Bjarne Rerup Schlichter

Erik Rostgaard Povl

Andersen

Value Creation from Public Healthcare IS -An Action Research Study in the Faroe Islands

Keywords: Healthcare information systems, IS business value, IS public value, action research, value realization, stroke process

The obtainment of value from IT is a recurring theme that has diffused into healthcare information systems (HIS). Having completed the implementation of an integrated HIS, the Faroese Health Service (FHS) has started discussions regarding the obtainment of value from its IT investment which is the subject of this paper. Based on an action research project focusing on the improvement of the stroke process, this paper reveals that it is not possible to distinguish between working processes and HIS and that the realization of value in this context has a much broader significance than mere financial value. During the project, specific key performance indicators (KPIs) were identified and a baseline was established for the stroke process. The outcome is a framework for measuring IS public value as: professional, organizational, patient-perceived and employee-perceived quality as well as learning. Selected non-financial measures for each dimension and their development are presented, e.g., a decrease in mortality.

Introduction

The creation of value through the use of IT has received increasing attention in recent years. The debate concerning the value of IT also has diffused into healthcare [START_REF] Devaraj | Information technology payoff in the health-care industry: A longitudinal study[END_REF][START_REF] Friedman | Evaluation methods in medical informatics[END_REF], and is closely related to a more wide-ranging discussion regarding the performance measures of healthcare organizations [START_REF] Murray | Ranking 37th -Measuring the Performance of the U.S. Health Care System[END_REF][START_REF] Reeves | Analysis: How to identify when a performance indicator has run its course[END_REF][START_REF] Bend | Public value and e-health[END_REF][START_REF] Sapountzis | Realising benefits in primary healthcare infrastructures[END_REF] and public organizations in general [START_REF] Cole | Unlocking Public Value -A New Model for Achieving High Performance in Public Service Organizations[END_REF][START_REF] Coats | Public Value: The Next Steps in Public Service Reform[END_REF].

The general discussion concerning the value of IT and the broader discussion regarding the performance measures of healthcare organizations motivated us to start an action research project in the Faroe Islands. The Faroese Health Service (FHS) completed the implementation of an integrated healthcare information system (HIS) in 2010; it was then time to consider reaping the value of the system. We initiated an action research project with the objective of creating (more) value from the newly implemented HIS. It soon came to our attention that one of the major challenges in this project was to establish a shared and sound understanding of what actually constitutes value in the healthcare setting and how to measure any status or progress that is rooted in the ongoing development of the processes. Also, we observed that FHS had defined no targets for value in the initial implementation of the HIS project (i.e., no business case was available).

This paper addresses the need for a more fine-grained framework for measuring (or evaluating) the creation of value in HIS settings. This is a response to Breese [START_REF] Breese | Benefits realisation management: Panacea or false dawn[END_REF], who stated in a recent paper that there is a need for the development of theories regarding the creation of value "which are based on in-depth analysis of practice, and acknowledge and incorporate ambiguity and uncertainty." Several studies have explored value creation methods [e.g. [START_REF] Bradley | Benefit Realisation Management[END_REF][START_REF] Ward | Benefits management: How to Increase the Business Value of Your IT Projects[END_REF] characterized by the functionalist, rational model that so often dominates the project management community [START_REF] Morris | Introduction: Towards the Third Wave of Project Management, in The Oxford handbook of project management[END_REF], and that, to some extent, lacks the complexity experienced in practice [START_REF] Breese | Benefits realisation management: Panacea or false dawn[END_REF]. The paper provides a framework for measuring the IS public value realized in a healthcare setting and demonstrates how the framework was used in practice; thus, it shows the actual value created by a present framework of multidimensional value categories and identifies the key differences between governmental and for-profit organizations. Hence, it shows that different approaches to the measurement of value are needed.

The paper proceeds as follows. The next section reviews the literature regarding value in a public sector context. This is followed by a section describing the action research method applied and the concrete activities in the two action research cycles. We then present the actual creation of value in the project with the offset in an empirically derived structure of value and quality dimensions. We conclude with the implications for research and practice.

2

From IS Business Value to IS Public Value

The economic consequences of IS investments have been a recurring theme for many years (at least from the 1980's to the present) [START_REF] Kohli | Business Value of IT: An Essay on Expanding Research Directions to Keep up with the Times[END_REF][START_REF] Melville | Information Technology and Organizational Performance: An Integrative Model of IT Business Value[END_REF][START_REF] Parker | Information economics: linking business performance to information technology[END_REF]. The terminology and notions vary when 'value,' 'benefit,' 'outcome' or 'worth' [START_REF] Schryen | Revisiting IS business value research: what we already know, what we still need to know, and how we can get there[END_REF] are the terms used and linked to benefit realization management [START_REF] Breese | Benefits realisation management: Panacea or false dawn[END_REF][START_REF] Bradley | Benefit Realisation Management[END_REF][START_REF] Ward | Benefits management: How to Increase the Business Value of Your IT Projects[END_REF], value management [17] and beyond. Different semantic understandings are put forward [START_REF] Schryen | Revisiting IS business value research: what we already know, what we still need to know, and how we can get there[END_REF]; some focus on financial and productivity measures [START_REF] Brynjolfsson | Computing Productivity: Firm-Level Evidence[END_REF], while others pay attention to both financial and nonfinancial measures, intangibles such as organizational capabilities [START_REF] Kohli | Business Value of IT: An Essay on Expanding Research Directions to Keep up with the Times[END_REF] or strategic impact [START_REF] Irani | Information systems evaluation: navigating through the problem domain[END_REF].

A fairly general understanding of value could be described as follows [20, p 140]:

[Value is] the relationship between the satisfaction of need and the resources used in achieving that satisfaction…Value is not absolute, but relative, and may be viewed differently by different parties in differing situations.

Value might be positive or negative for specific stakeholders depending upon the benefits or disadvantages that accrue to them. A more specific definition of IS business value is presented by Schryen [16, p 141]:

IS business value is the impact of investments in particular IS assets on the multidimensional performance and capabilities of economic entities at various levels, complemented by the ultimate meaning of performance in the economic environment.

The definition of IS business value presented above has multiple facets that have been elaborated further by several scholars in various settings [e.g. [START_REF] Gregor | The transformational dimension in the realization of business value from information technology[END_REF][START_REF] Seddon | A MULTI-PROJECT MODEL OF KEY FACTORS AFFECTING ORGANIZATIONAL BENEFITS FROM ENTERPRISE SYSTEMS[END_REF]. We adapt the following classification in this paper [adapted from 6, 21]: To change the organizational structure of a company as a result of the implemented IT systems that provide a greater capacity for further future benefit realization. This is typically a longer term effect (lag effect) Unplanned/emergent value A result of a transformation or change of process These value categories underline the multidimensional nature of IS business value as suggested by Schryen [START_REF] Schryen | Revisiting IS business value research: what we already know, what we still need to know, and how we can get there[END_REF]. Seddon et al. [START_REF] Seddon | A MULTI-PROJECT MODEL OF KEY FACTORS AFFECTING ORGANIZATIONAL BENEFITS FROM ENTERPRISE SYSTEMS[END_REF] elaborate on differentiating between short-term and long-term values. Short-term values are seen as being connected to the project level and tied to the immediate realization of an IT system while long-term values are connected to the organizational level. Despite the very comprehensive literature that addresses IS business value [e.g. 13, 14, 16], it appears to be incomplete when it comes to public organizations. We therefore suggest an alternative concept for public organizations coined 'IS public value' instead of continuing to stretch or force the IS business value concept into the public domain [START_REF] Svejvig | FROM BUSINESS IT VALUE TO PUBLIC IT VALUE -AN ACTION RESEARCH STUDY OF HEALTHCARE IN THE FAROE ISLANDS[END_REF].

IS public value research identifies key differences between governmental and forprofit organizations, which naturally leads to other means of evaluating the value of information systems in this sector. The differences are summarized in Table 2 below [START_REF] Moore | Managing for Value: Organizational Strategy in For-Profit, Nonprofit, and Governmental Organizations[END_REF][START_REF] Moore | Creating public value: Strategic management in government[END_REF]:

Find better ways to achieve mission

Table 2 shows that the public sector needs alternative measures, especially with regard to non-financial measures. However, the public sector might also subscribe to traditional financial measures such as cost savings from the optimization of processes [START_REF] Cole | Unlocking Public Value -A New Model for Achieving High Performance in Public Service Organizations[END_REF]. The IS public value concept has formed the theoretical foundation for this study.

