^5%^
Center for Information Systems Research
Massachusetts
Institute of
Alfred P, Sloan School of
Technology
Management
50 Memorial Drive
Cambridge, Massachusetts. 02139
617 253-1000
HOSPITAL STAFF INTERFERENCE
WITH MEDICAL COMPUTER SYSTEM
IMPLEMENTATION AND EXPLORATORY ANALYSIS
Alan Dowling
August 1979
CISR No. 49
Sloan WP No. 1073-79
TABLE OF CONTENTS
I
Introduction
Background and Purpose
1
The Staff Resistance Problem:
& Definitions
II
Clarifications
Three Cases of Staff Interference with MCBIS's
An Overview
Case
I:
Case II:
Case III:
10
An ECG Interpretation System
A Clinical Laboratory Information
System
An Admission, Discharge, and Transfer
System
IV
11
16
21
Further Implications
25
An Attempt to Diagnose the Causes of the
Resistance
25
Diagnosis:
Case
Diagnosis:
Case II
29
Diagnosis:
Case III
31
I
A Consideration for Other Hospitals
III
5
26
38
An Experiment to Estimate the Level of MCBIS Interference
Purpose
35
Experimental Design
37
Data Collection
38
Parameter Estimation
41
Testing Hypothesis HI
42
Types of Resistance Found in the Survey
44
Conclusions and Research Recommendations
S50\5^^
49
HOSPITAL STAFF INTERFERENCE WITH
MEDICAL COMPUTER SYSTEM IMPLEMENTATION:
AN EXPLORATORY ANALYSTS
INTRODUCTION
Background and Purpose
Although computerized information processing
existed
in
a
technology
commercially available state for over twenty years,
its use in health care delivery facilities has lagged
other
high
and
was
field,
Why
systems
do
based
which
hospitals?
Why are such systems still failing"'
guided
man
Computer system vendors in the
general, the
The
it
on
did
19'SPis
viewed the
same
the
to his lunar satellite fail
technology
as
when
in
marked by some of the more noteworthy system failures
of the last fifteen years.
industry
use
its
industries.
technology
moderate
even
introduction of the computer to the medical
occur,
has
in his
health
virgin and profitable territory for their wares.
systems
they
marketed
were
business
care
in
transaction
oriented with respect to their operating capability and efficiency
and
failed to contend with some of the more unique aspects of the
hospital
setting.
After
relatively
a
number
small
of
installations occurred, many were removed and generally only those
as
billing,
accounting, payroll, and personnel continued to operate.
Isolated
dedicated
to
business
classical
functions
such
medical practitioners
and
developed
task-specific application software met with
their
own
significant success;
information
or
who
but, the vendor-generated applications
usually undistinguished and
testing
researchers
system
a
were
significant number failed acceptance
The reasons for most of the failures
implementation.
were seldom fully understood, and are now lost as the opinions
vendor
and
hospital
passage of time.
personnel
become
of
accepted 'fact' with the
been
However, the reasons seemed to have
many.
Frequently, hospital personnel claimed their system failed because
its
hardware and/or software was unreliable.
Conversely, several
some
because
system vendors assert that their system failed only
hospital staff members were computer-phobic.
Today, the health care industry is one of America's
and
the
medically-oriented
computer-based
largest,
system
information
industry is quite active.
Many of the largest and
medical
vendors of the sixties are no longer in
computer
system
the business of developing
medical
systems
best
software.
financed
However,
they have been replaced by many firms which, although smaller, are
better
versed
idiosyncrasies.
the
a
in
the
hospital's
managerial
and
large
variety
especially
Hardware and software technology,
database and telecommunications areas are at
of
medical
and
managerial
operational
a
in
state in which
applications
are
feasible.
Indeed,
large
a
of these applications is in
subset
operation in hospitals in either production or
prototype
states.
applications range from the classical business functions to
These
direct patient care support in the practitioner-patient encounter:
computerized EKG
computer
interpretation,
controlled
scanning
computer
automated
devices,
diagnosis,
aided
clinical data
collection and dissemination systems for clinical laboratories and
inhalation therapy and radiology departments, etc.
research
underway
Further,
much
tougher
medical
information processing nuts such as multi-facility shared
network
is
patient health
efforts
records
the
fragmented and the systems available through medical
are
include
systems,
shared
reliability,
and custodial systems, vary significantly in quality,
with
Most are usually difficult or impossible
each
other.
Still,
available which work well
today,
this
many
for
and
are
implementations
systems are
applications,
cost-beneficial.
But,
appropriate,
often
and
frequently
either
fail
have
even
Research into the causes of this
writing
information systems
on
(MCBIS)
the
difficult
very
and are removed
hospital or are not used to their designed or intended
current
interface
to
latter subset of systems, the technically successful
and operationally
Most
service
in-house or remote proprietary software systems,
systems,
and cost.
individual
development
Unfortunately,
systems.
computer system vendors, which
bureau
of
information systems and the classical
hospital
'total'
some
crack
to
problem
has
from the
potential.
been
sparse.
subject of medical computer based
has
been
oriented
toward
an
.
explanation of the hospital systems in existance and how to design
successful
systems.
General information systems research on this
subject is useful but its application may
fact
from that of most other industries.
confusion
MCBISs.
suspect
contribute
Not
to
of health of
state
multiple
lead
which
factors
all
of
been
have
factors
these
Nor have the strengths of correlation between factors
an MCBIS's level
a
a
However, the
been established.
government hospital when
attempting
to
different systems points to the possibility that
three
resistance to
'success'
of
problems experienced by
its
are
factor,
the problem whenever an MCBTS experiences less than
to
identified.
with
there
that
the
of
by researchers and
discussed
discussing
when
planned-for success.
implement
the
Additionally, the meaning
'either/or',
binary,
a
significant
We
usually
'failure',
and
practitioners as
and
by
the hospital's organization and operation is different
that
'success'
confounded
be
system by hospital staff,
implementation
and
or
operation, may have
direct correlation to the degree of
the
interference
their
system's
significant,
a
implementation
problems
This paper represents the beginnings of exploratory
into
the
staff
resistance/interference
problem.
research
First,
clarifications and definitions applicable
to
this
discussed.
of
staff resistance to
MCBISs exist
describing
Since
in
such
documented
no
the
research
incidents
above will be presented.
at
cases
literature,
the
research
three
are
cases
the government hospital mentioned
Then, diagnoses of the primary causes of
the resistance in the three cases will
followed by
estimate
exploratory
discussion of
a
They will be
be attempted.
undertaken
research
level of incidence of staff resistance to MCBTSs in
the
American hospitals.
Finally, several conclusions derived from the
cases and the level of incidence survey will be discussed.
than provide an exhaustive
problem,
to
this
paper
is
treatise
on
interference
staff
the
limited to establishing
a
Rather
possible basis
for future research into this area.
The Staff Interference Problem:
Clarifications and Definitions
Staff interference with an MCBTS implementation occurs when
member of the hospital's staff deliberately acts or fails
such
that
he
activity so
as
interposes
to
oppose,
to
implementation.
in
Resistance
the
or
impeed
the
and interference, hereafter referred
in
numerous ways.
may be violent or non-violent.
It
act
MCBTS implementation
hinder
retard,
as interference, may be manifested
covert or overt.
planned
to
a
Tt
Tt
may be
may
range
from passive non-cooperai ton to physical destruction.
The interference investigated in this paper is not limited by
motive or scope.
may
However, since some resistance and
be harmless or constructive (eg:
research only focuses
actually
degrades
on
instances
interference
the devil's advocate), this
in
which
the
interference
the system's effectiveness or causes some type
of unplanned cost,
regardless of intent.
The issue of the staff's
justification for interference is not considered
the
issue
of
whether the interference caused the implementation
problem or system deficiencies
caused
interference
the
is
not
Again, we are concerned with incidents of interference
addressed.
regardless
which,
Further,
here.
justification
of
resulted in
or causality,
a
tangible negative impact on the MCBTS's implementation.
employee
general,
In
interference
with
successful
the
of an information system can be limited through various
operation
hardware and software mechanisms which limit access to
authorized personnel
However,
there
is
only
still
(Hsiao,
the
Kerr
system to
197S).
