Assessing Positive Predictors for Implementation Success: Defining Organizational Readiness for Digital Transformation in Healthcare

by Jennifer Matthews, BIB, RN, BScN, MN, Prosci
Athabasca University
Corresponding author

Kim Burgess RN, BScN, MN, PhD Assistant Professor
Athabasca University

Citation: Matthews, J., & Burgess, K. (2025). Assessing positive predictors for implementation success: Defining organizational readiness for digital transformation in healthcare. Canadian Journal of Nursing Informatics, 20(2). https://cjni.net/journal/?p=14795

Abstract

Digital health transformation is the process of redefining workflow, process, and policy through the digitization of tools and data sets. Healthcare has historically been slow to respond to advances in technology, but the COVID-19 pandemic accelerated digital health tool adoption significantly. Large scale digital health transformation projects are complex, costly, and impact every aspect of an organization; organizational readiness for implementation is of critical importance for the success of the implementation and adoption of novel technology. This narrative literature review aims to define organizational readiness through identification of positive predictors for digital health transformation success. A review of the most recent literature on digital health transformation has yielded five themes: system capacity, organizational capacity, culture and leadership, human resources capacity, project management, and training and adoption. Organizational readiness is difficult to define and assess; however, the five themes and their components allow nurse informaticists and leaders to have foresight in pre-implementation, proactivity during design and build phases, and reaction management for implementation and sustainment. Ultimately, the themes identified in this review are guiding principles, not a detailed road map for success. Further research into standardizing organizational readiness assessments is recommended.

Background

Digital transformation is a phenomenon that has redefined workflow, process, and policy in multiple industries that transcends geographical borders and reinvents how we do what we do (Al-Kahtani et al., 2022; Brommeyer et al., 2024; Kraus et al., 2021; Kruszy?ska-Fischbach et al., 2022; Kutnjak et al., 2020; Michelotto & Joia, 2024; Silva et al., 2022; Tenggono et al., 2024; Yunis et al., 2020). It can be described as the radical evolution of organizations into a cycle of continuous improvement and change, driven by digitization and novel technology (Brommeyer et al., 2024; Silva et al., 2022; Kruszy?ska-Fischbach et al., 2022; Kutnjak et al., 2020). Healthcare has been historically slow to adopt new technologies; however, a tremendous shift in technological growth was necessitated by the COVID-19 pandemic (Iyanna et al., 2022; Lemak et al., 2024). Social distancing precautions drove the advancement of health information technology including telehealth, virtual care, and mobile health management tools. The pandemic also accelerated organizational prioritization of digital transformation projects, evidenced by the massive shift from paper to electronic documentation via the use of clinical information systems (CISs), electronic medical records (EMRs), and electronic health records (EHRs). Health organizations, both in Canada and abroad, have begun to remove barriers and to dedicate resources towards the implementation of digital solutions to create a landscape that fosters this development.

Digital health transformation projects, such as clinical information system or electronic health record implementations, can provide tremendous value for patients, care providers, and leaders through good data, streamlined workflows, and clinical decision support (Al-Khatani et al., 2022; Bilgic & Camdoz Akdag, 2023; Brommeyer & Liang, 2022; Iyanna et al., 2022; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022; Yunis & El-Kassar, 2020). These are also extremely complex, expensive, and have high rates of cost and schedule overruns that negatively impact the delivery of patient care (Francis-Auton et al., 2023; Tenggono et al., 2024). This would suggest that organizations must set-up for success prior to implementation, indicating that a degree of organizational readiness is required. Whether an organization is prepared to implement is of critical importance to the implementation and subsequent adoption of the new technology.

This review focuses on research that highlights the myriad of readiness factors for digital health transformation. Specifically, when considering the significant cost and resource effort required for digital health transformation, how do organizations know when they are ready? What are the success factors associated with readiness for digital health transformation? There are several organizational readiness factors that are positive predictors for successful implementation and adoption of digital health transformation projects that can be assessed (Al-Khatani et al., 2022; Bilgic & Camdoz Akdag, 2023; Brommeyer & Liang, 2022; Brommeyer et al., 2024; Iyanna et al., 2022; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022; Yunis et al., 2020). In the following sections of this paper, the findings of a literature review will be presented and a thematic analysis performed. The implications for nurse informaticists and leaders will be discussed, followed by a case study that will allow readers to apply what was learned by the themes to evaluate a hypothetical healthcare organization’s readiness for a successful implementation.

Literature Review

A narrative approach was used for the review of current research, using CINAHL Plus Full Text and Google Scholar as the primary sources for academic literature. A Boolean search was executed, using the keywords “digital transformation”, “digital readiness”, “organizational readiness” and “digital health”, each yielding several hundred articles. The search was refined by limiting the search to studies that came from full-text, peer-reviewed, scholarly journals. The writers were most interested in research taking place after the onset of the COVID-19 pandemic, so the search was further narrowed to include only articles that were published between 2021 and 2025. While reviewing the literature, the authors were also able to identify several important articles of interest using the snowball method. Additional key words utilized in this search included “electronic health record”, “health technology implementation”, “digital health barriers”, and “digital health benefits”. References were managed using the Zotero citation management software. Ultimately, this effort yielded fifteen (15) articles of substance that have been used as the foundation of this literature review.

