Agile Development as a Change Management Approach in

Healthcare Innovation Projects

Jan Baljé, Anke Carter and Hugo Velthuijsen
Hanze University of Applied Science
Groningen, The Netherlands

Abstract
Although many pilots with new eHealth products have been developed, only very few of these
products reach widespread adoption within healthcare organisations. The literature mentions
a wide range of bottlenecks for the acceptance of new technology in the healthcare industry,
among which insufficient attention for change management and acceptance by intended
users. In this paper, we argue that agile software development, with its practices for user
involvement and product visibility, can be used as a change management approach in
healthcare innovation projects. We compare agile methods with the change approach of
Kotter (1995). As an illustration of our theoretical findings, we describe a development project
of an innovative eHealth application to support the care for persons with intellectual disability.

1. Introduction
The healthcare sector is a challenging field for innovation, with many innovations never achieving
large scale adoption (Heeks 2006, Kaplan, Harris-Salamone 2009). Innovative ideas are often
developed as proof-of-concepts but subsequently do not lead to a lasting change within the
organisations involved. With the ever increasing pressure on healthcare budgets, the growing
demand for care and the shortage of available staff, there is clearly a need to improve the success
ratio of these innovation projects.

For an innovation to succeed, many critical success factors must be addressed. A general model of
success factors for innovation is provided by the STOF model (Bouwman et al. 2008). This model
organises success factors in four groups: those dealing with Service, Technology, Organisation, and
Finance (see Figure 1). Key is that successful introduction and adoption of innovations in society
requires the development of an overall business model that covers all aspects of the STOF model and
thus creates sufficient value to the intended users and other stakeholders. Omitting any of the
aspects may lead to pitfalls that eventually prevent widespread adoption of an innovation. Critical
success factors mentioned for innovation in healthcare include technology, user acceptance,
financing, and legislation (Kaplan, Harris-Salamone 2009, Broens et al. 2007).

Within the scope of this paper, we focus on one particular success factor: the people side of change
management. This success factor covers the actions that should lead to higher user acceptance of the
developed innovations. In terms of the STOF-model this concerns ensuring that prospective users
understand and accept the added customer value. Since healthcare innovations invariably imply
change for the intended users , chances of promising innovations being embraced are small without
explicit attention for managing the change.
 Figure 1. The STOF model

We have experienced the people side of change management while participating in an innovation
project to develop an expert system for supporting healthcare workers caring for people with
intellectual disability. In this project, we used a so-called agile software development method (see
section 3) to develop the healthcare innovation together with intended users. This agile method
turned out to be a strong driver for the change management process. Prahalad and Ramaswamy
(2004) have argued that the creation of customer value should involve collaboration between the
innovators and prospective users in a development process that essentially becomes a process of co-
creation. Our approach led to such a form of co-creation.

The goal of this paper is to show that agile software development methods can be applied as a
change management approach to achieve user acceptance and innovation adoption. We show this
by comparing agile methods with theory from the field of change management and providing an
illustration from practice.

In the remainder of this paper, we first discuss change management, in particular literature on
change management in healthcare innovations and the theory of Kotter (1995). We then introduce
agile software development methods in section 3, followed by the main contribution of this paper, a
comparison of the agile method Scrum against Kotter’s theory. In Section 4, we illustrate our findings
by describing the abovementioned innovation project and the effects on the intended users and
management of the healthcare organisation. Section 5 contains the conclusion and discussion.

2. Change Management
In this section we first introduce some theories on change management to be able to assess the
applicability of agile software development methods as a change management approach. Based
upon the characteristics of typical eHealth innovation projects we select Kotter’s change
management model to compare the agile methods with.
2.1. Change management in Healthcare Information Technology
Healthcare organizations face a number of challenges that force them to change: increasing pressure
on budgets, a growing demand for care and an increasingly tighter job market. As Stace and Dunphy
(1991) showed, change ranges from incremental fine tuning to radical transformation, where more
radical changes have greater impact on an organization and its members. The magnitude and
diversity of the challenges in healthcare are such that they cannot be faced with relatively small
adjustments but require radical changes in the form of innovations. Innovations usually require
major changes for individuals in organizations. The implementation of new ways of working requires
people to explore previously unknown ways of working and adopt these as their new day-to-day
standards. Changes like these do not come easily, but need to be supported by deliberate change
management. This is even more true for the the healthcare sector since it has a number of specific
complicating characteristics, such as a wide range of roles, responsibilities and disciplines, the
legislation and regulations involved, highly disciplined professionals who are trained to follow
protocol, and the costs in case of failure (LeTourneau 2004). As this paper focuses on the intersection
of healthcare, change management and informatics, we will use the definition of change
management by Lorenzi (2003): “the process of assisting individuals and organizations in passing
from an old way of doing things to a new way of doing things”.

