows that the benefits of an ‘prescribing system’ and ‘interoperable digital health record’ can be substantial, albeit that these systems will start producing socio-economic benefits after minimally six to seven years (European Commission, 2009). A way to overcome the adversities facing the implementation of IS in healthcare, is to carefully and thoroughly manage the numerous healthcare actors who are (or will be) affected by the IS (Chen, 2003). Furthermore, Shaw and Stahl (2011) argue that qualitatively good communication with stakeholders, in an healthcare environment, can result in: “… information systems, designed to support quality assurance, change from having a passive role to being actively involved in healthcare delivery” (p. 269). By conversing with stakeholders, one can actively involve these stakeholders in the healthcare delivery, IS can support the stakeholders in their discourse by providing a central platform (Shaw & Stahl, 2011).
Freeman (1984) defines stakeholders as: “any group or individual who can affect or is affected by achievement of the organization’s objectives” (p. 46). This definition is
considered to be “one of the broadest definitions in the literature, for it leaves the notion of stake and the field of possible stakeholders unambiguously open to include virtually anyone” (Mitchell, Agle & Wood, 1997, p. 856), while this is true, Freeman’s definition is
all-embracing and when it comes to the sector of healthcare, ‘virtually anyone’ should indeed be considered a stakeholder. Anyone is or will be affected by healthcare at some point in his or her life, be it personally or to someone close to him or her.
the increasing scale of IS, spanning across individual healthcare organizations and integrating them (for example, by integrating patient data across multiple healthcare agencies (see:
Boonstra, Boddy & Bell, 2008), results in more people being affected by the IS, increasing the number of stakeholders. Managers of healthcare organizations are therefore set before a tougher task when implementing the IS: an increased number of stakeholders enter the arena. Stakeholders which should be managed with care, be it to reduce resistance (Lapointe & Rivard, 2005; Lapointe & Rivard, 2007), to achieve “a common set of shared meanings and understandings about the situation” (Boonstra, 2006, p 50), or to get stakeholders to
participate in the IS implementation (Markus & Mao, 2004).
The current study focuses in particular on the cooperative aspect between (project)manager and stakeholders during the implementation of an IS in an healthcare environment. More specifically, it tries to build on and empirically test the proposed bilateral, double-motive perspective (BDM) model by Vos and Achterkamp (in press). Vos and
Achterkamp (in press) argue that: “cooperation is a two-way activity in which both
management, as the organizational representative(s), and the stakeholder come to decisions about their mutual engagements” (p. 2). The theoretical background will be structured as follows: first, the elements of the BDM model will be discussed. Subsequently, the research question along with sub questions will be presented.
Theoretical Background
The theoretical background of the BDM model will be laid out in this section. First, the stakeholder literature concerning healthcare organizations in relation to IS initiatives will be discussed. Secondly, bilateral perspective of the BDM model will be presented. Thirdly, the transactional and relational motives (the double motive perspective) will be elaborated upon. Fourthly, the importance of the impact of the issue at hand for both promoter and stakeholder will be explained. Finally, the aforementioned elements of the BDM model will be tied together to form a comprehensive view of the proposed model.
information technology stakeholders’ in the following ten categories: Government agency stakeholders; healthcare consumers; healthcare providers; health organization administrators and staff; academic/research institution stakeholders; professional associations: leaders and members; private sector vendors; regulatory/standards agency stakeholders; and non-profit stakeholders (p. v). This is not a comprehensive list, but it gives an idea of the intricate complexities of stakeholder management and stakeholder identification within a healthcare organizations.
Moreover, various studies have identified the importance of the part stakeholders play in IS development and implementation (Pan, 2005; Robey & Boudreau, 1999; Boonstra, Boddy & Bell, 2008). Pan (2005), for example, examined the implementation and eventual abandonment of an electronic procurement project in an organization in Singapore. He argues that the interests of the various stakeholders should be understood thoroughly, and that the stakeholders’ expectations should be managed throughout the IS implementation.
A way to overcome these potential difficulties when implementing an IS, is to cooperate with stakeholders, be it internal stakeholders or external stakeholders. This way, information can be shared between stakeholders and/or the promoter of the IS initiative, and thereby making people aware of each other’s expectations, desires and expertise (Teo, Srivastava, Ranganathan & Loo, 2011). That establishing and maintain cooperative
relationships with important stakeholders is imperative for organizations has been recognized by numerous researchers (Hillman & Keim, 2001; Sawhney & Zabin, 2002). But which stakeholders are important to cooperate with for the promoter of the IS? And, on what basis does a promoter collaborate with a stakeholder? The proposed BDM model aims to explain promoter-stakeholder cooperation. What the BDM model entails will be discussed below.
Bilateral perspective. As mentioned in the introduction, the BDM model incorporates a bilateral and double motive perspective. In this sub-section, the bilateral perspective will be discussed.
The bilateral perspective assumes that cooperation is established by the willingness of both parties to engage in a cooperative relationship (Vos & Achterkamp, in press). Both the manager (or in this study: the promoter of the IS initiative) and the stakeholder have a certain drive to collaborate, both have various intentions of engaging in the relationship. This
managers’ point of view, ignoring the stakeholders’ side of the story. A finding which is reflected in the meta-analysis done by Laplume, Sonpar and Litz (2008). However, Frooman (1999) tries to enrich the stakeholder theory by adding how stakeholders, instead of the organization, try to affect decision-making in the company by using various ‘influence strategies’. For the BDM model, this concretely means that cooperation is a result of both parties intentionally (Harrision, Bosse & Philips, 2010) acknowledging the need for each other’s help to solve a certain problem.
Double motive perspective. Next to the bilateral view of cooperation, the BDM model also entails a double-motive perspective, relating to what motivates the manager and stakeholder to engage in a cooperative relationship (Vos & Achterkamp, in press). The word ‘double’ in the double-motive perspective refers to transactional motives and relational motives. Both the bilateral and double-motive perspective can identify why managers and stakeholders want to cooperate with each other, what factors motivate them to collaborate. The specific elements of both the transactional and relational motives will be explained below.
Transactional motives. Transactional motives are about direct gratification for either
party to collaborate (Vos & Achterkamp, in press). For example: a promoter of an IS initiative might want to cooperate with a specific stakeholder because of his or her specialized
knowledge, which the promoter could use to solve an issue of the implementation of the IS. The transactional motive is derived from the study by Mitchell, Agle and Wood (1997) and the conceptualization of these attributes for measurement by Samaras (2010). In short, Mitchell et al (1997) argue that management considers a stakeholder as having a salient claim on an issue if the stakeholder is legitimate and urgent in relation to the issue at hand.