Madnick,
and
possibility
a
that those employees
purposely allowed access are the individuals who seek to resist or
interfere with the implementation of
these
the
Let
us
call
individuals, who have access to the system as part of their
work, the system's 'trusted agents'.
would
system.
include
the
authorized
analyst and
access
operators
hardware
operators), the medical
to
management
staff
the
Tn
and
(both
hospital
The
CPU
they
and terminal
managers
who
were
and the hospital's systems
database,
staff.
context,
the MCBTS
research
presented
here
restricts itself to examining the resistance or interference which
may
be manifested by those members of
a
hospital's staff who are:
-the trusted agents of the system;
-individuals in
a
position of power such that they are
able to affect some aspect of the MCBTS's implementation; or
influence leaders (Beckhard, 1977)
with respect to the prior two groups.
hospitals,
interference to MCBISs is occuring in our
If
ramifications are potentially significant.
factors
leading
could be one of the
variance in costs associated with
high
the
to
Tt
its
similar logical application groups.
Tf
it delays
a
planned
and
budgeted implementation, it could place an unexpected constriction
the hospital's cash flow,
on
serious problem for most community
a
or general medical and surgical hospitals.
hospital
functions, the
or rental
would
still
be
is
a
the
a
for
Thus, the cost of
subsystem
disuse,
pall of unreliability on MCBISs in general.
very real problem
in
the
the
artificially inflated.
Should interference lead to system or
cast
responsible
fees for the entire system.
the functions actually used
would
if
causes the failure or disuse of some of the system's
interference
purchase
Tn most cases,
industry
health
which
in
it
This is
computer
systems have had to prove themselves application by application to
a
generally
cases,
a
reticient
system
medical
'failure'
population in the past.
hospitals
caused
consideration of other systems for
a
to
Tn many
reject
period of years.
Perhaps the most dangerous implication of interference is
the
area of patient care.
the
in
Should interference manifest itself in
erosion or partial and inconspicuous destruction of
associated
with
information system,
unknowingly
integrity
the
Potentially
lost.
situations could result from
erroneous data.
may
data
by
care
patient
therapy
basing
destruction
occur
in
on
loss
confidence
of
in
management
hospital's
a
information database, inappropriate decisions
management's
laboratory
a
fe- threaten ing
practitioner
a
as
patient
of
1 i
such
This scenario, unfortunately, is not far fetched.
similar
Should
application
clinical
a
database
the
could
made
be
or
the potential of management
information or decision support systems could ensue.
is clear
It
quite
serious.
difficult.
such
of
that the
interference
Tt
topic.
research
that
have
legal,
the
ethical,
instances
privacy
and
that this is not
potentially
it
success
or
important.
frequently
a
failure
of
MrBT<^
an
There are many cases in which
a
system's functions go unused by the hospital's staff.
other
cases in which the system is being used in
and
paying for
'failure'
becomes
is not an
subset
a
system but is not using it at all.
are and who defines them is
research presented here does not attempt to
a
beneficial but
hospital
What 'success'
very moot issue.
define
of
There are
There are still other cases in which the
unplanned way.
is
a
sensitive
a
also
it
be
subject is
this
into
But the same reasons which make it
"either/or" situation.
a
result,
is not surprising
subject also make
apparent
a
may
interference
of
The hospital's release of information about
implications.
discussed
As
implications
these
The
terms.
Instead, it controls for this by considering systems in all states
of 'success'
or
'failure'
THREE CASES OF STAFF INTERFERENCE WITH MCBIS'S
An Overview
cases
The three
presented
here did,
hospital
of
staff
Certain data about the cases
fact, occur.
in
identity
have been omitted or altered to assure that the
alter the nature of the events as they are described.
to
These cases occurred at one of
hospitals
the
of
However, in no case was this disguise
hospital remains disguised.
allowed
interference
members'
hospital was
United
the
in
a
the
during
States
mid-1
the
medium sized facility which served
approximately
people.
70,000
The
owned
government
2,14"?
hospital
9'7Pl
'
s
The
.
population
a
had
an
of
active
outpatient service attached to its inpatient facility and provided
most medical specialties to its patients.
systems staff (CS staff)
implemented
more
years preceeding
than
the
which
a
had
It
developed
small computer
a
successfully
and
half dozen applications during the two
events
described
This
below.
computer
staff had developed relatively good working relationships
systems
with most
departments
in
the
hospital
and
reputation for reliability and user advocacy.
which
had
acted
It was
as the interface between the hospital
vendor in each case.
developed
had
a
the CS staff
and the system
.
]]
Each case represents the interference of one employee of
hospital.
Each
incident falls into the interference category of
covert, non-violent sabotage, as defined in
"2
or
(Merriam,
researched, in vivo, by the
d
a
standard dictionary:
willful effort by indirect means to hinder,
discredit..."
the
1971).
author
of the incidents were
All
who
undo
prevent,
was
involved
their
in
iscovery
Case
An ECG Interpretation System
I;
Alpha was the head medical
Mr.
health
screening
technician of one of the
facilities that the hospital operated.
The two
screening sections were co-located and differed primarily
populations
they
served
and
a
addition to sharing
provided.
In
physician
staff
provided
same
Mr.
Alpha
same
the
ten
miles
from
The
the
electrocardiograph
^ETG)
general medical technician, phlebotomist or screening
coordinator, when needed.
it
the
functioned as the resident manager of his
section in addition to filling in as an
technician,
building,
medical support to both sections.
screening complex was located approximately
hospital.
in
of the medical services
subset
the
two
His operation was entirely manual
was decided by the hospital's management to implement
provided remote processing ECG interpretation system
screening at the health screening complex.
for
a
when
vendor
routine
17
The hospital's CS staff and cardiology
investigating
interpretation
ECG
the implementation
characteristics
of
systems for over
system.
subject
the
department
a
year before
The
operating
the system which was actually implemented had
of
undergone six months of testing and
comparison
with
results.
completed,
it was
After
been
had
testing
the
was
physician's
felt that,
although the system had an acceptable level of false positives and
false negative interpretations for
levels
screening
a
these
facility,
were too high for the cardiology department's environment.
The patients of
incidence
cardiology
the
had
higher
much
a
than would be expected in an average
abnormalities
of
department
Therefore, the system was to be removed
screening population.
to
the health screening complex from the cardiology department.
The system
appearance,
to
itself
the
technicians at the
was
three
very
similar,
channel
ECG
screening
health
operation
in
machines
facility
that
used.
and
the ECG
The
only
operational difference the ECG technician would encounter was that
after
a
attaching the patient leads, the technician would establish
data communication link
activating
an
auto-dialer.
ECG unit normally.
the
to
CPU
via
telephone
He would then proceed
lines
by
to operate the
Approximately, three to five minutes after the
trace was finished, the interpretation would be printed at the ECG
room and would be forwarded to the screening physician
would actually see the patient.
before
he
n
which
reported
Alpha
Mr.
manager
hospital
While planning the implementation, the
to
decided that the change to the MCBTS
offered an excellent opportunity to combine the ECG operations
the
of
screening sections, thereby increasing the efficiency of
two
developed
design
a
for
a
staff
CS
The
the staff and utilization of the computer system.
refurbished ECG room which would allow
two sets of patient leads to be connected to the ECG machine by
selector
switch.
One
month later, construction of the room was
There was still some
complete and the system went into operation.
confusion about
its
including
Alpha,
Mr.
had
been
and each demonstrated
trained
But, the technician trained
from the other section still had duties there
upon
process
to
Hospital management
decided
replacement
person
for
a
his
section's
to
hire
retiring
technicians,
Three
however.
operation,
proficiency in the use of the system.
counted
a
from
be
not
share of the patients.
new
a
could
and
technician
the
as
a
health screening
months.
complex;
but, the new employee would not arrive for
Hospital
management left the two screening sections to work out
mutually acceptable work schedule.
Mr.
Alpha was
two
instructed
a
to
contact the CS staff if any problems developed with the system.
As
far as hospital management knew,
without difficulty, for Mr.
But,
Alpha had registered
no
complaints.
six weeks after implementation, the financial manager called
the CS manager to ask why the bill
so
the system was being used
low.
from the ECG system vendor
was
The CS manager found that the fixed fee was correct but
that the 'per ECG' charge indicated that only approximately thirty
14
ECGs had been taken.