On an organizational level, change management literature has two main theoretical approaches:
planned and emergent change (Burnes 2009, Palmer, Dunford & Akin 2008). Planned change
approaches describe a clearly defined goal, are top-down and use strict control mechanisms such as
project management. Emergent change approaches describe a bottom-up process of interaction that
leads to change. Although often positioned as opposing approaches, some consider the combination
of both approaches the best road to achieve organizational change. Two examples of this
complementary approach are Kanter et al.’s (1992) bold strokes and long marches and Beer and
Nohria ‘s (2000) theory E and theory O. Based on the complementary approach both Kanter et al.
(1992) and Kotter (1995) developed a generic plan to facilitate emergent change. These generic plans
contain a sequence of steps. When the steps are followed, the implementation of the desired
changes is a logical outcome. Kotter’s (1995) generic plan, the eight steps, is the most widely used
approach in the field.

On an individual level, organizational change requires individual change. In research on

organizational change, resistance to change is seen as one of the main causes that change does not
“stick” (Kotter 1995, Kanter, Stein & Jick 1992, Beer, Nohria 2000). Resistance to change can be
reduced by enhancing readiness for change. Holt et al. (2007) found that four factors influence the
individual readiness for change: 1. Am I capable to bring about this change (self-efficacy); 2. Are our
leaders committed (management support); 3. Is this the right change for our organization
(appropriateness); and 4. Is the change beneficial to our organization (personal valence). For
transformational changes self-efficacy and management support are confirmed as key factors
(Rafferty, Simons 2006). Self-efficacy is often achieved by end-user involvement or co-creation, as
systems that are co-created better fulfil the user’s needs (Prahalad, Ramaswamy 2004) and the
opportunity to experiment with new ways of working while creating the system adds to individuals
belief in their own capacity (Rafferty, Simons 2006). In recent years a number of papers have
focussed on end-user involvement when developing healthcare innovations (Nies, Pelayo 2010,
Scandurra, Hagglund & Koch 2008, Teixeira, Ferreira & Santos 2012). Some have even gone so far as
to title users as heterogeneous engineers (Roed, Ellingsen 2011).

Innovation projects in eHealth typically share a number of characteristics: 1. the transformational

nature as described before, 2. the outcomes of the projects are not exactly known when the projects
are initiated, and 3. some system or software is developed. From the previous paragraphs follows
that approaches for eHealth innovation projects must ensure management support, self-efficacy and
a way to allow for emergence (Burnes 2004). From a software development perspective, the so-
called agile methods have been specifically tailored for projects that have uncertain outcomes and
require user-involvement, as will be explained in section 3. We believe that, apart from their value
for realizing a system, agile development methods can be seen as a valid change management
approach for this kind of changes. To support this statement we will compare agile with the most
widely used change management model for emergent change, Kotter’s eight steps (1995). For
reference, we now give a brief overview of Kotter’s model.

2.2. Kotter’s theory of change management

Kotter focuses on the people aspects as a method for realizing lasting changes in organisations. He
proposes an 8-step model (see Table 1Table 1) which can be divided in three different phases. Kotter Formatte
states that all 8 steps need to be addressed or else it will be difficult to realize the change.

The first phase consists of three steps necessary to create the right climate within the organisation.
Step 1 involves developing a sense of urgency in the people involved. A lacking sense of urgency
occurs when people do not see the necessity of the change. This may lead the people involved to
resist the change because it will drive them out of their comfort zones. Step 2 is to create a guiding
team representing the different stakeholders. This guiding team will be the main force driving the
change. The guiding team needs shared commitment and enough organisational power to take the
necessary decisions. A pitfall for this step is senior management not having a significant role, since
management commitment reflects the urgency of the change. Step number 3 is the creation of a
vision that will guide the change effort. The quality and clarity of the vision can make or break a
change effort.

