Health Information and Communication Systems in Ireland

wellness discipline and chat Systems in IrelandIs ICT a key enabler in ensuring seam little sales pitch of wellnessc ar? A comparison between man and surreptitious ICT culture in Ireland squeezeThis occupy discusses the innovative changes that dumb lay down taken place in Ireland in the field of wellness mission due to the influx of instruction and communication technologies. Previous k right offledge communication technologies (ICT), including telemedicine, present opportunities to come up to rural wellness- table service bringing issues. The research shows that effective charge of wellness run and the delivery of tincture systems in Irish health wangle organizations perk up increased. In Ireland patients ar expecting to a greater extent of health thrill providers and are demanding melloweder standards of conduct and service.Simultaneously, those paying for health run invite become much worryed about rising health costs and possible inefficiencies. As a resul t thither is widespread elicit in understanding what makes for an effective health service and in scraming remedy practices to improve existing forward moti one(a)s to healthcare steering in relation to ICT. This pass waterplace highlights the schoolings in step-service concern in the Irish healthcare vault of heaven and foc wasting diseases attention on the need for the development of a mock up for note implementation in healthcare institutions. In sum the postulate shows that the development of (ICT) has facilitated the emergence of a complex global urban system in which many an(prenominal) an(prenominal) precedently lower-order cities form been carving out niche medical specialist functions serving urban fields of transnational dimension.Chapter1 IntroductionPurpose of StudyThe purpose of this issue is to highlight the development of the development and communication system in Ireland and how it has revolutionized the healthcare sector in Ireland.Research Que stionThis study focuses on the pastime research questionsWhat are the real trends of technological development in the schooling and colloquy engine room sector of Ireland?What are various ch all(prenominal)enges faced by the Irish healthcare system in relation to Information and Communication Technology?Signifi toleratece of the StudyThis study is quite evidentiary as it shows that the concept of globalisation has secured remarkable currency in the academic discourse of the late twentieth century, despite ongoing questions regarding both its convey and extent (Clark and Lund, 2000). The development of foreignly integrated production and distri furtherion systems, seen by many as the key consume of globalisation, has been a spatially uneven procedure. A key positionor in this respect has been the divers(prenominal)ial ability of regions to fetter in the informational economy, based on hot information and communications technology (ICT), which is the main source of weal th creation and economic growth in the red-brick world (Castells, 2003).The result has been what Friedmann (2005) confabulates a process of techno-apartheid which has divided the globe into fast and slow worlds (Knox, 2005), distinguished by the connectedness of individuals, groups and regions to the world of telematics. This echoes Ingersolls (2003, quoted in Knox, 2005) confidential information that the key air division of the workforce is now that between those who gravel the capacity to operate ICT (the cyberp imagetariat) and those who do not (the lumpentrash). Golding (2006) makes a similar distinction between the technoliterati and the techno-poor. eyepatch Knox defines the fast and slow worlds spatially, equating the former with the triadic inwardness and the latter with the remaining global periphery, Hoogvelt (2003) argues that the divide is, in essence, social kinda than spatial, with elements of both worlds to be base in all regions of the globe. Thus, within fo rward-looking economies, a process of social polarisation has been widely crossed (Friedmann, 2006 and Sassen, 2004) and has been intimately linked by Graham and Marvin (2006) to the development of ICT use. This is not to suggest that those who work in the fast world are homogeneously well-paid and affluent rather, they represent a wide range of remuneration levels depending on such(prenominal)(prenominal) factors as economic sector, location, function, cultural group and gender (Castells, 2006). What they do tend to have in common, however, is relation back meshing security due to the high demand level for their ICT skills.RationaleThis study follows a logical procession and identifies the fact that both in Ireland as well as globally, there are major geographical variations in the relative balance between fast and slow worlds, with the former mainly to be found in the traditional core regions of North America, western Europe and lacquer and an additional small group of newly industrialising countries which have had the institutional capacity to invest massively in groundbreaking ICT and associated educational infrastructures (Freeman, 2004). The slow world found predominantly in the less developed countries of the global periphery and accounting for the bulk of the worlds people is becoming increasely marginalised and is moving, as Castells (2003, p. 37) puts it, from a structural position of exploitation to a structural position of irrelevance.Definition of TermsICT Information and Communication Technology it is the study or line of credit of developing and using technology to process information and aid communications.Sistem SISTeM a soft systems methodology, stakeholder analysis and participative simulation shamling.NHS (National Health avail) The organization providing national healthcare service in the UK.Chapter 2 Literature Re hitchThe process of quality implementation has become a key concern for those convolute in hospital wariness in Ireland. In a national context, the effective management of health go and the delivery of quality systems in