Tn
response to
This was about 400 below the expected level.
query from hospital management,
a
Alpha
Mr.
had
indicated that the health screening facility's physician staff was
highly
dissatisfied with the ECG system and had instructed him to
the
cardiology
management
Hospital
discontinue its use.
department
manager to investigate.
CS
and
requested
immediately
The
cardiologists spoke with the screening physicians and learned that
the system
satisfactorily
unreliable
highly
was
reliable
in
areas
hospital tests.
in
selector switch was the prototype, the
r<^
found
to
be
Since the dual lead
conjunction
manager, in
with the system vendor, attempted to determine if it was at fault.
It
was
found
to
be operating perfectly.
problems were eliminated
the
list
of
system and hardware
ECG technician from the hospital was sent over
complex
to
knowledgable.
was
It
be
Alpha was the operator.
They
indicated
system not be used.
not
malfunction.
Further,
should
be
unreliable
was
that
they
to
do
were
had not ordered that the
They had merely agreed with Mr.
Alpha
that
discontinued when he personally showed them all of
and
then confronted Mr.
nothing
it
Next, the screening physicians
the bad tracings and interpretations and had stated
too
sufficiently
that when the system was used during the first six weeks,
contacted.
it
They were found to
noted, however, that during the personnel
evaluations, the system did
Mr.
screening
the
to
An
assess the ability of the screening complex personnel
to
properly use the machine.
learned
problems,
possible
was left with the operators to consider.
management
hospital
from
As
with
labor intensive to use.
Alpha with the fact
the
that
that
it
was
Hospital management
the
computer
had
quality of the trace and that hospital
IB
system
tests showed after over 1100 tests, that the
than
more
percent
five
operator
than
time
the
standard E^G
manner
beligerant
less
neerieri
that
his
machine.
Mr.
Alpha responded in
facility
was
fine before they had forced the computer on him and
a
disrupted his way of doing things.
manager
learned
thereafter
Shortly,
the
had deliberately misplaced the leads on the patients when
taken the ECGs
would
deny
not
Shortly
it.
Further,
true.
suspicion
earlier
indicated
he
In
was,
in
that he could misplace the
leads or use insufficient electrolytic cream
and
Alpha indirectly
thereafter, Mr.
disclosed to the CS manager that the
fact,
had
he
Alpha was confronted with this suspicion and
Mr.
.
Alpha
another employee suspected that Mr.
that
CS
for
contact
prober
that the computer would still attempt to interpret the trace.
fact, this was designed
generate
signals
weak
their inability
Alpha
transferred Mr.
responsibilities.
patients
motion
their
another
problems
patients
job
with
immediatelly
management
Hospital
to
(eg:
constrained
with
were encountered with the system
Alpha's reassignment.
after Mr.
When Mr.
Alpha produced bad EKG
traces
and
the
resultant
system interpretations, he disrupted the ability of the
erroneous
hospital to render
Instead
No
many
signals with high noise levels due to
or
control
to
disease).
Parkinson's
into the software since
of
a
consistantly good quality
repeating
of
patient
care.
the ECGs that he degraded, the physicians,
under time constraints, attempted to read
patient was still in the facility.
Mr.
the
traces
while
the
Alpha then filed both the
ECG
and
record.
the
erroneous
He did not
interpretation
keep
track
in the
patient's
which
of
patient's medical
were
ECCs
degraded so it was impossible to exhaustively search the thousands
of
records
increased the chances that
received
attention
was
a
cardiac condition which
missed.
man-days
many
and
Alpha
have
should
Also, he cost the hospital
the
interpretation
charges of the ECG
rental and variable ('per ECG')
service
More importantly, Mr.
stored in the hospital.
hospital management and CS staff
of
problem research effort.
Case II;
A
Beta had only been working as
Ms.
the
Clinical Laboratory Information Ryster
clinical
a
clerk/receptionist
reception desk for one month when the
laboratory's
clinical laboratory information system (LIS) was
had
at
She
installed.
been hired specifically to augment the lab staff's data entry
The LIS design
capability for the new system.
was
developed
by
another government agency, the government's central systems staff.
When the contract was awarded for the LIS, the hospital's lab, CS,
and
management staff were still not completely satisfied with the
design
deficiencies
design.
They
cripple
the system in an operating lab environment.
noted
several
which
However, the
whole hospital was aware of this and knew that since the
had
been
attempt to
contracts.
awarded,
redesign
LIS
they
would
troublesome
could
contract
have to implement the system and
subsystems
under
modification
would radically alter the information processing
17
However,
methods used by the lab.
alter
processed
Tests would be
equipment;
essentially,
on,
was
She
lab.
significantly
not
types
same
the
a
hectic
very
given cursory training
in
time
for
they
very
already
were
the
the old manual methods.
She used these procedures to help the other two receptionists
since
of
test requests and reporting would be automated.
but,
Beta had become an employee at
Ms.
would
in which most of the lab's work was accomplished.
way
the
it
handled
they
proficient,
but
result,
Ms.
Beta would spend much of her time away from her work station.
The
approximately ninety percent of the workload.
lab
management
As
a
During the
staff did not keep track of her time.
intensive
week before the system was to go on-line, she was given
training
in
use
the
of the system's data entry terminals.
seemed to have no difficulty mastering the
able
sufficient
demonstrate
to
proficiency
system's marked document readers fMDRs)
methods
new
in
and
be
the
grown to
a
processing
was
the use of the
and CRTs.
The lab and hospital management had decided to allow the
to
She
lab
prototype site for LTS because the lab's workload had
volume
within
which
the
would
next
require
three
years.
information
automated
Already,
the small
analysis and reporting system that the rs staff had built for them
was insufficient.
enthusiastic
or
All
of
indifferent
the
to
were
either
the system's potential.
The lab
hospital's
staff
management staff had committed itself to the success of the system
after involving all of the lab technicians in the
decision.
The
hospital management had fully supported the lab's decision and had
IP
attempted
increase
to
clerks, such as Ms.
to
the
lab's manpower to inclurle data entry
Beta, and the operators who would be required
run the new in-house CPU.
The hospital would be LTS's prototype installation.
As noted
above and as typical for many governments, the initial design
produced
was
government's central staff.
for
Run on
a
dedicated mini-computer, LIS would support the hospital ?7 hours
a
LIS
day, seven days
laboratory
a
by
the
week.
It had
information
most
systems
of
and
the
features
provided
direct
reporting to many nursing units.
Test requests would be
marking
and
the
appropriate
tests
physician identification on one of
Prior
to
a
entering
the
set of test
a
for
patient
by
and
cards.
ordering
test requisition, however, the patient's demographic
the
reception
lab's
desk.
cards would be entered into the system's MDRs by Ms.
They
master
a
This ordering process would be manual
patient.
until the cards reached the
co-workers.
result
made
data would have to be entered into the system to create
record
other
of
There,
the
Beta and her
would verify the information on the CRT screen
and enter the demographic data on
a
special CRT screen if
a
master
record did not exist for the patient.
Much effort had been devoted to the implementation plan.
provided
for
a
phased
departmental
implementation and parallel
processing with the manual system until the software was
as correct.
Tt
Additional, temporary personnel, like Ms.
verified
Beta, were
19
required
effort since one of the two veteran reception
this
for
desk workers was used for
of the lab than
other
vetern
a
job that required
new employee
a
clerk accepted
would
a
a
stronger knowledge
Unfortunately,
have.
different position
in
and was not available for the implementation effort.
Ms.
Beta suddenly found that she, with
the hospital
As
a
result,
experience,
month's
one
the
was the senior of the three data entry clerks.
The implementation was thrown into chaos, however.
after the
implementation
unilaterally
decided
commenced,
the
director
begin
of
the
departments
operation
of the entire system.
As
a
directed to preventing the collapse of the system.
fully
de-bugged
the software and the first two weeks of the
input operations reached
data entry
employed
desk
frantic
However, the system was kept operational.
As the system settled
reception
be
The vendor had
system's life were characterized by software failures and
software patches.
to
result,
software testing was delayed and the CS staff's efforts had to
not
lab
to abort the phased- impl ementation plan and
issued instructions to his staff and all clinical
immediately
Ten hours
was
stations
resolving
a
into routine use after the first month,
steady
state.