Creating a climate for change

1. Develop a sense of urgency
2. Building a guiding team
3. Creating a vision
Engaging and enabling the entire organisation
4. Communicating for buy-in
5. Empowering others to act on vision
6. Creating short term wins
Implementing and Sustaining the Change
7. Consolidating and producing more change
8. Institutionalize new approaches
Table 1: Kotter's 8-step model

The second phase in Kotter’s model is Engaging and enabling the entire organisation. This phase
consist of three steps as well, starting with the communication of the vision and the necessary
changes. Frequent communication of the vision and upcoming changes is important to get people
engaged. Obviously, the behaviour of the management and the guiding team is in itself an important
message, they have to “walk the talk”. Step 5 is enabling action through empowering others to act.
When the required changes start to take effect and the ‘early adopters’ start to function in the new
situation, there will be roadblocks, resistance and pitfalls along the way. At this step it is important to
quickly identify and remove these blockades. In Step 6 the short term wins are created. These quick
wins are important to keep the stakeholders motivated and to get the followers on board.

The third phase in Kotter’s model concerns implementing and sustaining the change. This phase
involves scaling up. In Step 7, the early wins are used to remove even more impediments and get
more people involved. In this step the effort should not stopped be too soon or the organisation may
risk losing the momentum. The final step is to connect the new approaches firmly in the
organisational structures such as policies, human resources, or new initiatives.

3. Agile as a change management tool

In this section we introduce agile software development and the Scrum method. We then continue
with the comparison of the Scrum method against Kotter’s model to assess the applicability of Scrum
as a change management approach.

3.1. Agile software development in healthcare

In software development, the last decade has seen the rapid rise of so called agile methods. United
through the formulation of the underlying values in the Agile Manifesto (Beedle et al. 2001) these
methods approach the development of software projects in an iterative, interactive, and exploratory
fashion. The approach is iterative in the sense that new working functionality is produced in so-called
iterations, each delivering fairly small increments. The approach is interactive in the sense that
customer representatives, for example the intended users, get actively involved in evaluating the last
iteration and in planning the contents of the next iteration. The approach is also explorative,
meaning that a full specification only emerges as the consequence of subsequently planned
iterations.

With regard to the agile methods in healthcare a number of papers have been written. Offenbeek
(1996) already suggested the applicability of interactive and iterative methods in situations with a
high resistance potential, to which we categorize healthcare. Krause and de Lusignan (2010) states
that, from the point of usability of clinical applications, agile techniques are more appropriate than
processes that separate developers from users, and test products against theoretical assurance
models. Kitzmiller (2006) presents the agile approach as an improvement and evolution over the
traditional plan-driven approach. For a general academic overview in agile methods we refer to
(Dybå, Dingsøyr 2008, Lee, Xia 2010). Since agile methods are a actively developing field, there is a
continuous need for more rigourous studies (Lee, Xia 2010, Abrahamsson, Conboy & Wang 2009).

The main industry survey (Version One 2010) shows that, at the moment, Scrum is the most widely
used agile method. Scrum is the method we applied in our healthcare project. Below, we describe
the Scrum method and then discuss how Scrum supports the change management steps in Kotter’s
model.

3.2. The Scrum method

Scrum (Schwaber, Beedle 2002) is an approach that emphasizes the project management aspects of
projects where it is difficult to know the full specification of the desired
desired end product at the beginning
of the project and therefore impossible to plan everything at the start of the process.
proces Scrum
originated in software development but is generic
gener enough to be applied lied in other domains. Central to
Scrum is empirical process control
ntrol whereby a self-organising
self ing team continuously inspects and adapts
its own process. Software is developed incrementally in periods of 2-4 2 4 weeks called sprints (see Figure Formatte
1Figure 1).. Features to be implemented in the system are registered in a product backlog.
b At the
sprint planning at the beginning of every sprint, the product owner (aa representative of customers,
management and intended users, users see Figure 2Figure 2) decides through prioritisation
ation which backlog Formatte
items have the highest business value and should be developed in the following sprint. Team
members estimate the amount of work and indicate how much backlog items they can commit to.

Figure 1: Scrum process,, from Lakeworks; Scrum Process; WikiMedia Commons;9 Jan 2009; Web; 20 May
2012
During the sprint, team members coordinate their work through daily stand-up
stand up meetings. One team
member, the Scrum Master,, is in charge of removing any impediments. Progress is tracked using
visual artefacts as a scrum board and a burn down chart.