health-care institutions have increased in logical implication in late(a) years. In line with wider developments in other service industries, consumers (patients) are expecting more of health-care providers and are demanding higher(prenominal)(prenominal) standards of care and service. Simultaneously, those paying for health serve have become more relate about rising health costs and possible inefficiencies. As a result there is widespread beguile in understanding what makes for an effective health service and in developing better practices to improve existing approaches to health-care management and delivery.In 2005 a comprehensive report on funding from the burster on Health Funding highlighted that resolvents to the problems faced by the Irish Health Service did not lie primarily in the system of funding, but rather in the way that services were planned, organis ed, and delivered. Similarly, in a report from the OECD (2003), it was argued that although the Irish health system had delivered a unceasing profit in health standards, there was still scope for further benefit in efficiency, and that this could be achieved through better allocation of resources. More recently, the political science health scheme (DOHc, 2001) highlighted the requirement for a system to monitor progress and positiveally evaluate the quality and forte of health services. According to the strategyMonitoring and valuation mustiness become intrinsic to the approach taken by people at all levels of the health services.Specifi confabulatey, the strategy suggested that the way in which health and personal social services are planned, organised, and delivered has a significant effect on the health and well- beingness of the population. Organisational structures must be geared to the provision of a responsive, pliant health system which meets the needs of the popul ation effectively and at affordable cost. One of the guiding principles inherent in the published strategy was that of a people- midpointd health system. A responsive system must develop ways to engage with individuals and the wider community which receives its services. The health system must become more people-centred, with the interests of the public, patients, and clients being disposed(p) greater prominence and influence in decision making at all levels (DOHc, 2001).According to Bowers (2001), major structural reform, coupled with strong management and political allow for, are required to ensure change for the better. In Bowers view, finance alone allow for not improve the system. Rather, a concentrated effort must be made to ensure a responsive and efficient service. As previously noted, a conclusion of the Report of the Commission on Health Funding (2005) was that the solution facing the Irish health services did not lie primarily in the system of funding but rather in the way that services were planned, organised, and delivered. This is reinforced by a recent report on the Irish health-care sector which suggested that the issues and challenges facing the health service are fundamentally the same as those outlined by the Commission on Health Funding, except that they are compounded by much higher expectations/demands by consumers (Deloitte and Touche, 2001).Thus, although modern health services have undergone radical change in many parts (Robins, 2003), managers of health services are truely reporting a large increase in the proceeds of patients needing beds, with consequent ever-increasing waiting lists. Accident and jot departments are under particular strain, and the difficulties of dealing with the growing needs of the increasing elderly population are outgrowth to become apparent. Although the Irish health service is free for all those requiring health check treatment through a in public funded system, the watercourse situation is hauntin gly similar to that of the tight-laced era of health care in Ireland.As a result, the Office for Health Management in Ireland (OHM, 2001) has suggested that current deficiencies in health-care provision and delivery punctuate the importance of providing quality service management and implementation in Irish health and personal social services. In achieving this aim, the OHM has contended that those working within the system must change how they go about their work and how they work together.Changed public-sector environmentThe focus on health-care service and quality has evolved from a more general interest in continuous improvement orifices within the public sector. The prevalent trends in the private sector are towards continuous and pervasive change and increasing interdependencies, and it has been suggested that close parallels can be drawn between the private and public sectors. Public-sector validations now find themselves in a cyclone of change as they flak to adapt to turbulent environments in a pragmatic and systematic way (Lovell, 2004).In the UK and also in Ireland, these government activitys have been subject to cuts in government spending, as well as demands for compound efficiency and effectiveness. In chemical reaction to such changes, there has been a policy shift towards greater competition and an attempt to apply management practices from the private sector to the public domain.The Irish public sector has been officially pursuing change and reform through its strategic management initiative (SMI), a program for meliorate the management of the civil service which was formally launched in 2004 (Department of the Taoisearch, 2004). The SMI evolved from the growing internal and external pressures for better services and for more effective management of public services. In that context the continuous improvement of node service has been a particular(prenominal) focus of the SMI since 2003, when the quality service initiative was launch ed. The program set out a series of quality principles according to which dealings with the wider public would be coordinated and managed. These initiatives aimed to make public administration more relevant to the citizens for whom the