EMPIRICAL RESEARCHUnderstanding champion behaviour in a he

EMPIRICAL RESEARCH
Understanding champion behaviour in a health-
care information system development project –
how multiple champions and champion
behaviours build a coherent whole
Joeri van Laere1 and Lena
Aggestam2
1School of informatics, University of Skövde,
Skövde, Sweden; 2School of Business, University of
Skövde, Skövde, Sweden
Correspondence: Joeri van Laere, School of
informatics, University of Skövde, P.O.
Box 408, SE-54128 Skövde, Sweden.
Tel: +46-70-5594895;
Fax: +46-500-448849;
E-mail: [email protected]
Received: 18 April 2013
Revised: 14 May 2014
2nd Revision: 10 December 2014
Accepted: 09 February 2015
Abstract
Champions are commonly suggested as a means of promoting
the adoption of
information systems. Since there are many different definitions
of the concepts
of champion and champion behaviour in the literature,
practitioners and

researchers may be confused about how to exactly use these
concepts.
A qualitative analysis of a single case study in a Swedish
health-care organisation
enabled us to explain how different champion behaviours relate
to each other
and how multiple champions interact. Combining our rich case
observations
with an analysis of champion literature reveals how champion
behaviours form a
coherent and meaningful whole in which networks of different
types of
champions at different levels in an organisation utilise their
network of relations,
their knowledge of the organisation and their insight into
strategic decision-
making politics to time and orchestrate the framing of
innovations and the
involvement of the right people. In conclusion, championing is
a complex
performance of contextually dependent collective social
interaction, varying
over time, rather than a heroic act of one individual promoting
an idea. Future
studies need to focus more on how the relations between
different champions
and their behaviours develop across innovations and over time,
in order to
develop a richer understanding of championing.
European Journal of Information Systems (2016) 25(1), 47–63.
doi:10.1057/ejis.2015.5; published online 28 April 2015
Keywords: champions; champion behaviours; information
system development; organisa-
tional change; health-care informatics

Introduction
Since 1963, studies of both product and process innovations
have identified
and confirmed the role of influential individuals associated with
the success
of a technological innovation, so-called champions of
innovation (Schön,
1963; Chakrabarti, 1974; Maidique, 1980; Howell & Higgins,
1990). Several
studies have specifically focused on the adoption of Information
Systems
(IS) as a type of innovation (Curley & Gremillion, 1983; Howell
& Higgins,
1990; Beath, 1991; Heng et al, 1999), confirming that lessons
learned from
champion literature in general also hold for champions
influencing IS
adoption. Even in health-care, the context of our case study, it
has been
shown how champions contribute to a change of work practices
(Soo et al,
2009) or IS adoption (Malik & Khan, 2009).
European Journal of Information Systems (2016) 25, 47–63
© 2016 Operational Research Society Ltd. All rights reserved
0960-085X/16
www.palgrave-journals.com/ejis/
Practitioners and researchers often suggest that cham-
pions could be a solution for successful IS implementa-
tion in health-care (e.g., Zandieh et al, 2008; Millery &
Kukafka, 2010), although what the exact role and con-
tribution of the champions could be has not been

explicitly discussed in their recommendations. The latter
is problematic, since a closer look at the champion
literature reveals that clear, generally accepted, uniform
definitions are lacking for what the champion role
involves and for what is regarded as champion behaviour
and what is not (Howell & Higgins, 1990; Howell & Shea,
2006). Even recent studies in IS literature, which discuss
champions and related concepts, such as top manage-
ment support (Dong et al, 2009), intra-organisational
alliances (Ngwenyama & Nørbjerg, 2010), charismatic
leadership (Neufeld et al, 2007) and organisational influ-
ence processes (Ngwenyama & Nielsen, 2014), confirm
that both the nature of championing and its assumed
impacts need further investigation.
Two research streams can be identified in the champion
literature:
● a heroic, individualistic perspective of one person acting
as an all-round champion (Schön, 1963; Howell et al,
2005; Walter et al, 2011),
● an interactive perspective where several specialised indi -
viduals cooperate, each serving a distinctive role (Witte,
1973; Witte, 1977; Rost et al, 2007; Fichter, 2009).
The heroic, individualistic perspective is the dominating
perspective in champion literature. Rost et al (2007) sug-
gest that the findings of both perspectives can be inte-
grated, in order to develop a more comprehensive
understanding of championing or promoting innovations.
Both research streams have put much effort into respec-
tively identifying unique champion behaviours and
unique champion roles. Although Taylor et al (2011,
p. 430) state ‘champion-driven leadership processes are
often highly dynamic, context sensitive and involve many

leaders’, little is still known regarding how different cham-
pion behaviours actually influence each other and how
different champions develop and execute their collabora-
tive performance.
The main contribution of our study is a more elaborated
conceptualisation of the interactive nature of championing
by, in detail, picturing how different champions cooperate
and how different champion behaviours interact. Our results
are primarily based on an in-depth qualitative analysis of
championing in a health-care information system develop-
ment project, complemented with an extensive literature
study. Furthermore, some additional specific lessons learnt,
which can inspire future research, are identified. Finally, our
findings are translated into implications for practitioners, in
the form of some straightforward guidelines.
Before presenting the applied research method and the
results of our case study, a short review is given of how
different champion roles and different champion beha-
viours are currently portrayed in the literature and what
issues are currently not being addressed.
Championing in the literature
The champion as one heroic individual
Champions can be defined as individuals who informally
emerge in an organisation (Schön, 1963; Chakrabarti, 1974;
Howell et al, 2005) and make a decisive contribution to the
innovation by actively and enthusiastically promoting its
progress to critical stages, in order to obtain resources and/or
active support from top management (Rothwell et al, 1974).
A problem with this definition is that it leaves quite a lot of
room for subjective interpretation of what a ‘decisive con-
tribution’ involves and what ‘progress to critical stages’
means. Schön (1963) is, for instance, more demanding when

using the following formulations: ‘the champion must be …
willing to put himself on the line for an idea of doubtful
success. He is willing to fail. … using any and every means of
informal sales and pressure in order to succeed … identify
with the idea as their own, and with its promotions as a
cause, to a degree that goes far beyond the requirements of
their job … display persistence and courage of heroic
quality’, as quoted in Maidique (1980, p. 60) and (Howell &
Higgins, 1990, p. 320). For a further illustration of the
differentiation in the definitions of the champion concept,
we refer to Walter et al (2011) and (Roure, 2001) who
respectively list 12 and 16 definitions that clearly differ
in highlighting certain aspects of the champion concept.
In addition, it is worth mentioning that besides the identifi -
cation of the product champion by Schön (1963), other
related roles have been ascertained, for example, gatekeepers,
project champions, business innovators, technological inno-
vators, user champions, sponsor/coach, godfather, power
promotor, expert promotor, process promotor, early adop-
ters, and opinion leaders (Rogers, 1962; Rothwell et al, 1974;
Witte, 1977; Maidique, 1980; Howell & Higgins, 1990;
Smith, 2007; Fichter, 2009). The existence of so many
identified roles, which are, just as the champion role, only
roughly defined and often clearly overlap, makes it hard to
compare studies, since determining what elements of differ -
ent innovation process roles are included or excluded in
their champion concepts may not always be clear (Howell &
Higgins, 1990; Walter et al, 2011). Also, this makes it hard to
correctly identify champions in this study and future studies.
Champion personality characteristics and champion
behaviours
Over the years, research has first focused on the question
of what kind of person a champion actually is (personality
characteristics) and then on the question of what a
champion actually does (champion behaviour). However,

since personality traits (charisma) are someti mes written as
behaviours (being charismatic), this distinction is proble-
matic when analysing the literature. Champion personal-
ity characteristics are often related to transformative
leadership, that is, leaders who inspire their followers to
transcend their own self-interests for a higher collective
purpose (Bass, 1985; Howell & Higgins, 1990). Champions
are risk takers, they are innovative and can articulate a
compelling vision, as well as instil confidence in others to
Understanding champion behaviour Joeri van Laere and Lena
Aggestam48
European Journal of Information Systems
participate effectively, and they can display innovative
actions to achieve goals (Howell & Higgins, 1990; Howell
et al, 2005). By being charismatic, champions capture the
attention of others, provide emotional meaning and
energy to the idea, and induce the commitment of others
to the innovation (Howell & Higgins, 1990; Heng et al,
1999). Champions rely on personal networks in and out-
side the organisation when scouting for new ideas and
obtaining support. They tailor selling strategies that tie
these ideas to stakeholder interests and positive organisa-
tion outcomes (Howell, 2005). In addition, Chakrabarti
(1974) has already suggested that product champions
should have knowledge about the technology, the organi-
sation and the market, besides having drive, aggressive-
ness, and political astuteness. Recently, more extensive
quantitative studies have been conducted to determine the
key components of champion behaviour. These studies
identify ‘expressing enthusiasm and confidence’, ‘getting
the right people involved’ (Howell et al, 2005), ‘pursuing

