Change Management for Hospital Information Systems Implementation: A Case Study at General Hospital of RAA Soewondo

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1 Change Management for Hospital Information Systems Implementation: A Case Study at General Hospital of RAA Soewondo Achmad Nizar, Dian Setia Hartana, Ika Chandra Hapsari Faculty of Computer Science, University of Indonesia [email protected], [email protected], [email protected] Abstract Along with the development of hospitals and information technology, Hospital Information Systems () RAA Soewondo deemed unable to meet the information needs. Implementation of got rejection from the employees. These limitations make the management plans to replace their Therefore, in order to get success in the implementation of new, it is necessary to conduct change management process that will help RAA Soewondo in preparing its organization in the new environment. To achieve that, we conduct a set of data collection through disseminating questionnaires and conducting interviews and observation. The data are analyzed to obtain SWOT matrix as a base for us in analyzing the strengths and weaknesses of the organization as well as its opportunities and threats. Results of SWOT analysis are grouped to formulate necessary strategic change management. In this research, we use Anderson and Anderson Nine Phase Model to guide us in formulating required change management. Our research showed that employee resistance is the most influencing factor that inhibits the implementation of To overcome this, some actions need to be done in accordance with changes management such as management support as part of the leadership, unified organization vision and mission, design changes with respect to the affected divisions, do the replacement with a parallel cutover method, gave awards to employees who join this program, as well as create new policies for existing policies to be permanent. The final results showed that the employees agree to succeed the implementation of R I. INTRODUCTION AA Soewondo hospital has a vision to be the best health care center in the area of Pati and also to be the pride of the community and its employees in Its mission is to provide qualified health services, professional, affordable and imbued morals and ethics for the sake of community satisfaction. To achieve this vision and mission, RAA Soewondo needs the help of information technology. Hospital information systems () of RAA Soewondo currently is less able to meet the information needs to support business processes. Existing is implemented using Windows DOS Foxpro 2.0 which is a client-server application and operating through a Local Area Network (LAN) of the hospital. maintenance cost becomes expensive because it has become a unique and legacy systems at this time. Improvement and development of needs to be done soon. Therefore, RAA Soewondo plans to migrate its existing into the desktopbased hospital information systems that enables the hospital to operate and maintenance it easily in its in internal environment. In the process of implementation of the in early 2005, RAA Soewondo experienced many obstacles. One of the main reasons for the cause of failure in project implementation is the lack of implementation of change management process, not only in the information technology but also in the entire organization [1]. This study aims to determine the level of employee resistance to the new hospital information systems. In addition, this study also aims to find suitable change management strategies to implement the hospital information systems at RAA Soewondo Pati. The analysis used in this research is quantitative analysis as well as qualitative analysis, taking into account the internal and external state of hospital. II. RELATED RESEARCH Several studies related to the topic of this paper have been done before. Research by Jick dan Peiperl[2] conclude that change initiative need to be done by project manager to make the project runs successfully. Levinson[1], by his research concludes that one main reason for the cause of failure in project implementation is the lack of implementation of change management process, not only in IT scope

2 but also in the whole organization. The research method used in this study was following the same method held by Mutholib, E.A[3]. Similarities exists above the three studies with this study is the using of change management process to overcome the system change. III. THEORETICAL BACKGROUND A. SWOT Analysis SWOT Analysis includes Strengths, Weaknesses, Opportunities and Threats. Strength and Weakness are internal factors within the organization. Meanwhile, Opportunity and Threats are factors that come from outside the organization. Obtained SWOT results can be used to formulate a systematic strategy of the organization [4]. In this case, the results of the SWOT analysis will be used as a strategy of change in the implementation of the new B. Resistance Factors of Change Resistance usually arises when the change occurs. Resistance can be clearly seen (explicit) or implied (implicit). Rejection factors can be divided into 2, namely the rejection of individual and organizational resistance [5]. Individual resistance factors, namely: security, economic factors, perception, uncertainty and habit. While the factors causing organizational resistance there are 6, namely: the impact of widespread change, group inertia, the threat of resource allocation, power threat, the threat of expertise, and structural inertia. C. Change Management Change management is an approach in planning, designing, implementing, measuring and maintaining the process of change in business activity or employment [6]. According [7], strategy changes include 3 things: 1) Contents which consist of areas within the organization and technical aspects that must be changed. 