SAMINT-MILI 2034
Master’s Thesis 30 credits
June 2020
Barriers, facilitators and success
criteria in the implementation of
eHealth solutions in healthcare
organizations
Orejuela Chaverra, Silvia Refana
Toledo Royo, Estefania
Abstract
Barriers, facilitators and success criteria in the
implementation of eHealth solutions in
healthcare
Orejuela Chaverra, Silvia Refana; Toledo Royo, Estefania
As a response to the need for efficiency and innovation that modern society has placed over healthcare organizations, they are constantly looking for more efficient and innovative tools that facilitate the daily practices for providers. In this context, the use of digital solutions or eHealth arises as an alternative for healthcare. Despite the potential benefits of eHealth solutions, healthcare leaders experience difficulties implementing them. For that reason, health services researchers acknowledge the critical role of implementation science in the sector. Seeking to motivate organizations to embrace eHealth solutions and their benefits, this research identifies the barriers and facilitators experienced by project managers during the implementation projects of innovations in healthcare. Moreover, it proposes the clarification of concrete criteria to assess success derived from the outcomes of an implementation project. Starting with a literature review, followed by qualitative research and a data collection through a total of ten semi-structured interviews with project managers. Moreover, the data analysis is made based on thematic analysis. The results identify three main facilitators for innovation: 1) maintaining a balanced level of understanding for all stakeholders, 2) to have open communication, and 3) to have a high involvement of the top management with the project. Moreover, the most relevant barrier faced by managers is the lack of skilled and competent people within the organization. Regarding the success of implementation projects, the most relevant criteria are: 1) delivering in the right time, budget, scope and quality (reach the project goals), 2) maintaining the customer and user satisfaction, and 3) increase in work efficiency in the healthcare organizations. To some extent, the mentioned factors contribute to facilitating the implementation of innovations in healthcare. The role of managers in implementation is highly valuable since they represent the bridge between top management and front-line employees. This research summarizes the experience of the managers -from a consultancy company- while working in the implementation of digital tools in healthcare. Therefore, the research provides a better understanding regarding the barriers, facilitators and success criteria for implementation.
Keywords: Implementation Science, eHealth, Project Managers, Barriers, Facilitator
and Success Criteria.
Supervisor: Anette Cederberg
Faculty of Science and Technology
Popular Science Summary
The constant struggle for managers to implement successfully
A relevant user of the digital tools in healthcare are the patients; common people who require medical attention and that is negatively impacted by the lack of efficiency in the organizations. Nevertheless, the poor outcome of the adoption of digital tools in healthcare is usually one of the reasons why medical practices result in lack of patient satisfaction. The adoption of digital tools benefits healthcare organizations since it improves their operations and daily practices; and consequently, contributes to better healthcare services provision.
Foreword
The present research was conducted by Silvia Orejuela and Estefania Toledo; who are students of Uppsala University and belong to the Industrial Management and Innovation program. The research was developed during the spring semester of 2020. The process of writing consisted of a progressive and iterative workload where both students were able to participate and agree on each section. Each one of the researchers has reviewed and approved each section of the document.
Moreover, the whole process has been supervised, revised and approved by Anders Brantnell, the subject reader of this thesis, and whom the researchers express their gratitude for the constructive discussion and positive feedback and support.
The research was conducted in collaboration with a consultancy company, located in Stockholm Sweden. Through the process, the researchers had a great support of the consultancy company staff, particularly developing the data collection, with the special participation of Anette Cederberg, Viktoria Loo Skyman and Kristina Langhammer, and who we are very grateful to. Their support has been crucial for identifying the right path and making the best decisions to move forward with this research.
Uppsala, 11th June 2020
Table of Contents TABLE OF CONTENTS ... IV LIST OF TABLES ... VI 1. INTRODUCTION ... 1 1.1. PROBLEMATIZATION ... 1 1.2. PURPOSE STATEMENTS ... 2 1.3. RESEARCH QUESTION ... 3 1.4. RESEARCH FRAMEWORK ... 3 2. LITERATURE REVIEW ... 4 2.1. IMPLEMENTATION SCIENCE ... 4
2.2. THEORETICAL FRAMEWORKS FOR IMPLEMENTATION ... 4
2.3. BARRIERS AND FACILITATORS IN IMPLEMENTATION ... 6
2.3.1. The structural level ... 8
2.3.2. The organizational level ... 9
2.3.3. The provider level ... 10
2.3.4. The innovation level ... 11
2.4. BARRIERS AND FACILITATORS IN IMPLEMENTATION FROM MANAGERS PERSPECTIVE 13 2.4.1. The structural level ... 14
2.4.2. The organizational level ... 15
2.4.3. The provider level ... 15
2.4.4. The innovation level ... 16
2.5. SUCCESS CRITERIA IN IMPLEMENTATION ... 17
3. METHODS ... 22
3.1. RESEARCH STRATEGY:QUALITATIVE RESEARCH ... 22
3.2. RESEARCH DESIGN:CASE STUDY ... 24
3.3. SAMPLING METHOD ... 25
3.3.1. Purposive/ Convenience Sampling ... 25
3.3.2. General Sampling Description ... 26
3.4. QUALITATIVE INTERVIEWING ... 27
3.4.2. Interview Guide ... 28
3.5. DATA ANALYSIS METHOD:THEMATIC ANALYSIS ... 28
3.5.1. Data Analysis Process ... 30
3.6. RELIABILITY AND VALIDITY ... 31
3.7. RESEARCH ETHICS ... 32
3.8. LIMITATIONS ... 33
4. RESULTS ... 34
4.1. THEME:BARRIERS AND FACILITATORS IN IMPLEMENTATION ... 34
4.1.1. Management ... 34
4.1.2. Communication ... 35
4.1.3. Education ... 36
4.1.4. Human factors ... 37
4.1.5. Non-repetitive Findings ... 37
4.2. THEME:SUCCESS CRITERIA IN IMPLEMENTATION ... 38
4.2.1. Gains for Managers ... 38
4.2.2. Gains for Users ... 39
5. DISCUSSION ... 40
5.1. MANAGEMENT ... 40
5.2. COMMUNICATION ... 41
5.3. EDUCATION ... 42
5.4. HUMAN FACTORS ... 43
5.5. GAINS FOR MANAGERS ... 43
5.6. GAINS FOR USERS ... 44
6. CONCLUSIONS ... 45
REFERENCES ... 48
List of Tables
Table 1. Target Group Barriers or Facilitators ... 5
Table 2. Barriers and Facilitators in Implementation ... 7
Table 3. Barriers and Facilitators in Implementation from managers perspective ... 13
Table 4. Success criteria in Implementation ... 18
Table 5. Outcomes to evaluate a successful implementation ... 19
Table 6. Method General Description ... 22
Table 7. Purposive/ Convenience Sample Description ... 25
Table 8. General Participants Description ... 27
Table 9. Analyzed questions according to themes ... 31
1. Introduction
1.1. Problematization
The growth of the economy has provoked the need for efficiency in modern society (Erlingsdottir & Lindholm, 2013). In this context, healthcare organizations are constantly in the search for more efficient and innovative tools that facilitate the daily tasks for healthcare providers and that improve the experience for patients (Omachonu and Einspruch, 2010). According to Chaudoir et al. (2013) “each year, billions of dollars are spent in countries around the world to support the development of evidence-based health innovation interventions, practices and guidelines designed to improve human health” (p. 2). With the aim of meeting the demands for innovative tools and increased efficiency of healthcare, eHealth arises as an alternative; which refers to the use of digital solutions in healthcare. According to The World Health Organizations, eHealth is defined as “the cost-effective and secure use of information communication technologies (ICT) in support of health and health-related fields, including health-care services, healthcare surveillance, healthcare literature, and healthcare education, knowledge and research” (World Health Organization, 2017). The digitalization in healthcare or eHealth offers new opportunities for the healthcare sector. From the care-giver’s perspective, eHealth can increase the business benefits, speed up the processes and the efficiency of the care-workers. From the patient's perspective, it improves access to care by giving them increased control over their care (Varsi, 2016). The benefits of both perspectives give healthcare organizations the opportunity to improve the quality of care and increase the efficiency of the care work (European Commission, 2016).