Legitimacy here, means that one has a justifiable and appropriate claim on the issue at hand. Urgency here, refers to the perceived need for immediate action or direct attention on the claim one has on the issue at hand (Mitchell, Agle and Wood, 1997; Samaras, 2010). Mitchell et al (1997) identify a third factor affecting the salience of an individual: the power the
other way around. The claim from a promoter on a stakeholder can also be considered as salient by the stakeholder, based on the same concepts (power, legitimacy and urgency). Thus, the salience of either the promoter or the stakeholder is a matter of perception, it is the
perceived salience one has of the other (see 3 and 7 in Figure 1).
Relational motives. Relational motives are about establishing a long-term relationship
with each other, a relationship from which one can reap what was sowed in the future (Graves & Waddock, 2000; Vos & Achterkamp, in press). For example: stakeholders might want to cooperate with a promoter of an IS initiative to establish a lasting relationship with the promoter, which can grant them certain benefits within the organization.
The relational motives originate from the perceived reputation the promoter has of the stakeholder, and vice versa. It concerns itself with the perception of the other party’s power, legitimacy and reliability to achieve future benefits. In contrast to the perceived salience, power here refers to the importance of ones resources (knowledge, and/or position in and outside the organization) and capabilities to dealing with potential future issues, or decision-making, within or outside the organization. In the same vein, legitimacy here entails the perceived justifiability and appropriateness of the other to lay claims on potential future issues and/or decision-making, both inside and outside the organization. Lastly, the perceived
reliability of the other refers to the believe that he or she is willing to share potential future assets the other party achieves (Vos & Achterkamp, in press). In short, reputation concerns itself with the perception of the relational assets of the other, and the likelihood that these assets can be acquired through the established relationship (see 4 and 8 in Figure 1).
high reputation, to establish a relationship with relevant stakeholders for potential future needs (Irvin & Stansbury, 2004) (see 2 in Figure 1).
If the issue impact perceived by the stakeholder is high, one can expect him or her to look for a highly salient promoter to solve the issue as soon as possible, as the risks and/or benefits is able to directly affect his or her work (Vos & Achterkamp, in press). On the other hand, if the impact of the issue is low for the stakeholder, he or she will pay more attention to the reputation of the promoter, hoping to engage a relationship from which the stakeholder can benefit in the future (see 6 in Figure 1).
The bilateral, double motive perspective model. By tying the previously discussed factors of the model together, Figure 1 can be presented. The perceived salience and
reputation of the promoter or stakeholder is thought to directly affect the willingness to cooperate with the other party (see 5 and 9 in Figure 1). The impact of the issue can
subsequently moderate which of the two factors is considered to be more important by either promoter or stakeholder. All these factors taken together will result in a successful,
Figure 1. The bilateral, double motive perspective model.
Effective cooperation with relevant stakeholders is considered to be a valuable asset in commercial organizations (Harrison, Bosse & Philips, 2010; Hillman & Keim, 2001), as well as in healthcare organizations (Shaw & Stahl, 2011; Janet, Nicholas & Michel, 2006). The BDM can identify which factors affect the establishment of cooperation between promoter and stakeholder (Vos & Achterkamp, in press) in IS projects in healthcare. By making these factors apparent, a promoter of an IS initiative is able to approach a stakeholder with these aspects in mind when requesting the help of a specific stakeholder. Consequently, the promoter can consider these important aspects and convince him or her to help with the IS and simultaneously maintain or establish a long-lasting relationship. Furthermore, by
investigating what the criteria are of willing to work with one another, the model can provide a richer, deeper insight into the stakeholder literature. Consequently, the aim of this study is to
empirically validate the explanatory power of the BDM model in a healthcare IS context. The
following research questions were formulated in aid to examine the validity of the BDM model:
1. How can stakeholder and promoter salience be assessed? 2. How can stakeholder and promoter reputation be assessed? 3. How do stakeholder and promoter assess the impact of the issue?
4. How do these factors result in the willingness to cooperate with each other? 5. How effective is the BDM model in explaining cooperation?
Research Method
This section provides a description of the cases and issues and the methodology used to collect and assess the acquired data. Firstly, two cases and their corresponding issues will be discussed. These cases were selected because they were situated in an health care
Case Study I: Elderly Care Organization
The first case study examined an elderly care organization. The multi-disciplinary organization spans across a province in the Netherlands, with various facilities specialized in helping elderly people with the specific needs they have. For example, the organization consists of facilities which specialize in: physiotherapy, occupational therapy and speech therapy. The organization employs 930 practitioners and also receives help from about 485 volunteers. Furthermore, the elderly being cared for in the organization are also residents in apartments, which are property of the organization. The implemented IS in the elderly care organization was an electronic patient file system (EPF). This EPF is unrelated to the Dutch national EPF initiative, it functions only within the elderly care organization. Moreover, the EPF was a standard software package which was not modified in any way. The
implementation process started in 2009, was operational in 2010 and was fully functional in 2012. This IS would initially make it possible for the organization to share patient data among the various facilities. This would have resulted in a more efficient way of providing care for the elderly in the organization. Furthermore, in a few years Dutch a law will state that all data should be delivered electronically, the EPF made it able to do just so. The project was funded by the Dutch government. The EPF made it possible for care givers to share their patient files. Instead of each care giver maintaining his or her own separate patient file, all individual patient files were merged into a single patient file. From this organization, two cases were drawn, the first issue will be labeled the ‘transparency issue’, the second issue will be labeled the ‘standardization issue’.
Transparency issue. The first issue involved the promoter of the EPF working together with an employee working as a speech therapist (the stakeholder) in the elderly care organization. The issue at hand was resistance towards the new IS. This resistance originated from the resulting increased transparency of the practitioners’ work. Before the EPF, the individual patient files were stored in a desk by each individual practitioner, a file which almost no one looked at except the practitioner him/herself. The new EPF would let everyone see who wrote what about a patient. The promoter mentioned that some practitioners showed resistance towards this development.
speech therapist. She mainly stated to have worked together with the promoter in order to streamline the implementation and resolve various minor issues, such as how to code various elements in the EPF.