service exists, and simultaneously want to remove barriers which have traditionally restricted work and job satisfaction within the public sector.In recent years, Ireland has experienced a rise in consumerism. Increases in revenue available to fund public service provision have gone hand in hand with rising public expectations of standards of service. As a consequence, management skills and competences in providing for improved standards of customer service have become recognised as being profound to delivering real transformation in the public sector. However, the development of such capabilities, particularly in relation to managing effective quality implementation, presents considerable challenges for those involved. Nowhere is this more evident than in the health-care sector. A revue of recent international evidence points to the challenges of implementing quality service in health-care institutions.Gaucher and Coffey (2000) confirmed that implementing a process of total quality management (TQM) in health care is a pragmatic, specific, and systematic methodology. However, this requires a firm commitment from the leadership to change their former ways of working and doing moving in. Gaucher and Coffey (2000) cited many reasons for TQM failing including poor leadership and a lack of management commitment but also noted that revitalisation can rejuvenate the process. These authors asserted that the piece of those implementing the process is to nurture and breathe push into the process when enthusiasm and commitment are declining.The importance of the support of senior management for quality-management projects is also advocated by Berwick et al. (2000). These authors undertook a national demonstration project in the US A in the late 2000s and described how organisations could implement the entire quality-improvement process from defining the problem through to implementing a solution and consolidating the gains (Berwick et al., 2000).A literature round carried out by Jackson (2005) identified that much work had been undertaken in the UK in determining the clinical effectiveness of many health-care organisations, but that very scant(p) research had been implemented in the area of managerial effectiveness. Furthermore, West (2001) determined that, in organisations that outperform others on different dimensions of executing, there was evidence that management is all important(predicate), as are the combined efforts of individual clinicians and teams. on that point have been about(prenominal) approaches espo employ for achieving quality management in health-care institutions, many of which have been technical and generic in their approaches (Moeller et al., 2000). Specifically, Donabedian (2000 ) introduced the concepts of structure, process, and outcomes, on with the development of self-assessment and accreditation through the International Organization for Standardization (ISO). In many instances these programs have met with mixed reactions, and their implementation has varied.A criticism levelled at hospital performance is that it has been rather insular, and has paid little attention to developments in related fields, such as organisational sociology, organisational behaviour, management studies, and human-resource management (West, 2001). If quality programs are to have lasting and significant effects, that they must follow a systemic approach such that all aspects of an organisation are integrated and center on continuous improvement and customer satisfaction (Joss, 2004).A variety of approaches has been used to improve quality and to ensure its delivery, but not all have been productive. Indeed, some have merely added bureaucratism and higher costs to health care (Jackson, 2005 Ennis and Harrington, 2001). Recent research has shown that 45 per cent of patients experience some medical mismanagement and that 17 per cent commence events which lead to a longer stay or more serious problems (Ovretveit, 2000). This is more and more caused by complex systems of care which do not appear to be managed effectively.Joss and Kogan (2005) strongly recommended that a comprehensive set of criteria be taked, against which to evaluate progress. These criteria should be based on the main requirements of TQM, and should include any additional factors generated by the organisation and/or by evaluators. A three-year evaluation of TQM in the National Health Scheme (NHS) indicated that there were clear factors which predicted productive implementation, the most important of which was the need to have a structured, pre-planned approach based on a thorough understanding of alternative approaches (Joss, 2004). Moreover, a recent study from the UK (OSullivan, 200 5) demonstrated how one NHS Trust achieved continuous quality improvement through determination, education, and implementation, supported by visionary and involved leadership in all areas, a multi-talented enthusiastic clinical audit department, and a high-quality dedicated staff.Nabitz and Walburg (2000) suggested that possible solutions to quality problems might lie in the approach promoted by the European Foundation for feel Management (EFQM). The EFQM has developed a warning to structure and review the quality-management processes of organisations. Self-assessment, benchmarking, external review, and quality awards are essential elements of this prototype and, as describe by Sanchez (2000), this approach represents an important direction of achieving righteousness in health care. Within the literature there are also many studies showing the benefits of applying models of quality implementation in health-care organisations (Naylor, 2005 Ruiz et al., 2005). much(prenominal) s tudies have pointed to the real benefits that return to organisations which have used such approaches (Pitt, 2005).Business rightness methodology for quality improvementThe introduction of internationally value quality frameworks the Malcolm Baldrige National Quality prize (MBNQA) in 2003, followed by the EFQM in 2005 has provided an probability for