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ERP Systems in Hospitals: A Case Study

Article  in  Journal of Information Technology Research · October 2010

DOI: 10.4018/jitr.2010100103 · Source: DBLP

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P a g e |104 Vol. 10 Issue 2 (Ver 1.0), April 2010 Global Journal of Management and Business Research

ERP Systems In Hospitals: A Case Study

Dr. Bernabé Escobar1 GJMBR Classification (FOR)
150402 150505
Dr. Tomás Escobar,2

Abstract- Purpose In this study, the process of ERP systems have a modular structure, which means that
implementation of ERP systems in hospitals is analysed, as an different combinations of modules can be utilized in
organisation with divided and heterogeneous functional areas. function of the needs of the company.
The purpose is to identify the principal technological These properties, together with the evolution of the
objectives that were set in the process of implementation, technologies of information and communication, and the
which of those objectives were achieved, and the deficiencies
that have subsequently become evident.
need for integration, have led to increasing interest in ERP
Design/methodology/approach – A case study approach is
as a tool for coordinating the management of different
used. The primary form of data collection was interviews with organisational units (Sikora and Shaw, 1998; Al-Mashari,
managers participating in the implementation and internal 2001).
documentation. For Newell et al. (2002), ERP systems represent a new
Findings – In a hospital, different groups of individuals class of information system designed to help integrate all
(basically the clinicians and the managers) co-exist, and each the key areas of activity of a company, particularly the
group has the capacity and authority to exert pressures during financial, productive and human resources functions. Thus,
the process of implementation of an ERP system. from the point of view of companies, ERP systems could be
Practical implications – The results may provide guidance to considered the most important development of the 1990's:
solve problems during ERP systems implementation in
according to some authors, even more significant than the
organisations in which highly differentiated functional areas
exist.
Internet and electronic commerce (Davenport, 1998). The
Originality/value – ERP systems have demonstrated their appearance of ERP marked a trend towards the acquisition
efficacy in a good number of of standardised information systems, rather than tailor-
companies, the more notable among which are companies with made systems designed to meet the specific needs of a
a large geographic spread. However, there isn‟t much particular organisation (Scheer and Habermann, 2000).
evidence in As a consequence of the division in functional areas,
organisations with differentiated functional areas. Often such traditional information systems were focused on supporting
areas have traditionally had independent information systems each functional area, and only rarely did they ensure that
and control over the interests of their area, such as, for data flowed smoothly between the different functional
example, hospitals. areas. This was aggravated by the fact of that the
Keywords-ERP, hospitals, integration. information systems of each area had, in many cases, been
developed independently, with data formats that were
I. INTRODUCTION incompatible or did not meet the information needs of the
rest of the processes of the business (Scheer and
A mong the factors that have been characterising the
business environment in recent years are increased
competitively between companies, the rapidity of
Habermann, 2000).
An ERP system overcomes these disadvantages by
technological change, shortened product life cycles, integrating the information from the different departments
increasing use of subcontracting, the flattening of and subsidiaries of the company in one single database
traditional bureaucratic structures in organisations, and the accessible to the whole organisation (Shang and Seddon,
growing importance of the communications media as a 2002). When a datum is entered in the ERP system by any
result of the globalisation of markets. Largely as a result of organisational unit, it is immediately available for use by
this situation many companies have decided to implement the rest of company's organisational units. In respect of this
ERP systems as one means of confronting the new key feature, Gattiker and Goodhue (2000) state that this
challenges and threats they face. (Robinson and Wilson, integration brings about an improvement in the flows of
2001; Fan et al., 2000). information between the various organisational units and
The reasoning behind this decision is that ERP is reduces administrative costs, since fewer tasks have to be
considered particularly appropriate since it brings together performed to obtain any particular piece of information.
three properties essential for adapting to a business Thus, for a large multinational firm, an ERP system
environment of this type (Chen, 2001): essentially represents a means of homogenising the work
ERP systems provide a multifunctional perspective that procedures utilised by its units, which should lead to
encompasses the various different areas of the company greater agility in responding to market demands and
(Finance, Inventory, Sales, etc.) reduced inventory levels (Davenport, 1998).
Since they are integrated systems, the same items of data Botta-Genoulaz et al. (2005) carried out a review of the
can be shared by different areas. literature on ERP systems during the period 1996-2004, in
Global Journal of Management and Business Research Vol. 10 Issue 2 (Ver 1.0), April 2010 P a g e | 105