Primarily qualitative studies were considered for this review. The articles were relatively evenly split between describing digital transformation in healthcare and digital transformation in heterogenous industries. This was an important inclusion in the research to identify broad themes that emerged irrespective of industry, while also taking note of unique barriers, challenges, and strengths of the healthcare industry specifically.

Thematic Analysis

To perform the thematic analysis, a spreadsheet was created to compare, contrast, and critique the selected studies to determine their quality, appropriateness for inclusion, and to support the study’s thesis statement. Categories of assessment included method, model/theory utilized, sample, strength, limitations, and critical findings. The writers used an inductive approach to analyze the qualitative findings for similarities, differences, and consensus. Through this analysis, five themes of importance were identified from the literature on positive predictors for successful digital health transformation implementation: system capacity, organizational capacity, leadership and change management, human resources capacity, project management, and training and adoption.

Theme 1: System Capacity

There are three major functional components under the theme of system capacity: technical readiness, financial readiness, and governance readiness. Technical readiness is an umbrella term used to describe the state of a health organization’s foundational technology, evaluating network infrastructure, physical infrastructure, cyber security and risk management, current fleet of medical and non-clinical devices, and the scalability of the organization’s information technology support tools (Al-Kahtani et al., 2022; Brommeyer et al., 2024; Iyanna et al., 2022; Kruszy?ska-Fischbach et al., 2022; Kutnjak et al., 2020; Michelotto & Joia, 2024; Yunis et al., 2020). Key considerations in this component include the state of digital corporate tools such as uninterrupted internet access and Wi-Fi, volume of workstations, and age and functionality of legacy software systems (Brommeyer & Liang, 2022; Iyanna et al., 2022; Kraus et al., 2021; Kruszy?ska-Fischbach et al., 2022; Yunis et al., 2020). Positive predictors for implementation in this area included robust cyber security controls, a redundant network protected by firewalls, ubiquitous Wi-Fi, sterling identify management, and compatible computing devices, among others (Brommeyer et al., 2024). Secure Information technology infrastructure must be flexible enough to balance the competing requirements of zero-trust security and privacy requirements with the ability to adjust based on system needs (Kruszy?ska-Fischbach et al., 2022). The use of business and artificial intelligence, cloud computing, the Internet of Things, and big data are further positive predictors for digital transformation readiness (Al-Kahtani et al., 2022; Brommeyer et al., 2024; Iyanna et al., 2022; Kruszy?ska-Fischbach et al., 2022; Kutnjak et al., 2020; Michelotto & Joia, 2024; Yunis et al., 2020).

The second component of this theme is financial readiness. Financial readiness in this context can be difficult to define; however, research would suggest that positive predictors include adequate financial commitment for the lifecycle of the transformation from senior decision and policy makers, personnel budgets for training and adoption, as well as on-going investment for optimization, training, and system improvements (Brommeyer et al., 2024; Francois-Auton, 2023; Kabukye et al., 2020). There is an inclination for health organizations to fund the initial purchase of the driving digital transformational technology, but securing funding for the true total cost of ownership is often woefully underestimated (Kabukye et al., 2020). This results in half-baked attempts that never see true benefits of implementation.

The third component of system capacity is governance; how the project will be operationalized, how decisions will be made, how risks will be addressed, and the associated policies and procedures related therein (Al-Kahtani et al., 2022; Brommeyer et al., 2024). Governance in this context extends from the macro level, describing the political and legal national climate where the digital transformation is taking place, to the meso level, where the organization’s leadership, mission, and priorities must be positively aligned with the project, to the micro level, where individual actors in the system are beholden to the workflows, policies, and procedures that enforce the implementation of the transformational change (Al-Kahtani et al., 2022; Brommeyer et al., 2024; Brommeyer & Liang, 2022). Positive predictors for success in this component include governing federal legislation that protects health information and encourages health systems to digitize, robust resourcing and empowerment of operational teams to execute the project’s requirements, and meticulously and proactively designing and socializing policy and procedure (Al-Kahtani et al., 2022; Brommeyer & Liang, 2022; Brommeyer et al., 2024.)

Theme 2: Organizational Capacity, Culture and Leadership

The second theme identified in the literature was organizational capacity, culture and leadership. This theme has three relevant components: organizational culture, leadership support, and change management. In this context, organizational culture refers to an organization’s identity, values, beliefs and attitudes (Deep, 2023). Organizational culture is an enabling factor for digital health transformation to thrive, particularly when it is developed in tandem with good data stewardship, with a focus on continuous learning and accountability, and together with the development of digital skill acquisition to foster digital readiness (Bilgic & Comdoz Akdag, 2023; Brommeyer et al., 2024; Francis-Auton et al., 2023; Lemak et al., 2024; Michelotto & Joia, 2024; Tenggono et al., 2024). Organizational culture is driven and indirectly defined by the next component, leadership.