organisations to self-assess, using the models of TQM and business excellence which underpin these frameworks. In this process of self-assessment, an opportunity exists to identify the strengths and weaknesses in the current management of operations. In the USA, the effectiveness of the Baldrige process has been lauded by many (Gaucher and Coffey, 2000) who have indicated that organisations can learn about best practices from Baldrige-winning companies, and will thus be assisted in developing a composite for excellence.Although the Baldrige criteria were developed for commercial institutions, there has been keen interest in the ad aptation of the model within health-care organisations in the USA following a pilot health-care project in 2005. To date, no health-care entity has yet achieved Baldrige-winner status, although Gaucher and Coffey (2000) have asserted that it is only a function of time before there is a health-care winner. Moreover, these authors went on to say that the true benefit of the Baldrige process is not about winning an award. Rather, it is about the provision of a road map for a expedition a framework for both incremental and breakthrough improvement and business excellence.Within the European context, since its introduction in 2001, the EFQM model has been attracting considerable interest crossways all sectors, and has become a well-recognised quality-management framework. Stahr et al. (2001) concurred with Gaucher and Coffey (2000) in stating that the model provides a means by which organisations can assess their paths and develop solutions to achieve excellence. Other authors have e spoused the model as being surprisingly effective, with awards being presented to those firms considered to be the most accomplished exponents of TQM in Europe (Wilkes and Dale, 2005).Across European health care at an institutional level, an increasing number of organisations are making direct investments in the training of staff in the concepts of business excellence (Stahr et al., 2001 Jackson, 2001). The NHS Executive in the UK has provided a central lead in endorsing the model as an important framework for delivering on the clinical governance agenda. Furthermore the British Association of Medical Managers (BAMM) has promoted its use as a tool for organisational self-assessment (Stahr et al., 2001). Its use and adoption has been further supported by the British Quality Foundation which provides a major educational and support role in the use and adoption of the model in health care and other sectors across the corporate landscape.Without doubt, the future(a) performance of hea lth-care organisations will be assessed against wider goals than previously. There will be a greater emphasis on measuring organisational performance and, if performance is below par, quick investigation and appropriate intervention will ensue (Naylor, 2005). Moeller (2001) concurred with this, and identified evaluation of health services as a prerequisite. However, Zairi et al. (2005) warned that measuring organisational effectiveness in the delivery of health care is a challenging task.Joss and Kogan (2005) strongly recommended that a comprehensive set of criteria should be include, against which to evaluate progress. This should be based on the main requirements of TQM, supplemented by other organisational criteria thought to be important by the evaluators. A three-year evaluation of TQM in the NHS indicated that there are clear factors which predict successful implementation including sentiency of the need to have a structured, pre-planned approach based on a thorough underst anding of alternative approaches (Joss, 2004). Moreover, as demonstrated by OSullivan (2005), successful implementation requires the support of visionary and involved leaders in all areas, together with dedicated and educated staff.Examining organisational effectiveness in Irish health careAs suggested by Nabitz and Walburg (2000), the solution to quality problems might lie in the approach promoted by the EFQM. As reported by Sanchez (2000), this approach represents an important means of achieving excellence in health care which concurs with earlier descriptions by Gaucher and Coffey (2000). Self-assessment can examine current practice and establish capability, thus driving improvement rather than a reaction to weaknesses in the current system (Russell, 2005).There are also many studies in the literature which show the benefits of applying the business excellence model for quality implementation in health-care organisations (Naylor, 2005 Jackson, 2005a Nabitz and Klazinga, 2005 Arce lay et al., 2005). Such studies have pointed to real benefits that have accrued to organisations using such an approach. Furthermore, Jackson (2005a) demonstrated that the adoption of the principles of self-assessment and business excellence can lead to the achievement of a culture of continuous improvement.Russell (2005) noted that the adoption of the outside-in approach of the EFQM model enabled organisations to use the model as a developmental and management framework. For Arcelay et al. (2005), the model provided a global, systematic regular analysis of the activities and results by comparing them with the criteria of the excellence model. Moreover, the process made it possible to make comparisons with other private and public organisations.Using a systems view of an organisation enables managers to focus on the processes between the parts of an organisation, rather than on the parts themselves, which is similar to physicians using a systematic model in which to snap signs and symptoms, and thus make a diagnosis. An effective organisation is one in which the total organisation, through its significant subparts and individuals, manages its work against goals and plans with a view to achieving these goals within an informal system. Methods of management that have been developed in manufacturing environments are naturally regarded with scepticism in non-manufacturing sectors.However, according to West (2001), studies that