Every sprint ends with a sprint demo.

demo During the sprint demo the progress of the system is
demonstrated to the stakeholders using the live system. Stakeholders are encouraged to experiment
with it and give feedback. Best practice is to deliver a working product with every increment,
increment since
immediate use increases the feedback during the remainder of the development. After the sprint
demo the team perform a sprint review during which it inspects and adapts itss own process.
 Figure 2: Scrum roles, from microTOOL.de; Scrum Roles; Web; 20 May 2012

Two things are essential in this process with respect to the notion of co-creation. The first is that
sprint demos enforce that the product owner and the building team repeatedly discuss visible and
tangible results that have meaning to both parties. This way a common understanding and even
shared language emerges, where often problem owner and team members come from completely
different disciplines and have difficulty to “speak each other’s language”. The second is that the
problem owner gets to decide each iteration (or sprint) what is to be developed next: this turns the
customer or intended users effectively into co-creators.

3.3. Change Management support through Agile

In this section we explore how the use of agile development methods can benefit change
management. The reverse of this question is outside the scope of this paper and is investigated in
(Hayes, Richardson 2008). We will analyse which parts of Kotter’s model are supported by an agile
approach. Results are summarized in Table 2Table 2. We restrict ourselves to the Scrum method since Formatte
it is widely used in practice and was also used in the project described in Section 4.

The first phase in Kotter’s model (steps 1-3) is developing a climate for change. Scrum does not
support developing the sense of urgency needed to start the actual project. If an organisation does
not yet view the change as important enough to start a project than other ways of developing a
sense of urgency must be applied. But once a project has been started, be it a small size pilot-project
or a full-scale one, Scrum has several supporting constructs. Since the basis of Scrum is a prioritised
product backlog, often projects start with an initial collaborative session with all stakeholders. In
such a session the initial vision is translated into finer grained backlog items which are then
prioritised by the appointed product owner. Such a session contributes to developing a sense of
urgency, building a guiding team and creating a vision. The fact that the first sprint will provide a first
rudimentary working version of the system within the space of weeks and that this can be examined
at the sprint demo also adds to the creation of the vision and the sense of urgency. Good practice is
to have a guiding team of management, healthcare staff and software developers present at the
sprint planning and sprint demo.

Kotter Supported through

Creating a climate for change
1. Develop a sense of urgency (Once a project has been decided upon)
 Periodic sprints, including sprint planning
meetings and sprintdemo’s
Prioritisation of product backlog
2. Building a guiding team Product owner role
Sprint planning meeting
Sprintdemo
3. Creating a vision Initial product backlog
Revisions of product backlog
Sprint planning meetings
Sprintdemo’s
Working product after first sprint
Engaging and enabling the entire organisation
4. Communicating for buy-in Working product after every sprint
Gathering feedback during sprintdemo’s
Possibility to prioritise demonstration items
Emphasis on visibility of progress
5. Empowering others to act on vision Periodic sprints
ScrumMaster role
Working product
6. Creating short term wins Prioritisation backlog
Input through product owner
Implementing and Sustaining the Change
7. Consolidating and producing more Periodic sprints
change Prioritised product backlog
8. Institutionalize new approaches n.a.

Table 2: Agile support for Kotter’s model

The next phase according to Kotter is engaging and enabling the entire organisation. Step 4 concerns
communication, a central principle in agile methods. The progress that is demonstrated through a
working product at the end of every sprint, has a powerful communication effect on the organisation
involved. It is good practice to make the sprint demo open for all interested parties. The fact that it is
possible for the organisation to view an intermediate version of the product and contribute feedback
or concerns adds to the buy-in. Stakeholders can actively participate in the process of change rather
than be confronted with the facts afterwards. Another supporting aspect of Scrum is that the priority
of the development of demonstrators can be adapted as the need arises during the project.
The empowerment to act on the visions (Step 5) is supported in several ways. Part of the process is
to regularly inspect which impediments are holding the project back. Within the development team it
is the task of the Scrum Master to remove these impediments. As far as other project participants are
concerned, the periodic nature of sprints forces them to fulfil their designated tasks quickly. The next
sprint demo and sprint review will quickly point out any impediments within the organisation and
allow for action to be taken. Another factor that improves empowerment to act is the fact that an
early version of the system actually exists, it is not some imaginary system in the future.

How well Scrum supports Kotter’s final phase of implementing and sustaining the change depends on
whether Scrum is still applied at that time or not. If Scrum is still in operation during Steps 7 and 8,
perhaps at a slower rate or with a smaller team, then the above benefits are still in effect. Another
scenario however is that Steps 7 and 8 are disconnected from the development phase, perhaps due
to the time needed to evaluate a pilot system, take decisions or change policy. In such a case there
exists a real risk that the momentum gained during the agile development phase is lost. A common
issue in practice is that agile development has fairly simple rules but requires strong discipline during
execution. When the pressure is off, other priorities often intervene.