In Sweden, the governmental and public agencies “have promoted the expansion of eHealth over the past five years” (Erlingsdottir & Lindholm, 2013, p. 1). For this reason, in 2013, an “Action Plan” was launched as a “part of a national strategy for eHealth services”, where the aim was to introduce the use of electronic patient records in the healthcare system (Erlingsdottir & Lindholm, 2013). Moreover, in 2017, the Government of Sweden and the Swedish Association of Local Authorities and regions agreed on ‘the Vision for eHealth 2025’. This vision establishes that Sweden will be the best user of the opportunities offered by digitalization and eHealth in the world by 2025 (e-Halsa 2025, 2017).
Based on existing data of the authorities and other national and international organizations, the Follow-up Report 2018 (e-Halsa 2025, 2018) shows that Sweden has successfully developed areas such as prescriptions and e-prescriptions, medical records, healthcare professional access to medical information across municipal and county councils, and pharmacies access to Electronic Expert Support (EES) (e-Halsa 2025, 2018). Moreover, the development of eHealth in Sweden is highly influenced by the regional implementation speed and capacity, and there are other initiatives that are taking place at the regional levels, alone and together with the private sector (e-Halsa 2025, 2018).
to organizations losing the perception of the benefits of eHealth solutions. Therefore, the number of innovations that are taken into healthcare practice is limited (Chaudoir, et. al., 2013). For which, “health service researchers are increasingly recognizing the critical role of implementation science” (Damschroder et al., 2009, p.2).
The implementation science enables change towards the introduction of innovations into practice (Moullin et al., 2015). Therefore, behavioral change has proven to be a key factor for implementation in order to improve healthcare and its outcomes (Cane et al., 2012). The evolution of implementation science is tightly linked to numerous organizational and individual factors influencing healthcare workers’ behavior (Cane et al., 2012). With this purpose, multiple frameworks have been developed; which are constructed around the ‘barriers and enablers or determinants of practice’ of the implementation (Moullin, et al., 2015). If the organization is interested in implementing a particular innovation, they must decide on a framework for the innovation to be implemented (Chaudoir et al., 2013). These frameworks seek to provide researchers, policy-makers, health administrators, and practitioners guidance for their implementation efforts (Moullin et al., 2015).
In order to support the vision that Sweden has developed towards eHealth for 2025, deeper research is needed in multiple aspects and stages of the implementation. Therefore, this research seeks to enable healthcare organizations to embrace eHealth solutions and its benefits, by identifying the barriers and facilitators experienced by project managers during the implementation projects of innovations in healthcare. Furthermore, the exposed lack of clarity, conceptualization and agreement in the literature and industry towards the measures to evaluate the success, requires clarification of concrete criteria in order to assess it. Therefore, this study aims at providing measures of success derived from the outcomes of implementation projects.
1.2. Purpose Statements
1.3. Research Question
● What are the barriers and facilitators that project managers face through the implementation of eHealth solutions in healthcare organizations?
● What criteria do project managers consider for assessing success inside an implementation project in healthcare organizations?
In order to address the proposed research questions, this study utilizes a qualitative approach to generate a deeper understanding of barriers and facilitators and criteria for assessing success in implementation in healthcare. Therefore, the study develops a case study of a private consultancy company in healthcare, based in Stockholm, Sweden. Moreover, in order to gain relevant insights for the study, a total of ten project managers, who belong to the mentioned company, are interviewed. These semi-structured interviews are guided by an interview guide, which was designed considering the most relevant issues for the study (See Appendix C). Furthermore, the interviews are performed through an iterative process, which allows modifications of aspects that do not provide satisfactory knowledge to address the research questions (See Appendix D). Finally, the empirical findings are analyzed by using thematic analysis, a commonly used method in qualitative research.
1.4. Research Framework
2. Literature Review
In this section, the literature review of this research is presented. The emphasis consisted of the barriers and facilitators of implementation science, as well as, the criteria utilized in order to measure the success of the implementation projects. Despite the extension of the coverage of implementation science, it still provides a consistent base to understand the challenges faced by the healthcare sector in the implementation of digital solutions. The search was done through the use of different journals and databases, such as Implementation Science, Google Scholar, Science Direct, and Pro Quest. Moreover, the articles were selected according to the relevance of authors within the implementation science field.
2.1. Implementation Science
The starting point is the evaluation of the concept of implementation. Implementation is widely used but still inconsistent when considering its definition in the literature (Damschroder et al., 2009). The general concept ‘implementation’ has been defined by Birken et al., (2012) as: “the transition period during which targeted organizational members ideally become increasingly skillful, consistent, and committed in their use of an innovation” (Birken et al., 2012, p. 2) in order to be critical towards the fulfillment of its purpose. In the case of Klein and Sorra (2006) (quoted by Damschroder et al., 2009), it is “the means by which an intervention is assimilated into an organization(...), the critical gateway between an organizational decision to adopt an intervention and the routine use of that intervention” (p. 3). Despite the wide range of definitions, it can be stated that they provide a good base for understanding the broad scope of circumstances in which implementation can happen and the multiple characteristics that the “context” can have (Damschroder et al., 2009).
