1. Health Care & Informatics Review Online
1 September 2006 - HINZ 2006 - Primary Care and Beyond: Building the e-Bridge to Integrated Care
Leadership in Times of Crisis During Change Due to Health IT Projects
AUTHOR(s): Karen Day
School of Population Health
University of Auckland
Auckland
New Zealand
Tony Norris
Institute of Information and Mathematical Sciences
Massey University
Auckland
New Zealand
Abstract
Introduction
The complexity of integrating health
Leading health IT projects in a complex environment
The Project
Leadership in Difficult Times
The Leadership Mix
Leadership and the Capability Crisis
The Leadership Crucible
Conclusion
Acknowledgements
References
Abstract
Leadership is an essential component of IT projects. The drive towards integrated health care, capitalising on an integrated electronic health record,
means that new approaches are needed for effective leadership of IT projects in complex health systems. A shared-services organisation merged the
Information Services departments of two District Health Boards and, by means of a large and complex project, established a single IT infrastructure. This
formed the platform for a research project reported in this paper on how people adapt to change brought about by health IT projects. People working in
the new IT area adapted to the changes but experienced a Capability Crisis grounded in their commitment and competencies associated with the project.
As part of that Crisis they sought leadership, which is important in difficult times. A new phenomenon, the Leadership Crucible, was identified and
described. New forms of collective leadership appeared to emerge: how we tackle the challenges of leadership within the drive for integrated health
care influences the success of IT integration projects.
Introduction
Electronic information is firmly ensconced in health service delivery, but in a way that reflects the traditional fragmentation of health services.[1] The
drive towards integrated health care demands that electronic opportunities for integration are created.[2,3] While the technological challenges of
integrated care are readily discussed and openly researched, the social and organisational implications appear to be more difficult to define and address.
Project managers therefore need to pay more attention to the people aspect of information technology (IT) projects than to the associated processes and
technology.[4] Health IT projects have a poor track record of success[5] and yet we must continue to implement technology to support the growing
demand for e-health, particularly since the advent of the integrated electronic health record (EHR), which straddles many services that are traditionally
not connected as services. These projects usually bring about significant change in technology, processes and for the people who must then use the new
technology on a day-to-day basis.[4] Integrating health care by means of an integrated EHR may result in unprecedented change in the health care
delivery system. This paper discusses the implications of leadership in IT projects, drawing on research from an IT infrastructure alignment project when
two Auckland DHBs formed a shared services9organisation.
The complexity of integrating health
Health care is a complex adaptive system in which we adjust to different stimuli, such as the demand for integration, in non-linear and often
unpredictable ways.[6,7] When something affects the system, unexpected consequences can arise out of responses to the predicted changes. Over time,
a system’s components interact with one another in a manner that ranges from simple to complex, as reflected in figure 1. Complexity falls along a
continuum, where we move comfortably when things are reasonably simple and mostly known, in the area of perceived low complexity. For the most
part, we are stimulated by forays to the other end of the continuum – the Zone of Complexity – where we are confronted by complexity that is unknown
and unpredictable. Although change occurs in patterns it is hard to predict them: it is also hard to replicate them in the same system and under the same
conditions.[7,8] In some instances, a small perturbance could result in a large change in the system,[8] eg, limiting the idle time of a computer to seven
minutes before closing to secure access seems like a small change but can disrupt an entire outpatients’ clinic. When implementing the EHR across
services, we need to bear in mind the compounding complexity when more than one complex system, which adapts in its own way to changes, begins
new relationships with other complex systems and they all generally fall within the same “health system” of a nation. New leadership challenges arise,
especially when systems are pushed into the chaotic state (or too much complexity) on the other side of the Zone of Complexity from their comfort zone.
[9,10] It is at this point that new organisations or groups of affiliated people become self-organised and could potentially break away from the existing
system in the absence of effective leadership from within it.[10] How leaders rise to the challenges of health IT projects determines how their followers
adapt to the resulting changes.

