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Innovating Mindfully: Two Stories, Two Endings' problems for each of the groups that would be affected by the change (radiologists, physicians, employees and unions) as well as key individuals in these groups who could promote the project, Description of the Alpha case find sources of funding and develop an operational plan. The action plan convinced the hospital's administration to invest in the project, and a The Alpha case took place from 1995 to 2001 in an acute care hospital in a suburb of a supplier was selected based on the quality of the proposed hardware (e.g, the monitors) and large Canadian city. The budget estimate for the project was $3.5 million. Before it acquired the software as well as compliance with the initial project criteria. The successful bidder had already PACS, the medical imaging department used film for all the images made with its various provided 70% of the hospital's medical imaging systems, and the organization hoped that by imaging devices. The department received a budget envelope to cover the cost of supplies and working with this supplier it could minimize integration problems. Before the supplier was hospital management made it responsible for managing the budget. However, large budget cuts in officially selected, the organization took some time to inform the employees who would be the 1990s made the department responsible for providing the same quality of service with a much affected by the changes about the imminent re-organization, including the abolition and smaller budget. This led them to consider a PACS implementation as a potential response to the transformation of certain positions. Some employees decided to leave before the system was budget cuts. In February 1995, the film supplier organized a PACS demonstration for the deployed, which greatly helped the transition. Shortly after the successful bidder was announced, hospital's general management and its unit heads. The hospital then asked the supplier to make a it installed some work stations and invited future system users to experience the quality of the submission to have an approximate cost for such a system. images for themselves. This gave users an opportunity to discuss their reactions and concerns. In the Fall of 1995, the head of the medical imaging department and the technologist in The supplier took these comments seriously, since it was keenly aware that user dissatisfaction charge of administrative services for the department attended the annual meeting of the can hinder the implementation of IT solutions. Radiological Society of North America, at which there were several PACS activities (such as In early 1998 the organization struck two committees for the PACS implementation. The seminars, lectures, system demonstrations). Participating in these activities gave them a better first committee, which would plan, coordinate, control and implement the project, consisted of understanding of how the system worked and how it could be beneficial to their medical imaging the initial project team, the technician who would be responsible for the system's future department and the hospital as a whole. This meeting reinforced the hospital's interest in management, a member of the administration and the supplier's project manager. The committee acquiring a PACS system and led them to develop the idea further, including an examination of met once a week. The second committee was charged with developing a communications plan Alpha's longstanding relationship with its film supplier. The department heads then sought a that would foster appropriation of the system by the targeted users and keep the medical second opinion from another supplier in order to compare the two proposals. In April 1996, a formal acquisition proposal was presented to the hospital's community informed of progress made in the project. The second committee consisted of the members of the first committee as well as representatives from various interested groups administration. The proposal was prepared by a team consisting of the two department heads who (management, the finance and technical department, etc.). attended the annual meeting as well as a clinical radiologist. The proposal included several Before the PACS was rolled out, the supplier updated the existing radiology information deployment phases and was designed to minimize interference with hospital operations. In system (RIS) so that the two systems would be able to communicate with each other. Employees addition, in order to meet the requirements of hospital management, a detailed budget was in the imaging department and physicians received individual training: the employees were prepared of the projected direct gains (e-g, reduced costs through the climination of film trained according to a pre-established schedule, and the physicians were offered training by purchases) and the projected indirect gains (e-g, PACS' impact on the length of hospital stays) appointment, given their busy schedules. In addition, a small but professional-looking journal, associated with the PACS acquisition. In July 1996, Alpha conducted a study of the path taken by "PACS in a Nutshell," was distributed to all employees. This communications tool included a radiology request in order to develop a better understanding of the operational flows that the several sections, including "PACS for Dummies," which was generally used to give simple system would need to support. explanations of the technology, but also to provide answers to frequently asked questions about The tendering process began in January 1997. Since the team was unable to determine the how the implementation would unfold. optimal