The
workload
at
the
usually heavy, but the continuous use of two
satisfied
minor
demand.
crises
and
departments were responsible for the most
card preparation errors.
The
third
clerk
was
determining which medical
frequently
encountered
?w
Approximately four
weeks
physician complaints reached
physicians
several
with
a
and
after
implementation
the
The CP manager met
critical level.
learned
values
Normal values were maintained in
incorrect.
were
were
functions
value
normal
beginning of the implementation
appeared
found
and
the CS manager that either
to
sex.
a
be
to
at
the
correct.
Tt
tested
exhaustively
for
system
a
test type, age, race, and
table, the indexes to which were:
The
which
problem
one
that
appeared to be widespread was that many of the normal
tests
began,
sporadic software error
was occurring or an interim software correction interacted with or
His
logic.
value
damaged the normal
staff
vendor's
the
and
Still,
rechecked the normal value logic and could find no errors.
The CS staff then checked the data entry
continued.
problem
the
logic to see if it was altering the input data.
entry
data
the
Next,
also.
transactions
Tt
were
inordinately high number of newborns (defined as
checked.
age
=
(^ ^
children.
one
Further investigation revealed that
the
of
staff
member
remained
entered correctly.
the
were
problems
at
management
She
After
re-occur.
denied
could
this;
trace
the
but,
errors
disciplinary action if the problem
seemed to end.
were
When the data entry clerks
would
When
a
reception desk, the data was
the
correlating
left
the
alone,
problem
Beta was found to be the
incidents with the staffing pattern, Ms.
offender.
data
was not entering the patient's age in all cases and
clerks
also was making random entries for some demographic data.
CS
An
Even more mysterious, many were found to have spouses and
found.
entry
correct,
was
when
she
was
told
that
to
her
and
would
take
occurred
again,
the
problem
?1
Beta's actions were particularly hazardous to
Ms.
Many
data.
these
of
alteration
Beta's
coincident to Ms.
at the hospital
normal values for infrequently ordered tests.
to
wrong normal range being associated with
test
and other truly abnormal
harried
a
respond to
Hence,
result.
a
results were indicated as normal.
take
might
intern
a
some
Additionally,
her
actions
system among clinicians and
led
a
to
a
normal.
loss of confidence in the
a
cost of
false
a
As
action to
inappropriate
false abnormal and fail to react to
a
which
tests
which were actually normal were flagged as abnormal
results
result,
tendency
a
Beta's activities led to
Ms.
normal limits.
within
not
They had
flagged
rely on the LIS test result report which
were
patient
of
not knowledgable about the
were
interns
care
arrived
A new group of interns had
the hospital's inpatients.
of
the
of
man-days
many
problem
tracking work on the part of the lab and CS staff.
Case III:
Mr.
Admissions
An Admission, Discharge, and Transfer System
Gamma
and
was
employed
Dispositions
as
clerk
a
Department
approximately eight clerks who shared the
functions
included
patient
discharge processing
Each
transfers,
and
bed
nursing
status
miscellaneous
was one of
He
(A&D).
many
hospital's
the
tasks.
A&D
patient admission, location of
record creation, communication with the
inter-unit
in
a
A&D
bed, medical
units,
tracking
maintenance, patient
administrative
chores.
clerk was fully trained in all of the tasks so that he could
0-)
be rotated onto night duty.
each
day
the week.
of
The A&D room was manned
position.
Tt
had
be
to
medical
and
The job of an A&D clerk
difficulties.
level
patient
between
demands
staff
was
point
the
at
considered
Transfer
(ADT)
system
entry
the unenviable reputation o^ being
implement
to
Admissions,
an
of
and
an
a
job
of
^&D.
Discharge
and
which one had to endure before being promoted up and out
The decision
of
Gamma and his co-workers frequently
Mr.
had to work overtime and always seemed
friction
hours
^^i
was taken by the hospital's management in
response to the government's central systems staff's design of the
system.
The system actually had several
functions other than apt.
A&D data was used as input to its financial
functions.
and
cost
allocation
The hospital was to be the prototype installation for
the software package.
The A&D staff were advised
after management had reached its decision.
that
implementation
proposed
the
of
The A&D clerks learned
with respect to their involvement, the system would automate
their manual methods without materially altering
section
would
provided
be
longer maintain their manual
with
The
them.
A&D
CRTs and printers and would no
files and card indexes.
The
system
would admit and discharge patients via CRT entries and some manual
functions,
such
as
preparation
of the discharge notice for the
billing office, would be triggered by
of an A&D clerk's intervention.
a
discharge without the need
The A&D staff were only minimally
knowledgable of the system's other functions.
A&D staff training by
was
software
staff
systems
central
prece'3ed
Parallel processing was planned to end as soon as
implementation.
the
the
validated.
Unfortunately,
a
freeze
hiring
prevented hospital management from providing temporary workers
assist
A&D
the
department
processing.
parallel
during
was
assigned
to
The first two weeks of the implementation
A&D.
functions not
demonstrated that there were several
specification
and
To
worker's
staff's
partially alleviate this problem, one of the CS
to
numerous
software
performing
Additionally,
bugs.
to
the
developers of the system had contracted for only one CRT which was
insufficient to handle the four hour peak processing load.
was
After the first four weeks of the system's operation, it
decided
to
drop
the
manual
census
A hospital-wide audit assured
indexes.
and locator files were correct before
later,
the
manager that
confused.
manager
new
the
He
census
indicated
of
and
the
A&D
locator
and
patient location card
that the ADT system census
the
department advised the
to
reinstate
that his employees had been complaining
the manual system until
discover and correct the computer's problem.
work,
the
r<^
hopelessly
were
files
about the workload ever since the system had been
decided
weeks
Two
cut-over.
installed.
the CR staff could
After
two
ADT files were reconstructed by the CS staff;
system problem could be found.
He
days
of
but, no
A&D resumed the use of ADT and the
?4
CS staff monitored the state of the
found
so,
data
that
assistance.
called
central
the
upon
night.
systems
was
staff
resolution, when one of the A&D clerks approached the
and
Tt
for
for two more weeks with no
continued
problems
The
each
every type would sporadically be erroneous;
of
staff
the CS
files
manager
CP
confided that one of her co-workers was deliberately changing
the data he entered
denied
discarding
and
conversation;
the
some
24
a
convened
discuss the problem.
working
'poor'
meeting
a
with
Most of the clerks'
conditions
of
hour period, an audit showed that
the data they entered was correct in the
then
later
She
but, when the CS staff took control
the data entry function for
manager
entirely.
and
the
system
files.
The
CS
the entire A&D staff to
comments were about
the
meeting became an emotional
release for the clerks, especially, the two female clerks who left
the meeting
except
in
tears.
They had few complaints about
for the higher workload
it
caused.
the group that his staff would have to
was destroying the
database
if
the
system,
The CS manager advised
identify the individual who
problems
continued.
The
data
destruction never re-occurred.
The damage caused by Mr.
health.
However,
There was
a
what
was
Gamma never endangered
a
it did disrupt the delivery of inpatient care.
cost associated with the efforts to trace and
thought to be
the greatest damage.
Mr.
a
software deficiency;
correct
but, this was not
Gamma's actions affected databases used
as source data by other system's functions
workload accounting.
patient's
such
as
billing
and
The lack of data integrity caused the entire
9S
implementation
to
stall
confidence in the system
personnel.
Mr.
engendered
and
both
by
cascading
a
nursing
and
unit
loss
of
management
The hospital did not fully recover from the effects of
Gamma's actions for about three months.
Further Implications
The hospital-wide
difficult
to
impact
ascertain.
Both
LT"^
incidents
three
these
of
and ADT had software problems
and neither implementation occurred as planned.
For each of these
systems, the employee interference compounded other
problems
brought them extremely close to total failure and removal
hospital.
The ECG system nearly failed as
employee's interference.
Tn
a
that
the
hospital,
years, has not attempted
to
from the
each case, the hospital was forced to
repair its damage.
which
and
direct result of the
expend monies, time and other resources in an attempt
the interference and
is
had
Tt
to
is significant
resolve
to note
implemented nine systems in five
expand
their
systems
capabilities
since the ADT implementation, even though other systems were under
consideration at the time.