Strong leadership for digital health transformation is a critical antecedent; without it, projects are unlikely to succeed (Al-Kahtani et al., 2022; Kutnjak et al., 2020; Lemak et al., 2024; Yunis et al., 2020). Strategic direction must be set, championed, and operationalized by leadership support (Lemak et al., 2024; Silva et al., 2022). Leadership support for digital transformation can take the form of distributed leadership and decision-making so that subject-matter experts are empowered at the workstream level (Brommeyer et al., 2024, Lemak et al., 2024). This is of utmost importance in the design and build of complex digital tools like electronic medical records, where leadership efforts must be focused on macro level issues within the program (Brommeyer & Liang, 2022, Brommeyer et al., 2024; Francis-Auton et al., 2023, Lemak et al., 2024). Francis-Auton et al. (2023) highlighted the vital importance of strategic, supportive leadership. They suggested that the leadership focus should be on the creation of networks led by an intentional mix of designated and distributed decision-makers. These networks are tasked with the creation of continuous feedback loops via timely, authentic, relevant data, with consideration for the organization’s past technological successes and failures to create a learning culture, while engaging physicians and other health professionals, and including patients and their families. Supportive leadership can also be defined by the style adopted and practiced by leaders. Particularly, transformative and servant leadership as these are the styles that recognize the vital importance.

The last component in this theme is change management which refers to the structured, intentional approach of leading teams through organizational change to achieve a predetermined goal (Creasy, 2022). Change management is both a leadership competency, and a psychological necessity to bring teams forward from an entrenched way of doing things, to help them embrace and adopt the necessary skills and behaviours required to realize the intended change (Brommeyer & Liang, 2022; Francis-Auton et al., 2023; Kruszy?ska-Fischbach et al., 2022; Kubukye et al., 2020; Lemak et al., 2024; Silva et al., 2022). At its most basic, digital transformation is a continuous change process, and change management poses the questions, are we ready to change? If not, what do we need to do to get ready? (Iyanna et al., 2022; Kutnjak et al., 2020; Michelotto & Joia, 2024). Kubukye et al., (2020) described four aspects of change as they relate to digital transformation; the change process itself (procedure), the content of the change (technology), the context of the organization (environment), and the individual characteristics of the group targeted for change. Change management becomes an essential positive predictor for digital transformation success when these aspects are well understood by all actors involved: why the digital health transformation is necessary, that it will improve their work, and that teams will receive the support, motivation, training and education, and resources required for adoption (Francis-Auton et al., 2023; Kruszy?ska-Fischbach et al., 2022).

Theme 3: Human Resources Capacity

The third theme identified in the literature surrounds the notion of human resources capacity. Human resources can be a complex entity, as it describes the management of the employee lifecycle, but it also speaks to the sum of the individual parts; the compliment of skills and expertise embodied in the individuals that make up the organization’s work force (Kubukye et al., 2020; Tenggono et al., 2024). Digital health transformation projects and their complexity have high demands on the bandwidth and capacity of teams; teams that are already over-burdened and over-worked in a post-COVID-19 pandemic world (Cohen et al., 2023; Kruszy?ska-Fischbach et al., 2022; Lemak et al., 2024). This theme has three main components, including norms and values, staff readiness, and burnout.

The component of norms and values describes what is important to the aggregate human resources factor in organizations (Brommeyer et al., 2024; Yunis et al., 2020). Closely related to organizational culture, norms and values speaks to the fundamental priorities of a work force, what motivates them, and their collective ability to adjust (Kubukye et al., 2020; Michelotto & Joia, 2024). Norms are a positive predictor for successful digital health transformation projects when employee norms include effective collaboration and communication, agility and continuous learning, innovation and experimentation, accountability and ownership, and transparency and trust (Francis-Auton et al., 2023; Iyanna et al., 2022; Kubukye et al., 2020; Silva et al., 2022). Values that are a positive predictor for digital health transformation projects include collaboration and teamwork, agility and resilience, commitment to continuous learning, patient-centricity, data-driven decision making, evidence based practice and a focus on the human side of change (Brommeyer & Liang, 2022; Kraus et al., 2021; Kubukye, et al., 2020; Yunis et al., 2020).

Staff readiness, the second component of the human resources capacity theme, relates to the collective ability of health human resources to operationalize the change, and to move from planning to implementation. Readiness is notoriously difficult to assess as it is both multifaceted and abstract, while also possessing individual and organizational factors (Bilgic & Camdoz Akdag, 2023; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022; Kutnjak et al., 2020; Micholetto & Joia, 2024; Silva et al., 2022). An important consideration for staff readiness includes psychological and behavioural preparation: are staff willing to make the change? Do they have the tools, resources, and know-how to do it? Although difficult to measure quantitatively, positive predictors for staff readiness include volunteerism for change, collective behaviour-changing efforts, and increased levels of intrapersonal collaboration (Brommeyer et al., 2024; Francois-Auton et al., 2023; Iyanna et al., 2022; Kabukye et al., 2020; Kutnjak et al., 2020; Kruszy?ska-Fischbach et al., 2022; Lemak et al., 2024; Silva et al., 2022). Specifically for digital transformation, staff readiness may be observed via performance indicators such as attitudes towards using technology at work, perceptions of the technology’s usefulness, anticipated difficulty of use, social influence, and the environment in which the technology is to be used (Francois-Auton et al., 2023; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022).