which they reported an increased number of studies Thus, if the likely re-structuring that will be required is not
published in recent years, and identified different categories properly taken into account in the process of design of the
in function of the area of interest of these studies: ERP (Molla and Bhalla, 2006), when the time comes to
Implementation of ERP systems. This category includes carry out the campaign of awareness and training needed
those studies associated with the various stages in the the process of implementation could lead employees to
implementation of an ERP system, the problems associated adopt postures of resistance to the change, for fear of the
with the process of implementation, the conditions unknown or simply due to the sensation of displacement
necessary for the process to be successful, and the reasons that some members of the organisation will feel.
why the process sometimes ends in failure. Experiences of the implementation of ERP systems in the
Optimisation of ERP systems. The idea underlying this type public sector have also been described (Gulledge and
of study is that the process of implementation does not end Simon, 2005). Watson et al. (2003) describe the
when the system is first put into effective operation: in the implementation of ERP systems in the State Government of
post-implementation period it is essential to analyse the Louisiana. They conclude that the management and
activities that the system is intended to support, in order to collaboration of the diverse groups involved were perhaps
optimise the system and thus obtain the expected the most difficult aspects of this implementation. Within
competitive advantages. the public sector, hospitals are especially interesting given
Management by means of the ERP system. These studies their particular characteristics. In this area, several studies
focus on considering the ERP system as a management have already been conducted, such as those of Trimmer et
tool, describing the changes that take place in the al. (2002) and of McGinnis et al. (2004). Rubin (1999)
management of companies that install an ERP system, analysed the use of ERP systems for improving the process
against other aspects that do not change as expected. of materials management in hospitals, and described the
ERP Software. These are studies that approach the topic success represented by the integration of the whole supply
from the systems perspective, in which various analyses are chain in one single system.
made of the aspects associated with the processing of However, difficulties arise when the management wishes to
information, the inter-operativity of the ERP system with extend the scope of the information system to include all
the other systems in use in the organisation, and the the information that is generated in the hospital. In effect, a
adaptation of standard systems to the individual needs of hospital needs an integral system of analysis, planning and
the company. control that allows the procedures that have to be applied to
ERP and the management of the supply chain. These the patients to be planned and executed in parallel with the
studies analyse the use of ERP systems in the context of provision of the capacity required (Merodea et al., 2004).
companies that form an integral part of an existing supply On this point, according to Khoumbati et al. (2006), studies
chain. have to be carried out to analyse how to increase the
Of the five categories of study identified, we consider the capacity of the existing information systems at the same
aspects associated with the process of implementing the time as reducing the costs of integration of the information.
ERP system, particularly in a large complex organisation, In addition to the complexity of the services that are
to be crucial. Serious problems can arise in organisations in provided, a hospital will contain groups of people with the
which highly differentiated functional areas exist; often capacity and power to exert pressures during the process of
such areas have traditionally had a high degree of implementation of the ERP system. This makes it important
autonomy, with independent information systems and to investigate the effects that the decision to adopt an ERP
independent control over the interests of their area. system will have on the hospital as an organisation, and on
Hospitals are one example of such organisations. In these such groups in particular. In this study an analysis is made
sectors, the success of the implementation process depends of the process of implementation of an ERP system in a
largely on the top management giving continuous active hospital, as an example of an organisation with divided and
support to the project, and on the commitment of managers heterogeneous functional areas. The method used is the
to the concept of integrating functions and improving case study. The purpose of the study is to identify the
operating processes (Berchet and Habchi, 2005). repercussions of the influence of the different functional
Achieving the participation, collaboration and acceptance areas that coexist in a hospital, basically the clinical area
of all the members of the organisation is, without doubt, and the administrative management, whose personnel have
one of the principal factors that are critical for the traditionally employed information and control systems
successful implementation of an ERP system. Akkermans independently of each other. By employing this strategy of
and Van Helden (2002) state that, during the process of qualitative research, an analysis is made of the principal
implementation, interdepartmental collaboration and objectives that were set in the process of ERP
communication will be reinforced if the top managers, the implementation, the successes that were achieved and the
project managers and software suppliers all demonstrate a deficiencies that have subsequently been demonstrated.
positive attitude. In many cases the tasks of leadership are Specifically, the following sub-objectives are established
really important and delicate, because the introduction of To determine what were the prior expectations of those
the ERP system in the company will modify procedures responsible for the hospital in respect of the