An Attempt to Diagnose the Causes of the Resistance
Approximately one to two years after the
implementations
of
?'-->
systems were completed, the systems had reached steady states
the
implementations
of 'Operation and the problems associated with the
were
emotional
longer
no
arranged with
involved
all
attempt
was
to
motivations
the
interference.
for
such action may lead
implementation
the future.
to
better
a
uncover
to
were
who
staff
The purpose of
or knowledgable about the incidents.
in
these interviews
in
ended interviews were
hospital
available
the
of
Open
issues.
causes
the
or
Understanding the cause for
understanding
mcbtR
the
of
environment and to more successful implementations
It should be
recognized that the diagnoses derived
from these interviews only represents the informed opinion of
researcher
are
and
not
necessarilly
correct
all aspects.
in
Further, each diagnosis is only an attempt to derive
cause;
it
is not
the
the
primary
intended to be exhaustive.
Diagnosis:
Case
T
These findings were based on discussions with Mr.
Alpha, his
facilities'
supervisor, the hospital administrator, the screening
physicians, the hospital's cardiologists, the ECG technicians, the
system vendor representative and the CS staff.
Mr.
have
Alpha had been working in his position
revised
its
considered optimal.
unofficial
office
He was content
in
long
procedures
his
to
section's
enough
to
what
he
operation.
-y
He,
retirement, and had internalized his
nearing
was
fact,
in
earlier.
routines and modes of interpersonnal relationships years
He
regarded
was
the
as
personification
referred
hospital management spoke of his section, they offer
it
as
Alpha's section."
"Mr.
Mr.
when
of his section:
Alpha had
a
history of poor
working relationships with other hospital staff when he worked
the
facility.
main
screening section because it was
contacts.
seemed
He
to
at
he was transferred to his health
fact,
In
to
a
work
job which required few
well
although,
there;
working
he had
received some criticism of his performance in prior positions.
pending
Alpha first learned of the
When Mr.
of the ECG system, he felt that the system was
annoyed
in
good idea but was
the decision had been made without his involvement.
that
He commented
a
implementation
that it was another case of the hospital
his operation.
interfering
Alpha first learned that he would also be
Mr.
working with the other screening section when the hardware arrived
and
room
construction
management,
during
completely
was
He
discussions
a
longer
uncooperative
in
complete
very different situation than normal.
before the ECG system, he had seen
facility
hospital
with
for
over
year.
a
Additionally, he
had
accommodate
system.
the
and
inflexible
held to arrange joint use of the system.
Alpha found that he was no
section,
dealing
became sullen and predicted that "the whole thing
he
won't work."
when
began.
to
Now,
change
He
no
some
felt,
hospital
they
of
due
were
his
to
Mr.
of
his
He claimed
that
control
manager
there
in
his
daily.
procedures
to
these changes, that
9P
management was, once again, unhappy with his performance
constraints
imposing
his
on
authority.
He
environment intolerable and decided to resist the
himself
of
it.
new
the
found
system
rid
to
the system were removed, he thought that he
Tf
able
would be
was
and
environment
work
his
return
to
its
to
pre- implementation state.
Considering the implementation as
1975)
,
appeared
it
(Schein,
midst of
1971).
a
insufficient
that
Alpha
Mr.
a
"change" phase.
change process (Ginzberg,
"unfreezing"
occurred
thrust, unwillingly, into the
was
In his case,
accept the change proved detrimental to
the lack of motivation to
the
change
effort.
Tt
appeared that the implementation of the ECG system, by itself, may
not
have
caused
Alpha to exceed his tolerance for change.
Mr.
However, management's
decision
also
to
alter
the
operational
structure of the two screening facilities' ECG services compounded
the
change and it became unacceptable.
to a pre-system state as sufficient
his
Mr.
Alpha saw the return
of
reward to justify the risk
actions, whatever that risk may have been perceived to be.
later, deliberate effort to unfreeze and motivate Mr.
failed.
opponents
Alpha
A
also
But, by this time, the change agents were perceived to be
their failure to convince Mr.
and
change should
introduction
not
of
been
have
any
similarly disrupted Mr.
system,
unexpected.
MCBIS
or
Alpha to accept the
Apparently,
other, which would have
Alpha's organizational environment
have been resisted by him.
the
would
79
Diagnosis:
Case
TT
This diagnosis is based on discussions with
co-workers,
her
physicians,
supervisor,
the
vendor
system
administrator,
hospital
the
staff
pathologist,
chief
her
Beta,
Ms.
representatives, and the CS staff.
Ms.
Beta,
a
recent high school
hired
was
graduate,
as
a
temporary employee for the duration of the test of the lab system.
She
been
had
advised that the job could become
but that since the system was
a
prototype,
permanent one,
promise
no
could
be
Before her training on the system began, she had frequently
made.
been absent from her job for hours at
was
a
weak
habits.
in
the
lab,
Her sabotage
installation
a
time.
Fmployee management
so she was seldom corrected
of
the
began
system
shortly
for her work
after
and, according to her co-worker, continued to
lesser degree even after management had
detected
and
a
the
much
"resolved"
it.
During the implementation of the system, the workload at
laboratory
reception
desk
stressful situation for Ms.
situation
system.
rapidly
Beta and
increased,
her
fellow
creating
workers.
a
the
very
The
rapidly deteriorated due to the frequent failure of the
When LIS failed, input operations from the reception desk
would cease but the patients would still have to be provided care.
^p(
When the system was reinitiated, all data accumulated during "down
overtime
by
Ms.
Beta
disruptions would
cause
receptionists,
outward
the
staff and patients.
Further, these
and other staff members.
practitioners
angry
confront
to
personification
the
the lab to most
of
constant
almost
engendered
Beta's job
Ms.
unscheduled
requiring
time" would have to be entered, frequently
stress and instability.
expressed
periodically
receptionists
Although all three
a
strong dislike of the system and their work environment, the other
two
apparently
workers
method of dealing with the situation
periodic
absence
her
from
the situation.
with
coped
sabotage
frequent
was
workplace.
One
Evidence
two.
indicates
that
Beta
Ms.
by
the
reversed
her
up
behavior toward work only when she thought that there was
possibility
of
from
sabotage
to
compliance with work policy.
frustration
with
calculated
Beta
Ms.
than
her
payback
Sabotage allowed
her
to
be
higher
environment
work
her
and
sabotage would
supervision;
go
stretched
Hence,
her
the
Tt
also
The probability was high that sporadic data
undetected:
she
had
almost
direct
no
there was little quality control of her work;
data errors would be masked
bugs.
her
from
vent
implementation period during which she would be employed.
required less effort.
real
a
full-time employment at the laboratory.
securing
This and other information imply that
payback
and
her co-workers
of
reported that her interference was frequently covered
other
Beta's
Ms.
sabotage
by
ensued.
hardware
Now
failures
and
and,
software
she would neither have to
^1
become proficient with the system nor cope with
She
she discussed
employee,
interference
her
was
who
Later, when
the trauma and retain her income.
escape
could
environment.
the
proiectinq
by
another
to
it
known to be innocent, it was learned that she
covered her continued, but occasional and random, data destruction
unknown, however, when she was offered
change
status
her
in
was
a
a
This was
if discovered.
by claiming them to be innocent mistakes,
full
The
time position.
sufficient alteration
in
her reward
more
adopted
structure such that she ceased her interference and
orthodox work habits.
Diagnosis: Case ttt
Gamma,
These findings are based on discussions with Mr.
his
co-workers,
his
supervisor, the hospital registrar, the hospital
administrator, nursing unit personnel, the central
staff
systems
and the CS staff.
Mr.
the
computer
system
was
implemented.
central systems staff described the ADT
co-workers,
he
understood
significantly easier and help
would
be
before
Gamma was dissatisfied with his work environment
that
it
reduce
When
system
would
their
government's
his
to
him
make
overtime
and
their
work.
far more accurate than their manual system, so
it
help reduce the friction between the A&D department and the
his
work
Tt
would
other
7?
departments
in
the
hospital.
expectations were elevated during
possibly,
the
work
would
his
Thus,
unfreezing
the
peers'
his
and
Quite
phase.
be far more interesting, would better
utilize his talents, and would provide more prestige to
his
job.