The third component of the human resources capacity theme is the concept of burnout and change fatigue. Burnout in healthcare is a phenomenon that is an observed response to occupational stressors, manifesting as sleep-deprivation, poor job performance, medical errors, poor quality of care, and professional ambivalence (Cohen et al., 2023; Montgomery et al., 2019). Change fatigue can be described as a cynical or exhausted response that individuals experience when experiencing frequent or complex changes (Beaulieu et al., 2023). Even prior to the COVID-19 pandemic, healthcare systems were in crisis with increasing acuity and decreased funding and resources (Beaulieu et al., 2023; Brommeyer & Liang, 2022; Cohen et al., 2023; Lemak et al., 2024; Iyanna et al., 2022). Although the implementation of digital health transformation projects is intended to positively address these system pressures, the effort to respond to the demands of an implementation schedule are significant. Rather than being a positive predictor, burnout and change fatigue are negative predictors for digital health implementation success; however, this can be mitigated over the long-term with a multifaceted approach including transparent communication, adequate training, supportive leadership, a positive organizational culture, and staff involvement (Beaulieu et al., 2023; Montgomery et al., 2019; Cohen et al., 2023).

Theme 4: Project Management

The fourth theme noted in the digital health transformation literature was project management. Digital health transformation projects are enormously complex, requiring the workflow integration of the multidisciplinary team, standardization for documentation and tools, as well as policy and procedure, and the maintenance of an interim-state duality of legacy systems and paper-based records until the project has been completely implemented (Brommeyer & Liang, 2022; Iyanna et al., 2022; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022). There are three components associated with this theme: implementation planning, communications, and continuous improvement.

The first component of this theme is implementation planning. Digital health transformation projects impact every functional area of a healthcare organization, so the project management team must be highly skilled in strategic planning (Kruszy?ska-Fischbach et al., 2022). There are several key aspects to this planning, including project human resources planning for design, training, and implementation support, determining accessibility, appropriateness of the technology for its target audience, and the integration of the novel technology with legacy applications (Brommeyer & Liang, 2022; Iyanna et al., 2022; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022). Positive predictors of success for this component include the project team’s depth of understanding of the problem and its proposed solution, well-documented plans of change, knowledgeable and experienced project planning professionals, strong leadership, and an official digital strategy to guide the organization (Kruszy?ska-Fischbach et al., 2022).

The second component of the project management theme is corporate communication. In this context, corporate communications refer to how information is shared within and outside of the organization and includes strategies to build stakeholder trust, project transparency, and employee engagement. Positive predictors for this component include a well-documented communications strategy for the digital health transformation project, with targeted messaging for specific stakeholder groups as to the status of the project, upcoming milestones, and any calls to action (Iyanna et al., 2022; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022; Yunis et al., 2020).

The third component of the project management theme is continuous improvement. Continuous improvement in the context of digital health transformation relates to the identification, analysis, and improvement of project outcomes whether it is in the software, hardware, human resources, or patient domains (Yunis et al., 2020). Digital transformation projects at their essence must have an established digital culture that puts continuous improvement at the heart of all project activities (Yunis et al., 2020). Positive predictors for continuous improvement include the adoption of an agile methodology for project management approach, the presence of established safety and ombudsmen committees to address patient and provider concerns, and a technical change management process that tracks and prioritizes technical modifications to the technology (Francis-Auton et al, 2023; Kabukye et al., 2020; Silva et al., 2022; Yunis et al., 2020).

Theme 5: Training & Adoption

The final theme noted in the literature for successful digital health transformation project implementation addresses training and adoption. The literature strongly emphasized the criticality of adequate training and adoption activities, yet also cautions that inadequate funding, poor attendance, and insufficient time and practice are common training and adoption pitfalls (Brommeyer & Liang, 2022). End-user training for an implementation of a complex digital health technology requires enormous organizational effort, including well provisioned personnel budgets for the scope and scale of competency-based training (Brommeyer & Liang, 2022; Iyanna et al., 2022). Organizational factors that impact training and adoption include the ability of operations to continue to function while massive training campaigns are underway, the learning mindset of staff, the development of appropriate and compelling training materials, the timing of when training is provided, whether or not there are paid opportunities to practice new skills learned, and whether the practice environment of the proposed implementation matches the future state (Brommeyer & Liang, 2022; Brommeyer et al., 2024; Iyanna et al., 2022; Silva et al., 2022).

Implications for Nurse Informaticists and Leaders

In today’s rapidly evolving healthcare landscape, nurse informaticists and leaders play a critical role in bridging the gap between technology, patient care, and organizational efficiency (Brommeyer & Liang, 2022; Francis-Auton et al., 2023; Kutnjak et al., 2020; Silva et al., 2022; Yunis et al., 2020). It is essential in understanding the implications of digital health transformation on informatics and leadership within nursing to help drive improved patient outcomes, workflow efficiency, and curate evidence-based practice (Lemak et al., 2024; Silva et al., 2022). In the previous section of this paper, the five reigning themes in the literature about successful digital health transformation project implementations were described: system capacity, organizational capacity, culture, and leadership, human resources capacity, project management, and training and adoption. The five themes identified in the literature provide a unique vantage point for the nurse informaticist or leader in an organization considering a large-scale digital health transformation project. The implications for nurse informaticists and leaders will be discussed as it relates to foresight in pre-implementation, proactivity during design and build, and managed reactions during implementation and beyond.