2. Figure 1: Change in a complex environment (based on Tan[7] and Dooley[10])
Leading health IT projects in a complex environment
In most situations, leadership can be broadly defined as the capacity to influence others to achieve a shared goal.[11-13] Generally speaking, this means
that: leaders have a vision that they communicate to others; that these others are their followers; that the situation in which they are leading is usually
complex; and that the leaders have certain attributes, styles, competencies and attitudes that predispose them to be leaders in a situation rather than
followers. Several types of organisational leadership have been identified over the last century but no specific style has been linked to project success.
[13] Some literature recommends that different styles are appropriate: during different phases of a project; where different cultures and multiple teams
are involved; and in different types of project.[4,13] The predominant leadership theories of the last century include theories of trait, behaviour,
contingency, charisma, emotional intelligence and competence.[13] The competence approach appears to embrace all the other theories, and lays
emphasis on the competences, attributes, attitudes and intellect required of leaders. Managerial competence is blended into the leadership profile as
part of the leadership competence of that person. According to Dulewitz and Higgs (cited in [13]) managerial competence accounts for 16 percent of
overall leadership competence.
The project manager’s competence is usually the first to be considered in terms of a project’s success. [4] Most research points to the project manager’s
management competencies as a key success factor, rather than their leadership capabilities.[13] Others state that a combination of project management
and leadership competencies are key.[4,14] It is the project manager’s responsibility to develop the project team’s effectiveness and take the project
through its process, tracking and controlling the project. All this in addition to providing an environment in which the team can function well, disparate
groups affected by the project can converge when necessary, and people are committed to and involved in an ultimately successful outcome.[4]
However, there are others who influence a project’s success and the forms of leadership they traditionally include are governance by means of steering
groups, leadership by sponsorship and the use of champions in the workplace to facilitate project success.[15] Other leaders who could influence projects
are the stakeholders, such as the managers of the various groups who are affected by the project’s process and outcomes, and their associated leaders,
such as a situation where the IT department of a district health board (DHB) introduces clinical software into a hospital and the clinical managers,
directors, CEO of the DHB and other leaders play a leadership role in the project process and outcome.
Leadership is usually one of the necessary components of organisational change, particularly change linked to IT projects.[4] When people adapt to
change we usually follow a process similar to that of grieving.[16] Applying those stages to change that results from the introduction of new IT, those of
us involved start off convinced that the new project is a good idea and a well-founded decision but it is not long before we find that our commitment to
the project begins to waver as we realise the losses we are about to experience (lost comfort zone, lost processes and, possibly, lost status or job as we
know it). While we adapt to the changes or the perceived losses our productivity is reduced while we grapple with the new processes, technology and
relationships.[5] Finally, we assimilate the new aspects of our work environment and become comfortable again because we can view our own job in
more simple and certain ways. Change management and leadership in this situation would involve assisting the people affected to adapt to the changes
that must be confronted, in this instance, as a result of the new IT project.[17] According to Kotter[18] there are eight steps of change leadership (see
Table 1). Aspects of the research project reported in this paper (refer next section) are matched up with these steps to show how they can be applied.
However, according to Kanter,[19] organisational change is multifarious, occurring on multiple levels, to multiple degrees and in multiple contexts, ie,
organisational change is complex. The kind of leadership needed in this type of environment relies on concepts (ability to imagine innovation),
professional competence and connections (capacity to collaborate).

3. Table 1: Summary of application of Kotter’s eight steps of change leadership[18]
The project used for this research was a multi-stage implementation of key elements of a unifying technological infrastructure during the establishment
of a shared-services organisation for two District health Boards (DHBs) in Auckland, New Zealand. The next section describes the project components and
its impact on people working in the two DHBs and the new shared-services organisation.