the innovative idea’, ‘network building’, ‘taking responsi -
bility’ (Walter et al, 2011) and ‘persistence under adversity’
(Howell et al, 2005; Walter et al, 2011) as key behaviours.
Interaction between multiple champions with fixed roles
Witte (1973, 1977) argues that innovation processes
involve very complex and multi-person decision processes
that cannot only be borne by one individual. Witte’s
Promotor Theory was initially a two-centre theory of
power, where two specialists cooperate; the expert promo-
tor contributes through expert knowledge and the power
promotor through hierarchical power (Witte, 1977; Rost
et al, 2007; Fichter, 2009). Later, other promotor roles have
been added (Rost et al, 2007; Fichter, 2009), for instance,
a process promotor, a relationship promotor, and techno-
logical gatekeepers. Promotor theory stresses that it is not
necessary for the different specialised promotor roles to be
played by different individuals. These roles can also be
combined in one person, the ‘universal promotor’, which
is then similar to the champion concept of one heroic
individual (Rost et al, 2007; Fichter, 2009). Even in the
literature on the individual all-round champion, there has
been some attention on the fact that champions do not
operate alone, but interact with project teams, executives,
and other stakeholders (Howell & Shea, 2006). Champions
positively influence team member beliefs in team effec-
tiveness and, in turn, rely on the extent to which they can
leverage the talents and resources of the innovation team
(Howell & Shea, 2006). Still, this is a perspective of a heroic
individual impacting and influenced by others, rather than
cooperation between different champions, as described in
promotor theory; or the kind of co-performance of cham-
pion behaviour as presented in this study.
Unaddressed issues in research on championing
Previous research has identified important individual

champion behaviours and ascertained several unique
champion roles that are taken on by different people. Still,
little is known about how these people, roles and beha-
viours actually interact. One reason for this could be that
research is predominantly based on quantitative surveys
that combine the insights gathered in a large number of
questionnaires or interviews. A clear benefit of those
studies is that they include many cases, which enables
generalisations stating that a single champion behaviour
or champion role is important in many instances. A draw -
back is that the analysis of each case is rather obscure and
any in-depth insight into how champion behaviours and
different champions interact in the specific case is lacking.
In addition, some recent studies have suggested that the
appliance or occurrence of champion behaviours may
depend on a range of contextual and situational factors.
For instance, there is increasing awareness that there can
be degrees of championing (Howell & Shea, 2001; Walter
et al, 2011), rather than defining individuals as either cham-
pions or non-champions. Walter et al (2011) and Hendy &
Barlow (2012) show that there is a limit to ‘persisting under
adversity’ and ‘taking responsibility’. A champion pushing
an innovation too long may be counterproductive (creating
resistance, lack of innovation spread) or harmful (imple-
menting a faulty innovation). Also, Taylor et al (2011) and
Hendy & Barlow (2012) describe how champion behaviour
varies between different phases of the innovation process.
In the initiation phase, when almost nobody believes in the
innovation, there may be one enthusiastic individual (cf. the
heroic champion perspective). During the endorsement
phase, when top management support needs to be obtained,
a project champion and an executive champion may work in
tandem (cf. Witte’s original two-centre theory of power).
Finally, in the implementation phase, when it is necessary to

spread the innovation throughout the whole organisation,
multi-disciplinary, cross-boundary project teams and high
levels of collaboration, involving many leaders from all parts
of the organisation, may be needed (cf. Promotor theory
with a network of multiple promotors).
Our study extends the current body of knowledge by the
in-depth study and analysis of how championing is per-
formed in different situations in an IS development project
and, hence, the detailed description of how champions and
champion behaviours interact, and how this interaction is
adapted to the context over time. Our analysis shows that
the interaction of champions and champion behaviours is
more situational and diversified than currently portrayed
in the literature.
Research method
Our research design is based on an inductive research
strategy and a qualitative research method. A single, in-
depth case study has been conducted, studying the phe-
nomenon of championing in a 14-month IS development
project at a large Swedish health-care organisation. Data
collection was based on participatory observation by the
second author and one in-depth interview by the first
author. Data sources included all the project documenta-
tion and personal notes, as well as reflective group
Aggestam 49
discussions and the interview. The data analysis was con-
ducted by both authors after the conclusion of the project

and comprised several iterations of comparing different
theoretical perspectives of championing with the collected
data. A more detailed discussion of each of these design
choices follows.
Inductive research strategy and in-depth single case
study
A clear theory on how champion behaviours are related
and exactly how champions interact is lacking. As such,
there is a need for theory building rather than theory
testing, which leads us to an inductive research strategy
(Eisenhardt & Graebner, 2007). Since our aim is to provide
unique and rich descriptions of champion collaboration
and the interaction of champion behaviours, a single case
study provided better opportunities for extensive data
collection and a deeper understanding of contextual cir -
cumstances. A drawback is, of course, that our findings
may be dependent on the particular circumstances in just
this case study. However, the aim of inductive qualitative
research with a theory-building objective is not to present
a statistical generalisation, from this single case study, to
the entire community of champions in IS development
projects or even innovation projects (Yin, 2014). Rather,
the aim is to expand and generalise theories (analytic
generalisation), implying that we aim to provide one
example of a new perspective on championing, which
can then be used to inform qualitative case studies in other
organisations/projects or to design quantitative survey
studies in a different way (Yin, 2014).
Data collection through participative observation
The second author was a member of the project studied in
this case and data collection was therefore primarily based
on participative observation throughout the whole period
of 14 months. In addition, the first author conducted a
complementary interview with one steering group mem-

ber, which focused on situations that did not include the
presence of the second author. The second author had
been an IS researcher for approximately 7 years before
leaving academia to work full time in the health-care
sector at the Västra Götaland Regional Council (Västra
Götalandsregionen (VGR). The second author documen-
ted and captured data in the project, not only from the
perspective of a project participant, but also from a
research perspective. The data collected comprised meet-
ing notations and personal reflection accounts of more
than 100 meetings held in different constellations during
the project, the power point presentation files used at
these meetings, the different versions and iterations of
work process models created in the project, personal
reflection accounts of informal discussions with groups or
individuals in the project, and the interview. The data
collection had a broad perspective and was focused on
capturing the events that occurred during this project in
general, from an IS development and organisational
change point of view (Aggestam & van Laere, 2012).
Championing as such was not a focus issue. As discussed
hereafter, the issue of championing emerged during the
analysis of the data. This is not seen as a weakness (e.g.,
champion issues may have been missed since capturing
them was not the aim), but rather as a strength (cham-
pioning emerged as an important factor during the analysis,
although we were not explicitly looking for it).
Data analysis through three iterations
As shown in Figure 1, our initial theoretical frame of
analysis was IS development (ISD) in general and, more
particularly, the use of certain critical success factors (CSF).
During the analysis of the case chronology from that
perspective, the personal charisma of one steering group
member and her ability to influence the support of the

project at decisive moments emerged as an important
factor not addressed in CSF.
As a consequence, the interview with the steering
group member was conducted. Thereafter, the data and
case chronology were analysed with the aim of identify-
ing different champion behaviours, according to the
championing perspective of one heroic individual (which
dominated the initial literature review). During the sec-
ond data analysis, it became increasingly apparent that
the steering group member’s contribution was consider-
able and this individual could be defined as a champion.
However, we became mired in the analysis in two ways.
First, it was hard to distinguish between the different
champion behaviours in our analysis, as they continu-
ously became entangled. Also, it became increasingly
clearer that the decisive contributions of the steering
group member were not the individual acts of one hero,
but cooperative efforts in which her qualities in combina-
tion with those of other important people together
enabled championing. This required a new literature
review where the perspective of different champion
behaviours performed by different people, as described
in the promotor theory, was identified. In the third
iteration of the case data analysis, taking into account
both these perspectives, it emerged that neither of these
theories could explain the interaction between beha-
viours and between champions, as had been observed
and documented in this case study. This led to a final
analysis based on both literature perspectives and the
data from our case study, which resulted in a more
elaborated conceptualisation of championing, captured
in Figure 12 and the many examples in our results
section.
The case study: the referral and answer subproject