Standardization issue. In order to tackle the second issue, the promoter worked together with a care coordinator (stakeholder) of one of the facilities in the elderly care organization. An inevitable consequence of the implementation of the EPF was that all practitioners in the organization had to work with standard labels for problems when they wrote a patient file in the IS. This means that when practitioners encountered a problem with one of the patients, they had to select a description for that problem from a list of
standardized terms. For example: a practitioner finds out that a patient has decubitus, now he has to select that description from a list of standard terms, or ‘codes’. Previously, the
practitioner could have described the problem in full, instead of reducing it to a single term. The main problem this caused for practitioners was that they have the conviction that care should be unique and applied from individual to individual. Labeling every problem with a standard term goes against this school of thought.
The promoter and care coordinator tried to fit these standard terms to the vision and conviction of the elderly care organization, in other words to construct a list of standardized terms which are able to approach an unique, individual approach as much as possible.
Furthermore, they worked together to convince the practitioners that this was something they had to deal with, that there was no way around this issue.
Case Study II: Healthcare Innovation Organization
The second case study examined a commercial organization which concerns itself with providing innovation in healthcare organizations. The organization develops and implements various healthcare innovations for healthcare organizations. These innovations are aimed at improving the quality of healthcare, self-management and streamlining healthcare processes. The organization is funded through its network of partners, such as health insurance
The innovation project, in this case, revolves around an online integrated patient portal, which enables patients to: make appointments with doctors or specialists; receive an e-consult, meaning that a patient can ask his or her doctor questions online and order repeat prescriptions. It also offers services for self service and self-management and integrates the health insurance of the patient. Finally, the IS is connected to various general practitioners, medical specialists and hospitals so data can easily be shared. From this organization, one case was drawn. This issue will be labeled the ‘investment issue’.
Investment issue. This issue revolves around a financial investment in the IS initiative by a major insurance company. The promoter of the IS is also the CEO of the innovative organization, responsible for the development and implementation of the IS. The person with which the promoter cooperated was a project engineer at the major insurance company from which the promoter hoped to receive the financial stimulus. The promoter and project engineer worked together to find a concrete way to have both companies to cooperate (the innovative organization and the health insurance organization). The health insurance organization had an interest in the IS because it could provide them with financial benefits (e.g. through the increased use of self-management). By injecting the IS initiative with an financial stimulus, the IS could be developed and implemented at a faster rate. The project engineer aided the innovative organization in making the beneficial effects for the insurance company tangible, in order to the insurance organization on board.
Materials
A qualitative approach was chosen to validate the BDM model and test its explanatory power (Yin, 2003; Dubé & Paré, 2003). As explained above, a multi-case study design was adopted in order to be able to acquire diverging cases and subsequently test the validity of the BDM model in varying contexts. In order to obtain data, the researchers developed two semi-structured interviews (see appendix 1), one version for the promoter, one version for the stakeholder. The open-ended questions were directly derived from the research model (Gibbert, Ruigrok & Wicki, 2008). After defining and conceptualizing the variables in the BDM model, interview questions were constructed based on these definitions and
Moreover, the two researchers responsible for interviewing the respondents discussed and practiced the interview in order to achieve a common mindset about what each concept and its corresponding interview question mean (Emans, 2002).
Data Collection
The organizations were approached to join the current study. The ones that replied were subsequently invited to an introductory meeting, in which the researchers explained what the study entailed and was expected of them. Furthermore, in these introductory meeting, which took about one to two hours, the promoters were asked to think of various stakeholders with which they have collaborated. To be more specific, they were asked to think of a variety of stakeholders with which the cooperation was either successful or unsuccessful. Next, the actual interviews were conducted by two researchers, these interviews lasted about one hour (two hours for the promoter from the elderly care organization, since he was
involved in two of the cases). These two researchers assisted each other during the interviews to attain a clear and accurate answer from the interviewee. First, the promoter was
interviewed, followed by the stakeholder with which he or she collaborated. These interviews were recorded and transcribed.
Analysis
Replication logic (Eisenhardt & Graebner, 2007; Eisenhardt, 1989; Yin, 1994) was used to verify if the BDM model was able to explain the success of the established
cooperation between promoter and stakeholder. Replication logic dictates that “each case serves as a distinct experiment that stands on its own as an analytic unit” (Eisenhardt & Graebner, 2007, p 25). This means that similar cases are expected to reveal similar results, based on the established theory, and contrasting cases reveal contrasting results for
predictable reasons (originating from the theory) (Eisenhardt & Graebner, 2007; Yin, 1994). The current study used replication logic because it used multiple, contrasting cases in order to verify the predictive power of the BDM model.
incidents. As a rule for the constant comparative method, Glaser and Strauss (1967) state: “while coding an incident for a category, compare it with the previous incidents in the same and different groups coded in the same category” (p 106). Once the same category is not able to hold its ground and make sense in other, similar incidents, the researcher can reformulate the category, or split the category in multiple categories which are more able to fit the incidents (Glaser & Strauss, 1967). The concepts initially defined in the BDM model were used as a starting point to develop the categories. While analyzing, the researchers to added, changed and/or integrated various concepts, as is prescribed by the constant comparative method (Glaser & Strauss, 1967). To justify the adding/changing/integrating of concepts, discussions were held within the research team. An example of this was the added category ‘perceived impact of issue on society’. Some respondents mentioned that the impact of the issue could have consequences for society, for example the promoter of the healthcare innovation organization stated: “(…) but even in the interest of citizens is the question: “how do we control the costs of healthcare? Because that just keeps rising”. The researchers discussed whether this incident belonged to the category ‘perceived impact of issue on system’ or not. The researchers agreed that a new category should be developed which would incorporate the impact that the issue could have on society. This resulted in the addition of the category ‘perceived impact of issue on society’. Finally, the BDM model was used for each case to examine on what basis each collaboration was established, and if the BDM model was able to predict willingness to cooperate.
Findings
In this section, the elements of the BDM model will be discussed from the promoter’s and stakeholder’s points of view. Three issues, drawn from two cases, will be discussed. These are contrasting issues which serve to test if the BDM model is able to predict why cooperation was established between those specific individuals. This section will first discuss the discovery of new concepts found while analyzing the data. Subsequently, the aspects of the BDM model along with the newly discovered ones will be discussed. Salience and
inserted in a figure of the BDM model to summarize the findings. The findings section will be concluded with the discovery of an additional finding which did not fit in the BDM model, but was important for explaining cooperation nonetheless.