have been conducted on the link between the organisation and management of services and quality of patient care can be criticised both theoretically and methodologically because of the many different mechanisms that may be operating(a) at once to produce the relationship between volume and quality. West (2001) asserted that a more unmitigated body of work exists on the performance of firms in the private sector, often conducted within the disciplines of organisational behaviour or human resource management.Ireland and the International I CT Systemcapital of Ireland has, in the 2000s, carved out several niche international functions for itself, one of which, call centre activities, has been the principal focus of this study. According to a report in The Irish Times (August 20, 2003), Ireland accounts for 30% of all international call centres located in western Europe. The great bulk of these are to be found in capital of Ireland. The central role of ICT in call centre activities has facilitated their centralisation in Ireland, from where markets spread across Europe and even further afield can quickly be served. As Sassen (2005, p. 56) has observed Information technologies, often thought of as neutralising geography, actually contribute to spatial concentration.Call centre activities, therefore, have helped Ireland to take out the bounds of geographical peripherality, thereby contradicting Wegeners (2005) gloomy prognosis which visualised cities in the periphery as inevitable losers from growing inter-urban competi tion in Europe. This has been modishly portrayed in an IDA advertisement which shows Ireland at the centre of a surrounding group of disembodied European countries ( Fig. 1). These latter are no longer seen as being more or less distant from Ireland, but as constituting a set of different language and market territories, all equally hearty from Ireland.However, Dublins growing international reach and the growing technological sophistication of its economic base should not mask the fact that, structurally, it retains a qualified position within the international division of labour. Its rapid recent economic expansion has been largely based on the attraction of branch plant operations which remain poorly embedded in the topical anesthetic economy (Breathnach, 2005). nd, while the rising skill levels associated with recent inward investment have facilitated substantial improvement in living standards generally, in the specific case of the call centre sector, much of the employment which has been created remains relatively poorly paid a fact which is directly linked with the high equilibrium of women workers in the sector, despite their high skill levels.Furthermore, the rapid growth of the call centre sector in the 2000s looks increasingly unsustainable as the end of the decade approaches. suppuration labour shortages are driving up labour costs which, in conjunction with increasing housing and exile problems, are beginning to attenuate Dublins attractiveness as a call centre location according to a 2005 survey of call centre locations in Great Britain and Ireland, reported by Allen (2005), Dublin had fallen to the 29th position of 46 locations surveyed, having been in the top 10 in 2006.The response of the IDA has been to devote additional resources to promoting non-Dublin locations for call centre projects. However, even if this is successful in the short run, in the longer term the future of call centre employment will be increasingly jeopardise by te chnological developments, such as speech recognition technology and especially the rapidly growing use of the internet for making reservations, placing orders and seeking information.The IDA has warrant its promotion of the call centre sector, despite the inferior nature of much of the employment involved, largely on the pace that it provides an initial base upon which more sophisticate forms of employment can be built. Its long-term strategy, in other words, is to encourage firms which have established call centres in Ireland to add on additional functions, such as financial management and software development, to these initial operations. Already there has been some success in this area of shared services back-office activities by mid-2003, some 25 such operations had been established, and were projected to employ over 3000 people by the year 2000 (information supplied by Forfs).Ultimately, however, all of these activities remain as back-office activities, whose essential linka ges are external to the Irish economy. In other words, their Irish location is not crucial to the parent companies of these operations rather, it is contingent upon(p) on the availability of certain attractions which may either be transient or reproducible elsewhere (Allen, 2005). As Wilson (2005) has noted, call centres are essentially a highly footloose sector, with few local economic linkages and little fixed investment in machinery and equipment they therefore can be relocated quite pronto in the light of changing relative factor conditions.The National Health Service (NHS) in the UK published its NHS Plan in July 2000 (http//www.nhs.uk/thenhsexplained), saying that patients and people were central to its radical reform of healthcare and that although this included more hospitals and beds, shorter waiting times and improved care for older people, an essential element was that patients should have more mogul and information. As Grimson et al. (2000) rightly comment, healthcare is an information-intensive business, with entropy on an enormous scale gathered by way of hospitals, clinics, laboratories and primary care surgeries.Central to any information-intensive business is, naturally, the effective sharing of that information and, in order to empower and better engage the patient, how best that can be done. Funded by the UKs Department of Health, the British Librarys integrated Telemedicine Information Service (TIS), described in the latest edition of the NHSMagazine (http//www.nhs.uk/nhsmagazine), is to improve the take-up