system configuration that would best meet the organization's needs, the decision was The system was deployed in the Fall of 1998, and the deployment took less than two made to prepare the document in a way that would transfer this responsibility to the supplier. The weeks. User reactions to the deployment were positive overall: the system made access to images tendering document, which only covered the organization's general expectations (95% reduction casier and reduced the number of required tasks. Six months after deployment, a postmortem was in the use of film, rapid access to images, a user-friendly system and full integration with the carried out. It revealed that six weeks of technical adjustments were required before the system existing radiology information system), was sent to six carefully selected potential suppliers. became fully functional, and that productivity gains could be seen after three months. A survey From February to May 1997, the team visited four hospitals located in the United States, conducted six months later revealed that all the users preferred PACS to the former system and Canada, Australia and Germany that had been using PACS for some time. These visits provided a that the system provided easier access to images, which saved time and enhanced productivity. better understanding of implementation strategies, potential challenges and the savings realized by health care organizations. This period was also used to conduct a survey of habits in the use of radiological film. The survey was sent to all the members of the hospital's board of physicians, dentists and pharmacists. Following these visits and an analysis of survey responses, the decision was made to change the preliminary deployment plan from two phases to a single phase, which would allow the hospital to start realizing savings earlier. A new, detailed action plan was presented to the hospital's administration in May 1997. The administration identified keydecision, a contract was signed by the supplier and hospital management, and the mandate of the management committee came to an end. The stakeholders who had initiated the project saw the Description of the Beta case implementation phase as a period of operational challenges. They abandoned the file and transferred responsibility for the project to a new team that consisted of the technologist The Beta case was a regional hospital located in the suburbs of another Canadian city. responsible for managing the system as well as two technicians: one from the supplier and the The budget for this project was close to $2 million, and it ran from 1997 to 2001. In the 1990s, other from the hospital's IT department. From the outset, this new committee naturally focused its the hospital's management decided that the hospital should be a state-of-the-art facility in order to efforts on technical issues. For example, it worked on the interfaces that would allow the PACS to retain the region's client base and facilitate the recruitment of medical specialists. Before this communicate with the RIS that the hospital had already been operating for several years, as well vision could be achieved, the hospital was already known as one of the first to acquire new as with existing equipment and devices acquired as part of the reorganization project. technology. This included being the first hospital to buy a computer-controlled axial Generally speaking, little attention was paid to the human and organizational dimensions tomodensitometer in 1980, and one of the first hospitals in this area to acquire a magnetic of the project. Once the contract had been signed, the supplier demonstrated how the system resonance device in 1990. would work, and two standard memorandums on the innovation were sent to hospital employees At Beta, the idea of adopting PACS came out of two parallel projects. First, the hospital to discuss the reasons for the acquisition and announce that the project had begun. At one point, wanted to replace the obsolete tomodensitometer using funds from the device's maintenance the committee decided to give some gifts (allocating more work stations of a better quality) to the budget. Then the hospital received funds to replace a fluoroscopy room and add two other rooms: two specialties who were their biggest clients, the orthopedists and the pneumologists, as a way to a fluoroscopy room and a magnetic resonance room. The problem was that this equipment would prevent dissatisfaction with the system. The technologist responsible for managing the system have increased the facility's treatment capacity, which would have increased the number of films had a week of training outside the hospital and then trained the other members of the team to act to be developed, since films were used to view and store radiology images. Another result was as super-users. The committee then sent out a letter that invited all future system users to attend that new laser cameras would be needed. their training sessions on a voluntary basis. These sessions were offered to large groups on a fixed These various acquisition projects were bundled into a single project to reorganize the schedule several days before deployment. Only 30% of the physicians attended. medical imaging department for a price of close to $7 million. Given the size of this expense, in Despite the low attendance, deployment of the PACS began in the Fall of 1999, but the Fall of 1997 four members of the project committee attended the annual meeting of the things did not go smoothly. We should point out that Beta had decided to begin by digitizing Radiological Society of North America to learn more about new devices on the market. It was at fluoroscopy and their digital