He and his co-workers were enthusiastic about the new system.
during
Unfortunately, his expectations went unfulfilled
implementation.
workload
due
increased
installed
and
it had
Only one CRT
hardware failures at room temperature.
Cognitions (Feldman, 196^) developed, one
at
time,
a
that
the
Hardware and
was far from what he had been led to expect.
system
materialize
to
sufficient numbers to offset the additional work.
was
parallel
the
to
The promised temporary employees failed
testing.
in
His
the
software problems increased his frustration since he would have
backlog
database.
of patients awaiting service while he tried to update the
These
conflicted
cognitions
which
resolution
provide.
Problems reached an intolerable
the
continued
no
training
expectations
with
level
division
his
was
for
to
sloughed off by the central systems staff in deference
problem resolution.
developed
would
be
on-the-job training.
and
available information was able to
demanded
when
a
Mr.
Gamma
receive was
to
system
They indicated that the training manuals they
sufficiently
But, when
thorough
they
left
to
the
permit effective
hospital,
their
training manuals were found to be entirely inadequate.
Mr.
Gamma recognized that the only
respite
he
would
have
?(
from
this
burden
would
when the data in the system were so
be
unreliable that management would decide that
even
Then,
used.
Evidence
indicates
system would "just go
desire
cognitive
Gamma's
followed.
away"
actually
could
the
data
until
dissonance
be
or
correct.
work group wished that the
resolution to Mr.
the
as
(Festinger,
This
correctly.
worked
it
construed
be
complete
be
entire
his
that
not
clerks still had to enter data, it
if the A&D
would not be important that
could
they
Sabotage
IQ'''?).
His actions were reinforced when management decided to
rely on the card file and other manual systems.
Three events occurred after the CS manager's meeting with the
A&D clerks noted above.
could
isolate
the
The A&D staff learned that the
offender;
sabotage were explained;
and
improve A&D working conditions.
his interference and began
a
the
staff
CS
negative implications of the
measures
several
were
Following this, Mr.
taken
to
Gamma ceased
prolonged period of cooperation.
A Consideration For Other Hospitals
were
If the experiences of our case hospital
problems
would
approximately
However,
be
"7,300
of
little
other
if their case
interest
hospitals
is not
in
to
the
unique,
their
the managers of the
United
States.
isolated, interference could be one
of the causes for the frequent inability of MCBTSs to achieve full
success within
many
hospitals.
This
is
not
interference is the major implementation problem;
suggest
that
it
may
be
a
desired
operation.
with
MCBIS
level
of
success
a
rather, to
but,
system's failure
during
We have already noted some
failures.
that
factor either alone or in conjunction
with other problems which leads to
the
imply
to
However,
we,
its
of
to
the
acheive
to
implementation
costs
date,
or
associated
have
had
information with which to estimate the frequency with which
interference impacts the success of MCBTS implementations.
no
staff
^5
AN EXPERIMENT TO ESTIMATE THE LEVEL OF MCBI'^ INTERFERENCE
Purpose
If
the case hospital
interference
survival of
hindered
which
a
system, the
an
alone
been
not
implementation or threatened the
become
may
problem
different statistic.
the
industry-wide
an
of incidence.
and, each will yield
There are numerous ways to define incidence;
a
experiencing
in
we wish to estimate its level
Therefore,
concern.
has
study
this
The definition chosen for
number of hospitals which have experienced CBMIS interference
with respect
number
the
to
experience.
experience,
By
of
we
mean
the
that
CBMIS
have
which
hospitals
hospital
operating
environment.
The
system
in-house or by any type of vendor.
as
computerized
axial
However,
tomography
been developed
have
could
or
devices
exclude
we
has
normal
attempted the integration of at least one MCBTS into their
such
is
analysis
chemistry
systems from being categorized as MCBlSs.
If we
find that the estimated level of incidence is more than
just background noise, the
hospital
may
manifestation.
its
government
events
be
illustrative
But,
a
which
occurred
at
interference
typical
of
case
the
major distinction of the case hospital
oriented
incidents were related to
management and funding methods.
the
fact
that
it
was
a
If
was
the
government
hospital,
this
would
provide
an
indicator
initial
direction of future research into the problem.
not
related
to
government
ownership,
Tf
for
the problem
health
delivery
a
problem
The
is
then our findings may be
applicable to both the government and private sector
facilities.
the
may also become
either
care
concern to
MCBIS vendors dealing with
hospitals
question
the incidence of interference the same
then becomes:
is
from
for hospitals from both the government and
private
sector-
The
sectors?
We
may resolve this question by testing the following hypothesis:
HI:
Pg = Pp
where
P =
the probability that
a
randomly selected hospital
has experienced at least one
incident of interference
given that it has had MCRTS
experience,
g
5
government hospitals,
p
=
private hospitals.
That is, we hypothesize that the probabilities of interference are
the same for both government and private hospitals.
The estimate of the level of interference and the test of the
hypothesis, HI, can be accomplished through the
experiment as described below.
execution
of
an
I
Experimental Design
The experiment designed to estimate the
parameter
and
quasi-experimental
is,
test
to
(R
hypothesis,
the
X 0)
level
the
of
is
HI,
incidence
of
That
Campbell, 19^^^).
type (notation:
randomized sampling of the population universe is made after
a
the event has occurred.
Each sample
represents
point
single
a
Bernoulli trial whose outcome is actually an experimental value of
The values which
the Bernoulli random variable x.
X =
(the hospital
has not had
takes on are:
x
inter f erence MPBTS experience)
or
=
X
Recall
1
(the hospital has had
inter f erence MCRTS experience)
I
an incident is considered as interference, under our
that
definition, only if it actually results in
a
money
time,
cost in
Such costs could range from an actual
or other tangible resource.
delay of the implementation to the complete failure of the system.
The experiment will be
defined as
number
a
of
a
series of Bernoulli trials which are
Bernoulli Process.
hospitals
which
The
have
random
variable
experienced
interference in
trials, the sum of n independent Bernoulli random variables.
defined by the binomial
sample
size
n
probability
mass
function
(pmf)
was chosen to be forty trials (n = ^0)
use of the Gaussian approximation to the
the
is
K
binomial
.
K
n
is
The
to allow the
PMF
when
the
TR
probability
approach
P =
interference
of
or 1).
P
extreme fi.e,:
is not
P
does not
More formally,
where R
Prob(RlE)
5
the hospital has experienced
MCBTS interference,
E =
the hospital has had MCBTS
experience.
n will
represent
hospitals.
be an equally sized two cell sample.
twenty
trials
To control
each,
for
The
cells
will
both government and private
for the fact that the case hospital
was
a
short-term facility, the sampling population will be restricted to
the
6,700 American short-term hospitals.
approximately
Further,
the trial will count only if it fulfills the conditioning event
E,
that the hospital has had MCBTS experience.
Data Collection
Since the
sensitive
data
collected
interference
about
of
are
a
nature and since the success of data collection depends
on the cooperation of the
hospitals
randomly
selected
for
the
survey, absolute accuracy on the part of the respondents cannot be
guaranteed.
The
experiment's
forty trials were operational i zed
via directed but open ended questions in
respondent (s)
at
a
telephone survey.
each hospital was chosen as the manager(s^
The
most
Initial contact at each
knowledgable about the hospital's MCBTRs.
facility was
with
the
administrator's
hospital
or
director's
office, which would provide the initial referral.
The survey was structured as follows:
-an introduction of the interviewer;
-an explanation of the purpose of the survey;
-initial questions about the types of the hospital's mcbtss,
-an explanation and example of interference as defined
in
this study;
-questions about the incidents of interference in his
hospital: its frequency, manifestation, perpetrator,
detection, and possible cause.
from consideration if
A hospital was rejected
individual
currently
could
be
if
its
as
a
uncooperative
As
implies,
this
implementations,
sample point.
management
proved
A
for
if
one
such
either
unwilling
after agreeing to participate.
participation.
repeated trials until
a
sample
that
hospital
was
hospital would also be eliminated
hospital was eliminated from consideration.
offered
no
found and he had personal knowledge of at least
one of the hospital's MCBTS
accepted
was
who was sufficiently knowledgable
employed
about any MCBIS implementation.
person
there
The
size
selection
of
40
to
participate
Of course,
No
or
the case
incentives
were
strategy called for
was
attained.