Foresight in Pre-Implementation

The foresight into success factors for implementation provide the nurse informaticist or leader with the context to identify gaps in the current state (Kruszy?ska-Fischbach et al., 2022; Michelotto & Joia, 2024). For example, a nurse manager of a medical in-patient unit who understands the success factor implications in the theme of training and adoption might make a mental note to strategize how to meet operational requirements for patient care, while also moving their entire staff through a just-in-time training program six weeks prior to go-live. This foresight might also prompt them to think about scaling up their pool of casual employees, and to start planning with their local clinical nurse educator. Conversely, the nurse informaticist who understands the success factors for project management may anticipate the need for increased standardization of clinical care and essential data sets.

Proactivity During Design and Build

Once a digital health transformation project is underway, the nurse informaticist or leader who understands the five themes will be better equipped to take ownership of the process, rather than be driven by it (Brommeyer et al., 2024; Kutnjak et al., 2020; Yunis et al., 2024). Nurse leaders who understand the technical readiness component of system capacity could, for example, work together with their vendors and stakeholders to ensure that there is an adequate amount of computing devices that are compatible with the future state workflows introduced by the digital health transformation (Iyanna et al., 2022; Michelotto & Joia, 2024). Nurse informaticists who understand the implications of the governance component of system capacity will expect to interact with a robust change control process to communicate, consider, approve, and execute change requests during the design phase of the project (Brommeyer et al., 2024; Silva et al., 2022).

Managed Reactions During Implementation and Beyond

The nurse informaticist or leader who is familiar with the five themes identified will anticipate and meet challenges with planned mitigations (Brommeyer & Liang, 2022; Francis-Auton et al., 2023; Iyanna et al., 2022; Silva et al., 2022; Yunis et al., 2020). Nurse leaders who understand the staff readiness component of human resource readiness will be able to support their staff through feelings of anxiety and uncertainty in the days leading up to implementation, understanding that for some staff, that is a normal and expected response to change (Brommeyer et al., 2024; Kabukye et al. 2020; Yunis et al., 2020). Nurse informaticists who are familiar with the continuous improvement component of the project management theme will see an influx of incident report tickets and will immediately begin an analysis to determine the root cause, facilitate a break-fix, and flag for official investigation and remediation (Kabukye et al., 2020; Silva et al., 2022; Yunis et al., 2020).

Case Study: Is the General Hospital ready for their site-wide implementation of a new electronic medical record?

The next section of this paper will present a hypothetical healthcare organization, the General Hospital in the Canadian mid-West, that will allow the writers and readers to apply what was learned by the themes to evaluate its readiness for a successful implementation of a clinical information system.

The Patient

Sam couldn’t believe his eyes as he read the morning paper. He took off his glasses and rubbed his eyes. Two hundred million dollars? For a few computers? Surely this was some kind of joke. Sam looked again. The province announced that the General Hospital was going to be getting a modern computer charting system that promised to improve patient care, increase patient safety, and free up time for physicians and clinicians to spend more time with patients. Sam considered this a moment. At eighty-two he couldn’t help but share the common fear in his community that getting access to healthcare was getting harder and harder. Ambulances took hours to arrive; his neighbour, Pat, slipped on the ice last winter and broke his hip. He laid there for eight hours before the ambulance rolled up, paramedics sweating, exhausted, and beyond apologetic and frustrated with the situation. On top of the fracture, Pat also developed several major pressure injuries because of his day laying on the icy driveway which complicated his initial course in the hospital.

Sam seemed to recall hearing that Pat’s wife had been completely unable to find him when he was in surgery, the hospital accidentally lost him between the Operating Room and the Surgical Unit, and she was told that he had been discharged home. Later, she explained that the current hospital computer system manages the admission and discharge of patients from unit to unit but there is a significant delay between the discharge from one unit to the admission at the destination which at times makes the patients appear to have disappeared. Remembering this now, Sam rubbed his palms on his knees. What a nightmare that was. He looked out at the window to see Pat hobbling down the sidewalk with his walker alongside his wife. He was glad that his neighbour made it home but grimaced to think of his experience with the healthcare in their city. Something needs to change.

The Nurse

Lisa hated being in charge. She looked at the census for tonight, the situation didn’t quite meet the criteria to activate emergency surge management protocols but there were still patients on stretchers in the hallway with makeshift privacy screens. There were three sick calls on day shift, so all the nurses were doubled up in their assignments; it was only noon and there were already two sicks calls for tonight. That’s the new normal since COVID. She did the mental gymnastics of recalculating the patient assignment and figured that they could probably make it work. Crystal would be on, and she’s a strong nurse, along with three new hires who were very green but very keen. Crystal would keep them safe, and they would keep the patients safe. That works. Next crisis.

