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Strategic Thinking in Telehealthcare: A Possible Solution to Easing the Financial
Strain on Ireland’s Overburdened Health Service
Ronán Bunting
MBA (Executive Leadership) August 2013
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Strategic Thinking in Telehealthcare: A Possible Solution to Easing the Financial
Strain on Ireland’s Overburdened Health Service
Submitted by: Ronán Bunting
Student Number: 1221350
Supervisor: Enda Murphy
Submitted in partial fulfillment of the requirement of the degree of
MBA in Executive Leadership, Liverpool John Moore’s University
Dublin Business School August 2013
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Declaration
I the undersigned declare that all the work within this dissertation is entirely my own
(with the exception of specific sources that are referenced in the text and
bibliography).
No part of this work has been previously submitted for assessment, in any form, either
at Dublin Business School or any other institution.
Signed: ______________________
Ronán Bunting
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Acknowledgements
I would like to acknowledge and thank a number of people who helped and supported
me throughout the MBA journey and the thesis. Firstly, I would like to thank my
dissertation supervisor Enda Murphy for his guidance, encouragement and support.
His vast experience and knowledge has contributed greatly to my understanding of
the business environment. I would also like to acknowledge and thank Shay Lynch for
encouraging me to undertake this particular course.
I would like to thank the representatives of the various organizations who assisted in
this research, the Health Service Executive, Muintir Na Tire, TASK Community Care,
Robert BOSCH Healthcare and the Northern Ireland Ambulance Service.
I would like to acknowledge the clients of TASK Community Care’s sample for
allowing me to include them in my research investigation. A big thank you to my
friend Eamon McGuire who had the confidence and belief in me, especially during
those times I doubted my own determination.
I would like to acknowledge and thank my parents, Gerry and Joan Bunting for their
encouragement and support throughout my MBA. I couldn’t have done it without you
both! To my sister Suzanne for her support and guidance along the MBA journey.
Last but not least, I would like to thank my girlfriend Dovile for sticking with me
throughout the process.
Without inspiration the best power of the mind remain dormant. There is a fuel in us
which needs to be ignited with sparks (Johann Gottfried Von Herder)
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“The Essence of Strategy is choosing what not to do”
(Michael Porter, 2010)
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Abstract
The purpose of this study is to examine the potential problems facing the Irish health
service going forward as a result of two key factors, Firstly, as a result of the current
economic climate the ability to operate the service is becoming significantly more
difficult as a result of greatly diminishing budgets. Secondly, the problem is being
exasperated by Ireland’s rapidly aging population which is set to double in the next
decade.
Chapter One illustrates the current position of the health service and overview of the
research topic generally. A possible scenario could be that the health service will no
longer be in a position to provide a suitable level of care to its patients. The research
topic looks at feasible alternatives to traditional care practices by embracing
technologies such as Telehealthcare. However, there is clear resistance to the
application of these technologies from various quarters within the health service.
In order to examine this issue, Chapter two illustrates the literature around the area of
research. The investigation has applied an extension of McKinsey’s 7’S model of
strategy. The objective for testing this model is aimed at highlighting the various
issues health professionals have with the technology and leading to a favorable
outcome.
Chapter three looks at the various methods applied to satisfy the requirement of a
thorough investigation. The researcher adapted a pluralistic approach, the use of
qualitative and quantitative data analysis to deliver reliable outcomes. The qualitative
element of this research involved seven individuals within the health field. A total
sample size of 106 existing users of telehealthcare agreed to take part, and enrich the
research with their experience of Telehealthcare technologies.
Chapter four addresses the researcher’s findings from the collection of primary data.
The findings highlight the general feelings of the research proposal from an industry
and patient perspective. Finally, Chapter five explores various conclusions and
recommendations as a direct result of primary data collection within the research.
The research also proposes various ways in which the health service can save millions
of
euro
annually
through
effective
strategic
thinking
and
planning.