within the company and the job functions of some of the implementation of the ERP system.
employees, at all levels, will change.
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To analyse the system design and subsequent process of of the hospital and identify the flows of information that
implementation to determine if the terms, objectives and should be included in the ERP system. The interviews have
initial expectations were met. also enabled us to seek and obtain the opinions of a
To check whether the heterogeneity of the various pressure representative of each of the groups involved in the process
groups that coexist in every hospital, with their different of implementation.
visions in respect of the hospital's role, has had some Direct observation of the management and operating
influence on the implementation of the system, and how behaviour in the different areas during the implementation
that influence affected it. of the ERP and once the process had been completed.
Participative observation in the working meetings held with
II. THE CASE STUDY APPROACH
the managers responsible for the various different areas of
It was decided to use the case study as our research method the hospital. Here we were able to identify the needs,
because the design, development and implementation of an problems, concerns, etc., related to the utilisation of the
ERP cannot be fully understood in isolation of its context, ERP system.
and therefore a contextual approach is necessary.
Unlike other empirical research methods, the case study III. DESCRIPTION OF THE HSP
permits the analysis of a contemporaneous phenomenon in
The HSP was constituted in 1990 under the juridical form
its real-life context, when the boundaries between the
of a Hospital Foundation. The project plan for the
phenomenon and the context are not clearly differentiated,
construction of the hospital was approved in June 1992.
and when numerous sources of evidence are utilised with
However, the building work did not begin until June 1993.
the object of bringing the research work into closer contact
In December 1996 the legal basis of the constitution of the
with the organisational reality (Hopwood, 1983; Otley and
HSP was changed, and it was brought under a new
Berry, 1994; Scapens, 1990; Tomkins and Groves, 1983;
normative framework dealing with the creation of new
Yin, 1993, 1994). Further, the case study has been
forms of management of the Spanish National Health
recommended as the ideal research methodology for
system.
gaining a better understanding of complex phenomena
The HSP has its own juridical personality, which gives it
(Flynn et al., 1990; McCutcheon and Meredith, 1993; Yin,
considerable autonomy in decision-making. Under this
1993, 1994), and the implementation of an ERP system in
autonomy it is allowed to have its own budget which it can
an organisation with sharply divided functional areas and
administer itself independently. In accordance with its
professional cultures is a very complex phenomenon.
degree of autonomy, it can therefore not only meet its own
We have opted to analyse the implementation of ERP in a
currents costs, including those for its personnel, but it can
hospital since it is an example of an organisation with
also make fixed investments, contract personnel and set
heterogeneous functional areas that are markedly divided,
their salaries.
basically, between clinical personnel and administrative
Once constituted, the HSP's governing body authorised the
managers, who have traditionally been employing
preparation of a Business Plan, which was approved for
information systems designed, implemented and operated
implementation in September 1997. When the HSP started
in a deliberately independent way.
operating as a hospital, one of the basic principles
This particular case has been chosen because it is a hospital
established was that the specification and installation of
(hereinafter referred to as the HPT) that possesses both
technological equipment should be carried out in a properly
administrative and financial management autonomy; in
planned way in accordance with agreed criteria of safety,
effect this means that the management is responsible for
efficacy and efficiency. Thus, in its Business Plan, in the
obtaining optimum effectiveness and efficiency in the
part describing the Organisational Model of the HSP, there
decisions taken. In addition, the opening of the hospital has
is considerable reference to information technologies and
coincided in time with the implementation of the system,
systems. Among the general objectives established, it is
and so it does not represent a change from previously-
stated that information systems constitute the key factor in
established procedures to which the personnel of the centre
this process of strategic development; in fact, the viability
might put up resistance.
of the hospital model to be put into operation, particularly
To obtain the information required for the study, diverse
in respect of its internal relationships, at both the functional
sources of evidence (Yin, 1994) have been utilised:
and strategic levels, is crucially dependent on the
Analysis of internal documentation containing the
development and implementation of information systems.
information utilised for the management of the centre. The
As an unalterable objective the Plan stipulates that the
analysis of this documentation has enabled us to define and
nucleus of information must be the interaction of the patient
delimit the requirements that were specified for
with the organisation and, following from this, the
implementing the ERP system.
integration of the clinical with the financial and cost
Interviews with the centre's most senior managers
information.
responsible for Human Resources and Financial
Thus, in the HSP it is understood that the management of
Accounting, and with the General Management and
information is one of the bases of how the organisation
personnel of the Area of Financial Administration. The
operates (in addition to the human and financial resources),
interviews, conducted both with individuals and with
and that the incorporation of technology is essential in
groups, have enabled us to clarify the goals and objectives
Global Journal of Management and Business Research Vol. 10 Issue 2 (Ver 1.0), April 2010 P a g e | 107

