Successful IT/IS Projects in Healthcare: Evaluation of Critical Success Factors

Within the recent years, a great evolution in healthcare IT/IS systems has been identified in part as a result of the rapid development of new technologies (Schönberger, 2014; European Commission, 2007). However, technological innovation in healthcare is an important driver of cost growth (Barbash and Glied, 2010; Goyen and Debatin, 2009). Faced with strong competition and pressure to reduce costs across the healthcare sector, medical device manufacturers are banking on growth through breakthroughs in innovation and engineering (Stirling and Shehata, 2016). This is also confirmed by a study by Forbes and KPMG in 2015, in which companies were asked about their strategic priorities for the Abstract

next twelve to 24 months. According to this study, 35% of the surveyed companies reported the reduction of costs and 49% the development of new products (Stirling and Shehata, 2016). In this context, a recent trend in the healthcare industry is the implementation of modern IT/IS systems (Archer, 2016;Horvath, 2016; Varelis and Williams, 2016).
However, many IT/IS projects experience significant time and cost overruns (Sumner et al., 2006;Kaplan and Harris-Salamone, 2009;Jun et al., 2011). According to a survey of IBM (2008), only 40% of projects met schedule, budget and quality objectives (IBM, 2008). McKinsey reported in a study on large scale IT projects, that on average, these projects run 45% over budget and 7% over time, while delivering 56% less value than predicted (Bloch et al., 2012). Flyvbjerg and Budzier (2011) found similar facts: One out of six IT projects has an average cost overrun of 200% and a schedule overrun of 70% (Flyvbjerg and Budzier, 2011). Therefore, it is apparent, that there are significant contradictions between the reduction of costs and the introduction of new IT/IS systems. This statement is consistent with the results of the Forbes and KPMG survey, where 22% of the medical device manufacturers surveyed indicated that they will face major challenges in updating and aligning IT systems with the demand from the business (Stirling and Shehata, 2016).
The difficulties of implementation of IT/IS projects as well as assessing their performance are a research focus of the last decades (e.g. Gomes Koumaditis et al., 2013). The investigation of critical success factors in the context of the implementation of IT/IS projects is also requested by some researchers (e.g. Axelsson et al., 2011;Santos et al., 2014). Moreover, Medina et al. (2013) noted that existing methods used for the identification of critical success factors have a number of shortcomings, regarding the subjectivity of survey based studies and the complexity of internal and external factors (Medina et al., 2013).
With regard to the aforementioned key problems, this research addresses the question of how companies can reduce costs while investing in new IT/IS systems. As Santos et al. (2014) discovered that current research mainly focuses on information technology, engineering and software development but not yet on (public) health projects, this research focuses on the identification of critical success factors in the healthcare sector. Furthermore, as a questionnaire by the Radar Group (2012) concluded that one reason for IT project failure is a lack of transparency regarding dependencies (Radar Group, 2012; Wolf, 2015), this study also tries to evaluate the interrelationships between success factors for the implementation of IT/IS projects, in order to get a better transparency for project managers. Therefore, the following research questions are to be answered within the scope of this research: is described. Therefore, a literature review was used to identify actual and contextspecific research. In section four, the findings of the literature review will be explained. Following this, the results are compared and evaluated with regard to the research questions in section five. Finally, this research concludes with a summary of findings and an outlook on further research activities in section six.

Critical Success Factor
Critical success factors were introduced by Rockart in 1979 as a guiding approach to help senior executives define their information needs in order to reach the objectives of the organization (Rockart, 1979;Axelsson et al., 2011;Gates, 2010). Since then, many researchers have focussed on describing different actions under which success is likely to occur (see chapter 'Introduction'), for example Boynton and Zmud (1984), Yew Wong (2005) or Morden (2016) who describe, that critical success factors have a significant effect on the achievement of enterprise objectives. In this context, Rockart (1979) identified four prime sources of critical success factors that reflect the way in which they contribute to the achievement of the business objectives: (1) the structure of the particular industry, (2) competitive strategy, industry position and geographic location, (3) environmental factors and (4) temporal factors (Rockart, 1979). This research focuses on strategic, environmental and temporal critical success factors for the successful implementation of IT/IS projects in the healthcare sector.