1
Contents
List of Figures ………………………………………………………………………………………………………………….. 4
Glossary of Terms …………………………………………………………………………………………………………… 5
Chapter 1: Introduction to the study
…………………………………………………………………………… 7
1.1 Research Problem …………………………………………………………………………………………………… 7
1.2 Research Proposal
…………………………………………………………………………………………………… 7
1.3 Barriers to Telehealthcare ……………………………………………………………………………………… 8
1.4 Justification of the Research
………………………………………………………………………………….. 9
1.5 Research Questions ……………………………………………………………………………………………… 10
1.6 Outline of Methods
………………………………………………………………………………………………. 10
1.7 Recipients for Research ………………………………………………………………………………………. 11
1.8 Research Problem/Objective ………………………………………………………………………………. 11
Chapter 2: Literature Review ……………………………………………………………………………………. 12
2.1 Introduction ………………………………………………………………………………………………………….. 12
2.2 Strategic Management …………………………………………………………………………………………. 12
2.3 Change Management – Skills ……………………………………………………………………………… 17
2.4 Organizational Style: Importance of Clear Leadership and Management to
assist in organizational change
………………………………………………………………………………….. 22
2.5 Leadership Theories …………………………………………………………………………………………….. 24
2.5.1 The Trait Approach
………………………………………………………………………………………. 24
2.5.2 The Style Approach ……………………………………………………………………………………… 25
2.5.3 The Contingency Theories
…………………………………………………………………………… 26
2.5.3.1 Fiedler’s contingency approach ……………………………………………………………….. 27
2.5.3.2 Situational Leadership ………………………………………………………………………………. 27
2.5.3.3 The Path Goal Theory……………………………………………………………………………….. 28
2.6 Organizational Staff …………………………………………………………………………………………….. 29
2.6.1 Motivation …………………………………………………………………………………………………….. 29
2.6.2 Content Theories
…………………………………………………………………………………………… 30
2.6.3 David McClelland ………………………………………………………………………………………… 30
2.6.4 Herzberg’s Two Factor Theory …………………………………………………………………… 31
2.6.5 McGregor’s Theory X, Theory Y ……………………………………………………………….. 32
2.6.6 Process Theories …………………………………………………………………………………………… 33
2.6.7 The Equity Theory ……………………………………………………………………………………….. 33
2.6.8 The Expectancy Theory
……………………………………………………………………………….. 34
2.7 Employee Engagement
………………………………………………………………………………………… 35
2.8 Summary ………………………………………………………………………………………………………………. 37
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Chapter 3: Research Methodology
……………………………………………………………………………. 39
3.1 Background
…………………………………………………………………………………………………………… 39
3.2 Research Methodology
………………………………………………………………………………………… 39
3.3 Research Philosophy
……………………………………………………………………………………………. 41
3.4 Research Approach ……………………………………………………………………………………………… 44
3.5 Research Strategy ………………………………………………………………………………………………… 44
3.6 Research Choices …………………………………………………………………………………………………. 45
3.7 Time Horizons ……………………………………………………………………………………………………… 46
3.8 Data Collection and Data Analysis
…………………………………………………………………….. 46
3.9 Sample and Population
………………………………………………………………………………………… 47
3.10 Ethical Issues and Procedures
…………………………………………………………………………… 48
Chapter 4: Data Findings and Analysis
……………………………………………………………………. 50
4.1 Overview ………………………………………………………………………………………………………………. 50
4.2 Qualitative Data Findings and Analysis
…………………………………………………………….. 50
4.3 Quantitative Data Findings and Analysis ………………………………………………………….. 53
Q1. Gender? ……………………………………………………………………………………………………………. 53
Q2. Age Group?
……………………………………………………………………………………………………… 54
Q3. Provision of System ……………………………………………………………………………………….. 55
Q4. Duration with Telehealthcare system
……………………………………………………………. 56
Q5. Living Arrangements ……………………………………………………………………………………… 57
Q6. Telehealthcare usage ………………………………………………………………………………………. 58
Q.7 Emergency Situations …………………………………………………………………………………….. 59
Q 4.7.1 Cross tabulation- Emergency Situation’s and Living Alone
………………… 60
Q8. Emergency Service Contact …………………………………………………………………………… 61
Q9. Frequency of Contact with Emergency Services …………………………………………. 62
Q10. Peace Of Mind Obtained from Telehealthcare
…………………………………………… 63
Q11. Does Telehealthcare represent good value for money ………………………………. 64
Q12. Dependency upon Alarm
……………………………………………………………………………… 66
Q13. Has Telehealthcare assisted in improving overall health?