Methodology

We initiated an action research study in the Faroe Islands to fulfill the objective of creating value in the FHS's implementation of a HIS. The action research began in 2010 and is expected to come to an end spring 2014. Below, we introduce action research in our context, provide an overview of the research setting and present a detailed description of the actual research process.

Action Research

Action research involves close cooperation between practitioners and researchers to bring about change. It essentially consists of the analysis of a social situation followed by the introduction of changes and the evaluation of the effects [START_REF] Baskerville | Special issue on action research in information systems: making is research relevant to practice--foreword[END_REF]. The action research process can be defined as a number of learning cycles consisting of predefined stages; each starts with a diagnosis, a process that involves the joint (practitioner and researcher) identification of problems and their possible underlying causes. Action planning specifies the anticipated actions that may improve or solve the problems identified and action taking refers to the implementation of those specified actions. Evaluation is the assessment of the intervention and learning is the reflection on the activities and outcomes (adapted from [START_REF] Myers | Qualitative Research in Business & Management[END_REF]). Action research has become widely accepted [START_REF] Baskerville | Special issue on action research in information systems: making is research relevant to practice--foreword[END_REF] and work has been done to conceptualize the approach to enable understanding of and enhance the different elements of action research practice (problem-solving and research activities) [START_REF] Mathiassen | [END_REF]. In two action research cycles, we diagnosed, planned and executed change. The final part of each action research cycle was the evaluation of the problem solving based on both process and outcome. Our action research is theoretically premised on an abductive inference style [START_REF] Mathiassen | [END_REF] as the project was initiated by a theoretical discussion regarding the obtainment of value from the implementation of a HIS but challenged and enlightened through observations from the case [START_REF] Gregor | The transformational dimension in the realization of business value from information technology[END_REF][START_REF] Seddon | A MULTI-PROJECT MODEL OF KEY FACTORS AFFECTING ORGANIZATIONAL BENEFITS FROM ENTERPRISE SYSTEMS[END_REF].

Research Setting

The Faroe Islands are a self-governing territory within the Kingdom of Denmark with approximately 48,000 inhabitants. The FHS is a relatively small organization consisting of three hospitals and 27 general practices (GPs). In 2005, the FHS began the implementation of an integrated HIS covering hospitals and GPs. The project faced many problems during its first years, even to the point that discussions were held considering the termination of the project, particularly due to the high costs that had been incurred (financial as well as personal) and doubts regarding the value realization [START_REF] Schlichter | Development of trust during large scale system implementation[END_REF]. However, the project continued and 530 healthcare professionals are currently using the HIS, which covers all areas of the hospitals and GPs.

Based on the initial implementation process, an evaluation report was prepared that drew on DeLone and McLean's success model [START_REF] Delone | The DeLone and McLean Model of Information Systems Success: A Ten-year Update[END_REF]. The users were satisfied with the solution, which greatly supported their clinical work, but no initiatives aimed at harvesting the potential value had been planned or implemented [START_REF] Andersen | Effektvurdering af EPJ/THS i det faerøske sundhedsvaesen[END_REF]. Thus, it was concluded that more needed to be done to obtain proper value and payoff.

Research process

The action research project was initiated in the fall of 2010 and is expected to come to an end spring 2014. The present part of the project, which focused on how to structure and realize value in a (public) healthcare setting, was prompted by management's wishes to realize value from the previously implemented HIS-system. The researchers have had a high degree of interaction with FHS [START_REF] Svejvig | Setting the stage for benefit realization of healthcare IS : The voice of health professionals[END_REF] and have used a variety of research methods related to diagnosing, action planning, action taking, and evaluation and learning. As a result of meetings with staff and observations of the processes in action, it was determined that the first obstacle was to actually define what 'value' means in the present setting and how to actually achieve it based on the limited transformational capacity in FHS. It was then decided that the Good Stroke Process would be replicated to explore and demonstrate the potential for value realization at the medical ward.

During the first action research cycle, it became increasingly difficult to distinguish between the information system (HIS) and the associated working processes; they are like Siamese twins [START_REF] Alter | The work system method for understanding information systems and information system research[END_REF] with regard to value creation. Also, it came to our attention that the creation of value in healthcare has a much broader scope than mere financial value [START_REF] Kohli | Business Value of IT: An Essay on Expanding Research Directions to Keep up with the Times[END_REF] and can be divided into three main areas: (1) professional quality (e.g., mortality rate after six months), (2) organizational quality (e.g., length of stay in hospital), and (3) patient-perceived quality (e.g., level of information about the course of disease).

The first workshops helped an understanding to emerge among the healthcare professionals of the need to document the present stroke process in detail. During the very detailed discussions of the process, several KPIs were identified to establish a baseline for the measurement of future improvements and a search for the KPIs was performed.

In the second action research cycle, we observed that the new HIS made it much easier to collect and calculate KPIs, thus making the measurement of improvements possible. Many KPI candidates emerged during the analysis. While the first cycle of the project identified three value dimensions: professional quality (the clinical treatment of diseases and cure -effectiveness), organizational quality (the optimal use of resources -efficiency), and patient perceptions of quality (customer/patient satisfaction), the second cycle of the project revealed that there was a lack of consideration of the "voice" of the employees. Based on the analysis described above, a baseline of observations and measurements was prepared by FHS staff under the supervision of the researchers, changes in processes were realized and, during the final part of action research cycle two, the measurement and collection of other data was repeated and evaluated against the baseline. The results were presented and discussed during a series of workshops held on the Faroe Islands in October 2013 that included the participation of staff from wards, management and members of the HIS-implementation organization.

Value Creation from the Good Stroke Process

During the two action research process cycles, which are mentioned above, we have been challenged in discussing IS public value at FHS. The first action research cycle revealed three value dimensions (benefit areas): (1) professional quality, (2) organizational quality, and (3) patient perceived quality. These quality dimensions are based on the Danish Healthcare Quality Model [START_REF]Indicators and Standards in The Danish National Indicator Project[END_REF] and can be linked to specific measures. However an additional dimension to the three abovementioned was found during the second action research. The healthcare professionals (nurses, doctors, therapists and secretaries) showed an understanding of quality/value which is not covered by the three dimensions 'Employee Perceive Quality' was added.

Fairly late in second cycle we decided also to include learning as an important value dimension due to the fact that projects are an arena for learning [START_REF] Hällgren | Mini-muddling: learning from project plan deviations[END_REF][START_REF] Packendorff | Inquiring into the temporary organization: New directions for project management research[END_REF], which is of future value to organizations although typically with a lag effect.

The more or less empirically derived dimensions are mentioned below: The satisfaction of the employees, i.e., do they believe that the process is well taken care of Learning

The capability to work in cross-functional teams Table 4 indicates five fairly broad areas which all can be related to IS public value in HIS settings. The following sections will describe these five dimensions in more detail and present selected measures for these dimensions.

Professional quality

The measures for professional quality are based on indicators from The Regions Clinical Quality Development Program [START_REF] Apopleksiregister | Indikatorskema for Dansk Apopleksiregister[END_REF]. These indicators have been defined and produced by a group of professional clinicians representing the public hospital owners and the Danish Government. At Danish hospitals these indicators are obligatory. The hospitals at The Faroe Islands were not using the standardized indicators for measuring the quality in different settings and different diseases as they are not obligated to, but to gain more easy compatible data it was decided to use the indicators for stroke patients for measuring the professional quality in the project. Only some of the indicators were relevant in the actual setting. In table 5 a subset of indicators for the treatment of stroke patients is shown. More indicators are in play in the project, but the validation of the values has not been completed yet. The year of 2011 is defined as a baseline for our measures. The baseline values have been calculated through an audit of the patient records. Most of the values were picked up from the text based electronic patient system. In the beginning of 2012 more features were added to the HIS system, which means that several templates were set up in the HIS so the registrations of specific events -e.g. assessment done by the physiotherapist (indicator 3 in Table 5) -were more user friendly and precise.

We faced different challenges in the work with clinical data from the electronic patient system. One was the data quality. For example proper registration of different events in regards of time; it could be the time registered for the physiotherapist assessment. Is it the time for the registration or is the time for the assessment? Another challenge was access to the data in the system. Did we get the right data from the database? It is an important question due to the fact that the data model for the system is not documented.

In accordance to those two challenges we put a lot of efforts into the data validation. One important initiative in that respect is presenting and discussing the data with the relevant group of clinicians.

Four of the indicators in Table 5 are process indicators, dealing with treatment and care processes. The last one is an outcome indicator, the only one in our measures. It deals with mortality, and measures the proportion of stroke patients who die within 30 days after admission. This value is interesting as it is below the limit value in 2012 and 2013. We are in the process of trying to get an explanation of that circumstance.

