Institutional Theory in Governmental Organizations Literature review

Institutional Theory in Governmental Organizations - Literature review Example This pressure has forced many of them to adopt new strategies such as Institutional Theory and Performance Measurement Systems, in order to overcome this pressure. Factors making Institutional Theory applicable in the Public Sector There has been an increasing pressure, for governmental and other nonprofit organizations to adopt strategies such as Institutional Theory. It is claimed that these new strategies, will make them act more like profit-making organizations than just nonprofit organizations. According to Oliver (1997, p. 697-698), governmental organizations are more vulnerable to all the three types of institutional forces than other profit-making organizations. As he explains, researchers have shown that the susceptibility of public sector organizations to institutional pressures is extremely high due to the many stakeholders and customers that it serves. All this pressure has doomed it highly necessary for the governmental organizations to adopt strategies such as Instituti onal Theory and Performance Measurement. According to Peter and Joseph (2004, p. 283-285), the pressure that the public sector is experiencing, mainly comes from the non-profit organizations that rely on the government for funding. It is argued that non-profit organizations have grown in numbers and have evolved from small-locally owned to large, national owned organizations. Therefore, these organizations are pressuring the governmental sector more. This is because they require more funds to accomplish their elevated goals and sustain their large workforce. The state is another stakeholder that is pressuring the public sector in many countries. According to Brunson and Olsen (1993, p. 44-46), many governmental and nonprofit organizations are owned by the state or the government in many countries. Therefore, it is argued that many governments place a lot of pressure on their organizations, in order to gather popularity from the citizens. As Grafstein (1992, p. 223-225), the governme ntal organizations are also currently facing another pressure from the many customers that they serve. As he points out, many profit-making organizations have been applying the concepts of intuitional theory in their firms, so as to maintain and attract more customers. According to Katz and Khan (1978, p. 147), the services and goods being provided by the private and many other profit-making organizations are far much better compared to the ones provided by the same organizations owned by the government. As Grafstein explains, this has resulted in the governmental organizations’ customers demanding the same quality goods and services as the ones provided in the profit-making organizations. Therefore, it is claimed that many governmental and nonprofit organizations are adopting the Institutional Theory in their institutions to enable them to overcome this pressure.

Can the U.S. Government Still Be Regarded as a Federal System of Essay

Can the U.S. Government Still Be Regarded as a Federal System of Government - Essay Example Across America’s history, federalism has been defined in different ways. Cooperative federalism implies that the two forms of government are to work in collaboration with one another. Dual federalism supposes that the two forms of government are working separate from one another. Creative federalism relates to a combined planning and decision making system amongst the two. Horizontal federalism relates to the interaction and shared programs amongst them while vertical federalism means the conventional systems of federal governance whereby the actions of the central government are considered to be supreme as interpreted by the constitution. Every state in the US is characterized with its own positions relative to legal authority and political importance. Although states are not considered sovereign entities they can assume power and take actions relative to the functions of other governmental set ups (McKAY, 2001). The US Constitution had established division of authority among st the state and federal governments that had initially put restraints on the federal government in areas of foreign policy, defense and the controls over currency and commerce amongst states. Over time, this bifurcation of authority has been diluted and currently the federal government enjoys extended authority relative to almost aspects impacting US citizens. However, despite such increase in federal authority, states in the US continue being very significant centers of governmental functioning. Over the years, there have been different policies enacted by different Presidents in regard to reducing the federal government’s powers and vice versa.... This essya stresses that federalism is understood as a governance system whereby the constitution partitions power amongst the state and central governments and both governments take direct actions relative to the people they rule, in terms of the prevailing laws. It is understood that both entities are supreme in the context of their respective spheres of authority. The central and state governments are required to give their consent in the event of proposals being made for changing the constitution. Very rarely does federalism appear in discussions and debates pertaining to modern public policies. A good feature of federalism is that it retains power, traditions and local dignity while permitting the central government to deal with common issues. This paper makes a conclusion that the founders of the Constitution displayed a great deal of loyalty towards their respective states and were not inclined to provide unlimited powers to the central government. While framing the Constitution, the founders created a document that greatly succeeded in bifurcating powers while creating a balance in favor of the nation as a whole. However, it is widely perceived that over the decades the US has diverted from what was intended by the founders of the Constitution because the original intent was not to provide the federal government with extensive authority over issues relative to law enforcement, housing and education

Slavery and Mason Dixon Line Essay Example for Free

Slavery and Mason Dixon Line Essay Women and african american slaves played a huge role during the American Revolution, womens roles became more valued for their aid in the revolution and were under the idea of Republican motherhood or mothers for the new nation, while african american slaves were used for harsh manual labor and received little in return. Women began to have ideas of the revolution stimulate hopes and expectations for equality and freedom. In some cases they even gained voting rights, however overall the revolution only lead to a limited gain of status. The same could be said of the slaves. Although the slave trade itself was banned and in the northern states, slavery was abolished, it did not completely remove slavery and make them considered as a real person. Nonetheless, the ideals of the revolution inspired women and slaves for equality, freedom and independence that would contribute in the future. The American Revolution significantly affected aspects of slaves and the status of women. It provided slaves with an opportunity to escape their bondage through joining the army, while it gave women an opportunity to proclaim a more public role in society. The American Revolution had an impact on both slavery and the status of women from 1775-1800. It gave the African American slaves opportunities to Escape the bondage and join the army. It significantly affected the legal position of white women. Revolutions within the Revolution took place causing vivid changes in the aspects of women and slavery. It gave a new light to the women who had been looked down on and hope for slaveries who helped fight the cause. African American Slaves who had only the slightest chance to obtaining their own freedom had a new hope that the army would direct them to that path. Nevertheless there were no intentions of giving new privileges to these slaves in the army. They were to be nothing more than extra support against the British with little value. African-American slaves still had the same treatment as those who were in bondage. However, the slaves believed that since they were fighting for the white people they would be given more freedom. With a few exceptions this did not happen. African-American soldiers did enjoy the few things white people took for granted but other than that they only continued to serve as a slave. Some slaves managed to escape the during the confusion and chaos of the war and  act as a freed slave without being caught and some went out to help others. Slavery continued after the war despite the efforts of African-American soldiers. Although slavery didnt undergo any major changes the aftermath of the war inspired many criticisms on slavery. A group called the Quakers formed to help free a small percentage of slaves. Much like slavery, white women were affected by the revolution. They were beginning to proclaim a public role in society. They were given a wide range of roles to further their independence in the war. Women were able to help support the cause which they played an important role in. This affected the relations between man and woman to a more bonded level. A woman was not only a wife and a mother but a mutual companion. Both Slavery and the status of women were in the first stages of gaining independence and liberty. Before the American Revolution African Americans had NO chance of freedom. They were being shipped as slaves along the triangle trade route , but after the revolution the question was discussed of abolishing slavery in the constitutional convention and the writing of the declaration of independence. Do to the fact that it was such a touchy issue for the south, due to the large economic impact of abolishing slavery, the question was thrown out and a treaty was signed that wouldnt let ANY laws on slavery be passed or even discussed for at lease 20 years. Moreover, many of the American Revolutionary Generals were slave owners in the first place and were reluctant to give up their own personal wealth. The effect of the American Revolutionary War on African Americans depended on where they lived. If they were slaves in the New England States, they were freed soon after the war ended. If they were slaves north of the Mason Dixon Line, they were freed about 30 years after the adoption of the constitution. If they were south of the Mason Dixon Line, some were freed but most were not.Slavery was also outlawed on mainland Britain- no man could land on British soil without being free. The British had promised many African-Americans their freedom from the colonists if they fought for the British, and around 20,000 of them did. When the British lost, they attempted to honor their agreement as much as possible by helping African-Americans travel to England and London with the retreating redcoats.  Some were even put ashore in Africa at their own request. Therefore many African-Americans clearly felt that their chances of freedom were better with the Brits.

