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A Generic Quality Assurance Model (GQAM) for successful e-health implementation in rural hospitals in South Africa Nkqubela Ruxwana, Marlien Herselman and Dalenca Pottas

Abstract Although e-health can potentially facilitate the management of scarce resources and improve the quality of healthcare services, implementation of e-health programs continues to fail or not fulfil expectations. A key contributor to the failure of e-health implementation in rural hospitals is poor quality management of projects. Based on a survey 35 participants from five rural hospitals in the Eastern Cape Province of South Africa, and using a qualitative case study research methodology, this article attempted to answer the question: does the adoption of quality assurance (QA) models add value and help to ensure success of information technology projects, especially in rural health settings? The study identified several weaknesses in the application of QA in these hospitals; however, findings also showed that the QA methods used, in spite of not being formally applied in a standardised manner, did nonetheless contribute to the success of some projects. The authors outline a generic quality assurance model (GQAM), developed to enhance the potential for successful acquisition of e-health solutions in rural hospitals, in order to improve the quality of care and service delivery in these hospitals. Keywords (MeSH):

Quality Assurance; Management Case Studies; Healthcare; Health Information Technology; Communication.

Supplementary term: E-health.

Introduction

The rapid uptake in the adoption e-health promises to have an enormous impact on healthcare delivery and management, including delivery of information that communities require to make informed decisions on healthy lifestyle, facilitation of designs for future medicines, and shaping healthcare systems to become more competent and reactive to providing home-based care through mobile healthcare technologies (Europa 2006). According to the World Health Organization (2004), the key drivers for e-health are the quality, safety, effectiveness and efficiency of healthcare services. In South Africa, we have seen an increase in e-health developments, including innovations such as district health information systems (DHIS), opensource-based medical record systems (OpenMRS), electronic medical records, hospital information systems, public networks, health decision-support and expert systems, telemedicine and community health information systems (IS), as well as other technical systems (IS) that have reduced healthcare costs, improved quality, increased accessibility and enhanced delivery of healthcare services (African Development 26

Forum 2001; Seebregts & Singh 2007). These developments can help to bridge the digital divide between rural and urban healthcare centres (Ruxwana, Herselman & Conradie 2010), promising solutions to many challenges faced by the the rural healthcare sector (Ruxwana, Herselman & Conradie 2010), and transforming healthcare services delivery and patient care, as well as management of the healthcare system (Louw & Hanmer 2002). However, e-health developments face challenges that hinder implementation; for example, the legal and regulatory environment; patients’ lack of trust in the new systems; limitations of information technology (IT) (Rawabdeh 2006); and failure of previous IT projects (Heeks 2002; Standish Group International 2004). Researchers have investigated the success and failures of IT projects (DeLone & McLean 2003; Standish Group International 1994, 2001, 2004), and, interestingly, many factors identified with failure might have been avoided through the adoption of project quality management approaches. Implementation of e-health has been more successful in the developed world than in the developing world, due to challenges such as lack of infrastructure, services and know-how, limited

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Research resources, low literacy levels and professional isolation (Herselman & Jacobs 2003; Olugbara et al. 2006). The lag in implementation may also be due to the higher failure rate of IT projects in developing countries (Standish Group International 1994; 2004). More recently, there have been some developments in IT projects but the failure rate is still distressingly high, especially on larger projects (Standish Group 2004; Jensen 2007: 919). South African healthcare IT initiatives are no exception. The few studies conducted on healthcare projects in South Africa show the failure rate to be higher than in developed countries (Mbananga, Madale & Becker 2002; Braa & Hedberg 2002), and an evaluation of IT initiatives by Littlejohns, Wyatt and Garvican (2003) found the reasons for failure in South African were similar to those in other countries. Other researchers have focused on understanding factors that underpin success (DeLone & McLean 1992; Gable, Sedera & Chan 2008). The DeLone and McLean (1992) IS success model is the most cited. It classifies success measures into six dimensions: system quality, information quality, organisational impact, individual impact, satisfaction, and use. Significantly, quality emerges as an essential element on all success models. However, these models focus on the quality of the final product, the solution; they have not particularly addressed aspects of quality from a project management context.