The
:
/I PI
selection
actual
was
by
short-term hospitals
Association
Guide
random number index into the list of
a
contained
the Health Care Field'
to
random numbers were generated by
PRIME
the
in
40PI
'American
the
in
a
Fortran
(\9'^P
edition).
program
tv
random number function, using the rPU
centiseconds as the initial seed.
contacted before the
desired
following list describes the reasons for the
s
accessing
clock time
completed.
was
size
'
The
of 5P hospitals were
A total
sample
Hospital
The
exclusions:
Iff
court trusteeship
- 1:
hospital closed and held under
-
1:
administrator not available for
-
4
no one knowledgable was still employed
-
2:
staff was uncooperative
a
1
Pi
calls
-10: no MCBISs
the cooperation of the management of
As these statistics indicate,
the
vast
majority
hospitals
of
However, the
excellent.
was
hospitals which were excluded from the sample, other than the
which
never
had
experience,
MCBIS
results.
Each may or may
incident
or,
indeed,
may
not
have
never
should be aware of their potential
of bias is unknown.
induce
could
had
MCBTS
an
have had
a
a
system.
ten
bias to the
interference
The reader
for bias even though the vector
^1
Parameter Estimation
experiment,
For this
probability
Bernoulli
a
interference,
of
process,
A
P,
derived
is
estimated
the
from
the
maximum-likelihood estimator.
P
=
"H-
The survey found that one or more incidents
of
interference
occurred in 18 of the 40 hospitals which comprised the sample set.
Thus, the estimate of K, K, as calculated from the survey is:
4j?
A
K
=
E
=
X.
IR
i=l
Thus,
^
18
40
and the confidence interval
(K
upper limit:
P
+
1)
for P with
F^^2;
+
(K+
1)
=
0.05 is
——
2(K + 1); 2 (n - K)
=
(n-K)
ct
F^/2;
2(K+1); 2(n-K)
=
0.6153
49
lower limit:
that
=
P =
K +
K +
1)
F
of the population under observation would
(0.274P,
PI.
2748
a/2; 2(n - K + 1); 2K
experimental P's derived from similar samples
95% of all
is,
(n -
fall
in
interval
the
Hence, we conclude that:
0.f^lS3).
the estimated probability that
a
randomly selected
short-term hospital, which has had MCBTS experience,
would have experienced interference is 4S% and the
estimate's confidence interval ranges from
27.5% to 'il.5% at the 5% level of significance.
Testing Hypothesis HI
Since
not
is
P
approximation
test
to
percentages of
an
incidence
extreme,
HI.
in
We
we
wish
government
may
to
use
Gaussian
a
compare the estimated
and
private
sector
hospitals, so
/n
U
(Pg - Pp)
=
/(Pg^Pp)a_Ei±lE)
approximates
a
Gaussian distribution and we will reject
HI
when
A t
U
>
where J
Jg
the a associated with the
=
percentage point of the
a
standardized Gaussian PMF.
The
experimental results showed that each category of hospital
in
the survey, government and private, contained nine hospitals which
indicated that they had experienced interference.
A
Pg
A
Pp
=
0.4 5
=
We want this test to be constrained to have
rejecting
where J
0.f;75
^2
=
K]
when
(^•'^'^^
I
but.
1.204
=
so we accept
HI:
Pg
Pp
=
and reject its alternative hypothesis.
Hla:
Pg
/^
high probability
a
that it will be discriminating.
so
HI
set a = 0.5, and we will reject
U >
Thus,
Pp
a =
(5|
.
5
of
We, therefore,
4d
To give
a
equality
better perspective
of
this
which
test,
due
to
the
of Pg and Pp would have accepted HI at the 0.99 level of
satisfied
have
would
significance, values of Kg±l or Kp±l
this
We, therefore, conclude that
test at the a = 0.85 level.
we do not have statistical evidence
to disprove HI.
As
a
result, we
estimate that the incidence of
MCBTS interference is approximately
the same in both government and
private sector short-term hospitals.
Types of Resistance Found in the Survey
interference
The manifestations of
hospitals
fairly
were
diverse,
found
began
but
Sixty-six percent of the
characterized
manifestation
interference.
was
found.
in one of the
that the
the
by
No
incidents
were
types
of
violent
interference
Rather, most individuals who resisted an MCBTS did so
categories described below.
reported
represent
The reader is cautioned
the
allegation
of
the
However, significant care was taken in an attempt to
exclude any incident which the respondent did not
deliberate.
into
multiple
of
incident involving overt,
incidents
respondent.
cluster
to
recognizable syndromes.
surveyed
the
in
As
a
result,
several
alleged
believe
to
be
incidents were not
admitted since the respondent was not certain that they
were
not
4S
This research did not attempt to discover the reasons
accidental.
interference in the surveyed hospitals.
the
for
the reasons
So,
Rxampi es of
given by the respondents will not be enumerated here.
each interference category
were
incidents
will
described,
be
These
however.
either in this research or in supplemental
found
discussions held with the staffs of six MCBTS vendors.
Type
I:
Passive Resistance:
hospital
when
occurred
This
used various acts of noncooperation with the other hospital
staff
implement
staff members and system vendors who were attempting to
system.
the
the Controller was the system's
Under perceived political pressure, the manager
primary advocate.
reported gave him permission
to whom he
install
to
system.
the
when the time came to cease parallel processing and cut-over
But,
to
hospital,
one
In
cut-over
upper
system,
new
the
and
withdrew
support
for
permission
withheld
management
system.
the
As
a
result,
parallel processing continued, unnecessarily, for six months.
were opposed to
employees
time.
their
workload reporting MCBIS, refused to make
a
available for system training for
This forced
Tn
the chiefs of several medical departments, who
hospital,
another
to
a
a
prolonged period of
delay in the implementation schedule,
during
which time, systems costs were still accruing.
Type TI:
dissatisfaction
Oral Defamation:
with
a
system
This is
by
attributes or by fabricating problems.
the
attempt
expounding
its
to
spread
undesirable
The top management of
one
4-=;
hospital
told that the MCBIS's CRTs were always breaking and
was
almost had the entire system removed
hospital.
the
from
management learned that the chief complainant,
a
Then,
data entry clerk,
was periodically dismantling parts of her CRT and halting her work
until
was
it
example.
Mr.
repaired.
Case
Alpha
causing
was
claiming the system to be
Type III:
manifests
a
T,
when
above, is another
inaccuracy
system
Operate
the
number
of
data
inability to use the system.
attributing
"errors,"
In one hospital,
all
and
makes
form
during
a
training session.
an
them
to his
clinic
clerks
demonstrated that they were able to correctly mark boxes on
input
This
System:
an employee takes an uncharacteristically
long period of time to learn how to use the system
inordinate
then
and
medical liability.
Alleged Inability to
itself
described
a
data
Subsequently, in several
clinics, the clerks opposed to the new data collection method made
"mistakes" preparing forms.
Their "mistakes" continued for
months and caused input reject rates which exceeded 50%.
three
In other
clinics, the form reject rate ranged from 0% to T% during the same
period.
The
problem was so severe that all of the input data to
the accounting system for those three months was useless.
Type IV:
akin
to
Type
HI.
It
occurs as
of the data input process and
sabotage
falls
This
Quality Control Failure:
within
this
a
is
somewhat
failure to control the quality
results in data
type.
type
The
destruction.
billing
clerk
Data
in one
hospital had over ten years experience in
billing
hospital's
the
manual
Rhe was known for her accuracy and reliability.
office.
After stating that she did not like the computer system, she began
to
prepare bills
incorrectly.
significant
complaints,
This
problems
possible loss of revenue.
resulted
many
in
with third party payers, and
Gamma
Beta of Case TT and Mr.