………………………… 67
Q14. Personal Feeling of Reliability ……………………………………………………………………. 68
Q15. Confidence in Telehealthcare
………………………………………………………………………. 69
Q16. How often portable panic button is worn …………………………………………………… 70
Q17. Satisfaction with service provided through Telehealthcare
………………………. 71
Q18. Likelihood of people purchasing telehealthcare if no grants were available
…………………………………………………………………………………………………………………………………. 72
Q19. Have existing Telehealthcare users recommended the service to others? . 73
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Chapter 5: Conclusion and Recommendations ………………………………………………………. 75
5.1 Conclusions ………………………………………………………………………………………………………….. 75
5.1.2 Limitations of the Research
……………………………………………………………………………… 80
5.2 Recommendations ……………………………………………………………………………………………….. 80
5.2.1 Recommendation One
………………………………………………………………………………….. 81
5.2.2 Recommendation Two:
………………………………………………………………………………… 82
5.2.3 Recommendation Three: ……………………………………………………………………………… 82
5.3 Researcher’s Concluding Statement
…………………………………………………………………… 84
Chapter 6: Self Reflection …………………………………………………………………………………………… 85
6.1 Introduction ………………………………………………………………………………………………………….. 85
6.2 Learning Style
………………………………………………………………………………………………………. 86
6.3 Application of Learning ………………………………………………………………………………………. 89
6.4 Learning: Strengths and Skill Development ……………………………………………………… 91
6.5 People Management …………………………………………………………………………………………….. 91
6.6 Inter-Personal Skills …………………………………………………………………………………………….. 91
6.7 Further Learning…………………………………………………………………………………………………… 92
Bibliography ………………………………………………………………………………………………………………….. 93
Appendix 1: Quantitative Survey …………………………………………………………………………….
111
Appendix 2: Qualitative Interview …………………………………………………………………………..
113
Appendix 3: Interview One ……………………………………………………………………………………….
114
Appendix 4: Interview Two
……………………………………………………………………………………….
119
Appendix 5: Interview Three
…………………………………………………………………………………….
122
Appendix 6: Interview Four
………………………………………………………………………………………
127
Appendix 7: Interview Five ……………………………………………………………………………………….
132
Appendix 8: Interview Six………………………………………………………………………………………….
141
Appendix 9: Interview Seven …………………………………………………………………………………….
151
Appendix 10: Further Benefits to Telehealthcare …………………………………………………
162
Appendix 11: Confidentiality Statement
…………………………………………………………………
164
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List of Figures
Figure 3.1 The Research Onion
Page 40
Figure 4.1 Responses to Question 1
Page 53
Figure 4.2 Responses to Question 2
Page 54
Figure 4.3 Responses to Question 3
Page 55
Figure 4.4 Responses to Question 4
Page 56
Figure 4.5 Responses to Question 5
Page 57
Figure 4.6 Responses to Question 6
Page 58
Figure 4.7 Responses to Question 7
Page 59
Figure 4.8 Responses to Question 8
Page 61
Figure 4.9 Responses to Question 9
Page 62
Figure 4.10 Responses to Question 10
Page 63
Figure 4.11 Responses to Question 11
Page 64
Figure 4.12 Responses to Question 12
Page 65
Figure 4.13 Responses to Question 13
Page 67
Figure 4.14 Responses to Question 14
Page 68
Figure 4.15 Responses to Question 15
Page 69
Figure 4.16 Responses to Question 16
Page 70
Figure 4.17 Responses to Question 17
Page 71
Figure 4.18 Responses to Question 18
Page 72
Figure 4.19 Responses to Question 19
Page 73
Figure 6.2.1. Kolb’s Learning Cycle
Page 87
Figure 6.2.2. Honey and Mumford’s learning style
Page 88
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Glossary of Terms
Telecare
Telecare is the remote monitoring and care provision for elderly and physically less
able individuals, providing reassurance and peace of mind 24 hours a day. Basic
Telecare involves the provision of a socially monitored alarm system that is
connected to a landline telephone or mobile telephone network allowing the system to
connect to a 24hr-monitoring center. Simply pressing the remote panic button worn
on the person is sufficient to summon help in an emergency situation. More advanced
Telecare packages involves the use of sensors which detect potential risks to
individuals. Such sensors include automatic Fall Detectors Smoke, Carbon Monoxide
and Flood Detectors etc.
Telehealth
Telehealth involves the transmission and analysis of physiological data from a patient
to clinician who are in separate locations. Telehealth assists in the autonomy for
individuals allowing them to monitor various vital signs from the convenience of their
own homes through the use of various devices such as blood pressure cuffs,
glucometers for diabetes, and home spirometers for testing patients with asthma or
COPD. The readings are then transmitted remotely to a care professional or a
Telehealth service provider. According to Irish Telehealth provider TASK
Community Care “ remotely monitoring patients’ vital signs on a daily basis, allows
more timely care decisions to be made”.
Telemedicine
Telemedicine is the system used to transmit real time audio and video image between
a patient and doctor or clinical professional. Telemedicine can assist individuals in the
management of their conditions without the need to travel or hospitals or GP
surgeries. Telemedicine also allows the transmission of patient’s medical data
between health workers in different locations. This assists in a more efficient and
effective service for the patient as an expert in a particular medical area can assist
from a wide geographical area.