International Marketing Plan For Allianz Marketing Essay

International Marketing Plan For Allianz Marketing Essay Allianz is an international company specializing in the provision of financial services, and the companys headquarters is in Munich, Germany. In the global business world of today, companies cannot afford to just remain domestic, as this could lead to a decline in the companys reputation and business. Serious companies have to work hard on their international presence, to ensure that their stakes in the market are maintained and increased. Founded in the year 1890, Allianz has branches in more than 70 countries and more than 180,000 employees worldwide. The company has acquired about 60 million customers to whom it provides property and casualty insurance services, health insurance, life insurance asset management and banking services. Allianz started to go international in the late 19th century when the company opened a branch office in London. Allianz now also has branches in Paris, Italy, Great Britain, Netherlands, Brazil, Spain, and USA. Allianz hopes to expand into Eastern Euro pe and establish branches either in Hungary or turkey. Since international marketing plans revolve around certain factors, the company will have to complete a thorough analysis of the countries in question, so as to determine the feasibility and viability of international services in these countries. This report will also discuss the viability of establishing branches in the Turkish or Hungarian market place. The Company is aiming to establish the organization in a global market. In order to do this an effective international marketing plan would have to be developed. Situation analysis The goal of this international marketing plan is the provision of specific directions for the companys marketing activities. Research will be carried out in various areas like segmentation, marketing, pricing strategy, targeting and positioning, promotional strategy, control and implementation, in order to achieve set goals. This marketing plan will also detail what the company can achieve with such an international marketing strategy and hoe this plan will help in realizing company objectives. When an organization has decided that it is beneficial to go international and start operations in another country, it is necessary to define company policies on international marketing and the companys objectives for creating promotional campaigns that are efficient. As long as Allianz continues to offer superior services that are efficient, then the company will be better than a domestic company. As the global market continues to grow bigger and population increase continues, the company must engage in effective international marketing, in order to acquire and maintain more clients. (An in depth analysis of Insurance Industry) Interest in Hungary and Turkey Numerous variables function within an international company such as this, which deals in a global market. These variables can influence the companys strategy either directly or indirectly. Being well implanted in various parts of the world Allianz seeks to invest other markets in Europe. Marketing strategy At Allianz, the goal of business is the acquisition of clients and maintaining these clients as customers. The companys international marketing strategy should reflect this, as the company continues to build its reputation. The strategies that would be used for this international marketing will be a push/promotional strategy and pull/selling strategy. The push/promotional strategy will use the companys trade promotion activities and sales force to create consumer demand internationally. The pull/selling strategy involves expenses on promotions for consumers and advertising in order to build up consumer demand for services SWOT analysis The sections highlighted below constitute the most relevant issues for Allianz, and the success of the company. Strengths The companys strengths include: a brand new international approach, staff experience, targeted focus and marketing prowess. Allianz would have to take advantage of these strengths in order to utilize the companys opportunities and also manage threats effectively. Possible weaknesses to the companys international campaign are basically those problems inherent in new product and financial services marketing. Allianzs Strengths also include Product differentiation Superior experience: since the Allianz team is quite experienced in marketing, the company has to capitalize on this experience and bring it to bear on the international market Popularity of the company: strong companies like Allianz tend to have a kind of cult or customer loyalty for many years, which will be brought to bear on the international scene Weaknesses Launching new products and services internationally brings disadvantages of having to build a whole new market structure Opportunities A growing international market Potential for continued improvement Vertical integration: Allianz also has the potential to integrate more services into its international presence and add more branches in various parts of the world Threats The latent competition ensures that there would be other companies who will begin to offer similar services internationally. Unforeseen economic downturn may also reduce fluid/disposable income in spite of a strong domestic economy and anticipated continuous growth. Marketing mix The company should Endeavour to employ a wide range of advertising promotions and communications in order to achieve set out international marketing goals Marketing budget The companys marketing budget must be reviewed and the marketing director would assume responsibility for the budget, excluding the budget for developing the company website. The budget for the international marketing campaign needs to be evaluated on a quarterly basis, with adjustments made to media vehicles, advert schedules, and effective frequency as required Promotion As part of international marketing promotions, there should be grand PR parties and sports events held and organized for prospective clients. Local, national and international media will also be used and sales personnel will be stationed in target market locations like shopping malls and concerts and other related events Financial projection In order to make Allianzs financial services more appealing internationally, the company will have to look towards market segmentation. In looking towards market segmentation, the company will be able to identify specific customer characteristics of interest in specific financial services. As noted on the website of the Center for Business Planning, the purpose of for segmenting a market is to allow the sales/marketing program to focus on the subset of prospects that are most likely to purchase what the company offers, and this can help to ensure the highest yield/return for sales/marketing expenditures, if done properly. (Center for Business Planning, 2009) The international marketing plan developed by Allianz must make a careful analysis of market research to lead to useful decisions regarding the nature of the market in hungary, and of the potential clients in that country. To be able to satisfy the needs of these customers, the company must identify ways to understand its internal and external situation, including the market environment, the customer and the capabilities