2) People which consists of mindset changes, behaviors and culture that are required in the change. 3) Processes which are the actions to be taken to plan, establish, and implement all changes in an integrated and comprehensive manner. D. Methods in Information Systems Replacement There are several methods in the replacement of information systems in the organization namely [8]: 1) Immediate Method Cutover: This method replaces immediately the old system by the new system. This method has the highest risk of failure but fast in its implementation when replacing the old system. Thus this method requires the lowest IT investment. 2) Cutover parallel method: This method has low risk in implementation failure. In its implementation, this method maintains 2 systems (old and new) that run at the same time. Termination of the old information systems is performed when the user is ready and accustomed to the new system. This method requires a high IT investment because they have to provide 2 systems running. 3) Cutover phased method: This method is a merger of two previous methods. Replacement of the old system is made per phase. For example, the replacement is applied in a certain business unit first, and the rest can be applied after the first implementation gets its success. E. Anderson and Anderson Nine Phase Change Process Model This model contains 9 phases of change. Each phase consists of several activities and tasks that can be followed for planning, designing, and implementing change. The nine phases of this model are: 1) Prepare to lead the change. In this phase, key people leaders are determined. The identification of key people leaders aims to prepare leaders who will control the change. 2) Create organizational vision, commitment, and capacity. This phase aims to develop understanding, commitment, momentum and capacity to change. 3) Assess the situation to determi`ne design requirements. This phase aims to look at the circumstances and situations that exist in the organization to make realistic design changes. 4) Design the desired state. This phase helps organization to design state of the desired changes. 5) Analyze the impact This phase assesses the effects of changes in the organization, people and habits. 6) Plan and organize for implementation This phase is aimed to identify what steps needed to implement towards the desired state. 7) Implement the change This phase implements change within the organization. 8) Celebrate and integrate the new state Celebrating victory over the results obtained from changes in the new circumstances. 9) Learn and course correct This phase creates a mechanism to continue to improve the situation has changed and make it permanent. IV. METHODOLOGY This research uses case study in organizations engaged in health care. The method used is combination between quantitative and qualitative approach. The quantitative method is used to assess employee perception on The qualitative method is performed by interviewing the management to

3 collect data needed to formulate change management. A. Data Collection Method There are two types of data collected in this study, primary data and secondary data. Primary data are data taken directly from employees and management of RAA Soewondo. While secondary data are data collected from documents owned by the RAA Soewondo. Primary data obtained in the following manner: 1) Interview Interviews were conducted at the director and some hospital officials associated with Interviews were conducted to find out the problems during the implementation of new 2) Observation Observation is conducted to observe the hospital environment in daily activities. This method is used to determine the situation on the ground to the process of implementing new 3) Questionnaire Questionnaire is given to hospital employees, especially in the divisions that have funds and information flow. We made three categories of questions in this questionnaire, namely: knowledge on organizing hospital, tasks and functions of information technology, and computer skills of respondents. The secondary data obtained from the existing documentation. Data was also taken from reference books and journals related to the purpose of research. B. Stages of Research Process The research stages at the RAA Soewondo can be explained as follows: 1) Problem identification as basis of research. 2) Literature review to obtain information and data required for preparation of research. 