(RASP) in VGR
A convenient way of reporting on a case study that
enhances readability is to apply a question and answer
format (Yin, 2014, p. 185). Hence, we set the scene by
answering the following questions: What innovation was
pursued in what kind of organisation? What kind of
Aggestam50
complexities existed that required championing? Who
were the main people involved that could perform cham-
pion behaviours? What happened chronologically? In the
results section, the focus is on the main research question,
that is, how did multiple champions perform multiple
interrelated champion behaviours in concert?
What innovation was pursued in what kind of
organisation?
Our analysis is limited to a subproject of the Referral and
Answer Project (RAP), hereafter called the RA SubProject
(RASP). RAP aimed to ensure patient security by imple-
menting a standardised way of working and information
content that support the referral process for all types of
referrals. The goals in achieving this aim included devel-
oping and implementing a VGR common-regulations
book, a desired common and unified VGR referral process,
as well as a common VGR IT solution. The first two goals,
and the additional goal of encouraging people to be
motivated and positive, were central to RASP. RASP started
in the autumn of 2010 and ended on 6 October 2011. RAP

had started earlier and continued after October 2011.
RASP developed a participatory way of working that was
regarded as an innovation in itself.
What kind of complexities existed that required
championing?
RAP was addressing a necessary and important change in
VGR, but the organisation had been struggling with this
desired change for 10 years and earlier initiatives had
become mired. Many people were aware that the current
referral and answer process was not functioning well,
but RAP was seen as a difficult project with a high risk of
failure for several reasons. First, RAP and RASP had to
overcome the size and accompanying complexity of the
health-care organisation that includes 17 hospitals, 121
health-care centres, and 170 public dental-care centres.
Changing the referral and answer work process involved
Data collected
a 14 months’
IS development project
in health-care
FIRST ANALYSIS
Appearance of charisma and
influence tactics at decisive moments
FIRST
LITERATURE PERSPECTIVE
IS development
Organisational change

Critical Success Factors
SECOND ANALYSIS
Champion behaviours are entangled
and cannot be isolated
Championing is not an effort of one
hero but a collective performance
SECOND
Theory
”champion as one heroic individual”
THIRD ANALYSIS
Champion behaviours are interelated
and strengthen each other
Champions do not work individually
on tasks which they are specialised in,
but perform champion behaviours
collaboratively while contributing
different expertise according to their
backgrounds and specialisations
THIRD
Theory
”Interaction between multiple
champions with fixed roles”

A MORE ELABORATED CONCEPTUALISATION OF
CHAMPIONING
Championing framework (figure12)
Rich exemplifying descriptions and detailed figures of
interactions (results section)
considering
”how multiple champions perform multiple interrelated
champion behaviours in concert”
Figure 1 Three iterations of data analysis.
Aggestam 51
the entire organisation of 15 administrations and 48,000
employees. Many different existing referral routines needed
to be aligned to enable a common IT support solution.
Second, VGR was organised into 15 highly autonomous
administrations, of which each had its own board con-
trolled by an administration manager. The high level of
autonomy meant that development projects, such as RAP,
had to work with agreements between the administrations.
As such, many different groups had to be convinced and
committed. Furthermore, earlier referral projects had not
achieved their aims and another recent high stake VGR-IT
project was, according to many stakeholders, regarded
negatively. Finally, in parallel with RAP and RASP, a
National eReferral project was planned. Consequently,
RASP would have to keep itself informed about the deci -

sions and results of the National eReferral project, since
VGR’s processes must comply with national rules. Also,
since VGR is a large organisation, several other develop-
ment projects that could at some point interfere with RASP
were being carried out.
Who were the main people involved that could perform
champion behaviours?
RASP comprised the RASP team, an informal steering
group, and a number of working groups. In addition, the
RASP team had important relations with the RAP team and
the formal RAP steering group, which included participat-
ing in meetings with RAP.
The RASP team consisted of three project team members:
a subproject leader with a health-care background (PL-HC), a
subproject member with a health-care background (PM-HC)
and a subproject member with an Information Systems
background (PM-IS). Both PL-HC and PM-HC have a health-
care education, a lot of experience in health-care work and
development projects, as well as long careers in VGR. PM-IS
(the 2nd author) has an academic background: a Ph.D. in
Data and Systems Science and a key research interest in CSF
in IS development. PM-IS had worked in VGR since March
2010. The team members were individuals with a strong
personality and an enthusiastic attitude.
The formal RAP steering group consisted of members
that represented different perspectives, both with regard to
professional roles and the administrations of VGR. One of
the RAP steering group members served as a contact person
(CP) for the RASP team. This CP was a well-respected and
experienced member of the VGR organisation who had
worked in its different administrations for more than
40 years. For example, the CP had worked both as physi-
cian and more recently as an administration manager,

which has given her much insight into how health-care
work is performed, a significant amount of leadership
experience in just this organisation, as well as a large
number of contacts at different levels in VGR. Although
semi-retired, when the RAP and RASP projects were carried
out, she was still active in some strategic projects and
maintained a strong position and a very good reputation
in the larger VGR organisation. She was also regarded as a
trustworthy person. The RASP team members and the CP
shared a strong belief in the importance of stakeholder
interaction. A participatory structure was created, includ-
ing a group with RASP administration managers and local
interdisciplinary working groups (Figure 2).
The group with RASP administration managers
included a representative from each of the 15 administra-
tions in VGR, who were members of or had a strong
connection to their respective administration’s manage-
ment board. As such, it became an informal steering
group. Each RASP administration manager was responsi-
ble for creating and managing an interdisciplinary group,
consisting of physicians, nurses and administrative staff,
at their local administration.
What happened chronologically?
RASP commenced in September 2010. To enable good
stakeholder interaction with all 15 administrations, a clear
common objective related to patient security was created
and the participatory structure was designed. A commit-
ment to work according to this participatory structure was
subsequently obtained, first from the formal steering
group, then from VGR’s top management board in which
all administrations are represented, and finally from the
15 selected RASP administration managers that would
become the heart of the participatory structure. In the

following phase, process modelling activities were carried
out with several iterations in the local interdisciplinary
work groups of each administration, where the RASP team
led the meetings supported by the local RASP administra-
tion manager.
In a final iteration, models were discussed and refined in
cross administration meetings. Results from all these mod-
elling meetings were analysed and synthesised by the
RASP team and then discussed with the RASP administra-
tion managers and the CP. Parallel to the modelling work,
time was spent maintaining commitment at all levels.
Finally, preparations were carried out to get a formal
approval for the results of RASP. RASP ended when its
results were formally ratified by the Director of Health-Care
on 6 October 2011.
Figure 2 The participatory structure in RASP as it was
described
in the project.
Aggestam52
Results and analysis: how champions and
champion behaviours interact and form a
meaningful whole
In this section, eight examples of championing, as
observed in RASP, are presented. Each example is illu-
strated in a small figure, according to the syntax shown in
Figure 3, and thereafter explained. The general champion
behaviours are adopted from lists of champion behaviours

identified in a number of earlier studies (Howell et al, 2005;
Howell & Shea, 2006; Walter et al, 2011).
The examples play an important role in achieving our
article’s aim, since they together provide an in-depth
insight into what championing is about. In the subsequent
analysis, a more elaborated conceptualisation of cham-
pioning is constructed from the example descriptions.
Example 1: Recruiting the RASP team members
During different moments in RASP, it was important to
recruit the right people. One example is when the CP
recruited PM-IS, PM-HC and PL-HC. This example illus-
trates how the CP relied on experience from earlier inno-
vation projects and how different champion behaviours
strengthen each other (Figure 4).
The CP and PM-IS knew each other from a network of
logistical change managers in which PM-IS was one of the
members and the CP was the mentor. When the CP
became aware that PM-IS was dissatisfied with her current
work role and planned to resign, the CP approached her
and discussed potential opportunities and needs for her in
VGR. Simultaneously, the CP spoke with a potential new
manager. After informally receiving a positive response
from both PM-IS and the new manager, the CP and the
new manager arranged the formal appointment of PM-IS.
The interview with the CP reveals that the strategy of
combining informal and formal channels to obtain the
interest and nomination of desired persons was applied
consciously. This strategy involved contacting both the
desired person and that person’s manager, first informally,
to check out the situation, and then, if the result was
positive, more formally, in order to obtain the formal
appointment decision. The informal discussions provided

insights into the person’s appropriateness, regarding com-
petence and motivation, and whether the person was able
to leave the current assignment. The informal discussions
prevented the necessity of posing an inappropriate formal
request that would be refused. The CP applied this strategy
not only in RASP: ‘to select the appropriate staff- and
project members has been my main success factor
throughout my career’.
The interview with the CP also reveals that PM-IS, PM-
HC, and PL-HC were recruited with a strategy in mind.
They were selected because they would contribute knowl-
edge or strategic relations that the CP or the project
currently lacked. The CP stated: ‘when I do not have a
certain relation with an important person or important
organisational unit myself, I invite someone into the
project that has that relation’. PM-HC was a Development
Manager and a respected member of the largest adminis-
tration who had been working with referral processes in
that administration. PL-HC was an Operation Controller
who represented another large administration and had
worked in organisation development projects across dif-
ferent administrations. Both had long careers in VGR and
understood the organisation well. PM-IS has an academic
background in ISD and CSF. The combination of these
RASP team members resulted in good knowledge in IS
development, insight into how health-care functions in
general and in VGR in particular, as well as access to many
personal networks in different parts of the VGR organisa-
tion. The involvement of these three people lifted the
capabilities and status of RAP (and later RASP).
Example 2: Recruiting interdisciplinary group members
Later, in RASP, RASP-administration managers had to
recruit members for the interdisciplinary work groups of

each local administration. This example shows how the
champion behaviours from Example 1 were applied differ-
ently in a later phase of the project and at a different level
of the VGR organisation. The adaptation involves multiple
champions cooperating and co-performing certain cham-
pion behaviours (Figure 5).
The RASP team supported each RASP administration
manager in recruiting by designing general require-
ments which were presented on a slide to the RASP-
administration managers. The requirements were that
the group should include experience from and knowl-
edge about the referral and answer process from different
perspectives, it should be interdisciplinary and it should
have members with enough time to work in RASP. With
the support of these requirements, the actual selection
was carried out by the RASP-administration managers, as
they had the contextual knowledge to find the appro-
priate persons within their administrations. The RASP
team was available for consultation, if the RASP admin-
istration managers had questions concerning how this
Actual application in
this example
Person(s) who
perform(s)
General champion
behaviour
Influence on next champion behaviourInfluence from previous
champion behaviour
Figure 3 Syntax for the example models presented in the results
section.