of the company PEST Analysis Political Factors Increased service tax on premium 5% discount on corporate premium Hike in FDI limit Pricing control in general insurance Favorable regulation for rural insurance Economic Factors Increase in Gross Domestic Savings Social Factors Low insurance coverage Rise in elderly population Growth of insurance Technological Factors Automation of processes Increase in CRM solutions Internet driven information era (Insurance Industry: An Analysis) Implementation and control Allianzs international marketing efforts will be designed to launch and provide sales of goods and services. The marketing director will be in charge of tracking the various programs and changes might be made to the marketing mix if there are no appreciable results. Attention should also be given to some other factors like economic recession, extremely low sales, and the expensive nature of certain types of media that will be used for the international marketing plan, as these factors might influence the budget and marketing mix. The companys international marketing efforts will be reviewed quarterly. Differences between revenue and sales goals during the first year of operation will be the main source of comparison. Customers feedback will also be sought on marketing efforts and there will be surveys and focus groups organized to evaluate the efficacy of adverts. Conclusion Assessment of external factors can help a company to position itself within the environment in which the company operates. Although there are various macroeconomic factors that can affect a company like Allianz, the direction and strength of major industry shaping trends can be gauged by environmental factor assessment. This type of assessment may seem to pose a threat on some occasions but on the other hand, this assessment can create new opportunities. During the environmental assessment, it is vital to seek out new opportunities for business, feasible market places and other companies with which some form of cooperative arrangement can be built. In order to be successful internationally, Allianz needs to understand, anticipate and take advantage of the changes in the business environment. The international environment does have a big impact on the determination of market decisions. A large part of international marketing requires the scanning of the external environment that affec ts Allianz, so that the company can respond profitably to the trends and market requirements of the targeted market. Allianz hopes to expand into Eastern Europe and establish branches either in Hungary or turkey. Due to Global currency issues and the effects of previous economic recessions which have created problems for the company and the services it renders, I believe that Hungary will be a more viable location for the company to invest internationally, as this country is more open to foreign investment. Industries in this country are also expanding and this represents more opportunity for the companys financial services. The firm has also been advised to take a long term view. This is a good strategy for the company, as most emerging markets are long term based, to guard against the negative effects of economic downturns

a paper -- essays research papers

Response Paper #1 The reading materials in Week 6 explore the impact of international law on states, and more specifically, state behaviors. The idea is not to oversimplify the influence of international law but to understand in what circumstances (under various theories) would the legal framework and rules of international society shape and limit the behavior of nations and their alternatives. And these include many scenarios that constitute a change in state behavior – such as abstaining from invasion to imposing tariffs. One notes that state actions are primarily motivated by state interests. A state might uphold international law or norms because it is advantageous to its interest or even when it comes as a great sacrifice. The readings offer several theories hypothesizing why states might or might not conform to international law. From a state psychology point of view, â€Å"Politics of Law Observance† suggests that some states may not observe the law because of a priori assumption of how other nations would behave. For instance if country A does not feel that the international community will impose threatening sanctions (or not threatening enough) to induce a change in behavior, then Country A would violate the law. Other (less cynical) reasons for non-compliance include ambiguity of legal rules, where the enforcement provisions are also vague that violating country knows that other nations wouldn’t know how to quite respond. Moreover there could be limitations on capaci...

Essay --

I watched a documentary on Youtube about the Super Volcano that lies beneath the oldest national park. I have always been very interested in this particular volcano because it is so close to my home in Colorado. I found this documentary to be thoroughly informative while being left extraordinarily frightening. All of those wonderful geysers, boiling mud pits, and pools of heated sulfur, all get their power by the magma chamber a mere 5 miles below the surface. This Magma chamber contains over one million tons of partially molten rock. Volcanologists have explored all parts of Montana, Idaho, and Wyoming. The discoveries that they made would shock the world, they have found 3 calderas from past eruptions. The last and biggest eruption ever known to man, taking place 64,000 years ago, left a huge Caldera towards the North part of Wyoming up into Montana that can only be fully seen in the air. The effects of this eruption were felt most heavily in a radius of 300 miles however there were devastating effects were felt worldwide and they lasted up to 9 years. This caldera is the biggest ever known to mankind, and with part of it overlapped with a caldera from a previous, smaller eruption, ultimately creating an even larger caldera. This is the foundation for a globally spread disaster. There’s only one eruption that can almost match the destruction that would come when the pressure starts to build and everything explodes. That is the Eruption in Toba. We know from this eruption that when a supervolcano erupts the immediate effects will take place in a Possible 450ft. Radius. A super volcano differs from the typical volcano in the sense that there is no dome or raise earth where the opening is. Instead, the magma chamber is rumbling ... ...fference of life and death. I liked the production and presentation of the documentary, it was VERY informative and chalked full of facts that I am dying to share with everyone now. If I could change anything about the message that they sent across would be that, yes if an eruption were to happen (which it probably will sometime in the not so far away future however far away that may be, anywhere from a year from now, to one thousand years from now) our future would be bleak and most likely the earth would be desolate. But I would have added in the factor and hope that comes with knowing that God’s in control and it was his will for this to happen. Overall It leaves me knowing everything I would have ever want to know about the Yellowstone Supervolcano. Yet in a strange way, it leaves me wanting to explore deeper into the mystery that lies just beneath our feet.