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Telehealthcare
The term Telehealthcare refers to the convergence of Telecare, Telehealth and
Telemedicine to provide a complete package to assist and promote independence,
health and peace of mind to individuals from the home environment.
Muintir Na Tire
Muintir Na Tire is a national voluntary organization dedicated to promoting the
process of community development. The organization aims to enhance the capacities
of people in communities, rural and urban.
An Garda Síochána
An Garda Síochána is the national police service of Ireland.
The Health Service Executive (HSE)
The Health Service Executive is responsible for the provision of healthcare, providing
health and personal social services for Irish citizens with public funds.
The National Health Service (NHS)
Is responsible for the provision of healthcare in the United Kingdom.
Chronic Obstructive Pulmonary Disease (COPD)
This is a common disease that affects the airflow of the lungs as a result of the
breakdown of lung tissue (Known also as emphysema).
Congestive Heart Failure (CHF)
CHF is a condition that affects the heart. Here the heart is unable to perform
effectively, resulting in inadequate blood flow being pumped around the body.
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Chapter 1: Introduction to the study
1.1 Research Problem
Research Problem: Leadership and Strategic Thinking to assist in effective decision-
making when considering Telehealthcare as a solution to easing the financial
constraints within the Irish Health Care system. A possible scenario could highlight
the consequences of a Health Service unable to provide adequate care for individuals
as a result of limited Public finances. At present, Ireland has an aging population
currently standing at 541,404 or 11% of the population. This figure is set to increase
to 25% by the year 2024 as highlighted by St. Vincent’s Hospital Dublin. Additional
pressure will restrict the performance for the Health Service in the coming years as a
result of reduced funding. The Health Budget allocation in 2013 currently stands at
€13.6 Billion, down €1.75 Billion on 2007 levels.
With a rapidly aging population, combined with a bleak economic forecast in the
coming years drastic action is needed to address the pending crisis within the health
service. Effective leadership and strategic thinking at senior government level and
within the Health Service Executive (HSE) will need to be embraced in order to avoid
operational difficulties in Irish hospitals within the coming years.
According to Campbell et.al (2012) ‘twenty nine percent of hospital beds (In the UK)
are occupied by patients who were admitted to hospital unnecessarily and could have
been treated elsewhere. For instance, asthmatics, diabetics and those with high blood
pressure take up 11.9% of beds. The bill for the 669,319 patients who were admitted
with vague symptoms cost the National Health Service (NHS) £410million in 2011’.
1.2 Research Proposal
Research Proposal: To investigate the suitability, feasibility and acceptability of cost
effective alternatives of Healthcare practices and institutionalization through
Telehealthcare technologies. Telehealthcare is the convergence of two well-known
remote monitoring services, Telehealth and Telecare that provides a broad home care
package covering medical and personal monitoring, assisting the management of risk
associated with independent living. Telehealthcare is a possible cost effective method
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of providing care to individuals from the home environment, significantly reducing
hospital admissions, thus saving the Health Service tens of millions of euro’s
annually.
In addition to Health Service Cutbacks, over 100 Garda stations are set to close
nationally as part of the Irish Governments Garda District and Station Consolidation
Program. This decision further creates a feeling of isolation among our aging citizens;
especially those living in rural isolated communities. In reality, for rural isolated
individuals, the community Garda may be the only person whom they meet and
communicate with on a daily basis. Through Telehealthcare, with the provision of
Socially Monitored Alarm systems (Telecare) older people feel less isolated and many
indicate a feeling of reassurance attained from the systems. Please see section 4.3 for
quantitative data findings relating to the end user satisfaction of Telehealthcare.
Telecare is widely recognized as a proven cost effective viable alternative to
institutionalization thus saving the public finances.
1.3 Barriers to Telehealthcare
The area of Telehealthcare would appear to be a viable method of improving the
efficiency of the Health Service. It is important to note that Telehealthcare is not a
suitable option for everyone. There are a considerable number of people who need
long term care in a health environment and Telehealthcare alone would not suffice.
According to University College Dublin there were 22,967 long-term stay beds
available in Ireland in 2008, 68.7% of occupants were classed as High or Maximum
dependent. However, it is believed that telehealthcare can make a significant
contribution to improving the standard of service provided.
Proposing such alternatives to Health Care practices would suggest that such
technologies would be embraced and implemented. However, the area is littered with
complexity and mixed evidence appears to be hindering its implementation.
According to the University of Hull a major barrier to Telehealthcare implementation
in the UK health service lies with senior management and clinicians who reject
change and an unwillingness to embrace technical advancements. Johnson, Scholes
and Wittington (2011) support the concept that without strategic leadership in
organizations strategic objective may be ineffective ‘strategic leaders may influence
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in organizations strategy: individuals (or perhaps a small group of individuals) whose
personality, position or reputation gives them dominance over the strategy
development processes’. The schools of medicine at the University of Missouri have
identified similar barriers to Telehealthcare implementation as the Hull findings.