Aggestam 53
could be achieved. In addition, PM-HC contributed to
forming the interdisciplinary group in her local admin-
istration. PM-HC discussed how to put the group
together with her RASP administration manager and
provided support by informally consulting some of the
identified key persons.
Example 3: Developing the participatory structure
One of the clearest impacts on how the involvement of
certain people redefined the nature and content of the
innovation process became obvious when PM-IS, PM-HC,
PL-HC and CP became involved in the discussion regard-
ing how the RAP objectives should be achieved. This
resulted in the development of the participatory structure
(Figure 2). Example 3 illustrates how different champions
contribute their range of experiences and backgrounds and
how they together create a meaningful whole when they
integrate their knowledge and champion behaviours
(Figure 6).
In the first meetings with the RAP project team, user
participation was discussed. Everybody shared the view
that user participation was important for achieving suc-
cess. However, during the forthcoming project planning
discussions, when the activities regarding how to achieve
user participation at a more detailed level were being
defined, it became clear that opinions diverged concerning

the practical implications of user participation. Opinions
varied from actually involving the users in each step of the
development work to the project team first carrying out
the development work and then asking some users to
provide feedback on the models. Taking experiences from
earlier research into account, PM-IS had strong scientific
arguments for the necessity of involving the users inten-
sively throughout the whole development process, a point
of view that was also in line with both PL-HC’s and PM-
Recruiting members
of the RASP team
CP
Getting the right
people involved
Knowledge about
the referral process
in health-care
CP
Knowing the
innovation
First check
appropriateness
informally, then
formal request
CP
Using informal and

formal processes
Need for an expert
on ISD
CP
Knowing the
innovation
Need for people
with social network
in parts of
organisation
CP
Having a
large social network
Need for
representative from
largest
administration
CP
Knowing the
organisational
context
Figure 4 Championing in example 1.

Deliberating
selection strategy
with the
the RASP team
RASP admin mgrs
PM-IS, PM-HC, PL-HC
Using informal and
formal processes
Knowledge about
CSF in IS
development
PM-IS
Knowing the
innovation
Formulating
requirements for
group design
RASP team
Knowing the
innovation
Strategy for
recruiting RASP
team members

CP
Getting the right
people involved
Knowledge about
appropriate
functions to involve
in work groups
PM-HC, PL-HC
Knowing the
organisational
context
Select members
interdisciplinary
work groups
RASP admin mgrs,
PM-HC
Getting the right
people involved
Knowledge about
appropriate work
group members
RASP admin mgr

Knowing the
organisational
context
Aggestam54
HC’s practical experiences. Since PM-IS shared an office
with CP and worked with CP on other projects, PM-IS
had the opportunity, during informal discussions, to
‘now and then’ discuss the necessity of actually invol -
ving the users in the project. From these discussions it
emerged that PM-IS’s scientific arguments and the
desired participatory approach were also in line with
the CP’s own experiences. Accordingly, the CP contrib-
uted to further developing the participatory way of
working. In this process, PM-IS served as a link between
the RASP team and the CP. During RASP team meetings,
which were often held in the building that housed the
office of PM-IS and CP, RASP team members had the
opportunity to consult the CP when questions arose, or
the CP could briefly join the meeting. When meetings
were organised elsewhere, PM-IS collected questions and
discussed them with the CP the next day.
While the RASP team developed the participatory struc-
ture, the CP contributed, among other things, with the
requirements that the RASP administration managers had
to have a connection to the local management board of

each respective administration and be nominated by
the administration manager. This is further described in
Example 4 concerning building support for this structure.
Example 4: Support from the higher decision-making
levels
Working according to the participatory structure was an
innovation in itself and, as such, it was necessary to
convince different stakeholders in VGR of its benefits. This
example also illustrates how different champions coopera-
tively orchestrate their champion behaviours and demon-
strates how informal anchoring and formal decision
meetings are used to build support (Figure 7).
Agreement about
the participatory
structure to be
applied
RASP team, CP
Building support
Discuss
participatory
structure with
Steering group
chairman
CP
Using informal and
formal processes

Discuss
participatory
structure with
Administration
managers
Using informal and
formal processes
CP
Listening to or
discussing the talks
Environmental
scanning through
people
CP, PM-IS
Obtain formal
support for way of
working from
steering group
CP
Building support
Obtain formal
support for way of
working from

VGR mgt board
Building support
CP
Knowledge about
CSF in IS
development
PM-IS
Knowing the
innovation
Lack of stakeholder
interaction in recent
previous projects
CP, PL-HC, PM-HC
Knowing the
organisational
context
Deliberation about
need for real user
participation
RASP team, CP
Using informal and

formal processes
Knowledge about
CSF in IS
development
PM-IS
Knowing the
innovation
Designing
participatory
stucture
RASP team
Formulating
the innovation
Requirement that RASP-
admin managers should be
admin-mgt-board member
CP
Getting the right people
involved
Lack of stakeholder
interaction in recent

previous projects
CP, PL-HC, PM-HC
Knowing the
organisational
context
Need for connection
with administration
mgt board
CP
Knowing the
decision making
context
Deliberation about
need for real user
participation
RASP team, CP
Using informal and
formal processes
Aggestam 55

As described earlier, PM-IS and CP shared an office and
worked together in other projects, which gave them
numerous opportunities for informal conversations.
Through these and other interactions between the RASP
team and the CP, as well as between PM-IS and the CP, the
RASP team had favourable opportunities to gain support
for their strategies from the CP. In turn, the CP was the
link between RASP and the steering committee and
between RASP and the management board in VGR. After
the CP was committed to the work structure proposed by
RASP, she focused on obtaining support from the RAP
steering group and the 15 administration managers that
form the VGR management board. On various occasions,
the CP discussed the intended working structure with the
Chairman of the Steering Committee. These conversations
were regularly communicated from CP to PM-IS, but some-
times PM-IS was, in a way, part of the conversations, since
CP met the Chairman or talked with him by telephone in
the office shared with PM-IS. This meant that PM-IS had a
clear and updated understanding of the steering commit-
tee’s opinions. Another challenge was to have the way of
working sanctioned by the VGR management board. This
was important because without their approval it would not
be prioritised and necessary resources would not be allo-
cated. In order to obtain their commitment, the CP had
informal meetings that served as a means of obtaining
information about the important aspects for the adminis-
tration, as well as an opportunity to explain why it was
necessary to work according to the intended structure.
Consequently, arguments were dealt with before the
formal meetings and, by listening well, the message at the

meetings could be attuned to addressing any important
matters of interest put forth by the Chairman and the
managers. The CP openly reflected over this informal
anchoring process in discussions with PM-IS: ‘Have we
talked with all now?’
Example 5: Support from the RASP administration
managers
After securing commitment from top management, sup-
port for the participatory way of working had to be
obtained from those who would participate in RASP. This
was primarily achieved during the first two formal meet-
ings with RASP administration managers (Example 5) and
the first meetings with the local interdisciplinar y working
groups (Example 6). Examples 5 and 6 illustrate how the
champion behaviour from Example 4 was adapted to
different contexts when applied in a later phase of the
project and at a different level in the VGR organisation
(Figure 8).
The first meeting with the group of RASP administration
managers was a critical step, because without their com-
mitment to the aims of RASP and the intended way of
working (the participatory approach), it would have been
necessary to re-plan everything. The fact that the man-
agers were not used to being involved so early in the
project is illustrated by the following comment: ‘Are we
included already now?’ The meeting was planned in close
cooperation between the RASP team and the CP, in a
highly iterative manner similar to the description in
Present the patient
security goal
CP

Building support
Present the
suggested way of
working
Building support
PM-IS
Possibility for local
adaptation
Formulating
the innovation
RASP admin mgrs
Present the facts
and figures of
referral processes
PL-HC, PM-HC
Building support
Committing to RASP
and the way of
working
Innovation success
RASP admin mgrs

Long career in VGR
PL-HC, PM-HC
Having a
respected status
Knowledge about
CSF in IS
development
PM-IS
Knowing the
innovation
Knowledge about
in VGR
CP, PL-HC, PM-HC
Knowing the
innovation
Prepare
presentation
participatory
stucture
RASP team