Management Information Systems in Process-Oriented Healthcare Organisations

Linkoping Studies in Science and Technology Thesis No. 1015 Management Information Systems in Process-oriented Healthcare Organisations by Anna Andersson Submitted to the School of Engineering at Linkoping University in partial fulfilment of the requirements for the degree of Licentiate of Philosophy Department of Computer and Information Science Linkopings universitet SE-581 83 Linkoping, Sweden Linkoping 2003 Management Information Systems in Process-oriented Healthcare Organisations by Anna Andersson Maj 2003 ISBN 91-7373-654-6 Linkopings Studies in Science and Technology Thesis No. 015 ISSN 0280-7971 LiU-Tek-Lic-2003:14 ABSTRACT The aim of this thesis work was to develop a management information system model for process-oriented healthcare organisations. The study explores two questions: â€Å"What kinds of requirements do healthcare managers place on information systems? † and â€Å"How can the work and information systems of healthcare managers and care providers be inc orporated into process-oriented healthcare organisations? † The background to the study was the process orientation of Swedish healthcare organisations. The study was conducted at the paediatric clinic of a county hospital in southern Sweden. Organisational process was defined as â€Å"a sequence of work procedures that jointly constitute complete healthcare services†, while a functional unit was the organisational venue responsible for a certain set of work activities. A qualitative research method, based on a developmental circle, was used. The data was collected from archives, interviews, observations, diaries and focus groups. The material was subsequently analysed in order to categorise, model and develop small-scale theories about information systems. The study suggested that computer-based management information systems in processoriented healthcare organisations should: (1) support medical work; (2) integrate clinical and administrative tools; (3) facilitate the ability of the organisation to measure inputs and outcomes. The research effort concluded that various healthcare managers need the same type of primary data, though presented in different ways. Professional evelopers and researchers have paid little attention to the manner in which integrated administrative, financial and clinical systems should be configured in order to ensure optimal support for process-oriented healthcare organisations. Thus, it is important to identify the multiple roles that information plays in such an organisation. Department of Computer and Information Science Linkopings universitet SE-581 83 Linkoping, Sweden Co n te n ts 1. Introduction †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 1 1. . 1. 2. Organisational and work process models in medical informatics †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 2 Aims of the study†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 3 2. Research methods†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 4 2. 1. The setting of the case study†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 4 2. 2. The data collection†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 2. 2. 1. Archival data †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 2. 2. 2. Interviewing †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 6 2. 2. 3. Diary method †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 2. 2. 4. Observation†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 7 2. 2. 5. Focus groups †¦Ã¢ € ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 7 2. . 6. Feedback loops †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 8 2. 3. Analyses†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 8 2. 4. Modelling†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 9 3. Results†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 9 3. 1. 3. 2. 3. 3. The requirements of healthcare managers for an HIS†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. Interpretation of organisational and work processes in relation to HIS†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 10 A management information system model for process-oriented healthcare†¦. 12 4. Discussion †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 14 5. Conclusions †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã ¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 15 6. Future work †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 15 7. References †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 7 Management Information Systems in Process-oriented Healthcare Organisations 1. Introduction Swedish healthcare organisations are required by law to maintain a holistic view of their processes (Prop. 1999/2000:149). Thus, such organisations need to have an overview of the entire scope of health service delivery. As a result, system thinking is vital (Senge, 1990). An organisation must be able to collect data from its operational processes and furnish health service management with data concerning the way in which th ey have utilised their resources (Kaplan & Norton, 1996). As a response to this imperative, many healthcare providers have begun to introduce process-oriented structures recently. There are a number of theories about how to design such structures. One theory is based on Business Process Reengineering (BPR), the purpose of which is to identify and redesign organisational processes (Davenport, 1993). Another approach is to analyse a healthcare organisation as a Complex Adaptive System (CAS), an interdisciplinary method that focuses on the self-organisation of systems and patterns, as well as the way in which outcomes emerge. The purpose of a CAS analysis is to resolve issues associated with adaptable systems (Zimmerman, Lindberg & Plsek, 2001). Regardless of whether a BPR or CAS approach is employed, process-oriented organisational structures face difficulties stemming from the fact that healthcare organisations operate on multiple levels, including county councils, hospital management, clinical management, and care providers, each with its own information requirements (Andersson, Vimarlund & Timpka, 2002). Each level struggles to survive under difficult economic constraints, limited growth and the constant threat of regulation (Luce & Elixhauser, 1990). Healthcare organisations need an integrated structure in order to quickly disseminate information among managers and care providers (Van de Velde, 2000). The first challenge is to structure information systems such that they support the workflow in a healthcare environment (Strauss et al. , 1985). Thus, it is not surprising that healthcare managers are increasingly seeking help from health information systems (HIS). Their objective is to minimise the overall costs of healthcare delivery, to improve the quality of their services (Greenes & Lorenzi 1998; Clayton & van Mullingen, 1996) and to correlate costs with resources consumed (Stead & Lorenzi, 1999). One option for gathering data in an 1 Management Information Systems in Process-oriented Healthcare Organisations HIS is to use censors and other devices that continuously furnish the healthcare organisation with data about its finances, quality, competence and level of satisfaction. However, before an HIS can be designed, both managers and developers need to be familiar with work routines, information requirements, and other key parameters at the clinical level, given that medical information is linked to the environment in which it is generated (Berg & Goorman, 1999). Thus, the organisation must outline its information requirements and work procedures. The HIS that ultimately emerges will be embedded in the organisation’s processes and must satisfy the care provider’s information needs (Berg, 1999). To sum up, in order to design an HIS in process-oriented healthcare organisations, attention must be paid to issues such as patient focus, cost effectiveness, service quality, adaptability to the constraints of the organisation, and integrated use of information at both the hospital and clinic level (Ovretveit, 1992; Flarey, 1995). Moreover, a holistic overview based on system thinking is vital, including the gathering of data from multiple sources in order to correlate costs with the utilisation of resources. The challenge is to define models that can support the design of an HIS. 1. 1. 