Lisa hated being in charge. She grabbed her pager and an enormous stack of patient Kardex folders, signed off with her team, and left the unit to go to bed rounds. The room of charge nurses was full of conversation when Lisa arrived. Rather than the usual beat down conversation about the same topics, too many patients, too few nurses, too few resources, everyone was discussing the recent clinical information system design session that had taken place the week prior. One of her peers self-identified as a volunteer change champion with the change network and said that she was receiving special communications from the project on things that were happening with the design and build, and things were coming along nicely. Another colleague scoffed and said that they heard the system had been implemented in other hospitals and failed miserably so the group shouldn’t get their hopes up. The bed manager joined the conversation and calmly interjected that since the failed implementation, the system has undergone significant improvements and has several peer-reviewed case studies of success that she would like to share with the entire group. “It’s important that we start from a place of truth and address what we’ve heard. Thank you for bringing that forward. Let me assure you that from my participation in the design sessions that the new workflows are going to save us a lot of time and make keeping track of our patients much easier. I for one look forward to not losing patients between the OR and the surgical unit once a month.” The entire group voiced their agreement.

Lisa hated being in charge. After bed rounds, she went back to her desk to get back to the steady and ever-increasing administrative burden of the role. Double checking orders are highlighted and signed off, ensuring that the surgical beds are booked, reassigning patients to accommodate sick calls absorbed a significant amount of her time. Time that would be better spent on the floor, with the multidisciplinary team doing rounds. Lisa actually liked being in charge in essence, it’s just that the job, right now, drowning in paper feels like a never-ending pit of bureaucratic hell. Lisa wants to be where she adds the most value doing what she does best, taking care of patients.

Lisa hated being in charge, but she loved being a nurse.

The Manager

Fatima had never been so stressed at work since she became manager of the surgical unit five years ago as she is now. It was long past when she was due to be finished her shift but she was staring at her computer, both screens open to compare the working schedules of her staff, the available training courses for the new clinical information system, and she had a print out of all of her staff’s vacation schedules in front of her on the desk. This was exhausting. There was a knock at the door, announcing the arrival of the General Hospital IT Support team on their daily rounds. Indicating that they didn’t have any hardware that needed fixing, Fatima was about to wave them away when she suddenly had an idea. She briefed the IT Support team on what she was attempting to do and inquired if there was a way that they could figure out how to do this using technology and not her tired brain. The IT Support team responded eagerly with several questions to collect her requirements. She was then sent home with the promise that help was on the way.

The next morning, Fatima was greeted by a smiling IT Support team. They had used a short piece of code to automate the data model that Fatima was working with to yield the results that she was looking for. They showed her how she was now able to manipulate the schedule of her staff so if she needed to switch someone to a different day, the automation ensured that the staff member was queued to register for the next available course. Fatima was relieved, this was going to make life so much easier. If this was the kind of thing that technology could do, maybe moving to this Clinical Information System wouldn’t be so bad after all.

The Director

Carla took a deep breath. Tonight’s the night. At 4:59 am the old system will be gone, and the new system will be here. She had butterflies in her stomach, but it was more excitement than apprehension. She reflected on the last ten years of her career. Hearing about this project, seeing the steady work that went into it. First, it was the expansion of the hospital’s network and the implementation of wireless internet access to all patient care and public spaces from wall to wall. Then clinical care areas were renovated to accommodate more computing devices. If staff were unaccustomed to using computers at work, training programs launched to meet their needs. Feedback was collected at every step of the way.

Then teams of change agents roamed the halls talking about the clinical information system, what it was, what people could expect. The project was managed using a consistent campaign of information sessions that complimented the milestones schedule and captured and responded to the concerns of the stakeholders consistently. Design sessions included operational subject matter experts and followed rigorous and transparent governance processes and were customized to the local context of the General Hospital. Testing was rocky, but testing should be rocky, the teams learned a lot. Training had been going well, with the usual low percentage of staff who really struggled and the vast majority learning the new workflows with relative ease.

Everyone was on deck. Clinical and technical experts, software engineers, and credentialed trainers were all ready and at the elbow of the anxious clinicians. Leaders at all levels of the hospital stayed all night and ran simulations and dress rehearsals for practice. Things were as ready as they were going to be. Progress is not perfection; implementation is just the beginning. Carla smiled. Bring it on.

Discussion

The General hospital as described in the previous section is on the precipice of the implementation of a clinical information system. To determine whether the General Hospital is truly ready for a successful implementation is impossible to predict; however, using the five themes as a guide, an evaluation can be performed.

Theme 1: System Capacity

The General Hospital demonstrated adequate system readiness in terms of technical capacity, as evidenced by substantial pre-readiness investments in renovations and the procurement of additional computing devices, which also reflects financial readiness (Brommeyer et al., 2024; Brommeyer & Liang, 2022; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022; Michelotto & Joia, 2024; Yunis et al., 2020). It is difficult to determine the exact governance readiness of the General Hospital as it is not covered in this case, but given the frequent, consistent communication, and vocal and visible leadership support, it is likely that it is present (Brommeyer et al., 2024; Iyanna et al., 2022; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022; Yunis et al., 2020).