New Concepts
Following the constant comparative method (Glaser & Strauss, 1967), some
additional concepts were discovered which were not present in the BDM model, but could be helpful in improving the predictive power of the BDM model once incorporated. These new categories were included in the findings because some categories were not inclusive enough to account for the resulting cooperation. In order to account for this data, five new categories were developed which, together with the already established categories provided by the BDM model, were able to account for all the responses that were given. These new categories will be shortly described in the subsections below.
Perceived impact of issue on society. This category was created in order to account for the responses the participants gave which were related to positive or negative effects the issue could have for society as a whole. Being active in a healthcare organization, it is not surprising that some respondents mentioned that the impact of the issue would not only have an effect on themselves or the IS, but on the citizens themselves. These arguments were important to the interviewees and played a role in their choice to cooperate in order to solve the issue.
Perceived impact of issue on organization. This category was created in order to account for the responses the participants gave which were related to the positive or negative effects of the issue could have on the organization they were active in. Some respondents mentioned that they were willing to cooperate in order to help the organization they were active in to advance, or to prevent it from having a negative effect on the organization. These arguments were important to the interviewees and played a role in their choice to cooperate in order to solve the issue.
dealing with the issue were not relevant for themselves or the IS. The impact the issue could have was simply irrelevant for them.
Reputation – relational. This category was created in order to account for the responses the participants gave which reflected statements about the other’s personality characteristics, which they valued as pleasant or unpleasant. Next to the power, urgency and reliability incorporated in the BDM model as consisting of someone’s reputation, the
interviewees mentioned personal aspects of the other to argue why they would like to cooperate, or not. These arguments were important to the interviewees and played a role in their choice to cooperate.
Taking these new concepts in mind, the ensuing paragraphs will display the findings of the analysis.
Issue 1: Transparency Issue In The Elderly Care Organization
The issue in which the promoter and the speech therapist (stakeholder) cooperated was the issue of the increased transparency due to the implementation of the EPF.
Promoter’s perspective. Table 1 indicates the promoter’s view of the impact of the increased transparency on the system. The promoter perceives impact of this issue as high. He argues that if the issue would not have been resolved, the EPF might not have been accepted by a dominant coalition of stakeholders, which would have resulted in rejection of the system. Table 1
Issue impact on system from the promoter’s perspective
Issue impact on system Transparency Issue Perceived benefits of issue
“And then you also get much better information, so it also invites one to work on a complaint like dysphagia within a multi-disciplinary setting. Look, at first you worked like a number of individuals around a single patient, now the system makes it possible to actually work together. “
Perceived risks of issue
I think that the risks, and luckily you don’t realize it before hand, were pretty big. Namely, that the system would not have been accepted; resistance. And that you end up with a unworkable product, that was a possibility.”
Perceived impact on organization of issue
Perceived impact on society of issue
“There are plenty of examples that practitioners just pick up a quote from the system, a sentence, and that they do really strange things with it.”
Perceived irrelevant impact of issue
-
Table 2 displays the promoter’s perception of the salience of the speech therapist. The overall salience of the speech therapist is perceived to be low by the promoter. He states that she is charismatic and could serve as an example for her colleagues to use the system. However, he also reports that there are more powerful stakeholders. Moreover, she does not have a legitimate claim to be involved in the IS development, but the promoter does mention that the speech therapist can contact him through informal channels within the organization. Finally, the speech therapist claims to work together with the promoter to deal with this issue, as the IS directly affects her work process.
Table 2
Speech therapist’s (stakeholder) salience from the promoter’s perspective
Salience Speech therapist (stakeholder) Asses
sment Power “[The speech therapist possesses] knowledge and skills. And next to that she
also has the right motivation and reliability. (…) I think that that are the resources that she could use.”
“As a user [of the system] she mainly had to work with it herself, and that had, obviously, some kind of emissive effect on her colleagues.”
“She was not that important, compared with other stakeholders. I eventually did not work a lot with her.”
-
Legitimacy Interviewer: “Did the speech therapist also have a formal right to approach you?”
Promoter: “No, they can say, from their practice, from their work processes: ‘guys, we have to do this and that, how can we fix that? “
“She was a representative of the division managers to be in that workgroup. So she really was there from her position and was formally positioned there.”
+/-
Urgency “[It] concerns her work processes very directly, of course, how she does her primary work. So it touched her how she was supposed to work, how she had to acquire information, how she had to file things.”
Interviewer: “Was it in her best interest to deal with the [problem] as soon as possible?”
Promoter: “Yes, in the end, you can’t work with a program if you think: ‘well, I’m just going to go with it’.”
The reputation of the speech therapist, from the promoter’s viewpoint, is shown in Table 3. The findings indicate that he considers the speech therapist’s reputation to be high. The promoter sees the speech therapist as a competent employee who has gained an
respectable position in the organization. He furthermore expects to work together with the speech therapist in the future, something which he does not mind since they have established a good relationship together.
Table 3
Speech therapist’s (stakeholder) reputation from the promoter’s perspective
Reputation speech therapist (stakeholder) Asses
sment Power Interviewer: “Would you describe the speech therapist as competent in her
function?”
Promoter: “Yes, absolutely.”
Interviewer: “Do you think that the speech therapist can influence, fix or obstruct potential future problems or issues?”
Promoter: “Yes, I think so. She is one of our senior speech therapists, with a good track record. So that is absolutely true.”
++
Legitimacy Interviewer: “Do you think that the speech therapist has a formal/justifiable right to work with you on potential future problems?”
Promoter: “Yes, the way we organized right now.. eventually, we are just a professional bureaucracy, to put it like that, so you have to involve
professionals in the things that need them.” +
Reliability Interviewer: “And you think that the speech therapist is willing to work with you in the future?”
Promoter: “Yes, I do think so.”
Interviewer: “Would you say that, in the future, you could benefit from the collaboration which you have established with the speech therapist?” Promoter: “Yes, I think so.”
++
Relational “You have a relationship with each other and that makes it easier, I think. Then there is also some mutual acceptance and good-will.”
“[The speech therapist] is someone who is positive.”
+
The willingness of the promoter to cooperate with the stakeholder can be summed up in his statement:
“She was not that important when comparing her with other stakeholders. I eventually did not work with her a lot. But if you look at the group of speech
employees). And in that setting, you take her opinions, remarks and questions quite
seriously.”