Project Management and IT/IT Projects
The Project Management Institute (PMI) defines the term "project management" as "the application of knowledge, skills, tools, and techniques to project activities to meet the project requirements" (PMI, 2013, p. 5). A similar definition is provided by ISO 21500 (2012) which describes project management as the "application of methods, tools, techniques and competencies to a project" (ISO, 2012, p. 4). In this context, a project can be described as a set of activities whose execution is unique, whose structure has a certain complexity, and whose defined objectives can be achieved in a given time and with given resources (Aichele and Schönberger, 2014). Project management includes the identification of requirements, the definition of clear objectives, the consideration of the competing requirements for time, quality and costs as well as the adaptation of specifications, plans and concepts to the different concerns and expectations of the various stakeholders (PMI, 2013). The management of IT projects differs from general project management mainly by the development, implementation or application of IT solutions in a specific business environment (Aichele and Schönberger, 2014). Here, development projects, such as strategy or innovation projects, and organizational projects, for example evaluation or implementation projects, can be distinguished (Wieczorrek and Mertens, 2008). This research focuses mainly on the implementation of IT/IS projects in the healthcare sector and is based on the definitions of the PMI (2013).

Healthcare Industry in Europe
Health is an important priority for Europeans who expect to receive appropriate healthcare (Eurostat, 2016;European Commission, 2007). In this context, the term "healthcare" comprises the sum of activities performed by institutions or individuals through the use of medical, paramedical and nursing knowledge and technology for the purpose of health protection and disease prevention, disease cure and reduction of premature mortality as well as the provision and management of public health (Eurostat, 2013 . Therefore, the healthcare sector and in particular the pharmaceutical industry are of economic importance (European Commission, 2017). In 2012, the EU pharmaceutical sector produced an output of 220 billion Euros and employed around 800,000 people (European Commission, 2014). Furthermore, the sector accounts for approximately 1.8% of the total manufacturing workforce and is one of the industries with the highest labour productivity (European Commission, 2017).

Related work
As described at the outset of this research, major challenges exist in the healthcare sector regarding the successful implementation of IT/IS projects (see chapter 'Introduction').
To investigate this problem, a literature review is used to determine existing research that has examined success factors for the IT/IS project implementation. Due to the heterogeneity of the companies established in the healthcare sector (see chapter 'Healthcare industry in Europe'), a complete overview of the literature is hardly realizable. Therefore, the aim of the review is to identify central literature on successful IT/IS project implementation, thus, within this chapter a general orientation of the literature will be presented.  Table 1, are briefly summarised. Axelsson et al. discussed critical success factors and best practice in relation to IT implementation in the healthcare sector. Therefore, the authors had conducted a qualitative and interpretive study of the implementation process of a health information system in a Swedish public health provider organisation in 2010. The data collection involved interviews, studies of documents, field work and systems studies. The case study indicated that the implementation of an IS system, that is based on best practices solutions for healthcare, is not automatically creating success by following critical success factors.
The study ends with the finding that the results are valid not only for health information systems but also for any other IT/IS project in the private or public sector (Axelsson et al., 2011).