We conclude that the characteristics of the Scrum method inherently support change management
in a number of ways. The strong points are in the development of a climate of change once a project
is underway and engaging and enabling the part of the organisation where the change will take
place. The support of Scrum for the third phase (implementing and sustaining the change) depends
on the way the project is run. If this phase involves implementing the system on a larger scale after
the pilot project has been finished then there is a real danger that the momentum created during the
pilot project is lost in the time between.

4. Illustration: developing an Intelligent Monitoring System

In the previous section, we gave a theoretical explanation why the application of agile methods can
be viewed as a valid change management approach. In this section, we offer an illustration of a
project in which we developed an intelligent monitoring system to support the care for persons with
intellectual disability who live semi-autonomously. Firstly, we give a brief description of the setting
and scope of the project. Secondly, we show how we used the Scrum method during the
development of the monitoring system. Thirdly, we discuss how the process and impact were
perceived by the major stakeholders, i.e. the users and the management of the healthcare
institution, to indicate how well the agile approach supported change management.

4.1. The Intelligent Monitoring System (IMS)

The project concerned the care for persons suffering from mild intellectual disability (IQ 50-70).
These clients are ambulatory resident and in general have some form of daytime activity such as
supported work. The NOVO foundation helps the clients with their basic living conditions, such as
safety, security, food and health, and also tries to promote self-reliance and personal development.
As a result of their disability the clients have issues with a sense of time, duration, place, distance,
risk estimation, "if-then" cause-effect, planning, taking action, continuing and finishing activities and
determining errors and / or dangers. Currently, the clients are mainly supported through human
intervention, in which personal coaches observe, identify and intervene. These personal coaches are
guided in their decisions by treatment plans written by behavioural specialists.

Due to shrinking of the potential workforce in the northern region of the Netherlands, NOVO expects
it will be faced with employee shortage in the future. An Intelligent Monitoring System was
envisioned as a potential solution to this problem. Such a system would be able to monitor the
clients situation and take appropriate interventions where necessary. This allows the client to resolve
the situation and, perhaps, over time learn how to avoid them. This would lighten the workload for
personal coaches, but the main potential benefit is in the shift from reactive care to proactive care.
Another benefit is that this category of clients generally prefers as little human intervention as
possible. If the client can resolve a situation with the help of the monitoring system then the
personal coach need not be notified.

The Intelligent Monitoring System consists of a number of components (see Figure 3Figure 3): Formatte
 • Sensors in the home of the client, i.e. a bed sensor to detect whether a client is in bed or not.
• A rule-based expert system containing rules for certain situations in the home of the client.
In evaluating the rules the system recognizes critical situations based on the received sensor
data and determines which interventions should be applied. These interventions are typically
first sent to the client and escalated to the personal coaches after a number of resends.
• Actuators in the home of the client which can perform an intervention, e.g. playing a sound
clip that tells the client it is time to go to bed or a phone that can be sent text messages.
Physical actuators like closing a window or shutting down a computer are technically feasible
but were not used in the project.
• A user interface for behavioural specialists to define and manage the rules for the clients in
the expert system. To create an Graphical User Interface that allows a healthcare
professional to create generic logical rules was both a technical and an usability challenge.
• A user interface for the coaches to see issues that require their intervention.
• A reporting system with which, among others, the effectiveness of interventions over a
period of time can be traced.

Client
Readings Warnings
Senso
r read
ings
Warnin
gs

Home Day time Activity

Esc
s ala
Rule ted
issu
es
rts Res
R epo olv
ed
issu
es

Behavioural specialist Personal Coach

Figure 3: Intelligent Monitoring System

The introduction of the IMS has major consequences for the organisation and for all stakeholders
involved. The following lists the most significant ones:

• The behavioural specialists would need to learn how to create logical rules to enter in the
expert system. An example of such a rule could be “IF time>=23.00 AND
isActiveInLivingRoom THEN send(timeToGoToBedMessage)”. Over time the specialists would
also need to verify which type of rule is effective for a client with a certain treatment plan.
 • The personal coach on duty needs to be able to interface with the system on a real-time
basis through computer or mobile device to see if there are issues that the client failed to
resolve. If so, the coach contacts the client and helps with resolving the situation. This is an
entirely different workflow than the current one in which there can be multiple days
between a situation, for example the client goes to bed too late, and the symptoms, for
example the supervisor complaining that the client has been late for work this week.
• The clients and their families need to get accustomed to the systems presence in the house
and how to handle notifications. In the pilot project the requirement for a client controlled
shutdown mechanism emerged, future use cases could include the client entering specific
settings.
• The entire process of informing clients and their families about the system, getting consent,
and having third parties perform the installation of the required components turned out to
be a major task for the management.