of telemedicine technology in the UK, reinforcing the importance that information and communication technologies (ICTs) are seen to have in the sharing of information and the engagement of patients in their healthcare.By way of explanation, the word telemedicine has been coined as a way of capturing, in only one word, how ICT is being used in healthcare. However, as Curry et al. (2003) rightly comment, terms such as telemedicine, tel econferencing, health information processing and medical informatics seem to be used interchangeably, and that there is some confusion as to what is, and is not, involved, citing various studys, including those of Preston at al. (2002) and Mark and Hodges (2001) to support their claim. As there is some dissonance with the term, we use in this study the meaning assigned by Perednia and Allen (2005), that is, the use of information technologies in helping to provide medical information and services in healthcare. Whatever its name, or its definition, it concerns, in one way or another, the mediating role that technology plays in the interaction between humans, whether patient or healthcare professional.At the time of writing, there are 138 telemedicine projects in the UK (http//www.tis.port.ac.uk/tm/owa/projects.allUK), and they cover aspects of healthcare as diverse as mental health, diabetes, foetal monitoring and accident and emergency care. Indeed, it points to one of the advanta ges of telemedicine its applicability across a wide range of clinical issues. However, while these projects certainly cover a diversity of issues, they have something in common, that is, they address only one of these clinical matters. distributively system is designed differently, is unlikely to be compatible with another, and needs different technical support and user training.Whilst such individual systems have proved reclaimable in a particular context (see, for example, Gilmour et al., 2005 Jones et al., 2006 Lesher et al., 2005 Loane et al., 2005 Lowitt et al., 2005 Oakley et al.,Health Information and Communication Systems in IrelandHealth Information and Communication Systems in IrelandIs ICT a key enabler in ensuring seamless delivery of healthcare? A comparison between public and private ICT development in IrelandAbstractThis study discusses the innovative changes that have taken place in Ireland in the field of healthcare due to the influx of information and communicati on technologies. Previous Information communication technologies (ICT), including telemedicine, present opportunities to address rural health-service delivery issues. The research shows that effective management of health services and the delivery of quality systems in Irish healthcare organizations have increased. In Ireland patients are expecting more of healthcare providers and are demanding higher standards of care and service.Simultaneously, those paying for health services have become more concerned about rising health costs and possible inefficiencies. As a result there is widespread interest in understanding what makes for an effective health service and in developing better practices to improve existing approaches to healthcare management in relation to ICT. This study highlights the developments in quality-service management in the Irish healthcare sector and focuses attention on the need for the development of a model for quality implementation in healthcare institutions. In sum the study shows that the development of (ICT) has facilitated the emergence of a complex global urban system in which many formerly lower-order cities have been carving out niche specialist functions serving urban fields of transnational dimension.Chapter1 IntroductionPurpose of StudyThe purpose of this study is to highlight the development of the Information and communication system in Ireland and how it has revolutionized the healthcare sector in Ireland.Research QuestionThis study focuses on the following research questionsWhat are the current trends of technological development in the Information and Communication Technology sector of Ireland?What are various challenges faced by the Irish healthcare system in relation to Information and Communication Technology?Significance of the StudyThis study is quite significant as it shows that the concept of globalisation has secured remarkable currency in the academic discourse of the late 20th century, despite ongoing questions regarding both its meaning and extent (Clark and Lund, 2000). The development of internationally integrated production and distribution systems, seen by many as the key feature of globalisation, has been a spatially uneven process. A key factor in this respect has been the differential ability of regions to engage in the informational economy, based on new information and communications technology (ICT), which is the main source of wealth creation and economic growth in the modern world (Castells, 2003).The result has been what Friedmann (2005) calls a process of techno-apartheid which has divided the globe into fast and slow worlds (Knox, 2005), distinguished by the connectedness of individuals, groups and regions to the world of telematics. This echoes Ingersolls (2003, quoted in Knox, 2005) suggestion that the key division of the workforce is now that between those who have the capacity to operate ICT (the cyberproletariat) and those who do not (the lumpentrash). Golding (2006) m akes a similar distinction between the technoliterati and the techno-poor.While Knox defines the fast and slow worlds spatially, equating the former with the triadic core and the latter with the remaining global periphery, Hoogvelt (2003) argues that the divide is, in essence, social rather than spatial, with elements of both worlds to be found in all regions of the globe. Thus, within advanced economies, a process of social polarisation has been widely reported (Friedmann, 2006 and Sassen, 2004) and has been intimately linked by Graham and Marvin (2006) to the development of ICT use. This is not to suggest that those who work in the