The speech therapist’s (stakeholder) perspective. Table 4 indicates the impact of the issue on the stakeholder J. It is interesting that the speech therapist acknowledges the importance of the system, but that she does not recognize the potential source of resistance R reported. An increased transparency in her co-worker’s files was not seen as problematic whatsoever by the speech therapist.
Table 4
Issue impact on speech therapist’s (stakeholder) from the speech therapist’s perspective. Issue impact on stakeholder Transparency Issue Perceived benefits of issue
The advantage is, indeed, that you can very easily read what you and others have done and how [that client] is doing with you. And that is a major benefit.”
“Yes, for years we have been shouting about a digital system, because earlier, we had to report everything four times.”
Perceived risks of issue
Interviewer: “And if no attention was given to this issue, in consultation with the promoter about how to deal with the information, what would have happened with the system then?”
Stakeholder: “If there was no consultation about all this? And if the system was just like it was in the beginning? Well, then everyone would have abandoned it, I think. Then you get a lot of resistance.”
Perceived impact on organization of issue
“[For example, mister] de Vries has problems swallowing, that a nurse could read that, and that she would take action on that bit of information, while that is only allowed when we say: ‘we are going to deal with it now.”
Perceived impact on society of issue - Perceived irrelevant impact of issue
Interviewer: “It is about the fact that it becomes transparent, like: ‘oh, the other people can see what I’ve written.”
Stakeholder: “I have not seen that as resistance.”
“(…) but after people had worked with [the system] for a month and a half, they were like: ‘oh well’, they were starting to get used to it.”
to solve the issue as soon as possible. Overall, the salience of the promoter from the stakeholder’s viewpoint seems to be high.
Table 5
The promoter’s salience from the speech therapist’s (stakeholder) perspective
Salience Promoter Asses
sment Power “He is really good at analyzing; he knows really well… like: he hears something
here and something from us and then, (…) he can connect those things really well. He is really good at thinking: ‘oh, the system can do this, so for the solution we have to move that way’.”
“And communication-wise… It is sometime hard to, how do you say this… It is hard to find the correct wavelength; he sometimes needs some more time.” “From the [transparency] issue you immediately notice that sometimes there are some miscommunications.”
+/-
Legitimacy Interviewer: “Do you see the promoter as a legitimate representative of the organization?”
Stakeholder: “ For the system? Yes I do.”
“That has also been said. Say that something comes up within the department, then we can invite him and he will explain to us how things work and how it can be improved. If we run into something. We have that freedom.”
+
Urgency Interviewer: “Do you think that it is important for him that the issue is taken care of as soon as possible? At that time?”
Stakeholder: “A lot of things have change at this time, within the system. It is a good thing that happened, or else… If you had just let it run rampant, then everyone will fall back to his own way of working. And now, all the things have been agreed upon. There is [ a report] from all of us, in consultation with the promoter, in which all the rules have been set. It’s just a good thing that it happened, on short notice.”
Interviewer: “Yeah, so that was important for him/the organization?” Stakeholder: “Yes, absolutely.”
+
The speech therapist’s view of the promoter’s reputation is reported in Table 6. Again, she reports that the promoter is knowledgeable and competent in his job, but that the
communication could be improved. She furthermore states that she expects the promoter will involve her in future decisions, simply because that is his job as the head of IT. In the
Table 6
The promoter’s reputation from the speech therapist’s (stakeholder) perspective
Reputation Promoter Asses
sment Power “That is part of him, how he looks at things. He sometimes hears different
things then there really are. And, of course, that also has to do with us, the communication, like: ‘how clear were we, communication-wise.”
“(…) I think that he, because he is positioned somewhat farther away and he sometimes has a total different view on some things, sometimes also another way of thinking: it results in different insights.
+/-
Legitimacy Interviewer: “Do you think he has the right to participate in future issues?” Stakeholder: “Yes, I think so.”
Interviewer: “Based on his function?” Stakeholder: “Yes, based on his function.” Interviewer: “And also based on his knowledge?” Stakeholder: “Yes.”
“It is not like he will come immediately towards me. It is more likely that, when the time comes, the people in charge and other departments will say: ‘who are we going to call for this?’. Or you get asked within the department: ‘who wants to be in it?’, ‘who wants to participate?’”
++
Reliability “I think his function is about supporting us, us on the work floor. To make it easier for us all.”
Interviewer: “Do you think that the promoter will keep your interests in the back of his mind when future collaborations might come up?”
Stakeholder: “Yes”
Interviewer: “Like, when he has to make decisions?” Stakeholder: “Yes, that happens, yes.”
++
Relational “(…) Yes, not always, but we can always talk to each other about what is going on, that it is sometimes hard to get on the same page as him. But that is also something which is inside our personalities, he just has a different personality then I do. But we will overcome that.”
“(…} I think that because he is positioned somewhat farther away, that he has a totally different look on things, sometimes also a different way of thinking. But that does help in coming to different insights. Meaning that you sometimes go for different solutions. Sometimes, the one with you have the most
resistance with, or… the one with which you have to talk to get on the same page… That process usually leads to very different, fun solutions. That is something I appreciate in him, yes.”
+
The willingness of the speech therapist to cooperate with the promoter can be seen in the following quote of the stakeholder:
Interviewer: “Could you tell us how important the cooperation with [the promoter]
Stakeholder: “When I look at the [EPF], the cooperation was very important. He is
the one who knows the system in and out, and if we run into some problem, he is the one who can find a solution for that problem.”
After inserting these findings about the first issue, Figure 2 appears:
Figure 2. Assessment of the promoter’s and stakeholder’s attributes and the resulting
cooperation for issue 1.
The impact of the issue on the stakeholder was marginal, in contrast to the promoter, which perceived the impact of the issue the be very high (see Figure 2). The moderating effect of the impact of the issue on the system for the promoter is in contrast with what was
BDM model: the stakeholder appreciated the salience and reputation of the promoter to be high and also willing to cooperate with him.
Issue 2: Standardization Issue In The Elderly Care Organization
The issue in which the promoter and the care coordinator (stakeholder) cooperated was the issue of the standardization of medical terms to describe patient’s problems, which was an inevitable consequence of implementing the EPF.
Promoter’s perspective Table 7 indicates the promoter’s perception of the impact of the issue on the system. The impact on the system is considered very high by the promoter. Reduced efficiency and less information could have been obtained from the IS if the issue would not have been solved. Furthermore, it could have led to a rejection of the system by the employees.