modalities instead of their analog modalities, yet no physician was this conference that the team came up with the idea of acquiring a PACS. since this system would looking at these images. The physicians thus had great difficulty seeing the usefulness of the eliminate the need to develop films and sidestep the need to procure additional development system. When the digitization of exposure imaging began six months later, the physicians quickly cameras, which cost $150,000 each. started to express their dissatisfaction with the quality of the images. The head of radiology had to Upon their return from the meeting, the committee members in charge of the project met ask the hospital's administrative manager to intervene and impose system use on specific to evaluate whether PACS could both meet the organization's needs and become part of the physicians. current reorganization project. Six managers of different departments joined the committee. This Then problems began to appear in the interfaces that had been developed to link the RIS larger group made the decision to make a PACS acquisition part of the medical imaging to the PACS, and this interfered with the use of these systems. The situation seriously disrupted department's reorganization, since it could be tied in to over half of the department's equipment, operations in the radiology department, where these systems were being used on a daily basis. thereby reducing the use of films. Beta also expected that, in the years to come, PACS would With the problems still unresolved one year after system deployment, the decision was made to begin appearing in other hospitals in its region, and it wanted to be one of the first to acquire a acquire a new RIS. system. The IT department was given responsibility for the process for acquiring the new RIS, Since the organization was operating in an environment where financial resources were since it would be assuming the costs. This time there was no call for tenders, and Beta acquired becoming harder to come by, it needed to demonstrate that the project could be self-funded. In the RIS from the same company that supplied the PACS in order to ensure better integration. November 1997, with this economic analysis underway, the tendering process for acquiring a Some processes had to be reviewed before the RIS could be deployed in order to ensure that it PACS and the other equipment began. The committee developed a series of documents to define would be fully compatible and integrated with the PACS. However, acquiring a new RIS did not all the characteristics of each project. The call for tenders was launched in January 1998. As the resolve all the problems, since the system crashed on the very day it went into operation. In submissions were being reviewed, particular attention was paid to the two least expensive bids, contrast to the former RIS, which was linked to the PACS by an interface, the new RIS was since they met the project's needs. completely integrated with the PACS, such that when one system crashed, it paralyzed the entire In February and March 1998, the committee visited the two shortlisted suppliers as well department. The supplier's explanation was that this technical problem was the result of under- as clinical sites that were using their PACS. After these visits, the committee met to review the estimating the amount of data that would have to be shared between the two systems. In order to two bids one more time. Based on several factors (c.g., PACS integration with the new equipment ensure continuity in the department's operations, the former system was re-installed and used for and image quality), the committee decided to accept the second bid, which was judged superior another eight weeks, giving the technicians time to make the necessary changes to the new RIS. due to the quality of the monitors, the customization options, the supplier's reputation, a lower The project team then tried to install the new RIS a second time, but in a phased implementation. price, etc. As it turned out, the same supplier had been selected to furnish the new medical Fifteen months after the PACS was deployed, it was still not an integral part of the organization's imaging equipment. The committee therefore hoped that this would ensure better integration operations. No productivity gains had been observed, but the main objective - the elimination of between their new PACS and the new equipment. The economic arrangements and the films - had been achieved. Furthermore, no official mechanism had been implemented to collect committee's selection of a supplier were submitted to hospital management in April 1998 and comments from users, but occasionally the staff expressed opinions about the system, especially approved a month later. The project was expected to pay for itself in eight years. Following this at tactical intervention group meetings, responsible for the analysis of ambulatory services.1. Identify and briefly describe the strengths and weaknesses observed in both the Alpha and the Beta cases. (10 pts) 2. Identify and discuss two dimensions/types of challenges/barriers related to the technology implementation observed in the two cases, and provide specific examples to illustrate and support your answer. (10 pts) 3. Describe whether the challenges/barriers that you identified in the previous question were consistent throughout the process of planning and implementation of the new technology. Explain why. (10 pts) 4. Identify three lessons learned from these two cases (you can refer to any or both of the two sites), and explain how these lessons may be leveraged by managers in the context of implementation of different technologies in other hospitals. (10 pts)