3) Data collection, both primary and secondary data. 4) Analysis of change resistance. This analysis produces factors that caused the rejection of 5) SWOT analysis to assess the strengths, weaknesses, opportunities, and threats related to implementation. 6) Define strategies of change management based on defined SWOT. 7) Grouping the change management strategies according to Anderson and Anderson's change management model. This grouping aims to classify the act of changing into a set of change management action. V. DISCUSSION AND ANALYSIS A. The current IS/IT Condition at RAA Soewondo Hospital information systems () has been implemented in RAA Soewondo on less than 5 years. It is developed by using FoxPro 2.0 LAN Network Novel. runs under Disk Operating System (DOS). Database, that is used to record transaction and patient data, uses internal database structure of FoxPro (dbf and fxp files). The database size is 1-2 Gb. Patient datas are recorded in the database by using an unique patient registration number, e.g , which the last 2 digits indicate the year. Registration number can be used to access different databases. runs in client-server system. Client system has no hard drive. It should be booted by the floppy drive to connect it to the server system. The specifications of the main server are Pentium GHz processor, 1 GB memory, 40 GB hard disk, Gigabit LAN, and DVDRW optical drive. system consists of several sub systems developed for each division in RAA Soewondo. However, the database of each sub system is integrated to central database server. consists of the following sub systems: 1) Payment sub system 2) Registration sub system 3) Logistics sub system 4) Pharmacy sub system 5) Outpatient sub system 6) Inpatient sub system 7) Nursing sub system 8) Medical record sub system RAA Soewondo hospital also has some other information systems, which is run separately from, for example human resources information systems (SIMDA) which is connected to the Local Government of Pati, funds mobilization system which is connected to the Central Java of Regional Banks, ASKES system which is connected to PT. ASKES, and the health insurance for the poor people system (JAMKESKIN) which is connected to the Department of Health. B. Advantages and Disadvantages of current In order to develop new and prepare necessary change management, we need to identify the strengths and weaknesses of current Weaknesses in the current system are: 1) Shared database violation FoxPro fitures does not allow the same data records modified at the same time. It causes a transaction should wait other transaction that currently accesses the data. 2) created in FoxPro 2.0 programming language that can not be run on a Pentium 4 processor or above. 3) The client PC must be booted with a floppy diskette to make a connection to The availability of diskettes is now rare. 4) menus are very complex. In order to go to the initial menu, the users should go through several menus. This process is very time-consuming compared to the drop-down menu model which usually exists at current desktop applications.

4 5) FoxPro 2.0 applications are no longer supported by Microsoft. While the advantage of FoxPro 2.0 based are: 1) The size of the program is small. Thus it requires diskless clients and low computer resources. 2) The main server has a backup server that serves to replace the main server in the event of damage. 3) connect to clients via a local network cable to almost all parts of the hospital. C. Improvement on Current Information Technology The current hospital information system will be replaced with the new system. The process of employee remuneration that is transparent and accurate is a major concern for this improvement. Current remuneration system still uses the employee position level and long term of work in this hospital. New information systems will use different references that are the unit cost, unit investment and services. People who provide health care services will get 50% of the revenue from the transaction of health services, while 50% remaining will be incorporated into the renumeration postal funds. Remuneration postal funds will be distributed to all hospital employees based on points of each employee. This point is divided based on position, the risk of employee s job, and how long the employee works for the hospital. However, they have agreed that the new will use the applications that run on desktop, not on DOS. D. The Result of Research Total respondents of this questionnaire are 78 people. They are divided into 2 major parts, 34 respondents (44%) in Administration and Finance section, and 44 respondents (56%) in the Service unit. Administration and Finance Section includes the subsection Courses and Management Information System, Finance, and Administration. Service Unit includes Services Section, Nursing and Supporting (lab, pharmacy). Questionnaire respondents mostly are subdivision of staff, pharmacists, information service staff and human resource staff. The following results are: 1) The Usability of These are respondent's answer to question about usability of 80% respondent said that can be operated easily, 16% of respondents said that is quite difficult and 3 respondents said that is difficult to be operated. 