1. Session 2: Enabling Benefits Through Change
eHealth Benefits Management Toolkit
Session 2: Enabling Benefits Through Change
v4.0
May 2009

2. Completing the Benefits Dependency Network
Session 2 Outline
Completing the Benefits Dependency Network
Stakeholder analysis
Defining Change
In the first session, we covered:
Objectives identification
Benefits identification and prioritisation
Benefits ownership
Mapping benefits to objectives
In this session, we will cover:
Completing the benefits dependency network or BDN
Carrying out a stakeholder analysis
Defining change
There will be opportunity at the end to ask questions, however, if you have any questions during the presentation please ask.
(Ask if there are any questions at this point, for instance about their putting into practice what was learned in session 1, before proceeding with the session.)
(allow 5 mins in case of questions)

3. Session 2 Purpose
At the end of the session, you will have an understanding of:
how to identify broad business and enabling changes required to deliver each benefit and map them out in the Benefits Dependency Network (BDN);
how to conduct a stakeholder analysis to ensure that the relevant groups are consulted with and identify and pre-empt resistance; and
how to identify appropriate owners for the changes required.
(1 min)

4. Business Changes and Change Owners
Completing the Benefits Dependency Network
Stakeholder analysis
Defining Change

5. Benefits Dependency Network (BDN)
Objectives B1 B2
Benefits C1 C2
Business changes E1 E2 E3
Enabling changes I1 I2
IM&T
Session 1
Session 2
We briefly talked about the benefits dependency network or BDN in session 1.
A great strength of dependency mapping is that it shows just how much change effort is going to be needed to deliver the selected benefits.
The Benefits Dependency Network diagram helps identify critical paths and can be used as the basis for the project plan and/or GANTT chart. It can be used to start the discussion about the relative contributions and allows further decisions to be made about priorities and allocating resources.
We identified objectives and benefits in session 1 and linked the benefits to the objectives they were supporting.
We are now going to work through each step required to identify all the dependencies (role and process changes, enabling activities, system capabilities) for one particular benefit and map these together.

6. Enabling Benefits Through Change
IM&T implementation will not bring benefits on its own: define how the system will be used to make improvements to the service and what changes are required to accomplish this
Changes definition and implementation should form part of the standard project management of the investment
Take account of constraints and assumptions defined in the project plan when defining changes
Ensure key stakeholders are involved in agreeing and setting the changes
Without the underpinning process and role changes, the benefits will not be delivered
Even if the system is deployed successfully, benefits will not be enabled unless the identified business changes and enabling activities are delivered. The changes identified will form the main activities that are to be undertaken as part of the execution of the project.
The changes will also depend on the constraints and assumptions defined in the project plan. Their detailed definitions and documentations should therefore be incorporated in the standard project management of the investment.
Getting the definitions and BDN right at an early stage can avoid misunderstanding and tensions later in the project. It is therefore important to ensure that all key stakeholders are involved in creating the BDN.
(1 min)

7. Defining Changes and Activities
Business changes:
new ways of working that are required to ensure that the desired benefits are, and continue to be, realised.
This includes changes to processes, pathways, roles and working relationships.
Enabling changes:
changes and activities that are pre-requisites for achieving the business changes or that are essential to bring the system into effective operation within the organisation.
These could be: infrastructure set up, data migration, training interventions, resolution of governance issues, decommissioning of legacy systems…
Once benefits have been identified, you need to consider which changes are required to realise each of them.
These could be permanent changes to ways of working, roles, management practices (referred to as: business changes), or one off activities necessary to bring about the business changes or to implement the new system and ensure it is used effectively (referred to as: enabling changes)
The focus on delivering improvement through change means that business managers must be involved in the workshops as they will, at least to some extend, be responsible for ensuring that changes happen. It is important that all IT, operational and clinical staff participate fully and willingly to contribute and share their knowledge and learn from colleagues.