The proliferation of innovations in the healthcare system regarding “enhancing life expectancy, quality of life, diagnostic and treatment options”, has increased the cost and demand for efficiency (Omachonu and Einspruch, 2010, p.1). Since implementation science has the purpose of bringing innovations to practice (Moullin et al., 2015), health service researchers recognize its critical role (Damschroder et al., 2009). Implementation science has developed multiple frameworks, which are constructed around the ‘barriers and enablers or determinants of practice’ of the implementation. These frameworks seek to provide researchers, policy-makers, health administrators, and practitioners guidance for their implementation efforts. In this context, implementation science can make a difference in the outcome through a designed and well-prepared implementation plan with a variety of interventions based on the evidence (Grol, 2001).
2.2. Theoretical Frameworks for Implementation
implementation of innovative tools in healthcare (Moullin et al., 2015). The construction of frameworks seeks to provide the foundation to build up studies (Omachonu et al., 2010).
In this context, Grol and Grimshaw (1999) propose an alternative framework to categorize the barriers and facilitators for implementation according to the group which they impact. The authors divide potential barriers and facilitators into three different segments that are developed around the target group setting:
Table 1. Target Group Barriers or Facilitators
Target Group Barriers or Facilitators (Adapted from Grol and Grimshaw, 1999)
The Individual Clinician Knowledge Skills Attitudes
Habits and Routines Personality
The Social Context Reactions and expectations:
● Of the patient
● Of the colleagues
● Of key persons in the network
● Of authorities
The Organizational Context Available resources Organization:
● Climate
● Structure
● Processes
The purpose of this categorization, according to the authors, is to create preventive strategies. Therefore, it should introduce a deep understanding of the target group and its setting for the decision-makers of the implementation projects.
by members of that community” allowed to create the base for CFIR, defined as a comprehensive framework. This framework contains a list of aspects, both positive and negative, that are believed to influence implementation (Damschroder et al., 2009)
The normalization process model seeks to identify and describe factors that promote or inhibit the implementation (May et al., 2007). The model assesses the possibility of a complex intervention to become incorporated in the routine (May et al., 2007). The aim behind the development of the normalization model is to provide explanations for the “phenomena revealed by empirical investigation” (May et al., 2007). The model proposes three components for an adequate description of the theory, starting by: 1) an accurate description, which aims at identifying the taxonomy “or set of definitions that enable the identification, differentiation, and codification of the qualities and properties of cases and classes of phenomena” to be followed by a 2) systematic explanation and the 3) Knowledge claims (May et al., 2007, p.7).
Another categorization is presented by Chaudoir et al. (2013). Since it has been challenging to assess the constructs that can compromise the success of an implementation, the author illustrates a synthesized classification of the causal factors of the unpredictable outcomes of implementation. These factors aim at providing a guide in the measure of the implementation outcomes in four levels: 1) the first level is structural, 2) the second level is the organizational, 3) on the third level, the relationship patient-provider is analyzed, the authors call it “provider-level factor” and finally, 4) the fourth and last level of the causal factors focuses on the innovation (Chaudoir et al., 2013). Despite the attempts of creating general frameworks to facilitate implementation (Chaudoir et al., 2013), implementation science still faces barriers and facilitators.
2.3. Barriers and Facilitators in Implementation
At this point, it is important to clarify how the terms barriers and facilitators are understood within implementation science. On one side, in their paper Chaudoir et al. (2013) define the term barrier as the “lack of agreement regarding constructs hypothesized to affect implementation success and identifiable measures of these constructs” (p. 1). Moreover, barriers are understood as those factors, problems, situations, perceived by different parties involved in the implementation project, that prevent, or even preclude, the opportunity to achieve a successful implementation outcome. On the contrary, in the Oxford Learner's Dictionary of Academic English (OLDAE) (2020), the term facilitator is defined as “a thing that helps a process take place”. Therefore, it could be said that, facilitators, the same as barriers, are factors, features, situations present in the implementation project, but instead, they enable or boost the way to success. As previously mentioned, this section describes the barriers and facilitators identified in the literature revised in this research.
Table 2. Barriers and Facilitators in Implementation
Barriers and Facilitators in Implementation
Implementation
Levels Barriers and Facilitators
Structural Level
Misinformation of stakeholders' roles and responsibilities Lack of awareness over middle manager role
Involvement of key personnel from all organizational levels Modification in organizational structure
A detailed systematic plan of the implementation
Organizational Level
Effective leadership Resistance to change Positive work attitude
Lack of satisfaction and motivation of the staff Usage of opinion leaders
Communication
Transparent access to information all over the organization
Provider Level
Uncertainty about change promotion The motivation for behavior change Creation of tailored strategies
Multiple behaviors and types of people
Understanding of staff and organization context
Feedback and audit of the performance of the healthcare staff
Innovation Level
Lack of training and education Skills and needed support
Usage of didactic intervention and passive educational approaches The high complexity of the innovation
Compatibility of the innovation
Lack of agreement towards the need for the implementation
2.3.1. The structural level
The structural level refers to the external structure of the socio-cultural context of a specific organization, involving aspects such as physical, environmental, political and social climate, public policies, and economic climate (Chaudoir et al., 2013). Therefore, the barriers or facilitators with common aspects to this level, are presented:
For the structural level, it is necessary to evaluate the impact of the different stakeholders in the implementation, as well as, their roles and responsibilities. Nevertheless, there has been evidenced misinformation over the role of certain participants, which leads to the lack of effective care and practice. Birken et al. (2015) emphasize the importance of managers and their influence in the implementation processes. From one perspective top managers are a crucial part of the implementation processes since they hold the responsibility to help overcome the challenges of implementation and influence directly the middle managers.
From another perspective, there is a lack of awareness over the influence of middle managers (Birken et al., 2012). Middle managers “have received little attention in extant health services research, yet they may have a key role in healthcare innovation implementation” (Birken et al., 2012, p. 1). Nowadays, the responsibility of middle managers has grown since the teamwork design has gained popularity; therefore, their influence over the implementation outcomes has also risen (Birken, S.A., et. al., 2015). Their importance relies on the fact that their tasks include the introduction of innovation to the healthcare system in order to facilitate the adaptation process for the staff (Birken et al., 2012).
Moreover, physicians should be natural leaders in healthcare since they are change agents who influence others to follow the desired course of action (Parkin, 2009). Therefore, it is important to examine implementation from their perspective (Jacobs et al., 2015). Despite the level of autonomy, they might have, they belong to the organization and play a significant role in the processes, their willingness to participate or their desire to implement an innovation could impede the ability to do it (Jacobs et al., 2015). Regarding this matter, Øvretveit et al. (2012) states that “the clinical leaders are the ones who play an important role in the successful development of service innovations, instead of managers” (p. 237). Furthermore, they argue that “significant involvement of key personnel from all organizational levels” performs as a facilitator, as well as, the continuous support from the senior management in all stages of the project (Øvretveit et al., 2012). Nevertheless, physicians often lack consensus building and emotional intelligence (Naylor 2006 and McHugh et al. 2007, cited by Parkin, 2009). An example of leadership failure is the conflict between leadership goals and workforce goals. The physicians suggest that in some cases the organization’s goals might not be aligned to the goals of their role inside the same (Jacobs et al., 2015).
represented a challenge for implementation in many ways. In one way, some researchers reflect on the perception of the managers about it. According to managers modifications to the structure of organizations could facilitate the implementation of an innovation (Grol and Grimshaw, 1999). Another way refers to the fact that: the organization “has access to expertise to help with the changes” (Øvretveit et al., 2012, p. 242).