They note physician’s resistance to change and adverse to new technologies,
Telehealth systems are not user friendly enough and clinicians/ management need
firm evidence of its value. The aim of this study is to address these concerns and
highlight the benefits to Health professionals and patients alike from the embracement
of such technologies.
1.4 Justification of the Research
The area of strategic thinking is of particular interest to the researcher for two reasons.
Firstly, the researcher’s employment within a fast growing family business in the area
of Telehealthcare is one motivator. As mentioned, Telecare is an established industry
in Ireland, providing systems to over 130,000 people nationally according to Muintir
Na Tire. However, Telehealth implementation is struggling to be adapted across the
board. From previous studies, such as that of the University of Hull a number of
barriers appear to lie with health professionals resistance to embrace such
technologies. The aim of this research is intended to highlight the benefits of
Telehealthcare, firstly to the patient through empowerment, secondly, to the Health
Service through cost saving measures and finally to the Health professionals who
currently resist such technologies. It is intended to identify and address these concerns
and disprove their misconceptions of Telehealthcare by highlighting to health
professionals the merits of adopting such technologies and the employment
opportunities that can be created both publically and privately in the field.
Secondly, experienced lecturers who provided vast experience and academic insight
in the area encouraged the researchers interest in Strategic Management. As a result,
the researcher has the opportunity to identify a real issue surrounding the Irish Health
Service and potential solutions that may not otherwise be considered. From this
standpoint, the researcher is now in a strong position to reflect on the process as a
whole, as an objective observer.
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1.5 Research Questions
The aim of the study will be achieved through addressing the following:
1. What are the key obstacles to Telehealthcare implementation?
2. Can Telehealthcare deliver and enhance business benefits to the Health
Service, Ambulance Service, An Garda Síochána and community
organizations.
3. What are the health benefits to the end user as a result of Telehealthcare
implementation?
1.6 Outline of Methods
The research study essentially consisted of two separate stages. The first stage
consisted of the literature review. The process was conducted in order to support the
second stage of the study. The second stage involved collecting and analyzing the
primary research data. The two stages and summary are outlined below.
Stage 1. Literature Review
The first stage involved an extensive search of academic literature to determine the
issues relating to strategic thinking through an extension of McKinsey’s 7’s model
(Please refer to Chapter two). The prediction of the model is that through strategic
direction, style, staff, skills, subordinate goals and change management will lead to
favorable outcomes, for example in this investigation, health service buy-in of
Telehealthcare and widespread rollout of the technologies.
Stage 2. Primary research data and Methodology
The second stage involved contacting and interviewing representatives from high-
ranking Pubic Sector bodies (key informants) involved with, or effected by
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Telehealthcare. This was conducted specifically for the purpose of determining
general feeling and obstacles to successful implementation. The method used for this
stage of the study was face-to-face interview.
Working with key players in the field such as TASK Community Care who have a
sizeable Telehealthcare clientele satisfaction surveys were conducted to obtain
general feeling from individuals already using Telehealthcare technologies in one
form or another.
1.7 Recipients for Research
The recipients for the research will include key personnel from all the necessary
agencies who work with older people including representatives from the Health
Service Executive (HSE), Muintir Na Tire, An Garda Síochána, NIAS (Northern
Ireland Ambulance Service), Robert Bosch Healthcare and TASK Community Care.
In addition, the researchers (McKinsey) who produced the original model and
measurements that the research aims to test on a healthcare setting will also be
recipients of this research. My dissertation supervisor, Mr. Enda Murphy and the
awarding body of Liverpool John Moore University will also be recipients of this
research.
1.8 Research Problem/Objective
The aim of this research is to investigate the factors associated with strategic thinking,
through change management and McKinsey’s 7s Model. In this regard, the research
objectives are to:
1. Identify the barriers to Telehealthcare implementation
2. Address the barriers to Telehealthcare implementation through change
management and appropriate strategic management models,
3. Establish if resistance to change exists, and if so how can it be overcome,
4. Highlight the merits of implementation through the identification of existing
operational Telehealthcare examples in other jurisdictions, and
5. Determine the measurements for success and if they can be achieved.
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Chapter 2: Literature Review
2.1 Introduction
This section comprises the review of the literature on (Four) core topics from
McKinsey’s 7’s framework, i.e. Strategic Management, Skills (Change Management),
Style (Leadership and Management) and Staff (Motivation and Engagement).