8. Business Changes ACTION:
Define the changes to processes and roles required to ensure that the benefit is realised.
what changes need to happen within the operational line and services?
what changes will be required to the activities that people do?
which roles are affected?
NEXT:
Connect the benefits to the business changes required in the Benefits Dependency Network (BDN).
If any benefits do not have associated changes, should they be included in this programme/project.
(B1)
C1: consult patient’s
history before ordering
test (clinicians)
What we are talking about here is not a detailed change plan, or process mapping , or process re-engineering. Just think about broad changes required, who is going to be affected and how much work is going to be involved. This will enable you to determine how likely these changes are to happen and consequently, how likely the benefits are to be realised.
If a change is deemed too difficult to implement (either because of lack of resources, organisational behaviours or governance constraints) a risk assessment will be required to determine whether these problems can be mitigated or whether both the change and the benefit it supports should be abandoned.
Exercise - Facilitator to distribute orange post-it notes and flipchart paper.
Break up delegates into smaller groups if required to facilitate discussion (ideally 4-8 per group)
Allocate between the groups the benefits from the list of benefits and objectives provided by the project team
Ask delegates to write on post-it notes: the business changes required, the benefit ID they relate to and who this will affect. Ask that they number their changes (C1, C2, C3, …) for future reference. They should then place them on a sheet of flipchart paper with the benefit they enable (one sheet per benefit). Delegates should list the objectives and benefits on the left and link them to the relevant change(s) to start creating the benefits dependency network. Leave some room on the right for enabling changes and IM&T features.
(timing will depend on whether the aim of the exercise is to list a few objectives for knowledge reinforcement; or whether it is to list all the objectives so delegates can leave the workshop with a completed benefit map)
B1: Fewer
repeat
procedures
O1: Safe
(B1)
C1: consult patient’s
history before ordering
test (clinicians)

9. Enabling Changes ACTION:
Define the changes to governance and behaviours, the training interventions, working relationships,… required to support the business changes.
what actions are required and when to ensure that the business changes can be implemented?
Who will be responsible for each of them?
NEXT:
Connect the enabling changes to the business changes they support in the BDN.
(C1)
E2: Doctor has
access to SCI Store
(governance)
(C1)
E1: Patient is
identified using CHI
(Clinicians)
Exercise - Facilitator to distribute yellow post-it notes.
Ask delegates to write on post-it notes: the enabling changes and activities required, the business change ID they relate to and who this will affect. Ask that they number their enabling changes (E1, E2, E3, …) for future reference. They should then place them on the flipchart paper and linked them to the relevant business change(s). Remember to leave some room on the right for the last component of the BDN: the IM&T features.
(timing will depend on whether the aim of the exercise is to list a few objectives for knowledge reinforcement; or whether it is to list all the objectives so delegates can leave the workshop with a completed benefit map) B1 O1
(C1)
E1: Patient is identified
using CHI (Clinicians) C1
E2: Doctor has access to
SCI Store (governance)

10. System Features
When considering IM&T solutions and capabilities, eHealth Leads to ensure the following questions are addressed:
Information management: Is information being collected and stored consistently?
Infrastructure/Physical environment: Is there adequate access to the system? Is it fit for purpose?
Technology integration: Are the system interfaces running? Is the appropriate information being fed into and out of the system?
Finally, the information management or system requirements need to be considered.
This may result in additional changes being identified, particularly enabling changes (e.g. training, access to hardware, process for account creation of new user groups…). They should all be added to the BDN.
IM&T are considered last to ensure that the focus of the project is on what service improvements the organisation wants to achieve and the related change programme, rather than the technology available.
It is important for eHealth Leads to work towards shared data and system standards to ensure future inter-operability. This is critical to the development of national solutions and economy of scale.
For further information and advice, contact the Architecture and Design Team:
[Read slide]
(1 min)

11. IM&T / System Capabilities
ACTION:
Define the system capabilities that need to be enabled to support the changes that will deliver the benefits.
are any system capabilities not enabling any of the changes? If it costs money but does not add value, then should it be removed?
are any of the benefits or changes on the map not enabled by a system capability? What is stopping the organisation
from implementing these right now?
NEXT:
Connect the business and enabling changes required to the system capabilities.
(E1)
I1: System
Integration with CHI
Exercise - Facilitator to distribute blue post-it notes.
Ask delegates to write on post-it notes: the IT systems or capabilities required and the change ID they relate to. Ask that they number their enabling changes (I1, I2, I3, …) for future reference. They should then place them on the flipchart paper and linked them to the relevant change(s) to complete the BDN.
(timing will depend on whether the aim of the exercise is to list a few objectives for knowledge reinforcement; or whether it is to list all the objectives so delegates can leave the workshop with a completed benefit map)
(E1)
I1: System
integration
with CHI B1 O1 E1 C1 E2