Formulating
the innovation
Sanction contents,
Propose changes
CP
Knowing the
organisational
context
Leadership
experience
CP
Having a
respected status
Academic career in
CSF/ISD
PM-IS
Having a
respected status
Early involvement
Building support
RASP admin mgrs
Vigorous support

CP
Persisting under
adversity
Aggestam56
Example 3. Furthermore, the RASP team prepared slides
whose contents were sanctioned by the CP, who also
meticulously reformulated certain sensitive matters that
could divert the discussion in the wrong direction (given
her knowledge of the organisation). The plan included
that each RASP member should be responsible for the
preparation and presentation of parts which related to
their specific competence. The CP, who represented a
direct link to the top management level and who is
favoured with a highly respected status in the organisa-
tion, presented the goal of RAP as an opportunity to really
increase patient security. PL-HC and PM-HC, with long
careers in VGR and extensive knowledge of how the
organisation functions at all levels, presented the facts and
figures of the referral processes, as well as real patient cases,
in order to substantiate the objective and make the appeal
more emotional. PM-IS, with academic experience regard-
ing CSF in IS development, presented the participatory
structure. The CP was vigorous and persistent concerning
the necessity of RAP and RASP to address patient security,
explicitly illustrating and repeating this message whenever

questions arose in the first meeting. At the same time,
although a commitment to this general objective was
required (the why and what), each administration was free
to choose how to reach this objective, thus allowing local
adaptions of the implementation (the how). This was
important since the prerequisites of the different adminis-
trations varied greatly. Hence, enabling local adaptations
was necessary in order to secure their commitment, but also
for increasing patient security. In addition, the RASP team
answered questions and took note of comments received,
reflected upon them and prepared more elaborate answers
for the next meeting with the same group. This created an
atmosphere in which doubts and scepticism were openly
discussed and used to strengthen the way of working and
the developed referral process (see also Example 7).
Example 6: Support from the interdisciplinary work
groups
Meetings with the interdisciplinary work groups in a way
mirrored those with the RASP administration managers, but
also included discussions of referral and answer challenges
at a more detailed level, as well as modelling work. The
design and implementation was in line with the description
in Example 5, however, the RASP team themselves designed
and carried out the presentations on the basis of the
decisions made and discussions held in the meetings with
the RASP administration managers and the CP. As such, this
example shows how previously applied champion beha-
viours once again are adapted to a new context and how
champions take over each other’s roles (Figure 9).
Again, the RASP team members utilised their different
backgrounds and, as such, their status related to different
topics, both during the presentation and when moderating
the following modelling activities. Owing to the large

number of meetings, it was not always possible to have all
three RASP members present, but at least two of them
participated in each meeting. Since the RASP administra-
tion managers had some pre-understanding from the meet-
ing with all the RASP administration managers, they were at
this stage actively used to supporting the RASP team in the
local context. The RASP administration managers were
Present the patient
security goal
RASP team
Building support
Present the
suggested way of
working
Building support
PM-IS
Clarify how RASP
canbe
implemented in
local context
Formulating
the innovation
RASP admin mgrs
Present the facts

and figures of
referral processes
PL-HC, PM-HC
Building support
Interdisciplinary
groups committed
to RASP and the
way of working
Innovation success
RASP admin mgrs
Long career in VGR
PL-HC, PM-HC
Having a
respected status
Knowledge about
CSF in IS
development
PM-IS
Knowing the
innovation
Knowledge about

in VGR
CP, PL-HC, PM-HC
Knowing the
innovation
Prepare presentation
participatory stucture
RASP team
Formulating
the innovation
Connection to local
administration
board
RASP admin mgrs
Having a
respected status
Academic career in
CSF/ISD
PM-IS
Having a
respected status
Understanding
local context

Knowing the
organisational
context
RASP admin mgrs
Discussion around
earlier presentations
of participatory
structure
RASP team, CP,
RASP admin mgrs
Formulating
the innovation
Vigorous support
RASP admin mgrs
Persisting under
adversity
Aggestam 57

already informed about the RAP and RASP mission of
increasing patient security. Therefore, the RASP team could
invite the administration managers to help confirm and
clarify the goal of RASP for the members of the interdisci -
plinary work groups. The local RASP administration man-
ager was also utilised by the RASP team when questions
and issues arose regarding how this could be performed
and achieved in their own situation and context. In this
way, the local RASP administration manager partly filled
the role of the CP. For example, in one administration
work group, members shared concerns about sometimes
not having the time to sign a referral before it had to be
sent. At that point, the RASP administration manager
vigorously stated that this matter needed to be solved by
adjusting the local working routines.
Example 7: Establishing the participatory approach and
that the object of design includes both the referral
process and the rule book
Although the RASP team and the CP were initially most
active in defining and formulating the participatory way of
working, others became more involved in defining the
participatory way of working and the new way of conduct-
ing the referral and answer process in VGR. This example
shows how the champion behaviours of ‘formulating the
innovation’ and ‘building support’ are closely interrelated
and, again, how championing is adapted to new situa-
tions, as well as how multiple champions contribute and
together create a meaningful whole (Figure 10).
After the first meeting with the RASP administration
managers, the RASP team felt they had not succeeded in
properly answering the question: ‘Why shall we succeed
this time?’ When this question was raised by the RASP
administration managers, the answers of the CP and the
RASP team had been based on stories and assumptions, not

on facts, and thus the answer had not been convincing
enough. The RASP team therefore put an effort into
analysing prior referral and answer projects in more detail.
The main differences between the former way of working
and the new approach were summarised on a slide as
answers to: ‘What is there to say that we will succeed this
time?’ At the second meeting with the RASP administration
managers, the CP presented this overview, a strategic move
to signal the importance of the issue. The same slide was
later used in the meetings with the interdisciplinary work
groups. The efforts of the RASP administration managers,
who questioned the first arguments, and those of the RASP
team, enhancing the motivation, resulted in a more con-
vincing first presentation to the interdisciplinary work
groups. When the RASP team evaluated the models of the
new referral process, which were developed collaboratively
with all the administrations, deficiencies in an official
document called the rule book became apparent. When
the reciprocal relationship between the rule book and the
referral process was discovered, the CP, the RASP team and
the RASP administration managers concluded that both
should be ʻobjects of design’. Next, the CP lobbied by
discussing this question informally and formally with the
RASP steering group, while the RASP administration man-
agers built support at the local level. Next the CP and PL-HC
presented the proposal that the referral process and the rule
book from then on would be included in one document at a
formal management meeting and obtained a formal deci-
sion. This meant that a new referral process automatically
implied a new version of the rule book.
Example 8: Maintaining support
After the initial engagement had been created at higher
decision-making levels (Example 4), among the RASP
administration managers (Example 5) and among their

interdisciplinary work groups (Example 6), a continuous
challenge was to maintain motivation and support at all
these levels. This example shows how multiple champions
are involved to maintain support (Figure 11).
Posing questions
about the
participatory
structure
RASP admin mgrs
Formulating
the innovation
Searching for and
developing
better answers
RASP team
Formulating
the innovation
Presenting the
participatory
approach
RASP team, CP
Environmental
scanning

through people
Presenting the
elaborated
answers
CP
Building support
Discovering
reciprocal relationship
between rule book and
referral process
RASP team
Formulating
the innovation
Gain support for
inclusion of rule book
as object of design
CP, RASP admin mgrs
Using informal and
formal processes
Collaboratively
developing
new referral process
RASP team

RASP adming mgrs
Formulating
the innovation
Obtaining formal decision
inclusion rule book in
referral process
C, PL-HC
Building support
Aggestam58
Although the CP was vigorous in her support at the first
two meetings with the RASP administration managers, she
was not as active in the discussions at subsequent meetings.
Instead, the RASP team handled the discussions while the
CP was supportive through her presence and body lan-
guage. The symbolic value of her presence was critical to
maintaining the commitment and support over time,
including that of the formal steering group. Nevertheless,
there was a clear difference in the degree of support between
the earlier and later meetings. Informal discussions were
not only utilised to build support in preparation for formal
meetings, but also to monitor whether support was being
maintained. Here, not only the CP, but each RASP team

member used their social network. For example, during a
coffee break at a meeting related to another project, a
person from one of the administrations approached PM-IS
and raised some doubts concerning RASP, as well as com-
municated some deficiencies in the local administration.
This made it possible for PM-IS to both explain some
matters and to adapt the forthcoming meetings for that
administration’s local work group, in order to deal with the
scepticism. In similar ways, all members of RASP promoted
the project and gathered relevant information to adjust the
project to local circumstances in different administrations.
In the concluding phase, when the RASP team and the CP
prepared the final presentation to the VGR management
board, it appeared that support for most of the decisions
concerning RASP was already in place, thanks to the applied
participatory structure. RASP administration managers and
interdisciplinary group members had already spread the
results of RASP and certified that the local interests of their
administration had been acknowledged in the end result.
Analysis
Table 1 and Figure 12 present the main elements of our
more elaborated conceptualisation of championing which
is based on a thorough analysis of the previously described
examples.
In all the examples (except Example 1), champion
behaviours are performed by multiple champions, either each
of those champions performs a single behaviour, or several
champions co-perform a single championing activity. This is
clearly shown in all the figures where the names of
different champions are connected to the behaviours, or
where more champions are connected to a single beha-
viour. Next, all the examples show how different champion
behaviours are interrelated and how they strengthen each other