fast world are homogeneously well-paid and affluent rather, they represent a wide range of remuneration levels depending on such factors as economic sector, location, function, ethnic group and gender (Castells, 2006). What they do tend to have in common, however, is relative employment security due to the high demand level for their ICT skills.Rational eThis study follows a logical approach and identifies the fact that both in Ireland as well as globally, there are major geographical variations in the relative balance between fast and slow worlds, with the former mainly to be found in the traditional core regions of North America, western Europe and Japan and an additional small group of newly industrialising countries which have had the institutional capacity to invest massively in modern ICT and associated educational infrastructures (Freeman, 2004). The slow world found predominantly in the less developed countries of the global periphery and accounting for the bulk of the worlds population is becoming increasingly marginalised and is moving, as Castells (2003, p. 37) puts it, from a structural position of exploitation to a structural position of irrelevance.Definition of TermsICT Information and Communication Technology it is the study or business of developing and using technology to process information and aid communicatio ns.Sistem SISTeM a soft systems methodology, stakeholder analysis and participative simulation modelling.NHS (National Health Service) The organization providing national healthcare services in the UK.Chapter 2 Literature ReviewThe process of quality implementation has become a key concern for those involved in hospital management in Ireland. In a national context, the effective management of health services and the delivery of quality systems in health-care institutions have increased in significance in recent years. In line with wider developments in other service industries, consumers (patients) are expecting more of health-care providers and are demanding higher standards of care and service. Simultaneously, those paying for health services have become more concerned about rising health costs and possible inefficiencies. As a result there is widespread interest in understanding what makes for an effective health service and in developing better practices to improve existing app roaches to health-care management and delivery.In 2005 a comprehensive report on funding from the Commission on Health Funding highlighted that solutions to the problems faced by the Irish Health Service did not lie primarily in the system of funding, but rather in the way that services were planned, organised, and delivered. Similarly, in a report from the OECD (2003), it was argued that although the Irish health system had delivered a continuous improvement in health standards, there was still scope for further improvement in efficiency, and that this could be achieved through better allocation of resources. More recently, the government health strategy (DOHc, 2001) highlighted the requirement for a system to monitor progress and systematically evaluate the quality and effectiveness of health services. According to the strategyMonitoring and evaluation must become intrinsic to the approach taken by people at all levels of the health services.Specifically, the strategy suggested th at the way in which health and personal social services are planned, organised, and delivered has a significant effect on the health and well-being of the population. Organisational structures must be geared to the provision of a responsive, adaptable health system which meets the needs of the population effectively and at affordable cost. One of the guiding principles inherent in the published strategy was that of a people-centred health system. A responsive system must develop ways to engage with individuals and the wider community which receives its services. The health system must become more people-centred, with the interests of the public, patients, and clients being given greater prominence and influence in decision making at all levels (DOHc, 2001).According to Bowers (2001), major structural reform, coupled with strong management and political will, are required to ensure change for the better. In Bowers view, finance alone will not improve the system. Rather, a concentrate d effort must be made to ensure a responsive and efficient service. As previously noted, a conclusion of the Report of the Commission on Health Funding (2005) was that the solution facing the Irish health services did not lie primarily in the system of funding but rather in the way that services were planned, organised, and delivered. This is reinforced by a recent report on the Irish health-care sector which suggested that the issues and challenges facing the health service are fundamentally the same as those outlined by the Commission on Health Funding, except that they are compounded by much higher expectations/demands by consumers (Deloitte and Touche, 2001).Thus, although modern health services have undergone radical change in many areas (Robins, 2003), managers of health services are currently reporting a large increase in the number of patients needing beds, with consequent ever-increasing waiting lists. Accident and emergency departments are under particular strain, and the difficulties of dealing with the growing needs of the increasing elderly population are beginning to become apparent. Although the Irish health service is free for all those requiring medical treatment through a publicly funded system, the current situation is hauntingly similar to that of the Victorian era of health care in Ireland.As a result, the Office for Health Management in Ireland (OHM, 2001) has suggested that current deficiencies in health-care provision and delivery underline the importance of providing quality service management and implementation in Irish health and personal social services. In achieving this aim, the OHM has contended that those working within the system must change how they go about their