12. Benefits Dependency Network (BDN)
Objectives B1 B2 B3
Benefits C1 C2 C3
Business changes E1 E2 E3 E4
Enabling changes I1 I2 I3
IM&T
Objectives and benefits were identified in session 1 and you have just worked your way through identifying the changes and IM&T features required to deliver those benefits.
The linkage shows that a benefit will only be realised if the connected changes are successfully achieved. Considering those changes, ask yourself: “Is the benefit significant enough for us to make the associated changes?” and explore which benefits will deliver maximum value from the investment.
Similarly, and as part of risk analysis, the BDN can be used to consider the changes that have been identified as fundamental to the success of the project and whether any of them may be unachievable or highly problematic (for instance tried before and failed) and whether they should be removed, together with the benefits they support.
In large projects addressing multiple organisational functions, the links between benefits and business chances or business changes and enabling changes can get very complex. It may help then to group the benefits into benefit streams (i.e. a group of related benefits), for example patient safety.
Exercise
In their group, the delegates bring all the benefits dependency networks they have created together and read through the business changes listed: Do any of them sound similar? Are they duplicates? If yes, the group agrees a final wording and record it on the BDN as one business change linked to the different dependent benefits.
The delegates then look at the enabling changes: Are any of them duplicates? If yes, the group agrees a final wording and record it on the BDN as one enabling change linked to the different dependent benefits/business changes/IM&T features.
Finally, the delegates consider the IM&T features listed: Are any of them duplicates? If yes, the group agrees a final wording and record it on the BDN as one feature linked to the different dependent business/enabling changes.
Once this has been done in each group, the outputs from all the groups have to be brought together and the same exercise carried out again (identify duplicates, agree wording and link to all dependent components), this time led by the facilitator.
(timing will depend on whether the aim of the exercise is to list a few objectives for knowledge reinforcement; or whether it is to list all the objectives so delegates can leave the workshop with a completed benefit map)
ACTION:
Are there any changes enabling more than one benefits (e.g. E2)? or benefits supporting more than one objective (e.g. B2)?...
Link them to those additional benefits to finalise in the BDN.

13. Completing the Benefits Dependency Network
Stakeholder Analysis
Completing the Benefits Dependency Network
Stakeholder analysis
Defining Change
Any questions?

14. Stakeholder Management
Planning and monitoring are essential to good benefits management but gaining the commitment of the people who are likely to be affected is just as vital. Not identifying potential stakeholder issues may result in:
People being defensive, refusing to acknowledge problems or blaming others rather than looking for solutions
Constant questioning and scepticism
Negative effect on job satisfaction and motivation
Increase in absenteeism or staff leaving the organisation
People not complying with the change agenda and not doing what they said they would
You should have identified most of your stakeholders when you listed the project/objectives sponsors, the benefit owners, and the people effecting or affected by change.
Stakeholders can also be partners or other areas of care who are going to be indirectly affected by, for instance, reduced staffing or service disruptions during the project.
When considering what stakeholders to involve in workshops, attendees should at least include one representative from eHealth (IM&T/technical), on operational manager, one financial manager and one clinician (or one from each profession involved in or affected by the project).
The more important the stakeholder group is to the success of the project, the more time and resources you need to devote to maintaining their involvement and commitment.
(2 mins)

15. Stakeholder Analysis The purpose of stakeholder analysis is to:
identify all stakeholders whose knowledge, commitment or action is needed to realise each benefit and who should therefore be involved;
determine perceptions of project (“what’s in it for me”, disbenefits);
understand changes that affect the group and their motivation to achieve or resist them; and
agree actions needed to gain the required commitment of all stakeholders and develop an action plan.
The stakeholder analysis will ensure that all the individual and groups who are affected by the project have been identified and that their attitude and potential impact on the project have been assessed.
The stakeholder analysis will often result in the identification of additional changes, in particular enabling changes, to address stakeholders issues.
Don’t forget about your key stakeholders: the patients. It may be helpful to take steps to increase their influence by organising them into groups and conducting active consultation.
(1 min)

16. Change/Benefits Balance Analysis (JW)
Benefits received
High
Low
NET BENEFITS
BENEFITS BUT…
Should champion the project – but must be aware of implications for others and use their influence
Will be positive about benefits but concerned over changes needed – ensure sufficient enabling changes are identified to offset any resistance
FEW BENEFITS BUT…
NET DISBENEFITS
Must be kept supportive by removing any inertia/apathy that may influence others negatively
Likely to resist changes – must ensure that all aspects of resistance are dealt with by enabling projects
It is important to understand how benefits and changes are distributed across stakeholder groups and whether the balance of “pain” and “gain” is acceptable from each stakeholder’s perspective and for the overall organisation. Where the effort required by far outweighs the benefits, this will have to be managed.
The change/benefits matrix allows a quick assessment of the changes required of stakeholders and what benefits they will receive. This should be used to highlight potential risks associated with high impact stakeholders (those whose effort and compliance are needed to make essential changes happen) on the likelihood of success (for instance if they have very little to gain out of the project and are therefore likely to be resistant to deliver the changes required of them).
It is important that the stakeholder analysis identifies possible resistance and antagonism and investigates what actions should be taken to minimise their impact.
(2 mins)
Changes required
Low
High