(as indicated by the arrows between the behaviours). This
is indicated within examples but also across examples. For
instance, within Example 4, ‘the use of informal and
formal processes’ strongly contributes to ‘building sup-
port’. It was hard to discern between ‘developing the
participatory structure’ in Example 3 (which is an example
of ‘formulating the innovation’) and building support in
Example 4. ‘Building support’ is enabled by means of
‘formulating the innovation’ in such a way that it attracts
the target groups and is recognised by them. Conversely,
the ‘building support’ process consists of carefully listen-
ing to target group representatives during informal discus-
sions so that their comments and viewpoints can later be
used to ‘re-formulate the innovation’ to better suit their
interests and, in turn, facilitate its acceptance. Combini ng
the previous observations, championing implies that the
collective knowledge of all involved champions, their
collective status and networks, and so forth, influence
how they collectively perform and co-perform champion
behaviours to impact overall project success. From this
realisation followed another aspect of championing that
became increasingly clearer during the analysis; champion
behaviours do not just (randomly) interact and champions
do not (randomly) choose behaviours, instead, both cham-
pions and champion behaviours form a meaningful whole. This
means that the different champions are continuously and
Gaining support
bottom up
through the participatory
approach
RASP admin mgrs
Using informal and formal

processes
Prepare final
presentation for VGR
management board
RASP team, CP
Using informal and
formal processes
Obtain commitment from
VGR management board
CP, PL-HC
Building support
Collect feedback
and explain
ambiguities
CP, RASP team
Using informal and
formal processes
Know people on
different levels and in
different units of VGR
CP, RASP team
Having a
large social network

Maintain support
for RASP
on all levels
on a continual basis
CP, RASP team
RASP admin mgrs
Building support
Symbolic value of
her presence
CP
Having a
respected status
Aggestam 59
consciously adapting their champion behaviours to each
other, thereby, together in interaction, creating a coherent
and meaningful whole. This coherent performance
becomes meaningful by adapting it to the current situation
and context in which championing is being performed.
‘Building support’ involved different champions and dif-
ferent champion behaviours, depending on the level in
the organisation and the phase of the project (Examples 4,

5, 6 and 8). In this continuous adaptation process, cham-
pions can switch roles completely. Where the CP is persistent
at defining moments during high level board meetings
(Example 3), the RASP administration managers fulfil this
role during modelling sessions that the CP does not attend
(Example 7). Similarly, recruiting is performed by the CP in
Example 1 and by RASP administration managers sup-
ported by the RASP teams in Example 2. Finally, in
Example 1, the CP states explicitly several times that she
heavily relies on championing experience from previous innova-
tion projects. This is implicitly expressed by other cham-
pions when they explain why they favoured certain
champion behaviours in particular situations. As a result,
champions learn from championing in previous innova-
tion projects and take the lessons learnt with regard to
championing from this project to future innovation projects.
The discussed aspects of championing are presented in
Figure 12. Figure 12 gives an overview how multiple cham-
pion behaviours performed by multiple champions form a
meaningful whole in a particular context and situation; how
this collective performance is adapted from situation to situa-
tion over time; how each collective performance utilises each
champion´s knowledge and experiences and simultaneously
generates new learning; and how this continuous process of
collective performance impacts innovation success. The figure
can be interpreted as a summary of how championing has
Table 1 Characteristics of championing observed in RASP
Characteristics of championing observed in RASP
Multiple champions perform champion behaviours
Champions co-perform a single champion behaviour
Champion behaviours are interrelated and strengthen each other

Champions and their champion behaviours form a meaningful
whole
Championing (the behaviours selected and who performs them)
is adapted to the situation and over time
Champions switch roles
Champions learn across innovation projects by relying on
acquired championing experience in earlier innovation projects
and by gathering
championing experience for future projects
multiple behaviours performed by multiple
champions forming a meaningful whole in a
particular situation
multiple behaviours performed by multiple
champions forming a meaningful whole in a
particular situation
Collective experience of
champion 1, 2, 3, 4, ...
Knowing the innovation
Knowing the organisational context
Knowing the decision making context
Having a large social network
Having a respected status
Using informal and formal processes
Getting the right people involved
Formulating the innovation
Building support
Environmental scanning through people
Persisting under adversity
Adaption to new situation over time

Utilising previous experience
Learning
Utilising previous experience Learning
Continuous adaption
to new situations over time
Collective championing
Continuous utilisation of experience
and continuous learning
Innovation success
•
•
•
•
•
•
•
•
•
•
•
Figure 12 A more elaborated conceptualisation of championing.
Aggestam60

been observed in our case study, and as a richer concep-
tualisation of how collective championing is performed in
general, that can inform future research and practitioners.
Discussion, limitations and implications for future
research
The way that championing has been observed in our case
study goes to the best of our knowledge beyond the
existing portrayal of championing in the literature. Cham-
pioning is not performed by single heroes (as in the heroic,
individualistic perspective); instead, there are multiple
heroes that collaborate intensively. In that collaboration,
they do not have strictly separate roles (as in the inter -
active perspective where several specialists each serve a
distinctive role), but can both co-perform championing
activities (while simultaneously contributing with experi-
ence from their specialisations) and even switch roles
completely, if situational circumstances require it. Finally,
our case examples show that adaption to situational con-
text over time is much more complex than an inverted U
relationship (Walter et al, 2011) or an adaption to three
general phases (Taylor et al, 2011).
As discussed previously, one limitation of our study is
that it is the study of just one project. This research design
choice was inevitable to enable the discovery and in-
depth study of interactions between champion beha-
viours. However, there is a clear need to apply our frame-
work in other organisations and other areas, in order to
validate and develop it further. Another limitation is how
the champions and champion behaviours have been
identified. Most often in studies on championing, many
different people involved in the innovation are first
invited to nominate a champion and then an analysis of

the particular behaviours the nominated champion exhi-
bits is conducted. However, our approach has been to first
identify champion behaviours and then seek out the
person who performs them. It is clear that nominating
champions by seeking out the most influential individual
(as in the individual heroic perspective) hampers the
identification of collective champion performance.
Therefore, an interesting option for future studies would
be to aim at combining our way of identifying champions
and the traditional way of broadly seeking out influential
individuals (plural!), to see whether the same persons are
identified.
Another research implication is that concepts such as
‘getting the right people involved’ can be interpreted in
multiple ways and more unified definitions should be
proposed. For instance, in our study, the concepts ‘getting
the right people involved’ and ‘building support’ were
clearly different notions, whereas others (Howell et al,
2005) have used them as synonyms. A completely unex-
plored topic is how groups of champions take champion
experiences from one innovation project to another, since,
to our knowledge, champion studies always limit them-
selves to studying just one innovation project and not
several sequential ones.
Implications for practitioners
As researchers, we have a pragmatist stance which implies
an interest for what works and what does not work
in a practical context (Goldkuhl, 2012). Hence, based
on our study, we have developed some guidelines for
practitioners:
● Be aware of the importance of champions for innova-
tion project success. People that are continuously posi-
tive about the project, talk well about it and can act as

sponsors must be involved in the project.
● Pay attention and put effort into finding good cham-
pions (plural) for the project. The champions should
complement, not resemble, each other, and each cham-
pion must be committed to the goal of the project. In
RASP, this was patient security.
● Collectively, the champions should have the following
qualifications:
� A respected status among stakeholder groups that are
critical for the project
� A relevant and strong social network
� Complementary skills and competences
� Knowledge about the organisational context and the
innovation itself
● The project leader is a key champion and, hence, the
most important qualification is that this person is
respected, confident, and has status in the context
where change is needed.
● Effective championing requires a holistic approach and
adaptation to situations and over time. Hence, it is
important that champions are good listeners and have
the capacity to reflect and learn, for example, to under -
stand people’s daily work experiences and to envisage
how the project may improve their situation.
Conclusion
Our main contribution is a rich illustration and exemplifi -
cation of championing presented in eight examples and a
more elaborated conceptualisation of championing cap-
tured in Figure 12, that explains:

● how champion behaviours are interrelated
● how champion behaviours are performed by multiple
champions
● how champions and their champion behaviours form a
coherent and meaningful whole
● and how the constellation of behaviours and champions
is adapted to situational context and over time.
In addition to this main contribution, some other
lessons learnt have been identified. Champions involved
in a project can co-perform certain champion behaviours,
while simultaneously contributing different expertise
according to their backgrounds and specialisations.
In adapting to situational circumstances, champions can
also exchange roles, in order to apply the best champion
behaviours available, during the various stages of a pro-
ject. Also, champions learn from championing in earlier
Aggestam 61
projects and gather experiences during the current pro-
ject that can enable more effective championing in the
future.
For practitioners, this implies that a diversified group of
champions should be recruited, rather than one heroic
individual. The members of this champion group should
complement each other’s knowledge, status and social net-

works, and be careful listeners who are eager to learn how to
adapt to each other and to situational circumstances.
The most important challenge for future research is to
study these championing collectives across several sequen-
tial innovation projects.
Acknowledgements
We thank the members of the VGR organisation for their
generosity in sharing their experiences. We are also grateful
for the support and insightful comments of the Associate
Editor and two anonymous reviewers.
About the authors
Joeri van Laere is an Assistant Professor at University of
Skövde, Sweden. He holds a Ph.D. in Information Systems
from Delft University of Technology, the Netherlands. Joeri
performs research at the interface of organisation science,
communication science and information systems. His
research interests include decision support, crisis manage-
ment, gaming-simulation, knowledge management, organi-
sational change and distributed work. He has published at
several international conferences such as ECIS, HICSS, and
ISCRAM, and in journals including the Journal of
Contingencies
and Crisis Management, the Journal of Information Fusion and
the Journal of Production, Planning and Control.
Lena Aggestam is an Assistant Professor at University of
Skövde, Sweden. She holds a Ph.D. in Computer Science
from Stockholm University, Sweden. Based on systems
thinking, in the areas of learning organisations and knowl -
edge management, her research interests include change
management and how to achieve sustainable development,
information systems development and critical success fac-

tors. She has published at several international conferences
such as ECIS, HICSS, and IRMA, and in journals including the
International Journal of Knowledge Management, Information,
the Journal of Cases on Information Technology and the Inter -
national Journal of Systems and Service-Oriented Engineering.
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Aggestam 63

Reproduced with permission of the copyright owner. Further
reproduction prohibited without
permission.
Chapter 8
Organizing Information Technology Services
Privacy is an individual's constitutional right
to be left alone, to be free from
unwarranted
publicity, and to conduct his or her life
without its being made public. In the health
care
environment, privacy is an individual's right to
limit access to his or her health care
information.
In spite of this constitutional protection and
other legislated protections discussed in this
chapter,
approximately 112 million Americans (a third
of the United States population) were affected
by
breaches of protected health information (PHI)
in 2015 (Koch, 2016). Three large
insurance-related corporations accounted for nearly
one hundred million records being exposed
(Koch, 2016). In one well-publicized security
breach at Banner Health, where hackers gained
entrance through food and beverage computers,
approximately 3.7 million individuals'

information was accessed, much of it health
information (Goedert, 2016).
Health information privacy and security are
key topics for health care administrators. In
today's
ever-increasing electronic world, where the
Internet of Things is on the horizon and
nearly every
health care organization employee and visitor
has a smart mobile device that is connected
to at
least one network, new and more virulent
threats are an everyday concern. In this
chapter we
will examine and define the concepts of
privacy, confidentiality, and security as they
apply to
health information. Major legislative efforts,
historic and current, to protect health care
information are outlined, with a focus on the
Health Insurance Portability and Accountability
Act
(HIPAA) Privacy, Security, and Breach
Notification rules. Different types of threats,
intentional
and unintentional, to health information will be
discussed. Basic requirements for a strong
health
care organization security program will be
outlined, and the chapter will conclude with
the
cybersecurity challenges in today's environment
of mobile and cloud-based devices, wearable
fitness trackers, social media, and remote
access to health information.

Privacy, Confidentiality, and Security Defined
As stated, privacy is an individual's right to
be left alone and to limit access to his
or her health
care information. Confidentiality is related to
privacy but specifically addresses the expectation
that information shared with a health care
provider during the course of treatment will
be used
only for its intended purpose and not
disclosed otherwise. Confidentiality relies on
trust. Security
refers to the systems that are in place to
protect health information and the systems
within
which it resides. Health care organizations
must protect their health information and health
information systems from a range of potential
threats. Certainly, security systems must protect
against unauthorized access and disclosure of
patient information, but they must also be
designed to protect the organization's IT
assets—such as the networks,hardware, software,
and
applications that make up the organization's
health care information systems—from harm.
Legal Protection of Health Information
There are many sources for the legal and
ethical requirements that health care professionals
maintain the confidentiality of patient
information and protect patient privacy. Ethical
and
professional standards, such as those published
by the American Medical Association and
other organizations, address professional conduct

and the need to hold patient information in
confidence. Accrediting bodies, such as the
Joint Commission, state facility licensure rules,
and
the government through Centers for Medicare
and Medicaid, dictate that health care
organizations follow standard practice and state
and federal laws to ensure the confidentiality
and security of patient information.
Today, legal protection specially addressing the
unauthorized disclosure of an individual's health
information generally comes from one of three
sources (Koch, 2016):
Federal HIPAA Privacy, Security, and Breach
Notification rules
State privacy laws. These laws typically apply
more stringent protections for information related
to specific health conditions (HIV/AIDS, mental
or reproductive health, for example).
Federal Trade Commission (FTC) Act consumer
protection, which protects against unfair or
deceptive practices. The FTC issued the Health
Breach Notification Rule in 2010 to require
certain businesses not covered by HIPAA,
including PHR vendors, PHR-related entities, or
third-party providers for PHR vendors or PHR-
related entities to notify individuals of a
security
breach.
However, there are two other major federal
laws governing patient privacy that, although

they
have been essentially superseded by HIPAA,
remain important, particularly from a historical
perspective.
The Privacy Act of 1974 (5 U.S.C. §552a;
45 C.F.R. Part 5b; OMB Circular No. A-108
[1975])
Confidentiality of Substance Abuse Patient
Records (42 U.S.C. §290dd- 2, 42 C.F.R.
Part 2)
The Privacy Act of 1974
In 1966, the Freedom of Information Act
(FOIA) was passed. This legislation provides
the
American public with the right to obtain
informationfrom federal agencies. The act covers
all
records created by the federal government,
with nine exceptions. The sixth exception is
for
personnel and medical information, “the
disclosure of which would constitute a clearly
unwarranted invasion of personal privacy.” There
was, however, concern that this exception to
the FOIA was not strong enough to protect
federally created patient records and other
health
information. Consequently, Congress enacted the
Privacy Act of 1974. This act was written
specifically to protect patient confidentiality only
in federally operated health care facilities, such
as Veterans Administration hospitals, Indian
Health Service facilities, and military health
care
organizations. Because the protection was limited

to those facilities operated by the federal
government, most general hospitals and other
nongovernment health care organizations did not
have to comply. Nevertheless, the Privacy Act
of 1974 was an important piece of
legislation, not
only because it addressed the FOIA exception
for patient information but also because it
explicitly stated that patients had a right to
access and amend their medical records. It
also
required facilities to maintain documentation of
all disclosures. Neither of these things was
standard practice at the time.
Confidentiality of Substance Abuse Patient
Records
During the 1970s, people became increasingly
aware of the extra-sensitive nature of drug
and
alcohol treatment records. This led to the
regulations currently found in 42 C.F.R. (Code
of
Federal Regulations) Part 2, Confidentiality of
Substance Abuse Patient Records. These
regulations have been amended twice, with the
latest version published in 1999. They offer
specific guidance to federally assisted health
care organizations that provide referral, diagnosis,
and treatment services to patients with alcohol
or drug problems. Not surprisingly, they set
stringent release of information standards,
designed to protect the confidentiality of

patients
seeking alcohol or drug treatment.
HIPAA
HIPAA is the first comprehensive federal
regulation to offer specific protection to private
health
information. Prior to the enactment of HIPAA
there was no single federal regulation
governing
the privacy and security of patient-specific
information, only the limited legislative
protections
previously discussed. These laws were not
comprehensive and protected only specific groups
of individuals.
The Health Insurance Portability and
Accountability Act of 1996 consists of two
main parts:
Title I addresses health care access,
portability, and renewability, offering protection
for
individuals who change jobs or health
insurance policies. (Although Title I is an
important piece
of legislation, it does not address health
care information specifically and will therefore
not be
addressed in this chapter.)
Title II includes a section titled,
“Administrative Simplification.”
The requirements establishing privacy and
security regulations for protecting individually
identifiable health information are found in

Title II of HIPAA. The HIPAA Privacy Rule
was
required beginning April 2003 and the HIPAA
Security Rule beginning April 2005. Both rules
were subsequently amended and the Breach
Notification Rule was added as a part of
the
HITECH Act in 2009.
The information protected under the HIPAA
Privacy Rule is specifically defined as PHI,
which is
information that
Relates to a person's physical or mental
health, the provision of health care, or the
payment for
health care
Identifies the person who is the subject of
the information
Is created or received by a covered entity
Is transmitted or maintained in any form
(paper, electronic, or oral)
Unlike the Privacy Rule, the Security Rule
addressed only PHI transmitted or maintained
in
electronic form. Within the Security Rule this
information is identified as ePHI.
The HIPAA rules also define covered entities
(CEs), those organizations to which the rules
apply:
Health plans, which pay or provide for the
cost of medical care
Health care clearinghouses, which process health

information (for example, billing services)
Health care providers who conduct certain
financial and administrative transactions
electronically (These transactions are defined
broadly so that the reality of HIPAA is
that it
governs nearly all health care providers who
receive any type of third-party reimbursement.)
If any CE shares information with others, it
must establish contracts to protect the shared
information. The HITECH Act amended HIPAA
and added “Business Associates” as a category
of CE. It further clarified that certain
entities, such as health information exchange
organizations,
regional health information organizations, e-
prescribing gateways, or a vendor that contracts
with a CE to allow the CE to offer a
personal health record as a part of its
EHR, are business
associates if they require access to PHI on
a routine basis (Coppersmith, Gordon, Schermer,
&
Brokelman, PLC, 2012).
HIPAA Privacy Rule
Although the HIPAA Privacy Rule is a
comprehensive set of federal standards, it
permits the
enforcement of existing state laws that are
more protective of individual privacy, and
states are
also free to pass more stringent laws.