Table 7
Issue impact on system from the promoter’s perspective Issue impact on system Standardization Issue Perceived benefits of issue
“If you want to do it, you can do it, the system can handle it, but you do lose some efficiency benefits.”
Perceived risks of issue
“The importance [of solving this issue] is big in my eyes. If we had supposed to change this, you wouldn’t have an EPF to work with anymore. It was the core of the EPF, seen from a healthcare point of view.”
Interviewer: “What were the risks for the system, had this issue not been solved?” Promoter: “I think you would have gotten less facts, you get less information from the EPF and the EPF will lose efficiency. It is less useful then. You can extract less management information from it, as an organization. You are then spending more time in typing than in healthcare.”
Perceived impact on organization of issue
“They were implementing a healthcare-live-plan at the same time, a different methodology: to work more on the questions the clients had. And a lot of people immediately saw the shortcomings of the EPF, like: ‘such a standard list?” Perceived
impact on society of issue
“Such an EPF works from the assumption of standardization. And that is contrary to what people believe in this healthcare organization. You have the school of thought here that every person is unique. Versus the idea that you can categorize
questions/problems clients have into standardized terms, and then combine them.” Perceived
irrelevant impact of issue
-
to this issue, she is powerful in both knowledge and position within the organization. Furthermore, she has both a legitimate and urgent claim to work with the promoter to solve the standardization issue.
Table 8
The care coordinator’s (stakeholder) salience from the promoter’s perspective
Salience The care coordinator’s (stakeholder) Asses
sment Power “She has a managerial function. She was there as an representative of the
officials who worked in the middle of the organization, in a hierarchical sense. So she also had some of the power of those officials.”
“(…) Also knowledge, she was very familiar with the matter, we knew the [software] package well. So knowledge, power… knowledge as a source of power so to speak.”
“[The care coordinator] is positioned in a lot of places, so she could have easily messed with the project, absolutely. By resisting the implementation on
different places. She could also have organized some kind of resistance against the system.”
++
Legitimacy “She was a representative of the division managers to be in that work group. So she really was placed there from her position and she was also formally
placed there.” ++
Urgency Interviewer: “Did [the care coordinator] have a direct interest in solving the issue?
Promoter: “Yes, in that sense she did. Her people have to eventually work with the system. So she has an interest, professionally speaking, to have a good instrument, but also an efficient instrument. So she most definitely had an interest in solving the issue.”
“She also had an interest in a successful implementation. She was herself involved in the process, with something that really matters, something that has an organization wide impact.”
++
The promoter holds the stakeholder’s reputation in high regard, he says she is capable, kind, valuable, decisive and he mentions more flattering adjectives (see Table 9). He
moreover states that he could most probably count on her help in future projects/issues.
Table 9
The care coordinator’s (stakeholder) reputation from the promoter’s perspective
Reputation The care coordinator’s (stakeholder) Asses
sment Power The care coordinator is the head of her team. She knows and sees a lot from
that position. Therefore, she also has the knowledge and position to be meaningful in other processes.
“She is easily approachable and competent.”
“I think that a lot of people – the MT [(Management Team)] members – value her opinion very much.”
++
Legitimacy “Requests from the staff officially run through a portfolio holder, but that is the official side. But she can just approach us and ask a question.” + Reliability “Yes, we have absolutely build a good relationship with each other. And if
something comes up, I would happily look up the care coordinator to ask for her help.”
Interviewer: “Do you think the care coordinator would be willing to work with you if you are in need of help, say in a future project?
Promoter: “Yes, I think so, yes. I can ask her something and she will do it or me, and also the other way around.”
++
Relational “Yes, we have absolutely build a good relationship with each other. And if something comes up, I would happily look up the care coordinator to ask for her help.”
“It is always fun to work with her. With her, I really have the feeling that we both want to go in the same direction.”
++
The importance of the care coordinator’s cooperation for the promoter, is reflected in his following statement:
“[The care coordinator] was really very important. She was a team manager – you needed two team managers to achieve the good-will and support. She was the one who eventually had to get them to go a long, also in the advice towards the board, as in: ’guys, this is a good plan.’ If she and a colleague had not done that, then the [IS implementation] could not have been achieved. So she really is an important
supporting player. I think that a lot of people – the MT members – value her opinion very much.”
Table 10
Issue impact on the care coordinator (stakeholder) from the care coordinator’s perspective Issue impact on system Standardization Issue Perceived benefits of issue
Interviewer: “So, a good solution [for the issue] will have a positive influence on your job?”
Stakeholder: “Yes, of course.”
“(…) We really wanted to work with an EPF, by whatever means. Because, yeah, that is something of this time and age. And besides: it most certainly has a lot of
efficiency.” Perceived
risks of issue
Interviewer: “ And this has really influenced your job?”
Stakeholder: “ Yes, that influences my job, because… What I always say is: ‘I’m in a sandwich position’, which results in… If I’m not getting trouble from one side, then I’ll get it from the other side.”
Perceived impact on organization of issue
(The care coordinator about the change to the use of standard lists in the EPF): ”I mean, if you are used to sitting on the left side, and after three years they want you to sit on the right side, because that is how you have to imagine it, that is a very hard thing to do for some people. Because they are like: ‘now we really do not know what to do anymore.” Perceived impact on society of issue - Perceived irrelevant impact of issue -
The stakeholder appraises the salience of the promoter in this issue as high (see Table 11). The care coordinator states that he does have the proper knowledge when it comes to the EPF, and that he was legitimately assigned to the project. But when it concerns matters outside the EPF, he does not have a legitimate claim to be involved. The promoter’s knowledge on non-technical matters are appreciated as outdated by the care coordinator. Moreover, the stakeholder states that the promoter overthinks matters, which results in a diminishment of his urgency claim from her point of view.
Table 11
The promoter’s salience from The care coordinator’s (stakeholder) perspective
Salience Promoter Asses
sment Power “I think he absolutely has a lot of knowledge about [the EPF], also because the
schooling which he has had beforehand.”
“If you are five years out of healthcare, you really do not want to know what has happened in the field, and that sometimes makes it hard. He has the
feeling that he also knows a lot about that, and he does, only it is a little outdated (…) It is not really of this day and age anymore.”
Legitimacy “The MT makes the choices in our case, and they chose for this system, the executive of that is [the promoter], project-wise.”
Interviewer: “ Would you say that [the promoter] is a legitimate representative of the organization?”