Ms.
patient
a
of
Case III may also be placed in this category.
causes others
interference
not
use
to
key
a
communication
system,
subsystem
admissions/discharge
office
long
Management discovered
disliked
system
the
units'
that
after
the
system's
the
nursing
director
simply
computerized
After
failure.
of
"refused
become
to
subsystem is still unused by the entire
nursing
control
poison
a
financial system,
"didn't
a
used."
it
replacement for
almost followed suit.
the system's report
want
a
'^R
And
years
trainee."
chief
one
of
The
Another
staff.
information
essentially unused for over one year because the
physician
to
because she would have to be trained to use
the system and she was afraid
she
a
was still not being used to place orders
installation.
hospital's
nursing
the
departments or to communicate patient information
to ancillary
experience,
that
of
which installed
One hospital
found
category
This
system.
the
is the most obvious.
hospital information
room
when
user refuses to use the system or when an influence leader
system
the
This occurs
Refusal to Use the MCBTS:
Type V:
system was
emergency
hospital's
prior system which "failed,"
One of the financial officers was not using
that
flagged
transactions
requiring
human
4P
intervention
resolve.
to
As
it turned
out, the hospital's cash
flow problem was not due to system problems but to
officer's
"fiscal
have uncovered.
never knew why.
the
financial
irregularities," which the unused reports would
Still, one vendor had to remove
his
system
and
^9
CONCLUSIONS AND RESEARCH RECOMMENDATIONS
This research has demonstrated
implementation
MCBJS
can
that
staff
interference
in
affect the survival of the system, the
organizational health of the hospital, and
quality
the
of
care
provided to the patient.
Although an attempt was made to discover the primary cause of
the interference in the three initial
contributing
numerous
and
cases,
interacting
incident
each
causative factors.
centered on the individual's inability to accept change.
instances,
the change was 'good'
environment).
acceptable but
attention
was
In
a
interfered
for other purposes.
Most
some
(e.g., one which led to improved
patient care), in others it was 'not good'
working
In
had
(e.g.,
degraded
it
the
few cases, the system was otherwise
with
to
management's
capture
The following list of contributing
factors was compiled from the cases and the hospital survey:
-Pre-existing organizational problems which the system or its
implementation may or may not aggravate.
management
support
The system, due
and/or visibility may serve as
a
to
its
platform for
individuals to express prior dissatisfactions.
-Failure of the change process.
to
Management, if they
attempt
manage the change process at all, may move to the change phase
S(^
before
unfreezing
the
psychological
phase
which
support
successfu]
been
has
reinforces
adoption
the
Or,
.
of
before
removed
organizational norms is either non-existant or is
new
"refreezing" occurs.
-Insufficient resource support for the implementation effort.
Manpower, time or other resources may not be made available in the
manner needed.
Insufficient
-Hardware and software problems.
hospital's operational
organizational
installation
before
verification
hardware
can
and
cripple
the
care
patient
endangering
capacity,
software
and
viability and inducing justifiable interference to
the system,
-Confounding and magnifying
with
system
other
change
the
operation
when
the
experiential data indicates that
cure
for
organizational
system
a
ailments
is
irrelevant
implemented.
system is not
by
the
management
Often,
change.
organizational
attempts to implement other changes which are
system's
engendered
to
the
Massive
automatically
a
and that compound changes may
cause interference which is vented on the system.
-Lack of user involvement.
has
risk,
Allowing early
involvement
however, it usually assists unfreezing since staff may
come to perceive the system as their own.
is also
user
Early user
involvement
important since it is the primary mechanism to assure that
the system's functions are actually useable in
a
real
environment.
SI
-Inattention to staff
reward
structures.
Frequently,
the
process may alter the individual's reward and risk
implementation
structure such that he is motivated to actions insolubrious to the
system.
-Failure to
advocates
raise
system and
gain
staff
user
expectations
Usually,
cooperation.
initial
effort to "sell" the
an
in
system
Frequently,
expectations.
meet
this
more
is
detrimental than beneficial.
These factors are not unique to hospitals but are
many
common
However, the rate of turnover of MCBT^ vendors
industries.
may be an indication that these implementation problems are
ignored
or
to
they
that
have
a
being
weighting which is different from
other industries.
The estimation
conclude
that
the
and
hypothesis
hospital
case
was
hospitals
interference.
hospital
has
implementation,
have
approximately
The probability that
had
staff
assuming
a
the
they
estimated to be approximately 45%.
alone
same
to
us
in
its
private
incidence
of
randomly selected short-term
interference
that
from
far
lead
The government and
difficulties with staff interference.
sector
results
test
have
The
for the estimate is from 27.5% to ^1.5%.
95%
with
or
their
MrBTS
had an mcbis, was
confidence
interval
.
s?
These results indicate that the problem
more
is
widespread
than
most of the MCBTS vendor managers and hospital
managers realized.
Four of the six vendor managers indicated that
serious
and
they were unfamiliar with such incidents.
awareness
The
of
the
problem among vendor staff varied directly with their proximity to
the implementation environment.
occurrences
these
that
are
Hospital managers tended to think
rare
unique to their hospital.
or
However, MCBTS implementations in the surveyed hospitals
one
in:
person
quitting, three
removed to another position, five people
being
being
resulted
fired
and
removal
whose
one
being
is
processed
The systems with which the forty surveyed hospitals have
experience
were
software
the
products
of
25
commercial MCBTS
vendors, one university, two cooperative hospital groups,
local
numerous
banks,
internal staffs.
ceased
Tn
operation.
served the same function.
no
information
is
were
replaced
But for nine
interference
o*^
29 of ^0 systems
had
by another system which
original
the
systems,
available about their implementations.
estimation of the number of systems
staff
several
government agencies, as well as their own
the surveyed hospitals,
Most
had
contributed
failures
would be highly unreliable.
that some of the 29 systems were removed for
Tt
is
upgrading;
So, an
to
by
only known
several
were research prototypes which the hospitals chose not to continue
to support;
not
and, several were rejected because the hospitals were
satisfied with them in some way.
in each of these
Staff interference occurred
categories to varying degrees.
The need for research on the subject of staff interference in
MCBIS implementation
organizational
significant
is
costs
involved
due
systems and implementation processes.
with
the
problem
database
particularly of
interference.
are:
Since
damage,
the
approaches
Two
detection
the
(a)
and
interference,
of
prevention
the
(b)
new
trusted agent may be the problem, most
augmented
distributions.
input data distributions with expected probability
distributions
parameters would be
Although
data.
been
a
which,
Further,
sustained.
Current
heuristics
insufficient.
whose
research
Thus,
of interference are very
methods
power
that
are,
To
varies
these
of
among
managers.
Tt
methods
are
cases
in
often
too
Implementation
signalling impending difficulties.
presented
above,
appraisal
which
methodology
reactions
Tn
two
of
of the pre-system
environment and advanced diagnosis of the system's effects on
staff
do
sets
generally,
feedback mechanisms for appraising the staffs'
should be useful
three
types
already
has
research to augment current heuristics with
new methodology is indicated.
provides
some
damage
must have methods for predicting and treating the causes
appears from this
the
some
Prevention is, therefore, preferred.
of the interference.
management
faulty.
signal that the input data could be
However, detection implies that
we
not match expected
do
time,
over
costly, this method may be feasible for critical patient
difficult to detect.
this
of
One approach may be for the software to compare
methods.
Actual
coping
to
traditional computer access restriction methods must be
by
and
need to design improved
the
and
human
the
to
would have alerted management to impending problems.
these and other Organization Development methods should be
the
Thus,
tested
.
S4
to
demonstrate
their
applicability to the interference problem.
Although such research outputs may not guarantee
they
may
be
success,
future
worth the effort if the interference problem can be
sufficiently damped.
Research is also needed to further
identify
types
the
and
distributions of costs and impacts which staff interference has in
an
MCBIS
Without such information, the level of
implementation.
effort warranted to develop prevention and
methods
detection
is
unknown
often
MCBIS implementations in American hospitals have
difficult
and costly experiences for both the hospital,
and the system
causitive
or
Staff
vendors.
contributing
interference
factor
may
herein
the
hospital
entire
been
demonstrates
such was the case in 45% of the surveyed hospitals.
to
its staff
a
of some of the implementation
problems, since the research presented
estimate
have
been
that
Applying this
population indicates that the
staff interference problem has the potential for enormous negative
impacts on the
attempting
hospital
MCBIS
industry
as
the
implementation increases.
deserves further attention.
number
of
hospitals
riearly, the problem
.
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Austin, C. and Greene, B., "Hospital Information Systems:
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c00^
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Lib-26-67
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