Project quality management The DeLone and McLean (2002) updated IS success model categorised quality into three dimensions: information quality, systems quality, and service quality. Clearly, the focus here has been on the actual product, whereas project quality management processes include all processes and activities of the performing organisation that determine quality policies, objectives, and responsibilities, so the project will satisfy the needs for which it was undertaken (PMI 2004). The project quality management process enforces quality processes of the actual products and also implements the organisation’s quality management system (QMS) through policy and procedures, with continuous process improvement activities conducted throughout as appropriate to each project (PMI 2004), including inter-functional processes, such as quality planning, quality control, and quality assurance (QA). Studies using a project quality management framework include the Standish Group’s CHAOS reports (1994, 2004), which showed that introduction of formal project quality management increased project success to 29% (Standish Group, 1994; 2004); and the study by Jones (2004), who identified six problems commonly associated with failed projects (poor project planning, cost

estimating, measurements, milestone tracking, change control, and quality control), which could all be identified and mitigated through QA as a subset of project quality management. These studies highlight that project management rather than technical expertise is the main driver of successful IT implementation; and, conversely, that inadequate project quality management, especially the lack of QA, is a contributing factor to the failure of projects. However, to date no study using a project quality management framework to examine the success and failure of IT projects has specifically addressed aspects of QA and its adoption in the context of rural hospitals.

The current research The present paper focuses on essential elements for a generic quality assurance model that can aid successful implementations of e-health in rural hospitals in South Africa. The aim of the study was to determine the essential components for a quality assurance (QA) model and to develop a generic quality assurance model (GQAM) that will aid successful implementation of e-health solutions in rural hospitals. The following general question and four sub-questions were posed: What are the components of a generic quality assurance model (GQAM) to assist rural hospitals in the Eastern Cape Province in South Africa with the successful acquisition of e-health solutions? 1. What are the QA methodologies used in e-health acquisition for rural hospitals? 2. How do these methodologies aid successful e-health acquisition in these rural hospitals? 3. What are the challenges experienced when applying these methodologies in rural hospitals? 4. What sensible model can be adopted to overcome these challenges and to improve the quality assurance processes used in e-health acquisitions in rural hospitals?

Method Qualitative research design The study used a multiple case study methodology, a type of qualitative research design where the researcher investigates a chain of single entities, phenomena or cases confined by time and activity and collects detailed information by using a variety of data collection procedures during a sustained period of time (Creswell 2003). According to Yin (2002), a case study of this nature is an empirical investigation of an existing event within its environment. It is mainly used when the boundaries between the event and its environment are not clear. It allows specific cases to be studied in greater detail from the viewpoint

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Research of the participant by using multiple sources of data (Feagin, Orum & Sjoberg, cited in Tellis 1997). The reason for adopting a qualitative research approach for this study was to gather non-numerical data to help explain and develop a GQAM for e-health acquisition. Methods used included questionnaires, observation, interviews and document analysis. Information derived from these instruments was combined into a GQAM that depicts the activities that should be included to ensure quality in e-health acquisition and to improve the chances of success in implementing such solutions in rural hospitals. Ethics approval was obtained from the Eastern Cape Department of Health and the Nelson Mandela Metropolitan University, and informed consent was signed with participants before interviews were conducted.