Theme 2: Organizational Capacity, Culture, and Leadership

The General Hospital demonstrated evidence of a culture committed to learning and growth and increasing transparency (Brommeyer & Liang, 2022; Francis-Auton et al., 2023; Kruszy?ska-Fischbach et al., 2022; Silva et al., 2022). Although at the front line there is the expected resistance and change fatigue, there is an intentional and informed approach to managing and mitigating these risks to adoption of the project (Francis-Auton et al., 2023, Kabukye et al., 2020; Iyanna et al., 2022; Yunis et al., 2020). From early in the project, consistent messaging was shared across stakeholder groups to keep them informed and to include them in the process. The writers estimate that the General Hospital scenario demonstrated many positive predictors for success this theme category.

Theme 3: Human Resources Capacity

The General Hospital appeared to have some pressures in the theme of human resource capacity. It is clear that there were norms and values in place to support a digital health transformation; however, there also appears to be some level of burnout among staff as a result of a lack of resources (Brommeyer et Liang, 2022; Francis-Auton et al., 2023; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022; Kutnjak et al., 2020; Lemak et al., 2024; Michelotto & Joia, 2024; Silva et al., 2022; Tenggono et al., 2024; Yunis et al., 2020). This is unlikely unique to the General Hospital, but staff readiness and burnout are negative predictors of success for this implementation. The director mentioned in the case above should take this opportunity to address these gaps strategically.

Theme 4: Project Management

The evidence demonstrated by the case study suggested that the General hospital had robust implementation planning, regular and consistent corporate communications, and was steadily building a culture of continuous improvement (Francis-Auton et al., 2023; Iyanna et al., 2022; Kabukye et al., 2020; Kruszy?ska-Fischbach et al., 2022; Silva et al., 2022).

Theme 5: Training & Adoption

While executing a hospital-wide just-in-time training program is a difficult feat, the General Hospital seemed to have taken every effort to ensure that training was a priority for the success of the project and considered it at every project phase (Brommeyer et al., 2024; Brommeyer & Liang, 2022; Iyanna et al., 2022; Yunis et al., 2020).

Limitations

The themes described in this document are guiding principles, not a prescription for success. They are not mutually exclusive or a sum of their parts; therefore, determination of organizational readiness will never be an exact science. For the purpose of this literature review and case study, the writers experienced the temptation to get very tactical within the themes, which quickly becomes overwhelming for the reader. The authors have attempted to balance keeping the themes high level enough for reading comprehension while maintaining meaningful applicability for the target audience of nursing informaticists, aspiring or practicing. Another limitation noted in the literature is a lack of road maps or frameworks that oversee the entire implementation process from beginning to end.

Further Research

In future studies, more detailed and tactical analyses of the different phases of organizational readiness for digital health transformation is required. It would be of interest to explore defining at which point in projects certain readiness milestones should be achieved using an agile methodology.

Through the review of the research, it is clear that the pre-implementation planning phase is noxiously short, with highly ambitious goals for implementation. This leads to a compressed timeline to establish foundational technology, inadequate standardization, compressed testing, and insufficient training and change management resources. Future research should be dedicated to the development of industry benchmarks to define readiness projects in detail.

Conclusion

In summary, there are several major positive predictors for success for digital health transformation projects. This literature review of recent studies produced five major themes including system capacity, human resources capacity, organizational culture, leadership and change, project management, and training and adoption. These five themes were used in the evaluation of the case study included in this analysis. This evaluation illustrates the implications for nurse informaticists, leaders, and healthcare organizations when embarking on digital transformation. Ultimately, defining organizational readiness through positive predictors for success has resulted in more questions and further research to be performed; however, the five themes serve as an excellent starting point for nurse informaticists and leaders embarking on a journey of digital health transformation.

References

Al-Kahtani, N., Alrawiai, S., Al-Zahrani, B. M., Abumadini, R. A., Aljaffary, A., Hariri, B., Alissa, K., Alakrawi, Z., & Alumran, A. (2022). Digital health transformation in Saudi Arabia: A cross-sectional analysis using Healthcare Information and Management Systems Society’ digital health indicators. Digital Health, 8, 20552076221117742. https://doi.org/10.1177/20552076221117742

Beaulieu, L., Seneviratne, C., & Nowell, L. (2023). Change fatigue in nursing: An integrative review. Journal of Advanced Nursing, 79(2), 454–470. https://doi.org/10.1111/jan.15546

Bilgiç, D., & Camgöz Akda?, H. (2023). Digital transformation readiness factors in healthcare. Hospital Topics, 101(3), 199–207. https://doi.org/10.1080/00185868.2021.2002745

Brommeyer, M., & Liang, Z. (2022). A systematic approach in developing management workforce readiness for digital health transformation in healthcare. International Journal of Environmental Research and Public Health, 19(21), Article 21. https://doi.org/10.3390/ijerph192113843

Brommeyer, M., Whittaker, M., & Liang, Z. (2024). Organizational factors driving the realization of digital health transformation benefits from health service managers: A qualitative study. Journal of Healthcare Leadership, 16, 455–472. https://doi.org/10.2147/JHL.S487589