All the mentioned specific barriers and facilitators for implementation, have the purpose of leading a concrete path to achieve a successful outcome of the project. Specifically, authors like Øvretveit et al., (2012) reflect on certain factors that can increase the possibility of success in implementation, which is the case for “the presence of a detailed systematic plan and an effective implementation project team” (p. 243).
2.3.2. The organizational level
According to Chaudoir et al., (2013) the organizational level defines the aspects of the organization where the innovation is being implemented. These aspects refer specifically to how much value does the organization give to the innovation, the leadership effectiveness, the culture or climate and the rewards to guarantee employee morale or satisfaction (Chaudoir et al., 2013). Moreover, the barriers or facilitators with common characteristics are presented:
Considering the relevance of the climate of the organization for the second level, Roger Gill (2002) analyzes the implementation of changes by evaluating aspects such as the introduction of a new routine or tool for the work environment. The author argues that changes require leadership in order to be successfully introduced and sustained. In this context, according to The Leadership Truth, leadership “is about showing the way: using personal power to win the hearts and minds of people to work together towards a common goal (Gill, 2001 cited by Gill, 2002). The empirical evidence suggests that effective leadership supports implementation processes since it promotes a healthy and functional team (Aarons et al., 2015). Jacobs et al. (2015) also emphasizes the negative impact of unsustainable leadership and resistance to change, since they can impact the budget, time consumption and ultimately patient care.
Moreover, leadership has also been associated with higher client satisfaction; therefore, it is fundamental to promote a positive work attitude which can result in the higher commitment of the staff (Aarons et al., 2015). Nevertheless, the lack of satisfaction and motivation of the staff can also affect the prolonged use of the tool and it is linked to the lack of resources for the implementation (Grol and Grimshaw, 1999). Parallelly, to stimulate acceptance in the target group, as well as to raise awareness over the innovation in the adoption stage, the authors argue about the use of opinion leaders due to their social influence (Grol and Grimshaw, 1999). Still, this is constantly questioned due to the lack of evidence about their performance (Grol and Grimshaw, 1999).
management goals, vision and strategy. Communication alludes to maintain cooperative human relations, training, problem-solving, increasing the speed and flexibility of business processes; and finally, workload (Lorden et al., 2014). Another barrier related to communication is presented by Birken et al., (2012), who assert that information gaps represent a challenge for implementation. Still, middle managers have the possibility to perform as facilitators. They have “the potential to bridge informational gaps that might otherwise impede innovation implementation” (Birken et al., 2012, p.2). This, by helping to manage the demands, for instance, the increased time for healthcare staff to use the innovation associated with the implementation (Øvretveit et al., 2012), align incentives, transcend professional barriers, and identify priorities to promote innovation implementation (Birken et al., 2015).
2.3.3. The provider level
The third level refers to the attitudes, motivation, beliefs, personalities and behavioral control, for implementing, of every user of the innovation (Chaudoir et al., 2013). The provider-level evaluates the relationship between the patient and the service provider (Chaudoir et al., 2013). Therefore, the barriers or facilitators related to these aspects are presented:
Behavioral change has proven to be a key factor in improving healthcare and its outcomes (Cane et al., 2012). Nevertheless, the different behaviors of individuals represent a challenge for implementation due to the level of uncertainty about the best way to promote change inside the organization. Moreover, implementation science evolution is tightly linked to the variable and numerous organizational and individual factors influencing healthcare workers’ behavior (Cane et al., 2012). Cane et al., (2012), rely on the importance of behavioral change in its ability to improve the implementation of evidence-based practices. The existence of multiple behaviors and types of people complicates the possibility of performing effective implementations (Cane et al., 2012). Nevertheless, despite the extensive focus on behavioral change, there is rarely an association with the evaluation and design of implementation interventions.
Seeking to facilitate implementation processes, researchers have argued different approaches to motivate the behavior change inside organizations. There are different approaches, some based on scientific evidence, other speculative, that contribute to the understanding of professional behavior and behavior change. These approaches clarify the circumstances or conditions that can increase the potential of dissemination and implementation strategies (Grol and Grimshaw, 1999).
individuals (i.e. leaders, scientists and academics) in a social network. 6) The organizational approach does not focus on individuals but on settling the adequate conditions for the change; it emphasizes the organizational and structural factors that could hinder the change. 7) The coercive approach utilizes pressure and control as a method to implement, it includes the creation of laws, regulations, financial consequences and external pressure to fix habits and routines (Grol and Grimshaw, 1999).
The presented approaches can provide guidance to identify barriers for the implementation since they clarify the conditions of the organization (Grol and Grimshaw, 1999). Also, selecting the appropriate approach requires a deep understanding of the staff, due to the fact that the application of an inadequate approach could trigger unwanted reactions among them. In this matter, a better understanding of the context of the organization acts as a base for the creation of tailored “interventions”, which have proven to facilitate the implementation (Grol and Grimshaw, 1999). The tailored “interventions” should be settled in a previous assessment according to the insights of the selected group or organization (Grol and Grimshaw, 1999). Moreover, addressing specific barriers through these interventions is more likely to lead to the introduction of changes into practice (Grol and Grimshaw, 1999). The level of adoption of these changes and the impact in the clinician’s daily routines is highly linked to behavioral change, and to the early preparation of the group for the change (Grol and Grimshaw, 1999).
Grol and Grimshaw (1999) also refer to the importance of feedback and audit of the performance of the healthcare staff. These aspects enhance the willingness and confidence of healthcare professionals, especially when they are supported by the intervention of the patients raising issues (Grol and Grimshaw, 1999). Contrarily, the distrust and lack of endorsement of medical practices from the patient can result in the “poor health outcome of the implementation” (Chaudoir et al., 2013).