Participants and sampling There were 35 participants from five rural hospitals in the Eastern Cape Province, from whom data were collected over an 18-month period. Purposive sampling was used to select the various hospitals and participants. This involves selection of units to be observed on the basis of the researchers’ own judgement as to which will be most useful or representative. Table 1

shows the hospitals selected for inclusion in the study, namely those serving rural communities and using the five e-health solution program implemented by the ECDoH. Only hospitals providing primary care, generally the point of first entry for patients in the different regions (the former Transkei and Ciskei), were included. Telemedicine solutions were the most common type of implementation and due to the small sample size the same people represented the ECDoH and the vendors. Participants included senior management, project managers and coordinators, the IT directorate and e-health team representatives from the ECDoH. Vendor representatives and the user community based at the five hospitals were also included (e.g. doctors, nurses, radiographers and other hospital staff). Only those involved within processes of acquiring identified e-health solutions within the selected hospitals were targeted. They also represented members of the project team for systems acquisition and for QA within the project. Experts in e-health QA in solution designs and project quality management fields, both industry and academia, were also involved. These experts were used mainly at the end to verify the model developed. Table 2 summarises all participants involved in the study.

Table 1: Case study hospital and solutions list CASE NO.

CASE DESCRIPTION (HOSPITALS)

LOCATION/CITY

SOLUTIONS

1

St Patrick’s Hospitals

Bizana

2

Madzikane ka-Zulu Memorial Hospital

Mount Frere

3

Uitenhage Hospital

Uitenhage

4

Settlers Hospital

Grahamstown

5

Frontiers Hospital

Queenstown

1. TeleDermatoloty 2. TeleECG/Spirometry 3. Teleconsultation 4. Mindset 5. Telemedicine

Table 2:Total participants STUDY PARTICIPANTS CATEGORY

TOTAL N

Vendors

3

Eastern Cape Department of Health (ECDoH)

6

Site Coordinators

5 (N=1 per case)

Users (doctors, nurses, radiographers etc.

15 (N=3 per case)

Expert reviews

6

Total

35

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Research

Phases of the study

QA methodologies used in e-health acquisition for rural hospitals

The study process proceeded through four phases. The first two phases (Phases 1 and 2) focused on case studies where data were collected to answer research questions using data triangulation to provide findings and conclusions. The findings obtained from the case studies were then used in Phase 3 to develop the first draft of the QA model in layers. The layers continued through to Phase 4 where the draft QA model developed from the case study findings evolved until the final generic QA model (GQAM) was produced. In Phase 4, the GQAM was used as input to the cycles for developing a QA value chain (excluded in this paper), which provides the implementation guidelines for the GQAM.

Generally, respondents agreed that there was a general quality management strategy in place, and these strategies were developed in terms of a quality management system and standards. However, implementation of these strategies and their use on a project implementation level was only consistently prevalent in the perceptions of vendors who supplied these e-heath solutions. Participants were not as confident as vendors were in terms of the level of detail of the strategies and their applicability to project implementation in ensuring quality. Likewise, participants demonstrated a lack of awareness of the quality processes in place for e-health IS implementation projects. Throughout the five organisations there were common limitations: all participants revealed the nonexistence of a ‘lessons learnt’ knowledgebase, which is an integral part of QA and a key for improved quality and continuous improvement in organisations and projects. Furthermore, findings revealed a need for

Development of the model

Findings

The development of the GQAM required an analysis of several research sub-questions. Key findings are discussed below.

9 8 Number of participants

It is important, if one considers the different complexities of rural areas in South Africa, to have a model that is relevant to the context and developed within the culture. Therefore, it was important to collect primary data on the ‘burning issues’ and key factors relating to QA in solution development within the e-health sector in South Africa. Although data gathered were not directly linked to rural hospitals and projects, it was important to consider those factors that are critical for any model that is aimed at introducing QA in solution development projects. To develop a relevant model that fits the context of its implementation, a user involvement approach was adopted where the e-health team and other relevant stakeholders were involved. To ensure the model remained within the general practice area and could fit any typical solution development life cycle (SDLC), experts’ reviews were also considered. These reviews were conducted with local experts from the fields of health informatics, QA, solutions design and project management. Experts were asked to reflect on their experiences, both industry and academic, on challenges inherent in implementing existing quality methods, standards and models in South African organisations, in relation to project quality management. In addition, the experts were asked about the elements of the most sensible model required to overcome the QA challenges in solution implementation for rural areas. This representative involvement was adopted throughout the series of cycles of the study to formulate the model elements, designs and testing.