The Project
This paper looks at the changes brought about by the inclusion in a shared-services organisation of the Information Services (IS) departments of two
Auckland DHBs in New Zealand. Shared-services organisations are described as an internal form of outsourcing common support services between two or
more similar organisations, such as DHBs. [20] The total cost of each participant organisation’s ownership of these services is reduced, and also becomes
transparent, and the resulting savings can be returned to the core business budget, which is clinical care in the case of a DHB. The IS departments of the
two Auckland DHBs were merged in November 2003.
The first major change associated with this move was a new project to develop a shared IT infrastructure. The project took a year to implement,
affected the desktops of over 7,400 personnel throughout the two DHBs in general, and impacted directly on the roles and processes of all the IT
personnel in particular. The infrastructure and related processes were standardised and, where possible, automated. At the same time, attempts to
standardise processes across the two DHBs were encouraged. The change that the IS personnel experienced was, therefore, not limited to the project –
the composition of their environment was changing while they were adapting to the change brought about by the infrastructure project itself. The
project milestones are illustrated in figure 2, where one can see that each milestone was dependent on the one before it, while the whole project
radically changed the way in which the IS personnel worked and the technology they used. The primary impact on the wider DHB personnel was
standardisation of hardware, general background software and some administrative process changes.

4. The resulting establishment of a single IT infrastructure formed the platform for a research project on how people adapt to change brought about by
health IT projects. The output of this project is reported in this paper.
Action research was the preferred methodology for the research based on the DHB shared-services project because of its practical nature.[21] Action
research is a form of participant research in which the research contributes to practice and theory concurrently.[21,22] The researcher (Day) was also an
employee of the new shared services organisation, already had a working relationship in one of the DHBs and was the change manager for the
infrastructure project. The action research cycle of plan, act, reflect on outcomes and modify the plan according to learning that has occurred[22,23]
corresponded with the project’s execution plan, while concurrently each milestone was deemed an action research cycle in itself. At each milestone,
time was set aside for members of the project team to reflect on that milestone and to modify the plan for the next one. The researcher also used
workshops, a reflection diary, emails to self, communication about the project and discussions with project team members, managers, project manager
and other staff belonging to the IS department to generate other data. Towards the end of the project, the researcher examined the data for themes
which subsequently formed the basis for interviews with IS personnel, mostly people who worked on the project team and the managers of the new
department. The interviews were undertaken in order to explore an aspect of the change process that had emerged in the themes analysis. The data
were analysed using a general inductive approach[24] to identify themes. A more detailed analysis will be the subject of future publications. The
preliminary findings are discussed below.
Leadership in Difficult Times
What emerged from the research was a description of a Capability Crisis[25] that occurred for most participants in the project. Typically, this crisis arises
after commitment to the project and at a time when the impact of the project’s goals is perceived to make a difference to an individual’s daily working
activities. People felt their workload increase, while resources for getting through all the work diminished. Too much was happening too soon. Although
communication was considered to be crucial, people found it hard to take in information and use it appropriately. Everything seemed uncertain and
ambiguous. This crisis embodied a fundamental and9frightening moment for most people at a time when they sought leadership and found it either
lacking, inappropriate or not where they expected to find it. Leadership was important for them to survive the project; they wanted their leaders to be
everything for everyone but the leaders could not be expected to fulfil this wish.
The Leadership Mix
In this project there was a range of sources of leadership. Within the IS department, there were those whose leadership role was mandated by the
position they held as manager. There were leaders in executive positions who were indirectly involved in the project because of their executive role in
the DHBs and the shared-services organisation. There were also unmandated or informal leaders whose leadership emerged as a form of contingency
leadership.
There were novice and mature leaders. There were formal leaders whose role positioned them as logically appropriate leaders. There were tangential
leaders who appeared to be mandated as leaders but had not aligned themselves to the project and appeared to be following a different vision. At one
extreme some of the leaders appeared to be in direct conflict with one another, while other leaders seemed to work as a well-oiled machine that
delivered the type of leadership their followers sought. There were also those who were in leadership roles but did not appear to lead at all.