C. Ghazvini and Shukur (2013). Security challenges and success factors of electronic healthcare system
The aim of the research by Ghazvini and Shukur was to explore and analyse the current state of e-health systems security and privacy of patient records. Therefore, the focus was on developing a framework for information security in order to protect electronic patient record. The authors conducted a literature review to identify relevant studies on the research focus. A total of twelve relevant research studies were analysed in relation to the research questions. As the results show, human error is the most challenging issue regarding the implementation of e-health systems (Ghazvini and Shukur, 2013). In order to answer the second research question (see chapter 'Introduction'), the literature listed in Table 1 was analysed more precisely and, thus, further similarities were found. The results of the research conducted by Abouzahra (2011) , only the top ten critical success factors identified in the literature will be chosen for further research (see Table 2). As these ten factors have been most frequently mentioned in the identified literature, it is highly probable that these factors can be implemented by companies in the healthcare sector and are also implemented in most project management approaches. The top ten critical success factors are briefly explained below.
Journal of e-health Management  Top management support 4 10 Under the factor "team" the team members and their different skills and expertise are subsumed (Koumaditis et al., 2009). The factor "clear goals / scope" means that there is a high level of understanding of the size of the project and its objectives (Axelsson et al., 2011). The formulation and adherence to clear communication rules are summarized under the factor "communication" (Abouzahra, 2011). The factor "experience / training" refers to the availability of a wide range of experience about the project, the processes and the environment during the implementation of the IT/IS project (Koumaditis et al., 2009). The term "project planning / long-term planning" is used to describe the project scope, objectives, staff and roles of the project as well as the activities to be processed after the implementation (Koumaditis et al., 2009). The identification and documentation of risks that may arise before, during and after the implementation of the IT/IS project is summarized under the factor "risk management" (Abouzahra, 2011).
Larger projects with several stakeholders, different ways to achieve objectives or other barriers to the successful implementation of the project, such as geographic obstacles, laws or linguistic problems, are summarized under the factor "complexity" (Ghazvini and Shukur, 2013;Koumaditis et al., 2009). The factor "process alignment" defines the need to align the business strategy with the business processes and the implementation of the IT/IS project (Koumaditis et al., 2009). A wide range of experiences about the project and the objectives, tasks and activities for a specific project member are summarized under the factor "Role" (Axelsson et al., 2011) and, thus, indicating a parallel to the factor "experience / education". The factor "top management support" means that financial, personnel or other support from the top management can have an impact on the project outcomes (Hung et al., 2014).
Finally, to answer the second research questions completely, the interrelationships between each success factor were examined in a further step. For this purpose, a functional analysis was conducted according to the approach by Adunka (2010a and 2010b) and signed to the TRIZ methodology (theory of inventive problem solving) and is normally used in the technical environment. Therefore, in a first step, an interaction matrix was developed that helped to determine which success factors interact with one another. To build up an interaction matrix, the success factors were entered into a table with identical order in a header row and header column. Following this, each cell of the matrix was analysed and in case of an interaction of the factors a "+" symbol was entered into the cell. If there were no interaction, a "-" symbol was entered. For example, a team must determine communication rules to define goals, tasks, deadlines or responsibilities within the project (interaction between team and communication: "+"), but the communication rules have no influence on the project planning (interaction between project planning and communication: "-"). The whole interaction matrix is shown in Appendix 2. In a second step, a function model was developed, which served to graphically represent the interrelationships between the success factors marked with a "+" symbol. As shown in Figure 1, the success factors are represented as rectangles and the relationships between the factors as arrows. In addition to the interaction matrix, useful and harmful relationships were determined. Useful relationships (green) between two success factors may change the project success in the desired direction, while harmful relationships (red) may change the project success in an unwanted direction. Any relationship described by a negative verb, such like "affects" or "requires", was classified as a harmful relationship. For example, a high level of experience and education of the project staff leads to the definition of clear project objectives (useful). However, a high complexity of the project can have a negative impact on the definition of clear project objectives (harmful). In this context, 16 useful and ten harmful relationships were identified (see Figure 1). the factor "team" has predominantly useful relationships with the other success factors, the factor "complexity" has only harmful relationships. The complexity affects, for example, risk management or project planning and requires clear communication rules to be handled. Therefore, the team must define clear communication rules before implementing the project in order to be able to conduct a conscientious project planning and risk assessment. The functional model also shows that the experience of the project staff has a significant influence on the project success. Thus, it can be assumed that due to the experience and education of the project staff, the complexity of a project can be better The identified critical success factors and their interrelationships between each other (see Figure 1) make it possible to formulate hypotheses for further quantitative studies. Furthermore, the third research question is answered by means of the following hypotheses.