4.2. The application of Scrum

When choosing a development method for the project, the main factor was the novelty of such a
system for all parties involved. This novelty posed difficulty for the elicitation of requirements.
Determining the correct requirements is a demanding task for any project, let alone for an
interdisciplinary innovative project with healthcare professionals who have to alternate between
their project tasks and operational crisis calls. The importance of these requirements however was
acknowledged by all parties involved and underlined by the signing of intellectual property
agreements. To address the requirements elicitation under uncertainty an agile software
development approach based on the Scrum method was chosen.

The typical Scrum components were implemented in the following ways. The Product Owner position
was performed by an behavioural specialist from NOVO. She was to be the one person in charge of
the requirements, gathered in the product backlog. The Scrum Master role was performed by one of
the authors. He was to ensure that the development process kept working and any impediments
were resolved. The development team consisted of staff and students from the Hanze University of
Applied Science. Care was taken to include expertise on Human Computer Interaction on the team.

The main product development was done in twelve sprints lasting three weeks each. Each sprint was
given an explicit sprint goal. These sprint goals were planned for several sprints upfront but adapted
after every sprint according to new insights. The work in the sprints was guided by the requirements
which were prioritised in the product backlog. The main meeting at the end of every sprint was the
sprint demo. In this meeting the developers presented their results directly to NOVO staff. Senior
management and behavioural specialists were present at the earlier sprint demos since those sprints
involved the rule editor functionality, later on the personal coaches and IT-staff also joined. Sprint
demos started with summarizing the sprint goal and then demonstrating the different backlog items
that had to be realized during the sprint. This demonstration would then trigger discussion about
(dis)advantages of the implemented solution, possible exception scenarios and how to deal with
them, implications for NOVO and their clients, and new ideas for features. Ideas and suggestions
were recorded on the spot to prevent them of getting lost in the following discussion. After the
demonstration and discussion the sprint planning for the next sprint was done. The product backlog,
together with the newly generated ideas, was again prioritised. The long term sprint planning was
reviewed and a decision was made concerning which backlog items were to be developed in the next
sprint. Organisational actions or impediments that were identified during discussion were handled by
management.

Finally, the typical Scrum practices such as daily stand up, scrum board and burn down chart were
applied by the development team, but were not part of the interaction with the product owner.

4.3. Results
In this section we will discuss the effects that applying Scrum had on this project and its stakeholders.
For the NOVO employees this was their first experience with using an agile method. It turned out
that the change management process was stimulated in ways NOVO had not experienced before.
The most significant observations were:

1. Due to quick feedback, NOVO staff were actively engaged. An idea suggested at the a sprint
demo could be implemented by the end of the next sprint.
2. The participants in the sprint demo’s acted as the guiding team. The demo’s ensured that the
entire team had the same vision. This vision was spread through the healthcare organization
during regular meetings and demonstrations.
3. The frequent increments led to a sense of progress prompting the NOVO to take necessary
actions to be ready for the next step.
4. The frequent demo’s gave insight into the effect of the system on their daily work. This often
led to exchanges like “For this to work we will need to change our working process. Let’s plan
a meeting to discuss this with the colleagues.”
5. The ability to steer the project created a sense of ownership. This was no longer a
technological product but a system the users controlled. If any function was not readily
understood this became clear during demonstration and was fixed in the next sprint.
6. Short-term wins and requirements from the work packages on privacy and ethics could be
included in the product backlog during the project.
7. With a working product early in the project there was the possibility to demonstrate the
product to colleagues, clients and family interested in the pilot phase. This led to widespread
familiarity of the project within the organisation.
8. All in all there was a sense of creating value by building expertise jointly

If we compare these observations with Kotter’s model as described in Table 1Table 1 and Table 2Table Formatte
2, we see that the phases Creating a climate for change and Engaging and enabling the entire Formatte
organization (steps 1 to 6) are realized. This coincides with the theoretical analysis as described in
section 3.2. For the project participants these effects came as an additional benefit, the original
reason for selecting Scrum being the novel and unclear requirements.