2) Replacement of the old These are respondent's answer to question about replacement of the old 74% of them agree to replace it, 16% of them is disagree, and another 10% are abstain. Some of the suggestions given by respondents who answer agree are: 1) They agree that the old is replaced by the new one if the new s usability is better than before. 2) Data processing can be more quick and accurate than before. 3) They agree to add new programs, but the older programs do not have to be replaced. 4) Replacement of is suitable with the development of computerization era. Respondents who disagreed with the change of give reasons: 1) Current is sufficient and does not need to be replaced. 2) Current only need to be improved without having to be replaced. 3) The Role of in Achieving Vision, Mission and Objectives From 78 respondents, 93% said that can help to achieve vision, mission and objective of the hospital, 5% said that it can help a little, 1 respondent did not know and 1 respondent did not fill out the form. In the terms of computer use, 92% of them said that they use computers in their jobs everyday, meanwhile, 8% do not. About function in accelerating the work, 94% said that can speed up their work and only 6% of respondents who answered do not speed up their daily work. E. Analysis 1) Analysis of Resistance Factor Only 16% of the total respondents who refuse to replace current They argued that the current is reasonable and just need to be improved. From the observation, we know that users are familiar with current operational conditions. They can enter and change data quickly. There are no employee training provided by the SIM to learn about There is only operational learning process of from supervisor to staff. When there is a change of then supervisor would give more training to their staff. Hospital staff consider that training provided by the SIM is still general and less detailed in their section. It causes the resistance of new implementation. Although this resistance is small, it still must be considered. Some solutions that are offered are : 1) Give more socialization activity to hospital employee. 2) Give operational training according to each unit service 2) SWOT Analysis Strength that exist at hospital are: 1) Hospital has supervisor whose role is to give the recent information to staff regularly. 2) The high willingness of employees to learn new applications. 3) High level of employees compliance of change.

5 4) The sharing information habit among employees. 5) Hospital has enough time for doing socialization and implementation activity. 6) The existence of clear standard operating procedures (SOP). 7) The existence of activity review by supervisors. Weaknesses that exist at hospital are: 1) The frequency of training activity is too rare (once a month). 2) There are only 5 IT staffs 3) The current vission and mission is not suitable to the new. 4) There are not IT training for new employees. 5) The current cannot upgrade its performance. 6) There are application and maintenance that are not under management of information system authority. Opportunities that exist in the hospital are: 1) There are a lot of patients who visit hospital. 2) The hospital has forefront position in Pati regency. 3) improved performance of hospital in each unit. 4) Having integrated information system is a competitive advantage. 5) The cooperation with third parties such as ASKES, BANK JATENG, and Jamkesmas. Threats that exist in the hospital: 1) Some service application units are not integrated with 2) The using of old 3) Budget for changes and implementation process of the new is not so large compared to other government hospitals in Central Java. 4) A lot of private hospitals in Pati Regency. F. Perform Change Management After doing SWOT analysis, changes actions should be done. Changes actions are determined by formulating strategies based on strengthsopportunities, weaknesses-opportunities, strengthsthreats and weaknesses-threats as can be seen in Table II. These changes action are not sequential, so it will be difficult to determine the order of execution. Ordering actions should be changes in a systematic model. The actions that obtained from SWOT analysis then be grouped into Anderson and Anderson's Nine Phase Change Process Model. TABLE II THE CHANGE OF ACTIONS BASED ON SWOT MATRICES Strengths-Opportunities Weaknesses-Opportunities - Maintain supervisor and management for support change process - Socialize changes - Evaluate periodically the implementation of the new - Training new gradually - Empowering the role of manager to succeed the implementation of the new - Conduct reviews of implementation periodically - Perform analysis of the impact of the implementation for each units. Threats-Strengths - Closure the old access and utilization - Looking for a good vendor. - Monitor performance of vendors in the making and implementation, - Keep the change process runs on time - Choose the right programming language. - Use open source information technology for the manufacture of - Conduct testing of new - Complete the SOP in accordance with the new - Interconnection of separate applications with the new - Conduct the comparison study with other hospitals - Increase the number and quality of IT personnel - Conduct meeting in management