Conclusions and hypotheses
• H1: The higher the experience / education of the team, the higher is the project success.
• H2: The clearer the roles within the team are, the higher is the project success.
• H3: The better the team roles have been formulated, the easier the project objectives can be achieved.
Hypotheses H1 to H3 are based on the finding that the internal factors in project failure involving the project team dynamics represent a large cause for the project failure than external factors (Abouzahra, 2011;Xiangnan et al., 2010;Ghazvini and Shukur, 2013). Furthermore, Koumaditis et al. report that IT/IS projects fail when there is a non-balanced team (Koumaditis et al., 2013).
• H4: The clearer the project objectives, the higher the project success.
• H5: The clearer the project objectives are, the better the project process can be aligned.
• H6: The better the project objectives are communicated, the higher is the project success.
Hypotheses • H7: The better the project was planned by the team, the higher is the project success.
• H8: The better the project process can be aligned, the better the project plan.
• H9: The better the project planning is, the better the project objectives can be achieved.
• H10: The better the project planning is, the better the project roles are defined. • H11: The more controlled the communication within the team is, the higher is the project success.
• H12: The better the communication within the project is, the better the project objectives can be achieved. • H13: The higher the experience / education of the project staff is, the better the project objectives can be achieved.
• H14: The higher the experience / education of the project staff is, the better the risk for the project can be determined.
• H15: The higher the experience / education of the project staff is, the easier it is to understand the complexity of the project.
• H16: The higher the experience / education of the project staff is, the easier it is to execute the project role.
Research shows that the capability of the project staff • H17: The better the risk for the project is determined, the better the project objectives can be defined.
• H18: The better the risk for the project is determined, the better the project can be planned.
• H19: The better the risk was determined by the team, the higher is the project success.
Hypotheses H17 to H19 are based on the finding that the identification and assessment of project, operational and financial risks must be permanently verified during the implementation of the project in order to ensure a subsequent project success • H20: The higher the complexity of the project is, the lower the support by the top management.
• H21: The higher the complexity of the project is, the more difficult is the project planning.
• H22: The higher the complexity of the project is, the more difficult is the determination of the risk of the project.
• H23: The higher the complexity of the project is, the more difficult is the determination of clear project objectives.
• H24: The higher the complexity of the project is, the more communication is required for project success.
• H25: The higher the complexity of the project is, the worse the project process can be aligned.
Although the success factor "complexity" is only recommended by a few authors (

Limitation and outlook
This study has tried to close the research gap initially mentioned by using a qualitative study. Based on a literature analysis, critical success factors were identified for the successful implementation of IT/IS projects in the healthcare sector. For a detailed analysis, the interrelationships between the identified success factors were evaluated. In summary, it should be noted that the literature often named identical success factors for the successful IT/IS implementation, and, thus, the literature collected on the subject area is very homogeneous. Based on the results of the literature review and the hypotheses developed and discussed in this research, the need for further research in the field of critical success factors in healthcare IT/IS projects, according to Santos et al. (2014), is demonstrated.
This research has several minor limitations. With regard to the consideration of the interrelationships between the critical success factors, only the top ten factors were considered. The inclusion of all identified success factors would possibly lead to further findings. Furthermore, the results obtained from this research would gain further in quality through a wider literature analysis with regard to the expansion of the search area.
Finally, this work provides several connecting factors for further research work. The hypotheses developed in this study provide a basis for future research to explore the iden-tified critical success factors and to examine their predictability for the success of IT/IS projects in the healthcare industry. Furthermore, this work could serve as the basis for the development of an approach to the use of critical success factors for IT/IS implementations. Further research can also deal with examining the identified success factors for use in other IT projects as well as in other industries.