Interestingly, although the people involved described the kind of leadership that they ideally would have liked to see, they appeared to select leaders
with whom they simply resonated, regardless of those leaders’ support or lack of support for the project. They expressed their expectations in terms of
leadership qualities they did not want to see in their leaders. Those involved appeared to feel that the project and departmental managers were the key
leadership figures. Yet they had several complaints about the perceived tone of the leadership that was provided, such as:
People were actually going to get it working and it was a sledgehammer approach. You don’t need to add more stress. It would have been a fun
environment to work in and change but you don’t need the Hitler approach saying, “we want this, this is going to happen, we don’t care”. I

5. understand why they wanted to say that because basically they didn’t want those things to be slid under the table.
On the contrary, others saw the same people as being more than adequate in their leadership roles. One person described three sorts of leadership –
overall project leadership, technical leadership and “. . . another form of leadership where . . . people were going out talking to people getting the word
out there, this is coming and all sort of things and people were aware of it”.
Different people saw different leadership from the same leaders. There were two instances where some people saw a leader as being capable and
successful, while others saw the same person as fundamentally unable to provide leadership for the project. In addition, people did not see the
leadership they felt should be happening:
Management tell us they are telling us everything but we know that isn’t the truth. We don’t trust them any more. We feel that they were
betraying their staff. We feel abandoned by them.
Despite this discontent, people chose to follow leaders with whom they resonated. Unfortunately, some of those leaders were either too distanced from
the project because they had no formal link to it, or they were tangential to the project in that they should have been involved but had a different
agenda.
I’m talking in terms of “the man has a vision and the man can express his vision”. He really was a man of the world. You want to be in that world
and work in that world. He’s a visionary. Not unrealistic. But a vision. I want to go there.
There were occasions when people were promoted into leadership positions, or hoped to be promoted, as a result of the project. Those promoted in this
way were therefore new to leadership and were in the difficult position of having to learn about leadership on the job while providing it under difficult
circumstances in a project with tight deadlines, critical dependencies and a group of people who were critical of the leadership they received. One such
novice leader described his opportunity to lead as follows:
And it was good, I really enjoyed it, I picked up things, hey, how to manipulate people, “I know we’ve got no people, but you’re the man,” you
know, just get him to actually do stuff that he hates doing but, yeah, and he does it with a smile on his face.
Leadership and the Capability Crisis
The times when leadership was most needed and could contribute most to the advancement of the project were during the Capability Crisis. Yet, this
was a time when the leaders themselves were grappling with their own situation, complex as it was, with their own Capability Crisis in some instances. In
addition, some leaders were unclear about their own role in the project or exhibited a leadership style that put their followers off. There were some who
were grappling with a promotion while other informal leaders were struggling with difficult situations where they were sandwiched between two
opposing and conflicting teams but had to rise to the occasion by providing leadership and ensuring project success from multiple teams on multiple
sites. It appears that in real life situations people do not necessarily provide leadership according to theoretical frameworks in the form of espoused
theory as described by Argyris.[26]
The Leadership Crucible
It is possible in a complex system, such as the one in which this project occurred, that a project can take people beyond the far side of the Zone of
Complexity from their normal or resting position of limited complexity as demonstrated by the arrow in figure 1. It is on the far cusp of the Zone of
Complexity, just before we enter a destructive chaotic environment, that mature leaders appear to thrive. It is the leaders who wrote the business plans
for this project and the stakeholders (also leaders) who approved it, knowing that this project would stretch most of the people who were involved in it
However, not every leader associated with the project supported it. If the leaders associated with the project were not of the same mind about it and
their roles within it; and their leadership competencies were not similar or compatible; and the time when their leadership was most needed was during
a Capability Crisis on the cusp of the Zone of Complexity; then one could say that a Leadership Crucible exists on that cusp.