order to handle the information adequately, not only on the complying with the minimum coverage required and as a
strategic and tactical levels, to serve as the support for step towards the definitive integral solution.
decision-making, but also on the operating level, to The competitive bids must take into account explicitly the
facilitate the daily clinical activity. following criteria, all of them essential:
For those responsible for managing the HSP, the Uniqueness of data. The capture of each datum will be
information systems are a set of procedures and functions unique, as will its storage. The design should be relational.
directed towards the collection, production, assessment, Total integration of all the modules.
storage, recovery and distribution of items of information Operative solutions must be provided. The adaptations
within the organisation, orientated to promoting the flow of required to meet the special requirements of the HSP
these items from the points where they are generated to the should be kept to a minimum.
final intended recipients. Therefore, the information There must be uniformity in the operating environments.
systems should be an integral part of the corporate strategy, The winning bid was selected in September 1997. The
since today all organisations are based on information. decision went in favour of a centralised solution for the
A series of criteria were set for the management of the implementation of the ERP system, presented by the
information systems, such as: company "OFFER", who would be responsible for its
The systems will be managed by contracting the services management and integration. The contract specified, among
required from an external company (i.e. by outsourcing). other matters, the final product to be supplied, comprising
To avoid technological incompatibilities and obsolescence, the implementation of 3 modules and 11 applications (all
and to avoid the outlay of funds without being able to take included under the name of the GENESIS Program):
full advantage of resources, the HSP will not invest in Module 1 (META 4 products and implementation):
either hardware or software. The supply contract will Module for Payroll, Personnel Management (Meta4 Mind)
specify the services to be provided and the results to be and Management of Shifts (Meta4 Shifts).
obtained. By this means the technology and the personnel Module 2 (SAP and HP products and OFFER
will at all times be appropriate for the needs of the HSP. implementation):
Modules for Financial & Cost Management (SAP R/3):
IV. CONTRACTING AND IMPLEMENTATION OF THE ERP
SYSTEM IN THE HSP
Supplies (MM), General Accounting (FI), Analytical
Management and Management of Costs (AM and CO),
The management of the HSP prepared detailed technical Payment of Suppliers' Invoices (MM), Inventory
specifications for the contract to provide the ERP system, Management (MM) and Maintenance (PM).
based on the requirements stipulated in the Business Plan. Modules for Supporting Services (HP-HIS): Catering,
Given the imminent entry into operation of the HSP, the Dietetics and Kitchen.
fundamental premise was the need for it to be equipped Executive Information System: Balanced Scorecard EIS
with an integrated system that would enable all the (SAP R/3 EIS and HP-HIS).
appropriate health-care functions to be carried out, and that Module 3 (HP-HIS products and HP implementation):
would constitute the principal tool for the financial and Module for Healthcare Management (HP-HIS:
administrative management of the hospital. Admission of in-patients, Waiting lists, Emergencies and
Competitive tenders were invited with the object of Emergency Boxes, and External Consultations. Also
selecting a single systems integrator capable of providing a included are Electronic Clinical History (HP) and Invoicing
solution for managing the information needs of the HSP. to the Customer (SAP R/3).
The successful bidder would be constituted as the only Modules for Clinical Management (HP-HIS):