1. Organisational and work process models in medical informatics The main purpose of reengineering was to focus on the processes rather than the functions or an organisation (Hammer, 1990). Further organisational enhancement could be achieved with quality methods such as Total Quality Management (TQM), which included process-oriented models. Another approach is to modify the business culture such that it becomes a learning organisation (Senge, 1990). In the financial area, Balanced Scorecard has been used to translate mission and strategy statements into operational objectives and measurement variables (Kaplan & Norton, 1996). When it comes to medical informatics, attempts have been made to design various kinds of organisational models, such as socio-technical modelling (Berg et al. ,1998). The rationale for introducing these models is to gain a greater understanding of the ways in which an HIS will affect the allocation and content of work tasks. Changes in work activities require modification of information management (Berg, 2001). The validity of a technology rests not only on the fulfilment of functional specifications, but also on the interaction of the technical system with its 2 Management Information Systems in Process-oriented Healthcare Organisations organisational environment (Brender, 1998). The resulting conclusion that has been drawn today is that social, organisational, cultural and contextual issues should be taken into consideration at an early stage of the development process (Kaplan, 2001). Moreover, approaches such as cultural-historical activity theory have been used to perform contextual analyses of clinical cognition and activity. Culturalhistorical activity theory argues that studying the present healthcare setting is insufficient – a researcher must also become acquainted with the history of the setting, given that clinical cognition is embedded in broader institutional structures and longstanding evolution (Engestrom, 1995). One method was to highlight patient data on the presumption that the objective of any healthcare organisation is to improve the health of individuals (Engestrom, 1999). Other researchers argue for a framework that allows for a constant interplay of different models, theories and perspectives (Maij et al. , 2002). The advantages of integrated frameworks are that methods and models can be optimised during the development process, while methods with specific weaknesses can be reinforced by others (Timpka, 1995). Finally, there are approaches for exploring the ways in which healthcare providers tend to reason in clinical contexts – such as situated action, an emerging perspective for studying human cognition and behaviour in order to design intelligent systems (Patel, Kaufman & Arocha, 1995). Such models address the clinical tasks that are to be performed within specific guidelines and define criteria for selecting appropriate options when there is a set of potentials (Wang et al. , 2002). 1. 2. Aims of the study The aim of this thesis is to develop a management information system model for process-oriented healthcare organisations, based on two questions: â€Å"What kinds of requirements do healthcare managers place on information systems? † and â€Å"How can the work and information systems of healthcare managers and care providers be incorporated into process-oriented healthcare organisations? The work is based on a circular process, during which models are developed by collecting and categorising data, as well as by designing small-scale theories about information systems. Organisational process is defined as â€Å"a sequence of work procedures that jointly constitute complete healthcare services†. A work 3 Management Information Systems in Process-orie nted Healthcare Organisations activity is defined as a set of work procedures that are closely related by virtue of their purpose and means of performance. A functional unit is the organisational venue responsible for a certain set of work activities. Healthcare Information Systems (HIS), Management Information Systems (MIS) and Information and Communication Technology (ICT) all define computer-based information systems. 2. Research methods A qualitative research strategy, based on an idiographic case study, was employed. Qualitative research, which has evolved within several disciplines, consists of a set of interpretive practices. It does not accord priority to any single methodology for data collection and analysis, nor does it have a theory or paradigm that is distinctly its own (Denzin & Lincoln, 1998). Qualitative research is best suited for understanding the processes inherent to a situation, along with the beliefs and perceptions of the people involved. Nevertheless, qualitative researchers can make their findings more widely applicable (Firestone, 1993). Furthermore, a case study is both a process of inquiry and the product of that inquiry (Stake, 2000). The researcher needs a wide array of information about the case in order to provide an in-depth assessment (Creswell, 1998). A primary distinction is between single-case and multiple–case designs of such studies (Yin, 1994). A case study whose primary mode of research is hermeneutic is idiographic in a natural setting – its main type of data is qualitative and its fundamental level of analysis is holistic (Fishman 1999). Interpretive studies are well served by a considerable degree of openness to field data, along with willingness to re-examine initial assumptions and theories. The result is an iterative process of data collection and analysis during which initial theories are expanded upon, revised or abandoned altogether (Walsham, 1995). 2. 1. The setting of the case study The setting of the study was a paediatric clinic at a county hospital in Sweden. In 1996, the county council adopted a wide-ranging quality program based on TQM and a Plan-Do-Check-Act (PDCA) cycle. In 2000, the county council started using Balanced Scorecard to measure the healthcare organisation’s outcomes. At the time of the study, the county’s development and change program for 4 Management Information Systems in Process-oriented Healthcare Organisations organisational quality was based on a CAS strategy. Furthermore, a processoriented healthcare information system was being designed. With some 30 clinics and 3,200 employees, the hospital had identified its main organisational objectives as the delivery of emergency and specialist healthcare, as well as county-wide rehabilitation and habilitation services. The purpose of habilitation is to enable someone with a congenital impairment, whereas rehabilitation focuses on recovering lost ability. Above and beyond the responsibilities of healthcare managers in accordance with the functional structure, all clinics at the hospital (including paediatrics) had developed work processes for specific groups of patients. These Patient Need Group Processes (PNGPs) centred on the healthcare needs of individual patients. The main objective of the PNGPs was to cultivate and maintain a high level of knowledge about medical care at the paediatric clinic. The scope of the processes varied considerably. However, a PNGP unit always comprised at least a doctor, nurse and secretary. If necessary, several clinics, hospitals and county councils could collaborate on the same process. In order to improve nursing care, development teams, staffed by practitioners interested in development work, were set up. Specific development areas included palliative care and the use of technical equipment. The teams produced documents concerning their specific areas that could prove of value for their co-workers. New work routines were developed for nursing care and for activities that are indirectly related to the patient care process, such as meal delivery, ordering medication and play therapy. The teams had contact people at each ward who were prepared to step in whenever nursing care problems arose. The team members normally attended meetings during their free time – or overlapping time when two shifts were on duty simultaneously. The paediatric clinic also cooperated with maternity wards and a total of 13 Child Health Centres (CHCs) throughout the county. The clinic was part of a network of specialist clinics in southern Sweden that focused on the exchange of knowledge and experience. At the time of the study, the paediatric clinic employed 12 senior physicians, 21 physicians, 91 nurses, 77 paediatric nurses (specialist nurse’s aides) and 13 secretaries. The management team consisted of six senior physicians, seven nurses and one secretary from the clinic. During the period of the study, the paediatric clinic supplied approximately 16,000 bed-days to inpatients, performed 5,000 scheduled surgical interventions and handled 5 Management Information Systems in Process-oriented Healthcare Organisations 6,000 emergency room visits by children. The paediatric clinic comprised one surgical unit and three wards, each with a physician responsible for medical matters and a nurse as manager. The ward for neonatal patients had eight beds for intensive care and ten for prenatal care. The ward for contagious patients had 16 isolation rooms for newborn babies and contagious children. The institutional care ward for children older than a year had 18 beds. The clinic used 15 PNGPs. 