This Crucible, as in the smelting metaphor being used here, is a melting pot of all leadership components associated with a project. Leaders of all types,
styles, capabilities and maturity meet in the Crucible, complete with their different agendas and followers. Those who are tangential or opposing leaders
also have followers, whom other leaders may or may not be able to influence. It is in this Crucible that Kanter’s leadership competencies and capacity to
collaborate[19] melt, mingle and renew themselves, emerging with new qualities, new agendas and new alliances. Sometimes, as in the research project
reported on here, some of the leaders conflict with and attempt to destroy other leaders, while yet other leaders form alliances and develop new talent
similar to the emerging networked organisation.[13] It is possible, if the Crucible is recognised in time, that all the leaders may form a collaborative
network of leadership in the interests of the project’s success. A lack of such recognition may have dire consequences for followers and for one novice
leader it was crucial for her ability to handle a difficult situation:
For a while there I felt very unsupported. (The project manager) was over at North Shore and (my boss) was on leave in January and
when he came back he was trying to get himself up to date and I felt very very unsupported. That was quite a dark time for me. I don’t
think we could’ve done it differently but I don’t think he (my boss) had a real understanding of what I was dealing with.
IT projects in general are known to fail with up to 80 percent reported worldwide as failures.[5,28] A new form of networked leadership can emerge
where followers have a group of leaders available to them who are committed to some or all of the project’s success. However, one cannot assume that
all the leaders who find themselves in the Crucible of Leadership will emerge unscathed. They may have a head-on collision with one another, as
occurred between two leaders in the project, both in the end finding that they were outside the realm of real influence within the project. Or they may
simply opt out as described thus:
If you approach (that manager) with a problem he is quick to say it’s not his or his team’s problem. He doesn’t take ownership.
It is in the intense periods of change during project implementations that demands on leaders escalate and their skills are tested, developed and refined.

6. Conclusion
It appears that IT projects, by introducing large scale change on multiple levels, result in people feeling as though they have been thrust into the chaotic
space in a complex environment. It is our leaders, not a single leader in the workplace, but a group of leaders, who usually take us out of our comfort
zone in the less complex world of the familiar and simple when they make decisions to implement such projects. They use these projects to shift us
through the normally stimulating Zone of Complexity, over the cusp and give us a taste of chaos where very little is predictable, comfortable or
knowable. The project under consideration in this research project did just that by implementing radical changes to technology, processes and roles. It is
the role of our leaders assist us in mastering all these changes so that we convert the new into what we perceive to be of low complexity and therefore
comfortable and known. As we master the project that has taken us to this cusp, our leaders meet, conflict, form alliances and agree (or not) to
collaborate during their time in the Crucible of Leadership. What emerges from that Crucible may or may not assist us in mastering the project and its
associated new skills and competencies so that we can pull back into the comfort zone of the known, familiar and seemingly simple world of everyday
living.
If a network of collaborating leaders emerges with a collective vision that converges on project success we are able to maximise our followership in the
interests of project success. If not, the Crucible will hold up the weak, the tangential and the opposing leaders in silhouette to the project, where those
working on the project become divided according to the leader/s they choose to follow. The Crucible brings out the best and the worst in our leadership
capabilities and people’s responses to us as leaders. It appears that contrasts and conflicts in the mix of leadership capabilities are heightened during the
early phase of a project as our leaders adapt to one another and the demands of the project. If these differences and varying levels of commitment to
the project are resolved early on, that is, in the Leadership Crucible, then the project has a fighting chance of success and followers are able to say:
(My boss) was confident. You knew no matter what, you were gonna get it done with him. He doesn’t show he’s stressing out. He answers
your questions . . . gives you advice where to go to solve your problem. He was an inspiration. His phone was red hot with all the calls
coming in. I saw what he was coping with and he was still sitting there! So many calls coming in. He was still able to have a good laugh.
The people around him were fine because of all that.
Acknowledgements
The authors would like to thank the Information Services of HealthAlliance, Waitemata DHB and Counties Manukau DHB for supporting this research.
References
1. Orr M. Evolution of New Zealand's health knowledge management system. Br J J Healthc Comput Inf Manag 2004;21(10):28–30.