7 6 5 4 3 2 1 0 1

2

3

4

5

6

7

Questions Yes

No

Don't know

No.

Question

1

Does a quality management system exist within your organisation?

2

Does a quality management strategy exist, which addresses the strategy to be followed during system implementation/development projects?

3

Has this quality management strategy been compiled taking into account QA standards such as ISO 9000: 2000, PMBOK, PRINCE2 and CobiT?

4

Is there an adopted quality manual which indicates the quality activities to be followed during a system implementation/development project?

5

Do the activities stated as part of the QA function’s responsibility address the key quality principles?

6

Is there a quality forum responsible for quality approvals and evaluations?

7

Is there a database or store for lessons learnt for projects?

Figure 1: General quality information

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Research improvement in existing methods covering the areas of traceability, accountability, quality upfront (quality planning in the inception of the project), customer involvement, independent QA and the use of modern tools and techniques in e-health acquisition in the Eastern Cape as depicted in Figure 1. On the basis these findings, we concluded that QA methodologies do exist in the participating organisations. However, there is much to be done to promote awareness of these methodologies for guiding QA at the project level, such as the development of a quality manual or policy with detailed QA principles and standards that have to be followed. It would also be useful to have a ‘lessons learnt’ knowledge base, where all the lessons learnt from projects can be stored to aid success and provide points of reference in future projects. Moreover, changes in environmental culture within the healthcare organisations to enable and promote a positive attitude towards e-health solutions, coupled with improved competencies and skills on IS development and its implantation process,

general project and change management aspects, strong leadership and senior management support and involvement, as well as user engagement, become critical factors that would promote and ensure the adherence to the cited QA methods adoption. The findings reveal that great value is added by adopting QA methodologies in projects. The findings collected using the various instruments reveal a consensus that, although QA does not guarantee project success, it does aid the project team in achieving its project objectives, evaluating progress and identifying risks, changes and actions to mitigate those risks identified earlier in the project lifecycle. However, the findings also show that there are limitations in the current methodology and if these are addressed earlier on in the lifecycle of the project, greater value can be added throughout the project process, as outlined in Table 3. These findings reveal positive feedback on the value added by QA in e-health solutions and in project success. However, there is room for improvement because participants also reported weaknesses in QA activities.

Table 3: Perceived value of methodologies NO.

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QUESTION

FINDINGS SUMMARY

1

Did the quality assurance activities within the project assist the project team in achieving the project’s goals?

All the participants acknowledged the positive impact of QA for project success. The findings show that 67% of the participants agreed with this statement, while 33% of the participants strongly agreed that QA activities adopted have assisted in achieving project goals

2

Are there weaknesses in the quality assurance activities that you feel should be addressed to add more value to future projects?

The participants indicated that there were existing shortcomings and weaknesses in the QA activities, which should be addressed to add more value to future projects. As participants all concurred on this statement, as shown by the findings showing that 56% of participants agreed with this item while 44% strongly agreed.

3

Was the system implementation process adopted successful?

This question differed in terms of each solution; it was found that - Teledermatology and Teleradiology solutions were viewed as successful in all cases/hospitals (n = 5) - There were mixed results in terms of the success of Mindset and TeleECG/Spirometry, however, they were viewed as successful in most cases (n = 3) - Teleconsultation was regarded as having failed in all cases (n = 5) The overall scores indicate that 67% of participants agreed, while 33% of participants neither agreed nor disagreed owing to the mixed results stated above.

4

Do you feel that the system implementation process would have been successful without the QA activities?

All the participants perceive QA as being an integral part of project success, as 78% disagreed and 22% strongly disagreed.


Research

Challenges experienced when applying these methodologies in rural hospitals

The sensible model for e-health acquisitions in rural hospitals

Although some of the challenges experienced by participants may have resulted from other factors, an effective QA methodology would have helped to identify and mitigate possible risks earlier on in all projects. Data collection instruments used highlighted the weaknesses in existing QA methodology, especially in the key principles such as quality upfront, user involvement, clear accountability, independent QA evaluations, the use of QA tools and techniques, qualified staff, traceability and continuous improvement. However, it was clear that most challenges were related to and the result of weakness in the adopted QA methodology (see Table 4).