The main potential problem identified in section 3.2. regarding the phase Implementing and
sustaining the change also surfaced in practice. After the main development work on the product
was done, there was a delay in starting the pilot due to finance discussions. With the dissolving of the
development team the sprint demo’s were abandoned and the momentum declined quickly.
A final confirmation of the effect the agile approach had at NOVO came later. Based on the
experiences in the IMS project the NOVO management decided to incorporate agile practices into
their organisation-wide innovation policy. A company-wide backlog was created, quarterly sprints
were defined and staff was given a large say in the prioritization of tasks. In the first iteration this
new policy resulted in solving issues that had been floating around in the organization for several
years (Molenaar 2011).

5. Conclusion and discussion

In this paper, we have examined the applicability of agile software development methods as a
change management approach. Our comparison with the change management model of Kotter has
shown that the practices of agile methods can facilitate organizations through the necessary steps of
creating a climate of change, engaging and enabling the organization and implementing the change.
In other words, agile practices can be seen as a valid change management approach. The main risk is
that agile methods are generally confined to the development phase, thus leading to a loss of
momentum in the implementing and sustaining of the change. This risk can be mitigated by
continuing agile practices such as iterations and demonstrations in some form throughout the final
phase. These conclusions were illustrated with a real-life project.

Healthcare organizations now have an additional approach at their disposal to address the critical
success factor of change management and user acceptance. Combined with attention to other
critical success factors, such as finance, legislation and organization, this may lead to an improved
success ratio of sorely needed healthcare innovation projects.

The results presented in this paper have a number of limitations. We have chosen to focus on the
Scrum method and did not consider other agile methods such as eXtreme Programming. However,
the underlying values are the same and Scrum is the most widely used method. From the change
management point of view we have chosen to focus on the model of Kotter. This is a widely used
model which fits the type of change management under discussion. However, other models could be
considered.

Another limitation is the amount of practical evidence. The experiences of the participants in the
illustration project support our theoretical analysis, but one individual case cannot be used to make
strong claims. This project was a small scale innovative project in the Netherlands, a large scale
implementation of electronic health records in another country might give different results.
Furthermore there is researcher bias as the authors participated in the project. Finally the data is
secondary, the primary purpose of the project was not to research the relationship between agile
and change management.

Future research could be aimed at systematically investigating healthcare innovation projects with
regard to the impact of the software development method on change management, such as a
longitudinal multi-case study measuring user acceptance when applying agile methods. Further
research on the applicability of agile methods in healthcare projects with different characteristics,
such as size or application type, would also be a valuable contribution.
Acknowledgements
The IMS project was partly funded by the EU (European Fund for Regional Development) and the
province of Groningen (Innovation Action Programme Groningen 2). Partners were healthcare
organisation NOVO and IT system integrator AVICS.

The authors wish to express their gratitude to reviewers and proof readers, both known and
anonymous.

References

Abrahamsson, P., Conboy, K. & Wang, X. 2009, "'Lots done, more to do': the current state of agile
systems development research", European Journal of Information Systems, vol. 18, no. 4, pp.
281-284.

Beedle, M., Bennekum, A.v., Cockburn, A., Cunningham, W., Fowler, M., Highsmith, J., Hunt, A.,
Jeffries, R., Kern, J., Marick, B., Martin, R.C., Schwaber, K., Sutherland, J. & Thomas, D. 2001, ,
Agile Manifesto. Available: http://agilemanifesto.org [2012, 9 April 2012]. Field Cod

Beer, M. & Nohria, N. 2000, "Cracking the Code of Change", Harvard business review, vol. 78, no. 3,
pp. 133-141.

Bouwman, H., Faber, E., Haaker, T., Kijl, B. & De Reuver, M. 2008, "Conceptualizing the STOF model"
in Mobile Service Innovation and Business Models, eds. H. Bouwman, T. Haaker & H. De Vos,
Springer Verlag, Berlin, pp. 31-70.

Broens, T.H.F., Vollenbroek-Hutten, M.M.R., Hermens, H.J., van Halteren, A.T. & Nieuwenhuis, L.J.M.
2007, "Determinants of successful telemedicine implementations: a literature study", Journal of
telemedicine and telecare, vol. 13, no. 6, pp. 303-309.

Burnes, B. 2009, Managing Change : a strategic approach to organisational dynamics, 5th edn, FT
Prentice Hall, Harlow.

Burnes, B. 2004, "Emergent change and planned change -- competitors or allies?", International
Journal of Operations & Production Management, vol. 24, no. 9, pp. 886-902.

Dybå, T. & Dingsøyr, T. 2008, "Empirical studies of agile software development: A systematic review",
Information and Software Technology, vol. 50, no. 9–10, pp. 833-859.

Hayes, S. & Richardson, I. 2008, "Scrum Implementation Using Kotter’s Change Model", Agile
Processes in Software Engineering and Extreme Programming, , pp. 161-171.

