Information Systems and Quality Management in Healthcare Organization: An Empirical Study

The paper explores current status of information systems, identifies gaps in the current information systems and assessment in healthcare organization. This paper is based on Critical Analysis of literature and a questionnaire is administered on administrative level employees of South Indian healthcare organizations. It has been identified that healthcare organization should have specific strategy and must implement measures derived from strategy. Data and information systems should be seen as business resources. The knowledge base of medical field is large and it is growing rapidly. Hence information system must be integrated across the enterprise. The results of the study determined the relationship between measurement, analysis and knowledge Management on performance. The Information system is the newest dimension among the MBNQA (Malcolm Baldrige National Quality Award) criteria. The Information system performance was assessed in terms of management relevant data and information. The outcomes suggest that there is a growing recognition of the administrators about the importance and use of information systems as a critical resource in healthcare organizations. From the study it is inferred that information system analysis continues to be a challenge. The higher utilization of technology, computerization and the Internet has resulted in dramatic change in the quality performance of the Healthcare Organizations. The paper provides an empirical evidence that information system has an impact on performance in the context of healthcare organizations. The information system is a key performance area of Quality management and it has received limited attention in improving quality performance including MBNQA. Finally, the study concludes that there is an immense scope for altering current information systems and it should be aligned with the quality management environment.


INTRODUCTION
T he globalization and liberalisation policies have significantly changed the healthcare scenario in India. The healthcare industry is going through a transition and the future is likely to see significant changes in the nature of provision of healthcare and roles of various players in the industry. The healthcare industry is worth INR 820,000 million today.

Information Systems and Quality Management in
Healthcare Organization: An Empirical Study

Abstract
The paper explores current status of information systems, identifies gaps in the current information systems and assessment in healthcare organization. This paper is based on Critical Analysis of literature and a questionnaire is administered on administrative level employees of South Indian healthcare organizations. It has been identified that healthcare organization should have specific strategy and must implement measures derived from strategy. Data and information systems should be seen as business resources. The knowledge base of medical field is large and it is growing rapidly. Hence information system must be integrated across the enterprise. The results of the study determined the relationship between measurement, analysis and knowledge Management on performance. The Information system is the newest dimension among the MBNQA (Malcolm Baldrige National Quality Award) criteria. The Information system performance was assessed in terms of management relevant data and information. The outcomes suggest that there is a growing recognition of the administrators about the importance and use of information systems as a critical resource in healthcare organizations. From the study it is inferred that information system analysis continues to be a challenge. The higher utilization of technology, computerization and the Internet has resulted in dramatic change in the quality performance of the Healthcare Organizations. The paper provides an empirical evidence that information system has an impact on performance in the context of healthcare organizations. The information system is a key performance area of Quality management and it has received limited attention in improving quality performance including MBNQA. Finally, the study concludes that there is an immense scope for altering current information systems and it should be aligned with the quality management environment.
With global revenues approximately USD 2.8 trillion, the healthcare industry is world's largest industry and India is emerging as a major player because of its high population (Pestonjee et. al, 2005). The healthcare market is estimated to touch USD 77 million by 2013 (IBEF, 2009). According to WHO report, India needs to add 80,000 hospital beds each year to meet the demand of its population. Healthcare organizations are considered the focal points for health services' delivery and they consume nearly thirty percent of the national healthcare budget (Pestonjee et. al, 2005). Moreover, service based economy growth is accomplished by technological advances, thus reinforcing service quality as an important and sustaining competitive advantage (Bharadwaj et.al, 1993). Service quality has emerging as a key issue in Indian services industries (Kunal et.al, 2005). In the healthcare environment, changes such as mature markets, alternatives of delivery systems, competitive health plans, powerful payer coalitions, increasing knowledgeable consumers and technology have placed a demand on hospital managers to have better understanding of service quality (O'Connor et. al, 1989). India's IT capability has a significant contribution in healthcare administration, and it has helped in improving efficiencies and facilitated control of delivery cost. Information system can add value by enhancing service quality as well as soft ware quality. Today Information system needs to look beyond system building and there is a need to examine how they can increase the quality of their service and enhance the performance of the organization. Quality management relies on large amounts of information to evaluate the effectiveness of the patient care, the efficiency of hospital operations, the appropriate use of resources and the degree to which the expectations of patients, physicians and other hospital customers are met (Lengnick-Hall, 1995). Successful implementation of Quality management (QM) requires a transportation of the healthcare organization's information system infrastructure and other management systems in alignment with QM environment. The information systems in healthcare organizations need to have seven objectives in relation to quality management: medical quality assurance, cost control and productivity enrichment, utilization analysis and demand estimation, programme planning and evaluation, simplification of internal and external planning, clinical research, and education (Austin, 1988). The information systems investments can contribute to a great extent in improving service quality, operational efficiency, patient satisfaction and patient care (DesRoches et.al, 2008). The importance of quality information system to the overall quality and productivity of an organization is evident from the inclusion of a dimension on Information and Analysis in the Malcolm Baldrige National Quality Award (NIST, 2000). While defining or measuring the effectiveness of the information systems (IS) function, there is also a need for IS assessment for effective management and continuous improvement . In addition, there is a need for investigating the relationship among the established IS assessment tools to better reconcile their existing differences. This research examines Malcolm Baldrige National Quality Award (MBNQA) framework and its new dimension, 'Information Systems' in relation with organizational quality. There is also a need to examine the interaction between the information system and the other quality management dimensions based on the MBNQA framework.