A key finding from the literature is that to have an impact on project success, there is a need for standardised methodologies. It is also evident that QA activities include several elements that have some form of review, inspection, approval and testing; which are an integral part of the methodology for solution implementation (Standish Group, 2001; ISO 2012; Schwalbe 2007; Ruxwana, Herselman & Conradie 2010). The Standish Group study (2001, 2004) listed the following factors, in order of importance, which contribute to the success of IT projects that a sensible QA model needs to consider: executive support; user involvement; experienced project manager; clear

Table 4: Interview results for sub-question 3 RESEARCH QUESTION

RESEARCH ANSWERS

1

What are the generic challenges that you are currently faced with during projects (not QA specific)?

Respondent 1: The biggest problem is training, we train and people leave and that leaves us back to square one. Respondent 2: User training is the biggest problem; the current model is involving only one user for from each hospital and that particular person can die or leave and leaves none knowing about the solution. Respondent 3: The lacking awareness, training, evaluation and clear accountability about the solution use, support and maintenance, as well as channels is the biggest problem in these projects. Respondent 4: The general attitude and user buy in to the solution – some have been trained but they opt not to use the solutions. Respondent 5: Limited user involvement and training is the problem. Respondent 6: IT infrastructure is the main barrier of these solutions’ use, and it affects quality as it is not always sufficient to cater for these solutions.

2

What specific QA problems are you currently experiencing?

Respondent 1: The lacking user involvement and user requirements leads to deployment of un-required solutions. Respondent 2: Poor user involvement, training and management reviews is the problem Respondent 3: There is challenge with evaluations and feedback of the solutions. No postimplementation evaluations Respondent 4: The sites do not take ownership and accountability of the solutions. Respondent 5: Limited QA activities in general is the problem, roles and responsibilities, communication, involvement, reviews, evaluations, testing and training.


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Research business objective for IS solution (such as e-health); minimised scope; standard software infrastructure; clear business requirement; formal methodology; reliable costing estimates; and other criteria, such as milestones, proper planning, competent staff, and ownership. It is clear that most, if not all, of these factors can be controlled and better managed if QA is continuously applied and planned for within a project. Indeed, the existing standards and models do not provide context-relevant guidelines on quality, but a generic view of quality management. From the experts’ reviews, it was evident that it is important for businesses to have standardised processes for delivering solutions in order to enable solution traceability and further support sustainability. The experts all pointed to people as being the main barrier to the adoption of methods and standards. The reasons for this relate to aspects such as education, knowledge, skills, applicability and implementability, and resistance to change. Findings of expert reviews relating to the most sensible model that can be adopted to overcome challenges faced with QA when implementing solutions are summarised below. The challenge to implementation of QA methodologies is the lacking of understanding of their intent and benefits, which then leads to resistance from the project team, especially if it changes their norm of doing things. Therefore the elements of the most sensible model include awareness and change preparation for those who are involved. (Respondent 1) The problem with QA methodologies is the lack of knowledge of those who are to implement them; thus a proper guideline which clearly states the accountability, roles and responsibilities and acceptable standards becomes key for QA methodology. (Respondent 2) The challenge is education, knowledge, understanding, and implementation of these methodologies in organisations. As a results people are resistant to using them, as they don’t know their intent and benefits, and they don’t understand how they can implement them within their processes. (Respondent 3) For any methodology to be sensible, it needs to fit in to the context of its use; thus it must meet the different needs of its users. (Respondent 4) QA is about continuous involvement; thus evaluations, knowledgebase and continuous involvement, training and evaluation become critical for the success of such models. (Respondent 5) The most sensible model for QA is the one that enforces standardisation of the project activities to 32

a certain degree, with the aim to support continuity and maintenance of such solution. (Respondent 6) Although most comments concur with the literature findings, what was interesting was that stakeholder participation and involvement were unanimously cited as the most effective ways to overcome challenges, with an emphasis on user awareness and involvement. There was consensus on the fact that models or methods that are customised to fit a certain environment can enforce standards and quality in solution design processes, and these models or methods should be used in a way that fits the culture of the environment and can only be successful when driven by its users. This is in line with the purpose of the study; that is, to develop a locally-relevant QA model, the GQAM, to establish quality and improve success in e-health acquisitions in rural hospitals.