Heeks, R. 2006, "Health information systems: failure, success and improvisation", International
journal of medical informatics, vol. 75, no. 2, pp. 125-137.

Holt, D.T., Armenakis, A.A., Field, H.S. & Harris, S.G. 2007, "Readiness for Organizational Change",
Journal of Applied Behavioral Science, vol. 43, no. 2, pp. 232-255.

Kanter, R.M., Stein, B.A. & Jick, T.D. 1992, The challenge of organizational change : how companies
experience it and leaders guide it, Free Press, New York.
Kaplan, B. & Harris-Salamone, K.D. 2009, "Health IT success and failure: recommendations from
literature and an AMIA workshop", Journal of the American Medical Informatics Association :
JAMIA, vol. 16, no. 3, pp. 291-299.

Kitzmiller, R., Hunt, E. & Sproat, S.B. 2006, "Adopting best practices: "Agility" moves from software
development to healthcare project management", Computers, informatics, nursing : CIN, vol.
24, no. 2, pp. 75-82; quiz 83-4.

Kotter, J.P. 1995, "Leading Change: Why Transformation Efforts Fail.", Harvard business review, vol.
73, no. 2, pp. 59-67.

Krause, P. & de Lusignan, S. 2010, "Procuring interoperability at the expense of usability: a case study
of UK National Programme for IT assurance process", Studies in health technology and
informatics, vol. 155, pp. 143-149.

Lee, G. & Xia, W. 2010, "Toward Agile: an Integrated Analysis of Quantitative and Qualitative Field
Data on Software Development Agility", MIS Quarterly, vol. 34, no. 1, pp. 87-114.

LeTourneau, B. 2004, "Managing physician resistance to change", Journal of healthcare management

/ American College of Healthcare Executives, vol. 49, no. 5, pp. 286-288.

Lorenzi, N.M. & Riley, R.T. 2003, "Organizational issues=change", International journal of medical
informatics, vol. 69, no. 2–3, pp. 197-203.

Molenaar, T. 2011, "Innoveren in de Scrum", ICT Zorg, vol. 12, no. 3, pp. 16-17.

Nies, J. & Pelayo, S. 2010, "From users involvement to users' needs understanding: a case study",
International journal of medical informatics, vol. 79, no. 4, pp. e76-82.

Offenbeek, M.A.G.V. & Koopman, P.L. 1996, "Scenarios for system development: matching context
and strategy", Behaviour & Information Technology, vol. 15, no. 4, pp. 250-265.

Palmer, I., Dunford, R. & Akin, G. 2008, Managing organizational change : a multiple perspectives
approach, 2nd edn, McGraw-Hill Higher Education, New York, NY.

Prahalad, C.K. & Ramaswamy, V. 2004, "Co-creation experiences: The next practice in value
creation", Journal of interactive marketing, vol. 18, no. 3, pp. 5-14.

Rafferty, A.E. & Simons, R.H. 2006, "An Examination of the Antecedents of Readiness for Fine-Tuning
and Corporate Transformation Changes", Journal of Business and Psychology, vol. 20, no. 3, pp.
325-350.

Roed, K. & Ellingsen, G. 2011, "Users as Heterogeneous Engineers-The Challenge of Designing

Sustainable Information Systems in Health Care", hicssIEEE Computer Society, , pp. 1.

Scandurra, I., Hagglund, M. & Koch, S. 2008, "From user needs to system specifications: multi-
disciplinary thematic seminars as a collaborative design method for development of health
information systems", Journal of Biomedical Informatics, vol. 41, no. 4, pp. 557-569.

Schwaber, K. & Beedle, M. 2002, Agile software development with Scrum, Pearson international edn,
Pearson Education International, Upper Saddle River, N.J.
Stace, D.A. & Dunphy, D.C. 1991, "Beyond traditional paternalistic and developmental approaches to
organizational change and human resource strategies", International Journal of Human
Resource Management, vol. 2, no. 3, pp. 263-283.

Teixeira, L., Ferreira, C. & Santos, B.S. 2012, "User-centered requirements engineering in health
information systems: a study in the hemophilia field", Computer methods and programs in
biomedicine, vol. 106, no. 3, pp. 160-174.

Version One 2010, , State of Agile Development Survey [Homepage of Version One], [Online].
Available:
http://www.versionone.com/pdf/2010_State_of_Agile_Development_Survey_Results.pdf Field Cod
[2012, 9 April 2012].