2. Health Information Steering Committee (NZ). Health information strategy for New Zealand. Wellington: New Zealand Ministry of Health; 2005.
3. Department of Health. Better information, better choices, better health: putting information at the centre of health (two screens). 2004.
Available from: http://www.dh.govt.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance Accessed 12 April 2006
4. Thamhain HJ. Leading technology-based project teams. Eng Manag J 2004;16(2):35–42.
5. Heeks R, Mundy D, Salazar A. Why health care information systems succeed or fail. Information systems for public sector management. Working
paper series 9. Manchester: Institute for Development Policy Management; 1999.
6. Wilson T, Holt T, Greenhalgh T. Complexity and clinical care. Br Med J 22 September 2001;323:285–8.
7. Tan J, Wen HJ, Awad N. Health care and services delivery systems as complex adaptive systems. Examining chaos theory in action.
Communications of the ACM 2005;48(5):37–44.
8. Glieck J. Chaos: making a new science. New York: Penguin Books; 1987.
9. Plesk PE, Wilson T. Complexity science: complexity, leadership, and management in healthcare organisations. Br Med J 2001;323:746–9.
10. Dooley K. A complex adaptive systems model of organization change. Nonlinear Dynamics Psychol Life Sci 1997;1(1).
11. Kouzes JM, Posner BZ. The credibility factor: what followers expect from the leaders. Bus Credit 1990;92(5):24–8.
12. Levy L. The call for leadership. Bus Rev 2004;6(1):2–8.
13. Turner JR, Muller R. The project manager's leadership style as a success factor on projects: a literature review. Proj Manag J 2005;36(2):49–61.
14. Ruuska I, Vartiainen M. Critical project competences – a case study. J Workplace Learn 2003;15(7/8):307–12.
15. Munro MC. What boards don't do – but must do – about information technology. Ivey Bus J 2004;69(1):1–4.
16. Elrod II PD, Tippett DD. The quot;death valleyquot; of change. J Organ Change Manag 2002;15(3):273–91.
17. Caldwell R. Change leaders and change managers: different or complementary? Leadersh Organ Develop J 2003;24(5):285–93.
18. Kotter JP. Leading change. Boston: Harvard Business School Press; 1996.
19. Moss Kanter R. Leaders with passion, conviction and confidence can use several techniques to take change or change rather than react to it. Ivey
Bus J 2000;64(5):32–8.
20. Dibbern J, Goles T, Hirshheim R, Jayatilaka B. Information systems outsourcing: a survey and analysis of the literature. The DATA BASE for Adv in
Inform Syst 2004;35(4):6–102.
21. Brydon-Miller M, Greenwood D, Maguire P. Why action research? Action Res 2003;1(1):9–28.
22. Waterman H, Tillen D, Dickson R, de Koning K. Action research: a systematic review and guidance for assessment. Norwich: Queen's Printer and
Controller of HMSO 2001; 2001.
23. Maynard MR. Action research in information management decision-making and implementation on the run. 1995 [cited September 2003].
Available from: www.online.anu.edu.au/CNASI/pubs/OnDisc95/docs/ONL45.html. Accessed 12 April 2006
24. Thomas DR. A general inductive approach for qualitative data analysis (11 screens). 2003. Available from:
http://wwwhealthaucklandacnz/hrmas/resources/Inductive2003pdf. Accessed 14 March 2006.
25. Day K, Norris AC. Supporting information technology across health boards in New Zealand: themes emerging from the development of a shared
services organization. Health Informatics J 2006;12(1):13–25.
26. Argyris C. Leadership, learning and changing the status quo. Organ Dyn 1976;4(3):29–43.
27. Southon G, Perkins R, Galler K. Networks: a key to the future of health services. J Aust Healthc Assoc. 2005;29(3):317–26.
28. Shore B. Failure rates in global IS projects and the leadership challenge. J Global Inform Manag 2005;8(3):1–5.