2. 2. The data collection The collection of data was conducted throughout documents, archives, interviews, observations, diaries, focus groups and feedback loops. 2. 2. 1. Archival data Archival data was used to place the research into context before, during and after the studies at the clinical site (Drury, 2002). An obvious danger posed by fixed data is that it can easily become outdated unbeknownst to the researcher. In these studies, archival data was related to: 1) annual reports by the clinic; 2) the county council’s quality pronouncements; 3) the government’s bill for the healthcare organisation; 4) the physical and mental health survey of hospital employees; 5) reports concerning the county council’s development plans for an HIS. 2. 2. 2. Interviewing A common interviewing technique is to meet face to face (Fontana & Frey, 1998). The interview may be structured, semi-structured or unstructured. The scope of an interview can range from five minutes to the lifetime of the subject (Fontana & Frey, 2000). This study involved semi-structured interviews with four doctors and four nurses. A series of open-ended questions addressed daily work routines and communication patterns. 2. 2. 3. Diary method The holistic perspective of this approach identifies connections among the individual, societal and organisational levels. One of the techniques that have evolved is the diary method, which proceeds from subjective assessments of time utilisation. The various steps require a practitioner to enter time, activity, Management Information Systems in Process-oriented Healthcare Organisations location, the names of co-workers with whom they interact and other comments during a specified period (Ellegard, Nordell & Westermark, 1999). In this study, a ward nurse kept a diary during one workweek. She entered the nature of her work tasks, the times that she performed them and the names of the co -workers with whom she interacted. 2. 2. 4. Observation Observation involves gathering impressions of the surrounding world. Qualitative observational research is fundamentally naturalistic (Adler & Adler, 1998). There is â€Å"descriptive observation†, in which the researcher assumes that he or she knows nothing about what is going on and takes nothing for granted. He or she employs â€Å"focused observation†, ignoring that which is defined as irrelevant. Finally there is â€Å"selective observation†, the most systematic approach, during which the researcher concentrates on the attributes of various activities (Angrosino & Mays de Perez, 2000). This type of observation requires a notebook, a storage location for the data that is collected during the process (Ely, 1993). The researcher observes and interacts with care providers at the paediatric wards before and after their rounds. Alongside the observations, the clinical staffs were interviewed again about what they were doing, why they were doing it, what they hoped to gain from an HIS and what benefits they expected. Field notes were entered into a log during the observation study. 2. 2. 5. Focus groups A focus group’s planning process should begin as soon as it is set up. The process includes the following steps: establish research objectives, appoint a moderator, develop moderator guidelines and draw up procedures. The moderator plays an important role during the group session. He or she conducts the interviews. It is important that the moderator not be the same person that put together the moderator guidelines and questions. In this study, a focus group session was held with seven nurses and three paediatric nurses, all of whom were women selected by a ward nurse. The participants had various duties at the paediatric clinic, where they had been employed for anywhere from 9? to 32 years. Five nurses were ward managers and two also managed development teams. They all had experience at each ward, as well as the paediatric surgery. The researcher had furnished the group moderator with 7 Management Information Systems in Process-oriented Healthcare Organisations guidelines and questions (Greenbaum, 1993). The questions were based on the clinic’s profile of itself: administrative activities, care provision and development work. Questions also dealt with work activities and the exchange of information with other units. Some questions focused in on a patient’s relations with the care providers, as well as the time and place for the performance of care activities. The entire focus group session was videotaped and transcribed. . 2. 6. Feedback loops Feedback loops throughout the research project permitted the generation of reports for evaluating data collection. A total of four reports were sent to the practitioners as a result of the case study. In addition, four seminars were held with the practitioners, the purpose of which was to discuss the research findings. The practitioners discussed and critiqu ed the results. 2. 3. Analyses There was no theory at the beginning as to how the material should be analysed. The first step was to break down healthcare management into the hospital, clinical and care process levels. Statements from the various management levels were interpreted on the basis of information requirement, i. e. main objectives, system functions, expected benefits and risks to be avoided. The second step was the analysis of three main work activities, each with three work procedures, at the clinic level. The third step involved the design of a management information system model. All empirical data was categorised. Various themes were identified and classified. After the categories had been cross-compared and clustered, abstract new categories were defined (Strauss & Corbin, 1990). The final analysis started with a category-by-category comparison, which enabled the identification of core categories that were sent to the paediatric clinic as a preliminary report for comment and critique (Glaser, 1978). Finally, the categories were modified in response to the comments. The focus was to come up with a context-based, process-oriented description and explanation of the phenomena (Orlikowski, 1993). The categories were incorporated into two small-scale theories. The first theory interpreted the information requirements of three management levels. The second theory interpreted the work processes employed by institutional care. 8 Management Information Systems in Process-oriented Healthcare Organisations 2. 4. Modelling In order to conduct the final analysis, the two small-scale theories were applied to the modelling of a management information system. Various possible approaches included data modelling (Connolly, Begg & Strachan, 1996), function modelling and object-oriented modelling (Booch, Rumbaugh & Jacobson, 1999). To handle such approaches, various modelling languages have been developed, including the object-oriented Unified Modelling Language (UML) (Fowler & Kendall 1999). The symbols and notations of the various languages can be difficult for the uninitiated to grasp (Sommerville & Sawyer, 2000). Furthermore, the notation and logic for modelling a system must work in tandem with the people involved in the development process. Thus, it is useful to visualise the information flow by means of a modelling approach, using notation and logic that have been established by consensus. As a result, the management information system models were designed in dialog with the practitioners in the case study. The notation was taken from Eriksson & Penker’s (2000) business processes but modified on the basis of the discussions. 3. Results The results are presented in accordance with the three sub-analyses. The first sub-analysis focused on the requirements of healthcare managers for an HIS. The second sub-analysis focused on interpreting organisational and work processes in relation to the HIS. The third sub-analysis focused on designing a management information system model for process-oriented healthcare. 3. 