The researcher’s motivation behind this approach is based upon various barriers to
Telehealth as identified by various institutions globally. One such institution is the
University of Hull who has identified four key barriers to Telehealth implementation,
all of which will be addressed by this research in some form. The barriers identified
by Hull University are a) Behavioral Barriers and the fear of change when dealing
with health professionals b) Managerial Factors, including the lack of support from
senior management in health organizations c) Economic Factors d) and finally
Technical Factors, and issues relating to reliability of equipment.
A key function of this section is to explore areas of focus within academic journals on
the relevant topics. From this an insight and understanding of the main areas
considered in the academic literature can be gained.
2.2 Strategic Management
“Strategy without tactics is the slowest route to victory, tactics without strategy is the
noise before defeat” (Kaplan & Norton 2004)
Strategic management literature focuses on one constant that is the fact that, for
organizations to maintain success they must plan for the future. Strategy is the
determination of the long-run goals and objectives of an enterprise and the adaption of
courses of action and the allocation of resources necessary for carrying out these goals
Chandler (1963). Strategy is about being different. It means deliberately choosing a
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different set of activities to create a unique set of values (Porter 1996). However, it is
a pattern in a stream of decisions (Mintzberg 2007).
A good strategy is a strategy that actually generates such advantages (Barney,
Hesterly 2006). Grant (2010) however, states that strategy is concerned with how the
firm competes within a particular industry or market. Our emphasis on strategy
analysis encourages the view that strategy is the result of managers engaging in
deliberate, rational analysis (Grant, 2010). All organizations now need to be
proactive, responsive and responsible to survive in today’s market (Manikandan,
2010). Mintzberg (1978) states that every organization is guided by its strategy, by a
design or plan for achieving an organization’s policy goals and objectives, however
inequity between intended and implemented strategies exist.
Strategy is an integrated, overarching concept of how the business will achieve its
implemented by all employees (Hambrick and Fredrickson, 2001). However, Poister
(2010) states that strategy/ strategic planning will have to play a more critical role in
the public sector if they are to manage change adeptly and effectively anticipate
rapidly emergent issues. The current economic conditions are posing great constraints
on the Irish Health system and the landscape for public organizations are changing as
a result. McInerney and Barrows (2000) state that market dynamics have created
challenges for public organizations, with the emergence of the global economy,
advances in technology, increased societal demands and the need to provide more
social services with fewer resources. Strategy is the long-term direction of an
organization (Johnson, Scholes and Wittington 2011).
The Irish health system must engage in strategic planning in the short term and deal
efficiently with forces such as social, economic and political factors whilst,
maintaining a health service who embrace the interest of citizens. This is effectively
the health service engaging in strategic planning to embrace change within the service
for the overall good. Keeping people out of hospital, by reducing the time they’re
there when they have to be and by being far more targeted and efficient with the use
of NHS resources, we estimate the widespread use of Telehealthcare could save the
NHS up to £1.2 billion over two years (Burstow 2012). On the contrary, Kling (2009)
states that for Telehealthcare to have an significant effect on the community’s health
care, it must obviously go beyond a few special applications and must be suitable for
14
many of the tasks involved in everyday clinical work, furthermore in projects
delivered in typical U.S civilian health care settings, physicians were not very
enthusiastic about telemedicine (Telehealthcare) and utilization was low. However,
Telehealthcare currently plays a major role in the department of Veterans Affairs in
the United States where healthcare is provided to approximately 23million veterans.
The veterans health budget in 2010 cost approximately $48bn (£30bn/€35bn) roughly
a quarter of the National Health Service’s Budget (Cruickshank 2012). Supporting
this, Telehealth can enhance quality of care by better supporting chronic disease
management, application of best practices, and improvements of knowledge and skill
development in local care providers and improvement of care coordination.
Telehealth demonstrated improvements in timelines of care, leading to improved
outcomes (Gill 2011). On the contrary, the literature identifies four different
categories of barriers to the implementation of telemedicine and wireless technologies
in healthcare delivery. These barriers are crucial in the understanding the difficulties
involved with the application of government policies that favour and encourage
implementation of telemedicine (Bush 2004). The first barrier relates to the technical
aspects of telemedicine (Telehealth) and the challenges in utilizing organizations and
professional groups in the healthcare industry (Parker, 2006). The second category of
barriers is the set of behavioral factors that tend to impede the successful
implementation of telemedicine and wireless technologies. Clinicians tend to show
aversion to change in their mode of practice and technical changes in particular are
not readily accepted unless they can clearly demonstrate improved performance
(Deutscher, 2008).