Proposed QA model to enable e-health implementations According to Arsham (2006), a model is an external and explicit representation of a part of reality, as seen by an individual who wishes to use the model to understand, change, manage and control that part of reality; and that the purpose of a model is to aid in designing a solution and assist with understanding a problem. To develop and test this model it was necessary to identify the QA methodologies currently used in rural hospitals for e-health solutions acquisition (sub-question 1); and to further evaluate the adopted QA methodologies to determine if they were the most sensible methodologies for successful acquisition and to determine their role in ensuring the acquisition success, their shortcomings and adoption challenges in system acquisition (sub-questions 2-4).

Discussion

Findings obtained from the data collection instruments, such as the interviews, questionnaires, observations, document analysis, expert reviews and literature study, revealed that there are QA methodologies appropriate for e-health solution acquisition in rural hospitals in the Eastern Cape Province. It is also important to note the critical support of these findings for literature relating to the importance of QA in solution design and implementation. The findings reveal the perceived critical role played by QA in ensuring project success. However, there are challenges and weaknesses in implementing QA methodologies. It was clear that there was no standardised methodology in use for implementing e-health solutions in the selected hospitals. Although the contracted vendors adopted their own methodologies, these seemed to focus more


Research on product development, thus the quality aspects were those that focused on solution functionality as per specifications. This suggests that project management and QA methodologies were used in system development but were lacking the acquisition and implementation states of e-health for rural hospitals; hence, the challenges were experienced at the end, with some solutions. It was evident that most problems that exist could have been identified and resolved earlier if QA had been adopted in the process of acquiring these solutions. However, there was no defined process for the solutions to follow, so each solution followed its own different methodology, which led to several challenges: traceability; accountability, sustainability, support and maintenance; training; awareness and involvement; compliance and standardisation; requirement analysis and readiness assessment; continuous improvement; independent QA, evaluation and knowledge base; quality upfront; qualified staff; and QA tools and techniques. It seems that the most sensible QA model is one that puts the solution’s stakeholders first, defines quality from their perspective and develops a means to ensure that the specified expectations are met. From these findings the key elements of such a model should be: user awareness and involvement; training and support; standardisation; clear accountability through roles and responsibility and stakeholder maps; promoting and enforcing the management of a knowledge base; traceability of expectations through continuous reviews; relevant and customised to fit the environment in which it is used; providing support for meeting technical and human expectations; and facilitating continuous improvement. Based on these findings, the proposed generic QA model (GQAM) for e-health acquisition in rural areas was developed. This model aims to mitigate the challenges experienced in e-health implementations as well as to aid future successful acquisitions of e-health solutions.

The Generic Quality Assurance Model (GQAM) Purpose of GQAM The purpose of GQAM is to aid the successful acquisition (i.e. identification, selection, development and implementation) of e-health solutions for rural hospitals in the Eastern Cape Province. This can be achieved by using the GQAM as a blueprint for the fundamental elements and project quality management processes that need to be followed to ensure that quality will be met in the end, irrespective of who is implementing the solution. The model is referred to

as ‘generic’ as it can be used for any e-health solution acquisition project, for any adopted systems development method, and for any given context for ensuring quality within project management processes. The authors suggest that, since e-health solutions are acquired for enhanced healthcare and are mostly adopted for safety and mission-critical activities, ensuring that these solutions are of high quality and that the processes used to develop and implement them follow the best QA methodologies and standards, by emphasising QA in project management, is pivotal.