interlocutor of the HSP for all matters related to its ERP Management of Operating Theatres, Radiology, Out-
system, and should present its offer with the following patients, Ward Control Points, Control Infrastructure,
requirements: Generation of Medical Reports, Unidose Pharmacy,
Listing of all the subcontracted suppliers and the products Pathology and Nursing Units. Also included are Document
that they are supplying, including the bidder if it will be Manager (HP), Medical Protocols (KPMG) and Laboratory
providing any product that would form part of the global (Behring) applications.
solution. Applications: Laboratory, Dietetics, DOCtor, Gacela,
Details of the way in which the various modules are going Carevue, GPC, Invoicing, Library, Balanced Scorecard,
to be integrated. Pharmacy and Pathology.
Any additional programming that will be needed to ensure In the standard version of each module there is a set of
the complete adaptation to the needs of the HSP. Human interfaces for the exchange of information between them.
and material resources necessary, and the delivery terms to However, this is not the case with the different applications
be met. acquired; for this reason it was necessary to incorporate up
Detailed plan of implementation: phases and timetable, to 11 interfaces, which are described below:
with terms linked to the achievement of levels of Interface I-1: This is the interface between the Personnel
operationality. Module and the Library Management. Its objective is to
On a complementary basis, the systems integrator will load onto the database of the Library the data of the
provide a contingency solution during the transition stage, hospital personnel that are considered necessary for
managing borrowings of publications.
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Interface I-2: This interface exchanges data between the objectives of the company, and identify not only the
Payroll Module and the Financial Accounting Module, with achievements obtained but also deficiencies that have
the object of recording the accounting details necessary for become evident. Since these persons were also active
each Payroll payment. participants in the process of implementation of the system,
Interface I-3: This is similar to the previously described we were also able to determine if the wishes and
interface; its purpose is to exchange data between the expectations generated in respect of the system have been
Payroll Module and the Analytical Accounting Module, fulfilled.
assigning the costs of each payroll item to its corresponding As a preliminary observation, the HSP had, from the very
cost centre. beginning, been conceived of as an organisation which
Interfaces I-4 and I-7: The Patient Care Module is would operate with an ERP system that would facilitate the
generated in function of the data obtained when the patient performance of its patient healthcare activities, its
is admitted to hospital. Therefore, it is necessary to transfer administrative management and its decision-making. Its
information corresponding to each patient. philosophy is to seek the maximum satisfaction of its users,
Interface I-5: From the data of the invoices, which reflect in both the scientific-technical and human aspects of its
the cost of all the services and products that each patient activities. It could be described as a young hospital that
has consumed during their hospitalisation, the total costs of aims every day to offer high quality healthcare, where the
each hospitalisation are determined and these costs are professionals who work in it are considered to be its
assigned to the corresponding units. greatest capital asset. Thus, in the Business Pan formulated
Interface I-6: In the same way as in the previous interface, when it was created, a part was included referring
the costs of each period of hospitalisation are assigned the especially to systems and information technologies; in this
corresponding units; the interface of Invoicing with part, it was stated as a general objective that the nucleus of