There is a positive trend in the proportion of patients who were admitted to a stroke unit (indicator 1 in Table 5), but still (in 2013) it is below the limit value of 90%. The reason for the positive trend is that in the beginning of 2012 one specific unit has been set up as a stroke unit

The second indicator in the table, the proportion of patients getting blood dilute pills shows values below the limit value and indicates and improves process for this area.

Organizational quality

We have focused on one main indicator for the organizational quality, which is the length of the hospital stay. We have the data, but still need to do data validation.

There is big dispersion in the data because a small number of patients stay a very long time at the hospital for different reasons. Therefore it is needed to make a journal audit and make adjustments in order to give a suitable and detailed picture of the length of stay in hospital for stroke patients.

Patient perceived quality

To contribute to the baseline and identify areas for improvement, interviews were held with two stroke patients. The interviews showed that the patients were quite happy with their experiences. One patient said: "I have received good information and I am very satisfied with the stay, I have to admit that…" (Patient 1, 60-year-old male, in his fifth month of hospitalization). We have not been able to conduct interviews with patients after the different initiatives for the stroke patients were implemented.

Employee Perceived Quality

Two surveys were conducted in September 2011 and in September 2013. They were based on a questionnaire and completed by the involved health professionals. The number of participants was respectively 24 in 2011 and 25 in 2013 1 . The questionnaire can be seen in appendix A. The questions in the questionnaire were related to informational and communicational issues.

At the same time a number of interviews were completed with the heads of the departments involved. The subject was the work processes related to the treatment of stroke patients and the collaboration between the different professional groups. In the interviews conducted in 2013 questions related to the project process were added because it was relevant to discuss learning from the process itself.

The data from 2011 from both investigations constitutes the baseline for the voice of the clinical staff. In figure 1 the answers from to two questionnaires are depicted. There is a positive tendency in the answers from 2011 to 2013. The average for answers on all 16 question is a bit below the neutral value of 4 in 2011, while in 2013 the value is very close to 5, thus above the neutral value. The difference between the average in 2011 and 2013 on all questions is 1.2 which is a significant difference.

The questions can be divided into groups. The group with the biggest gap between 2011 and 2013 can be labeled 'Well formulated goals and plans for stroke patients' (question B6, B7, B8 and B9). The smallest difference in answers is related to 'Use of data from other profession groups' (question B13). Here we see a high score above 5 in 2011 as well as in 2013. This means that employees are and were satisfied with the data they can get from other profession groups. These data are and were available through the HIS.

Answers have to be given on a 7-point Likert scale, where 7 = strongly agree and 1 = strongly disagree.

Learning

The project has created a lot of learning, especially with respect to the process of running a cross-functional project. It was a new way of working for the employees from the different departments. The project manager recognized that the success of the whole initiative (working with this type of interdisciplinary tasks) was caused by the fact that it was set up and completed as a project with a steering committee, a project group and project manager:

"The first things you should clarify is: What you wish to achieve, And if you are approaching it with interdisciplinary and not mono-disciplinarily: Who is in charge?, That there is an action behind it whenever you do something…I think that it has helped that a steering committee, project group and project manager was appointed. Otherwise it would never have worked." and "I feel that the project has been understood. It has been supported which has been great" (Project manager).

Supported by the executive consultant:

"There are some things that you wish to improve because the patient is not feeling well. We are not there yet, but we have come a long way. But if we agree now that Mean --sept 13

we will give this to [the board] and the management group will give this to day-today operations. Then we need some kind of management of this, which we have discussed a bit. We have discussed checklists and regular management meetings, where we will address if there are any issues where something is insufficient, is there something we need to be updated on etc. You could say that we took ownership back then (when the project started) and we are holding on to this." (Executive consultant).

But other issues were also present on the learning agenda. The usefulness of clear goals and plans for the treatment of stroke patients is recognized by the clinicians working with stroke patients.

"Well I think the difference is that now it is a bit more established in terms of goals and plans etc. All patients are now being taken care of and we try to set goals for all patients." (Therapist).

The measures set up for the project were also addressed in the interview with the project manager, who was not satisfied with the measures and indicators set up for the professional quality. In her opinion it only covered a limited part of the professional quality. She argues that it is important also to have measures regarding life quality for the stroke patients:

Discussion and Concluding remarks

During the action research project it has been shown how value in a public sector HIS context can be conceptualized and selected actual measurements of baseline values have been provided (2011). Values was measured in 2012 and 2013 after the establishing the baseline showing how value were created by the use of the newly implemented IHIS thus fulfilling one of the objectives of the action research project In this section we will discuss the empirical derived quality/value dimensions using the structure of multidimensional value categories presented earlier in the paper. Table 6 indicates how IS value can be understood using a two dimensional structure consisting of measured qualities and category of values. For illustrative purposes we have described one example from each cross of rows and columns below following the structure of the Value Categories.

Strategic value [START_REF] Devaraj | Information technology payoff in the health-care industry: A longitudinal study[END_REF] can in the context of The Good Stroke Process be related to the main objective of FHS to provide high professional quality treatment of patients. In our case one of the measurements was the 'proportion of patients who are admitted to a stroke unit no later than the 2nd day of hospitalization' which showed improvement by rising from 28% to 80% during the project.

Informational value (2) can, naturally, be exemplified by the obvious fact that the structuring on what to measure also created possibility to actually do it and hence provide information for decision making in the FHS. Another example is the Patient Perceived Quality where interviews indicated a fairly high satisfaction which was highly appreciated by the ward management and used to support self-confidence among staff.

Transactional value (3) was shown by addressing organizational quality when measuring the 'length of stay in the hospital' which by the FHS management is seen as an important enabler of cost saving and supporting operational management. Quite interesting this was one, out of many, examples on how difficult it is to agree on concrete definitions due to difficult traditions, procedures and possibilities in the same organizational system of FHS as the project could not provide reliable figures for this indicator.

Transformational value (4) has been achieved by the learning done in the FHS and HIS organization. As such FHS is now in a better position of facilitating new IS value creation projects in the future.

Unplanned/Emergent value [START_REF] Bend | Public value and e-health[END_REF], which is result of a transformation or change process, was observed when the need to include employee perceived quality came up hence highlighting the importance and potential of including the voice of the employees in the IS value creation process. The present research indicates the need and the many challenges to conceptualize both a more fined grained framework for IS public value creation and to assure the actual measurements in a HIS setting. We suggest that the presented framework can be used as a foundation for further research of IS public value in the given context but acknowledges the limitations and need for refinement and challenging of findings in related contexts thus coming closer to the call by Breese [START_REF] Breese | Benefits realisation management: Panacea or false dawn[END_REF].

Fig. 1 .

 1 Fig. 1. The voice of the clinical staff related to informational and communicational issues in 2011 and 2013. Exact questions are given in annex A.

Table 1 :

 1 Multidimensional value categories

	Value category	Description
	Strategic value	To change the nature of how a company competes
	Informational value	To provide information for decision making in the
		company
	Transactional value	To enable cost savings and support operational man-
		agement
	Transformational value

Table 2 :

 2 Key differences between governmental and for-profit organizations

		For-profit sector	Public sector (i.e., healthcare)
	Normative goal	To maximize shareholders'	Achieve social mission
		wealth
	Principal source	Sales of services and products	Tax appropriations
	of revenue
	Measure of per-	Financial bottom line	Efficiency and effectiveness in
	formance		achieving the mission
	Key calculation	Find and exploit distinctive
	of improvements	competence of firm by posi-
		tioning it in product/service
		markets.

Table 3 :

 3 Summary Table of Research Cycles

	Cycle	Goal	Learning
	First action research cycle	Define value	Value in healthcare has broader scope
		measures	than mere financial value
			Understanding of need to document
			processes
	Second action research cycle	Achieve value	New HIS made it easier to collect KPI
			The lack of the voice of the employees
			revealed
			Framework for IS value in healthcare
			setting established

Table 4 :

 4 Empirically derived quality/value dimensions

	Empirical derived dimension	Example
	Professional quality	Mortality rate after 30 days for stroke patients
	Organizational quality	Length of stay at hospital
	Patient perceived quality	Level of information about course of disease
	Employee Perceived Quality

Table 5 :

 5 Measures for a subset of indicators of the professional quality

	Indicator	Type	Base-	2012	2013, until
		Standard/	line/		mid-October
			2011
	1. Proportion of patients who	Process	28%	61%	80%
	are admitted to a stroke unit
	no later than the 2nd day of	>= 90%
	hospitalization
	2. Proportion of patients with	Process	58%	91%	87%
	acute ischemic stroke without
	atrial fibrillation where treat-	>= 95%
	ment with antiplatelet inhibi-
	tor is initiated no later than the
	2nd day of hospitalization
	3. Proportion of patients who	Process	79%	Missing	Missing
	undergo a CT/MR scan on the
	first day of hospitalization	>= 80%
	4. Proportion of patients as-	Process	45%	Missing	Missing
	sessed by a physiotherapist no
	later than the 2nd day of hos-	>= 90%
	pitalization in order to clarify
	of the extent and type of reha-
	bilitation and time for initia-
	tion of physiotherapy
	5. Proportion of patients who	Outcome	Missi	8%	7%
	die within 30 days of admis-		ng
	sion for acute stroke	<= 15%

  Defining value in relation to organizational change never ends. It is important to be open-minded in order to pick up or plan harvesting new benefits in a never ending process when implementing it-projects or other organizational change. The project manager recognizes this and is ready for the challenges related to emergent value.