level for unified vision and purpose. - Increase the frequency of meetings in each unit. - Expand the responsibility of SIM division. - Make clear the rules about the use of - Enter the ability of operational knowledge application in the assessment of employee. - Surveys and interviews to obtain information about the desired changes. - Choose the proper method of replacing Threats-Weaknesses - Give awards to employees who support the successful implementation of - Replace the old Foxpro - Stop support for old - Prepare of SOP that is easily understood. - Development of performance-based employee remuneration system - Inform all employees that the implementation of the new runs successfully. G. Discussion of Step Change Management Strategy In implementation of the new, strategic steps that must be taken are: 1) Prepare to lead the change Management and supervisor leadership is very important in leading the change. The role of supervisor in each departement can speed up implementation. Supervisor can monirtor when implementation execute. 2) Create organizational vision, commitment and capability Management level meeting need to be done for sharing vision and comitmnet of the new Socialization activities regarding change to all employees need to be done, so all of the hospital layers have same vision and commitment. Socialization activity is expected to suppress employee resistance. Change implementation process also have to pay attention to hospital

6 capacity that included the ability of human resources, budget, and time. 3) Assess the situation to determine design In this step, user surveys and interviews is taken to find out more details of new components change that they want. The ultimate goal of the new is a system that can relieve and speed up users work. 4) Design the desire state The design changes should be clearly defined in this step. The system built should not use programming language that is rarely used. New will be expected to connect the hospital with special applications such as SIMDA, ASKES, Assurance and laboratory equipment that uses a computer. 5) Analysis the Impact change Impact analysis on hospital care units, need to be done before implementation process. It is intended during the process of change, hospital services did not decline. is need to be tested before implemented as a whole system in hospital. 6) Plan and organize for implementation Before the implementation of done, a comprehensive plan on socialization, training, and purchase software and hardware need to be made. It is intended that the implementation of can be run on time. 7) Implement the change The method chosen for implement the new is parallel cutover. This method was chosen because the risk is small. Be sides that, by using this system, the hospital management can ensure users do not see difficulties. Users can adapt and learn to operate the new system freely. Selection of parallel cutover method also due to the old are tight-coupled with applications within, so it can t use phased cutover method. 8) Celebrate and integrate the new state The award should be given to employees who have good performance and contribute to the implementation of new The way of thinking, works, and habits of employees will be motivated to change with this celebration. 9. Learn and course correct The process of change is a dynamic process and must be constantly studied and improved. New regulation of new need to be made and improved in accordance with hospital s conditions and state. This is need to be done so that the process of change that have occurred become permanent in RAA Soewondo hospital. 1) There are individual resistance that is relatively small (16%) on the implementation of the new 2) Appropriate change management needs to be used to improve the success of implementation project. The changes actions are formulated through the mapping of strengths and weaknesses over opportunities and threats in the SWOT matrices. Our research had formulated 31 necessary changes actions for RAA Soewondo. 3) To group changes actions into more ordered actions, we use Anderson and Anderson's Nine Step Change Process Model. VII. REFERENCES [1]. Levinson, M. (2006). When Failure is Not Option, Framingham. [2]. Jick, T.D., & Peiperl,M.A. (2002). Managing Change: Cases and Concepts. New York: McGraw-Hill irwin [3]. Mutholib, E.A. (2007). Strategi Manajemen Perubahan Untuk Mempercepat Implementasi Sistem Informasi Rumah Sakit: Studi Kasus Rumah Sakit Medistra. Thesis: Universitas Indonesia. [4]. Tozer, E.E. (1996). Strategic IS/IT planning, Professional ed., Betterworth-Heinemann [5]. Robbin S.P. (2003). Organizational Behavior 10 th ed. Upper Saddle River. Prentice Hall [6]. Lientz B.P & Rea K.P. (2004). Breakthrough IT Change management. USA: Elseiver Butterwoth Heinemann [7]. Anderson, D. & Anderson L. D. (2001). Beyond Change Management: Advanced Strategies for Today s transformational Leaders. USA:Jossey-Bass [8]. Phookun, P. (2009, Desember 21) Audit of IT Systems Development. VI. CONCLUSIONS Our research is aimed to formulate suitable change management for RAA Soewondo Pati in implementing its new Hospital Information Systems (). Based on our research, we can conclude the followings: