NSMT 221 PEC 2011

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NSMT 221 PEC 2011 Powered By Docstoc

Study guide compiled by:

Prof Hester Klopper

Edited nn.
#Page layout by Marijke Reyneke, graphikos.

Printing arrangements and distribution by Department Logistics (Distribution Centre).
Printed by Nashua Digidoc 018 299 2827
Copyright  2011 edition. Date of revision 2012.
North-West University, Potchefstroom Campus.
No part of this book may be reproduced in any form or by any means without written
permission from the publisher.

Module goal ........................................................................................................................... v
Module objectives .................................................................................................................. v
Study process ........................................................................................................................ v
Prescribed study material ...................................................................................................... vi
Groupwork and facilitators ..................................................................................................... vi
Evaluation .............................................................................................................................. vi
Learning strategies ............................................................................................................... vii
Action verbs .......................................................................................................................... vii
Study icons ............................................................................................................................ ix
Course unit map .................................................................................................................... x
Warning against plagiarism .................................................................................................... xi

Study unit 1                  Total quality management ................................................................... 1
Study section 1.1             Quality improvement in a health service ................................................. 3
             1.1.1            Overview of study section 1.1 ................................................................ 4
             1.1.2            Summary ............................................................................................... 9
Study section 1.2             Implementation of a quality improvement programme .......................... 10
             1.2.1            Overview of study section 1.2 .............................................................. 10
             1.2.2            Summary ............................................................................................. 24
Study section 1.3             Total quality management .................................................................... 25
             1.3.1            Overview of study section 1.3 .............................................................. 25
             1.3.2            Summary ............................................................................................. 41

SUGGESTED READINGS................................................................................................... 41

IMPORTANT CONCEPTS OF STUDY UNIT 1 .................................................................... 42

SELF-ASSESSMENT FOR STUDY UNIT 1 ........................................................................ 42

GUIDELINES FOR SELF-ASSESSMENT ........................................................................... 43

Study unit 2                  Dimensions of management ............................................................. 45
Study section 2.1             Risk management ................................................................................ 47
             2.1.1            Overview of study section 2.1 .............................................................. 47
             2.1.2            Summary ............................................................................................. 54
Study section 2.2             Change management........................................................................... 55
             2.2.1            Forces for change ................................................................................ 56
             2.2.2            Role of a change agent ........................................................................ 60
             2.2.3            Resistance to change........................................................................... 64
             2.2.4            Summary ............................................................................................. 78

IMPORTANT CONCEPTS OF STUDY UNIT 2 ................................................................... 78

SELF-ASSESSMENT OF STUDY UNIT 2 ........................................................................... 78

GUIDELINES FOR SELF-ASSESSMENT OF STUDY UNIT 2 ............................................ 79

REFERENCES OF SOURCES USED IN STUDY SECTION 2.2 ......................................... 79

Study unit 3              Information systems and health service management.................... 81
3.1                       Computers information systems and health service management ........ 83
           3.1.1          Overview of study section 3.1 .............................................................. 83
           3.1.2          Summary ........................................................................................... 101
3.2                       Information management technologies............................................... 102
           3.2.1          Overview of study section 3.2 ............................................................ 102
           3.2.2          Summary ........................................................................................... 121
3.3                       Information systems in health service management ........................... 123
           3.3.1          Overview of study section 3.3 ............................................................ 123
           3.3.2          Summary ........................................................................................... 127

IMPORTANT CONCEPTS OF STUDY UNIT 3 .................................................................. 128

SELF-ASSESSMENT OF STUDY UNIT 3 ......................................................................... 131

SKILL-BUILDING EXERCISE ........................................................................................... 132

ASSIGNMENTS               ........................................................................................................... 135

ASSIGNMENT 1              ........................................................................................................... 135

ASSIGNMENT 2              ........................................................................................................... 136

VOLUNTARY ASSIGNMENT ............................................................................................ 136

After you have completed this module you should be able to understand and apply a quality
improvement programme to operationalise total quality management, implement risk
management and case management and apply information systems in the health care


After studying this module you should be able to:
     discuss the principles of quality improvement;
     apply the process of quality improvement;
     implement a quality improvement programme in the health service;
     formulate and apply total quality management in the health service;
     apply risk management and case management; and
     Implement information systems in the management of the health organisation.


Overview of module
NSMT 221 is a study of the dimensions of management. Health Service Management
consists of a group of health care managers who manage the health care organisation.
Management is the process by which nurse managers practice their profession. This module
addresses the dimensions of Health Service Management.
Study unit 1 discusses total quality management with a focus on quality improvement and the
implementation of a quality improvement programme.
Study unit 2 deals with the dimensions of management and addresses risk management and
case management.
Study unit 3 presents a framework for information systems in Health Service Management.

An adragogic approach will be followed. Teaching relies on the assumption that students
have an informed commitment to further personal and professional development and that
you (as student) will therefore take personal responsibility for learning to become an active
constructor of knowledge and that your learning affects a conceptual change.

The study guide
Great effort is taken in the preparation of the study guide to provide you with interactive study
material. The first few pages will provide you with the organisational detail of the module.
Give attention to the icons used in the study guide as they will guide you throughout the
material and will indicate the expected activity. The study guide is what it means – it will
guide you through your studies. Your prescribed textbook will be your main source of

information and will be clearly indicated where applicable. Where additional text is used it will
be referred to in the study guide.

(If you have the new edition of the prescribed book, the page numbers may differ.)
The prescribed textbook for this module is:
Booyens, SW 1998: Dimensions of Nursing Management; second edition. Cape Town: Juta
& Company
Any references to other textbooks will be integrated in the text of the study guide and be
referred to at the end of each study unit under sources/references.

Group discussions and critical debating are the preferred teaching methods and this
demands that students come well prepared to the contact sessions. Each learning objective
as set out in the study guide should be prepared by the student in anticipation of the contact
sessions. Video tapes will be used at the contact sessions to stimulate debate, but they are
not referred to in the text as they are not part of your preparation.

Your semester grade will be calculated from the results of your assignments and the
semester tests. You will need a semester mark of at least 40% to obtain admission to the
exam. The examination will consist of one three hours paper with a total of 100 marks. All
the content will be evaluated. Your semester mark is calculated as follows:
Tests:                      60%
Assignments:                40%
Semester mark:             100%

Calculating the marks
The final mark will be calculated from the semester mark and your examination results. The
following ratio will be used:

Semester mark:                                      50%

Examination mark:                                   50%

Final mark:                                       100%

In order to pass NSMT 221, you must:
1.    Obtain a sub-minimum of 45% in the final examination; and
A final year mark of at least 50%.

Active self-study and preparation of prescribed sections are essential. Make sure that you
understand the context. It is important that you must be able to analyse, synthesise and
evaluate the subject matter in order to apply it effectively in practice.
The following steps can be identified when working through the modules:
    Read the study unit goals and understand how the study sections are related to the
     study unit goals.
    Start with each study section by studying its goal, structure and study objectives.
    Read through the text of the study section and make notes for yourself.
    In case of uncertainty, consult the suggested readings.
    Define and understand all the important concepts.
    Evaluate yourself by completing the self-reflection exercises.
    Complete the assignments as indicated and hand in at the learning centre.

These action verbs are included, in order to provide clarity of what is expected of you as a
student. Please study them and make sure that you understand the meaning of each.

    Analyse
Identify parts or elements of a concept and describe them one by one.
EXAMPLE: Analyse the research process.

    Compare
Point out the similarities (things that are the same) and the differences between objectives,
ideas or points of view. The word “contrast” can also be used. When you compare two or
more objectives, you should do so systematically - completing one aspect at a time. It is
always better to do this in your own words.
EXAMPLE: Compare the Christian philosophy and the American philosophy.

    Criticise
This means that you should indicate whether you agree or disagree about a certain
statement or view. You should then describe what you agree/disagree about and give
reasons for your view.
EXAMPLE: Write critical comments about a Christian world view for Africa.

    Define
Give the precise meaning of something, very often definitions have to be learnt word for
EXAMPLE: Define the concept research.

    Demonstrate
Include and discuss examples. You have to prove that you understand how a process works
or how a concept is applied in real-life situations.
EXAMPLE: Give a demonstration on the aseptic technique.

      Describe
Say exactly what something is like, give an account of the characteristics or nature of
something, and explain how something works. No opinion or argument is needed.
EXAMPLE: Describe the characteristics of philosophy thought.

      Discuss
Comment on something in your own words. Often requires debating two viewpoints or two
different possibilities.
EXAMPLE: Discuss the differences between meta-theoretical and theoretical assumptions.

      Distinguish
Point out the differences between objectives, different ideas, or points of view.    Usually
requires you to use your own words.
EXAMPLE: Distinguish between a positivistic and a hermeneutic view of science.

      Essay
An extensive description of a topic is required.
EXAMPLE: Write an essay about the value of philosophy for the nursing researcher.

      Example
A practical illustration of a concept is required.
EXAMPLE: Give an example of a descriptive study.

      Explain
Clarify or give a reason for something, usually in your own words. You must prove that you
understand the content. It may be useful to use examples or illustrations.
EXAMPLE: Briefly explain the following research methods:
      The experiment
      Correlational studies
      Identify
Give the essential characteristics or aspects of a phenomenon e.g. a good research design.
EXAMPLE: Identify the characteristics in a text about the research process which is
indicative of a good research design.

      Illustrate
Draw a diagram or sketch that represents a phenomenon or idea.
EXAMPLE: Explain the menstruation cycle. Write a short essay and illustrate the cycle.

      List
Simply provide a list of names, facts or items asked for. A particular category or order may
be specified.
EXAMPLE: List ten problems associated with progesterone therapy.

      Motivate
You should give an explanation of the reasons for your statements or views. You should try
to convince the reader of your view.
EXAMPLE: Write an essay about your own philosophical viewpoint on research.         Motivate
your answer.

    Name or mention
Briefly name/mention without giving details.
EXAMPLE: Name three research methods in Nursing.

    Outline
Emphasise the major features, structures or general principles of a topic, omitting minor
details. Slightly more detail than in the case naming, listing or stating of information is
EXAMPLE: Outline the major features of a qualitative research.

    State
Supply the required information without discussing it.
EXAMPLE: State three functions of a community health nurse.

    Summarise
Give a structured overview of the key (most important) aspects of a topic. This must always
be done in your own words.
EXAMPLE: Give a summary of the core characteristics of an explanatory study.

    Clarify
Make, or become clearer to see in order to be easier to understand.

    Debate/reasoning
Follow a question attitude, and have a formal argument.

    Indicate
Point out, make known, state briefly.


                Test your current                            Individual exercise

                Important information
                                                             Take your answers with you to
                                                             the contact session/group
                                                             meeting for discussion

                Study the following                          Study the indicated material(s)
                section/explanation/                         in the textbook / article, etc
                discussion, attentively

                Outcomes                                     Assignment

               Answers/solutions                       Summary of main learning

               Approximate study time


                                        NSMT 221

       STUDY UNIT 1                     STUDY UNIT 2            STUDY UNIT 3

Total quality management      Dimensions of              Information Systems and
                              management                 Health Service Management

Study section 1.1             Study section 2.1          Study section 3.1
Quality improvement in a      Risk Management            Computers Information
health service                                           Systems and Health Service

Study section 1.2             Study section 2.2          Study section 3.2
Implementation of a quality   Change Management          Information Management
improvement programme                                    Technologies

Study section 1.3                                        Study section 3.3
TQM                                                      Information Systems in Health
                                                         Service management


Copying of text from other learners or from other sources (for instance the study guide,
prescribed material or directly from the internet) is not allowed – only brief quotations are
allowed and then only if indicated as such.
You should reformulate existing text and use your own words to explain what you have
read. It is not acceptable to retype existing text and just acknowledge the source in a
footnote – you should be able to relate the idea or concept, without repeating the original
author to the letter.
The aim of the assignments is not the reproduction of existing material, but to ascertain
whether you have the ability to integrate existing texts, add your own interpretation and/or
critique of the texts and offer a creative solution to existing problems.
Be warned: students who submit copied text will obtain a mark of zero for the
assignment and disciplinary steps may be taken by the Faculty and/or University. It is
also unacceptable to do somebody else’s work, to lend your work to them or to make
your work available to them to copy – be careful and do not make your work available
to anyone!

                                                                                                                 Study unit 1

    1                         TOTAL QUALITY

Time schedule for this study unit is approximately 25 hours

Study unit contents
Study section 1.1         Quality improvement in a health service ................................................. 3
           1.1.1          Overview of study section 1.1 ................................................................ 4
           1.1.2          Summary ............................................................................................... 9
Study section 1.2         Implementation of a quality improvement programme .......................... 10
           1.2.1          Overview of study section 1.2 .............................................................. 10
           1.2.2          Summary ............................................................................................. 24
Study section 1.3         Total quality management .................................................................... 25
           1.3.1          Overview of study section 1.3 .............................................................. 25
           1.3.2          Summary ............................................................................................. 41

SUGGESTED READINGS................................................................................................... 41

IMPORTANT CONCEPTS OF STUDY UNIT 1 .................................................................... 42

SELF-ASSESSMENT FOR STUDY UNIT 1 ........................................................................ 42

GUIDELINES FOR SELF-ASSESSMENT ........................................................................... 43

Study unit 1

After having studied study unit 1 you should be able to:
    explain the principles and process of quality improvement,
    implement a quality improvement programme; and
    describe total quality management in health care.

Planning for quality starts with the acknowledgement that there is no single indicator of
quality. Quality has variously been defined as value, conformance to standards, excellence,
meeting expectations (Hellriegel & Slocum, 1996: 185). In study unit 1 the principles and
process of quality improvement are addressed and how to implement a quality improvement
programme in health care. Lastly we will investigate total quality management (TQM) in
health care.

                                                                Study unit 1


After having studied study section 1.1 you should be able to:
    clarify the concepts:
     -     Quality;
     -     Quality assurance;
     -     Quality improvement;
    explain various quality improvement models;
    discuss the principles of quality improvement; and
    describe the process of quality improvement.

Study unit 1

In study section 1.1 the focus is on quality improvement in a health service. Various quality
improvement models are investigated and the principles of quality improvement are
discussed. Lastly, the process of quality improvement is studied with a focus on standards
and the evaluation of quality.

Concepts: Quality, quality assurance and quality improvement

Muller, in Booyens, 1998, pp. 596 – 597, elaborates on the three concepts.        Study the
concepts and complete the following:
    What are the characteristics associated with quality?
    How will you define quality in your own words?
    What does quality assurance refer to?

    What is quality improvement?

                                                                             Study unit 1

    What are the characteristics associated with quality?
    How does quality improvement differ from quality assurance?

Stakeholders in the health care quality movement

Various stakeholders are identified by Muller, in Booyens, 1998, pp. 598 – 599. Study the
content and make notes on which the stakeholders are:

Study unit 1

Reasons for formalising quality improvement

Why do you think it is important to have a formal quality improvement plan?

Muller, in Booyens, 1998, pp. 599 – 600, provides reasons for formalising quality improve-
ment. Study the content and summarise her rationale.

                                                                               Study unit 1

Principles of quality improvement

Study the principles of Deming’s approach to quality improvement as discussed by Muller, in
Booyens, 1998, pp. 600 – 604.
What are the principles?
What are the principles and prerequisites for quality improvement according to Muller, in
Booyens, 1998, pp. 604 – 605.

Quality circles and elements
Quality circles and elements involve the setting of standards, evaluation based on the
standards and remedial steps.

Study unit 1

Muller, in Booyens, 1998, pp. 605 – 614, discusses the process of quality management.
Study the content and complete the exercise:
    What are the three types of standards?
    Define each in your own words.
    Identify the different methods of evaluation.
    What are the requirements that evaluation instruments should meet?
    What are the principles of data gathering?

                                                                               Study unit 1

    The third phase in the process is remedial steps. How will you accomplish this? List
     the remedial steps recommended to rectify the process.

1.1.2      SUMMARY

Quality improvement is based on specific principles and follows a process. In study section
1.1 we have addressed the principles and process and investigated various models that can
be utilised in quality improvement. In the next study section we will examine how a quality
improvement programme can be implemented in a health care service.

Study unit 1

                    IMPROVEMENT PROGRAMME

After having studied section 1.2 you should be able to:
     discuss the principles and responsibilities of the quality improvement committee;
     describe the development phase;
     identify and explain the approaches to the formulation of standards;
     develop a monitoring and evaluation system; and
     discuss the principles of the formalisation phase.

The quality improvement programme is a plan focused on the improving of service
excellence to the patient. In setting up a programme, a centralised or decentralised
approach can be followed. In study section 1.2 we will investigate the principles for setting
up a quality improvement committee, which will base its work on the implementation of the
programme through the development phase formulation of standards and of formalisation

The quality improvement committee

Study Muller, in Booyens, 1998, pp. 630 – 631.

                                                                                  Study unit 1

    What is the purpose of a quality improvement committee?
    List the principles you will apply to set up the quality improvement committee.

    Make a list of the responsibilities of the quality improvement committee.

Developmental phase
The developmental phase is the foundation of the formal quality improvement programme.
This phase will determine the success of the formalisation phase.
Muller, in Booyens, 1998, pp. 631 – 635, debates the development phase.

Study unit 1

    What are the components of the development phase of a quality improvement pro-
     gramme? List the components and make notes on each.
    Identify the approaches to the formulation of standards and criteria.

There is an enormous amount of “jargon” used in the setting and monitoring of standards.
The following terminology provides a clear understanding of concepts used in standard
setting (quoted from Sale, 1996, pp. 47 – 62).

Compare the content to that of Muller that you have studied.

Standard statements are professionally agreed levels of performance, appropriate to the
population addressed, which reflect what is acceptable, observable, achievable and
measurable. The first part of the statement, “Standard statements are professionally
agreed”, means that a group of professionals or members of the health care team get
together and in discussion agree on a standard, taking into account research findings and
changes in practice. The first and vital step in standard setting is the beginning of the
provision of continuity of care for the patient. The discussions about “what we do” and “who
does it” prior to setting the standard are very valuable. These discussions may identify
duplication of effort by professionals, differences in the way care is given and a debate on
what should be done by whom, how and when.
The standards statement should include the indicators of quality. For example: Every
resident chooses and wears his/her own clothes at all times – Why? So what? The indicator
of quality is “In order to promote dignity and self respect”.

                                                                                       Study unit 1
Residents who are dressed by staff in clothes from a general stock of clothes are given no
choice. This is a very poor indicator of quality: their dignity has been removed, they have
become institutionalised. The standard is written and implemented to ensure that all
residents are enabled to retain their self respect, dignity and right to chose.
The second part of the statement, “Related to a level of performance”, means establishing
what you are trying to achieve for your patients/clients within your resources, and reaching
the desired outcome. “Appropriate to the population addressed” means the care group for
which the standard is written, taking into account the patient’s/clients and relative’s needs,
negotiating care with patients/clients, developing shared plans of care. The standard may be
written for children or patients admitted for surgery, and so on.

Criteria may be defined as descriptive statements of performance, behaviours,
circumstances, or clinical status that represent a satisfactory, positive or excellent state of
A criterion is a variable, or item, that is selected as a relevant indicator of the quality of care.
Criteria make the standard work because they are detailed indicators of the standard and
must be specified for the area or type of patient.

Criteria must be:
     Measurable: illustrating the standard and providing local measures.
     Specific: giving a clear description of behaviours/action/ situation/resources desired or
     Relevant: items that you can identify that are required in order to achieve a set level of
      performance. There may be numerous criteria that you can think of, but you have learn
      to be selective and pick out only those criteria that are the relevant indicators of quality
      of care and that must be met in order to achieve a set level of performance.
     Clearly understandable: therefore they should each contain only one major theme or
     Clearly and simply stated: so as to avoid any misunderstanding.
     Achievable: it is important to avoid unrealistic expectations in either performance or
     Clinically sound: therefore they must be selected by practitioners who are clinically up
      to date and evidence based.
     Reviewed periodically: to ensure that they are reflective of good practice based on
      current research.
     Reflective of all aspects of the patient or client status:             that is physiological,
      psychological and social.

In summary, a criterion must be:
     A detailed indicator of the standard
     Specific to the area and type of patient or client
     Measurable

Study unit 1
Think of the standard as a tape measure or ruler and the criteria as the measurements
marks. The criteria allow you to measure the standard; they make it possible to measure the
standard statements.

There are three types of criteria:
    Structure
    Process
    Outcome

Structure criteria
Structure criteria describe what must be provided in order to achieve the standard – the
items of service that are in the system, such as:
    The physical environment and buildings
    Auxiliary and support service
    Equipment
    Staff, numbers, skills, mix, training, expertise
    Information: agreed policies and procedures, rules and regulations
    Organisational system

Process criteria
Process criteria describe what action must take place in order to achieve the standard:
    The assessment techniques and procedures
    Methods of delivery of care
    The assessment procedures
    Methods of intervention
    Methods of patient, clients, relative and/or carer education
    Methods of giving information
    Methods of documenting
    How resources are used
    Evaluation of the competence of staff carrying out the care
The following headings indicate the areas to include in process criteria:
The professional assesses …
The professional includes in the plan …
The professional does …
The professional reviews …
The professional and the patient or client …

                                                                                  Study unit 1
Outcome criteria
Outcome criteria describe the effect of the care – the results expected in order to achieve the
standard in terms of behaviours, responses, level of knowledge and health status. In other
words, what is expected and desirable described in a specific and measurable form.
Consider the following headings:
     The nurse can state …
     The patient can state …
     There is documented evidence …
     The professional observed …
One of the reasons for developing the outcome criteria into immediate measurable criteria is
to ensure that the standards are measured all the time as part of the evaluation of care.
Many professionals see the measurement of standards as “someone else’s responsibility”,
rather than part of patient or client care. Outcomes that are not being achieved need to be
corrected immediately, not left for quarterly of six-monthly formal monitoring.

In summary, criteria state:
    What we need to meet the standard
    What must be done to meet the standard
    Expected results or outcome (see figure 1.1)

    STRUCTURE                PROCESS            OUTCOME

Resource                 Action              Results
What you need            What has to be Outcome

Figure 1.1: Criteria: a summary
In the past the outcomes set were very broad criteria, for example: “the discharge was
carried out in accordance with the individual’s need and wishes”. This outcome requires a
monitoring toll in order to measure the patient’s satisfaction. It is much simpler to state:
                                                       YES       NO
The patient can state:

that the discharge plan was discussed with
the discharge plan is clear

There was a documented assessment of the
patient’s need prior to discharge

It is important to remember that the criteria describe the activities to be performed, whereas
the standard states the level at which they are to be performed. The criteria are like the
strings on a puppet, making the standards come alive. By following this process, patient or
client care can be measured by comparing actual practice against the stated criteria and then
checking to see if the activity has met the agreed standard.

Study unit 1

Classifying standards
This method of writing standards is a dynamic approach, as it involves writing standards
about an area of interest or concern, or in order to solve a problem. As you can imagine, this
could lead to vast amounts of information and there is a danger of overwhelming the system.
In order to organise the information, Helen Kendall devised a simple format to co-ordinate
the information. Every standard must be classified according to the following headings:

This is a major activity classified according to a particular coding system (see figure 1.2).
The area of interest, concern, or the problem on which you have decided to write your stan-
dard, can be located under one of these topics. For example, a standard being written to
solve a problem of transferring patients from a hospital to the community would be “continuity
of care”.

This is a sub-system of classification which enables you to define further the area of interest,
concern or problem. So, if the topic is “continuity of care” and the sub-topic is “transfer of
patient” the problem concerns the transfer of patients or clients (see figure 1.2).

               TOPIC                                         SUB-TOPIC
Safety                               Eliminating hazards theatre standards control of
                                     infection standard
Individualised care                  Systematic approach
Activities of daily living           Maintaining a safe environment communicating
(i)      Physical                    Breathing, eating and drinking eliminating
(ii)     Psychological               Personal cleansing and dressing, controlling body
                                     temperature, mobilising, working and playing,
                                     expressing sexuality, sleeping, dying, pain
Continuity of care                   Reception/admission of patient or clients, discharge of
                                     patients, transfer of patients
Independence and involvement         Promotion of self-care, decisions/ choices, ability to
                                     care for self, rehabilitation, family/carer, participation
Privacy and confidentiality          Privacy – environment and attitudes to privacy access
                                     to records
Personnel                            Selection/interviewing recruitment
Basic and continuing education Competences, orientation programmes, professional
and appraisal                  development

                                                                                   Study unit 1

Figure 1.2: Topics and sub-topics
The form in figure 1.3 is used to record all standards and is based on one designed by Helen
Kendall. This is an example of the type of form used and you may need to use some or all of
the headings. Topic and sub-topic have already been discussed above. The explanation of
the rest of the form is as follows.

     Standard ref. no: ……………………                  Achieved standard by: ……………..
     Topic: ……………………………….                        Review standard by: ……………….
     Sub-topic: …………………………..                     Signature of facilitator: ……………..
     Care group: …………………………                      Signature of manager: …………….
     Clinical area: ……………………….                   Date standard set: ………………….
     Monitoring results: …………………                 Date to be monitored: ……………..
                                                 Date of monitoring: ………………..
     Standard statements: ……………………….…………………………………..
               Structure                      Process                        Outcome

Figure 1.3: Form for recording statements

     Standard reference number
In the top left-hand corner there is the “Standard Reference Number” – this is where the
index number is recorded. An index system is used to organise the information and make it
quick and simple to find standards and divide them up by topic, sub-topic, care group, clinical
area, review-by date and monitoring results. If anyone is having problems writing a standard,
they can ask for a copy of those that have already been written and this helps them to get

     Care group
This is the target group of patients, clients or staff for whom the standard is written, such as
“care of the elderly”, patients in the recovery room, patients with a specific problem, such as
diabetes or those recovering from a cerebral vascular accident, mother and baby, children,
patients or clients in the community, and so on.

     Clinical area
This is the ward, unit, department locally based unit, clinic, surgery and soon.

     Achieve by date and review by date
It is important to decide when the standard will be achieved and to set and record a realistic
date. You will also need to discuss and decide when it would be reasonable to review the

Study unit 1
standard and decide if it is still relevant, achievable, acceptable, and in line with current
practice and research. If it is not, then it should be removed from the system and replaced by
an appropriate standard. It is important to realise that standards set today are not set in
tablets of stone forever but are reviewed and rewritten; they are dynamic and change as the
patient’s or client’s needs change, as new research changes practice, as patients or clients
change, or as staff change.

    Facilitator’s signature
The person who has been trained to facilitate the process of setting standards signs here.
These people must be given training to enable them to work with groups, set and monitor
standards and facilitate their colleagues in the clinical areas.

    Managers signature
The manager signs the standard statement to say that he or she agrees that the content is
acceptable, observable, measurable, applicable, to the group specified and achievable in the
particular unit by the specified date.

    Result of monitoring
Here “achieved” or “not achieved” is written. If the standard has not been achieved, then an
action plan should be developed to ensure achievement.
Classifying standards in this way helps to keep them specific and clearly focused on a
particular care group.
The good news is that standards should only be a page long. If they go on for longer, then
you may well be rewriting the procedures. It is very easy to write down everything that you
can think of in relation to a problem, but more difficult to be specific and only include the
indicators of quality.

    Checking standards
Once you have written a standard, check that the criteria:
    Describe the desired quality of performance
    Have been agreed
    Are clearly written (not open to misinterpretations)
    Contain only one major thought
    Are measurable
    Are concise
    Are specific
    Are achievable
    Are clinically sound.

    Monitoring standards
There are two approaches to monitoring standards, through:
    Retrospective evaluation
    Concurrent evaluation

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Retrospective evaluation involves all assessment methods that occur after the patient or
client has been discharged. Concurrent evaluation involves assessment that takes place
while the patient or clients are still receiving care.
Figure 1.4 lists the approaches used to assess the quality of care. The use of concurrent
evaluation is perhaps more valuable, as it gives staff the opportunity to correct any negative
outcomes while the patient is still under care. This approach is further developed in figure

    Retrospective evaluation of the            Concurrent evaluation may be
     quality of health care may be                      effect by:
              effected by:
    Post care patient interview              Assessment of the outcome
    Post-care patient questionnaire          Patient interview
    Post-care staff conference               Conference between patients,
                                               staff and relatives
    Audit of the records
                                              Direct observation of care
                                              Measurement of the competency
                                               of the nurse
                                              Audit of the records

Figure 1.4: Retrospective and concurrent evaluation of care

YES       NO       N/A              MONITORING STANDARDS
                            Questions to be answered. Developed from the
                            criteria in the standard. Auditor checks the criteria in
                            question form:
                               Asks the patient about care received
                               Asks the staff about care given
                               Observes care given/structure of area and
                                reviews documentation
                               Responds by answering YES/NO/Not applicable
                            Responses should be 100% “YES” any “NO”
                            answers should be investigated and an action plan
                            developed, a date should be set to re-monitor

Figure 1.5:        Monitoring standards using retrospective and concurrent
When monitoring standards or when establishing patient, client or relative views it is some-
times necessary to develop questionnaires.

Approaches to monitoring standards

      Type 1
As discussed earlier, the process of monitoring standards may be made simpler and more
effective by writing the outcome criteria in a form which requires a “YES” or “NO” answer.
Remember that each outcome criterion must contain only one question or theme.

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    Type 2
An alternative approach is to take criteria from structure, process and outcome and turn them
into a list of questions. Each questions is used as an indicator which requires a “YES” or
“NO” answer. The total number of “YES” answers may be added together to calculate a
score and demonstrate whether or not the standard has been achieved.

Methods of monitoring standards
There are various methods of monitoring standards, of which the most commonly used are:
    Observation of care
    Asking the patient, client of relative questions
    Checking the records

The various types of measurements need to be discussed by the group and the most
appropriate method selected. Motivate your answer. Share your own experiences from

The techniques for asking questions have been thoroughly researched and there are many
different approaches. Many examples are given of different approaches to patient surveys.
From these findings and recommendations, the following points arise:
    Questions should be phrased so that they do not patronise the respondent, while at the
     same time being easily understood, and so meet the intellectual abilities of a cross
     section of society.
    Questions must be expressed simply and clearly, making sure not to use words and
     phrases that have more than one meaning.
    Ask questions one at a time: do not include two topics in one question – for example:
     “Was your discharge planned and negotiated?” The care may have been planned with
     the patient but not necessarily negotiated. Ask two separate questions, as the answers
     could be very different.
    Questions should be short.
    Give the respondent an opportunity to write his or her comments.
    Respondents tend to choose a middle answer if given a choice so a simple “YES” or
     “NO” will overcome this problem.
     Sometimes a respondent may show a bias by answering “YES” to every question. To
      avoid this you can ask a question where a positive answer is required and then later in
      the questionnaire ask the same or a similar question where a negative response is
      required. Including different forms of the same question can also check for consistency
      and misunderstandings.
These are only a few suggestions, but they may help you when you have to prepare a
questionnaire to monitor a standard.

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The care plan
The patients or client’s care plan is a very effective method of monitoring when a standard
that is written for a group of patients or clients is monitored for an individual.

The final stage
The final stage in standard setting is to compare current practice with the standard and to act
on the monitoring result. If the standard has not been achieved, you need to check why.
Ask yourself: is it an achievable standard? If it is achievable, then develop an action plan to
ensure that practice meets the required standard.
As demonstrated in figure 1.6 the measurements of standards is not “quality assured”.
Quality assurance only occurs when the gaps have been identified following measurements,
and action has been taken to ensure standards are achieved.
                                      Determine criteria

                                        Set standards

                      Devise tools to assess/measure based on criteria

                            Compare what is, with what should be

                                  = QUALITY MEASURED

                                        Identify gaps

                                  Take action to ensure that

                                   Standards are achieved

                                   = QUALITY ASSURED

Figure 1.6. Quality measured. Quality assured

The formalisation phase
When the quality improvement committee has completed the groundwork, it is time to
formalise the implementation of the quality improvement programme.

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Study Muller, in Booyens, (1998, pp. 640 – 641).
    What are the principles that underlie the formalisation?
    Identify the components of the formalisation phase.

Evaluation of the quality improvement programme

Muller, in Booyens, 1998, p. 643, determines why evaluation of the quality improvement
programme is needed. Study the content and list the aspects that will require formal

                                                                                   Study unit 1


To ensure the quality of care the appropriate tool must be selected. The tools are essentially
date collection systems using retrospective and concurrent audit – that will give an indication
of the quality of patient care for a participating ward/department/unit (quoted from Sale, 1996,
pp. 21 – 22).

Retrospective audit
A retrospective audit involves all assessment mechanisms carried out after the patient has
been discharged. These include:
    Closed-chart auditing: This is the review of the patient records and identification of
     strengths and deficits of care. This can be achieved by a structured audit of the
     patient’s records;
    Post-care patient interview: which is carried out when the patient has left the hospital or
     care has ceased in the home. It involves inviting the patient and/or family members to
     meet to discuss experiences. This may be unstructured, semi-structured or structured
     using a checklist or questionnaire;
    Post-care questionnaire: This should be completed by the patient on discharge. It is
     usually designed to measure patient satisfaction.

Concurrent audit
Concurrent audit involves all assessments performed while the patient is in hospital and
receiving care. These include:
    Open-chart auditing: This is the review of the patients’ charts and records against pre-
     set criteria. As the patient is still receiving care, this process gives staff immediate
    Patient interview or observations: which involves talking to the patient about certain
     aspects of care, conducting a bedside audit or observing the patient’s behaviour to pre-
     set criteria;
    Staff interview or observation: which involves talking to and observing nursing
     behaviour related to pre-set criteria;
    Group conferences; which involves the patient and/or family in joint discussion with
     staff about the care being received. This leads to problems being discussed and
     improved plans being agreed on.

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1.2.2      SUMMARY

The implementation of a quality improvement programme implies a development phase and
a formalisation phase. In study section 1.2 we have given attention to both these phases.
The quality improvement programme should be implemented with the long-term and with
cost-effectiveness in mind.

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    1.3              TOTAL QUALITY MANAGEMENT

After having studied section 1.3 you should be able to:
    explain and apply Deming’s theory to TQM;
    describe the contribution of:
     -     Juran;
     -     Crosby;
     -     Taguchi to TQM;
    discuss the role of leadership in TQM; and
    describe the application of TQM to nursing.

Total Quality Management (TQM) was developed in the USA by Deming and Juran as a
business philosophy. This philosophy was welcomed by the Japanese and implemented in
the 1980’s. In study section 1.3 we will address TQM and the application thereof in nursing.

Swansburg (1996:568) describes TQM as “a way of life that can ensure the survival of
business. Among its elements are decentralisation and participatory management – the
process of making decisions at lower levels in the organisational hierarchy. Other elements
of TQM are matrix management and management by objectives (MBO)”. Sale (1996:31)
states that the concept of TQM is fairly simple. Any organisation requires processes for
ensuring that the service it provides is needed by the consumer and is of an acceptable
standard. The organisation should (quoted from Sale 1996, pp. 31 – 35):
    Focus on the needs of expectations of its market and its consumers
    Achieve top quality performance in all areas of its activity (product, service and internal
    Install and operate procedures, simple and complex, necessary for the achievement of
     top quality performance

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     Critically and continuously examine processes to reduce and remove non-productive
      activities, inefficiencies, and waste
     Develop and monitor measures of performance, set standards against which this
      performance is measured and set required improvements
     Understands and develop an effective communication strategy
     Develop a non-hierarchical team approach to problem-solving and delegating respon-
      sibility for change
     Develop good procedures for communication and feedback to staff at any level of good
     Continuously review the above process to develop a culture for never-ending improve-
In the business world companies must constantly address issues of quality to ensure that
they are not overtaken by their competitors: the consumer demands a high quality product or
GP’s will refer patients to the service that is responsive, effective and efficient and not to the
hospital or service where there are waiting lists or a history of poor quality.
TQM can enable a trust to meet patient’s needs through an organised approach to
monitoring and enhancing the quality of care or service delivered by all the staff. In order to
do this there must be commitment by all the staff to improve the quality of service to patients
and their families.
In the past within the Health Service it tended to be a “top down” approach to quality
assurance, people with the responsibility for quality, developing standards and distributing
them to wards and departments for “comments” prior to the standards being implemented.
TQM is about the development of a culture in which all staff is involved in ways of improving
care and are supported by management systems with the same commitment to quality

What approach to TQM will you prefer to use? Motivate your answer from own experience.

                                                                                        Study unit 1
TQM is about meeting and exceeding the consumer’s requirements. These may be the
requirements of the GP’s, patients and patients’ families. To do this there must be ways of
establishing what the patients or GP's require of the service and developing ways of
responding to this need, by understanding not only the external customer but also the
internal staff requirements.
Another key aspect of this approach is the monitoring of the standard of the service by
constant review of the key elements. It is necessary to ensure that standards set are indeed
true standards that are explicit, measurable, a true reflection of quality and include patients
and relatives using the service. The whole organisation needs to be clear about the need for
compliance with these standards and the implications of non-compliance.
Perhaps the key issue of all those mentioned is the issue of ownership and commitment of
quality of care and service by all staff, at all levels of the organisation. Historically staff within
the health service has been committed to deliver quality care and have worked hard to
improve the care they give and the service they deliver. The main difference is that instead of
having pockets of enthusiasm within the organisation, the whole organisation is part of a
structured system of quality that is managed systematically. TQM should encourage every
member of staff to be an active cog in the quality wheel, to be loyal to the hospital and
department and support staff to deliver higher quality and cost effective care and service.
Health care units should develop systematic plans and continuously review quality, using a
format and contents determined locally but consistent with national and regional policies.
They were instructed to monitor all aspects of quality of patient care and service, including
outcome. The specific areas included:
     Medical and clinical audit
     Reducing waiting terms (outpatient and inpatient)
     Specification of quality elements to contracts
     Measurable criteria or standards of care and service
     Improved appointment systems
     Information to patients
     Reception and public area arrangement
     Customer feedback on strategies
     Improved environments

The TQM approach is about putting the needs of patients at the centre of every activity at all
levels of the organisation with the support and involvement of management. Sale (1996:35)
demonstrates the approach visually in figure 1.7.

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Figure 1.7. Total quality management in health care

Application of theories in TQM
    Deming’s theory
The application of Deming’s theory is quoted from Swansburg (1996, pp. 568 – 573).
Using Deming’s methods, managers and workers have a natural division of labour; the
workers do the work of the system while the managers improve the system. Thus the
potential for improving the system is never-ending. Workers know where the potential lies for
improving the system, consultants are not needed. Managers know the system is subject to
great variability and that problem events occur randomly. The common language for
managers and workers is elementary statistics, which all workers learn. Deming summarises
his approach in fourteen points:
    Create constancy of purpose toward improvement of product and service. Everyone
     should have a clear goal every day, month after month. Satisfy the customer and
     reduce variation so all employees do not have to constantly shift their priorities.
    Adopt a new philosophy by learning how to improve systems in the presence of
     variation, thus reducing variation in materials, people, processes, and products. End
     tampering and overreacting to variation.
    Cease dependence on inspection to achieve quality by thoroughly understanding the
     sources of variation in processes and working to reduce variation.

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    End the practice of awarding businesses on the basis of price tag alone. Instead,
     minimise total cost by working with a single supplier.
    Improve constantly and forever every process for planning, production, and service.
     Everyone uses PDCA (plan-to-check-act) cycle.
    Institute training the job. Know methods of performing tasks and standardise training.
     Accommodate variation in ways people learn.
    Adopt and institute leadership. Work to help employees do their jobs better and with
     less effort. Learn which employees are within the system and which are not. Support
     company goals, focus on internal and external customers, coach, and nurture pride in
    Drive out fear, including fear of reprisal, fear of failure, fear of providing information,
     fear of not knowing, fear of giving up control, and fear of change. Fear makes accurate
     data non-existent.
    Break down barriers among staff areas, between departments. Promote cooperation.
     What is the constant, common goal?
    Eliminate slogans, exhortations, and targets for the work force. Improvement requires
     changed methods and processes. Leaders change the system.
    Eliminate numerical quotas for the work force and numerical goals for management.
     All people do not work at the same level of speed. There will be variation. Use realistic
     production standards. Eliminate management by objectives and use a system that
     rewards people’s efforts towards improvement.
    Remove barriers that rob people of pride of workmanship. Eliminate the annual rating
     or merit system.
    Institute a vigorous program of education and self-improvement for everyone. This can
     be any education that improves self-esteem and potential to contribute to
     improvements in existing processes and advances in technology.
    Put everyone in the company to work to accomplish the transformation.

Contrary to the fourteen points he sets out the “seven deadly diseases”:
1.   Lack of constancy of purpose
2.   Emphasis of short-term profits
3.   Evaluation of performance, merit rating, or annual review
4.   Management by use of only visible figures
5.   Mobility of management
6.   Excessive medical costs
7.   Excessive costs of liability

In addition to Deming, other wise persons in the field of TQM include Joseph Juran, Philip
Crosby and Genichi Taguchi. Their contributions are quoted from Swansburg (1996, pp. 573
– 576).

Study unit 1

    Joseph Juran
To Juran, quality means fitness to serve, doing it right the first time to meet customers needs,
and freedom from deficiencies. Quality means employee involvement, with management lea-
ding the effort in planning, control, and improvement so that requirements are met. It means
identification of customers and their needs in a product-by-product and step-by-step process.
Juran describes leadership that charts a new module that breaks with traditional mana-
gement. This new module applies quality management to all functions at all levels of the
enterprise and incorporates the exercise of personal leadership and participation by top
managers. All managers would be educated in quality management techniques. There
would be an all-pervasive unity in which everyone knows the direction of the new module and
is stimulated to go there. The resisting forces are multiple functions, levels in hierarchy, and
product lines. All of these resisting forces are prominent in health care agencies.
Juran’s philosophy of quality is based on three major premises:
    quality planning
    quality control and
    quality improvement.

A process for meeting established goals under operating conditions is created by quality
planning that includes the following:
    Identify customers, both internal and external
    Determine customer needs
    Develop products features that respond to customer needs
    Set goals that meet needs of customers and suppliers
    Develop processes to produce the product features
    Prove process meets quality goals during operations

Quality control, the second activity of the quality process, is performed by operations
personnel who put the plan into effect, identify deficiencies, correct them, and monitor the
process. Quality control includes the following:
    Choose what to control
    Choose units of measurement
    Establish measurements
    Establish standards of performance
    Measure actual performance
    Interpret the difference
    Take action of the difference

The third and final premise of the Juran philosophy is quality improvement, which should be
purposeful and in addition to quality control. Quality improvement includes the following:
    Prove and need for improvement
    Identify projects for improvement

                                                                                 Study unit 1
    Organise to guide the projects
    Diagnose to find the causes
    Provide remedies
    Prove remedies are effective under operating conditions
    Provide for control to hold the gains
According to Juran, the quality trilogy can be grafted onto the strategic planning process. A
corporate task force may be set up to design appropriate training. A quality planning council
can be established for policies, goals, plans, resources, and performance reviews, thus
incorporating quality into the merit rating system. Goals would be written for the future, for
the marketplace, and for competition. The entire infrastructure would be used in this
process, which would require putting money into quality improvement. Juran even
suggested the creation of a new role of quality controller to:
    Assist management in preparing strategic funding goals
    Set means of reporting performance against quality goals
    Evaluate competitive quality and market trends
    Design and introduce needed revisions in quality planning, quality control, and quality
    Conduct training to assist company personnel in carrying out the accessory change

According to your perception, what are the major contributions of the work of Juran in the
field of TQM?

Study unit 1

Use Juran’s three major premises of quality planning, quality control and quality improvement
to do a quality plan for your department unit. How will this plan look like?
What guidelines will you use in the description of a plan for quality improvement?

                                                                                    Study unit 1

     Philip Crosby
Crosby earned his spurs as a quality guru at International Telephone and Telegraph (ITT).
He defines quality as “conformance to requirements”, the first of his four absolutes. If the
process is done right the first time, there is no need to redo it. Management sets the
requirements and supplies the where-withal to employees to do the job by encouraging and
Crosby second absolute is that the system of quality is prevention rather than appraisal. His
third absolute is a performance standard of zero defects. A policy should be to deliver
defect-free products on time. Other quality gurus, notably Deming and Taguchi, do not
advocate zero defects, which they view as focusing upon numbers rather than on the quality
The fourth and final Crosby absolute is that the measurement of quality is the cost of non-
conformance, because service companies spend half of their operating expenses on the cost
of doing things wrong. Achieving these absolutes should be a constant priority. It requires
the determination of management and the commitment of the entire organisation. It requires
the training and education of all employees as part of a continual, formal preparation of the
organisation for the future. Everyone should be taught the common quality language. All
people are trainable, interested, and ambitious. They will make TQM work if they know and
understand management’s policy. All levels of management are trained early.

Summarise the four absolutes of Crosby’s work in your own words.

Culture and climate are important to achieve Crosby’s absolutes. A climate of innovation is
created because continuous innovation keeps customers coming back. The organisational
culture often must be changed to raise every person’s basic expectations. A small group of
people may be used to keep ethics and integrity on the up-and-up. People come to believe
that quality is as important and has the same importance as financial management. If
managers think and operate in terms of quality, they will change the culture and create a
climate of consideration for people, employees, customers, suppliers, and the community.
Crosby’s strategy uses a no technical approach beginning with an awareness campaign and
a focus on behaviour among people. During the campaign the organisation is stripped down
to examine it for problems, to identify and satisfy the customers, to eliminate waste, and instil

Study unit 1
pride and teamwork. By policy every department and unit has a quality strategy and a quality
function. All managers participate in TQM, it becomes a part of how they think, feel and act.
Health service managers may want to use Crosby’s Quality Management Maturity Grid to
measure the quality assurance aspects of their departments or units and then extend its use
to other units. (Table 1.1)
     Measure-        Stage one:             Stage two:           Stage three:         Stage four:           Stage five:
      ments          Uncertainty            Awakening           Enligthenment          Wisdom                Certainty
 Management        Non comprehen-        Recognize that        While going         Participating.        Consider quality
 understanding     sion of quality as    quality manage-       through quality     Understand            management an
 and attitude      a management          ment may be of        improvement pro-    absolute of           essential part of
                   tool. Tend to         value but not wil-    gram, learn more    quality manage-       company system
                   blame quality         ling to provide       about quality       ment. Recognize
                   department for        money or time to      management          personal role in
                   “quality              make it all           becoming sup-       continuing
                   problems”             happen                portive and         emphasis
 Quality           Quality is hidden     A stronger quality    Quality depart-     Quality manager       Quality manage-
 organisation      in manufacturing      leader is             ment reports to     is an officer of      ment is on board
 status            or engineering        appointed but         tope manage-        company, effec-       of directors.
                   departments.          main emphasis is      ment, all           tive status repor-    Prevention is
                   Inspection is         still on appraisal    appraisal is        ting and preven-      main concern.
                   probably not part     and moving the        incorporated, and   tive action. Invol-   Quality is a
                   of the organi-        product. Still part   manager has role    ved with              thought leader.
                   sation. Emphasis      of manufacturing      in management       consumer affairs
                   on appraisal and      or other              of company          and special
                   sorting.                                                        assignments
 Problem           Problems are          Teams are set up      Corrective action   Problems are          Except in unusual
 handling          fought as they        to attack major       communication       identified early in   cases, problems
                   occur, no reso-       problems. Long        established.        their develop-        are prevented
                   lution, inadequate    range solutions       Problems are        ment. All func-
                   definition, lots of   are not solicited     faced openly and    tions are open to
                   yelling and                                 resolved in an      suggestions and
                   accusation                                  orderly way         improvement
 Cost of quality   Reported:             Reported: 3%          Reported: 8%        Reported: 6.5%        Reported: 2.5%
 as percentage     unknown
 of sales
                   Actual: 18%           Actual: 18%           Actual: 12%         Actual: 8%            Actual: 2.5%
 Quality           No organised          Trying obvious        Implementation      Continuing the        Quality improve-
 improvement       activities. No        “motivational”        of the 14-step      14-step program       ment is a normal
 actions           understanding of      short-range           program with tho-   and starting          and continued
                   such activity         efforts               rough understand    Make Certain          activity
                                                               and establish-
                                                               ment of each
 Summation of      We don’t know         It is absolutely      Through mana-       Defect prevention     We know why we
 company           why we have           necessary to          gement commit-      is a routine part     do not have
 quality posture   problems with         always have           ment and quality    of our operation      problems with
                   quality               problems with         improvement we                            quality
                                         quality?              are identifying
                                                               and resolving our
 “It isn’t a business of hanging up a whole bunch of signs and doing a whole bunch of things; it is a matter of instituting
                               new policy, telling everyone this the way we’re going to do it”

Table 1.1. Crosby’s Quality maturity grid

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    Genichi Taguchi
The Taguchi method focuses on “robust quality” of service to meet customer performance
expectations every time, even under server operating or environmental conditions. Taguchi
invented the theory of robust quality, which says that the product should be robust enough to
achieve high quality in spite of fluctuation on the production lines. Taguchi’s approach to
quality control involves complicated mathematical formulas.
The theory of robust quality is important to nursing in so far as it may be used to produce the
supplies and equipment nurses use. Clinical nurses would be interested to know if Taguchi’s
methods have been used in developing products they could be applied to the nursing
process in a research and development project. Variance in the application of nursing
process using various nursing modalities, nursing diagnosis, and nursing care standards
could be studied using the theory of robust quality. The object of this theory is to reduce the
things that can go wrong in applying the theory of nursing. Thus, the objectives are to
minimise variations around the customer (patient) performance requirements.
In education the theory of robust quality could be applied to eliminate state board failures as
well as module failures. The goals would be to make the educational system work harmo-
niously. Thus, college faculty would work in harmony with high school faculty to reduce
problems with student placement in such subjects as English and mathematics.
Taguchi opposes zero defects, saying that robustness begins from meeting exact targets
consistently, while zero defects stops only within a certain tolerance. He uses “orthogonal
array” a system of product development using signal-to-noise ratios. It balances the levels of
performance demanded by customers against the many variables in the health car system
that affect it. The robust service would be one that meets a determined ratio of the mean
total divided by the standard deviation. This robust service minimises the average of the
squared deviation form the target averaged ones over the different customer-use conditions.
This system verification test would need to be tested through nursing research to establish a
model for application to nursing.
To begin with, upon entering the system customers would be asked their expectations of
providers. Nursing literature is short on customer expectations and long on provider-
imposed prescription. If variance in the production of nursing service is to be reduced, the
variances must be identified.
Zeroing in rapidly on the variation in nursing care delivery will distinguish the bad part from
the good and sustain quality.
One takes the best of the theory of total quality management and applies it assiduously. The
best approach is to develop a pervasive philosophy that continuous improvement by all
employees and managers is both desirable and possible.

Which theory will you use as framework for TQM implementation in your unit? Motivate your

Study unit 1

    Internal and external customers
The customer is the focus of TQM philosophy. Two categories of customers can be
identified, i.e. internal and external customers (quoted from Swansburg, 1996, pp. 577 –
In TQM there are internal and external customers, all of whom should be given service. In
health care management the external customer are patients, employers, and the community.
These customers will be satisfied by quality care that procedures a patient improving to the
point of being discharged and able to get on with her or his life. A patient facing death wants
a quality of care that makes his or her remaining time a peaceful one. The employer wants
knowledgeable and skilled workers, the community, and a productive citizen. Internal
customers are those who interact with each other within and among departments and
disciplines. Internal customers to health care are those departments that contribute to
patient care, such as pharmacy, radiology, medical laboratory and the others. Clinical
nurses are customers of nurse managers, admission services and others. For each
organisation the goal of quality care is defined by each self-managed team and possibly by
an interdepartmental team. Quality takes time. It’s quickly and economically if nurse
managers are to stay in business. Business, including that of nursing, focuses on core
customers and includes those who generate a profit and inspire nurses to their best ideas
and highest motivation.
The focus of TQM is harmony, not competition or adversarial relations. The optimal system
of delivering patient care is achieved when all managers and workers function as teams.
The next shift in nursing is also an internal customer. Quality control focuses on satisfying
such customers, not confronting them.
The continual quest for improvement would reduce variation caused by confrontation,
adversarial relationships within and among departments, and disharmony. This can be done
developing information and using statistical tools to analyse it.
Quality improves nursing services because it reduces cost and keeps customers happy.
Even in a recession customers buy quality products and services.
Quality is not a program but philosophy and a way of life. It is a survival issue. Traditional
management is out. Quality management is customer oriented, decentralised, empowering,
and quality focused. Quality nurses aim for a world-class quality of care. This entails
learning to deal with the most difficulty of patients and families. Health service managers
would facilitate the capability of personnel to deal with difficult customers.
Health service managers and practitioners decide who their customers are, internal and
external. To do this, they project a path of health service through the health care system of
these potential input points: definition of health services, production of health services,
delivery of health services, and follow-up of health services. Health care personnel identify
customers of their services at each of these points.
Teamwork is absolutely essential. This will include cross-functional teams and an open,
trusting, co-operative relationship. It will be trained to develop needed relationships, do
networking, deal with vendors, and manage projects.
Successful customer relations require constant training and education programs. The need
for staff deals with improved technology, greater product reliability, a customer service orien-
tation, and flexibility in adapting to change. Health service managers will continue to move
decisions down the chain of command to all associates or team members. An educated and
well-trained work force is an health care imperative. Every team member will need the skill
of reading, understanding math, and conveying ideas.
Each health care associate will know the status of the work entering the unit, how to handle
the customer, and what the next internal customer requires. Such a quality system requires
massive and continuous training to prevent errors. Authority and responsibility for quality of

                                                                                  Study unit 1
nursing care resides in the work station where associates take pride in craftsmanship and
group output as well as ownership of the process.
According to Peters, three percent of gross revenues should be spent on training to produce
quality products and service. CEOs (Chief Executive Officers) who put customers first, put
employees first. The latter will keep learning new skills and knowledge to be marketable.

Use a team that represents both health service leaders and customers; construct a question-
naire for measuring external customer satisfaction. Analyse the results and plan for changes
to improve external customer satisfaction.
Using a team that represents health service leaders within the organisation and internal
customers, identify problems and make plans to fix them. Aim for cooperation and win-win
Evaluate your efforts by checking if patient care has improved.

    Leadership
Leadership is an essential element of the theory and philosophy of TQM. Swansburg (1996:
578) states that (quoted) leadership is an essential element of the theory and philosophy of
TQM. It transcends the process, requiring a people-oriented leadership style, cooperation in
all ventures, and win-win relationships. This will include all persons who work in nursing.
TQM requires total commitment by top management. It is long-range, focusing on the
achievement of top quality in every relationship with every customer. Leadership will make
each worker a “business person” with commitment to total responsibility for patient care.
Every worker will be cross-trained and have access to all information. Every worker will have
customers and be a manager.
Long-term leadership is needed to achieve continuous improvement of productivity and
services for the customer. These require innovation and investment in research and
education, long-range planning, and focus on the future. Long-term leadership is needed to
maintain constancy of purpose and common purpose, part of which is to stay in business and
provide jobs. Leaderships oversee the mental revolution required when TQM becomes the
process, with its constant focus on training and instruction. Leadership focuses goals and
conserves productive energy by efficient direction; it builds quality with every stage of
production, beginning with the purchase of high-quality raw materials.
If managers do not attend to quality in today’s health care environment, they will lose their
leadership to someone else. Deming indicates that leadership aims to improve performance
of person and machine, to improve quality, to increase output and provide pride of
workmanship. Juran states that leadership will be of the hands-on type and leadership will
provide the breakthrough.
Leaders have a clear set of values and the integrity to institutionalise them. This occurred at
an organisation (LTV) where integrated process management was the model of the quality
process improvement implemented. As a result, LTW went from a bottom-quality steel
producer to a top-quality ranking. They did this by establishing a culture in which workers
were obsessed with customer satisfaction, innovation became the norm, people were turned
on throughout the organisation, and common-sense systems were used. Successful nursing
leadership will change climate and culture to foster TQM.

Study unit 1

    Culture and climate
(Quoted from Swansburg, 1996, pp. 578 – 580). TQM requires a favourable environment for
total quality behaviour in which values are shared as worthwhile or desirable and beliefs as
truth. All employees, including top management, believe in focusing on customers, both
internal and external. They believe in an employee focus, teamwork, safety, and candour.
There is total involvement because individual employees are empowered to identify and
solve problems. There is process focus that prevents errors and problems rather than fixing
The total quality culture exists in a warm, friendly climate in which employees feel good about
themselves, others, and their work. They trust managers who facilitate their work and treat
them as equals who have intellect and the power to be creative. Fear has been driven out
through leadership that has promoted teamwork, respect, and trust. All employees feel
empowered to speak freely and to suggest changes. The heroes of the culture include
employees who accept blame even though they are not at fault, who frequently defend
employees of other departments or units, and who model total quality behaviour to all
customers. Myths and artefacts include the elimination of all titles form name tags, business
cards, and nameplates. Rights and rituals include the abolition of reserved parking and the
visibility of managers throughout the workplace. Management has spent great effort to
create a strong total quality culture that has thickness, breadth, and clarity of ordering.
Linkow suggests changing the culture through a total quality culture matrix tool that follows
these steps:
1.   Describe the current culture through group brainstorming and interviewing.
2.   Establish seven core total quality values and beliefs.
3.   Correlate core values and beliefs with current culture.
4.   Determine the strength of the current culture.
5.   Identify targets for culture change. These will be core values and beliefs with negative
     or nonexistent correlation, or low in strength.
6.   Use group of change culture.
7.   Use external threats to mobilise internal forces of change.

Compare your perception of “traditional” quality control with that of total quality management.
Is there any difference? In what way? Tabulate your answer.

                                                                                 Study unit 1
Now that you have compared the two, Hellriegel & Slocum (1996: 657) provide a
comparison. Evaluate your comparison to theirs:

Traditional Quality Control                      TQM
Screen for quality                 Plan for quality
Quality is the responsibility of   Quality is everybody’s
the quality control department     responsibility
Some mistakes are inevitable       Strive for zero defects
Quality means inspection           Quality means conformance to
                                   requirements to need patient’s
Scrap and reworking are the        Scrap and reworking are only a
major costs of poor quality        small part of the cost of non-
Quality is a tactical issue        Quality is a strategic issue

Application of TQM to nursing
Quoted from Swansburg (1996: 583 – 589). Before deciding to apply the principles of TQM
to health care, top managers should learn the theory of TQM. TQM can be implemented in
health care with or without implementation in the total organisation. If there is a source of
knowledge of TQM theory within the organisation, it may be tapped first. This will give
recognition to employees as experts within their own organisation. Schonberger suggests
that using outside persons to interpret quality is not effective.
The lead team should all read Out of the crises, in which Deming described his theory of
quality management and the deadly diseases of management, and recommends a
management philosophy. Then the team can write its management plan for implementing
TQM. It will be a never-ending process because quality is a complicated construction and
producing high-quality nursing service is a complicated process.
The first goal of a management plan is to write the stated purpose of the health service so
that it is constant and provides a clear goal for everyone for every day, month after month.
This is the first of Demings fourteen points. All fourteen points should be discussed by the
lead team. The management plan should list activities to achieve each of these points.
Teams can be assigned to develop plans for assessing the culture and climate and making
plans to change them, for planning training in statistical methods with particular emphasis on
variance, of improving supplier relationships, for breaking down interdepartmental barriers,
for developing realistic production standards, and for transforming the entire nursing
Quality assurance should be decentralised so that practicing health professional own quality
and applying the process needed to deliver quality health service. They would develop
quality methods to check the application of health care process to patients, check process
and outcomes, and fix any deficits (variance) in the process. They may repeat the process at
more specific levels to identify the solution to the problem. They will “commit to do right”
principles, maintain control of every process, post quality evidence on the walls, brook no
compromises, find a way to check every unit (where checks are necessary), fix their own
mistakes, and assess continual involvement in quality improvement projects.
Traditional American management theory “motivates employees by fear (principally of losing
their jobs), be requiring them to meet quotas, and by attempting to maximise their merit
increases. Deming’s principles require a fundamental change in American habits”.

Study unit 1
Management habits often cause problems. Habits are based on immediate consequences of
behaviour, on short-term success. Their long-term consequences are subsequent problems
which have been very destructive. Well established destructive habits of management can
be changed. The following are some principles for making changes.
1.    The individual manager or leader must perceive a need to change must genuinely
      admit and accept that he or she must change, and must commit to the change. Unfor-
      tunately, managers or leaders often do not perceive a need for change unless their
      business is in serious trouble.
2.    The change must be voluntary, not coercive.
3.    The change process requires a philosophical base. The philosophical base is a
      statement of beliefs about how people will be managed. If TQM is to be implemented,
      the philosophical base may be a statement of beliefs that include all or some of
      Deming’s fourteen points. The leader who implements this change process acts as
      teacher and planner and is the object of a process called transference.
4.    The change process requires the support of other participating in the same process.
      Thus a group interacts, shares insights and feelings, and provides social support while
      implementing a philosophy of TQM.
5.    The process should be broken into steps that can be accomplished in sequence. Aim
      for at least one quick success. Make a road map or plan. Provide education and
Today’s manager is “a high-tech management” trained individual with a focus on profitability
through quality and sensitive, but widely encompassing, utilisation of work-force talent.
Committed to TQM this manager leader knows that if quality is improved, productivity will be
The following are some goals for this new breed of leader:
1.    Change management style and operating climate.
2.    Do the job right the first time to meet and exceed customer’s expectations?
3.    Stop producing waste, stop sorting good from bad to avoid poor products or service to
      customers, stop paying people to produce waste. Innovate and excite the customer
      with the quality of the product.
4.    Look at the waste standards and spoilage problems of nursing.
5.    Identify and eliminate performance inhibitors and continuously improve productivity.
6.    Use process data to change methods, techniques, and technology to create
7.    Replace boss-imposed solutions with group interaction.
8.    Eliminate as many layers of management and support personnel as possible. Replace
      with integrated, self-governing work teams.
9.    Train managers to be coaches, trainers and information resources.
10.   Reach out and involve customers and suppliers.
11.   Recognise that all improvements take place project by project.
12.   Publish quality goals with names of projects and names of team members to fix
      responsibilities and give rights to teams. Review progress on projects.
13.   Constantly work to improve the work system for employees by fixing related problems:
      better tools and raw materials, a culture of trust.

                                                                                  Study unit 1
14.   Scrap quality control departments, numerical goals, and quotes. Give workers the right
      to shut down the production line if the quality of the product is in danger. Spot and fix
      defect in process. Give authority to practicing health care professionals.
15.   Drive out fears by throwing out or simplifying worker performance evaluations.
16.   Learn to live without enemies. Get workers to cooperate, not compete.
17.   Use plan-do-check-act (PDCA). Hospital Corporation of American hospitals use a
      quality improvement strategy called FOCUS PDCA:
          Find opportunity for improvement
          Organise a team that knows the process
          Clarify current knowledge of the process
          Uncover root causes of process variations
          Start an improvement cycle based on theory
          Plan the process improvement
          Do the improvement
          Check the results against the theory
          Act on the process and theory

1.3.2      SUMMARY

TQM bring about a new philosophy that leads increased productivity and profitability. TQM
focuses upon customer satisfaction, which is an internal and external customer. Leadership
is paramount for success in TQM as it is leadership that will change the culture and the
climate of the business. All these aspects of TQM have been addressed in study section 1.3.


BOOYENS, SW 1998: Dimensions of Nursing Management; second edition. Cape Town:
Juta – or newer edition.
HELLRIEGEL, D & SLOCUM, JW 1996: Management; seventh edition. USA: Thompson
SWANSBURG, RC 1996: Management and leadership for nurse managers; second edition.
London: Jones and Bartlett Publishers.

Study unit 1


    Quality assurance
    Quality improvement
    Quality
    Structural standards
    Process standards
    Product standards
    Developmental phase
    Finalisation phase
    Standard
    Criteria
    Retrospective audit
    Concurrent audit
    Total quality management (TQM)
    Internal customer
    External customer


After you have studied this study unit, you should be able to answer the
1.   Why should a health care organisation adopt a total quality management philosophy
     and system? Motivate your answer.
2.   How will you label Deming’s three categories of performance within the system, outside
     the system (high) and outside the system (low).
3.   TQM asks for a culture change and paradigm shift. Which beliefs and values will you
     need to change in your organisation? Draw up a plan to facilitate these changes.
4.   Compile a quality improvement plan for your health organisation.

                                                            Study unit 1


1.    Refer to Booyens (1998:599-600)
2.    Refer to Booyens (1998:600-604) and study unit 1-3.
3.    Refer to study unit 1-3.
Refer to study unit 1-3.

Study unit 1

                                                                                                              Study unit 2

    2                       DIMENSIONS OF

Time schedule for this study unit is approximately 15 hours

Study unit contents
Study section 2.1       Risk management ................................................................................ 47
          2.1.1         Overview of study section 2.1 .............................................................. 47
          2.1.2         Summary ............................................................................................. 54
Study section 2.2       Change management........................................................................... 55
          2.2.1         Forces for change ................................................................................ 56
          2.2.2         Role of a change agent ........................................................................ 60
          2.2.3         Resistance to change........................................................................... 64
          2.2.4         Summary ............................................................................................. 78

IMPORTANT CONCEPTS OF STUDY UNIT 2 ................................................................... 78

SELF-ASSESSMENT OF STUDY UNIT 2 ........................................................................... 78

GUIDELINES FOR SELF-ASSESSMENT OF STUDY UNIT 2 ............................................ 79

REFERENCES OF SOURCES USED IN STUDY SECTION 2.2 ......................................... 79

Study unit 2

After having studied study unit 2 you should be able to:
Discuss and implement risk management in your health organisation and describe the nature
of case management and its influence on health care management.

Risk management is a relatively new concept, but is important to protect the resources and
assets of a health organisation. The purpose of risk management is to prevent malpractice
claims. In study section 2.1 detailed attentions will be given to risk management. Study
section 2.2 focuses on case management. The framework, structural elements, functions
and process of case management will be discussed in detail.

                                                                               Study unit 2

    2.1                RISK MANAGEMENT

After having studied study section 2.1 you should be able to:
    define risk management;
    discuss the purpose of risk management;
    classify risks;
    describe the risk manager’s competencies;
    identify and discuss the components of a risk management programme;
    discuss the importance of an incident report; and
    explain the role of the health service manager in risk management.

As stated, risk management is a relatively new concept. Study section 2.1 explores the
concept of risk management and discusses the purpose of risk management. Risks are then
classified and the components of a risk management programme are identified. The
competencies of the risk manager are investigated, as is the role of the health service
manager in risk management.

Recall the days of your general/basic/first degree training.   List your perceptions of the
concept of medico-legal hazards.

Study unit 2

Risk management can be defined as a “process that centres on identification, analysis,
treatment, and evaluation of real and potential hazards” (Swansburg, 1996: 608). In some
cases risk management is also described as the risk of financial loss resulting from legal
liability. Three aspects of risk identification should be monitored on a continuous basis
(Swansburg, 1996: 608), namely:
    monitoring, clinical settings, clinical problems, personnel and specific incidents invol-
     ving patients, employees and visitors;
    safety management; and
    Procedures for evaluation and follow-up of identified risks.

How does you initial perception of medico-legal hazards correlate with the definition of risk


Write down what you think the purpose of risk management is.

                                                                                    Study unit 2

Study Booyens, 1998, p. 582 as she describes the purpose of risk management. Compare
the notes with your answer.
What are the objectives of a risk management programme?


Booyens, 1998, p. 583 provides a simplistic classification of risks. List these categories.

Study unit 2

Risk manager’s competencies
The risk manager should make use of carefully planned public relations makes private
explanations, apologies when necessary, and collects, prepares and presents evidence.
Swansburg (1996: 609) provides a description of the risk manager’s job.
1.    Keep an up-to-date manual, including policies, lines of authority, safety roles, disaster
      plans, safety training, procedures, incident and claims reporting, procedures, and
      schedules, and description of retention/insurance program.
2.    Update programmes with changes in properties, operations, or activities.
3.    Review plans for new construction, alterations, and equipment installations.
4.    Review contracts to avoid unnecessary assumptions of liability and transfer to others
      where possible.
5.    Keep up-to-date property appraisal.
6.    Maintain records of insurance policy renewal dates.
7.    Review and monitor all premium and other billings, and approve payments.
8.    Negotiate insurance converge, premiums, and services.
9.    Prepare specifications for competitive bids on property and liability insurance.
10.   Review and make recommendations for coverage, services, and costs.
11.   Maintain records and verify compliance for by independent physicians, vendors,
      contractors, and sub-contractors.
12.   Maintain records of losses, claims and all risk management expenses.
13.   Supervise claim reporting procedures.
14.   Assist in adjusting losses.
15.   Co-operate with director of safety and risk management committee to minimise all
      future losses involving employees, patients, visitors, other third parties, property, and
16.   Keep risk management skills updated.
17.   Prepare annual report covering status, changes, new problems and solutions,
      summary of existing insurance and retention aspects of the programme, summary of
      losses, costs, major claims, and future goals and objectives.
18.   Prepare annual budget.

                                                                           Study unit 2

Components of a risk management programme

Study Booyens, 1998, p. 583 and identify the components of a risk management programme.
What will risk management activities entail?

Study unit 2

Incident report
Incident reporting is an effective technique of a good risk management programme. The tool
itself should be constructed to collect complete and accurate information (Swansburg, 1996:

Booyens, 1998, p. 587 investigates the importance of incident report. Study the content and
complete the following questions.
What are the points you will take note of when writing a report of an incident?
Evaluate you health institutions incident report form. Can you identify all the aspects that
need to be covered? How will you adapt the form?
How much information will you provide in a report? Why?

Swansburg (1996: 612) provides a table that summarises the do’s and don’ts of incident
reporting. Refer to table 2.1.

                                                                                Study unit 2

                    DO’S                                          DON’TS

 1. For any event involving patient mishap      1. Place blame on anyone.
    or serious expression of dissatisfaction
    with care.
 2. For any event involving visitor mishap.     2. Place on patient’s chart.
 3. Be complete.                                3. Make entry about an incident report on
                                                   the patient’s chart.
 4. Follow established policy and               4. Alter or rewrite.
 5. Be prompt.                                  5. Report hearsay or opinion.
 6. Act or reduce fear by the health care       6. Be afraid to consult, ask questions, or
    staff.                                         complete incident reports. They can be
                                                   part of your best defense and protection.
 7. Correct as any medical record.              7. Prescribe in the M.D.’s domain.
 8. Include names and identifies of             8. Be cold and impersonal to patients,
    witnesses, record their statements on          families or visitors.
    separate pages.
 9. Report equipment malfunctions,
    including control numbers. Remove
    them from service for testing.
 10. Keep the report confidential.
 11. Report to health service manager.
 12. Confer with risk manager.
 13. Work to provide nursing care to meet
     established standards.
 14. Attend all staff development programs.
 15. Confirm all telephone orders in writing.

Study unit 2

Role of the health service manager

What do you think is the role of the health service manager in risk management?
Study Booyens, 1998, p. 592 on the role of the health service manager regarding risk
management. What is the role she identifies?

2.1.2      SUMMARY
Quality management is a management process that provides a sound basis for decision--
making and problem solving. Management of care by competent clinical nurses and nurse
managers ensures that the quality and risk management are evident. In this study section
we have explore the concept, the classification and purpose of risk management. The
competencies of the risk manager were explained, followed by the components of a risk
management programme. Lastly the role of the health service manager was addressed.

                                                                                 Study unit 2

    2.2             CHANGE MANAGEMENT


After studying study section 2.2 you should be able to:
    explain change management;
    discuss and analyse the forces for change;
    explain how you will manage planned change;
    describe the role of a change agent and identify what a change agent can change;
    debate the dynamics of resistance to change;
    discuss and analyse the following approaches to Managing Organisational Change:
          Lewin's Three Stop Change Model
          Morrison's first and second curve;
          Tichy's waves of change;
          Tetenbaum's shifting paradigm;
    explain your understanding of building a chaordic organisation.

Mullins (1999: 821) states that "Change is a pervasive influence. We are all subject to
continual change of one form or another. Change is an inescapable part of both social and
organisational life". What is Organisational Change? Let's answer this question with an
answer provided by Jaffe & Scott (1999: 1-2). “The word change is used so much by
organisations that its meaning has been diminished. Minor shifts in procedures and
technology, and small differences in the external environment have been labelled as
"changes". People all agree that change is happening everyday, but they are less clear
about what they are expected to do about the changes. Anything new and novel that
appears on the horizon is labelled change!
The word 'change' refers both to a shift which occurs in the organisation's external
environment as well as the response to that shift on the inside of the organisation (i.e.
dealing with the changes that the organisation makes to respond to external shifts, or in
anticipation of external shifts). For purposes of clarification the term environmental change

Study unit 2
will be used to refer to external shifts and the word change will refer to the organisation’s



Another issue is the degree of change. Both "little c" and "Big C" changes are taking place.
These are sometimes referred to as incremental and breakthrough (or revolutionary) change.
The difference lies in the depth of the change. Many organisations today are proposing "Big
C" changes that affect all parts and layers of the organisation. The organisation that is
changing must look at change as taking place at multiple levels and groups. The process
must be coordinated and integrated.
Saying "yes" to change means very little unless the organisation sets up an infrastructure to
accomplish it. The key tasks of the infrastructure to support change include:
    A persuasive story of why change is necessary
    A shared vision of where the organisation is going
    Total involvement of every part of the organisation
    Gatherings of all people involved to be informed and design together
    Continual two-way communication to everyone
    Clear, fairly implemented policies for workforce transition
    Investment in the resources to support the transition
    Training in new roles and skills
    Support for people's personal difficulty with change
    Transition structures to manage design and implementation
    Challenging people to question old ways and consider new paths
    Learning of new ways by individuals and the organisation
    Personal support for the stress of change.


State the forces that you can identify that bring about change.

                                                                                     Study unit 2


Continue to study the forces that the literature identifies and compare it with your list. Mullins
(1999: 822) explains the forces of change as follow:
"An organisation can only perform effectively through interactions with the broader external
environment of which it is part. The structure and functioning of the organisation must
reflect, therefore, the nature of the environment in which it is operating. Factors such as
uncertain economic conditions, globalisation and fierce world competition, the level of
government intervention, scarcity of natural resources and rapid developments in new
technology and the information age all create an increasingly volatile environment. In order
to help ensure its survival and future success the organisation must be readily adaptable to
the external demands placed upon it. The organisation must be responsive to change.
Other major forces of change include:
     increased demands for quality and high levels of customer service and satisfaction;
     greater flexibility in the structure of work organisations and patterns of management;
     the changing nature and composition of the workforce.
Change also originates within the organisation itself. Much of this change is part of a natural
process of ageing - for example, as material resources such as buildings, equipment or
machinery deteriorate or lose efficiency; or as human resources get older; or as skills and
abilities become outdated. Some of this change can be managed through careful planning -
for example, regular repairs and maintenance; choice of introducing new technology or
methods of work; effective human resource planning to prevent a large number of staff
retiring at the same time; management succession planning - training and staff development.
However, the main pressure of change is from external forces. The organisation must be
properly prepared to face the demands of a changing environment. It must give attention to
its future development and success and this includes public sector organisations and the
armed forces".

Study unit 2
Robbins (1998: 626 - 627) identifies very specific forces of change and lists them as follow:

         FORCE                                  EXAMPLES
Nature of the workforce           More cultural diversity
                                  Increase in professionalism
                                  Many new entrants with inadequate skills
Technology                        More computers and education
                                  TQM programs
                                  Reengineering programs
Economic shocks                   Security market crashes
                                  Interest rate fluctuations
                                  Foreign currency fluctuations
Competition                       Global competitors
                                  Mergers and consolidations
                                  Growth of specialty retailers
Social trends                     Increase in college attendance
                                  Delayed marriages by young people
                                  Increase in divorce rate

"The truth about organisational change is that getting the structure and the numbers right is
the first step, and very important, but animating the structure to achieve the right actions by
right motivated people is vital. For any organisation, and any organisational change, the
central purpose is to create so thriving and developing an organic activity that the
organisation can provide excellent well-paid employment for its entire people". Robert Heller
(in Mullins 1999: 823).
Mullins (1999: 825) states it clearly that the effective management of change must be based
on a clear understanding of human behaviour at work. Organisational change can result in a
feeling of a lack of identity, a lack of involvement, a lack of direction and a lack of affection.
He further elaborates that most people feel threatened and disoriented by the challenge of
change. Elliot (in Mullins, 1999: 826) explains change as a complex psychological event.
The power of change needs to be respected and managed. Managing change places
emphasis on employee (and customer) needs as the highest priority. To be successful,
organisations need a dedicated workforce and this involves the effective management of
change. Change impacts each person differently and management must accept the
individual nature of change.
Forces can bring about change. - They must happen - or planned change can take place.
Planned change is defined as change activities that are intentional and goal oriented
(Robbins, 1998: 629).
What is the goal of planned change? Robbins (1998: 629) says there are essentially two.
First, it seeks to improve the ability of the organisation to adapt to changes in its
environment. Second, it seeks to change employer behaviour.

                                                                                  Study unit 2
If an organisation is to survive, it must respond to changes in its environment. The following
abstract from Robbins (1998: 629 - 630) demonstrates the management of change.
"When competitors introduce new products or services, government agencies enact new
laws, important sources of supply go out of business, or similar environmental changes take
place, the organisation needs to adapt. Efforts to stimulate innovation, empower employees,
and introduce work teams are examples of planned-change activities directed at responding
to changes in the environment.
Since an organisation's success or failure is essentially due to the things that its employees
do or fail to do, planned change also is concerned with changing the behaviour of individuals
and groups within the organisation. In this section, we review a number of techniques that
organisations can use to get people to behave differently in the tasks they perform and in
their interactions with others.
It also helps to think of planned change in terms of order of magnitude. First-order change
is linear and continuous. It implies no fundamental shifts in the assumptions that
organisational members hold about the world or how the organisation can improve its
functioning.      In contract, second-order change is multidimensional, multilevel,
discontinuous, radical change involving reframing of assumptions about the organisation and
the world in which it operates. Mikio Kitano, director of all production engineering at Toyota,
is introducing first-order change in his company. He's pursuing slow, subtle, incremental
changes in production processes to improve the efficiency of Toyota's plants. On the other
hand, Boeing's top executives have recently committed themselves to radically reinventing
their company.
Responding to a massive airline slump, aggressive competition for Airbus, and the threat of
Japanese competitors, this second-order change process at Boeing includes slashing costs
by up to 30 percent, reducing the time it takes to make a 737 from 13 months to 6 months,
dramatically cutting inventories, putting the company's entire workforce through a four-day
module in "competitiveness," and bringing customers and suppliers into the once secret
process of designing new planes.
Who in organisations are responsible for managing change activities? The answer is
change agents. Change agents can be managers or non-managers, employees of the
organisation or outside consultants.
Typically we look to senior executives/managers as agents of change.
For major change efforts, top managers are increasingly turning to temporary outside
consultants with specialised knowledge in the theory and methods of change. Consultant
change agents can offer a more objective perspective than insiders can. However, they are
disadvantaged in that they often have an inadequate knowledge of the organisation's history,
culture, operating procedures, and personnel. Outside consultants are also more willing to
initiate second-order changes - which can be a benefit or a disadvantage - because they
don't have to live with the repercussions. In contract, internal staff specialists or managers,
especially those who've spent many years with the organisation, are often more cautious
because they fear offending long-term friends and associates."

Study unit 2


Against the background of the content that you have read, what do you predict would the role
of a change agent be?

Before we answer the abovementioned question, let's look at what are the change options.

Figure 2.2.1 Change options Robbins (1998: 630)

ROBBINS (1998: 630) states that changing structure involves making an alteration in
authority relations, coordination mechanisms, job redesign, or similar structural variables.
Changing technology encompasses modifications in the way work is processed and in the
methods and equipment used. Changing the physical setting covers altering the space and
layout arrangements in the workplace. Changing people refers to changes in employee
attitudes, skills, expectations, perceptions, and/or behaviour. A detailed explanation is given
on the role of the change agent through the following abstract from Robbins (1998: 630 -

                                                                                 Study unit 2
Changing Structure
Organisational structures are not set in concrete. Changing conditions demand structural
changes. As a result, the change agent might need to modify the organisation's structure.
An organisation's structure is defined by how tasks are formally divided, grouped, and
coordinated. Change agents can alter one or more of the key elements in an organisation's
design. For instance, departmental responsibilities can be combined, vertical layers
removed, and spans of control widened to make the organisation flatter and less
bureaucratic. More rules and procedures can be implemented to increase standardisation.
An increase in decentralisation can be made to speed up the decision-making process.
Change agents can also introduce major modifications in the actual structural design. This
might include a shift from a simple structure to a team-based structure or the creation of a
matrix design. Change agents might consider redesigning jobs or work schedules. Job
descriptions can be redefined, jobs enriched, or flexible work hours introduced. Still another
option is to modify the organisation's compensation system. Motivation could be increased
by, for example, introducing performance bonuses or profit sharing.

Changing Technology
Most of the early studies in management and organisational behaviour dealt with efforts
aimed at technological change. At the turn of the century, for example, scientific
management sought to implement changes based on time-and-motion studies that would
increase production efficiency. Today, major technological changes usually involve the
introduction of new equipment, tools, or methods; automation; or computerisation.
Competitive factors or innovations within an industry often require change agents to
introduce new equipment, tools, or operating methods. For example, many aluminum
companies have significantly modernised their plants in recent years to compete more
effectively. More efficient handling equipment, furnaces, and presses have been installed to
reduce the cost of manufacturing a ton of aluminum.
Automation is a technological change that replaces people with machines. It began in the
industrial revolution and continues as a change option today. Examples of automation are
the introduction of automatic mail sorters by the Postal Service and robots on automobile
assembly lines.
Many organisations now have sophisticated management information systems. Large
supermarkets have converted their cash registers into input terminals and linked them to
computers to provide instant inventory data. The office of 1998 is dramatically different from
its counterpart of 1978, predominantly because of computerisation. Desktop microcomputers
that can run hundreds of business software packages and network systems that allow these
computers to communicate with one another typify this.

Changing the Physical Setting
The layout of workspace should not be a random activity. Typically, management
thoughtfully considers work demands, formal interaction requirements, and social needs
when making decisions about space configurations, interior design, equipment placement,
and the like.

Changing People
The final area in which change agents operate is in helping individuals and groups within the
organisation to work more effectively together. This category typically involves changing the
attitudes and behaviours of organisational members through processes of communication,
decision making, and problem solving. As you'll see later in this chapter, the concept of
organisational development has come to encompass an array of interventions designed to

Study unit 2
change people and the nature and quality of their work relationships. We review these
people-changing interventions in our discussion of organisational development.
Mullins (1999: 826 - 829) explains the human and social factors of change.           Read the
following abstract from Mullins:
Activities managed on the basis of technical efficiency alone are unlikely to lead to optimum
improvement in organisational performance. A major source of resistance to change arises
from the need of organisations to adapt to new technological developments. The following
discussion on how to minimise the problem of change centres on the example of the impact
of information technology.     The general principles, however, apply equally to the
management of change arising from other factors.
    An important priority is to create an environment of trust and shared
     commitment, and to involve staffs in decisions and actions which affect them.
     There is a considerable body of research and experience, which demonstrates clearly
     the positive advantages to be gained from participation. It is important that members of
     staff understand fully the reasons for change. Organisations should try to avoid
     change for the sake of change as this can be both disruptive and lead to mistrust.
     However, considerations of the need to change arising from advances in information
     technology simply cannot be ignored.
    There should be full and genuine participation of all staff concerned as early as
     possible, preferably well before the actual introduction of new equipment or
     systems. Information about proposed change, its implications and potential benefits
     should be communicated clearly to all interested parties. Staff should be actively
     encouraged to contribute their own ideas, suggestions and experiences, and to voice
     openly their worries or concerns. Managers should discuss problems directly with staff
     and handle any foreseen difficulties in working practices or relationships by attempting
     to find solutions agreed with them. The use of working parties, liaison committees,
     steering groups and joint consultation may assist discussion and participation, and help
     to maintain the momentum of the change process.
    Team management, a co-operative spirit among staff and unions and a genuine
     feeling of shared involvement will help create a greater willingness to accept change.
     A participative style of managerial behaviour which encourages supportive
     relationships between superiors and subordinates, and group methods of organisation,
     decision-making and supervision, are more likely to lead to a sustained improvement in
     work performance. A system of Management by Objectives (MBO) may allow staff to
     accept greater responsibility and to make a higher level of personal contribution.
     Participation is inherent if MBO is to work well, and there is an assumption that most
     people will direct and control themselves willingly if they share in the setting of their
    As part of the pre-planning of new technology there should be a carefully
     designed 'personnel management action programme'. The development of
     information technology, together with the growth of service organisations may, in the
     longer term, lead to the creation of new jobs. However, it must be recognised that the
     extra efficiency of new technology and automation can result in the more immediate
     consequence of job losses. The action programme should be directed to a review of:
     recruitment and selection; natural wastage of staff; potential for training, retraining and
     the development of new skills; and other strategies to reduce the possible level of
     redundancies or other harmful effects on staff. Where appropriate, arrangements for a
     shorter working week, and redeployment of staff with full financial support, should be
     developed in full consultation with those concerned. If job losses are totally
     unavoidable, there should be a fair and equitable redundancy scheme and provision for
     early retirement with protected pension rights. Every possible financial and other
     support should be given in assisting staff to find suitable alternative employment.

                                                                                 Study unit 2
    The introduction of incentive payment schemes may help in motivating staff by an
     equitable allocation of savings that result from new technology and more efficient
     methods of work. Incentive schemes may be on an individual basis, with bonuses
     payable to each member of staff according to effort and performance; or on a group
     basis, where bonus is paid to staff in relation to the performance of the group as a
     whole. An alternative system is 'measured day work'. Staff receives a regular,
     guaranteed rate of pay in return for an agreed quantity and quality of work based on
     the capabilities of new equipment and systems. Management may also be able to
     negotiate a productivity bargain with unions. By accepting changes in work methods
     and practices, staff shares in the economic benefits gained from the improved
     efficiency of information technology and automated systems.
    Changes to the work organisation must maintain the balance of the socio-
     technical system. Increased technology and automation may result in jobs becoming
     more repetitive and boring, and providing only a limited challenge and satisfaction to
     staff. It is important, therefore, to attempt to improve the quality of work, to remove
     frustration and stress from jobs, and to make them more responsible and interesting.
     Actual working arrangements rely heavily on the informal organisation and effective
     teamwork. Groups and teams are a major feature of organisational life and can have a
     significant influence on the successful implementation of change. New working
     practices should take account of how best to satisfy people's needs and expectations
     at work through the practical application of behavioural science.
    Careful attention should be given to job design, methods of work organisation,
     the development of cohesive groups, and relationships between the nature and
     content of jobs and their task functions. The introduction of new technology has
     also highlighted the need to give attention to the wider organisational context including
     the design of technology itself, broader approaches to improved job design, employee
     involvement and empowerment, the development of skills and problem-solving
     capacity, and the effective management of change.
The successful implementation of new work methods and practices is dependent upon the
willing and effective co-operation of staff, managerial colleagues and unions. People are the
key factor in the successful management of change. For example, as Murdoch points out,
change management is potentially the most effective way to improve an organisation.
Organisations have realised that all the structures in the world are of no use if the people
implementing them are not convinced of their necessity. Change management means much
more than changing the chart. It means changing the nature of an organisation. And this
involves people. In good times or bad, the key to success is good communication within the
Continued technological change is inevitable and likely to develop at an even faster rate.
Managers must be responsive to such change. Attention must be given not only to products
and processes but also to people. The full, potential benefits of information technology and
automation will only be realised if the management of change takes proper account of human
and social factors, as well as technical and economic factors.

Study unit 2


I'm sure you can recall a situation that people resisted to change. Think back of this situation
and reflect on the following:
     What led to the resistance?
     What are the reasons people gave for their resistance?
     How did the situation make you feel?

ROBBINS (1998: 632 - 638) provides a detailed outline of:
     what is resistance to change;
     individual resistance;
     organisational resistance, and
     overcoming resistance to change.

                                                                                   Study unit 2

Study the following verbatim quote from Robbins (1998: 632 -638) and compare notes with
your answers.
One of the most well documented findings from studies of individual and organisational
behaviour is that organisations and their members resist change. In a sense, this is positive.
It provides a degree of stability and predictability to behaviour. If there weren't some
resistance, organisational behaviour would take on characteristics of chaotic randomness.
Resistance to change can also be a source of functional conflict. For example, resistance to
a reorganisation plan or a change in a product line can stimulate a healthy debate over the
merits of the idea and result in a better decision. But there is a definite downside to
resistance to change. It hinders adaptation and progress.
Resistance to change doesn't necessarily surface in standardised ways. Resistance can be
overt, implicit, immediate, or deferred. It is easiest for management to deal with resistance
when it is overt and immediate. For instance, a change is proposed and employees quickly
respond by voicing complaints, engaging in a work slowdown, threatening to go on strike, or
the like. The greater challenge is managing resistance that is implicit or deferred. Implicit
resistance efforts are more subtle - loss or loyalty to the organisation, loss of motivation to
work, increased errors or mistakes, increased absenteeism due to "sickness" - and hence
more difficult to recognise. Similarly, deferred actions cloud the link between the source of
the resistance and the reaction to it. A change may produce what appears to be only a
minimal reaction at the time it is initiated, but then resistance surfaces weeks, months, or
even years later. Or a single change that in and of itself might have little impact becomes the
straw that breaks the camel's back. Reactions to change can build up and then explode in
some response that seems totally out of proportion to the change action it follows. The
resistance, of module, has merely been deferred and stockpiled. What surfaces is a
response to an accumulation of previous changes.
Let's look at the sources of resistance. For analytical purposes, we've categorised them by
individual and organisational sources. In the real world, the sources often overlap.

Individual Resistance
Individual sources of resistance to change reside in basic human characteristics such as
perceptions, personalities, and needs. The following summarises five reasons why
individuals may resist change:
Habit                    Every time you go out to eat, do you try a different restaurant?
                         Probably not. If you're like most people, you find a couple of places
                         you like and return to them on a somewhat regular basis.
                         As human beings, we're creatures of habit. Life is complex enough;
                         we don’t need to consider the full range of options for the hundreds
                         of decisions we have to make every day. To cope with this
                         complexity, we all rely on habits or programmed responses. But
                         when confronted with change, this tendency to respond in our
                         accustomed ways becomes a source of resistance. So when your
                         department is moved to a new office building across town, it means
                         you're likely to have to change many habits: waking up ten minutes
                         earlier, taking a new set of streets to work, finding a new parking
                         place, adjusting to the new office layout, developing a new
                         lunchtime routine, and so on.

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Security                People with a high need for security are likely to resist change
                        because it threatens their feelings of safety.     When Sears
                        announces its laying off 50,000 people or Ford introduces new
                        robotic equipment, many employees at these firms may fear that
                        their jobs are in jeopardy.
Economic Factors        Another source of individual resistance is concern that changes will
                        lower one's income. Changes in job tasks or established work
                        routines can also arouse economic fears if people are concerned
                        that they won't be able to perform the new tasks or routines to their
                        previous standards, especially when pay is closely tied to
Fear of the unknown     Changes substitute ambiguity and uncertainty for the unknown. The
                        transition from high school to college is typically such an
                        experience.    By the time we're seniors in high school, we
                        understand how thinks work. You might not have liked high school,
                        but at least you understood the system. Then you move on to
                        college and face a whole new and uncertain system. You have
                        traded the known for the unknown and the fear or insecurity that
                        goes with it.
Employees in organisations hold the same dislike for uncertainty. If, for example, the
introduction of TQM means production workers will have to learn statistical process control
techniques, some may fear that they'll be unable to do so. They may, therefore, develop a
negative attitude toward TQM or behave dysfunctionally if required to use statistical

Organisational Resistance
Organisations, by their very nature, are conservative. They actively resist change. You don't
have to look far to see evidence of this phenomenon. Government agencies want to
continue doing what they have been doing for years, whether the need for their service
changes or remains the same. Organised religions are deeply entrenched in their history.
Attempts to change church doctrine require great persistence and patience. Educational
institutions, which exist to open minds and challenge established doctrine, are themselves
extremely resistant to change. Most school systems are using essentially the same teaching
technologies today as they were 50 years ago. The majority of business firms, too, appear
highly resistant to change.
Six major sources of organisational resistance have been identified.
Structural Inertia            Organisations have built-in mechanisms to produce stability.
                              For example, the selection process systematically selects
                              certain people in and certain people out. Training and other
                              socialisation techniques reinforce specific role requirements
                              and skills. Formalisation provides job descriptions, rules, and
                              procedures for employees to follow.
                              The people who are hired into an organisation are chosen for
                              fit; they are then shaped and directed to behave in certain
                              ways. When an organisation is confronted with change, this
                              structural inertia acts as a counterbalance to sustain stability.
Limited focus of change       Organisations are made up of a number of interdependent
                              subsystems. You can't change one without affecting the
                              others.     For example, if management changes the
                              technological process without simultaneously modifying the
                              organisation's structure to match, the change in technology is

                                                                                   Study unit 2
                             not likely to be accepted. So limited changes in subsystems
                             tend to get nullified by the large system.
Group Inertia                Even if individuals want to change their behaviour, group
                             norms may act as a constraint. An individual union member,
                             for instance, may be willing to accept changes in his job
                             suggested by management. But if union norms dictate
                             resisting any unilateral change made by management, he's
                             likely to resist.
Threat to expertise          Changes in organisational patterns may threaten the expertise
                             to specialised groups. The introduction of decentralised
                             personal computers, which allow managers to gain access to
                             information directly from a company's mainframe, is an
                             example of a change that was strongly resisted by many
                             information systems departments in the early 1980's. Why?
                             Because decentralised end-user computing was a threat to
                             the specialised skills held by those in the centralised
                             information systems departments.
Threat to established power relations        Any redistribution of decision-making authority
                                             can     threaten      long-established    power
                                             relationships within the organisation. The
                                             introduction of participative decision making or
                                             self-managed work teams is the kind of
                                             change that is often seen as threatening by
                                             supervisors and middle managers.

Overcoming Resistance to Change
Change agents in dealing with resistance have suggested six tactics for use. Let's review
them briefly.
Education and Communication         Resistance can be reduced through communicating
                                    with employees to help them see the logic of a change.
                                    This tactic basically assumes that the source of
                                    resistance lies in misinformation or poor communi-
                                    cation: If employees receive the full facts and get any
                                    misunderstandings cleared up, resistance will subside.
                                    Communication can be achieved through one-on-one
                                    discussions, memos, group presentations, or reports.
                                    Does it work? It does, provided that the source of
                                    resistance is inadequate communication and that
                                    management - employee relations are characterised by
                                    mutual trust and credibility. If these conditions don't
                                    exist, the change is unlikely to succeed.
Participation                       It's difficult for individuals to resist a change decision in
                                    which they participated. Prior to making a change,
                                    those opposed can be brought into the decision
                                    process. Assuming that the participants have the
                                    expertise to make a meaningful contribution, their
                                    involvement          can    reduce       resistance,  obtain
                                    commitment, and increase the quality of the change
                                    decision. However, against these advantages are the
                                    negatives: potential for a poor solution and great time

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Facilitation and Support       Change agents can offer a range of supportive efforts
                               to reduce resistance. When employee fear and anxiety
                               are high, employee counselling and therapy, new-skills
                               training, or a short paid leave of absence may facilitate
                               adjustment. The drawback of this tactic is that, as with
                               the others, it is time consuming. Additionally, it's
                               expensive, and its implementation offers no assurance
                               of success.
Negotiation                    Another way for the change agent to deal with potential
                               resistance to change is to exchange something of
                               value for a lessening of the resistance. For instance, if
                               the resistance is centred in a few powerful individuals,
                               a specific reward package can be negotiated that will
                               meet their individual needs. Negotiation as a tactic
                               may be necessary when resistance comes from a
                               powerful source. Yet one cannot ignore its potentially
                               high costs. Additionally, there is the risk that, once a
                               change agent negotiates with one party to avoid
                               resistance, he or she is open to the possibility of being
                               blackmailed by other individuals in positions of power.
Manipulation and Co-optation   Manipulation refers to convert influence attempts.
                               Twisting and distorting facts to make them appear
                               more attractive, withholding undesirable information,
                               and creating false rumours to get employees to accept
                               a change are all examples of manipulation.             If
                               corporate management threatens to close down a
                               particular manufacturing plant if that plant's employees
                               fail to accept an across the board pay cut, and if the
                               treat is actually untrue, management is using
                               manipulation. Co-optation, on the other hand, is a form
                               of both manipulation and participation. It seeks to
                               "buy-off" the leaders of a resistance group by giving
                               them a key role in the change decision. The leaders'
                               advice is sought, not to seek a better decision, but to
                               get their endorsement. Both manipulation and co-
                               optation are relatively inexpensive and easy ways to
                               gain the support of adversaries, but the tactics can
                               backfire if the targets become aware that they are
                               being tricked or used. Once discovered, the change
                               agent's credibility may drop to zero.
Coercion                       Last on the list of tactics is coercion, that is, the
                               application of direct threats or force upon the resisters.
                               If the corporate management mentioned in the
                               previous discussion really is determined to close a
                               manufacturing plant if employees don't acquiesce to a
                               pay cut, then coercion would be the label attached to
                               its change tactic. Other examples of coercion are
                               threats to transfer, loss of promotions, negative
                               performance evaluations, and a poor letter of
                               recommendation. The advantages and drawbacks of
                               coercion are approximately the same as those
                               mentioned for manipulation and co-optation.

                                                                                   Study unit 2
The Politics of Change
No discussion of resistance to change would be complete without a brief mention of the
politics of change. Because change invariably threatens the status quo, it inherently implies
political activity.
Internal change agents typically are individuals high in the organisation who have a lot to
lose from change. They have, in fact, risen to their positions of authority by developing skills
and behavioural patterns that are favoured by the organisation. Change is a threat to those
skills and patterns. What if they are no longer the ones the organisation values? This
creates the potential for others in the organisation to gain power at their expense.
Politics suggests that the impetus for change is more likely to come from outside change
agents, employees who are new to the organisation (and have less invested in the status
quo), or from managers slightly removed from the main power structure. Those managers
who have spent their entire careers with a single organisation and eventually achieve a
senior position in the hierarchy are often major impediments to change. Change, itself, is a
very real threat to their status and position. Yet they may be expected to implement changes
to demonstrate that they're not merely caretakers. By acting as change agents, they can
symbolically convey to various constituencies - stockholders, suppliers, employees, and
customers that they are on top of problems and adapting to a dynamic environment. Of
module, as you might guess, when forced to introduce change, these long-time power
holders tend to implement first-order changes. Radical change is too threatening.
Power struggles within the organisation will determine, to a large degree, the speed and
quantity of change. You should expect that long-time career executives would be sources of
resistance. This, incidentally, explains why boards of directors that recognise the imperative
for the rapid introduction of second-order change in their organisations frequently turn to
outside candidates for new leadership.

In the following discussion we investigate the different approaches to managing
organisational change.
Lewin's Three-step Change Model
(Quoted from Robbins, 1998 : 638 - 640)
Kurt Lewin argued that successful change in organisations should follow three steps:
unfreezing the status quo, movement to a new state, and refreezing the new change to
make it permanent. The value of this model can be seen in the following example when the
management of a large oil company decided to reorganise its marketing function in the
western United States (refer to figure 2.2.2).
The oil company had three divisional offices in the West, located in Seattle, San Francisco,
and Los Angeles. The decision was made to consolidate the divisions into a single regional
office to be located in San Francisco. The reorganisation meant transferring over 150
employees, eliminating some duplicate managerial positions, and instituting a new hierarchy
of command. As you might guess, a move of this magnitude was difficult to keep secret.
The rumour of its occurrence preceded the announcement by several months. The decision
itself was made unilaterally. It came from the executive offices in New York. Those people
affected had no say whatsoever in the choice. For those in Seattle or Los Angeles, who may
have disliked the decision and its consequences? The problems inherent in transferring to
another city, pulling youngsters out of school, making new friends, having new co-workers,
undergoing the reassignment of responsibilities - their only remodel was to quit. In actuality,
less than 10 percent did.

Study unit 2

               Unfreezing - Movement - Refreezing

Figure 2.2.2 Lewin's Three-step change model.
The status quo can be considered to be an equilibrium state. To move from this equilibrium -
to overcome the pressures of both individual resistance and group conformity - unfreezing is
necessary. It can be achieved in one of three ways. The driving forces, which direct
behaviour away from the status quo, can be increased. The restraining forces, which
hinder movement from the existing equilibrium, can be decreased. A third alternative is to
combine the first two approaches.
The oil company's management could expect employee resistance to consolidation. To deal
with that resistance, management could use positive incentives to encourage employees to
accept the change. For instance, increases in pay can be offered to those who accept the
transfer. The company can pay very liberal moving expenses. Management might offer low-
cost mortgage funds to allow employees to buy new homes in San Francisco. Of module,
management might also consider unfreezing acceptance of the status quo by removing
restraining forces. Employees could be counselled individually. Each employee's concerns
and apprehensions could be heard and specifically clarified. Assuming that most of the fears
are unjustified, the counsellor could assure the employees that there was nothing to fear and
then demonstrate, through tangible evidence, that restraining forces are unwarranted. If
resistance is extremely high, management may have to resort to both reducing resistance
and increasing the attractiveness of the alternative of the unfreezing is to be successful.
Once the consolidation change has been implemented, if it is to be successful, the new
situation needs to be refrozen so that it can be sustained over time. Unless this last step is
taken, there is a very high chance that the change will be short-lived and that employees will
attempt to revert to the previous equilibrium state. The objective of refreezing, then, is to
stabilize the new situation by balancing the driving and restraining forces.
How could the oil company's management refreeze its consolidation change?                  By
systematically replacing temporary forces with permanent ones. For instance, management
might impose a permanent upward adjustment of salaries or permanently remove time clocks
to reinforce a climate of trust and confidence in employees. The formal rules and regulations
governing behaviour of those affected by the change should also be revised to reinforce the
new situation. Over time, of module, the work groups own norms will evolve to sustain the
new equilibrium. But until that point is reached, management will have to rely on more formal

I think it is important, before we continue to study the different approaches, that we look at
how we assess the climate for change. Robbins (1998 : 639) provides a framework for the

Study the framework and evaluate your organisation against the questions.

                                                                                  Study unit 2

Assessing the Climate for Change
Why do some change programs succeed and others fail? One major factor is change
readiness. Research by Symmetrix, a Massachusetts consulting firm, identified 17 key
elements to successful change. The more affirmative answers you get to the following
questions, the greater the likelihood that change efforts will succeed.
1.    Is the sponsor of change high up enough to have power to effectively deal with
2.    is day-to-day leadership supportive of the change and committed to it?
3.    is there a strong sense of urgency from senior management about the need for change
      and is it shared by the rest of the organisation?
4.    Does management have a clear vision of how the future will look different from the
5.    Are there objective measures in place to evaluate the change effort and are reward
      systems explicitly designed to reinforce them?
6.    Is the specific change effort consistent with other changes going on within the
7.    Are functional managers willing to sacrifice their personal self-interest for the good of
      the organisation as a whole?
8.    Does management pride itself on closely monitoring changes and actions taken by
9.    Are the importance of the customer and knowledge of customer needs well accepted
      by everyone in the workforce?
10.   Are managers and employees rewarded for taking risks, being innovative, and looking
      for new solutions?
11.   Is the organisational structure flexible?
12.   Are communications channels open both downward and upward?
13.   Is the organisation's hierarchy relatively flat?
14.   Has the organisation successfully implemented major changes in the recent past?
15.   Is employee satisfaction and trust in management high?
16.   Is there a high degree of cross-boundary interactions and co-operation between units
      in the organisation?
17.   Are decisions made quickly, taking into account a wide variety of suggestions?
Morrison's first and second Curve

Study unit 2

Compare the changes in your organisation that took place over the
last 10 years and list them below.
               1990                               2000

I'm sure you could identify a number of changes, e.g.
               1990                               2000
The focus is on:                   The focus is on:
    Money                            People
    Computers                        Internet
    International Trade              E-commerce
    Capital ($)                      International Capacity

                                                                                 Study unit 2

The work of Morrison (1996) is based on these changes that occurred over the last decade.
He classifies it as a first curve and second curve organisation. Study the comparison
between the two types of companies.

         FIRST CURVE                        SECOND CURVE
Mechanistic                          Organic
Engineering                          Ecology
Corporations                         Individual and Networks
Horizontal     and       Vertical Vertical Integration
Business Processes                   Culture

Studying the information presented to compare the first curve organisation and the second
curve organisation, it is evident that over the last decade a change in focus has occurred.
People have become more important; with a specific focus on the individual and networks
that demonstrates a new culture. Morrison (1996) states that putting the spirit back into the
organisation is imperative to cope with change. Morrison (1996) suggests changes for the
Second Curve Organisation to cope with the uncertainty:
    Learn to jump (take the risk)
    Serve the new customer or fail
    Build a diverse management team
    Out with the old, in with the new
    Focus on the pace of change
    Build a second curve capacity
    Build resilience in the organisation
The third approach of management change is Tichy's waves of change.

Tichy's Waves or Change
Noel Tichy's theory is based on the pioneering work of Kurt Lewin. While the three probes
are not distinct sets of events, it is relatively easy to determine if the organisation is:
1.   Getting ready to change
2.   Designing the change
3.   Putting change into action

Study unit 2

Waves or Phases of Change
The following explanation of Tichy's theory is abstracted from Jaffe & Scott (1999: 3 - 6):
In order to divide the implementation of change into its three major phases and give a mental
picture of their flowing nature, each phase has been called WAVE.

WAVE ONE:             Mobilizing the Organisation for Change
This frequently neglected phase is where the organisation gets a wake-up call and everyone
is put on alert to get with the process. The whole organisation learns the story of why they
have to change and the reason for the changes that are being set in motion. Rather than
keep change a secret in the early phases, the whole organisation must engaged in the

WAVE TWO:             Designing the New Organisation
Every part of the organisation takes a role in the creation of a map for proposed change.
People seek new models, exchange information and envision the future organisation. This is
exciting and demanding work.

WAVE THREE: Sustaining the Transformation
The organisation puts the change into action with a vast and difficult learning process, which
impacts every person. To the degree that people have been prepared and part of the prior
process, they are ready to take up the challenge.
The other element concerns the four LEVELS of the organisation that are involved in creating
change. Each level has a different perspective or place in successful change.

FIRST LEVEL: Top Leadership
This level consists of the Executive Team of the organisation (or business unit) under whose
umbrella the change occurs, who provides the necessary resources and visibly and actively
supports the change. It contains the Change Sponsor, the person who makes the decision
to carry out the change. This person must be active, not in controlling the process, but in
inspiring people to take part in the change.

SECOND LEVEL:                 The Change Team
This level includes the Change Leader and the Change Navigator. The Change leader is the
operational leader of the team or group that must change. This person leads the change
team and the group that implements the change. Many people may be the change leaders,
but there should be one person who takes the responsibility for the change. Once a person
shifts from being a manager to being a change leader, he or she must adapt a different per-
spective and use new skills. The Change Leader is also part of the Top Leadership Team.
The Change Leader delegates activities to the other members of the Change Team and the
Change Navigator.
The Change Navigator is a partner with the Change Leader and designs the process for
creating change and acts as the guide for the Change Team. Change Navigators may be
either internal or external consultants. They may also be line managers, or members of
human resources, information systems, or support functions.
Change Navigator - guides the process
Change Leader - responsible for the outcome

                                                                                    Study unit 2

THIRD LEVEL: Employee Involvement
This level includes the people that are affected by the change - those who have to do the
changing. They are represented in the change process through the Employee (or
Stakeholder) Involvement activities through which the organisation as a whole will become
aware of, involved in and committed to the change.
Stakeholders are those who are affected by the change. These people may be in the
organisation itself, or they may be outside the organisation, like customers, suppliers and
spouses of the employees. All stakeholders need to be involved frequently and early in the
This level contains those that are directly under the authority of the Change Leaders; these
are the Team Members. They must make the most difficult changes and need to develop a
real commitment to learning new skills and ways of working together.

FOURTH LEVEL: Organisational Culture and Process
This level refers to the deep structure of the organisation where the values, structures,
policies and core processes are stored. It is often called the Organisation Culture.
If this level is not aligned with the desired changes, change will not "take", and will not last.
This level is beyond the people and represents the foundation of the organisation.
The chart on the following page will show you how the waves and levels interact with each
other in order to create change. Each wave contains four key tasks that take place at each
level of change.
Jaffe & Scott (1999: 6) provide a condensed framework for designing change.

Table 2.2.1 Framework for designing change
                             Wave One                 Wave Two                Wave Three
                               Mobilize                 Design                 Transform
Level One

TOP LEADERSHIP          Align Top                Make the case for       Champion New
                        Leadership               Change                  Ways
Sponsor Executive
Level Two
                        Convene and              Design New              Cascade Change
                        Charter Change           Processes               Leadership

Change Leader
Change Navigator

Study unit 2

                                 Wave One              Wave Two             Wave Three
                                 Mobilize               Design               Transform
Level Three
                          Develop Individual   Employee                Develop New Teams
                                               Involvement Process
EMPLOYEE                  Change
INVOLVEMENT               Capabilities

Team Members
Level Four
                          Asses Organi-        Align Systems With      Develop New Teams
                          sational Change      New Processes

The last approach that we address is Tetenbaum's (1998) shifting paradigm.

Tetenbaum (1998) advocates a paradigm shift from a linear paradigm (Newton) to a new
paradigm (Chaos). The shift proposal is demonstrated in the following table:

      The Linear Paradigm (Newton)                      The New paradigm (Chaos)
    World is a well-behaved machine              World is full of unintended
                                                   Consequences and counter intuitive
    Universe - predictable and law abiding       Chaos has order:
                                                        complex, unpredictable and orderly
                                                        disorder in which patterns of
                                                        behaviour unfold in irregular but
                                                        similar forms
    Cause and effect                             Chaos as a self-organisational entity
        clear, simple, linear                         Patterns that emerge from chaos
                                                        have a hidden recognisable form
    Organisational success                       Focus
        Maintenance of stable system                  Web of feed back loops present in
                                                        every system
    Focus
        Regularity
        Predictability
        Efficiency

                                                                                Study unit 2
Based on the work of Tetenbaum (1998) the new tendency is to build a Chaordic
Organisation (Chaos + Order = Chaordic). So how will you build a chaordic organisation?
Tetenbaum (1998) stipulates the following principles and guidelines:
    Knowledge and information sharing
          Knowledge is one of the primary preconditions for emergent change.
          Rely on collective intelligence of staff to create the future.
          Offer incentives and rewards to best knowledge sharers.
    Innovation and creativity
          Require organisational culture in which rules are meant to be broken and
           assumptions be continually tested.
          Environment supports risk taking, experimentation and failure.
    Teamwork and Project Orientation
          Knowledge, growth, information sharing, creativity and innovation thrive best in
           small groups where people can interact freely.
          Delayer and decentralise
           -     organised around tasks performed in teams
           -     ensure teams are flexible enough to form, change and dissolve as needed.
    Diversity
          Homogenous groups tend to produce homogenous ideas.
          Diverse groups advance learning faster than traditional groups.
          Requires high tolerance for conflict.
    Strong core values
          Autonomy (don't allow to dissolve into anarchy)
          Bonding glue is the focused purpose based on principles.
          Despite the complexity and chaotic nature of the environment and the messy
           state of emergent change, ideology/values that can provide its direction and
    The Role of the manager:
          Manage the transition
          Build resilience
          Destabilise the system
          Manage order and disorder, the present and the future
          Create and maintain a learning organisation

Study unit 2

2.2.4      SUMMARY

In study section 2.2 we have given attention to a new tendency in organisations - change
management. The changes that organisations desire today cannot come about unless there
is a fundamental change in the way people are involved as partners in the organisation.
Organisational change is a community - learning process that involves many successive
steps and large - and small group learning activities. I hope that the covered content in this
study section will help as a guide and map when change in your organisation occurs.


    Change management
    Change agent
    Change management approaches
    Risk management
    Incident report


After you have studied study unit 2 you should be able to answer the following:
1.   What are the criteria for proper incident reporting?
2.   Explain the components of a risk management programme and how you will
     operationalise it in practice.
3.   Discuss the role of the change agent in change management.
4.   Explain the dynamics of resistance to change.
5.   Compare the different approaches to organisational management and motivate one
     approach that you will utilise.

                                                                             Study unit 2


1.   Refer to table 2.1 (DO'S)
2.   Refer to Booyens, 1998, p583
3.   Study section 2.2
4.   Study section 2.2
5.   Study section 2.2


Jaffe DT & Scott, CD 1999: Getting your organisation to change. USA: Changeworks
Morrison, I 1996: Jump into the Second Curve, World Executive's Digest, November
Mullins, LJ 1999: Management and Organisational Behaviour; fifth edition
Great Britian : Financial Times Pitman Publishing
Robbins, SP 1998: Organisational Behaviour; eighth edition USA: Prentice - Hall
Tetenbaum, T 1998: Shifting paradigms: from Newton to Chaos,
Organisational Dynamics, Spring pp. 31 - 32

Study unit 2

                                                                                                                Study unit 3

      3                       INFORMATION SYSTEMS AND
                              HEALTH SERVICE

Time schedule for this study unit is approximately 20 hours

Study unit contents
3.1                       Computers information systems and health service management ........ 83
           3.1.1          Overview of study section 3.1 .............................................................. 83
           3.1.2          Summary ........................................................................................... 101
3.2                       Information management technologies .............................................. 102
           3.2.1          Overview of study section 3.2 ............................................................ 102
           3.2.2          Summary ........................................................................................... 121
3.3                       Information systems in health service management ........................... 123
           3.3.1          Overview of study section 3.3 ............................................................ 123
           3.3.2          Summary ........................................................................................... 127

IMPORTANT CONCEPTS OF STUDY UNIT 3 .................................................................. 128

SELF-ASSESSMENT OF STUDY UNIT 3 ......................................................................... 131

SKILL-BUILDING EXERCISE ........................................................................................... 132

Study unit 3

After completing study unit 3 you should be able to:
    discuss the use of computers hardware and software as tools in information systems in
     health institutions,
    explain the effects of information technologies on the health industry, and
    discuss and operationalise information systems in Health Service Management.

The computer has come to stay. These machines are tools that already assist us globally in
performing numerous tasks. Nurse Managers are finding themselves in crucial positions. In
the information era, the computer is a necessity in managing the complex structure of a
health institution. Study unit 3 explores the use of computers in information systems, how
information technologies can be used in health care and how to operationalise an information
system. Welcome to this exciting journey! I’m sure you will enjoy the ride. BON VOYAGE!

                                                                                Study unit 3


After completing study section 3.1 you should be able to:
    distinguish between computer hardware and software;
    identify and describe issues/barriers in health service management, related to
     information systems;
    explain the general-purpose of microcomputer software; and
    differentiate between various information systems.

With the turn of the century upon us, the techno-revolution is a fact. Our world is run by
computers – auto tellers, credit cards, debit cards, television, VCRs, home computers and
work computers. The health service manager should be prepared to utilise the technology.
Study section 3.1 provides an introduction and overview of the basics of computers and
information systems. Nurses should be prepared to practise in the increasingly technological
environments of the future, and to direct and control the impact of technologies on nursing.

Computer hardware and software

What is your understanding of:
    Computer hardware?

Study unit 3

    Computer software?

Swansburg (1996:487) distinguishes between hardware and software (quoted).

Read this section and ensure that you will be able to distinguish between computer hardware
and software.

    Hardware
Even in this era of downsizing, many companies may view their mainframe as the centre of a
large, corporate-wide network. The mainframe is a hub connecting distributed minicomputers
and PC/LAN (personal computer/local area network) clusters. It serves as an information
reservoir, siphoning data to PCs, workstations, and minicomputers. A minicomputer may be
used to handle the needs of a large nursing department, and may also serve as a hub
connecting workstations and microcomputer-based LANs.
A LAN cluster is the focus of hardware for each nursing department. Workstations and
microcomputers act as point-of-care technology centres at the patient’s bedside. These
computers can integrate computerised patient monitoring systems which measure ECG,
arterial blood pressure, pulmonary artery pressure, temperature, chest drainage, urine,
cardiac output, respiratory cycle pulse, tidal volume, peak airway pressure, blood I/O and
fluid I/O.
These point-of-care computers would have colour displays and be capable of 3-D graphics
and full-motion video. Interaction would be via a pointing device – your finger, a mouse, or a
light pen. A camera would supply the capability for video interaction and monitoring. Finally,
stacks of compact disk drives are attached to provide access to a never-ending electronic

    Software
State of the art software centres on an open-system model and a multitasking operating
system. The open-system approach seeks to integrate many different software environ-
ments, regardless of their hardware platforms.
A multitasking operating system provides greater computing power and efficiency for the end
user. The workplace is managed through a graphic user interface, and diverse automated
systems are integrated and presented via interactive multi-media.
Interactive multimedia combines full-motion video, narration, animation, text and stereo
music. It allows people to interact with information from multiple sources in new ways. The
same information may be expressed simultaneously from many different points of view. It is
the medium that will replace paper and printed information as we know them.

                                                                                 Study unit 3

Health Service Management concerns

Read the following quote from Swansburg (1996:487-491) and identify the obstacles you
might experience regarding the uses of computers in the health service.
Due to increasing economic pressure and government regulation, nursing care delivery
systems have been created with important implications for Health Service Management. In
an effort to streamline operations and improve efficiency, nursing personnel are being cross-
trained and are being increasingly exposed to computers and information systems. Cross-
training prepares professionals to function effectively in multiple areas, and faced with
increased patient acuity, changing technology, and specialisation, professionals have to
accurately co-ordinate clinical information to deliver quality health care. They use relevant
information logically, systematically, and cost-effectively to make sound decisions.
Health Service managers must work with educators to face the challenge of developing
effective and efficient training programs for staff who may be working with a variety of
computers and information systems. They must address such issues as barriers to
computerisation and learning, ethical, legal and security concerns, and the recruitment and
retention of highly effective professionals.

Barriers to computerisation
The first barrier to overcome in dealing with computers is computer phobia. A general fear of
change seems to exist within us all, and for some, being forced to work with computers elicits
common reactions of apprehension and anxiety. Some tips for conquering computer phobia
    Do not procrastinate.
    Seek a non-threatening environment, one in which everyone will feel comfortable.
    Maintain a positive attitude, an assurance that learning will take place. Fear of not
     learning is a problem.
    Encourage hands-on opportunities.
    Indicate that knowing how to type is helpful but not essential.
    Do not allow the use of computer jargon. Use words that everyone understands.
    Insist that learning sessions should last less than two hours and not cover too many
    Do not allow interruptions.
    Encourage assertiveness and requests for help.
    Encourage practice.
    Have everyone relax.

Other reasons for computer phobia would be fear of making mistakes and erasing data, and
the fear that jobs will be lost. Computer phobia can be overcome through proper
management, education and hands-on training.

Study unit 3
Another barrier centres on the perception of cost versus benefit. The health and human
services secretary’s commission of health care projected that health-care institutions would
allocate approximately 2.5% of their operating budget for information technology. In contrast,
other service industries such as banking and insurance allocate from 7 to 10%. The inappro-
priateness of this low allocation of revenues is that health care is more information intensive
than the figures imply.
Often administrators and health professionals have a hard time believing that computer
technology can enhance productivity and improve quality. Although some studies appear to
show that computerised information systems are a time saver, nurses may circumvent the
information system, thus defeating its time savings. Even if time is saved from paperwork,
there is concern that nurses will not use this time to focus on patient care. Managers should
become involved by researching information technology, installed or planned, and
determining whether it is beneficial to nursing. Finding it so, they should inform others about
its positive effects and advantages.
A final barrier relates to a system whose capabilities do not meet the organisation’s need.
Professionals who feel that the information system does not promote their clinical decision-
making and that it will detract from the amount of time spent doing patient care will not use it.
This is usually due to not involving staff nurses in the decision-making process from
beginning to end. The solution seems to be to involve the staff in any decision related to
automation. Staff should be allowed to develop the system and fit it to the organisation.

Ethical, legal and security issues
Being ethical means conforming to professional standards of conduct. Privacy means control
over exposure of self or information about oneself and freedom form intrusion. Privacy
denotes the right of an individual to decide how much personal information to share. It
includes a right to secrecy of information and protection against the misuse of release of this
information. Confidentiality means being entrusted with the privacy of others. The
relationships of the three can be expressed as a patient entrusting privacy to a professional
who has an ethical responsibility to maintain the confidentiality of the privacy.
Legal issues associated with automation may involve the confidentiality of patient
information, and the risk associated with clinical decision-making based upon computerised
information. One method of addressing these issues is by maintaining professional
standards. Information systems should be signed, developed and implemented to validate
patient outcomes and support professional health care standards. This means that computer
technology for health care use needs to be based upon health care input from start to finish.
This requires the use of expert health that has sufficient clinical, theoretical, education,
research, and management expertise to adequately represent professional standards. It also
requires a unified viewed that can specify clear design criteria and professional standards
Health professionals should be capable of assessing and managing the legal risks
associated with automated information management. Computer data should be examined,
analysed, interpreted and appraised. Forced selections and unclear logic should be
questioned. Health professionals should not hold as fact the belief that clinical decision-
making based upon the use of technology results in better patient care.

                                                                                     Study unit 3

What strategies will you put in place to limit risks, e.g. confidential information leakage?

Read further now to determine what is suggested by Swansburg with regard to the guidelines
and strategies to minimise legal risk.
Guidelines and strategies offered for minimising legal risks associated with automated
charting are:
     Never give your computer password to anyone.
     Do not leave a computer terminal unattended after you’ve logged on.
     Follow procedures for modifying mistakes. Computer entries are part of the permanent
      record and cannot be deleted.
     Do not leave patient information displayed on a screen for others to see. Also, keep
      track of printed information about patients, and dispose of it appropriately when it is no
      longer needed.
     Follow your institutional confidentiality policies and procedures.

Security means the level to which hardware, software, and information is safe from abuse
and unauthorised use or access, whether accidental or intentional. From a management
standpoint, professionals need to be aware that security must be overseen from physical,
operational, and ethical viewpoints.
Physical security deals with the control of access to hardware, the assessment and
determination of environmental threats, and the prevention of loss. Operational security
deals with the threat of information. It includes the assessment and prevention of
unauthorised access or use of information, the policies and procedures governing the
management of information, and the procedures required for recovery from loss of
information. Ethical security deals with the individual’s ability to conform to professional
standards of conduct. This means that nurses have to respect the privacy of information.
They must accept and enforce all guidelines imposed for the maintenance of physical and
operational security of computer systems.
Health care managers should be aware of various security measures which may be built into
information systems. One of the first things that should be present is the ability to perform

Study unit 3
auditing. This means leaving a trail of who did what, where and when. Logs can record who,
when and where the system is accessed. This same information is created, modified, or
deleted. Once this information is captured, standard procedures should be in place for the
routine auditing of this information.
A significant amount of security may be associated with an individual’s computer ID. Every
individual should be assigned his or her own personal ID. This ID should have the person’s
name, title, department, security level, and menu linked on it. There should be a password
which protects the ID and is known only by the user. Procedures should be in place to force
users to change their passwords every 30 to 90 days, and to allow them to change more
often on their own as desired. Also, a number of each user’s old passwords should be
stored for comparison purposes, and the user should not be allowed to re-use these
passwords. The security level should be implemented in a hierarchical manner from
administrator to nursing assistant. It can be a range of numbers from largest to smallest
which can be tested to determine who can perform particular functions. Menus which
determine the capability to interact with the system should be developed and assigned based
upon departmental and job requirements.

Recruitment and retention
Strategies which promote health care satisfaction are paramount, considering the investment
in recruiting, training, developing, and retaining qualified health professionals. The reasons
why health professionals select an employer include location, salary and benefits, and
flexibility of scheduling. The reasons why health professionals remain in their jobs include
peer and medical staff support, open communication to management and input into decision-
making, model for professional practice, and reimbursement of tuition.
It is also time to consider the use of technology to create an environment to promote
satisfaction. Technology can be the building block to develop positive and attractive work
surroundings. The use of point-of-care information systems, telecommunications, and
automated skill-mix and resource scheduling will help successfully recruit and retain nursing
The activities related to recruitment and retention are important enough that the development
of an automated recruitment programme may be warranted. The objectives would be to
provide accurate and timely tracking and monitoring of recruitment activities and costs.

How will you handle barriers to computerisation?
What will you use the computerised system for in your hospital?

                                                                                  Study unit 3


General purpose microcomputer software

Identify and list the areas in the hospital where you have seen computerised systems.

Visit the computer workstations in your organisation and identify their functions. Do you think
it is functional? Give a motivation for your answer.

Compare your list with the identified purposes as quoted by Swansburg (1996:491–503).

Study unit 3

    Spreadsheets
A spreadsheet is a tool used to record and manipulate numbers. Originally spreadsheets
were paper ledgers used for business accounting, such as the recording of debits and
credits. With the coming of the microcomputer, electronic spreadsheets were developed. An
electronic spreadsheet is a software package that turns a microcomputer into a highly
sophisticated calculator. Huge quantities of number can be recorded, manipulated, and
stored quite simply and easily. Nurse Managers could use spreadsheets to maintain
statistics, create graphics, and plan budgets.
A spreadsheet is made up of columns and rows of memory cells. These cells can be varied
in size to allow for small or very large numbers. In addition to numbers cells can store text
and formulas. Text is used for titles, column and row headers, comments, and instructions.
Formulas are used to perform the actual mathematical manipulation of memory cells and
their numbers, such as addition, subtraction, multiplication, division, and even special math
functions such as averages and standard deviations. Formulas are what really make a
spreadsheet a powerful number-crunching tool. Spreadsheets also have functions for
copying, moving, inserting and deleting cells. One of the most important spreadsheet
functions is graphing, which allows numbers to be displayed in a graphic form.
Spreadsheets are the best tool to use in situations that require the management of a lot of
numbers. For this reason, they are particularly pertinent to financial management, where they
speed up the process of budgeting, forecasting, developing tables and schedules, and so on.

Visit your organisation’s accounts department and ask the manager for a spreadsheet. Will
you be able to utilize this function in your management of the unit? Motivate your answer.

    Word processing and desktop publishing
Word processing is the manipulation of words and special characters to produce a printed
document. Desktop publishing is the manipulation of text and graphics to produce
documents of publication quality. Five years ago the difference between the two was vast.
Today each has incorporated aspects of the other. Examples of documents produced from
both are memorandums, letters, policies/procedures, forms, labels, instruction sheets,
manuals, signs, books and others.

                                                                                 Study unit 3
Advantages of word processing and desktop publishing are:
    A document can be visualised on a computer display screen exactly as it will look when
    A document can be modified or changed very quickly and easily without one having to
     entirely redo it.
    A document can be printed numerous times with the same material in different formats.
    Special graphics can be incorporated to enhance or highlighted the content of a
    Document management is simplified with the linking of chapters and the automatic
     generation of a table of contents and index.
    Multiple documents (upwards of 750 typed pages) can be stored as compressed
     electronic files on a removable and transportable magnetic disk as small as 6 cm
     square by 2 millimetres deep.
Word processing and desktop publishing programmes have facilities for the management of
multiple document styles. Styles contain formatting codes that are grouped under a single
structure. When applied to a section of text or an entire document, they can save time and
insure consistency. A library of styles can be created and used between different documents.
Styles can establish:
    Font type, size and style, such as Courier 10-point normal, Times Roman 12-point
     italic, or Helvetica 14-point bold.
    Spacing between lines and paragraphs.
    Margins and tabs.
    Page headers and footers.
    Footnote and outline formats.
    Paper size and type.

Other tools often used and included in these programmes are a spell-checker, a thesaurus,
and a grammar checker. The speller contains a dictionary to which the text can be
compared; words not in the dictionary can be added to a supplement. When the dictionary is
invoked, words that are not recognised are highlighted. A list of alternative words is
generated along with options to replace, edit, or add the word to the supplement. The
thesaurus generates a list of synonyms and antonyms that can be used in place of selected
words. The grammar checker is used to check the document for grammar and style errors.
It will interpret the presentation of the subject and make recommendations for improvements.
Other utilities are available for performing block functions that operate on words, sentences,
paragraphs, or pages within a document. These functions include copying, moving, deleting,
bolding, underlining, and case conversion. Searching for and replacing particular words or
phrases can be done by a simple request. Text can be justified and words hyphenated
within set margins automatically. Pages can be defined and numbered automatically as well.
Shell documents can be created where the main content of a document never changes, but
some areas are reserved for text that will change each time a new document is created from
it. The best examples of this are in memoranda and letters, where the same memo or letter
goes to many different destinations. The document and a list of variable information can
actually be created separately and merged at printing time.
In health service management there are many different documentation tasks that can be
efficiently managed by word processing and desktop publishing programmes.

Study unit 3

How often during the last month have you needed a document prepared through word
If you were fully computer literate, would the task of completing your own documents have
made your task easier? In what way?
How would you utilize word processing effectively in the management of the organization.

    Database management

What data do you need daily/weekly/monthly to make decisions on management?

                                                                                  Study unit 3


A computer database is the electronic counterpart to the standard file cabinet and its
contents. It is used to store data and can be manipulated for information much like paper
files. Health service managers could use a microcomputer and a database management
programme in place of a manual filing system to handle many of their information and record-
keeping needs.
Examples might include personnel records, education records, and equipment inventory.
A microcomputer database programme allows for database to be created by defining their
record layouts and data fields. When a data field is defined, its length is set and the type of
data that can be stored in it established. Data types can be character (allowing letters,
numbers and special symbols), numeric (allowing only numbers), logical (allowing only yes or
no, true or false), or date (allowing only numbers in a date format). Once a database has
been created, procedures can be established to:
    Create information.
    Modify information.
    Display information.
    Delete information.
    Generate printed reports.
Menus can only be created to allow easy access to and execution of the procedures. Most
database tools have application generators which will lead the user through a series of steps
to define a database, its procedures, and its menus. The greatest advantage to database
management is the ease in maintaining information and the timely retrieval of this information
in report format.

    Graphics

How would you utilize the database information in your daily management?

Study unit 3
Health service managers can realise another valuable tool through the utilisation of graphics
programmes. These programmes can produce graphics that can be used for presentations,
illustrations, and teaching. Graphics can be printed, displayed to a monitor, or projected onto
a screen for viewing by large numbers of people. They can also be converted to overhead
transparencies, videotapes, slides, and other presentation aids.
In the past, graphics programmes focused on the visual display of numerical data in the form
of bar, line and pie graphs. This relates to the early use of graphics by business and mana-
gement. Marks emphasises this point when listing the following advantages of computer
graphics for health service management:
    They can illustrate the whole picture concisely.
    They can display trends.
    They can summarise analysis for planning.
    They can show relationships among factors.
    They can provide control information for decision-making by quickly providing facts.
Today graphics systems can be used in a multitude of ways to visually illustrate almost
anything. Features have been incorporated to display graphics like a slide show or with
animation. This presentation capability can be very helpful to the health service manager
trying to present information related to various clinical subjects.
There are a number of ways in which graphics can be created. They can be created as part
of the programme in association with some numerical data, they can be scanned by a hand-
held or full-page scanner, they can be created free-hand by the user, or they can be
purchased as an add-on on the graphics programme.

    Communications
Communications software permits nurse managers to access other computers for a variety of
purposes. This may be in a dedicated manner (the link is maintained even when it not in
use) or it can be in a non-dedicated manner (the link is only maintained while being used).
Dedicated links can often be associated with access to the organisation’s information
systems, or access to resources on a LAN. Non-dedicated links can be associated with
access to various online services such as bulletin boards, support services, and remote
information systems.
Communications can allow the nurse manager to support staff nurses in their interaction with
information systems. The manager, when contacted about a problem, can access the
system and mirror what the staff member is doing. The nurse manager can also use
communications to move information in the form of a file transfer. This might be to transfer
data to and from the host system (mainframe or minicomputer), across a LAN, or to another
microcomputer at home.

    Integrated software
Integrated software seeks to combine word processing, spreadsheets, database
management, graphics and communications. This integration allows information to be
readily moved among the components. A report being created in the word processor can
draw a table of number from the spreadsheet, a graph from the graphics component, and
other information from a database. This document can then be sent to another location via
the communications component.
This integration can simplify preparation and analysis of information. However, these
programmes tend to lack the full functionally of programmes in the individual components
domains. The standard programmes of today also provide excellent import and export
facilities to most of the popular software in other areas.

                                                                                 Study unit 3

Which of these identified purposes are relevant to the health industry?        Motivate your

Information systems
The demand for integrated systems is ever-increasing.          Various systems have been
identified by Swansburg (1996:503–507) (quoted).

    Health service information systems
Health service information systems are software packages developed specifically for health
care usage. These programmes may be explicit to a particular nursing application, or they
may be general to the support of the health services division. Examples of areas which can
benefit from unique information systems support include mental health, neonatology, acute
care, urology, enterostomal therapy, oncology, maternity, operating room, and infection
General information systems have multiple programmes or modules which are used to
perform various clinical, education, and management functions. Most information systems
have modules for patient classification, staffing, scheduling, personnel management, and
report generation. Other modules may be included, such as budget development, resource
allocation and cost control, case mix and analysis, quality management, staff development,
modelling and simulation for decision-making, strategic planning, short-term demands for
forecasting and work planning, and programme evaluation.
Modules for patient classification, staffing, scheduling, personnel management, and report
generation are often closely interrelated. Patients are classified according to established
acuity criteria. The patient classification information is input into the staffing module, and
staffing levels are calculated according to various workload formulas. Also, actual staffing
can be recorded via input and a comparison of census, patient acuity, needed staffing, and
actual staffing can be made. Schedules are then prepared using the information from the
staffing and personnel records modules.
Analysis and quality management are done to associate patient acuity and quality of care.
This is helpful for establishing future guidelines and care needs for patients. The budget is
also supported by the census, patient acuity, and needed staffing patterns. This information
is invaluable to support request for additional full and part-time employees. The report
generation module allows all the stored information to be retrieved and output to be effected
in a timely and presentable manner.
Health service information systems can be used to make patient care more effective and
economical. Clinical components include patient history and assessment, care plans,
progress notes and charting, patient monitoring, order entry and results reporting, patient

Study unit 3
education, and discharge planning. This can all be done at the stations or, with more
progressive systems, from the patient’s bedside.
Clinical nurses can use the nursing information system to replace manual systems of data
recording. This may reduce costs while permitting improved quality of care as well as quality
of work life. Clinical nurses can collect and effect input of clinical data and use the computer
to analyse it to formulate treatment plans. They can use quantitative decisions analysis to
support clinical judgements. Automated consultations can be applied to screen for adverse
drug reactions, interactions, and preparation of correct dosage. Computers can be
programmed to reject orders that could cause problems in these and other areas, thus
preventing errors.
Curtin reminds nurses to provide “high touch” in this inhuman “high-tech” world. Technology,
computers, and information systems provide the knowledge to save lives or prolong them.
Health professionals can return control over their lives in terms of care of patients and
families who have lost their freedom of action or become unable to understand. Health
professionals can keep control of cybernetics through the exercise of human compassion.
High-tech includes the new scientific knowledge of microelectronics, computers, information,
sensors, processors, displays and education. It has as object the solution of society’s total
problems, not just those of health care, including nursing. Helping health professionals
provide high-touch while using high-tech should be a primary goal of health service

     Hospital information systems
Hospital information systems are large, complex computer systems designed to help
communicate and manage the information needs of a hospital. They are tools for inter-
departmental and intradepartmental use. A hospital information system will have appli-
cations for admissions, medical records, accounting, business service, nursing, laboratory,
radiology, pharmacy, central supply, nutrition services, personnel, and payroll. Numerous
other applications can exist for any department and for practically any purpose.
Admissions applications include patient scheduling, pre-admission, admissions, discharges,
transfers, and census procedures. Some medical records applications include master
patient-index maintenance, abstracting (diagnosis/procedure/ DRG coding), transcription and
correspondence, and medical record locator procedures. Business and accounting proce-
dures include patient insurance verification, billing, billing follow-up, billing inquiries, accounts
payable, accounts receivable, cash processing, and service master and third-party mainte-
Applications in other areas such as nursing (the nursing information system), laboratory,
radiology, pharmacy, and central supply may be so voluminous and complex that they have
their own information systems. These systems stand alone and run independently of the
hospital information system, but are usually interfaced for information transfer.
Hospital information systems tend to be developed with mainframe and minicomputers in
mind, although the trend today seems to be towards downsizing and distributed data
networks. The advantages and disadvantages of each strategy should be weighed prior to
information systems implementation. Selection, development, and implementation of
information systems can take years. This time will vary depending on the system and the
complexity of its applications. It may actually be a continuous process. The initial cost can
be millions of rands for the hardware and software. Continued yearly maintenance is
required and can cost hundreds of thousands or even millions of rands.

     Implementation of hospital systems
Health service managers should be involved in the implementation and development of
information systems and the direction of their users. Implementation of an information

                                                                                    Study unit 3
system requires preparation of a management plan. The first step is to form an imple-
mentation committee to assess the current system and what is wanted of the proposed
system. This assessment should lead to a strategic plan, as acquiring an information system
requires expenditure of a large amount of human, material and financial resources. It will
include provision for continuous updates, a characteristic of a service economy in the
information age.
Assessment: The study team that makes the assessment should include information
systems personnel, health service managers, health care educators, clinical nurses, human
resource personnel, and ancillary personnel from other departments that will be exposed to
the system. They can use many references and techniques to gather assessment data.
These will include liaison with the information system department, visits to business,
industries and other departments, professional consultants, in-house resources, and the use
of phone banks, conferences, and seminars.
Information systems have to be modelled for the organisation and the personnel that will use
them. If health professionals are not involved in developing these systems, then they will not
make a major impact on clinical decision-making or meet the needs of the health care
professions. Therefore, each phase of the development process can benefit from input.
The assessment team will have to work within the capital investment policies and procedures
of the institutions, as procurement of hardware will fall within the realm of the capital budget.
Thus, time schedules and budget procedures are important. The team will look at the
management style of the organisation, as the information system will reflect centralisation to
increase decentralisation of control. If there is a desire to increase decentralisation and
participatory management, development of the information system can be used to facilitate
these processes.
Availability of space for hardware, personnel, and supplies will be determined. Determination
of external environmental influences will be assessed. Does the information systems
department or higher corporate entity affect information systems development? In one
hospital the mainframe computer was physically located and controlled by the university’s
computer centre, thus placing many restrictions on the information system. The assessment
team will analyse types of systems available, including hardware and software.
Once a thorough assessment has been completed, the formal findings are presented to top
management and interested other for analysis and approval. The assessment team can be
converted to a planning team or a new one can be formed. There should be some
uniformity. This is achieved in many organisations by having a full-time nursing information
systems specialist whose job is to coordinate the activities of nursing information systems.
Planning: The second major step in implementing an information system is developing of
the specific management plan. The plan will include objectives, resources needed,
communication strategy, a phase in schedule, a budget that includes operating costs,
identification of savings, benefits, and possible revenues, and an evaluation plan. The
management plan should be concrete and in writing.
To support the information system objectives, the team will identify the system requirements
needed. They can obtain and evaluate sample requests for proposals (RFPs) from vendors.
Criteria for a specific system are recommended.
Security should be considered during this phase. Provision must be made for confidentiality
of records. An aspect often overlooked is the protection of software copyright. In this
information age we transact intangible property as opposed to tangible property – information
business versus manufacturing. It is difficult to retain control of the property of computer
information. McKenzie-Sanders indicate that software will be safeguarded by law, or
programmes will be given away as a promotion, thus eliminating the need for safeguards.
The information systems plan should provide for computer downtime. How will critical
functions be managed when the computer is down? Procedures and forms will need to be

Study unit 3
developed to capture and manipulate information during periods of downtime. Also, this
information will have to be entered into the computer when it becomes available again.
The completed plan is presented to top management for approval. They will coordinate it
with the policies and procedures required for approval of capital expenditures, which usually
includes action by the board of trustees. With final approval the information system is
selected and purchased, sometimes through a bidding system that may keep the cost down.
Another option proposes that the system can be totally developed in-house. Careful
planning of the system avoids waste. The information system will be expensive.
Implementation: The nursing information systems specialist will coordinate the imple-
mentation of the information system with involvement of nurse users throughout the total
project. This process will build user trust and confidence. This person will work with the
implementation team which includes the key users. The team should keep track of nurses’
attitudes towards implementation of computer systems.
Health service managers can work with educators and the information systems specialist to
develop a curriculum for educating health professional in computer use. The organisation
provides a comfortable setting for health professional to make the best use of computers.
Implementation of the information system can be done using the principles of planned
change. The information systems specialist can be the change agent. Peers will influence
others to learn. A teaching plan should be developed. Audiovisuals, computer terminals,
and a system-specific manual are used for training. Formal teaching sessions should be
provided, with the staff being allowed to leave their stations for uninterrupted training. A pilot
unit can be selected and used. Resource personnel (to include staff development educators,
health care managers, staff nurses, etc.) should be available on all shifts for assistance.
Vendors frequently provide training in use of hardware and software. In addition, there are
self-directed training programmes.
Evaluation: A predetermined evaluation plan that includes Gantt charts or a similar con-
trolling process is best for keeping the plan on target. Questionnaires, surveys, interviews,
observations, and quality circles can be used to evaluate user acceptance and achievement
of objectives. Feedback from these sources will be used to modify the information system.
Even after the initial implementation of an information system, education is a continuous
need. New capabilities are developed and added and staff experience turnover. This educa-
tional need requires dedicated resources, including a special classroom designed to include
the computer hardware which mimics is used in the work environments. These may be
computer terminals, microcomputers, and printers. It should also include a big-screen
Software should include a training system which mirrors the real system. This should be
completed with nursing stations, patients, and physicians. Some type of multimedia software
should also be available for presentations to the big screen. Last but not least, there is a
requirement for resource personnel. For larger institutions there should be at least two nurse
liaisons for automation. It has been advocated that all management and staff development
personnel should be cross-trained for this area, as automation affects all areas of nursing
practice. The overall co-ordinator for computer direction should be the nursing information
system specialist.
Health service managers and staff development educators must develop effective and
efficient training programmes for a diverse staff using diverse information systems. As
Axford states that established principles of teaching and learning are as applicable to
computer training as to any other teaching-learning setting. Specifically, effective computer
training will accommodate individual variation in learning styles. Sound computer training
addresses the cognitive, affective, and psychomotoric aspects of the learning tasks. Adult
learning principles are as important in computer training as they are in any continuing
professional education endeavour.

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    Application for Health Service Management

You have now read extensively about the possibilities of information system usage. How will
you apply it in Health Service Management?

(Quoted from Swansburg, 1996:507–508).

There are many applications for health service managers. In addition to those associated
with the use of general purpose microcomputer software, other applications might include a
calendar of events, an employee database management for staff and employee education.
A calendar can be useful in supplying clinical staff with dates and times of staff meetings,
committee meetings, and educational events. Educational events would include continuing
education, annual reviews, and patient education. Information for the calendar can even be
provided from the employee database.
An employee database management system can be an effective method of collecting and
reporting staff credentialing, special skills, and educational development. Access to this
information can identify employee participation in education and those with special skills or
credentials. It can also identify employees facing credentialing renewal deadlines and those
who need additional training.
This information can also meet the reporting needs of the institutions as to the requirements
of the state board of nursing and the Joint Commission on Accreditation of Healthcare
Organisations. Education components may include:
    New employee orientation.
    Clinical speciality modules.
    Continuing education offerings.

Study unit 3
     Competency validation of skills.
     In-service education.
     Annual required reviews.
The development and implementation of this employee information system can follow the
assessment, planning, implementation, and evaluation cycle.
Interactive multimedia is the educational media of tomorrow. It has the capability to solve the
problems related to education today. It mixes multiple media sources to provide interaction
with the user. This method of instruction provides flexibility, independence for learners,
reinforcement, and feedback. Students are able to control the presentation of content. They
can work the programme in any order, and segments can be selected and repeated as
desired. The programme provides students with immediate, individualised feedback based
upon their answers to the programme questions.
The development and authoring of an interactive programme involves a number of steps, the
first of which the determination of the content of the instructional programme. The second
relates to the preparation of a script for the video components of the program. Next a
flowchart is constructed to direct the authoring process.
Finally, the computer programming is done using a software package developed specifically
for interaction. These programmes are commonly called authoring systems. The implications
for applications using this technology appear to be unlimited.

     Human resource information
The management of human resources can be a formidable task            for today’s health care
organisation. The collection and manipulation of information            associated with this
management can require significant time and manpower in itself.        The development and
implementation of a human resources information system can             be a blessing to the
organisation and the professional who manage these resources.
A couple of front-end systems can be established to analyse information related to all of the
job applicants who apply to the organisation, and to analyse information related to the
advertising and recruitment of these applicants. Some information needs to be retained on
everyone who applies for any job position. This information can be useful for understanding
the professional market. There are also concerns about equal opportunity based upon race
or disability. The applications analysis system can show how many people apply for a
position by these indicators. The advertising analysis system can provide recruitment
information related to the method and placement of advertisements.
The central foundation of the human resources systems is the employee database system.
Individuals who are hired can be pulled from the applicant’s analysis system and added to
the employee system. This system maintains all of the relevant information related to
employees and their positions, from the moment they are hired until they are terminated.
This part of the human resources system will be the basis for integrating additional
components, such as an educational database system and a time and attendance system.
The educational system maintains all of the information associated with the education of
employees. The time and attendance system maintains the information associated with
employees’ work, vacation, holiday and sick time. The information here produces
timesheets. From these systems, information can be exported and imported to the hospital
and health care information systems. It may also be exported to general-purpose
microcomputer software for various purposes.

                                                                                  Study unit 3

Visit the Human Resource Department of your organization. Do an analysis of the system,
i.e. what is kept on computer, e.g. vacation leave, sick leave, hours of work. Do you think the
system is utilized effectively? Motivate your answer.

3.1.2      SUMMARY

Study section 3.1 intended to provide an overview of nursing and computers. Computers are
a necessary tool in the management of health care. Computers are used to support and run
highly, complex information systems which have tremendous capabilities for manipulation
and storage of information. All health service managers therefore have to interact with

Study unit 3

    3.2              INFORMATION MANAGEMENT

After completing study section 3.2 you should be able to:
     identify the effects of information technologies on individuals and organisations;
     describe the role and value of information as a resource;
     explain the essential capabilities of information technologies that support and link the
      basic management functions;
     discuss the issues involved in information system design;
     state factors that facilitate effective implementation of information systems; and
     identify ethical concerns in the development and use of computer-based information

In study section 3.2 the focus is more specifically on information management technologies.
Attention is given to the effects of information technologies, the role of information,
capabilities of IT, information system design and how to effectively implement an information

How have computers and information influenced your daily lives? Can you identify aspects?

                                                                                    Study unit 3

     Effects of information technologies
The digital world involves the linking of people (in business, in government, in the home, and
on the road) via computers and computers with other computers. Digital refers to the method
of data transmission, through on/off signals, by computers. The term cyberspace usually
refers to real-time transmitting and sharing of text, voice, graphics, video, and the like over a
variety of computer-based networks. However, cyberspace will soon become much more
than communication connections between points A and B. Its broader attributes and
capabilities will allow (1) people to come together from remote distance to dialogue in the
same three-dimensional virtual electronic space, (2) computers to talk to other computers,
and (3) individuals to interact with computer-based machines to create and shape three-
dimensional virtual realities.

     Profound predictions
Nicholas Negroponte, author of Being Digital – via Electronic Mail suggests that networking
through computers “will eventually be as ubiquitous as the phone, lights, and running water.
But recognise that your connectivity may not be just your pecking at a keyboard. It may be
your fridge ordering milk or your vacuum cleaner calling the police to report a breaking and
entering. The speed at which this will happen will knock the sock of the people”. For many
organisations, computer-based networks have already become fundamental to their ability to
produce to deliver goods and services – the organisation’s nervous systems.
In 1958, in the Harvard Business Review, Harold J Leavitt and Thomas L Whisler forecast
what organisations of the future would look like. Their predictions for the 1980s included the
     The role and scope of middle managers will change: Many middle management jobs
      will become more structured, have less status, and command less compensation. The
      number of middle managers will decline, creating flatter organisations. The middle
      management positions that remain will be more technical and specialised. New mid-
      level positions with titles such as analyst will be created.
     Top management will focus more on innovating, planning and creating: The rate of
      obsolescence and change will quicken, and top management will continually have to
      address developments on the horizon.
     Large organisations will recentralise: New information technologies will give top mana-
      gers more information. This advantage will extend top management strategic control
      over crucial decisions. Some top managers choose to decentralise only because they
      are unable to keep up with the changing size and complexity of their organisations and
      external environment. Other top managers are using information technology in
      strategically planning, controlling, and leading their organisations.

     Observed Impacts
The information technology revolution continues to have a great impact on organisations.
Information technologies (ITs) are electronic systems that help individuals and organisations
assemble, store, transmit, process and retrieve data and information. The new generation of
managers and other employees naturally are more knowledgeable than their counterpart of a
few decades ago about the uses and benefits of technological advances.                 Many
organisations are using information technology as a strategic asset to maintain an edge in a
fiercely competitive world market. Advances in telecommunication and networking allow
people to exchange information more freely than ever. Computer-based systems are now
available that can intelligently link, learn, and make recommendations to decision makers by
applicants of artificial intelligence, mainly through expert systems.

Study unit 3
Leavitt and Whisler’s predictions were strongly criticised throughout the 1960’s, 1970’s and
early 1980’s. But now they not longer seem far-fetched. Organisations have indeed
undergone radical changes in design and methods of operation because of new information
technologies. These advances, coupled with re-engineering, make the reduction of the
information float in organisations possible. In the past, decision- making took a lot of time
because information and proposals had to pass through numerous organisational layers
before anything was decided or actually happened. Today’s information technologies cut
through several of those layers and even allow some to be eliminated.
Recall that the streamlining of decision and information flows, especially through the use of
more horizontal networks, is a key feature of re-engineering. The new information
technologies are a vital component to most re-engineering initiatives. Managers whose main
function was to serve as assemblers and relayers of information are no longer needed.
Organisations continue to reduce the number of first-line and middle managers because
information technologies streamline many of the communication, coordination, and control
functions that such managers traditionally performed. The managers who remain have been
freed from most routine tasks and can take on more responsibility for tactical planning and
decision making.
Organisations now need many more knowledge workers to help ensure the successful
integration of information systems. Their skills allow them to deliver the appropriate
technology and provide instructions for using it efficiently and effectively. The magnitude of
the information revolution and the need for more knowledge workers is underscored by the
following fact. In 1991, companies in the United States and Canada for the first time spent
more money on computing and communication equipment than on industrial, mining, farm
and construction machines combined. In an automobile, the $675 worth of steel is obvious,
but the $780 worth of micro-electronics is less apparent.
Changes in an organisation design and the composition of the work force often lead to
decentralisation of tactical decisions – but greater centralisation of strategic decisions and
controls, as predicted by Leavitt and Whisler in 1958. Decentralisation results in the
empowerment of lower level employees, managers, and teams allowing them to engage in
tactical planning, self- and mutual control, and day-to-day decision-making. In some ways,
organisations increasingly resemble professional firms (e.g. CPA firms, law firms, and group
medical practices). The most successful of such firms attract, motivate and retain skilled
employees through a steady stream of challenging projects.
In these organisations, few jobs consist solely of overseeing the work of others. Many
employees take a managerial role for short periods of time by serving as team leaders.
Employees’ jobs change all the time, depending on the project being worked on. The
following small business insight illustrates how new information technologies are effecting the
options and life-styles of freelance professionals.

What impact does computers/information systems have on your health institution?

                                                                                 Study unit 3

Can you think of other systems that can still be implemented?
How do you think this would change your work situation?

Role of information
Health Service Managers need information to manage effectively. Read the following and
evaluate whether it is applicable in your situation.
Organisations store and process vast amounts of data, which managers and other
employees must turn into useful information. In turn, this information enables them to
perform their jobs better. Although the terms data and information are often used
interchangeably - we make a distinction between them in order to emphasise the unique role
of information.
Effective organisations and managers control their information – they aren’t controlled by it.
At times, users’ lack of knowledge places them at the mercy of an information system
department. To reduce this problem, some organisations have created the position of chief
information officer. The chief information officer (CIO) is usually a top manager who provides
leadership in assessing the organisation information processing needs and developing the
information systems to meet those needs in collaboration with managers and key employees
throughout the organisation.

    Data and information
Data are facts and figures. Every organisation processes data about its operations to create
current, accurate and reliable information. Many decisions require data such as market
statistics, operating costs. Inventory levels, sales figures, and the like. However, raw data
are much like raw material – not very useful until processed. Processing data involves
comparison, classification, analysis and summarisation to make the data usable and
Information is the knowledge derived from data that people have transformed to make the
data meaningful and useful. In effect, data are subjected to a value-added process that
yields meaningful information from decision-making. Individuals use their knowledge –
concepts, tools, and categories – to create, store, apply and share information. Knowledge
can be stored in a book, a person’s mind, or a computer programme as a set of instructions
that give meaning to streams of data.

Study unit 3

     Value-added resource
In contrast to that of physical resources, the value of information can’t be easily determined.
The value added to data, especially through information technologies, is determined by those
who use the resulting information to achieve desired goals. In organisations these goals may
be wide-ranging: (1) maintain or increase market share, (2) avoid catastrophic losses, (3)
create greater flexibility and adaptability, (4) improve the quality of goods and services.
Individuals at different organisational levels and in various functional, project or product units
or teams have different information needs. Certain information is essential to the specific
types of decisions they must make to serve their customers, whether internal or external to
the organisation. For example, top managers typically are interested in information on
overall organisational performance and new product ideas.
Detailed information on daily production and quality at each manufacturing site isn’t likely to
be as useful to them as to self-managing teams in the plants. These teams need specific
information about the availability of raw materials, changes in productivity, rates of defects,
and similar operating characteristics. To sales managers, detailed information of various raw
materials probably has little value. Sale personnel want to know the amounts and types of
goods and services that can be promised for delivery at various times and at what prices.
To be considered a value-added resource, information must possess value over and above
that of the raw data. The criteria for a value-added resource are:
Quality: The quality of information refers to how accurately it portrays reality. The more
accurate the information, the higher is its quality. The degree of quality required varies
according to the needs of those who will use the information. Employees responsible for
production inventory control need high-quality (precise) information about the amounts of raw
materials available and re-supply schedules required to meet customer’s delivery
expectations. Sales managers concerned with five-year sales forecasts might be able to use
lower quality (less precise) information, such as general market trends and sales projections.
Such long-term forecasting cannot be developed from detailed daily or weekly sales data.
Relevance: The relevance of information depends on the extent to which it directly assists
decision-making. Too often managers and other employees receive information that is of
little or no use. For example, a self-managing production team needs detailed information
about production schedules, inventory levels, and promised delivery dates in order to make
good decisions. Such information is relevant to providing quality goods when desired by
customers. These team members don’t need detailed information about the organisations
global strategy. However, the relevance of information can differ for the same person or
function at different times.
Quantity: Quantity refers to the amount of information available when people need it. In the
decision-making process, more information isn’t always better. If fact, too much can lead to
information overload, particularly if the extra information isn’t relevant to the decision being
made. Therefore care must be taken in advance to determine the amount of information
needed and wanted. The provision of information – relevant or not – costs time and money,
and information overload can cause stress and reduce effectiveness. For example, Charles
Wang, Chairman of Computer Associates international – a software firm that sells an e-mail
software package – no longer sends or receives e-mail. He also made the decision to shut
down the company’s e-mail system for five hours a day so that the employees would not be
so distracted. He comments: “As a leader in a company, you have to go to an extreme to
demonstrate a point. With subordinates copying their bosses on practically every memo they
write (using e-mail), it has become a cover-you (self) tool.
Timeliness: Timeliness means that managers and other employees must receive the
information they need before it ceases to be useful for decision-making purposes. Top
managers who make strategic plans may be interested in quarterly or monthly (or at most,
weekly) production and sales information. In contrast, production managers and employees

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probably need daily – and sometimes even hourly or minute-by-minute information
concerning operations to ensure that they meet their production schedules. If they received
such information only quarterly or even monthly, it wouldn’t be timely and could hurt the
quality and amount of outputs and slow down promised deliveries to customers.
These four criteria – quality, relevance, quantity and timeless – are interrelated and are
essential to the process of philosophy of total quality management. The following quality
insight suggests how one firm initially blundered by discounting anticipated customer
response based on these criteria.

Taking the described criteria into consideration – how would you use the criteria in the health
context? Is it relevant to your situation?

    Capabilities of information technologies

As health service manager you have the managerial function of P-O-L-C. How will you use
information technologies to support these basic managerial functions?

Study unit 3


Now read further.
The capabilities and applications of computer-based (digital) information technologies are
developing at a breath-taking pace. These technologies continue to become exponentially
less expensive and exponentially more powerful. The most conservative forecasts claim that
the cost-performance relationship for these technologies as a whole will improve by 15 to
25% annually in the foreseeable future. Computer chip (microprocessor) manufactures are
on the leading edge of these cost-performance leaps. For example, the Intel 486 chip with
1.2 million transistors and an initial speed of 20 million instructions per second (MIPS) was
introduced in 1989. By early 1991, only 2,5 years later, Intel expected to introduce its P6
chip with 5.5 million transistors and an initial speed of 250 MIPS. This new microprocessor
will lead to rapid new developments and improvements in voice recognition, video-
conferencing, multimedia, engineering workstations, and the like.
In the remainder of this section, we focus on four interrelated categories of information
technologies used to support the basic managerial functions of planning, organising, leading
and controlling. These categories are communication systems, decision support systems,
expert systems, and executive support systems.

     Communication systems
The ability to transmit and share all types of data and information has exploded with the
introduction of inexpensive and improved communication systems. These systems enhance
the ability of those in an organisation to be in touch with everyone else in the organisation –
as well as important suppliers, customers, and other external stakeholders – from any place
at any time. Communication systems include tele-conferencing, facsimile machines, local
and wide area networks, electronic mail, voice recognition systems, integrated systems and
the like.
Tele-conferencing allows people in one room (place) to participate in meetings with people in
another room (place) by means of video transmission systems and television screens.
Facsimile (fax) machines scan a sheet of paper electronically and convert the light and dark
areas to electrical signals, which are transmitted over telephone lines. At the other end, a
similar machine reverses the process and reproduces the original image.
A network is the interconnection of computers, peripherals and communication lines (signals)
that allows users to transmit data and messages. A local area network (LAN) is a system of
interconnected computers linked by cable that share data, software and storage devices in a
limited geographical area. A wide area network (WAN) often consists of linked multiple LAN
in widely spaced geographic areas (all the way across the country of even between
countries). The computers in a WAN may be linked through television or television cables,

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fibre optic cables, microwave signals, and/or satellite communications. Electronic mail (e-
mail) allows users to transmit messages (text) through network terminals or personal
computers. Voice recognition systems involve the conversion of spoken words into
electronic form for conversion by computer-based software systems into printed form.
Integrated systems are networks or information systems that were created to link the various
functions, tasks and decision-making processes in an organisation and to permit direct
information exchanges and dialogue with customers, suppliers and others outside the
organisation. Integrated systems make horizontal communication and coordination within
network organisations easier and more effective, regardless of location. These integrated
systems are fostering the development of global markets for goods and services giving small
and large firms alike the opportunity to conduct business throughout the world. The following
Global insight describes Citicorp’s integrated, world-wide communication systems.

    Decision support systems
A decision support system (DSS) is a complex set of computer hardware of software that
allows end users – usually managers and professionals – to analyse, manipulate format
display and output data in different ways. Such a system aids decision-making because the
user can pull together data from different sources, view them in ways that may differ from the
original formats, and create information from them. The system allows data and information
to be printed out or to be presented in the form of charts or graphs.
A DSS enables decision-making to represent features of the environment (e.g. customer
purchasing practises) and business phenomena (e.g. changes in prices and inflation) and
quickly evaluate many alternatives and assumptions within models. Actually you may be
familiar with DSS and not even know it. If you have used an electronic spreadsheet such as
Lotus 1-2-3, Multiplan, Javelin, EXCEL or QUATTRO, you have used one form of DSS
software. These electronic spreadsheets will automatically recalculate a quantity when you
change the value of one of the variables in a formula.
The capabilities of a DSS give the decision-maker flexibility and ability to explore and
    Data collection and organisation capabilities: These capabilities allow the acquisition of
     needed data from internal and external sources. Current DSS systems often have links
     to databases and LAN’s, enabling rapid creation of a database. A database is an
     organised collection of facts, figures, documents, and the like that have been stored for
     easy, efficient access and use. The computerised card catalogue at a library is a
    “What-is” capabilities: These capabilities provide the current status of developments
     from the DSS, external database, or other internal databases.
    “What-if” capabilities: These capabilities allow the decision-maker to propose alter-
     native actions (by means of a model) and test their likely consequences.
    Goal-seeking capabilities: These capabilities suggest actions to be taken to achieve a
     goal specified by the decision-maker.
    Presentation and report generation capabilities: These capabilities allow the user to
     create various types of tables, graphs, text, pictures, art, audio and video displays.
The following diversity insight reveals the important role of DSS in tracking, assessing,
planning and controlling in human resources management. It emphasises affirmative action
compliance and decision support systems.

Study unit 3

Do you know any DSS that you can utilise in the management of a health organisation? List
them here

If I can help you identify, have you thought about Oracle Corporation Microsoft, Optimum
Management Insight systems, HR assistant?
There are so many systems available that if you need any one for a specific task, just shop
around and you will find one to suit your needs.

     Expert systems
Recall that an expert system (ES) is a computer programme based on the decision-making
processes of human experts that stores, retrieves, and manipulates data, diagnosis
problems, and makes limited decisions based on detailed information about a specific
problem. These systems have problem-solving capabilities within a specific area of
knowledge. Expert systems differ from decision support systems in that they actually
recommend or make a decision. If requested, the system can explain its path of reasoning to
the user. The expert system is an application of artificial intelligence (AI), the ability of
computers to simulate some thought processes of human beings.
Expert systems vary in complexity, both in terms of knowledge and technology. An example
of the simplest type of systems is a personal budgeting system running on a PC. The thrust
of low-level expert systems is to improve personal decision-making and thereby increase
productivity. In contrast, strategic impact expert systems involve high levels of knowledge
and technological complexity. Lincoln National’s Life Underwriting Systems is an example.
The process of underwriting and individual’s life insurance application requires complex
medical, financial and insurance knowledge. Lincoln National also requires that an
applicant’s hobbies (e.g. mountain climbing) and vocation (e.g. possibly requiring frequent
travel to politically unstable countries) be factored into policy evaluation and pricing. In many
of these areas, the information that an underwriter receives needs to be clarified and
interpreted. Lincoln National’s four best senior underwriters spent much of their time for
several years as consulting experts helping to develop this expert system.

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    Executive support system
An executive support system (ESS) is an organised network of electronic messaging
systems, multimedia presentation systems, management information systems, and/or group
decision support systems. Some people are beginning to call such a system an enterprise
support system (ESS) because these systems are being made available to lower level
managers and professionals, not just executives. The information technologies that comprise
an ESS can integrate managers and other professionals – not just top executives – into an
organisation and decision-making will flow. Users of electronic messaging systems may send
messages over the phone that can be stored, annotated with comments, and distributed to
many different people. This book’s illustrations exemplify the types of graphics that a fairly
sophisticated executive presentation system can produce. Management information systems
provide up-to-date financial, market, human resources, or other information about the status
of an organisation, its major departments or divisions, and its environment.
Finally, a group decision support system (GDSS) is a set of software, hardware and
language components that support a team of decision-makers by removing common
communication barriers, providing techniques for guiding the decision process, and
systematically directing the pattern, timing, or content of the discussion. Facilitators play a
crucial role in the use of GDSS. They allow the participants to concentrate on the issues at
hand rather than struggling to use the technology themselves.
Most executives and many managers aren’t proficient on a computer and lack keyboard
skills, which must be taken into account in designing and implementing ESS’s. A requirement
that executives must be fully computer-proficient to use executive support systems, such as
GDSS, is likely to minimise their use. Slowness in manipulating data and resulting frustration
may even lead to disinterest and lack of support. Several estimates indicate that, in 1995,
only 25% of senior executives world-wide were fully using executive support systems. Even
computer-literate users need time to become familiar with the GDSS. A typical GDSS room
might include a series of terminals or workstations linked by some form of computer-based
network, a large main screen visible to everyone and controlled by the facilitator, a
photocopying whiteboard on which to record the options as they emerge, and a three-colour
video projector or large monitor.

    Information system design
Four major interrelated issues affect information system design: (1) determine information
needs, (2) identify system constraints, (3)set goals, and (4)work through the developmental

While studying the content, make notes of the needs of the health organisation that you
manage. This will provide you with a list of opportunities to better the organisation.

    Determine information needs
The most important decision concerning the development of any form of information system
may well be determining what information actually is needed. Far too often organisations
develop information systems without an adequate understanding of their true needs or the
costs involved. Information systems development should be approached in the same way.
Many organisations have a strategic plan, either by design or by default. Managers should
ensure that any proposed information systems will fit the organisation’s overall mission and
strategy. In other words, the information system should make sense in terms of

Study unit 3
organisational plans, financial and technical resources, customers, competitors, and desired
return or investment. Questions that need to be asked include: Is the organisation planning to
change or add to its customer base or its goods and services? What are the current financial
constraints? Do competitors use such technology? What type, quality, relevance, quantity,
and timeliness of data and information do employees currently use?
Figure 3.1 illustrates the transformation of raw data into information and then into decisions.
Note that knowledge of the environment progresses from disorganised data into refined and
sharply focused information.
Information needs often vary by organisational level, department and individual employee
and according to the type of decision to be made. Decision-making activities occur at three
levels: strategic, tactical and operational. The characteristics of information most used by
employees and managers at these levels are summarised in Table 3.1: focus, scope,
aggregation level, time horizon, currency, frequency of use and type.
Note that strategic decisions often require information from external sources, such as
customers, suppliers and competitors. The information must be broad in scope, composite
(highly aggregated), future-oriented, and both qualitative and quantitative. In contrast,
information needs for operational decisions are substantially different. Operational decisions
basically require internal information (e.g. inventory levels) that is well defined, detailed,
reported daily or weekly, precise and quantitative. Tactical decisions, which are of most
concern to middle managers and professionals, represent the middle group between
strategic and operational decisions.

Figure 3.1 Evolution in information needs

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List your identified information needs.

Compare the identified needs with Table 3.1, which serves as a summary of information
requirements on decision level.

        Information         At operational level   At tactic level    At strategic level


    Focus                   Internal to external                     External to internal

    Scope                   Narrow, well defined                     Broad

    Aggregation level       Detailed                                 Composite

    Time horizon            Historical                               Future-oriented

    Currency                Recent                                   Long term

    Frequency of use        Continuous                               Periodic

    Type                    Quantitative                             Qualitative to

Table 3.1 Information requirements by decision level

Study unit 3

     Identify system constraints
After the organisation’s information needs have been identified, prospective users and
system developers must consider the constraints on the existing system. Constraints are the
limitations on the discretion available to decision-makers and may be internally or externally
imposed. External constraints vary from organisation to organisation and may include
government regulations, supplier requirements, technological progress, and customer
demands. For example, government regulations require automobile manufacturers to
produce cars with safety features such as seatbelts, exhaust systems that emit limited
amounts of certain chemicals and engines that meet fuel efficiency standards.
Internal constraints are created by the organisation itself. They also vary among organi-
sations and even among departments within an organisation. Probably the most common
internal constraint on the development of an information system is cost. Everyone usually
wants the best system possible. Unfortunately, the best available information technology may
be very costly. That is true even though the price-performance relationships for information
technologies continue to improve dramatically year-by-year. Another internal constraint is
lack of support from employees and top management. Without top management’s support, or
with only limited support, an information system is unlikely to be successful.

What are the constraints that you can identify in your context?
How will you overcome them?

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    Set goals
After the organisational information needs have been established and systems constraints
identified, the general and operational goals for the information system should be set. They
should focus on the purposes the information will serve, who will use it and how it will be
used. One goal for international executive information systems was that it had to be useful as
an investigative tool, that is, for answering “what-if” questions such as: “What would happen
if the company relied on more overtime to meet an increase in demand rather than adding
more employees?” Goals should also be established for the number and type of operating
personnel and the systems cost. Setting goals provides the direction for developing and
implementing the information system.

Set at least three goals for the implementation of an information system in your health

    Working through the developmental stages
An information system may be created in various ways. However, the basic underlying
developmental processes are generally the same. Figure 3.2 shows the four stages in the
development of information systems. The dashed arrows indicate feedback loops, illustrating
the process is never cut and dried.