"We have NIP-measurements [the indicators in table 5]. And that is in principle

what they are interested in, the board. And every aspect of quality apart from that, we have actually not set any measures for. I believe we should have other measurements as well. It cannot be right that the only measure you have is whether people die or not. That is not quality in my world. You should measure life quality and find out if they get the information needed. You should, in my opinion, move towards this. I know it is hard to measure something like this on patients. They were just super pleased" (Project manager).

Table 6 .

 6 IS Value in a Healthcare Setting

	Value Category	Professional	quality	Organiza-	tional quali-	ty	Patient-	perceived	quality	Employee	Perceived	Quality	Learning
	Strategic	(1)	+		+		+		+
	Informational	+	+		(3)		+		+
	Transactional	+	(2)		+		+		+
	Transformational	+	+		+		+		(4)
	Unplanned/emergent	+	+		+		(5)		+

The survey has not been conducted as a pairwise study. Some of the respondents are identical; every answer is given anonymous. In

nearly 80% of the population (all clinicians participating in the treatment and care of stroke patients) participated and in 2013 100% of the population participated.

Acknowledgments

The project was done under and with support from Center for IT Project Management and Innovation at Aarhus University and support from the Faroese Ministry of Healthcare. We are thankful for the open doors, friendly interaction and professional discussions provided by the clinical staff (doctors, nurses and therapists at the medical ward) and staff from the HIS unit.

B.8 I find that there is a well-formulated plan for the stroke patient after being discharged from the hospital.

B.9 I feel well-informed about the goals and plans for treatment of stroke patients. B.10 I find that an individual care-and treatment plan is formulated for every single stroke patient.

B.11 I experience that the entire course of treatment of stroke patients is well managed and coordinated.

B.12 I experience the treatment of stroke patients as being good. B.13 I find that I have good use of other profession groups' records about stroke patients in my own treatment of patients.

B.14 I experience that I can give patients continuous good information about treatment and caretaking.

B.15 I find that the physical surroundings are good and appropriate in connection to treatment and caretaking of stroke patients.

B.16 I find that the ward is sufficiently staffed to treat and take care of stroke patients.


Shegaw Frank Ulrich

Anagaw Mengiste

Shegaw Anagaw Mengiste

The Challenges of Creativity in Software Organizations

des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Introduction

Creativity has inherently become an important part of software development and use because the creative mindset is the pre-requirement in any innovation effort [START_REF] Govindarajan | The Other Side of Innovation: Solving the Execution Challenge[END_REF]. As Florida and Goodnight [19;131] noted: "The creative economy is here to stay, and companies that figure out how to manage for creativity will have a crucial advantage in the ever-increasing competition for global talent". Successful IS development companies such as Google and SAS have incorporated creativity as an important part of their strategies to create lasting innovations by creating creative environments, clear incentives for their employees, and a culture of social creativity where the contributions from each employee become important [START_REF] Florida | Managing for Creativity[END_REF][START_REF] Iyer | Reverse engineering Google's innovation machine[END_REF]. Companies like LEGO have successfully created a business model that involves creative interactions with their customers through collaborative virtual worlds and online communities [START_REF] Piller | Overcoming mass confusion: Collaborative customer co-design in online communities[END_REF]. However, as Couger [15;230] argued, creativity is often treated as a "dangerous opportunity" that requires leadership and willingness to take risks. Hence, creative endeavors are not always equal to massive success, and organizations will often experience organizational challenges when embarking on creative endeavors [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF].

To understand the challenges of managing creativity in a software setting, we define software organizations as information systems (IS) organizations, information systems development (ISD) organizations, and clone organizations (clone). In this paper, we treat IS organizations as those that use IT as a strategic driver for business operations and must be creative when implementing existing technologies, exploring new business opportunities, and enhancing their existing business in a competitive market [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. ISD organizations are those that develop IT for others and must be creative when designing and creating innovative products or services [START_REF] Cooper | Information technology development creativity: A case study of attempted radical change[END_REF]. Hence, IS and ISD organizations use time and effort in creating novel ideas for new market innovations to strategize their efforts for optimizing organizational performance, gaining competitive advantages, and attracting talented employees [START_REF] Florida | Managing for Creativity[END_REF]. In between IS and ISD organizations, there are clone organizations. These are a mix between the IS and ISD organization because they develop IT as ISDs, and at the same time use this IT for internal and external business operations as an IS organization would. Regardless of the typology, however, software organizations are driven by continuous innovation to obtain and maintain their competitive advantages. As Couger clearly indicated, creativity has proven to be an important driver for IS, ISD, and clone organizations [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. Moreover, creativity enhancing software has already proved useful for companies that are unrelated to IS or ISDs. As Rose [START_REF] Rose | Software Innovation -Eight work-style heuristics for creative system developers[END_REF] explained, creativity enhancing software have been developed for businesses in the areas of art, medicine, and chemistry. Likewise, creativity techniques originally developed for non-IS development have proven useful when software organizations are developing or exploring novel ideas for innovative software [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF].

We wrote this paper upon a previous literature review [START_REF] Müller | Creativity and Information Systems in a Hypercompetitive Environment : A Literature Review[END_REF]. This paper is a contingency of the original review where we address the subject of managing creativity challenges in software organizations. This paper differs from the original review by including literature we excluded from the original review. We examined the literature through a systematic process and provided interpretations to create a new framework of creativity management in software organizations. Moreover, we supplemented the literature with practical experiences collected through multiple empirical sources. We structured the paper as follows: We initially provide a short research perspective for the study. Then we explain our research strategy, collection methods, and analysis. Next, we provide initial data analysis and describe in detail 21 challenges that software organizations experience when embarking on creative endeavors. We divide these challenges into seven different factors of creativity management and add our empirical findings. Finally, we collect our findings into a comprehensive framework for software organizations and explain how our study can help research and be deployed into practice. facilitating creativity in the organizational setting [START_REF] Couger | Un)structured creativity in information systems organizations[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. Moreover, the organizational environment's influence over creativity [START_REF] Amabile | How to kill creativity[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF] and creating working strategies for creativity [START_REF] Woodman | Toward a theory of organizational creativity[END_REF] have also proven important when enhancing creativity in software organizations.

Rhodes [START_REF] Rhodes | An analysis of creativity[END_REF] suggested a framework of four interconnected components influencing creativity. These consist of press (environment), person (individuals and groups), product (creative results), and process (training and management) -each explaining aspects of creativity in the organizational context. We follow Rhodes' [START_REF] Rhodes | An analysis of creativity[END_REF] track by examining a similar framework of interconnected factors and their underlying challenges.

The general consensus on creativity is that it is individuals' or groups' ability to come up with novel and useful ideas or solutions to problem [START_REF] Amabile | Affect and creativity at work[END_REF][START_REF] Amabile | Assessing the work environment for creativity[END_REF][START_REF] Couger | Un)structured creativity in information systems organizations[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. However, there is somewhat of a misconception of what a creative individual or group is in a software setting. Innovative software individuals or teams are typically viewed as either software designers or system developers [START_REF] Beyer | Contextual Design -Defining customer-centered systems[END_REF][START_REF] Cooper | Information technology development creativity: A case study of attempted radical change[END_REF][START_REF] Kappel | Creativity in design: The contribution of information technology[END_REF]. Nonetheless, creativity in IS or ISDs is a conjoined effort by the entire organization and consists of many different factors and roles beyond the traditional software designer or system developers, as technology users can be equally creative [START_REF] Nambisan | Organizational mechanisms for enhancing user innovation in information technology[END_REF]. Creative software individuals or groups can consist of customers, system developers, software designers, business analysts, portfolio managers, marketing managers, web designers, university researchers, computer and traditional artists, sourcing experts, project managers, CIOs, security experts, network analysts, customers, users, SPI specialists, etc. They all contribute with their own creative ideas for innovations to happen in the software organization, and they all use different practices, where creativity is needed and beneficial. Each profile must be taken into consideration when exploring the challenges of creativity in the software organization. Hence, our perspective on creativity management is the ability to understand the creative potential of the entire organization, by knowing how each organizational factor contributes to creating novel ideas, to identify them, to implement them, and finally to commercialize them into working innovations. This paper revolves around these factors of organizational creativity by examining those challenges that software organizations experience when they embark on creative endeavors. As such, our research subject is focused on the organizational aspect of creativity and not a study of creativity in a specific software setting (e.g. [START_REF] Aaen | Essence: facilitating software innovation[END_REF]. Hence, our research approach is guided by this overall question for inquiry: "What are the challenges of creativity in software organizations?"

3

Research Approach

To answer our research question, we used an adaptive multi-strategy approach [START_REF] Layder | Sociological Practice -Linking theory and practice[END_REF] by providing interpretations from both quantitative and qualitative sources. According to Layder [START_REF] Layder | Sociological Practice -Linking theory and practice[END_REF] the multi-strategy research approach offers several advantages over traditional research, as it increases the strength, density, and validity of the research by incorporating many data sources and strategies to approach the research subject, which enables the researcher to create more "robust" theoretical perspectives [START_REF] Layder | Sociological Practice -Linking theory and practice[END_REF].

Hence, we divided the data collection between a survey in 27 software organizations and six interviews with employees of two of the organizations that participated in the survey.

We constructed the survey around a cross-sectional research design [START_REF] Bryman | Social Research Methods[END_REF][START_REF] De Vaus | Research Design in Social Research[END_REF][START_REF] Yin | Case Study Research -Design and Methods[END_REF], as the survey is consistent with more than one case and is fixed to a single point in time [START_REF] Bryman | Social Research Methods[END_REF]. Moreover, we used a systematic and standardized approach for collecting data and examining relationships between variables [START_REF] Bryman | Social Research Methods[END_REF]. This approach enabled us to view the integration of creativity management practices in software organizations and their relation to the literature reviewed by Müller and Ulrich [START_REF] Müller | Creativity and Information Systems in a Hypercompetitive Environment : A Literature Review[END_REF].

For the interviews, we used an embedded case study design [START_REF] Yin | Case Study Research -Design and Methods[END_REF] by collecting data from different subunits in the organizations (e.g. departments, projects or management levels). This helped us to analyze different management perspectives in correlation to the challenges and factors from the literature.

Analytically, we worked interpretively both in our use of theory and in our data collection, whereby the theory and data played an equally vital role throughout the study when providing interpretations. For the interpretative approach, we used Walsham [START_REF] Walsham | Doing interpretive research[END_REF][START_REF] Walsham | Interpreting Information Systems in Organizations[END_REF][START_REF] Walsham | Interpretive case studies in IS research: nature and method[END_REF], who emphasized collecting and interpreting key concepts from the participants' social reality. However, when creating new interpretations, we analyzed all the data with a "healthy skepticism" [START_REF] Walsham | Interpreting Information Systems in Organizations[END_REF]. This approach enabled us to support new ideas and concepts created during the analysis of the data provided by triangulating the findings [START_REF] Layder | Sociological Practice -Linking theory and practice[END_REF] from the two data sources, which we transferred into a framework for creativity management at end of the paper. Moreover, these interpretations make the study highly inductive, as we locate management practices from the empirical data, rather than testing existing theoretical frameworks.

Data Collection

We collected the data through a survey of 31 managers and business analysts in 27 Danish software organizations. In addition, we conducted interviews with the CIO, a project manager, and a business analyst from the IT-department in a local Danish municipality, and the CIO, the head of innovation, and the head of product management in GameSim, a medium sized subunit of a much larger private and international organization. GameSim specializes in high tech computer game development for the private sector. The participants from the interviews also participated in the surveylisted as cases 1-3 and 21-24 in Table 1. For conducting the survey, we used the social networking site Linkedin to locate participants. As Table 1 demonstrates, representatives from several types of software organizations chose to participate in the survey. In total, 38 chose to participate and complete the survey. However, we removed seven participants due to lack of credentials in the software sector or for not providing personal or company information.

We asked each participant to rate the integration of creativity management within the underlying challenges of the seven factors. In addition, participants were asked to provide information about their organization size (very large, large, medium, small), type of organization (private or public), management level they represent (CIO, project manager, or business analyst), IS use (developing for others, developing for themselves, or using IS developed by others). Moreover, we asked them if their organization uses IS to support creativity (use specialized IS, do not use IS for creativity, or use IS for creativity that is not designed for the purpose).

We asked each participant to rate the integration of creativity management within the underlying challenges of the seven factors. In addition, participants were asked to provide information about their organization size (very large, large, medium, small), type of organization (private or public), management level they represent (CIO, project manager, or business analyst), IS use (developing for others, developing for themselves, or using IS developed by others). Moreover, we asked them if their organization uses IS to support creativity (use specialized IS, do not use IS for creativity, or use IS for creativity that is not designed for the purpose).

Data Analysis

We analyzed the survey using SurveyXact, by conducting measurements on data frequency and the average distribution of data. Moreover, we calculated cross references between average distributions of data through Excel. We analyzed the survey results to establish casual relationships [START_REF] De Vaus | Research Design in Social Research[END_REF] between the factors of creativity and their chal-lenges and the other groups of variables. These variables are organizational size, type of organization, management level, IS use, and use of creativity-enhancing software.

We analyzed the interviews using section transcription by providing in-depth notes for each interview [START_REF] Bryman | Social Research Methods[END_REF]. We labeled each note with time, subject, and respondent, which provided a quick overview of the combined interview data. This approach enabled us to collect relevant key concepts when we interpreted and triangulated the survey and interview data.

Mapping the Challenges

To operationalize the challenges within the technology, environmental, institutional, individual, group, leadership, and external factors, we first identified each challenge by examining the existing literature. Second, we placed each challenge within a complementary factor. Specifically the work of several researchers [START_REF] Amabile | How to kill creativity[END_REF][START_REF] Cooper | Information technology development creativity: A case study of attempted radical change[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF][START_REF] Florida | Managing for Creativity[END_REF][START_REF] Goffee | Leading clever people[END_REF] worked as guidelines, as they each provide a normative emphasis on the challenges of creativity in software organizations or provide emphasis on creativity challenges applicable to any organization regardless of internal structure or commercial output. However, most creativity challenges in the literature were descriptively operationalized by rigorously reviewing each challenge after reoccurrence in the literature and adding their normative guidelines to our in-depth description of each challenge. Finally, we connected the theoretical finding with our empirical findings. Hence, to clarify our observations from the survey and the interviews, we initially present our preliminary data findings in section 4.1 below. We then review the literature for each factor and connect our data findings in the subsequent sections for each factor.

Preliminary Data Findings

The survey elaborates how different managers in Danish software organizations have integrated the diverse challenges related to creativity in their organizations. The data collected in the survey demonstrates that the average integration score across the challenges is just below average. Their integration is aligned with the comments from survey and interview data. Our data demonstrated that Danish software organizations still face a range of challenges when integrating creativity management practices in their organizations. In addition, 45% ( 14) of the managers and business developers participating were within public organizations and 55% [START_REF] Davenport | Process Innovation -Reengineering work through information technology[END_REF] were within private organizations. Moreover, there is little difference between private and public organizations when integrating the different creativity management challenges. The difference between the combined replies from private and public organizations is 3.6%. Furthermore, when viewing employment among the participants, 23% (7) of the participants were employed within top management as CEOs or CIOs, whereas, 64% [START_REF] Gallivan | The influence of software developers' creative style on their attitudes to and assimilation of a software process innovation[END_REF] were employed as mid-level managers such as project managers or department heads. Finally, 13% (4) were not employed within management, but were business developers. This finding demonstrates that the survey provided wide perspective within public and private software organizations.

In the area of use and deployment of IS, 26% (8) of the respondents answered that their organization developed IS for other organizations (ISD organizations). Also, 48% [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF] deployed IS as a part of their daily business, but did not develop it themselves (ISD organizations), and 26% (8) deployed IS as a part of their daily business and developed the systems themselves (clone organizations). Furthermore, clone organizations were 16.7% less likely to integrate management practices to deal with challenges in creativity than IS organizations, and equally 16.7% less likely to do it than ISD organizations. This finding demonstrates two different possibilities: ISD and IS organizations have a higher need for managing creativity; they are more likely to be driven by communities of creative practices as they are more engaged in creative behavior on a daily basis.

To our surprise, only one of the organizations had deployed specialized creativity support systems, and 29% (9) used IS for supporting creativity that were not designed for that purpose. In comparison, 65% [START_REF] Gallivan | The influence of software developers' creative style on their attitudes to and assimilation of a software process innovation[END_REF] did not use any form of IS driven creativity support. One did not know if their organization used it or not. The fact that the majority who used IS driven creativity support have chosen to use existing systems to support it is somewhat strange, because specialized systems could provide better possibilities. However, when interviewing the CIO of the local municipality the reason became apparent. As he stated:

"After an innovation management course we conducted for the managers in the municipality, we deployed a specialized tool to get people to work with idea development. However, people only partially used it because it was not a part of their daily workflow and they had to remember to use it. When people got back to work, they started to go back to use Outlook instead."

Hence, the reason for using existing systems to support creativity may be due to employees' and customers' preference to be creatively engaged in systems they use in their daily work activities.

The Technology Factor

Technology makes information and communication flow between stakeholders and is an important factor in organizational creativity [START_REF] Woodman | Toward a theory of organizational creativity[END_REF]. When managers seek to increase organizational creativity, they can deploy computerized tools to support creative processes in organizations. Greene [START_REF] Greene | Characteristics of applications that support creativity[END_REF] demonstrated several characteristics of creativity software tools including: being exploratory in a sandbox mode; being engaged with content to advance learning and discovery; and being able to support collaboration, iterations, and challenging tasks. Creativity tools should also be domain-specific for the given task and make it easy for users to store, classify, relate, and retrieve things [START_REF] Greene | Characteristics of applications that support creativity[END_REF]. However, deploying or developing creativity tools or systems is not without challenges. When designing creativity tools or systems, developers must include the challenge of human-computer interaction by encapsulating user preferences, playfulness, interaction between design, and task-specific appliances [START_REF] Shaw | The effects of computer-mediated interactivity on idea generation -An experimental investigation[END_REF][START_REF] Webster | Microcomputer playfulness: development of a measure with workplace implications[END_REF]. Hence, before development, business analysts must set design requirements that capture the organizational necessities and include business benefits from existing system portfolios through specific business plans [START_REF] Kappel | Creativity in design: The contribution of information technology[END_REF][START_REF] Ward | Building better business cases for IT investments[END_REF]. In addition, implementation of new IS requires user acceptance [START_REF] Davis | Perceived usefulness, perceived ease of use, and user acceptance of information technology[END_REF]. Users frame and make sense of technology differently within their own social and work-based arenas, which often collide with the implementation efforts [START_REF] Orlikowski | Technological frames -Making sense of information technology in organizations[END_REF][START_REF] Weick | Organizing and the process of sensemaking[END_REF]. Thus, when implementing new IS (including creativity supported IS), managers must consider the social setting and users' preferences and take proper action when needed [START_REF] Gallivan | The influence of software developers' creative style on their attitudes to and assimilation of a software process innovation[END_REF].

Findings.

Our findings showed that focus on human-computer interaction was less significant in organizations that develop creativity enhancing IS for themselves than in ISDs. Human-computer interaction was, however, slightly less integrated in clone and ISD organizations than IS organizations. Similar in technology acceptance, integration in clone organizations tends to be significant at a lower level than in ISDs, and somewhat lower than IS organizations. These findings demonstrate that ISD and IS organizations have a closer relationship to suppliers and customers and are more likely to collect management practice experiences and new system ideas when implementing and developing new systems. Another explanation can be a closer interaction with their business and an increased knowledge of organizational management practices when developing IS for creativity enhancement. Moreover, IS and ISD organizations prefer to implement creativity enhancement within their existing IT-portfolio. This increases technology acceptance, as employees and customers are more likely to use creativity enhancing software when it is included in systems they know and use.

The Environmental Factor

The environment in software organizations influences the creative output by providing social spaces for creative individuals and teams, which enables them to be inspired and construct ideas [START_REF] Couger | Un)structured creativity in information systems organizations[END_REF]. The physical environment in organizations have proven to have an impact on creativity efforts when developing new IS [START_REF] Amabile | How to kill creativity[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. Likewise, substantial evidence indicates that virtual environments in creativity enhancing software increases organizational creativity by creating social spaces for developers to share thoughts, find inspiration, compile relevant information, and conjoin creative efforts [1, 2, 25, 29, 32-34, 37, 39, 41, 50]. Moreover, when organizations are embarking on creative endeavors, managers must be aware of existing institutional practices and cultural norms that could create barriers for organizational creativity [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF][START_REF] Leonardi | Innovation Blindness: Culture, Frames, and Cross-Boundary Problem Construction in the Development of New Technology Concepts[END_REF]. Hence, they must create an organizational culture that supports creativity through direct strategies and leadership [START_REF] Amabile | How to kill creativity[END_REF][START_REF] Woodman | Toward a theory of organizational creativity[END_REF].

Findings.

Our findings demonstrated equal medium integration in IS, ISD, and clone organizations when creating physical and virtual environments for creativity. For physical environment, some participants in the survey stated that their organization lacked proper equipment and facilities, which decreased creative thinking. When interview-ing the business developer in the municipality it was also apparent that they had the proper equipment for enhancing creative thinking. However, the technology had technical difficulties, and they lacked training:

"We have this smart board as a part of a test for the schools, but we primarily use it as an overhead projector… It is not properly calibrated... It is simply faster to do it with pen and paper and then take a picture and send it by mail… The school teachers are much better to use it than we are… the learning curve is simply too high."

This problem is also apparent with virtual environments. Most organization uses analog devices, such as group brainstorming and pen and paper techniques, instead of software based solutions. However, some organizations use online idea boards in existing knowledge management systems. Here, employees share new ideas or save them for later use.

Private organizations are more likely than public organizations to create social environments for creativity. However, Danish public organizations are only just beginning to think in creativity and innovation, due to new policies for the public sector. Hence, they must continuously reform their business to save money while keeping or increasing the overall service level. Private organizations, however, have done this for years to gain competitive advantages. As the CIO of the municipality explained, they focused increasingly on creativity and innovation. To achieve their goals, leaders from the schools, nursing homes, and all other business areas of the municipality had to undergo innovation training and were included in the overall innovation efforts.

The Institutional Factor

Institutional barriers include negative perceptions towards new ideas and creative employees, not sharing relevant data, autocratic leadership, lack of task support, and fear of the unknown in creative processes, all of which negatively affect the outcome of organizational creativity [START_REF] Catmull | How Pixar Fosters collective creativity[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. Also, employees can have different creative styles, which place barriers on an individual level [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. To reduce institutional barriers, managers must understand their employees' creative styles and create change-strategies for removing institutional barriers that poses negative influence on the creative output [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. Moreover, Cooper [START_REF] Cooper | Information technology development creativity: A case study of attempted radical change[END_REF] argued that creativity requires proper structures to be successful. Clear development goals reduce misplaced efforts by employees and groups and encourage productivity. However, tight control over creative processes will reduce autonomy and motivation of employees and negatively affect the creative outcome [START_REF] Catmull | How Pixar Fosters collective creativity[END_REF]. Managers must seek a balance between structure and over-the-edge autonomy ( [START_REF] Cooper | Information technology development creativity: A case study of attempted radical change[END_REF]. Agile development techniques such as extreme programming (XP) and the dynamic systems development method (DSDM) has proven to capitalize on employees' strengths [START_REF] Cockburn | Agile Software Development: The People Factor[END_REF], and give goals and constraints that provide boundaries for creativity to flourish instead for running amok [START_REF] Highsmith | What Is Agile Software Development?[END_REF]. However, creative endeavors in organizations are not without costs. Training and deployment strategies within the physical and virtual environment requires allocation of resources when enhancing the creative abilities in employees and leaders [START_REF] Amabile | How to kill creativity[END_REF][START_REF] Couger | Un)structured creativity in information systems organizations[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF].

Findings.

Institutional barriers still provide a massive problem by preventing creative people from being creative and exploring their potentials. Our findings revealed that both in the municipality and GameSim, many barriers were related to working in top-down governed organizations. These included strong expectations to get returns on investments, lack of possibilities to experiment without providing strong business cases for support of projects, lack of time to be creative, political trends influencing decisionmaking, expectations of continuous growth and system functionality, and lack of creative visioning in top management. However, this was much more apparent in GameSim, where traditional top management dictated the development strategies of the sub-unit. There was a better linkage in the municipality between the ITdepartment and the political leadership, which provided an increased ownership over projects and opened opportunities for experimentation without requirements of return of investment.

Defining structures for creativity is equally important. As one participant from a private developer in the survey stated:

"The waterfall model is our approach to project management … This kills the creativity in the projects. The employees fight against this, which equal positive results. However, this process is very ad hoc when we have the time and resources."

Development processes in GameSim were equally very ad hoc. The creative process would stop when the requirement specifications were defined for a given project. In the municipality, they acted differently by strategizing projects as implementations projects. Requirements were either set in advance or defined as "next practice projects". Next practice projects included continuous creativity and experimentation during the entire project life cycle to provide more benefits and increase organizational knowledge in new areas. Hence, availability to experimentation is a valuable resource when embarking on creative projects. In GameSim, they created a system due to a larger certification. However, there were loosely defined requirements for the system, and government funding provided the proper time and resources for conducting the project. This provided GameSim room for developing new ideas by continuously interacting with their customers over a two-year period. The result was a very innovative product that both GameSim and their customers benefited greatly from.

The Individual Factor

To increase the creative output of the organization, employees require continuous education for developing their creative skills [START_REF] Couger | Creativity: Important addition to national joint undergraduate IS curriculum[END_REF]. IS organizations also thrive from the individual's ability to be creative and create new ideas for continuous innovation ( [START_REF] Florida | Managing for Creativity[END_REF]. However, several factors influence individual impact on creative output. Creative employees are especially known for being exceptionally difficult to manage. They often know their own worth, have expert knowledge, and have A-type personalities and behavior that often results in conflicts with authorities [START_REF] Florida | Managing for Creativity[END_REF][START_REF] Goffee | Leading clever people[END_REF]. Managers must create an environment that not only empowers creative employees, but also attracts them to the organization [START_REF] Catmull | How Pixar Fosters collective creativity[END_REF].

Findings.

There is low overall integration in the challenges connected to the individual factor in comparison to the challenges connected to the other six factors, which indicates that the participating organizations have little emphasis on training their employees in creativity and manage creative people. However, our analysis showed many different approaches to provide training for creative employees. Some organizations would provide individual courses for employees, while others would hire external consultants for enhancing the overall creativity and innovation ability in the organization. Some would not provide any training at all and would rely on their employees' natural ability to be creative. However, training in creativity provides many benefits for organizations. In the municipality, a creativity and innovation workshop helped the employees to think differently and engage in experimentation, which provided solutions for a range of problems they faced. Equally, in the daily management of employees, empowerment was important. Where the municipality used empowerment to encourage creativity for the employees, employees in GameSim were already empowered. The employees engaged in the creative development were some of the few specialists within their field. As the head of product development argued:

"Our employees are small kings within their own field and there is not a lot of team spirit".

Hence, the challenge in GameSim was not to enable creative empowerment in their workforce, but to control the highly creative employees, as the individuality of these specialists often collided with the needs of the customers. Consequently, one of the job specifications for the head of product development was to enable communication between customers and the creative employees to provide encouragement for the employees and to insure business value to the customers from their new ideas.

The Group Factor

Creative activities are often conducted in teams. As Cooper [START_REF] Cooper | Information technology development creativity: A case study of attempted radical change[END_REF] argued, IT-specific knowledge is an important capability in development teams. It enables them to act creatively according to the organizational context. Professional differences in development teams are thus important for the composition of development teams and overall success of projects [START_REF] Cooper | Information technology development creativity: A case study of attempted radical change[END_REF]. Moreover, when giving tasks to creative individuals or creating creative teams, an important consideration is that individuals are different in their cognitive abilities, knowledge, behavior, and personality [START_REF] Amabile | How to kill creativity[END_REF]. Equally important is the demographic, cultural, and social composition. Creative development teams perform better when they are composed of employees with different experience and education levels [START_REF] Amabile | How to kill creativity[END_REF][START_REF] Cooper | Information technology development creativity: A case study of attempted radical change[END_REF][START_REF] Gero | Computational models of creative designing based on situated cognition[END_REF][START_REF] Tiwana | Expertise integration and creativity in information systems development[END_REF]. However, teams are less creative when they are comprised of employees with different social or cultural backgrounds, or different sexes [START_REF] Thatcher | Individual creativity in teams: The importance of communication media mix[END_REF]. Managers must understand these factors and their employees when they create development teams composed of individuals with different professional, social, and cultural backgrounds [START_REF] Amabile | How to kill creativity[END_REF][START_REF] Cooper | Information technology development creativity: A case study of attempted radical change[END_REF][START_REF] Thatcher | Individual creativity in teams: The importance of communication media mix[END_REF]. When teams are comprised of employees with different backgrounds and experiences, they require a higher level of communication and interaction to collaborate. As Cockburn and Highsmith [11;132] argued "Interestingly, people working together with good communication and interaction can operate at noticeably higher levels than when they use their individual talent". Hence, managers are required to use increased time and effort to create working development teams and to facilitate mediated communication and interaction in the teams [START_REF] Thatcher | Individual creativity in teams: The importance of communication media mix[END_REF].

Software organizations are also an entity of different communities of practices that influence organizational culture and norms, which results in learning and innovation, defines organizational structures, and creates institutionalization of those practices [START_REF] Brown | Organizational learning and communities-of-practice: toward a unified view of working, learning, and innovation[END_REF]. When creating creative groups, communities of practices are important for transferring organizational knowledge from individual to individual [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF][START_REF] Malhotra | Radical innovation without collocation: A case study at Boeing-Rocketdyne[END_REF]. In managing for creativity, managers must understand the existing communities of practices in the organization and actively use these in the knowledge creation processes, when changing culture and norms, and when transferring knowledge to create a shared understanding of problems.

Findings.

Creativity workshops can do a lot when attempting to increase organizational creativity. During a creativity and innovation workshop in the municipality, leaders across the organization were divided into groups. The purpose of the workshop was to place the participants out of their normal comfort zone and encourage them to think in digital solutions for their everyday problems. During the workshop, the leaders would then change groups and further develop the problems within a new group of people. This approach of constantly changing the leaders' environment broke down cultural differences and enabled the leaders to think differently, which resulted in novel ideas for digitalizing problems across the organization. Moreover, the survey showed that IS and ISD organizations have a similar integration of communities of practices, while clone organizations had a lower integration. This cause of difference can be related to a higher inclination in IS and ISD organizations to institutionalize existing practices through software use and development (e.g., [START_REF] Orlikowski | The duality of technology -Rethinking the concept of technology in organizations[END_REF][START_REF] Orlikowski | Technological frames -Making sense of information technology in organizations[END_REF]).

The importance of mediated communication is also apparent. Without proper communication between team members and between departments, actors will lose important information that they can use as a source of inspiration of novel ideas. In both the municipality and GameSim they solved this problem by using IS for mediating the communication and information sharing process. GameSim used an intranet solution for their developers and business analysts, which contained design and development ideas and other relevant information provided by the employees. The municipality, alternatively, used an open intranet solution that allowed departments across the organization to view detailed information from digitalization projects in other departments.

The Leadership Factor

Managers' leadership abilities in software organizations are an important and often overlooked factor in the organizations' goal of increased creativity [START_REF] Florida | Managing for Creativity[END_REF]. Managing IS does not only include delegating tasks and resources or creating of business plans for projects. IT also requires clear leadership, which involves individual human empathy and empowerment of employees [START_REF] Amabile | How to kill creativity[END_REF][START_REF] Catmull | How Pixar Fosters collective creativity[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF], and a clear understand of the group dynamics in development teams [START_REF] Cooper | Information technology development creativity: A case study of attempted radical change[END_REF][START_REF] Malhotra | Radical innovation without collocation: A case study at Boeing-Rocketdyne[END_REF]. Managers must be willing to take risks when needed [START_REF] Catmull | How Pixar Fosters collective creativity[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF][START_REF] Sutton | The weird rules of creativity[END_REF]. Fear of failure in top management discourages employees and decreases the flow of novel ideas [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. Moreover, managers must deploy creative techniques when needed and create incentives and motivation for employees and groups to enhance the creative output [START_REF] Couger | Un)structured creativity in information systems organizations[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF], while being able to include employees' personal characteristics when transferring techniques to system use [START_REF] Cheung | Does knowledge reuse make a creative person more creative?[END_REF]. Hence, managers must strategize and conceptualize the creative endeavors in IS organizations with the existing business processes, by providing plans for implementation of systems and change, training, evaluation, and diffusion of creativity tools and techniques [START_REF] Couger | Un)structured creativity in information systems organizations[END_REF][START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF].

Findings.