Therefore, health care organizations must still
be familiar
with their own state laws and regulations
related to privacy and confidentiality.
The major components to the HIPAA Privacy
Rule in its original form include the
following:
Boundaries. PHI may be disclosed for health
purposes only, with very limited exceptions.
Security. PHI should not be distributed without
patient authorization unless there is a clear
basis
for doing so, and the individuals who
receive the information must safeguard it.
Consumer control. Individuals are entitled to
access and control their health records and
are to
be informed of the purposes for which
information is being disclosed and used.
Accountability. Entities that improperly handle
PHI can be charged under criminal law and
punished and are subject to civil recourse as
well.
Public responsibility. Individual interests must
not override national priorities in public health,
medical research, preventing health care fraud,
and law enforcement in general.
With HITECH, the Privacy Rule was expanded
to include creation of new privacy requirements
for HIPAA-covered entities and business
associates. In addition, the rights of individuals
to
request and obtain their PHI are strengthened,
as is the right of the individual to prevent

a health
care organization from disclosing PHI to a
health plan, if the individual paid in full
out of pocket
for the related services. There were also
some new provisionsfor accounting of disclosures
made through an EHR for treatment, payment,
and operations (Coppersmith et al., 2012).
The HIPAA Privacy Rule attempts to sort
out the routine and nonroutine use of health
information by distinguishing between patient
consent to use PHI and patient authorization
to
release PHI. Health care providers and others
must obtain a patient's written consent prior
to
disclosure of health information for routine
uses of treatment, payment, and health care
operations. This consent is fairly general in
nature and is obtained prior to patient
treatment.
There are some exceptions to this in
emergency situations, and the patient has a
right to
request restrictions on the disclosure. However,
health care providers can deny treatment if
they
feel that limiting the disclosure would be
detrimental. Health care providers and others
must
obtain the patient's specific written authorization
for all nonroutine uses or disclosures of PHI,
such as releasing health records to a school
or a relative.

Exhibit 9.1 is a sample release of
information form used by a hospital, showing
the following
elements that should be present on a valid
release form:
Patient identification (name and date of birth)
Name of the person or entity to whom the
information is being released
Description of the specific health information
authorized for disclosure
Statement of the reason for or purpose of
the disclosure
Date, event, or condition on which the
authorization will expire, unless it is revoked
earlier
Statement that the authorization is subject to
revocation by the patient or the patient's
legal
representative
Patient's or legal representative's signature
Signature date, which must be after the date
of the encounter that produced the information
to be
released
Health care organizations need clear policies
and procedures for releasing PHI. A central
point
of control should exist through which all
nonroutine requests for information pass, and
all
disclosures should be well documented.
In some instances, PHI can be released

without the patient's authorization. For example,
some
state laws require disclosing certain health
information. It is always good practice to
obtain a
patient authorization prior to releasing
information when feasible, but in state-mandated
cases it
is not required. Some examples of situations
in which information might need to be
disclosed to
authorized recipients without the patient's consent
are the presence of a communicable disease,
such as AIDS and sexually transmitted
diseases, which must be reported to the state
or county
department of health; suspected child abuse or
adult abuse that must be reported to
designated
authorities; situations in which there is a
legal duty to warn another person of a
clear and
imminent danger from a patient; bona fide
medical emergencies; and the existence of a
valid
court order.
The HIPAA Security Rule
The HIPAA Security Rule is closely connected
to the HIPAA Privacy Rule. The Security
Rule
governs only ePHI, which is defined as
protected health information maintained or
transmitted in
electronic form. It is important to note that
the Security Rule does not distinguish between

electronic forms of information or between
transmission mechanisms. ePHI may be stored
in
any type of electronic media, such as
magnetic tapes and disks, optical disks, servers,
and
personal computers. Transmission may take place
over the Internet or on local area networks
(LANs), for example.
The standards in the final rule are defined
in general terms, focusing on what should be
done
rather than on how it should be done.
According to the Centers for Medicare and
Medicaid
Services (CMS, 2004), the final rule specifies
“a series of administrative, technical, and
physical
security procedures for covered entities to use
to assure the confidentiality of electronic
protected health information (ePHI). The
standards are delineated into either required or
addressable implementation specifications.” A
required specification must be implemented by
a
CE for that organization to be in
compliance. However, the CE is in compliance
with an
addressable specification if it does any one
of the following:
Implements the specification as stated

Implements an alternative security measure to
accomplish the purposes of the standard or
specification
Chooses not to implement anything, provided it
can demonstrate that the standard or
specification is not reasonable and appropriate
and that the purpose of the standard can
still be
met; because the Security Rule is designed
to be technology neutral, this flexibility was
granted
for organizations that employ nonstandard
technologies or have legitimate reasons not to
need
the stated specification (AHIMA, 2003)
The standards contained in the HIPAA Security
Rule are divided into sections, or categories,
the
specifics of which we outline here. You will
notice overlap among the sections. For
example,
contingency plans are covered under both
administrative and physical safeguards, and access
controls are addressed in several standards and
specifications.
The HIPAA Security Rule
The HIPAA Security Administrative Safeguards
section of the Final Rule contains nine
standards:
1. Security management functions. This standard
requires the CE to implement policies and
procedures to prevent, detect, contain, and
correct security violations. There are four
implementation specifications for this standard:

Risk analysis (required). The CE must conduct
an accurate and thorough assessment of the
potential risks to and vulnerabilities of the
confidentiality, integrity, and availability of ePHI.
Risk management (required). The CE must
implement security measures that reduce risks
and
vulnerabilities to a reasonable and appropriate
level.
Sanction policy (required). The CE must apply
appropriate sanctions against workforce
members who fail to comply with the CE's
security policies and procedures.
Information system activity review (required).
The CE must implement procedures to regularly
review records of information system activity,
such as audit logs, access reports, and
security
incident tracking reports.
Assigned security responsibility. This standard
does not have any implementation
specifications. It requires the CE to identify
the individual responsible for overseeing
development of the organization's security
policies and procedures.
Workforce security. This standard requires the
CE to implement policies and procedures to
ensure that all members of its workforce
have appropriate access to ePHI and to
prevent those
workforce members who do not have access
from obtaining access. There are three
implementation specifications for this standard:
Authorization and/or supervision (addressable). The
CE must have a process for ensuring that
the workforce working with ePHI has adequate

authorization and supervision.
Workforce clearance procedure (addressable). There
must be a process to determine what
access is appropriate for each workforce
member.
Termination procedures (addressable). There must
be a process for terminating access to ePHI
when a workforce member is no longer
employed or his or her responsibilities change.
Information access management. This standard
procedures for authorizing access to ePHI.
There are three implementation specifications
within
this standard. The first (not shown here)
applies to health care clearinghouses, and the
other two
apply to health care organizations:
Access authorization (addressable). The CE must
have a process for granting access to ePHI
through a workstation, transaction, program, or
other process.
Access establishment and modification
(addressable). The CE must have a process
(based on
the access authorization) to establish, document,
review, and modify a user's right to access
a
workstation, transaction, program, or process.
Security awareness and training. This standard
requires the CE to implement awareness and
training programs for all members of its
workforce. This training should include periodic

security
reminders and address protection from malicious
software, log-in monitoring, and password
management. (These items to be addressed in
training are all listed as addressable
implementation specifications.)
Security incident reporting. This standard
procedures
to address security incidents.
Contingency plan. This standard has five
implementation specifications:
Data backup plan (required)
Disaster recovery plan (required)
Emergency mode operation plan (required)
Testing and revision procedures (addressable);
the CE should periodically test and modify
all
contingency plans
Applications and data criticality analysis
(addressable); the CE should assess the relative
criticality of specific applications and data in
support of its contingency plan
Evaluation. This standard requires the CE to
periodically perform technical and nontechnical
evaluations in response to changes that may
affect the security of ePHI.
Business associate contracts and other
arrangements. This standard outlines the
conditions
under which a CE must have a formal
agreement with business associates in order to
exchange ePHI.
The HIPAA Security Physical Safeguards section
contains four standards:

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