1. The requirements1 of healthcare managers for an HIS Hospital management expressed its intention to use an HIS to empower patients while maintaining control of resource utilisation. Thus, the planned HIS was expected to encourage a greater overall awareness of cost effectiveness with respect to the services provided by various units of the hospital. The biggest risk noted was that of a mismatch between the system and the existing organisational culture, in which it was easy to identify and reward employees who handled 1 Requirements and demands are used as synonym in this chapter and in article 1. 9 Management Information Systems in Process-oriented Healthcare Organisations mergencies. As a result, some of the staff appeared to resist a new way of transmitting information throughout the various levels of the organisation. The goals of the functional units (i. e. clinic management) focused on patients and the introduction of leadership based on co-determination. While management accepted patient empowerment and cost effectiveness as the their main objectives, they thought it was important that employees be allowed to make their own organisational decisions. Management wanted to see a new approach to measuring the activities of their organisational unit. In order to achieve these goals, they sought a way to define the data that is essential to making a reliable estimate. In managing the healthcare process, the objectives of an HIS centred on developing and maintaining specific clinical competence by enhancing support for decision-making and co-operation on the part of care providers. While all the process managers agreed that sharing information and knowledge was important to improving the decision-making process, they were unaware of resource competition issues. However, the withholding of information was not always intentional. Due to limited resources and full schedules, process managers were often unable to share their knowledge with other employees. 3. 2. Interpretation of organisational and work processes in relation to HIS Work activities included: (1) co-ordination of information exchange management; (2) care, including documentation of the care provided and the practice that had evolved at the clinic; (3) supply, including patient assistance and psychosocial support. The work procedures of the various activities were often related to and dependent on each other. Co-ordination activities were oriented toward management of the wards and the clinic. The activities focused on co-ordinating various types of information in order to support the care effort. External co-ordination is related to the exchange of information between the paediatric clinic and other care units. This coordination continued after the patients had been discharged from the clinic. Thus, the coordination of external resources and inter-organisational collaboration was important to the management of the clinic. Patient co-ordination started before a patient was admitted to institutional care. There were two 10 Management Information Systems in Process-oriented Healthcare Organisations easons for such approaches. First, the amount of time that patients stayed at the wards proved expensive for the healthcare organisation. Thus, such approaches saved money. Second, these approaches enhanced the relationship between care providers and caretakers, assuming that patients and their families were kept well informed. Internal co-ordination was related to management and planning activities at the clinic and the wards. Such activities were linked to external and patient co-ordination, given that providers needed to cooperate with other units and patients in order to manage ward care. Care activities were underpinned by what had been agreed upon during the coordination of work activities and the information that was to be used by various co-ordination procedures. Care provision involved medical and nursing care performed by physicians, nurses and paediatric nurses. Care activities were broken down among the various professions. But care was regarded as teamwork from the point of view of the patients. Thus, the work tasks of the various professions cumulatively became what are referred to as the outcome of care provision. Practice development took in both medical and nursing care issues. The knowledge and information cultivated was incorporated into the ordinary work routines of the paediatric clinic. Care documentation activities were linked to care work and development efforts. Documentation provides protection for both care providers and patients. Care documentation served as a means of communication among care providers. Supply activities were indirectly related to care activities. Among employees who performed supply activities were nurses, paediatric nurses, kitchen staff, cleaning staff, play therapists and teachers. Material provision furnished care activities with pharmaceuticals, equipment and materials. Based on the resources that material provision furnished to care activities on a daily basis, estimates were prepared concerning the resources the activities would require over time. Bandages, diapers, syringes, etc. were also a part of material provision. Material provision also included equipment and supplies for play and school activities, such as games, videotapes and textbooks, as well as kitchen and cleaning supplies. Psychosocial support activities called for an information system that could offer emotional support, such as administrative tasks associated with permitting patients to have their own personal phones. Thus, psychosocial support depended on the ability of patient co-ordination efforts to proceed smoothly, assuming that both patients and their families could be kept well 11 Management Information Systems in Process-oriented Healthcare Organisations informed. The main purpose of Patient assistance, which included both material provision and psychosocial activities, was to assist care activities. Such activities were related to supporting the physical and mental well-being of patients while undergoing medical and nursing care. 3. 3. A management information system model for process-oriented healthcare The county council formally required that hospital management monitor and report on service production with regard to quality and cost. As a result, hospital management needed data about resource utilisation and healthcare quality from the hospital organisation, along with information systems that could support methods such as Total Quality Management (TQM) and Balanced Scorecard. To monitor costs and quality, hospital management needed data from the functional units after determining what needed to be collected. The focus of process management was developing and maintaining a high level of quality in the medical and nursing care processes. The process unit was responsible for documentation and quality control operations. Process management needed directives from the functional management unit about both data collection templates and quality for medical and nursing care. Process management generated information about medical and nursing quality data for functional unit management. Best practice guidelines and decision support protocols for clinical practitioners were involved in the clinical process. The HIS application required by process management was a service quality control system that could extract data from and support decision making for medical and nursing care. Functional unit management comprised managers at both the clinic and ward levels. Clinic management organised the monitoring of the clinic’s resources, while ward managers co-coordinated the exchange of information at the wards. Functional unit management requested information about resource allocation specifications and templates for expenditure reports, as well as for patient satisfaction and staff work satisfaction data, from hospital management. Functional unit management needed data concerning the perceptions of patients and staff with regard to the services provided by the unit. Management was also looking for a way to relate its expenditures to resources utilised. In other words, its primary needs were in the areas of data collection, storage and access tools. 