LITERATURE REVIEW
The purpose of an Information System is to support decision making in an organization and to enhance organizational efficiency, quality, and productivity (Davis and Olson, 1985). Several models have attempted to determine how information systems aid individual decision making by specifying the decision making process and some models have focused on organizational decision making. In recognition of the importance of information systems as a critical decision and operational tool in an organization, several research efforts have focused on the development of an IS assessment framework (Beise, 1989). The simple decision making model has five components; task, decision maker, decision process, decision environment, and decision outcome. Further, the IS -performance evaluation model has the following has dimensions in order of importance 1) IS function impact on strategic direction, 2) integration of the IS function planning with corporate planning, 3) the quality of information outputs, and 4) the IS function's contribution to organizational financial performance (Saunders and Jones, 1992). The IS function is evaluated in relation to top management and its contribution to the business results (Moad, 1993). In recognition of the importance of an emerging dimension of 'information service quality' in information systems assessment, Pitt et al. (1995) proposed a model of information system success similar to the model by DeLone and McLean (1992), except service quality was included as one of the dimension that affects both use and user satisfaction. Myers et al. (1997) proposed an Information Systems Assessment (ISA) framework with the inclusion of an additional dimension 'Work group impact' within IS success model by Pitt et al. (1995). The IS assessment efforts would allow for enhancement of IS quality and productivity and would ultimately influence organization's performance and profitability. However, the proposed models were developed from an information systems perspective and they reside in an information systems specific domain. There is a need Journal of Technology Management for Growing Economies, Volume 2, Number 1, April 2011 to discuss information systems in relation to quality management using MBNQA framework.

MALCOLM BALDRIGE NATIONAL QUALITY AWARD
Malcolm Baldrige National Quality Award (MBNQA) was created by the United States Department of Commerce in 1987 to enhance competitiveness (Bell and Keys, 1998). The MBNQA has been accepted widely as service excellence standard in education and healthcare institutions (Chow-Chua and Goh, 2000). Specific goals of the award include promoting awareness of the relationship between quality and competitiveness, increasing understanding about the level of quality required to achieve world class recognition, and fostering the sharing of information about quality by world class organizations (N.I.S.T., 1995). According to MBNQA, the quality management and performance is embodied in leadership, strategic planning, customer focus, measurement, analysis, knowledge management, workforce focus; process management, and results (US Do CNBS, 2008).
Leadership examines how senior executives guide the organization and how the organization deals with its responsibilities to the public and practices good citizenship . Strategic planning examines how the organization sets strategic directions and how it determines key action plans. Customer and market focus examines how the organization determines the requirements and expectations of customers and markets, builds relationship with customers and acquires, satisfies and retains customers. Measurement, analysis and knowledge management (Information and analysis) is how organization selects, gathers, analyzes, manages, and improves its data, information, and knowledge assets and how it manages its information technology. Workforce focus is about how the organization engages, manages and develops workforce. Process management is how the organization designs its work systems to deliver value to patients and employees. Finally the results as performance outcomes healthcare outcomes, customer -focused outcomes, financial and market outcomes, workforce -focused outcomes, process effectiveness outcomes, and leadership outcomes. These dimensions are termed as seven categories and points (US Do CNBS, 2008). Information and Analysis is the newest among the MBNQA criteria and evaluates an organization's processes to measure its performance in terms of the scope, validity, and management of relevant data and information. Information and Analysis Category is critical to the effective management of an organization and to a fact-based system for improving performance and competitiveness. Information and analysis serves as a foundation for the performance management system and serves as a moderator in a systems perspective.