GQAM layers The GQAM encompasses several layers and each layer or stage comprises functions or processes to be executed that have different interlinking deliverables. Although there is limited literature on project implementation in South Africa, there is none that covers aspects of project quality management in e-health projects or of IT project implementation in rural areas. Even the work that has been done in e-health solutions internationally does not cover aspects of QA in solution acquisitions. However, the existing literature does provides the fundamentals that were required to develop the GQAM in that it gives the key principles and elements of QA, as a subset of project quality management, obtained from the quality standards, methods and models. Furthermore, the literature reveals common barriers and artefacts that lead to the failure of IT projects worldwide, including those that have been implemented in rural areas of South Africa. These findings together with the primary findings obtained from this study, were use to develop the model in layers. Table 5 below summarises the layer development, linking each layer to the most important data source. As shown in Table 5, the model layers were developed primarily based on the study findings with consideration and support from the secondary sources. In order to develop such a model in a manner that is relevant and fits the context of its implementation, a user involvement approach was adopted where the e-health team and other relevant stakeholders were involved. This representative involvement was adopted in a series of cycles to formulate the model elements, designs and testing. This model was developed from the inside out, with users forming the central point of departure, with other stakeholders being considered through to the outer layer of continuous improvement of the processes adopted inside and the implementation of the model. From the study findings and literature reviews, it is evident that one critical element for success, yet currently overlooked in the e-health


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Research solutions was identification of the various e-health project stakeholders and their different roles and influence in the project (Herselman & Jacobs, 2003; Olugbara et al. 2006; Schwalbe 2007). Key to this is identification of the solution users, whose needs and expectations are to be met by the implemented solution (ISO 2012; Schwalbe 2007; Foster 2007). The second layer of the model advocates quality definition based on user needs and expectations. The findings revealed that most of e-health solutions failed due to lacking user involvement and clearly identification and specification of their needs and expectations. Moreover, the development of this layer resulted from the consideration of secondary sources on the theories of quality; ISO standards; TQM – the quality principles (Goetsch & Davis 2002), as well as discussion on challenges on ICT implementation in rural South Africa (Matthews 2007; Herselman & Jacobs 2003; COFISA 2008). Thus, user needs and expectation have to be

ascertained, analysed and specifically documented. As needs and expectations change, user involvement throughout the project cycle will assist in decision making on quality impact and the mitigation steps resulting from the changing user needs and expectations. According to the International Organization for Standardization (ISO) 9004:2009, (ISO 2012) the success of the organisation depends on understanding and satisfying the current and future needs and expectations of present and potential customers and end-users, and on understanding and considering those of other interested parties. Once the needs and expectations have been understood and defined, quality from the user’s point of view can be defined. The third layer also asserts the standardisation of process and ways of doing this to enable control, measurement, integration and interoperability of solutions. The findings revealed the lack of standardised process and understanding of quality methods or approaches,

Table 5: Method layer summary LAYER

DESCRIPTION

DATA SOURCES

Layer 1

Identification of each project stakeholder and understanding their different roles and influence in the project and its success becomes critical. Key to this is identification of the solution users and catering for their different needs

In addition to the study findings, the literature sources on reflection on lessons learnt on the implemented solutions (Kerzner 2006; Heeks 2002; Matthews 2007; Herselman & Jacobs 2003; Olugbara et al. 2006; Littlejohns, Wyatt & Garvican 2003); the project management body of knowledge (PMBOK 2004) and project quality management (PM4DEV 2008; Kerzner 2006; Foster 2007; Schwalbe 2007).

Layer 2

This layer focused on issues relating to user involvement, user needs and expectations as the drivers of quality.

Literature discussion on the theories of quality; ISO standards (ISO 9004:2009; Schwalbe 2007; Kerzner 2006; Foster,2007; Gryna, Chua & Defoe 2007); TQM – the quality principles (Goetsch & Davis 2002; Claver & Tari 2007; Crosby 1979; Deming 1982; Feigenbaum 1983; Juran 1988); discussion on challenges on ICT implementation in rural South Africa (Heeks 2002; Matthews 2007; Herselman & Jacobs 2003; Olugbara et al. 2006; Littlejohns, Wyatt & Garvican 2003; COFISA 2008; Qiang, Clarke & Halewood 2006).