Economic and financial factors compose the third category of barriers. The cost of
implementing telemedicine includes the equipment, software and training of
caregivers. Healthcare providers carefully assess the cost effectiveness of these
technologies, but there are still difficulties in precise evaluations of outcomes and
benefits from telemedicine (Krizner & Povich, 2008). Finally, the fourth identified
barrier relates to managerial and organizational factors, which include lack of support
from senior management to the implementation of telemedicine. Partly because of
their inability to clearly assess benefits in new technologies, senior managers in
healthcare delivery organizations tend to delay or withhold support for the
implementation of telemedicine (Paavola, 2006).
15
Alternatives to traditional health care practices are urgently required, however the
economic downturn and the fear of change may be hindering health professionals
desire to embrace new strategic directions. At present, a major trigger of change
within public sector organizations is the turbulence of the recession and the need to
anticipate and embrace change constructively and creatively (Baker, 2007). For
optimum results and effectively dealing with the pending health service issues, it is
imperative to embrace proposals to improve operational capabilities of the health
service. The Telehealthcare concept is a feasible strategy proven to work at various
points of the UK health service. This is a great example of how austerity can be a
virtue. Being focused on cost-effectiveness allows us to work creatively and
innovatively to really improve the quality of services. We are enabling people to look
after themselves and live more independently which is given them a better quality of
life. We are also seeing other benefits, including reductions in unplanned
consultations and hospital admissions (Prosser, 2012). As stated by Hill (1987)
structure should always follow strategy. Considering this, many nurses around the
world provide expert nursing through distant technologies but few undergraduate
programs expose nursing students to the full range of technologies available. Nursing
education in Telehealth needs to reflect the roles, responsibilities and capacity for
knowledge building and innovation of the various constituencies within the profession
(Shea 2013). Therefore indicating, a clear strategic direction for Telehealthcare is
currently not being embraced by nursing agencies. In health care, stakeholders have
myriad, often conflicting goals, including access to services, profitability, high
quality, cost containment, safety, convenience, patient-centeredness, and satisfaction.
The lack of goals has led to divergent approaches, gaming of the system, and slow
progress in performance improvement (Porter 2010). In contrast, Heide, Gronhaug
and Johannessen (2002) argue that fruitful strategy formulation and effective strategy
implementation require the coordination of multiple actors and their activities. Top
management is responsible for the strategic and organizational decisions that effect
the organization as a whole (Helfat, Harris and Wolfson, 2006). Line managers
operate as an intermediary between strategic and operational organizational activities,
the interaction between these two key actors in order to minimize the gap between
strategies is essential (McCarthy, Darcy and Grady, 2010).
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As a result of the global recession and the aging population in many developed
countries, public health services are becoming increasingly inefficient. Such changes
anywhere in the system reverberate unpredictably and often chaotically and
dangerously- throughout the society. Strategic planning can help leaders and
managers of public and non-profit organizations think, learn and act strategically
(Bryson, 2008). However, the strategic process may vary with the sector or
organizational type under consideration (Mintzberg, 1998). Successful enduring
companies have visions that are “built to last” and demonstrate how they will advance
and remain steadfast concerning the values and purposes they will stand for. The two
main components of any lasting vision are core ideology and an envisioned future
(Collins and Porras, 1996). Interestingly, from an Irish Health Service perspective,
Collins and Porras (1996) continue and state that an organizations strategy and
practice should constantly change whilst the core ideology should not.
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2.3 Change Management – Skills
Resistance has been cast as adversarial, the enemy of change that must be defeated if
change is to be successful (Weddell, 1998)
Innovation is change that creates a new dimension of performance. All nonprofit
organizations must be governed by performance, not merely good intentions
(Drucker, 2003). Innovation can be regarded as the successful implementation of new
ideas, commonly divided into three stages: identification (invention), growth
(including adaption, testing and evaluation), and diffusion (or spread). Without
innovation, public sector costs tend to rise faster than the rest of the economy – the
inevitable pressure to contain costs can only be met by forcing already stretched staff
to work harder (Clarke & Goodwin, 2010). Krause (2006) defined change as a
coordinated program, in companies or business units, which typically involves
fundamental changes to the organization’s strategy, structure, operating systems,
capabilities and culture.
Garvin & Roberto (2005) identify the question, why is change so hard? Firstly, most
people are reluctant to alter their habits, what worked in the past is good enough; in
the absence of a dire threat, employees will keep doing what they’ve always done.
However, managing change requires consideration of the individual (employee), the
group in which the individual belongs (team or department) and the organization as a
whole, if it is to be effective (Lewin, 1947). Despite the huge investments companies
have made in tools, training, and thousands of books, most studies show that 60-70%
failure rate of organizational change projects, a statistic that has stayed constant from
the 1970’s to the present (Ashkenas, 2013).