2.3.4. The innovation level
The innovation level evaluates the quality of existing practices, referring to previous knowledge or experience, as well as, the support and need over the innovation (Chaudoir et al., 2013). The barriers or facilitators with common characteristics to this level are presented:
A detractor for the implementation mentioned by Jacobs et al. (2015) is the lack of training towards the implemented innovation. The authors claim that, when members have the skills and support needed, it leads to a stronger implementation climate and effectiveness (Jacobs et al., 2015). For the mentioned statement, Grol and Grimshaw (1999) recommend didactic interventions, especially when dealing with negative attitudes of the healthcare professionals, instead of having passive educational approaches, such as mailing guidelines and publishing findings. The passive educational approaches are ineffective to change professional behavior (Grol and Grimshaw, 1999).
Grimshaw (2003) propose that better compatibility of the innovation with existing values inside the organization can result in less complexity for the decision-making process. By contrast, the authors claim that the lack of agreement between all the involved parties, over the ideal framework to deploy the implementation, can lead to the opposite result (Grol and Grimshaw, 1999). In the same line, Øvretveit et al., (2012) also perceived as a facilitator the compatibility of the innovation regarding existing skill mix, work practices and strategic goals. Nevertheless, the progress of the integration of changes in the health and social service can be slowed due to the lack of agreement from the operational level staff towards the need for the innovation to be implemented (Øvretveit et al., 2012).
The evaluation of the multiple barriers and facilitators for implementation, according to the four levels proposed by Chaudoir et al. (2013), evidenced multiple gaps in the literature. These gaps represent a challenge since they are important aspects of the implementation. In this matter, there is not enough literature regarding the impact of the socio-economic and political climate in the implementation. Nevertheless, Chaudoir et al. (2013) elaborates on these aspects as a part of the structural level in the framework. Moreover, the effects of the awareness over the value of the innovation for the climate and culture of the organization are not explicit. Therefore, there is not enough knowledge about the way in which awareness improves the general setting for the implementation.
Regarding the third level, the provider level, some authors, such as Grol and Grimshaw (1999) relate patient feedback as a source of motivation. Nevertheless, the lack of details about the impact of a highly motivated staff, do not provide enough clarification on its benefits for the implementation climate, and the sources to achieve it. Other aspects of the relationship between the provider patients are relevant but also not covered enough in the literature. This is the case of the effect that the lack of endorsement of the patients has on the providers. It is important to evaluate this effect in a more detailed way. The patients’ role, as end-users and consequently stakeholders, targets them as a priority inside the implementation; therefore, it is beneficial to identify the ways in which they can facilitate the implementation.
Furthermore, Grol and Grimshaw (1999) attempt to provide approaches, which allow a smooth transition to the needed change. Nevertheless, the lack of evidence, mentioned by the authors, provides merely a circumstantial certainty about the effects of these approaches inside the organization. Therefore, the creation of ‘tailored strategies’ for organizations is conditioned by the unawareness over the effects of the utilized approach.
2.4. Barriers and Facilitators in Implementation from Managers Perspective
According to Birken et al. (2012), there is evidence that middle managers may limit implementation effectiveness. Middle managers hold direct interaction with the end-users of the implementation). Therefore, they hold power over the information flow. It is a constant threat for the organization that middle managers choose to express negatively about the innovation since they would prevent frontline employees from engaging it. Due to the relevance of middle managers, it is important to assess the existing literature and its focus on the identification and description of the barriers and facilitators from their perspective. The barriers and facilitators based on managers perspective are presented in Table 3:
Table 3. Barriers and Facilitators in Implementation from managers perspective
Barriers and Facilitators in Implementation from managers perspective
Implementation Levels Barriers and facilitators
Structural Level
Prioritization of implementation projects
Administration of incentives for increasing motivation Lack of management involvement
Flat organizational structure
Giving authority and empowerment of middle managers Workload
Lack of available resources
Organizational Level
Healthcare conservative culture
High professionalized, ambiguous and complex environment Open communication
Establishment of an implementation team Physician influential power
Provider Level
Encouragement of frontline employees Attitudes toward the implementation Informal feedback
Innovation Level
Privacy and security of sensitive information from the patients Technical limitations of digital solution
Lack of IT abilities from healthcare staff Education and training
2.4.1. The structural level
This level introduces the factors that are relevant to the structural level and that are not evidenced in the previous review. Therefore, it evaluates the responsibilities and roles of the different levels of management within the implementation. Nevertheless, adding to what has been stated, managers argue for the need of prioritization of the implementation inside the organization from the top management (Birken et al., 2012). The lack of prioritization from top management can compromise the engagement of the staff with activities associated with the implementation (Varsi, 2016). The responsibilities of top management also recall for the administration of incentives, which can be used to increase motivation (Birken, 2011). The challenge of increasing middle managers’ motivation can be mitigated by the recognition of a job well-done by top management (Birken, 2011). Top managers hold the responsibility of assessing the conditions of middle managers’ performance, to increase their commitment to the implementation of the innovation. Furthermore, it is critical for the implementation of complex innovations to rely on management support (Chuang et al., 2011) and commitment (Birken et al., 2012). A way to achieve the full involvement of managers with the programs, which has proven to improve significantly the success of the implementation, is by allocating resources to address their needs (Chuang et al., 2011). Contrarily, the lack of involvement of managers from the planning stage reduces their commitment to the implementation process (Varsi, 2016). The reduction of the commitment among managers is perceived as a barrier since it is linked to the efficiency of operations, implementation speed, and positive organizational outcomes (Birken et al., 2012)
solution (Kooij et al., 2018), high start-up costs, maintenance costs, and uncertainty about return on investment (McGinn, 2011).
2.4.2. The organizational level
The barriers and facilitators towards communication have been documented in the implementation sciences. It is important to address the communication issues perceived by managers, due to the constant interaction that they hold during the implementation with all the stakeholders. Also, large organizations represent more participants in the projects, which difficulties the achievement of good information flow (Varsi, 2016). Moreover, open communication with top management has evidenced to be highly relevant for implementation success; nevertheless, managers seek more regular and informal communication in order to facilitate their performance (Birken, 2011). Open and regular communication between middle and top management reduces the professional’s misunderstanding and raises awareness and commitment to innovation (Birken, 2011; Kooij et al., 2018).
Considering that the organizational level involves the culture and climate of the organization, it is also relevant to evaluate these aspects from the manager’s perspective. Implementing innovations requires cognitive, emotional, physical, and spiritual demands from the employees (Birken et al., 2012). But often aspects of the organization such as incentives, professional barriers, competing priorities, and inertia are not evaluated towards the objective (Birken et al., 2012). Therefore, the healthcare culture has been identified as a critical factor while implementing innovations. Considering that, the healthcare sector has been characterized for having a conservative culture (Kooij et al., 2018); the healthcare staff is often slow in adopting new things, and they present an aversion to doing it (Varsi, 2016). Moreover, the healthcare culture relies on a highly professionalized, ambiguous, and complex environment, which represents another barrier for an implementation process (Aij et al., 2013). The complexity of the environment is further enhanced by significant variation in the measures of healthcare to assess quality in aspects such as: safety climate and patient experience (Birken et al., 2012).