Stakeholder: “Well, I think especially for this whole project.” + Urgency Interviewer: “Was it back then, and well, now still, for the organization and also
for [the promoter] himself important that the problem would be taken care of quickly?”
Stakeholder: “ No, No, he really overthinks matters. Look, not everyone has his own interests and his interests are different than those of mine, but it always works like that. Even though you have the same kind of function, you always have other interests.”
-
Table 12 displays the appreciation of the promoter’s reputation, judged from the care coordinator’s (stakeholder)’s point of view. The stakeholder perceives the reputation of the promoter to be moderate to high. She again mentions that his knowledge is mostly technical and that this area is probably his only area of influence. He does not have the power to single handedly make decisions for the organization. Furthermore, their relationship is good,
although she does mention (just like the speech therapist), that communicating with the promoter can sometimes pose problems.
Table 12
The promoter’s reputation from the care coordinator’s (stakeholder) perspective
Reputation Promoter Asses
sment Power “When I and three colleague team managers want to go a certain direction,
yeah, than he has to comply, we will submit it to the MT, if that was necessary. And the chances are that he has to comply to that.”
“He sometimes still holds on to the experiences he has had from the past, although, that is how I interpret it, let’s be clear about that. And in this case it sometimes happened that you did not comprehend each other and where you simply were not talking the same language.”
“Then you can also see how divided the knowledge is, because his knowledge is particularly technical.”
+/-
Legitimacy Interviewer: “Do you think that [the promoter] has a formal right to participate in future issues, issues that lie in his area of expertise? And do you think [the promoter] will have a lot of influence on these future issues?”
Stakeholder: “That really depends on what the issues are… It strongly depends on that. Everyone has influence in his own area of expertise of course.”
+/-
Reliability “I personally appreciate the cooperation with him, because I know that he is approachable, and that I can approach him.”
[the promoter] cannot make decisions about my business.”
Relational “He sometimes still holds on to the experiences he has had from the past, although, that is how I interpret it, let’s be clear about that. And in this case it sometimes happened that you did not comprehend each other and where you simply were not talking the same language.”
“We work together just fine. But you sometimes have to make compromises. That is something we both have trouble with.”
+
The care coordinator’s willingness to cooperate with the promoter to solve the issue can be found in her following statement:
Interviewer: “Could you tell us how important it was to work together with [the
promoter] in relation to solving this problem?”
Stakeholder: “Well, very important (…). I honestly have to say that [the promoter] is
someone (although that also has to do with the intensity we had together)… I
approach him very quickly about questions about whatever, actually. Things in which he can support me, and then it usually works out fine.”
Figure 3. Assessment of the promoter’s and stakeholder’s attributes and the resulting
cooperation for issue 2.
The promoter appreciated all aspects of the care coordinator to be very high, he furthermore was very willing to cooperate with her. Also, the impact of the issue on the system was perceived to be very high by the promoter. On the other hand, the stakeholder was indifferent about the promoter’s reputation and valued the promoter’s salience as high for this issue. She was very willing to cooperate with the promoter.
Issue 3: Investment Issue In The Healthcare Innovation Organization
The issue in which the promoter and the project engineer (stakeholder) cooperated was the issue of obtaining a financial investment from a major insurance company.
investment is not essential for the IS, without the funding from the insurance company they would be able to advance in the project as well. Furthermore, the promoter states that a successful implementation of P in more organizations could result in better healthcare, it would be beneficial for society, next to the organization the promoter works (Payton, Paré, LaRouge & Reddy, 2011).
Table 13
Issue impact on system from the promoter’s perspective
Issue impact on system Investment Issue Perceived benefits of issue
“It can simply help with up scaling, and the acceleration of that up scaling of P.” “I’m convinced that P is going to be successful, but financial stimuli can accelerate that success.”
Perceived risks of issue
Interviewer: “So then you had to contact the hospitals directly in order to promote P there (instead of doing it through the insurance company)?”
Promoter: “Yes, but we still do [contact hospitals directly].” Perceived impact on organization of issue - Perceived impact on society of issue
“(…) but even in the interest of citizens is the question: “how do we control the costs of healthcare? Because that just keeps rising.”
“Self-management (for the civilian) is stimulated through P, because of the environment it offers, so the healthcare insurance companies simply have a big interest in that.”
Perceived irrelevant impact of issue
Interviewer: “Yes, because then you would have tried to obtain sponsoring through another healthcare insurer…”
Promoter: “Yes.”
Table 14
The project engineer’s (stakeholder) salience from the promoter’s perspective
Salience project engineer (stakeholder) Asses
sment Power “[The project engineer] is a good guy, he is clever, he is critical, so he knows
how to challenge you in order to get the proposition sufficiently clear and such.” “(…) and also the skills and experience and other things he brings to the table.” “You also ask [the project engineer] questions in order to get [the insurance company’s] agenda to be, at least partly, dedicated to P.
++
Legitimacy “He is responsible for innovation, and he is deemed to be working an innovative matters, and to report it to the upper management.”
“(…) [The insurance company] is a sponsor of the network of [the healthcare innovation organization] anyway, it has a seat in the board of supervisors, so from there is a strong relationship with [the healthcare innovation
organization].”
Interviewer: “Would you say that [the project engineer] has a justifiable right to ask you for help?”
Promoter: “Of course.”
++
Urgency Interviewer: “So you could say that it was not in your best interest to finish the negotiations as soon as possible?”
Promoter: “No.” --
Table 15 indicates the reputation of the project engineer, from the promoter’s point of view. Similarly to the project engineer’s salience, the promoter appraises his reputation as very high. He helps the organization the promoter works for by asking critical questions, which can subsequently help them improve their IS. Furthermore, the project engineer is legitimately connected to the promoter’s organization, which can justify future collaborations. This is strengthened by the common goal the promoter’s organization and the project
engineer’s organization have: innovation in healthcare.
Table 15
The project engineer’s (stakeholder) reputation from the promoter’s perspective
Reputation Project engineer (stakeholder) Asses
sment Power “[The project engineer] is a good guy, he is clever, he is critical, so he knows
how to challenge you in order to get the proposition sufficiently clear and such.”
“What I said about [the project engineer]: the feeling that he is the right man, also because he has sufficient knowledge of the [insurance company], he knows who to approach there, on the one hand, and has sufficient experience and also has stature within the organization on the other hand. People listen to him. He simply brings those skills to the table.”