Layer 3

This is about considering the existing Study findings (Chapters 5–6); the discussions on methodologies, organisational methods, principles and standards and models (ISO 9004:2009; Schwalbe 2007; Kerzner 2006; standards for projects. This includes Foster 2007; Gryna, Chua & Defoe 2007). adoption or adaptation of methods and principles.

Layer 4

This layer fosters QA as a subset of project quality management

Project quality management literature, TQM and PMBOK (Chua 2001; Harry & Schroeder 2000; Hahn, Doganaksoy & Hoerl 2000; Chua & Janssen 2000; Hanson 2006; Schwalbe 2007; Gryna, Chua & Defoe 2007: 145; Hahn, Doganaksoy & Hoerl 2000).

Layer 5

This layer recognises QA as an integral part of continuous improvement in project processes, activities, knowledge base, deliverables and methods.

This need was clearly identified in the results of this study in concurrence with literature reviews such as those on continuous improvement topics such as, the PDCA methods; CMMI and Six Sigma (PM4DEV 2008; ISO 9001:2008; Gryna, Chua & Defoe 2007: 145; Hahn, Doganaksoy & Hoerl 2000; CMMI v 1.1, 2002: 624; SEI, 2007).

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Research which is critical for e-health solutions. The key principles and standards should be selected for evaluating and measuring quality by ensuring that the requirements that have been defined are met. These should range from a project management perspective to a systems development perspective; the elements of ISO standards; and TQM – the quality principles (Claver & Tarí 2007; Juran, Gryna & Bingham 1988). QA methods and stands were considered from the literature to guide this layer development (Hanson 2006; Schwalbe 2007; Gryna, Chua & Defoe 2007). The fourth layer was developed to focus on project quality management as a process of ensuring that all project activities necessary to design, plan and implement a project are effective and efficient with respect to the purpose of the objective and its performance (PM4DEV 2008). In either case, failure to meet product or project quality requirements can have serious negative consequences for any or all of the project stakeholders. Project quality management includes three processes: the quality plan, the QA, and the quality control (Foster 2007; Schwalbe 2007; PMI 2004). Thus, for e-health solutions, project quality management is essential to help overcome the challenges stated in the findings of this study. The final layer focused on issues of continuous improvements which were evidently lacking in e-health implementations. According to the PMI (2004), quality improvement includes taking action to increase the effectiveness and/or efficiency of the policies, processes and procedures of the performing organisation. QA provides an umbrella for continuous process improvement, which is an iterative means for improving the quality of all processes. Continuous process improvement reduces waste and eliminates activities that do not add value. Literature sources focusing on continuous improvements, such as the PDCA and DMAIC, were considered (PM4DEV 2008; ISO 2012).

Conclusion

This is the first study to use a project quality management framework to specifically examine aspects of QA in relation to IT and IS projects in rural contexts in South Africa. Findings presented in this article show that although QA methodologies are used, there is no formalisation or standardisation of the processes of applying these methodologies. In spite of this, QA methods had a major impact on the success of projects. The study also identified several weaknesses in the QA methods being used, which if addressed and corrected could add further value to the projects. A major outcome of this study was the development of the GQAM, which can be used to ensure e-health solution

success in rural hospitals by overcoming the challenges and introducing additional standards that will support sustainability and future maintenance of these solutions, while facilitating user buy-in and ownership through increased user involvement levels.

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Corresponding author: Nkqubela Ruxwana, PhD Nelson Mandela Metropolitan University South Africa email: [email protected] Marlien Herselman, PhD Nelson Mandela Metropolitan University & Mareka Institute, CSIR South Africa [email protected] Dalenca Pottas, PhD Nelson Mandela Metropolitan University South Africa [email protected]