Financial Accounting allows the invoicing to be assigned to information must be the interaction of the patient with the
the account of each unit. organisation, and that, on the basis of this source, both the
Interfaces I-8 and I-9: Among their functions, the Nursing clinical and financial/cost information would be integrated.
and Pharmacy Modules support the control of the ward sub- This stipulation was accepted by all the employees, as
stores and orders for supplies placed on the central demonstrated by the following statement of the Sub-
warehouse; therefore interfaces are created that enable both director of Nursing:
the completion of orders placed automatically in function "The integrated system (…) was an objective for this
of the level of stock of certain materials, and the generation hospital; we wanted to have an integrated system of
and shipment of orders placed manually to the Supplies management that will provide us with information. In the
Module. large hospitals the problem they had (…) was the topic of
Interface I-10: This allows modifications to be made to the information; that is, at the level of the administrative
planned capacity of the External Consultations, in function management, the information was being received
of the periods of time that the equipment of each Service is piecemeal from the different departments”.
not available due to maintenance or repair work. However, from the conceptual point of view, the
Interface I-11: This interface allows the localisation of the organisation of the hospital provides its services to certain
electronic file of documents associated with each medical basic clients, the clinicians (doctors and other specialists),
history from the application that manages the Clinical who in turn provide these to the patients, who are therefore
Records. the final clients of the organisation. Thus, the entire
executive organisation is set up in such a way "that the
A. Insert Figure
doctors and specialist medical personnel may perform to
The process of implementation of the ERP system by perfection their work of patient care". The doctors are thus
OFFER began at the end of 1997 and lasted approximately the direct clients of the organisation and are dependent on
6 months. According to the evidence obtained, the the organisation in a strictly functional, not hierarchical,
involvement of the top managers was continuous, and they sense. Hence, the situation in which the doctors consider
kept up the pressure to complete the project on time. themselves to be clients of the HSP and not simple users of
the ERP system, like the rest of the employees, has clearly
V. DISCUSSION
conditioned the implementation of the system.
For the analysis of the evidence obtained, the information is Although the process of implementation of the ERP system
grouped according to the following three phases (Escobar had the support and active participation of the top
et al., 2004): (1) prior or preliminary, (2) implementation management, there was a need to bring together the
and (3) operation. Interviews  were held with the interests of functional areas with different cultures. The
directors responsible for Human Resources and fundamental concern of the doctors and clinical
Accounting, and with the General Management and practitioners is to return their patients to good health,
managers of the Finance and Costs Area of the centre, with whereas the managers are responsible for obtaining
the object of identifying the degree of satisfaction of these efficiency in the utilisation of limited resources. The effect
user groups with the system. The interviews, both of this was that the design of the ERP system was
individual and in groups, enabled us to clarify the goals and orientated towards ensuring the good functioning of each of
the functional areas, separately, rather than towards
Global Journal of Management and Business Research Vol. 10 Issue 2 (Ver 1.0), April 2010 P a g e | 109