17. Identifying Stakeholders
ACTION:
Think of all the people or groups that will be affected by the change:
Who are the key stakeholders who have a significant influence on the project?
What business changes will they contribute to make the project successful?
What benefits will they get, “What’s in it for them?”
How committed to success will they be?
What could they do to jeopardise the realisation of the benefit?
What could be done to discourage negative influences and support positive ones?
The project need ask themselves the following questions to understand what support they will be receiving from stakeholders or what resistance they will have to neutralise.
Exercise - The facilitator draws the change/benefits matrix on the flipchart.
Ask delegates to identify the stakeholder groups and individuals (use the benefits owners and change owners/enablers that have been identified in previous exercises to get them started if required). For instance: Who will receive the benefits? Who will be affected by the change programme?
Write each stakeholder on a post-it note and ask the delegates where they should go on the matrix.
Ask the delegates to consider each question in the exercise (the first four for all stakeholders and the last two for stakeholders classified as “benefits but…” and “net disbenefits”).
At the end of the exercise, the facilitator asks the delegates to consider the spread of stakeholders in the matrix: is there a concentration of stakeholders in a particular quadrant? what does this mean for the project? (e.g. if most stakeholders are in the “benefits but…” or “net disbenefits” categories, are the working relationships and organisation culture toward change strong enough for the changes to happen and the project to be successful?)
(timing will depend on whether the aim of the exercise is to assess the impact and attitude a few stakeholders for knowledge reinforcement; or whether it is to do it for all stakeholders so delegates can work through a complete stakeholder analysis)

18. Stakeholders Contribution
Engaging with the stakeholders will enable you to:
Avoid conflict and associated delays
Identify additional enabling changes
Refine business changes
Refine benefits
Formulate a benefits plan that is practical, sensible and do-able
Prioritise efforts and understand current service performance
Develop process ownership and gain commitment
Without stakeholders commitment at the outset of a project, the issues that inevitably arise during the project can be difficult to resolve, leading to conflict, added cost and time, and potentially failure to realise some or all of the benefits. Stakeholder analysis and engagement are therefore pivotal activities in project management.
Remember to include clinical staff who deliver your day to day service. Their contribution will enable you to identify potential problems early and understand them from the perspective of the busy doctor or nurse.
It is important to learn from stakeholders’ experience and knowledge. Encourage change enablers and benefits owners to take responsibility for working with their colleagues to improve or set-up processes. However, beware of “this is how it has always been done” attitude and encourage innovation.
Engaging with the stakeholders will enable you to:
Identify additional enabling changes required to address stakeholder issues
Refine business changes based on working knowledge
Refine benefits based on better understanding of practicality of achieving them
Formulate a benefits plan that is practical, sensible and do-able, reflecting previous experience of what will work and what won’t
Prioritise efforts and understand current service performance
Develop process ownership and gain commitment of other colleagues by involving someone well known to their peers and/or with natural authority
(2 mins)

19. Completing the Benefits Dependency Network
Defining Change
Completing the Benefits Dependency Network
Stakeholder analysis
Defining Change
Any questions?

20. Completing the Benefits Management Templates
Transfer and expand into more detail the information from the Benefits Dependency Network in separate templates
Use the templates for benefits, changes and stakeholder analysis available in the eHealth Benefits Management Toolkit, or devise your own
Share the changes and IM&T capabilities identified with relevant parties to inform the project plan and system functional specifications
Plan training and communications to coincide with roll-out and deployment schedules
The BDN is a good tool for the initial brain storming and linking of the different elements of benefits realisation but it can only hold core information and may become complex, particularly for large project involving different areas of work or seeking to deliver a wide variety of benefits.
Once this high level representation of the benefits and their dependencies has been agreed, the information should be transferred and expanded into templates or spreadsheets. Remember to update the templates if amendments are made to the BDN and vice versa.
Developing a coding system will help you make identification of the different components across the documents easier (e.g. all objectives identified by the letter “O” and numbered (O1, O2,…); all benefits identified by the letter “B” and numbered (B1, B2,…); C1, C2, … for business changes; E1, E2, … for enabling changes and I1, I2, … for IM&T capabilities).
Completing the change and benefit templates will enable you to give more thoughts about whether and how the benefits are likely to be realised and how feasible the project is.
This section of session 2 deals with the change template; session 3 deals with the benefit template.
(1 min)