The integration of incentives for creative development was the lowest of all the challenges despite it being a powerful motivator for increasing organizational creativity [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. In our survey, 48% [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF] answered that this challenge was not very well integrated in their organization, and only 6% (2) replied that it was very highly integrated. Hence, these software organizations lack a leadership culture that provides incentives. However, the findings from the interviews demonstrate a positive culture for empowerment, as employees and managers are encouraged to take ownership over projects.

Our findings also showed that there is some kind willingness to take risks with new ideas in software organizations. However, private organizations had a substantial higher integration than public organizations when it came to practices in risk-taking. The cause of this difference can come from Danish public organizations being subject to government laws, which prevent them for hiding their failures. This exposure to their customers' opinions (politicians and citizens) can make them less inclined to take risks, which affects their overall ability to engage in high-risk creative projects.

Deploying creativity techniques IS and ISD organizations were mostly on ad hoc initiatives. In the municipality, they would hire outside consultants to conduct their workshops, and when asked about the techniques deployed, they would only provide sporadic information about them. In GameSim, the same problem was apparent. The managers utilized creativity techniques such as brainstorming, but they had no defined approaches or predefined knowledge for deploying different creativity techniques.

The integration of strategizing creativity in the organizations was almost equally below average in both private and public organizations. The interviews somewhat explained this finding. In the municipality, they had only recently created a strategy for creativity and innovation one year prior to this study. In GameSim, a similar strategy was created only four months prior. However, this finding also indicates that both private and public organizations increasingly attempts to integrate creativity management practices in their organizations by defining overall strategies for creativity and innovation.

The External Factor

User and customer involvement are an important factor in system development [START_REF] Davenport | Process Innovation -Reengineering work through information technology[END_REF]. As customer do not always know their needs, it is important to understand the user to make requirements [START_REF] Beyer | Contextual Design -Defining customer-centered systems[END_REF]. Hence, for new business opportunities to emerge, novel ideas must be evaluated and screened before implementation [START_REF] Couger | Creativity & Innovation in information systems organizations[END_REF]. Florida and Goodnight [START_REF] Florida | Managing for Creativity[END_REF] recommended locating a balance between creating novel ideas and allocating customer needs through relationship building and testing schemes. However, analyzing customer needs in creative processes requires a culture of constructive criticism to deliver continuous quality [START_REF] Florida | Managing for Creativity[END_REF]. This also requires a culture that emphasizes that some projects just fail. Organizations who punish employees who fail with projects will remove any incentives to be creative [START_REF] Amabile | How to kill creativity[END_REF].

Using quality assurance schemes such as Software Process Improvement (SPI), Lean, and Six Sigma are common practices in software development to provide product and service quality and standardization of business processes for continuous customer value [START_REF] Conradi | Improving software process improvement[END_REF][START_REF] Hicks | Lean information management: Understanding and eliminating waste[END_REF]. However, the discipline aspect of quality assurance schemes have been criticized for inhibiting creativity [START_REF] Roger | Lean Six Sigma, creativity, and innovation[END_REF]. Conradi and Fuggetta [START_REF] Conradi | Improving software process improvement[END_REF] and Herbold [START_REF] Herbold | Inside Microsoft -Balancing creativity and discipline[END_REF] argued that organizations should balance their quality assurance efforts between discipline and creativity, where discipline support inspections and standardization of business processes, and creativity and collaboration support engineering and software design.

Findings.

Data from the survey and interviews revealed that organizations' business primarily use business cases before and after software implementation to evaluate novel ideas. Business cases have the advantage of providing a quick determination of business value for a given idea (e.g. [START_REF] Ward | Building better business cases for IT investments[END_REF]). In the two organizations in which we conducted interviews, they measured the quality of new ideas by level of business value. They would rarely use strict management methods, such as Lean, Six Sigma, and SPI, to ensure quality control of new ideas, which could be the cause of low integration in creating quality assurance schemes. Instead, their employees was encouraged or simply told to determine business value for each new idea before implementation. However, in the municipality, they would follow up on the business cases during implementation. This ensured that new ideas could emerge and add additional business value over the project's life cycle.

In most of the software organizations, user and customer involvement was important to insure business value for creative ideas. However, user involvements in the private organizations were significantly higher than in public organizations. In the municipality, the CIO agreed that they were good in involving their own users and suppliers in new digitalization project. However, they lacked a clear emphasis on involving their customers (the citizens). In GameSim, the customers were highly in-volved in the creation of new products, as they were a source of novel ideas during the requirements specification of new products and services. Moreover, the survey demonstrated a clear contrast to the overall integration of user and customer involvement between ISD, clone, and IS organizations. ISDs were far better at integrating user and customer involvement than IS organizations and somewhat better than clone organizations.

A Framework for Creativity in Software Organizations

From our synthesis of the literature and the empirical evidence, we constructed a framework consisting of the seven identified factors for creativity in software organizations. Moreover, we identified 21 challenges in creativity management within the seven factors.

The schematic representation of our proposed framework is presented in in Figure 1 and demonstrates how multiple challenges can unfold themselves in software organizations. These challenges exist within seven factors in the creative context of organizational creativity. The framework also demonstrates the mutual influence from each of the seven factors on a software organizations creative output (ideas generation). Each factor has individual challenges attached that are illustrated with unbroken lines between the challenges and their factors. The challenges define the factors, which in return affects the creative context and ultimately the creative output of software organizations. For example, a challenge can be the demographic composition of creative development teams in the group factor, or the challenge of organizational barriers in the institutional factor.

Inspired by Rhodes' (1961) thinking, no individual factor of creativity stands alone, but all are connected in unity. Hence, the different factors can impose influence over other factors. For example, creativity support systems can influence the creativity in individuals and groups, while individuals can affect how groups function. Moreover, leadership influences the creative environment, while external factors like idea evaluation schemes and relationships with customers can influence the institutional structures of the organization. Hence, this area of influence represented in the middle of Figure 1, demonstrating how each factor influences the organizational context through interaction with other factors. This interaction between factors also defines the creative context of the organization. As illustrated, this mutual influence and interaction between different factors ultimately outlines the creative output of the software organization.

Conclusion

Creativity management has become an increasingly important factor in conducting product and service innovation in software organizations. Creativity management involves increasing expertise in techniques, leadership, strategies, evaluation, and human-computer interaction in order to break down management challenges and achieve the necessary benefits of organizational creativity initiatives.

In this paper, we asked ourselves the following research question: "Which challenges of creativity does software organizations experience?" To this end, we created a framework that influences creativity management in software organizations. We identified seven organizational factors of the technology, environment, institution, individuals, groups, leadership, and external issues. Moreover, we identified 21 common challenges within the different factors and provided a combined framework with a comprehensive theoretical foundation and an interpretive research study to support it, which demonstrates how managers in software organizations practice creativity management. The framework also shows that organizational creativity is a combined entity consistent of different factors, which impose mutual influence on each other. Managers and researchers must be aware of this mutual influence and are encouraged to provide new initiatives for practice and research that support organizational creativity as a combined entity.

The research provides several insights for creativity management in technologydriven organization. For example, our results showed that managers or employees often conducted creativity in practice through ad hoc initiatives rather than doing it in a structured form. However, the study also provided valuable insights into creativity management practices that are transferrable to normative guidelines for creativity enhancing software that practitioners could benefit from. As such, it became clear that creativity enhancing software requires a number of different features, including integration in the existing IS-portfolio, integration of knowledge management systems, and information awareness, design usability and training, mediated communication, pre-selection of tools, empowerment through incentives, and computerized evaluation of new and novel ideas. In addition, it requires additional management practices including clear strategies for creativity and innovation before implementation, culture building, and empowerment trough ownership of projects and freedom for experimentation. Such experimentation must include allocation of the necessary resources and clear leadership from top management when taking new risks.

However, when writing this paper, we also realized that creativity encompass a far wider complexity across a software organization than this paper is able to present. Hence, researchers can use our findings to gain a better understanding of how these factors and challenges are interconnected and influence the complex and often chaotic endeavor of creating novel and useful ideas for new software innovations.

Fig. 1 .

 1 Fig. 1. A framework of creativity challenges in software organizations

Table 1 . Participating organizations in the survey Case Organizational size Public / private organization Type of organization

 1

	1-3	Medium	Private	Computer game developer (same
				organization)
	4	Very large	Public	Local municipality
	5	Very large	Public	Local municipality
	6	Very large	Public	Government organization
	7	Medium	Private	E-learning software developer
	8	Very large	Public	University college
	9	Medium	Private	AV equipment distributor
	10	Very large	Public	Local municipality
	11	Medium	Public	Knowledge organization in IT-research
	12	Very large	Private	IT-infrastructure developer