establishing an information system in which the source data information to come out as you want, you have to enter it in
only needed to be captured once, in which all the modules the correct way. Well, at the time other things were given
were fully integrated with each other and the system as a priority, and now is the time to change it‖. Lastly, in an
whole, and in which all the operating settings were uniform attempt to find an explanation for this situation, he stated
(the original objectives). Despite a total of 11 interfaces that "the integration with the patient care information is a
having been designed to inter-connect the different modules failure for us because each system in its part (package)
and applications that comprise the HSP's system of functions well". As can be observed, in this statement the
information, in the opinion of the Subdirector responsible Subdirector tacitly accepts the balance of power in the
for financial and cost control, ―if we are speaking of hospital between the clinicians, who are preponderant, and
integration of all the systems, what has failed most is the the managers.
integration between the patient care system and the rest of
the systems not directly related to patient care‖. For his part, the manager responsible for the Accounts
Department stated that "now everything is much more
In consequence, not all the users are equally satisfied with stabilised, but there have been many disputes with the
the results of the process of implementation and with the departments, and we have basic problems that have not
way the information system operates. In this respect, we been solved because at the time they were not put forward
can identify two large groups of users: clinical practitioners correctly". In particular, he complained that ―every time
and administrative managers. that I have to finalise accounts with Pharmacy,
complications!, and many years have gone by like this.
The clinical practitioners have ensured that the part of the When I have any difference and have to investigate, I have
system that they utilise (Modules 1 and 3) cover all their to go to their program, extract data, cross-check the figures
needs. In general terms, those responsible for Patient Care with mine, see what they have charged to me and what they
Management, Clinical Management, Human Resources and have not charged to me, trust in what they tell me and then
Payroll are fairly satisfied with the performance of the check it. It's not easy, it's not easy, and then there is a slip, a
system, according to the views expressed by the Medical gap of information, also very important, between one
Subdirector, who stated that "having an Integrated System module and another. (…) In the case of the interfaces there
of Management in this case, in the part of the patient care is information that we are not picking up, and that also is
area, enables you in principle to have everything close to not good". Lastly, there is also the complaint that "the
hand; in other words, to have clear, up-to-date information interface is not transparent. A payroll is transferred to me,
rapidly at your disposal, which is also directly connected but I don't get to see the concepts of the payroll, I do not
with the management of the patient". The Subdirector of see the number of persons. They transfer them to me
Nursing stated: "I believe that we have one of the best grouped by cost centre‖.
integrated systems because, despite some of the
interdepartmental aspects remaining to be done, it is VI. CONCLUSIONS
perfectly integrated, or practically integrated. We only have
In this study we have set out to identify, from a technical or
very little still to do, very little".
technological perspective, the impact of the influence
However, the managers (the users of Module 2) appear
exerted by the various heterogeneous functional areas that
rather unhappy given that they do not receive correctly the
coexist in a hospital, basically differentiated into clinical
information generated in the other modules. On this
and management personnel, and that have traditionally
question, the Subdirector responsible for finances and cost
been accustomed to employing information systems that
control emphasised that "the integration between patient
were designed, implemented and operated independently of
care information and cost information did not function as
each other.
we wanted. An ABC system of costing and an advanced
system of clinical guidelines, in which each step was
It has been demonstrated how the very same decision
associated with its cost, were tried and failed. It was not
regarding the type of ERP system to implement has
possible because, in practice, it was very difficult to collect
reflected, from the first moment, the organisational
the information; that is, the guidelines were so detailed that
complexity over which the system had to be implemented.
there was no way the data could flow towards the SAP, no
As can be confirmed in the choice of the design of the
way all this could be handled with the patient care
system and its modular structure, these factors demonstrate
information in detail and was not being received. That was
the not-always coincident interests of the two groups of
where a lot of effort was made and it was not achieved. The
personnel, clinical practitioners and managers, previously
guidelines were prepared, they did not get to be
mentioned.
implemented, and there was no way of collecting this