21. Completing the Change Template from the BDN
Change (C) or Enabler (E) ID
Change or Enabler description …
Prerequisite changes/ enabler (if relevant)
Dependent changes / enabler (if relevant)
Dependent benefit(s)
System feature(s) required
System feature(s) enabled
Enter ID number from BDN
Enter change name from Benefit Dependency Network (BDN)
Enter the ID and name of the enabling change required to effect the change
Enter the ID and name of the business/enabling change enabled by the change
Enter name of the benefit this change enables
Enter the name of the system feature / functionality required to effect the change
Enter the name of the system feature enabled by the change
ACTION:
Transfer the information from the BDN into the change template:
What preliminary actions are required prior to the change?
What system capabilities do they require or enable?
What benefits do they support?
The first stage is to transcribe what was captured on the BDN into the template.
Exercise - The facilitator distributes copies of the change template.
Give delegates one change to work on and ask them to complete the fields in the template that come directly from the BDN. Attendees may use the ID numbers instead of the descriptions to save time in the exercise.
Once this is done, the facilitator asks if there are any questions and moves on to the next step: “Enablers and changes owners”.
(5 mins) 21

22. Enablers and Change Owners
Those who will need to mobilise change in their departments.
They will be responsible for ensuring that each change is translated to the operational line.
They will be expected to lead the change.
Enablers:
Those whose working practices need to change for the benefits to be realised and whose effort is required to ensure that each benefit is achieved.
The change owners should be named individuals, not large groups of people. They may not personally make the changes but will be accountable for the changes being effected successfully. They should be senior or influential enough to ensure that resources are available to effect the changes and that any issues can be addressed.
It is also necessary to identify enablers, who are the people who will effect the changes. They may be individuals or groups of people.
If the change owners and / or enablers are not the ones who will reap the benefits, you should consider whether any action (e.g. explaining the bigger picture) is required to ensure that they will willingly effect the changes. This could be a significant issue and needs to be addressed early as part of the stakeholder analysis.
(1 min) 22 22

23. Who are the Enablers and Change Owners?
Change (C) or Enabler (E) ID
Change or Enabler description
Change owner(s) …
Enabler(s)
Enter ID number from BDN
Enter change name from Benefit Dependency Network (BDN)
Enter name and role of the person who will ensure that each change is translated to the operational line and is implemented
Enter the people whose jobs will change
Exercise
Ask delegates to agree and complete the change owners and enablers information for the change concerned.
Once this is done, the facilitator asks if there are any questions and moves on to the next step: “Change Implementation”.
(5 mins)
ACTION:
Define and record the following information about the changes:
Who will be responsible to ensure the changes are effected?
Who will actually implement them? 23

24. Change Implementation
Change (C) or Enabler (E) ID
Change or Enabler description …
Due date
Resources required
Enter ID number from BDN
Enter change name from Benefit Dependency Network (BDN)
Enter the date the change will be implemented
Enter what staff, equipment, logistics, financial resources … will be required to deliver the change
ACTION:
Define and record the following information about the changes:
When will the change be effected?
What resources will this require? Is this reflected in the “change owner”, “enabler” and “prerequisite change/enabler” columns?
Exercise
Ask delegates to agree and complete the change owners and enablers information for the change concerned.
Once this is done, the facilitator asks each group to read through their completed change profile.
Allows other groups to comment and feed back.
(5 mins) 24

25. Change Management
Most of the change management will be done as part of the standard project management process:
Use change identification to assess the amount of work required to achieve each benefit and therefore its feasibility and viability.
Have regular discussions to ensure that these activities have been included in the project plan and that all prerequisite changes and IM&T are in place in time.
Keep track of progress. Any delay or issues should be investigated and remedial actions identified.
Assess effect on the realisation of the benefits and amend the BDN and other templates accordingly.
The realisation of the benefits is dependent on the changes being successfully implemented. It is therefore just as important to monitor the change as it is the monitor benefits.
Keep track of progress and have regular discussions with the project manager to ensure these activities have been included in the project plan and are taking place. Any delay or issues should be considered and remedial actions identified and taken. The effect on the realisation of the benefits should be assessed and the BDN and other templates amended accordingly.
(1 min)

26. Further Reading and References
Definitions, tables and diagrams marked (JW) are borrowed from:
John Ward and Elizabeth Daniel, “Benefits Management: Delivering Value from IS & IT Investment”, John Wiley & Sons Ltd, 2006
Improvement Leaders’ Guide series, “Managing the Human Dimension of Change”, NHS Institute for Innovation and Improvement, 2005;