Cohen, C., Pignata, S., Bezak, E., Tie, M., & Childs, J. (2023). Workplace interventions to improve well-being and reduce burnout for nurses, physicians and allied healthcare professionals: A systematic review. BMJ Open, 13(6), e071203. https://doi.org/10.1136/bmjopen-2022-071203

Creasy, T. (2022). Definition of change management. Prosci. https://www.prosci.com/blog/definition-of-change-management

Deep, G. (2023). Digital transformation’s impact on organizational culture. International Journal of Science and Research Archive, 10(2), 396–401. https://doi.org/10.30574/ijsra.2023.10.2.0977

Francis-Auton, E., Long, J. C., Sarkies, M., Roberts, N., Westbrook, J., Levesque, J.-F., Watson, D. E., Hardwick, R., Hibbert, P., Pomare, C., & Braithwaite, J. (2023).Four system enablers of large-system transformation in health care: A mixed methods realist evaluation. The Milbank Quarterly, 102(1), 183–211. https://doi.org/10.1111/1468-0009.12684

Iyanna, S., Kaur, P., Ractham, P., Talwar, S., & Najmul Islam, A. K. M. (2022). Digital transformation of healthcare sector. What is impeding adoption and continued usage of technology-driven innovations by end-users? Journal of Business Research, 153, 150–161. https://doi.org/10.1016/j.jbusres.2022.08.007

Kabukye, J. K., Keizer, N. de, & Cornet, R. (2020). Assessment of organizational readiness to implement an electronic health record system in a low-resource settings cancer hospital: A cross-sectional survey. PLOS ONE, 15(6), e0234711. https://doi.org/10.1371/journal.pone.0234711

Kraus, S., Schiavone, F., Pluzhnikova, A., & Invernizzi, A. C. (2021). Digital transformation in healthcare: Analyzing the current state-of-research. Journal of Business Research, 123, 557–567. https://doi.org/10.1016/j.jbusres.2020.10.030

Kruszy?ska-Fischbach, A., Sysko-Roma?czuk, S., Napiórkowski, T. M., Napiórkowska, A., & Kozakiewicz, D. (2022). Organizational e-Health readiness: How to prepare the primary healthcare providers’ services for digital transformation. International Journal of Environmental Research and Public Health, 19(7), Article 7. https://doi.org/10.3390/ijerph19073973

Kutnjak, A., Pihir, I., & Furjan, M. (2020). Assessing digital transformation readiness using digital maturity indices [Paper Presentation]. Central European Conference on Information and Intelligence Systems, Varazdin, Croatia. https://www.proquest.com/openview/dd5d4cb96dc10e54330825726083ebbb/1?pq-origsite=gscholar&cbl=1986354

Lemak, C. H., Pena, D., Jones, D. A., Kim, D. H., & Guptill, J. (2024). Leadership to accelerate healthcare’s digital transformation: Evidence from 33 health systems. Journal of Healthcare Management, 69(4), 267. https://doi.org/10.1097/JHM-D-23-00210

Michelotto, F., & Joia, L. A. (2024). Organizational digital transformation readiness: An exploratory investigation. Journal of Theoretical and Applied Electronic Commerce Research, 19(4), Article 4. https://doi.org/10.3390/jtaer19040159

Montgomery, A., Panagopoulou, E., Esmail, A., Richards, T., & Maslach, C. (2019). Burnout in healthcare: The case for organisational change. BMJ, 366, l4774. https://doi.org/10.1136/bmj.l4774

Silva, R. P., Saraiva, C., & Mamede, H. S. (2022). Assessment of organizational readiness for digital transformation in SMEs. Procedia Computer Science, 204, 362–369. https://doi.org/10.1016/j.procs.2022.08.044

Tenggono, E., Soetjipto, B. W., & Sudhartio, L. (2024). Managing digital transformations: The intermediary function of digital readiness in facilitating strategic renewal within the healthcare industry. Cogent Business & Management, 11(1), 2423276. https://doi.org/10.1080/23311975.2024.2423276

Yunis, M., El-Kassar, A.-N., Markarian, C (2020). A conceptual model for sustainable adoption of eHealth: Role of digital transformation culture and healthcare provider’s readiness [Paper Presentation].  International Multi-Conference on Complexity, Informatics and Cybernetics, Beirut, Lebanon. https://www.iiis.org/CDs2020/CD2020Spring/papers/ZA615SE.pdf.

Author Biography

Jennifer Matthews, BIB, RN, BScN, MN, Prosci

Jennifer Matthews is a passionate Registered Nurse, an internet-era servant leader, and a champion of evidence-based practice. With a background in International Business, Nursing, and Informatics, Matthews is serious about bringing the value that digital transformation creates to healthcare. Jennifer Matthews lives and works in Nova Scotia, Canada.

Kim Burgess RN, BScN, MN, PhD Assistant Professor

Dr. Kim Burgess (Munich) is an experienced professor, educator, and researcher of nursing practice with a background in obstetrics and public health. Dr. Burgess teaches primarily in the areas of health promotion, understanding complex health issues, and leadership. Kim Burgess lives and works in Nova Scotia, Canada