To achieve the staffing and logistical efficiencies seen in the Veterans Health
Administration, the NHS needs to find ways to deliver a step-change increase in the
scale of Telehealth implementation (Cruickshank, 2012). Supporting this, everything
is in a state of constant change, the business environment especially. The adoption of
Telehealthcare to date had been hampered by a number of factors, including a lack of
robust benefit, organizations resistance to change, and a lack of skills and technology
issues (buildingbetterhealthcare.co.uk). On the contrary, Clarke and Ellis (2011) state
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the leadership response to the inability or unwillingness to change existing work
practices is not clear. Most leaders say that after initial resistance, clinicians see the
value of Telehealthcare, that is, exposure to the service raises awareness, competence
and acceptance. There is furthermore a clear link between strategic planning and
change management as identified by Clarke and Ellis (2011). They state that there are
some good examples of strategies to change or influence clinical practice, particularly
between GP’s. The most powerful strategy was to include clinicians who would make
good use of telecommunications technologies at the earliest stages of planning, and to
encourage them to be actively engaged at the design stage of the project (Clarke and
Ellis, 2011).
Management’s greatest challenge is to ensure that the enterprise adapts to the changes
occurring within its environment (Grant, 2010). Considering this, Telehealthcare
inevitably brings change. Hospitals are hierarchical organizations. They are typically
resistant to change, and Telehealth is only one of the many changes they face at the
moment. Working to develop health services using Telehealth involves camaraderie
(Darkins & Cary, 2000). The current economic uncertain climate for health care
delivery, acute care general hospitals are often caught up in crisis management and
lack the management capacity and resources required for adequately developing
Telehealth services. Hospitals can feel a sense of threat, even paranoia, associated
with Telehealth (Barkins & Cary 2000). Grant (2010) continues and states the forces
of technology drive change in an industry environment, consumer needs, politics,
economic growth and a host of other influences. Supporting this, Prehalad and Hamel
(1990) state that, the greatest source of advantage is found in management’s ability to
merge technologies and organizational skills into competencies that empower
organizations to adapt quickly to changing opportunities.
Change Management often comes with miss-steps, and poor communication is
usually the reason behind those failures (Babcock, 2006). It is clearly recognized that
in order for organizations such as the HSE to change its opinions on Telehealthcare
implementation the involvement and dialogue with employees at all levels will be
required to assist buy-in. This concept is supported by Morgan & Zeffane (2003) who
state that the best way to avoid the negative consequences of change is to involve
employees in the organizational decision making in order to increase buy-in with
change incentives from the beginning. This concept has not been the case with
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Telehealthcare and considerable levels of resistance to change now exist. However, as
every manager is aware staying competitive now more than ever depends on
achieving higher levels of performance for customers whilst reducing costs (Rayport
and Sviokla, 1996). However, as a result of the current economic downturn,
knowledge management in coordination with the harnessing of information
technology will ultimately drive and ensure that organizations respond quickly to
customers, markets trends and demands on certain sectors (Nonaka, 2007).
Interestingly, Albright (2004) believes that environmental scanning, the gathering of
external information and its communication internally regarding issues that may
influence the organization and its strategic planning, could identify emergent issues,
situations and pitfalls that can impede the organization in the future if ignored.
The basic premise regarding change is, that unless the underlying assumptions of
culture are changed, ‘the way we do things around here’ will not change (Carnall,
2003). Culture is the acquired knowledge that people use to interpret experience and
generate social behavior. This knowledge forms values, creates attitudes, and
influences behavior (Luthans & Doh, 2012). Supporting this, Grant (2010) states that
we view the culture of the organization as a mechanism for achieving coordination
and control. One could argue, the context, culture or environment in which a decision
is made makes a huge difference (Handy, 1993). Culture is the basic or hidden
assumptions, interest practices, or values within an organization (Meyerson, 2011).
Interestingly, Johnson, Scholes and Wittington (2008) state that organizational culture
is the basic assumptions and beliefs that are shared by members of an organization,
that operate unconsciously and define in a basic taken for granted fashion an
organization’s view of itself and its environment.
Considering the situation within the Irish health service and clinicians intransigence to
change any movement towards Telehealthcare implementation may be a slow
process. Carnell (2003) supports this and states that because of deeply ingrained
manner of organizational culture which is often developed over a number of years,
changing it is easier said than done and often takes a very long time. Goodwin (2011)
states that a significant number of cultural and organizational barriers remain, the
technology itself is only a small part of making Telehealth a success; some wider