According to managers, the establishment of a well-functioning implementation team is another factor that facilitates implementation (Varsi, 2016); since it would ensure the health care staff’s fidelity and the sustainability of the implementation (Chuang et al., 2011). Nevertheless, when implementing innovations in healthcare organizations, the influential power holding by physicians regarding the adoption of new solutions, often results in slowing down the implementation process (Varsi, 2016; Houser and Johnson, 2008). Due to the importance of the implementation team, it must be dedicated to coordinate and facilitate the implementation activities (Varsi, 2016). In order to create the implementation team, managers recommend the recruitment of formal implementation leaders (Varsi, 2016).
2.4.3. The provider level
2011). The importance of frontline employees relies on their direct interaction with the innovation (Kirchner et al., 2012). Therefore, successful implementation requires the participation and motivation of the stakeholders whom interventions would affect (Kirchner et al., 2012).
Other aspects such as personal attitudes (knowledge and beliefs of healthcare staff) toward the implementation could be perceived in two opposite ways (Varsi, 2016). In one way, it is a facilitator if the healthcare staff have a positive perception of the implementation (Varsi, 2016). On the other hand, negative personnel attitudes can act as a critical barrier, since they promote resistance against the implementation (Varsi, 2016).
In the general assessment regarding the barriers and facilitators within implementation sciences, Grol and Grimshaw (1999) highlight feedback as a facilitator. When evaluating the manager’s perspective, the importance of feedback is also mentioned. Nevertheless, middle managers emphasize the preference for informal feedback (Birken, 2011). Managers perceive that informality was more valuable than formal performance reviews; since it allows them to resolve issues before it became significant to report during formal performance reviews (Birken, 2011).
2.4.4. The innovation level
Managers have identified barriers and facilitators related directly to the tool intended to be implemented. An important related barrier is the privacy and security of sensitive information from the patients (Kooij et al., 2018). According to managers, healthcare staff is concerned since the use of digital tools may compromise the security or confidentiality of personal and patient information (McGinn, 2011). Regarding the tool, managers state that other aspects such as: the tools technical limitations regarding software or hardware; system problems (i.e. slow system speed, unplanned downtime, and so on); and system obsolescence, also represent barriers for the implementation (McGinn, 2011).
The reviewed literature about barriers and facilitators for implementation evidenced multiple gaps. Further research is needed emphasizing the different contexts, considering the type of organization, size, service that they provide and the tool to implement (Varsi, 2016). Moreover, the different stakeholders also represent a challenge for implementation due to their different perspectives. There is a variety of professionals in healthcare with unique views of what are the needs of implementation (Kirchner et al., 2012; McGinn, 2011).
Moreover, the literature confirms what is stated by Birken et al. (2012) regarding the level of detail in the literature about middle managers. The actions that middle managers can take to facilitate the implementation of innovations are limited and seldom mentioned. There is also a lack of clarification about who the actors are behind ‘middle managers’; in some cases, the literature refers to ‘middle managers’ as managers inside the healthcare organizations, but these managers are not necessarily inherent to the implementation team.
Finally, compared to the general assessment of the barriers and facilitators in implementation sciences, the manager's perspective does not provide enough information about either motivation or education. The impact of education and motivation is quite relevant for successful implementation and are big allies to facilitate the process of adoption. Motivation and education are tightly related to behavioral change. Authors as Birken et al. (2012) have emphasized that implementation effectiveness depends on the ability to promote the willingness of individuals to implement them. Beside the mentioned gap, Aij et al. (2013) asserts that only 40–50% of the intended actions after training are not, or partially, implemented; this fact exposes the need for further research or studies regarding training and education within the implementation. Also, Varsi (2016) claims that there is a need for further research regarding the most effective data collection methods for identifying potential facilitators and barriers.
2.5. Success Criteria in Implementation
According to Jacobs et al. (2015), the failure rates for implementing complex innovations in healthcare organizations “range from 30% to 90% depending on the scope of the organizational change involved, the definition of failure, and the criteria to judge it” (p. 2). In this regard, May et al. (2007) highlight the importance of developing evaluative processes that inform about the implementation success, in order to achieve workable and integrated healthcare practices. Moreover, Chaudoir et al. (2013) claim that the lack of measures over the success or failure of an implementation process is highly linked to the number of constructs to be considered, referring to factors or “moving parts”. Therefore, at this point, it is important to extend the understanding of the assessment over the measures of success within implementation project outcomes.
The subject of success within implementation projects is complex due to its different and diverse insights. For instance, it depends on stakeholders’ perceptions, circumstantial factors, the project’s characteristics, interdependence with other projects (Varajão, 2016), the phase of the project lifecycle (Jugdev and Muller, 2005), among others. All of them make the understanding of the implementation of the project success difficult, complex and ambiguous. This, since the concept of project implementation success, is a matter of perceptions (Rosacker et al., 2011).
In order to understand the different perceptions of stakeholders about project success, Cooke-Davies, (2002) states that distinctions for the following categories must be drawn; these are: 1) project success, 2) project management success, 3) success criteria and 4) success factors. The first one, relates to the measured overall objectives of the project; while the second one involves the traditional measures of performance of a project, such as: cost, time and quality (Cooke-Davies, 2002). In the same context, Varajão (2016) and Cooke-Davies (2002) distinguish success criteria and success factors. On one hand, success criteria are “the measures used to evaluate the project success” (Varajão, 2016, p. 1100). On the other hand, success factors refer to aspects that influence the likelihood of success (Varajão, 2016).
Table 4 presents a summary of the different success criteria identified in the literature review. As can be seen, these criteria include factors that refer to organization level (i.e. contribution to the firm’s strategic mission) as well as, a more individual level (i.e. personal growth):
Table 4. Success criteria in Implementation
Success Criteria in Implementation
Desired provider behaviors Duration
Measurement of clinical outcomes The satisfaction of end-user’s needs Improvement of the process of care information and service quality
Time, cost and quality Technical performance
Learning from experience Meeting objectives and goals Value (economic returns, an increase of
market share, etc.) Personal growth
Learning as continuous improvement Contribution to the firm’s strategic mission
Adoption Preparation of the organization for the future
Table 5. Outcomes to evaluate a successful implementation
Outcomes to evaluate a successful implementation
Outcome Concept
Acceptability Perception of the stakeholders over how agreeable, palatable, or satisfactory is the implementation
Adoption The intention, decision, or action to utilize an innovation
Appropriateness Perceived fit, relevance, or compatibility of the innovation with a given practice to address a particular issue or problem
Feasibility The extent to which a new treatment, or an innovation, can be successfully used or carried out within a given agency or setting
Fidelity The degree to which an intervention was implemented as it was prescribed in the original protocol as it was intended by the program developers Implementation
Cost
Economic impact of developing the implementation
Penetration The integration of practice within a service setting and its subsystems Sustainability The extent to which a newly implemented treatment is maintained or
institutionalized within a service setting ongoing, stable operations
Within this context, the authors highlight the need to define implementation outcomes, since they serve as indicators of the implementation success (Proctor et. al., 2011). These outcomes serve for the purpose of evaluating and rating specific treatments and the implementation strategy used. Besides the outcomes, there are other aspects to evaluate within an implementation project. Success has been measured in subjective and objective ways. Several authors have encompassed a high focus on factors such as time, cost and quality, as success measures (De Wit, 1988; Belassi and Tukel, 1996; Cooke-Davies, 2002; and Jugdev and Muller, 2005). Nevertheless, Belassi and Tukel (1996) state that in early studies the project was assumed to be a failure if it exceeded its due date, budget, or if its outcomes did not satisfy company’s criteria; however, nowadays it is common to have delays or overall projects’ costs, and still be considered a success (Belassi and Tukel, 1996).