IMPACT OF INFORMATION SYSTEM ON THE ORGANIZATIONAL PERFORMANCE
The impact of information system (IS) on organizations has been one of the main issues in the modern times. IS managers face the critical issue of assessing the impact of IS and there is a need of technology investment in organizations. Some of the research efforts have investigated the impact of IS investment on orgnisation's strategic and economic performance. Aboveaverage spending on information system (IS) can enhance a firm's profitability (Norton and Company, 1985). The high-performance firms spend a significantly higher proportion of revenue for IS than lowperformance firms (Harris and Katz, 1989). The individual IS investment variables were found to be only weakly related to organizational strategic and economic performance, they were significantly related to performance when grouped together (Mahmood and Mann, 1993). IS alone has not produced sustainable performance advantages but number of firms have benefited from using IS to leverage intangible, complementary human and business resources, such as flexible culture, strategic planning, IS integration, and supplier relationships (Powell and Dent, 1997). The firms with high IS capability tend to out-perform on a variety of profits and costbased performance measures (Bharadwaj, 2000). A significant component of the value of IS is its ability to enable complementary organizational investments, such as business processes and work practices. These investments also lead to productivity by lowering costs and allowing firms to increase output quality in the form of new products or improvements in intangible aspects of existing products, such as convenience, timeliness, quality, and variety (Brynjolfsson and Hitt, 2000). There is a huge financial impact associated with lack of Information quality (Olson, 2003). There is a need of measuring this impact with the view of minimizing poor quality information (Adelman and Moss, 2005;Sangwan and Bass, 2007). MBNQA framework and IS are important indicators of business results in an organization wide perspective (Wilson and Collier, 2000). There is a need to investigate the impact of IS on business results with regard to other quality management dimensions of MBNQA framework.

DATA COLLECTION PROCEDURE
The studied population covers the hospitals affiliated to medical colleges of southern India. There were seventy six medical college's hospitals (healthcare organizations) and the sample survey was derived from the database of healthcare organizations based on the official report of Medical Council of India (2009). One of the healthcare organization was selected for the unit of analysis to obtain an overall glimpse of administration, operations, standards and practices as it is uniform under the Medical Council of India. To obtain clear representation of samples from southern India, healthcare organizations of Karnataka, Kerala, Andhra Pradesh and Tamil Nadu were purposively selected based on inclusion and exclusion criteria for this study. Inclusion criteria: Location, quality certification, willingness to participate, multi-specialty healthcare organization, minimum five years of service, emergency department, healthcare organization with more than 500 beds, and divisional/State representation of the Organisation.
Exclusion criteria: Unwillingness to participate, single specialty, super specialty, less than 500 bedded healthcare organization, and less than five years of service.
A total of twelve healthcare organizations participated in the study. The respondents selected for this survey were administrative level employees who have knowledge of Quality management and are exposed to organizational practices. In order to achieve sampling uniformity the respondents at administrative level consisted of 76 departmental heads, 38 administrative staff, 13 nursing superintendents, and 3 medical superintendents through purposive sampling technique. Out of 250 questionnaires, 130 were obtained in complete with a response rate of 52 percent. The validity of the survey instrument was done using expert's opinion and piloted for a small group of respondents and reliability by Cronbach's alpha. The analysis was done using SPSS package.