Figure 3.2. Stages in information systems development (Hellriegel & Slocum,

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     Preliminary problem definition: A team of information users, with technical support
      personnel, may be given the task of determining information needs, rough cost esti-
      mates, constraints and goals.
     Conceptual design: The conceptual design stage should be primarily user-led,
      although system development experts can act as resources. During this stage, infor-
      mation generated in the preliminary problem definition stage is used to develop alter-
      native designs. They are evaluated in terms of how well they satisfy organisational
      needs and goals. More accurate cost estimates are obtained at this stage. This
      evaluation usually leads to a preliminary selection of specific system characteristics for
      further review. However, it also may lead back to the problem definition stage.
     Detailed design: During the detailed stage, performance specifications are
      established. The team selects or develops hardware and software components.
      Information systems experts are heavily involved, mapping information flows, preparing
      formation system and evaluating, testing, refining and re-evaluating it until the stated
      requirements are satisfied. Users are still involved, but their role is primarily advisory. If
      problems arise, returning to the conceptual design stage or even to a re-analysis of the
      problem definition may be necessary.
     Implementation: During the final stage, modules of the information system are
      connected and users begin testing the system. As operational problems are identified
      and corrected, one module after another is added. Eventually, the entire system is
      assembled and tested for all conceivable types of errors. Corrections continue to be
      made until the information system’s performance satisfies all the performance criteria.
      At that point the information system is ready to be phased into the organisation for full-
      time use. In sae situations, the design process may even have to begin after
      implementation. For example, a Pennsylvania bank decided to automate its branches
      with a new automatic teller computer system. Six months after installations, the system
      response time was four times longer than expected, customers waited in long lines,
      and daily processing differences were out of control. A large write-off and a new design
      were required. How could such a fiasco occur? The primary reason was too little user
      involvement from the beginning.

Your nurse manager will not develop a system, but will utilise an expert. It is, however,
important that you know the steps, as the developer will expect some input from you during
the development!

     Effective information system implementation
Each information system has unique characteristics. However, the seven factors shown in
figure 3.3 commonly influence the effective implementation building blocks. They emerge
during the initial stages of system development, continue through implementation, and then
become important to everyday operations.

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Figure 3.3 Building blocks for effective implementation of information systems
(Hellriegel & Slocum, 1996:628)
User participation during the implementation stage is crucial because those who are to apply
it can often spot problems or deficiencies before the new system becomes fully operational.
Taking part in implementation also helps users understand the reasons for the new system
and prepares them for the necessary changes in the way that tasks are performed.

    Top management support
Another key factor in the effective implementation of information systems is strong, visible
support from top management. Like many major organisational undertakings, information
technology applications must involve top managers in order to succeed. Without their
support, information technology is less likely to be integrated into the organisation. Thus
strategic information system planning involving top management is essential to foster a
positive attitude towards systems development from the beginning.

    Evaluation of time and cost
A third important factor involved in effective implementation of information systems is a
thorough evaluation of time and cost requirements. New information systems often require
more time to develop and cost more than anticipated. During the initial development stages,
predicting these requirements accurately is difficult. However, management initially should
have some idea of the cost involved in not improving the organisation’s information system.
To keep the developmental process on schedule and within budget, system designers must
project time and costs in detail. The projected schedule should include project milestones
and perhaps even a PERT network, is as common for many construction projects.
Justification of the design, installation and projected maintenance cost helps prevent cost
overruns and guides decision-making.

Study unit 3

     Phased implementation
Any significant new technology normally should be introduced in phases. A new information
system should not be turned on one day and the old system abandoned at the same time.
Too many things can and will go wrong. The new system does not work as expected, it
generates bad information, no one knows how to us it and so on. By implementing the
systems in phases, problems owing to design glitches and unforeseen events can be
managed. Software problems can be resolved before employees become too dependent on
the system. Technical support staff can train users to work with the new system before their
jobs depend on it. Gradual implementation also gives employees time to adjust, thus
minimising resistance to change.
As recently as 1985, students in Texas A&M University (and many other universities) had to
pick up computer cards for each class during registration. Because they had to go to so
many different locations around campus and wait in lines, the registration process often took
at least a full day. Then a new registration system was slowly phased in. At first data entry
personnel entered only late registrations on terminals linked to the main computer. 1987
handled the entire registration process by the information system. Students now register
through the telephone by contacting the main computer directly. They enter class sections
and fee information from a push-button telephone and respond to a computer-triggered
voice. The problems and confusions of an immediate and direct transition from computer
cards to telephone registration were avoided.

     Thorough testing
Another factor that affects the effective implementation of information systems in thorough
testing of both hardware and software. Testing should be performed on individual modules,
on sets of modules as the system is assembled, and then on the entire system before it
becomes fully operational. The testing process should anticipate probable errors and those
that aren’t likely to occur. The effects of incorrect commands, improper data, poor
environmental conditions, and other possible all should be checked. The biggest problems
with new technologies arise from events that system designers claim are not expected to
occur or could not occur – but do. Users should be intensively involved in this testing and
debugging process.

     Training and documentation
The introduction of new technologies requires training of users and adequate documentation
of operational procedures. An information system is of little value if no one knows how to use
it properly. At times, those in charge of the information system have gained power because
many others in the organisation are overly dependent on them. As a result, a power struggle
may develop between managers and other employees who formerly controlled the flow of
information and the system development staff. Organisations can avoid this sort of
interdepartmental conflict by fostering co-operation. Users don’t have to know how to
programme computers, but they should understand the capabilities and limitations of their
information system. And systems development personnel must understand the capabilities
and information needs of the users.

     System backup
The last factor, but not the least important by any means, that influences the effective
implementation of information systems is the presence of an alternative information system
for accomplishing the same task in case of system failure. Computer systems are notorious
for developing problems, especially software problems, at the wrong time. If users are too
dependant on a single information system, they may believe that the quicker the fix, the
better. A backup procedure or even access to a backup computer system will give analysts
time to track down such problems, carefully evaluate them, and properly correct them. This

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approach does not ensure a problem-free future, but it does encourage solutions that are
less likely to create additional problems.
Perhaps the most extreme example of system backup is the computer-based voting system
developed by the NASA’s space shuttle programme. Four identical computers run IBM
software. A fifth computer runs software designed by Rockwell international. If the first four
computers disagree, they decide what to do by majority vote. In the event of an even split,
the Rockwell system steps in to break the tie. Should some subtle software bug common to
all the IBM machines cause them to stop in their tracks at once, the Rockwell backup stands
ready to take over crucial functions. The use of independently designed systems is known as
dissimilar redundancy. “We’ve never had to use that backup computer to flight”, stated Ted
W Keller, IBM’s manager for the shuttle’s onboard service. He claims that statistical models
predict less than 3,6 bugs per million lines for the software. Thus the normal 500 000-line
programme should have at most 2 bugs, but nobody knows for sure.

    Ethics and information technologies
As the capabilities and persuasiveness of computer-based information technologies
increase, concern with their ethical, and unethical or criminal uses is deepening in the United
States, Canada, and other countries characterised as information societies.

    Computer ethics
Some ethics are even specialising in a sub-field known as computer ethics, or the analysis
on the nature and social impact of computer technology and the corresponding formulation
and justification of policies for its ethical use.
Why are an increasing number of individuals and organisations concerned with computer
ethics? The reason is that ethical issues surrounding computer arise from their unique
technological characteristics:
    They make mistakes that no human being would make.
    They communicate over great distances at high speed and low cost.
    They have huge capabilities to store, copy, erase, retrieve, transmit, and manipulate
     information quickly and economically.
    They have the effect of radically distancing (depersonalising) originators, users and
     subjects of programs and data from each other.
    They may collect and store data for one purpose that can easily be used for another
     and be kept for long periods of time.
The computer ethics institute, a professional association headquartered in Washington, DC
was formed because of the growing interest in this area. It has issued a “ten command-
ments” of computer ethics, which are listed in table 3.2. The commandments provide an
ethical code of conduct for guidance in situations that may not be covered by law.

Study unit 3
If employees, the media, and general population reflected on and accepted these
commandments, many would come to hold very different attitudes toward computer crime.
                1.   Thou shalt not use a computer to harm other people.
                2.   Thou shalt not interfere with other people’s computer work.
                3.   Thou shalt not snoop around in other people’s computer files.
                4.   Thou shalt not use a computer to steal.
                5.   Thou shalt not use a computer to bear false witness.
                6.   Thou shalt not copy or use proprietary software for which you have not
                7.   Thou shalt not use other people’s computer resources without
                     authorisation or proper compensation.
                8.   Thou shalt not use other people’s intellectual output.
                9.   Thou shalt not think about the social consequences of the programme
                     you are writing or the system you are designing.
                10. Thou shalt always use a computer in ways that demonstrate
                    consideration and respect for your fellow humans.

Table 3.2 Ten Commandments of computer ethics (Hellriegel & Slocum,

     Privacy issues
A wide range of privacy issues is central to computer ethics, as suggested in previous
sections. The types of information available about most individuals in the United States to
just about any business (or individual in that business) or government agency are
astounding. Most of this information originates with the individual through the process of
borrowing money, participating in a government program, or purchasing goods. Consumers
and borrowers routinely give information voluntarily to retailers and creditors so that they can
purchase goods on credit. At least once a month, millions of banks’ electronic files detailing
their customer’s purchases and payment send material to credit bureaux.

Has your right to privacy and sense of individualisation ever been violated by computer-
based information technology?
Give details.
Have you thought of the bank system, hospital admission system, registration system at
colleges/universities, etc?

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3.2.2      SUMMARY

Hellriegel & Slocum (1996:633-634) provide a clear summary of study section 3.2.

    State the far-reaching effects of information technologies on individuals and
Information technologies continue to have profound effects on the design of organisations,
the roles of managers, and the ways employees perform their jobs. The numbers of organi-
sational levels and middle managers are being reduced, top managers of organisational
levels and middle managers are being reduced, top managers are gaining more strategic
control over critical decisions, information technologies often are used as a strategic asset
necessary to compete in the market place, more knowledge workers are needed by
organisations, knowledge workers are taking on temporary managerial roles as team leader
of special projects, information float (e.g. delay) among positions and organisational levels is
being sharply cut, and real-time information networks are enabling an increasing number of
knowledge workers to perform their tasks any place at any time.

    Describe the role and value of information as a resource
Some organisations have created the role of chief information officer to provide leadership in
developing information systems as a strategic asset for use of employees. Information is a
value-added resource derived from data that have been transformed to make them useful.
Knowledge is used by individuals to create, store, share and apply information. Four
interrelated criteria may be used to assess the value of information: quality, relevance,
quantity and timeliness.

    Explain the essential capabilities of information technologies that support and
     link the basic managerial functions
Information technologies continue to become exponentially less expensive and exponentially
more powerful. By means of real-time communication networks and other computer-based
capabilities, the basic managerial functions of planning, organising, leading, and controlling
are dramatically changing, rapidly improving, and quickly becoming more closely linked. Four
categories of interrelated information technologies are the primary sources of these
capabilities: communication systems (e.g. teleconferencing, facsimile machines, local and
wide area networks, electronic mail, voice recognition systems, integrated system, and the
like) decision support systems (DSS), expert system (ES) and executive support system

    Discuss the issues involved in information system design
The creation of an information system should begin with a careful determination of
information needs. This assessment should be linked to the organisation’s market-related
goals, strategies and plans. System constraints, which are the internal and external
limitations on decision-making discretion, must be identified and assessed. The general and
operational goals for the information system should then be developed. The last task is to
specify the content of the developmental stages for the system. These stages include
preliminary problem definition (which normally reflects the information needs, system
constraints, and system goals), conceptual design, detailed design and implementation.

Study unit 3

     State the factors that facilitate the effective implementation of information
Seven interrelated building blocks contribute to effective information system implementation:
(1) user involvement, (2) top management support, (3) evaluation of time and cost, (4) phase
implementation, (5) thorough testing, (6) training and documentation, and (7) system backup.

     Identify several ethical concerns in the development and use of computer-based
      information technologies
Concerns about the unethical and criminal uses of computer-based information technologies
are deepening in the United States, Canada, and other information societies. Ethical issues
arise from the unique technological characteristics of computers. The ten commandments of
computer ethics suggest that radically different attitudes and actions are needed by many
individuals and the media toward computer crime and the unethical use of computer-based
technologies. A wide range of privacy issues also is central to computer ethics. The private
and government sectors have yet to put significant control on the current wide-open access
and use of all types of data and information about individuals.

                                                                                  Study unit 3

                    SERVICE MANAGEMENT

After completing study section 3.3 you should be able to:
    discuss the requirements for successful implementation;
    explain how you will utilise computer information in the health organisation; and
    evaluate the impact of information systems on the social and political structure of an

In the two previous study sections we have given attention to computers and information
management technologies in detail. In this study section we are applying it to Health Service
Management. The uses of computers may be very useful in the hospital organisation. We will
address the requirements for successful implementation, how we can use computer
information in the health context and then lastly we will evaluate the impact of information
systems on the organisation.

Identify uses of computers in Health Service Management.

Study unit 3

     Requirements
If you want to implement more systems, you will need to take a number of requirements into

Study Booyens, 1998, pp. 647-648. What are the aspects you will take into consideration?

                                                                             Study unit 3

    Utilisation of computer information in the hospital

Booyens, 1998, pp. 650-659 identifies several purposes that computer information can be
used for. Identify the purposes and state whether you agree/disagree with her motivation.
Can you add any purposes? Be creative!

Study unit 3

     Observed Impacts

From your own experience, what influence/impact did information technology have on your
Study Booyens, 1998, pp. 659-660 and state whether you agree with her statements on
professional and ethical dilemma.

                                                                                 Study unit 3

Can you add to the list of identified aspects?

3.3.2       SUMMARY

The computer is a valuable tool for the health service manager. The utilisation of the
computer and appropriate programmes will lighten the task of the health service manager
and she/he will be able to manage more effectively, as management data/reports will be
readily available. It is important that the health service manager understands the effects of
computer information on people, organisation culture and management.

Study unit 3

As information technology might be a relatively new concept to registered nurses, a full
glossary of commonly used computer terms are given from Swansburg (1996:579-520). By
keeping this to hand, you will be able to understand “computer terminology”. You don’t need
to know all the definitions. It is given as a reference to you.
Abend:                      Abnormal end of task.
Algorithm:                  A prescribed set of rules for the solution of a problem in a finite
                            number of steps.
Artificial intelligence:    The capability of a machine that can proceed or perform
                            functions that are normally concerned with human intelligence,
                            such as learning, adapting, reasoning, self-connecting, automa-
                            tic improvement.
Authoring:                  A structured approach to combining all the media elements in
                            an interactive production.
Authoring system:           Software which integrates the multimedia components of an
                            interactive production. To include the computer, CD-ROM,
                            sound, etc.
Bar code reader:            An optical scanning unit that can read documents encoded in a
                            special bar code. A laser scanner.
Batch processing:           A systems approach to processing where similar input items are
                            grouped for processing during the same machine run.
Binary:                     (1) The number of systems based on the number 2, and (2)
                            pertaining to a choice or condition where there are two
Bit:                        The smallest unit of data, a binary digit of 0 – 1
Buffer:                     Intermediate storage, used in input/output operations to
                            temporarily hold information.
Bug:                        A mistake or error in a computer programme.
Byte:                       A set of eight adjoining bits thought of as a unit.
Cache:                      A storage buffer that contains frequently accessed instruction
                            and data.
Central processing unit (CPU): The part of the computer that contains the circuit that
                           calculate and perform logic decisions based on a set of
Character:                  A letter, digit, or other symbol that is used in magnetic optical
                            recording and lasers.
Compact disk (CD):          A type of disk storage that uses magnetic optical recording and
CRT (cathode ray tube):     Cathode ray terminal. A display terminal used as an
                            input/output station.
Data:                       Representation of information in a form suitable for processing.
Database:                   A collection of files or tables.

                                                                                  Study unit 3
Disk:                      A round, flat, data medium that is rotated in order to read or
                           write data.
DOS:                       Disk operating system.
Downtime:                  The elapsed time when a computer is not available for use, may
                           be scheduled for maintenance or unscheduled because of
                           machine or programme problems.
Expert systems:            Systems that rely on large amounts of information to provide
                           assistance in decision-making.
Field:                     A unit of information within a record.
File:                      A collection of related date with a given structure.
Forecasting:               Describing the possible future, anticipating the impact of pre-
                           sent decisions of actions of future activities of nursing. Fore-
                           casting uses simple techniques, such as graphs and hand
                           calculators, and complicated mathematical models that can be
                           developed using desktop computer software packages.
GUI (graphical user interface): Graphic software which allows you to interact with and
                            perform operations on a computer.
Hard copy:                 Printed computer output: reports, listings and documents.
Hardware:                  The physical computer equipment.
Hospital information systems (HIS):     A system designed to facilitate the day-to-day
                          needs of a hospital, a system that stores and manipulates
                          information for inter-hospital communication and decision
Input/Output (I/O):        The transfer of data between an external source and internal
Interface:                 The point at which independent systems or computers interact.
Key field:                 A field within a record that makes that record unique with
                           respect to other records in a file.
Kilobyte (KB):             1, 024 bytes or characters
Laser scanner:             A type of device that utilises a laser to recognise a received
Local data network (LAN): Two or more computers connected for local resource sharing.
Mainframe computer:        A large computer capable of being used and interacted with by
                           hundreds of users seemingly simultaneously.
Management information system (MIS): A system designed to manipulate information to
                        assist in management decision-making.
Megabyte (MB):             Approximately 1 000 000 bytes.
Microcomputer:             A small computer built around a microprocessor.
Modelling:                 Development of mathematical equations that can be used to fit
                           and balance relationships between or among variables. Fore-
                           casting uses models. Managers decide which variables to
                           include to form the model. In management there are budget
                           models, inventory models, production process models, cash-
                           flow models, models for work-force planning, models for

Study unit 3
                          distribution systems, linear programming resource allocation
                          model and many others.
Modem:                    A device that converts digital data from a computer to an analog
                          signal that can be transmitted on a telecommunications line and
                          that converts received analog transmissions to digital data.
Multimedia:               The combination of different elements of media, such as text,
                          graphics, audio, video, animation, and sound.
Multitasking:             A mode of operation that provides for concurrent performance
                          of two or more tasks.
Number crunching:         A process of taking numbers and performing mathematical
                          functions on them.
Nursing management information system (NMIS):       A type of information system
                        geared towards assisting nurse managers in performing their
                        management functions.
On-line processing:       A form of input processing where information is input and
                          updated at that time.
Operating system:         An organised collection of techniques and procedures
                          combined into programmes that direct a computer’s operation.
Optical disk:             Same as compact disk.
Printer:                  A terminal or peripheral that procedures hard copy or printed
Programme:                A set of computer instructions directing the computer to perform
                          some operations.
Random access:            A storage technique whereby a record can be addressed and
                          accessed directly at its location in the file.
Record:                   A group of related fields of information treated as a unit.
Robotics:                 Machines that work automatically and perform physical
Scenario projection:      Use of a scenario, or set of planning assumptions, to describe
                          and plan for the possible future state of the environment at a
                          point in time and considering the economic, political, social,
                          technological and natural effects. Scenario projections use
                          trends and trend analysis.
Sequential access:        A storage technique whereby a record can be addressed and
                          accessed only after all those before it have been.
Software:                 A programme of set of programmes written to tell the computer
                          how to do something.
Spreadsheets:             A specialised type of software for manipulation of numbers.
Table:                    A collection of related data with a given structure.
Trend:                    Systematic pattern of change (increase or decrease) over time
                          based on history or a particular theory. Example: an increase in
                          the acuity level of patients over a one-year period.
Trends extrapolation forecasting: Describing the possible future by projecting the
                         systematic pattern of change (increase or decrease) using the
                         prevailing tendencies of a time series.

                                                                                     Study unit 3
Trend impact analysis:      Analysis of the impact or consequences of the pattern change
                            (increase or decrease) over time. Example: How will the
                            increased acuity level of patients over a one-year period affect
                            operational costs, use of resources, cash flow, etc.
Trend line:                 A straight line fitted to a graph plotting trends in a time series. It
                            shows the pattern of change (increase or decrease).
User-friendly (software):   Easier to use because of menus and help facilities.
Voice communication:        Interaction with a computer by voice recognition.
Word processing:            The manipulation of words within documents by a computer.
Word processor:             A specialised type of software for manipulation of printed


After you have completed this study unit, you should be able to answer the
1.   Why are computer-based information technologies reducing the number of
     management levels in organisations?
2.   Why is information increasingly viewed as a strategic asset and a value-added
3.   Compare communication systems and expert systems.
4.   Why are the information needs of top managers different from those of first-line
5.   What types of resistance to information technologies may workers exhibit? How can
     employees best be introduced to, oriented to, and encouraged to be participatory in
     these new information technologies?
6.   How can new technologies such as interactive media contribute to today’s health

Study unit 3

Computer ethics survey
Twenty statements appear in this survey. You should evaluate each statement in terms of
the following five-point scale:
1:    True
2:    Somewhat true
3:    Neither true or false
4:    Somewhat false
5:    False
If you think a statement is true, record a “1” next to it. If you think a statement is neither true
nor false, place a “3” next to it, and so on. Do not skip any statements.
             1.    The courts have provided clear guidance on who should have access to
                   electronic mail at work.
             2.    Employees are usually informed by employers if their voice mail is going to
                   be monitored.
             3.    Medical records are not available to employees.

             4.    Most organisations have clear written policies and procedures regarding the
                   use of electronic mail.
             5.    The confidentiality of faxes is generally well maintained.

             6.    Nothing inherent in computer technology raises unique ethical questions.

             7.    Public perceptions of computer and computer professionals generally have
                   been good.
             8.    Computer professionals have a level of influence that is matched by
                   equivalent level of organisational controls and professional associated
             9.    The best way to deter unethical behaviour in the use of computers is
                   through legal deterrents and remedies.
             10.   The best way to deter unethical behaviour is the use of computers is
                   through professional codes of conduct.
             11.   The majority of computer science graduates have had at least one module
                   in computer ethics by the time they graduate.
             12.   There are many controls over what information is kept on private citizens,
                   who keeps it and who can access it.
             13.   The majority of businesses in the United States have well-documented
                   policies regarding what employee information is kept in personnel
                   databases and who has access to it.
             14.   Computerised medical records pose no greater danger to privacy and
                   potential for misuse than do paper records.
             15.   Electronic bulletin boards are fairly well “policed” and do not certain
                   potentially harmful information.
             16.   The majority of computer crimes are reported, and the perpetrators are
                   successfully prosecuted.

                                                                              Study unit 3
          17.   Computer abuse, such as gaining unauthorised access to system or placing
                a virus or other potentially damaging programme into a computer, is not a
                minor problem.
          18.   Software theft, including unauthorised copying of software, is clearly a
                problem, but monetary losses are not yet significant.
          19.   Although the failures of computer systems have been reported in the media,
                none have resulted in serious injury or significant property loss.
          20.   Because computer ethics is a relatively new application of older ethical
                concepts to new technology, there is little understanding about what can
                and should be done.

Scoring: Sum the point values for statements 1 – 20. The total points may range from 100 –
20. Most experts on computer ethics would consider the perfect score as 100, that is, all
statements are considered to be false.

Study unit 3


    Study the content in the relevant study units in your prescribed study material;
    Comply with the rules indicated in “Quoting Sources” and “Report Writing”. If you omit
     to use these booklets, you will be penalised with a maximum of 10% of the
     assignment mark per booklet!
    Do not copy the study guide or prescribed study material – PLAGIARISM IS A
    Please keep to the deadline.
    Mark allocation: ½ mark per correct, relevant fact, statement and/or motivation in full
    Length: Max 5 typed pages.


QUESTION 1                                                                               50
You as the Nursing Service Manager has received numerous complaints of poor nursing
care. After your investigation you found the following; EN’s are giving medication while the
RN’s are making the patients’ beds and the AN’s are sitting at the nurses’ station writing the
patients’ report. One of the nurses reported that vital signs were being recorded without
being done.
Solve this problem by describing a quality improved program that you would implement.
Make use of applicable examples.

                                                                               TOTAL: 50


QUESTION 1                                                                              50
Because of the shortage of nurses you as the Nursing Service Manager together with your
committee decided to change the working hours of the nursing staff to make better use of the
human resources available to you.
   a) The steps in the change process
   b) The strategies that effect change and;
   c) Describe how you will handle resistance to change

Make this applicable to your working environment by using relevant examples.
                                                                               TOTAL: 50

QUESTION 1                                                                               50
Health Service Managers must work with educators to face the challenge of developing
effective and efficient training programmes for staff who may be working with a variety of
computers and information systems (Klopper, 2004).
Discuss how you will manage the Health Service Manager’s concerns, barriers to
computerisation and the ethical, legal and security issues in your workplace with regards to
computerisation and information systems. Use applicable examples.

                                                                               TOTAL: 50


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