product sales or margins, maximized return on R&D spend, leading directly to the creation of new streams of operating revenue, encourage people to learn and to embed that learning into continuous improvement” as criteria to determine projects success (Cooke-Davies, 2002, p. 5).
Moreover, Nutt (1998) claims that success has been treated as a single outcome; however, the consequences of implementation have many effects that call for multiple measures. As previously mentioned, Nutt (1998) measures success in terms of three different aspects: ‘value’, that comparable to Cooke-Davies (2002) refers to economic returns, an increase of market share, improvement of quality of service and it is used to measure the benefits of the implementation to the organization. The second aspect is ‘adoption’, and is tied with ‘use’, referring to ‘instrumental use’ (Nutt, 1998, p. 222). Finally, ‘duration’ which alludes to “the time from need recognition to the development of a plan [and] the elapsed time from development to full use” (Nutt, 1998, p. 222).
De Wit (1988) exposes that the high tendency to focus on aspects such as cost, time and quality performance can reduce the interest over all the stakeholder’s objectives. Nevertheless, according to Proctor et al. (2011), the implementation success depends on the preferences and priorities of those who shape, deliver and participate in care; therefore, the considerations around a project's success may be differentially salient to various stakeholders. As previously stated, Kash et al. (2014) identify outcomes of a successful process in the healthcare sector according to the clients’ perspective, these are: access to information and service quality and client satisfaction. Moreover, Munns and Bjeirmi (1996) also argue about the satisfaction of the end-user’s needs. However, the author oriented the criteria for the long-term utilization of the project outcome.
For authors as De Wit (1988) “high level of satisfaction concerning the project outcome” for all the stakeholders, concerns not just users and clients, but also the key people in the organization and the project managers. Jugdev and Muller (2005) also support and acknowledge the importance of the client, project team and supporters’ satisfaction to measure the success of a project. Moreover, the evaluation around the client or consumer well-being provides the most important criteria to evaluate the implementation success (Proctor et al., 2011). Considering that, the treatment or service will not be effective if it was not properly implemented (Proctor et al., 2011). It is claimed that there are other appropriate criteria for evaluating success. These include aspects such as: the level to which project objectives have been fulfilled; guaranteeing “the technical performance specification and/or mission to be performed” (De Wit, 1988, p.165). From the same perspective, Jugdev and Muller (2005) also assess project success by meeting objectives and goals, as well as evaluating its technical performance: efficiency of execution; personal growth; value (i.e. positive impact, merit, improved organizational effectiveness).
contractors; and the preparation of the organization for the future (i.e. innovating, and developing core competencies), among others (Jugdev and Muller, 2005).
3. Methods
The following section is a detailed description of all the research methods utilized in the present study. The methods section presents the selected tools and approaches to performing the data collection and data analysis. The following methodology is supported by the motivations for their suitability for this research. In this matter, Table 6 presents a concrete summary with the general description of the selected outline:
Table 6. Method General Description
Method General Description
Research Strategy Qualitative Research
Research Design Case Study (single organization) Data Collection Semi-structured Interviews Sampling Method Non-probability sample
Purposive
Data Analysis Method Thematic Analysis
3.1. Research Strategy: Qualitative Research
In order to choose an appropriate research strategy, it is important to consider how the organizational reality should be studied. For doing that, it is necessary to broach epistemological considerations. These considerations respond to whether the social world could be treated with the same principles as natural science or not (Bryman and Bell, 2011). Epistemological considerations have two positions, namely positivism and interpretivism. Positivism allows the application of natural science methods to the study of social realities, such as senses as warranted knowledge, generation of a hypothesis that can be tested and allow the explanation of laws or gathering of data that allow the explanation of laws (Bryman and Bell, 2011). On the other hand, interpretivism establishes that the subject matter of social science is different from natural science; and therefore, it requires procedures that encompass the differentiation between humans and nature (Bryman and Bell, 2011).
Given the epistemological and ontological considerations, it is possible to talk about research strategies, namely quantitative and qualitative strategy. The quantitative strategy emphasizes the quantification and the collection of data and places importance in the testing of theories (Bryman and Bell, 2011). This strategy incorporates the natural scientific model and understands social reality as external and objective (Bryman and Bell, 2011). On the other hand, a qualitative strategy is focused on the analysis of words, placing more attention in the generation of theory. Therefore, it emphasizes in the individuals’ interpretation of the social world (Bryman and Bell, 2011). As it has been mentioned, the present research study is exploratory by nature and seeks for understanding a social phenomenon related to the implementation of eHealth solutions; in other words, it tries to understand managers’ perceptions within a complex social context, which encompass different actors, processes, organizational structures, as it happens in healthcare organizations. On one hand, it could be said that the study has an interpretive epistemological position since it looks to comprehend a social situation based on the interpretation of research participants, specifically managers' viewpoints (Bryman and Bell, 2011). On the other hand, the studied social situation depends on the interpretation of research participants, and consequently, the study is based on a constructionist ontological position. Both factors lead to the present research study to have a qualitative research strategy (Bryman and Bell, 2011).
The qualitative methods are a consistent tool, its use has grown with the developments of science. Its importance departs from the need for an in-depth understanding of certain matters, as well as, the possibility to evaluate the context and the complexity of social change (Sofaer, 2002). Qualitative research emphasizes words and proposes an inductive view, where the theory can be generated out of the research (Bryman and Bell, 2011).
3.2. Research Design: Case Study
Qualitative and quantitative methods propose several types of research design, such as: experimental design; cross-sectional or social survey design; longitudinal design; case study design; and comparative design (Bryman and Bell, 2011).