In the case analysed, evidence is obtained on the attempt
information‖. He also states "well, the financial system is
made to resolve this complexity from the technological
well implemented, but perhaps we lack something in
perspective, by means of the sophisticated set of interfaces
management control, because we have not fully developed
described here. Although all the interfaces were developed,
all its possibilities, and to do that, we now have to take
not all are utilised. In particular, interfaces I-5 and I-6 are
advantage of the change to a new version. Not because each
not currently utilised. These interfaces would allow the
of the tools is not implemented but because, in order for the
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Invoicing module to be related to the General Accounting on ERP systems‖, Computer in Industry, Vol.56,
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correct integration of information between Modules 2 and 5) Davenport, T. (1998): ―Putting the Enterprise into
3. the Enterprise Systems‖, Harvard Business
Despite this, on analysing the degree of satisfaction of the Review, Vol.76 Nº.4, pp. 121-131.
users of the ERP system, in the case of the clinical 6) Escobar, B., Cullen, J. and González, J.M. (2004):
personnel it meets practically 100% of their expectations, ―Impacts of the Implementation of ERP Systems
whereas those responsible for the management of the on Cash Management: The Redesign of Treasury
hospital are found to be rather less satisfied, as they have Processes‖, The International Journal of Digital
not seen their initial expectations fulfilled in respect of the Accounting Research, Vol.4 No.7, pp. 31-55.
system. 7) Flynn, B.B., Sakakibara, S., Schroeder, R.G. and
A plausible explanation for this situation could start from Bates, K.A. (1990): ―Empirical research methods
recognition of the heterogeneity of these two pressure in operations management‖, Journal of Operations
groups, which exist in some form in all hospitals; this Management, Vol.9 No.2, pp. 250-284.
heterogeneity is encapsulated in their respective general 8) Gulledge, T. and Simon, G. (2005): ―The
objectives: effectiveness in healthcare for the clinicians, evolution of SAP implementation environments: A
and organisational efficiency for the managers. This case study from a complex public sector Project‖,
generates a fierce struggle for control of the organisation. Industrial Management + Data Systems, Vol.105
In this framework the process of implementation of the No.5/6, pp. 714-736.
ERP system, seen as a formalised instrument of the 9) Hopwood, A.G. (1983): ―On trying to study
hospital's control system, is taken as an opportunity by the accounting in the context in which it operates‖,
managers to try and increase their degree of control over Accounting, Organization and Society, Vol.8
the organisation and, therefore, to increase their relative No.2/3, pp. 287-305.
power in the hospital. For their part, the clinical personnel 10) Khoumbati, K., Themistocleous, M. and Irani, Z.
interpret the situation basically in a similar way to the (2006): ―Evaluating the Adoption of Enterprise
managers, and their reaction is one of rejection faced with a Application Integration in Health-Care
perceived reduction in their control and power; this Organizations‖, Journal of Management
therefore translates into resistance to key integrative Information Systems, Vol.22 No.4, pp. 69-108.
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In our particular case, that of a newly-established hospital ―Conducting case study research in operations
in which its initial specifications already included the management‖, Journal of Operations
implementation of an integrated system of information, the Management, Vol.11 No.3, pp. 239-256.
resistance shown by the clinical personnel has not been as
radical as a refusal to use the system at all, but has been 12) McGinnis, S.K., Pumphrey, L., Trimmer, K. and
more selective and nuanced. As we have been able to Wiggins, C. (2004): ―A case study in IT
confirm, those modules concerned with basically clinical innovation in a small, rural community hospital‖,
information are being utilised: what the clinicians have Research in Healthcare Financial Management,
succeeded in resisting is the full integration of this clinical Vol.9 No.1, pp. 9-19.
information to allow the ERP system to be used as 13) Merodea, G., Groothuisb, S. and Hasmanb, A.
originally intended by the specifiers. (2004): ―Enterprise resource planning for
hospitals‖, International Journal of Medical
VII. REFERENCES Informatics, Vol.73, pp. 493-501.
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MODULE 2
MODULE 1
Financial and cost management

Human Resources
I-2 Supplies General
Accounting
Personal Shifts

Analytical
Maintenance
Management

Payroll
I-3 Invoicing Inventory
Payroll by suppliers Control

Support
Executive
Catering, Information
Dietetics & System
Kitchen
Balanced
I-1 Scorecard
Library

I-5 I-8 I-10

I-6 I-9

MODULE 3
Patient Care Management Waiting Lists Emergency & External Consultations
Accidents
Client Invoicing
Clinical Electronic
Admissions Patient Care Histories I-11 Files
I-4
I-7
Clinical management Out-patients Pathology Nursing Units

Operating Theatre Pharmacy/Unidose

Management Laboratory Specific Modules
Radiology

Figure 1. Diagram of the implementation of the ERP modules.

Source: Author's own elaboration according to information provided by the HSP.

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