12 Management Information Systems in Process-oriented Healthcare Organisations Thus, functional unit management required data from clinical activities, but not at an individual or contextual level. The systems it was seeking were to supply data for use at a composite level, including the volume of financial and human resources that specified care activities necessitated. To monitor service delivery, management units in process-oriented healthcare organisations need data in three distinct areas: (1) medical and nursing care, (2) patient flows and (3) the utilisation of human and material resources. Although the management units may have access to a common data warehouse, requirements for data analysis and presentation vary considerably. Similarly, data collected from the healthcare organisation during daily work routines can be shared, but the primary data must be converted into a format that is usable by healthcare managers. The data that is collected should ideally be located where it can be made available to ordinary healthcare activities. For instance, networked devices can be used to monitor pharmaceutical use. Intelligent devices can also be connected to equipment in order to track their use, and material storage and use (diapers, sheets, etc. ) can be traced by bar-code systems. Furthermore, patients and healthcare staff can be registered with smart cards as they come and go. However, computerised patient records (CPRs) are the most logical central resource for data collection in the clinical setting. The data that is documented in the records can be used to monitor the clinical activities that have been performed. CPRs can also furnish data about work activities at the healthcare organisation. Such data is of little value as long as it is limited to individual patients. What is useful is to analyse cumulative data, such as the number of radiology examinations that have been conducted on leukaemia patients. The purpose of the data warehouse is to store what has been collected from various sources. The application and its interface are the parts of the HIS with which healthcare managers interact and with which users most readily identify. Thus, the application must help healthcare managers use information and must supply the right information to the right healthcare managers. Moreover, the application must support the specific analysis methods, tools and data formats required by current organisational analysis procedures, such as Balanced Scorecard and quality assurance methods. 13 Management Information Systems in Process-oriented Healthcare Organisations 4. Discussion The aim of this thesis was to develop a management information system model for process-oriented healthcare organisations. The research effort employed qualitative methods such as archival data analyses, interviews, observations, diary analyses and focus group analyses. Constant feedback loops among the participants in an idiographic case study helped establish a balanced interpretation. Meanwhile, categorising and modelling formed the pattern of interpretation for the management information system model. The main findings of the study are that an HIS in a process-oriented organisation must support the medical work, integrate clinical and administrative tools, and furnish information that allows for the measurement of organisational inputs and outcomes. As a result, it is important to identify the multiple roles that information plays in a process-oriented healthcare organisation. Most of the organisational development methods that healthcare currently takes advantage of, such as reengineering and quality management, include process definitions. However, the interaction between various groups of processes has seldom been analysed. Several recent organisational methods, such as Balanced Scorecard (Kaplan & Norton, 1996), address the problem of relating costs to resources. The areas in which information systems are expected to enhance care delivery range from access to medical knowledge bases, patient and clinician communication, and the minimisation of medical errors. Nevertheless, little attention has been paid to how integrated administrative, financial and clinical systems should be configured in order to support process-oriented healthcare organisations in an optimal manner. Internal co-ordination is informed by and dependent on documentation of care activities, particularly by monitoring the way in which human resources are harnessed to take care of patients. Furthermore, such co-ordination relies on information about the utilisation of material resources, i. e. durable equipment and disposables. Thus, internal coordination must obtain information from care activities in order to synchronise the work of the clinic, as well as to track costs associated with care and supply activities. The various processes monitor costs and allocate resources, relating them to the kinds of care activities that have been provided. 4 Management Information Systems in Process-oriented Healthcare Organisations The third sub-analysis discovered that the various management levels in process-oriented healthcare organisations need the same type of primary data, though in differing formats. An HIS for healthcare management in a processoriented healthcare setting can adhere to its structure and practice activities. Moreover, CPRs and other tools can be used to directly collect management data where and when the activities take place. But the data is useful only if healthcare management has the opportunity to examine it with its own analysis tools. For instance, while computerised ordering systems are regarded as important, the fit between organisational and information system models is not identified as a success factor. Clearly, there is a need for systems that optimise clinical workflow, as well as those that support the maintenance of equipment and supplies. However, systems provide optimal organisational value only if they support an integrated organisational model and business plan. 5. Conclusions This thesis points out that healthcare managers at different levels in an organisation all need the same primary data. The differences among the various management levels all concern the ways in which they compile the data that they need for their work. One problem when developing management information systems for healthcare organisations has been a lack of interest in integrating administrative, financial and clinical systems. In process-oriented healthcare organisations, integration is essential to obtaining the full benefits of such a structure. System thinking must also pervade the development of healthcare management information systems. As a result, the multiple roles played by information in process-oriented healthcare organisations must be identified. 6. Future work Identifying the multiple roles played by information in a process-oriented healthcare setting requires additional research about the process of designing an HIS. In the complex environment that healthcare organisations represent, various practitioners are required to pinpoint data sources and information 15 Management Information Systems in Process-oriented Healthcare Organisations requirements, as well as to advocate for the process of change in the organisational and information structure. Healthcare managers have differing preferences when it comes to information requirements, organisational processes and work activities. Thus, the development process relies on tools that can incorporate those divergent needs into system thinking. As a result, primary data is refined into information differently at the various levels of a processoriented healthcare organisation. More research is required concerning information system models and their notation. Though various groups (system analysts, designers, programmers and healthcare managers) can employ models and modelling activities during a development process, their objectives differ. Healthcare managers need to visualise their work environment and organisational processes, system analysts are interested in developing information systems in collaboration with designers, and programmers are looking for coding specifications. They may share a vision in terms of designing a healthcare information system, but their perspectives vary. Thus, the modelling effort should be based on at least two dimensions: (1) furnishing models with notations and objectives oriented towards specific groups; (2) ensuring that the models visualise the same system but address varying interpretations. Arguments based on the cognitive and practice perspective have identified prototyping as a fruitful approach to the development process (Houde &Hill, 1997). Prototyping is often used when the design calls for a high degree of involvement on the part of practitioners and end-users (Bodker & Gronb? k, 1991). Modelling, on the other hand, is linked to an organisational perspective and is frequently employed by system analysis methods. Thus, there is an opportunity to combine these two perspectives during the development process. Modelling is useful as part of a design theory with a high degree of practitioner involvement alongside of system analysts, designers and programmers. 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