Descriptive Statistics
The means and standard deviations for all variables in the data set were consistent (Table 1). Standard deviations indicated that the scores in the distribution deviated or varied from the mean regarding the usefulness of Measurement, Analysis and Knowledge Management in healthcare organization. There was a strong response with means ranging from 3.5 to 4.2 and standard deviation was varied from 0.6 to 0 .9. The results suggest that there is no strong response bias and the degree of variation is not very high.

Kaiser-Meyer-Olkin (KMO) and Bartlett's Test
The KMO measures the sampling adequacy and it was found greater than 0.5, satisfactory for a factor analysis. The KMO measure was found 0.940, indicating high sampling adequacy. The Bartlett's test of sphericity was significant and correlation matrix is not an identity matrix indicating that there is correlation among variables. Factor analysis confirmed that the attributes on scale were reliable in their measurement and most of them were found above the adequacy level (Table  3). Factor loading of 0.50 and above on a specified factor has been considered to be acceptable (Hair et al., 1995), and thus this level was used as a cut off value within this paper. Reliability coefficient that assessed the consistency of the entire scale and Cronbach's alpha was found 0.9155, indicating high level of internal consistency ( Table 3)  We regularly check the software to make sure they are reliable and meet current healthcare needs We have a comprehensive system to align measures of daily operations and hospital performance Inter organization coordination is achieved using electronic links Our information systems are standardized across the departments Our systems suppor t front line employees Our performance analysis is aligned with senior leader's strategic planning We communicate the analysis results to work in team/ group at the functional level operations Our data analysis shows improvement in cycle times (reducing length of stay) We ensure that the needed data and information is available to the staff, suppliers, and customers We regularly communicate and share the knowledge/ skill through seminar or on site information We ensure that the data and information matches current healthcare needs We ensure data and information integrity and accuracy We effectively use comparative data and information to analyze the performance We use the results to act as the basis for improvement and benchmarking

MBNQA DIMENSIONS AND PERFORMANCE
Pearson Correlation Matrix indicated that there was significant correlation between MBNQA dimensions and performance (Table 4). Very high significant correlation was found between 'strategic planning and process management' and performance ( Among the six dimensions of MBNQA, measurement, analysis, and knowledge management yielded 38.9 percent explanatory power on performance (Table 5) and had a strong positive relationship on performance( ß =0.624 for H mak ) (Table 6).

ALIGNMENT OF INFORMATION SYSTEMS IN HEALTHCARE ORGANIZATIONS
There is a need to integrate information systems with quality management (QM) environment. The bureaucratic systems must be transformed into QM friendly systems. The critical analysis identifies there are three categories that describe the scope of information systems with quality management: l Clinical or medical information system -to be designed primarily to support patient care activities (i.e., patient vital signs monitoring, medical record retrieval) l Operational Administrative system-to be designed to provide non patient-care activities (i.e., financial, personnel and payroll systems). l Decision-support systems-to be designed to provide management with information for decision -making (i.e., Strategic planning, analysis and evaluation of specific programme).
The healthcare organization need to have well designed information systems and should be integrating with quality management dimensions. There is a need of systematic and on going performance reporting and monitoring.
There is a need to implement mechanisms that ensure reliability of data, accurate and up-to-date information for continuous quality improvement.
There is a need to describe how an information system appears in QM environment. Primarily the Information regarding the patients and patient care should be given maximum importance. The care givers or clinical practioners are the initiators of the patient records and the information that they generate serves as core of patient medical record system. In level two, users begin compiling the information from financial, accounting and billing systems. Level III is third -order time frame and this information is used primarily by reviewers of the organization's quality, productivity and utilization functions. At this juncture many users involved with quality improvement may experience difficulty in accessing the information. It is observed that most of the information systems are not truly integrated to deliver quality performance. The last time frame is long-term strategy function that should include strategic planning, managed care-software, enterprise resource planning, case mix analysis, and marketing. This suggests that the healthcare systems need to promote improved customer services IS-design, judicious use of IT and reengineering of conventional process so that it can align itself with continuous quality improvement.