Considering certain characteristics, some designs are more suitable to quantitative research, in the case of experimental design, they are unusual in business and management research since it does not allow to achieve the needed level of control when dealing with organizational behavior, which defines it as unsuitable for this research, still, its advantage compared to other designs is clear due to the provided confidence over the causal findings (Bryman and Bell, 2011). Moreover, the cross-sectional design is highly linked to a social survey, that can be associated with questionnaires and structured interviews. Also, this design usually requires a collection of quantifiable data on more than one case. Both experimental and cross-sectional design, seek for a deductive method to relate theory and research (Bryman and Bell, 2011).
According to Pettigrew (1990), a longitudinal design is commonly used for understanding organizations, which makes it appropriate for business and management research. However, it demands a high cost and time to develop, which implies a non-suitability of this methodology. Despite the advantages of the previous designs, a case study is characteristic of qualitative research to create theory (Beverland and Lindgreen, 2010). It has been used for researchers due to the flexibility of the methodology towards its suitability for the study (Beverland and Lindgreen, 2010). Nevertheless, some authors suggest that the criteria over the quality of the work tend to be questioned in single study cases, for which the way in how quality is addressed is determinant to produce richer insights and better theory (Beverland and Lindgreen, 2010).
As a contrast, the comparative design, as its name suggests, allows the use of “two identical methods of two or more contrasting cases” (p. 63), to promote comparisons and contrasts of the situations (Bryman and Bell, 2011). It is acceptable for both qualitative and quantitative research (Bryman and Bell, 2011), which allows considering it an appropriate tool for this research, nevertheless, the single organization available limits the possibility to establish comparisons between more cases.
Moreover, a case study suggests a detailed analysis of a single case, which is implied thanks to the particular nature of the case, characterized for conceiving a single organization, as well as, a single location and a high focus on a “situation or system, an entity with a purpose” (Bryman and Bell, 2011). On the other hand, the aim of generating in-depth insights over the thematic is aligned to the study cases general purpose while acknowledging the unique features of the case. The case of the study itself suggests being instrumental since it focuses on the use of a case to understand a broader issue (Bryman and Bell, 2011), with the expectation of generalizing the findings.
team. This team serves the public and private healthcare sector with coverage on a national level, with The Swedish Association of Local Authorities and Regions (SALAR), as well as all the twenty-one regions in Sweden. ‘The subject’ operates in the Swedish healthcare market, which in 2019 had revenue of approximately $56.3 billion (MarketResearch, 2020); for the same year, the company reached a revenue of 37.226K SEK 1. Their customer base is constituted by private
caregivers, municipalities and regions. In addition, the potential competitors are organizations that provide services such as interim management, eHealth consultancy, or maintenance of the Stockholm region e-Health Record system (EHR). Even though there are several companies that offer one of the mentioned services, ‘the subject’ of this research has the uniqueness of offering the combination of all the mentioned services.
The ‘company A’ has thirty consultants employed, everyone has a medical background of some category, such as a registered nurse or physiotherapist. Furthermore, its Interim Managers and Project Managers have leadership experience in the healthcare sector. The ‘company A’ is also linked with IT-architects, solutions-architects, software developers and scrum managers.
‘The subject’ owns a wide customer segment that goes from regions and regional councils to municipalities in Sweden, and private caregivers in Stockholm and authorities. The ‘company A’ acknowledges the importance of their role regarding implementation matters when transforming into a new system, which is supported by their customer’s segment, targets them as an interesting organization to perform a case study that provides an in-depth understanding of the barriers and facilitators in implementation projects of eHealth solutions in healthcare organizations.
3.3. Sampling Method
3.3.1. Purposive/ Convenience Sampling
Table 7 presents a general description of the most relevant aspects of the sampling method of this research, such as the population, the criteria to select the sample, its size and the procedure followed to select it:
Table 7. Purposive/ Convenience Sample Description
Purposive/ Convenience Sampling Description
Population Implementation project managers
Criteria Job title/ Position: Project Managers or Project Leaders Experience in implementation projects in healthcare Sampling procedure: Purposive sampling
Size Ten individuals
In order to get an understanding of the subjects of the present research study, project managers involved in the implementation of eHealth solutions were taken as a population. Furthermore, due to the researchers’ restrictions regarding resources, time and workforce, non-probability sampling is selected as a sampling method. According to Etikan et al. (2016), non-probability sampling is often implemented more quickly and cheaper; therefore, they constitute useful methods for researchers with limitations such as the mentioned ones. In non-probability sampling, subjective methods are used in order to choose which elements are included in the sample (Etikan et al., 2016).
As a second step, the purposive-sampling procedure is used. With this procedure interviewees are selected based on their ability to contribute to the understanding of the research study, meaning their qualities, availability and willingness to provide information (Etikan et al., 2016). The researchers used two criteria for choosing the participants: experience (years) and job title (position). The years of experience working with implementation projects provide the participants with sufficient knowledge that can help to understand the phenomenon of interest. Moreover, the role of managers demands a high level of participation along with all the stages of the implementation, therefore, their perception can provide significant insights for this research. The interviews were planned for around thirty participants, which was reduced to fifteen considering the time constraints. From the group, there were five non-respondents, therefore, ten interviews were conducted. Still, one interview was dismissed due to the poor quality of the recording. Nevertheless, regarding the sample size, it can be said that more attention has been placed on factors such as depth and duration of the interview rather than in sample size since the research seeks to generate an in-depth analysis of the case study (Al-Busaidi, 2008).
3.3.2. General Sampling Description
Table 8. General Participants Description
General Participants Description
Description No. Participants Sample percentage
Gender F 8 80% M 2 20% Experience with Implementation Projects 10 - 20 years 3 30% 20 - 30 years 1 10% 30 - 40 years 3 30% N/a 3 30% Experience as Manager 0 - 1 year 1 10% 1 - 2 years 2 20% 2 - 3 years 3 30% 3 - 4 years 2 20% 4 - 5 years 1 10% N/a 1 10% 3.4. Qualitative Interviewing
Qualitative research offers a variety of techniques and methodologies, nevertheless, interviews are the most common technique used to gather research information (Al-Busaidi, 2008). Qualitative interviewing contains a less structured character, which might affect the validity and reliability of the measurements (Bryman and Bell, 2011). Still, considering the research questions, the general formulation is a suitable base to provide a better understanding of the different perspectives from the interviewees. Furthermore, qualitative interviewing, compared to quantitative methods, seeks to understand the meaning of information or opinions, managing to explore the respondent’s emotions, experiences, and values (Brennen, 2013).
3.4.1. Semi-Structured Interviews
According to some authors, the semi-structured interview is more commonly used in healthcare-related qualitative research due to its flexibility, which promotes the use of open questions that allow exploring experiences and attitudes, as well as, the discovery of new areas and production of richer data (Al-Busaidi, 2008).