Legitimacy “(…) [The insurance company] is a sponsor of the network of [the healthcare innovation organization] anyway, it has a seat in the board of supervisors, so from there is a strong relationship with [the healthcare innovation
organization].”
++
Reliability “(…) there are numerous reasons to cooperate with each other in the future, also with the innovative environment of [the insurance company] and the connection with [the healthcare innovation organization] in mind.”
Interviewer: “Do you think that he is willing to work with you in the future on a different project?”
Promoter: “ If he is willing to do so? Yeah, he will have to. And that does not necessarily stem from P, but more from the relation there is with [the healthcare innovation organization].”
++
Relational “[Both our organizations] have a strong relation with each other and we know [the project engineer] from that angle. There are also discussions from which
we know him from whole other connections.” +
The importance of the stakeholder’s cooperation for the promoter can be summed up in his following statement:
Interviewer: “Could you tell us how important the cooperation with [the project
engineer] was in relation to solving this issue? Compared to other stakeholders?”
Stakeholder: “There are more important stakeholders. The involvement of, say [a
major hospital], is much more important for the success of P then the involvement of [the insurance company].”
Figure 4. Assessment of the promoter’s and stakeholder’s attributes and the resulting
cooperation for issue 3.
The promoter states that the impact of this issue on the IS was limited. His willingness to cooperate with the project engineer was high. However, the willingness to cooperate with him was indifferent in relation to this issue. The promoter does value the stakeholder’s reputation to be very high, which did lead to cooperation. This is in line with the predicted moderating effect of the impact of the issue on the system.
Additional Finding: Own Perceived Legitimacy
in the problem-solving/decision-making. Therefore, a new category was created to reflect these statements (see Table 16).
Table 16.
Own perceived legitimacy of the participants in the current study Promoter of
issue 1 and 2
“That there is a project leader who knows the people, and also the history of the organization. This project has been executed in some organizations by external project leaders (…). That has its advantages, because then you have a more objective
position. But I also think it has a lot of disadvantages: because you don’t know your way around the organization, because you do not know the people, because you do not understand the people. And I did know them, obviously.”
Speech therapist
“(…) The system is primarily aimed at healthcare, so if you’re talking about
resistance… Our resistance was more like: ‘yes, it is not writing for treatment, but more for healthcare’. And that was what we were working on with [the promoter], in the sense: ‘how can we refine the system.”
Care coordinator
“(…) [The promoter] must leave the healthcare part mainly to us.”
“(…) I always say: ‘stick with what you know’. He has knowledge about business from the digital world and we have knowledge about healthcare.”
Promoter of issue 3
-
Analysis
An in depth analysis of each issue is provided below. How and why did cooperation occur between the promoter and stakeholder? This section will conclude with a cross-case analysis, comparing how each cooperation was established in its own way.
Issue 1: Transparency Issue In The Elderly Care Organization
The willingness of the promoter to work with the speech therapist (stakeholder) was low in the transparency issue, but still, cooperation was established. In this specific case, the promoter was forced to work with the speech therapist because she was a representative of the of the division managers. Consequently, she was formally placed in a position to work
Furthermore, the promoter rated the importance of dealing with this issue as very high, but he also stated that the speech therapist was not imperative for dealing with this issue, which could have lowered his willingness to work with her.
The stakeholder appreciated both the salience and reputation of the promoter to be high, she valued his knowledge of the IS and stated that he is competent in dealing with IT (information technology) related matters. The impact of the issue on the speech therapist herself was not high. Even though she emphasized the efficiency benefits from the system and she recognizes the risks involved if this issue would not have been dealt with. However, she relativizes this by saying that is was merely a transitional period for the employees. It took the practitioners a while to get used to the system and realize the increased transparency was not a real problem. Furthermore, she explained that she valued the promoter’s reputation because he was the one she could turn to if she experienced problems with the IS. The promoter would be the one to come over immediately and fix it. This reflects a personal advantage she
achieved in establishing a relation with the promoter. The resulting willingness to cooperate with the promoter, then, is concurrent with the BDM model. The impact of the issue was not important for the stakeholder, but the willingness to cooperate was high because of the
reputation of the stakeholder (i.e. he was willing to personally come over and fix the problems experienced with the IS). This moderating effect of the impact of the issue is in line with the predictions of the BDM model (Vos & Achterkamp, in press).
Issue 2: Standardization Issue In The Elderly Care Organization
In the standardization issue, the promoter appreciated both the salience and reputation of the stakeholder to be very high. Additionally, the promoter stated they already knew each other and had established a fun, good relationship. Furthermore, the impact of the issue on the system was also very high, according to the promoter. Consequently, in line with the BDM model, the willingness to work with the stakeholder was very high.
The care coordinator mentioned (just like the speech therapist) that the knowledge of the promoter is mostly technical. His power, both in the salience and reputational sense, stems mainly from his competence in the IT area. He does not have any leverage within the
the EPF because she had a large role in the implementation of the EPF. And furthermore, the practitioners working in her department also had to work with the EPF. To avoid problems within her own department she wanted to deal with the issue as soon as possible. In this case, the BDM model was able to explain how cooperation was established. The main reason they cooperated, was because the promoter was the only person in the organization who knew the system good enough to implement and modify it. In other words, the impact of the issue on the stakeholder and her own department was reason enough to be very willing to work with the only salient person in the organization: the promoter.
Issue 3: Investment Issue In The Healthcare Innovation Organization
The final issue concerned the financial stimulus the healthcare innovation organization could obtain from a major health insurance company. The promoter valued the reputation of the project engineer to be very high. He is a knowledgeable, competent man who is
legitimately connected to the healthcare innovation organization. Furthermore, the promoter is very certain of future collaborations between them. The impact of the issue on the system was perceived as limited. Although he does state that the IS could be of great help to society, by increasing self-management and reducing healthcare costs (Payton, Paré, LaRouge & Reddy, 2011). The promoter argued that they would be able to make the IS succeed, with or without the help of the project engineer. Taking this into consideration, it is in line with the BDM model that the promoter was very willing to work together with the project engineer. The reputation of the stakeholder, which the promoter held in high regard, and the indifference of the impact the issue had on the system, made sure the promoter was indeed willing to
cooperate with him, in order to acquire potential future benefits from the established/strengthened relationship (Vos & Achterkamp, in press).
Cross-Case Analysis
The cooperation in the transparency issue was mainly established because both