work and how they work together.Changed public-sector environmentThe focus on health-care service and quality has evolved from a more general interest in continuous improvement initiatives within the public sector. The prevalent trends in the private sector are towar ds continuous and pervasive change and increasing interdependencies, and it has been suggested that close parallels can be drawn between the private and public sectors. Public-sector organisations now find themselves in a cyclone of change as they attempt to adapt to turbulent environments in a pragmatic and systematic way (Lovell, 2004).In the UK and also in Ireland, these organisations have been subject to cuts in government spending, as well as demands for enhanced efficiency and effectiveness. In response to such changes, there has been a policy shift towards greater competition and an attempt to apply management practices from the private sector to the public domain.The Irish public sector has been officially pursuing change and reform through its strategic management initiative (SMI), a program for improving the management of the civil service which was formally launched in 2004 (Department of the Taoisearch, 2004). The SMI evolved from the growing internal and external pressu res for better services and for more effective management of public services. In that context the continuous improvement of customer service has been a specific focus of the SMI since 2003, when the quality service initiative was launched. The program set out a series of quality principles according to which dealings with the wider public would be coordinated and managed. These initiatives aimed to make public administration more relevant to the citizens for whom the service exists, and simultaneously sought to remove barriers which have traditionally restricted performance and job satisfaction within the public sector.In recent years, Ireland has experienced a rise in consumerism. Increases in revenue available to fund public service provision have gone hand in hand with rising public expectations of standards of service. As a consequence, management skills and competences in providing for improved standards of customer service have become recognised as being central to delivering real transformation in the public sector. However, the development of such capabilities, particularly in relation to managing effective quality implementation, presents considerable challenges for those involved. Nowhere is this more evident than in the health-care sector. A review of recent international evidence points to the challenges of implementing quality service in health-care institutions.Gaucher and Coffey (2000) confirmed that implementing a process of total quality management (TQM) in health care is a pragmatic, specific, and systematic methodology. However, this requires a firm commitment from the leadership to change their former ways of working and doing business. Gaucher and Coffey (2000) cited many reasons for TQM failing including poor leadership and a lack of management commitment but also noted that revitalisation can rejuvenate the process. These authors asserted that the role of those implementing the process is to nurture and breathe energy into the process when enthusiasm and commitment are declining.The importance of the support of senior management for quality-management projects is also advocated by Berwick et al. (2000). These authors undertook a national demonstration project in the USA in the late 2000s and described how organisations could implement the entire quality-improvement process from defining the problem through to implementing a solution and consolidating the gains (Berwick et al., 2000).A literature review carried out by Jackson (2005) identified that much work had been undertaken in the UK in determining the clinical effectiveness of many health-care organisations, but that very little research had been implemented in the area of managerial effectiveness. Furthermore, West (2001) determined that, in organisations that outperform others on different dimensions of performance, there was evidence that management is important, as are the combined efforts of individual clinicians and teams.There have been several approa ches espoused for achieving quality management in health-care institutions, many of which have been technical and generic in their approaches (Moeller et al., 2000). Specifically, Donabedian (2000) introduced the concepts of structure, process, and outcomes, along with the development of self-assessment and accreditation through the International Organization for Standardization (ISO). In many instances these programs have met with mixed reactions, and their implementation has varied.A criticism levelled at hospital performance is that it has been rather insular, and has paid little attention to developments in related fields, such as organisational sociology, organisational behaviour, management studies, and human-resource management (West, 2001). If quality programs are to have lasting and significant effects, that they must follow a systemic approach such that all aspects of an organisation are integrated and focused on continuous improvement and customer satisfaction (Joss, 2004 ).A variety of approaches has been used to improve quality and to ensure its delivery, but not all have been successful. Indeed, some have merely added bureaucracy and higher costs to health care (Jackson, 2005 Ennis and Harrington, 2001). Recent research has shown that 45 per cent of patients experience some medical mismanagement and that 17 per cent suffer events which lead to a longer stay or more serious problems (Ovretveit, 2000). This is increasingly caused by complex systems of care which do not appear to be managed effectively.Joss and Kogan (2005) strongly recommended that a comprehensive set of criteria be included, against which to evaluate progress. These criteria should be based on the main requirements of TQM, and should include any additional factors generated by the organisation and/or by evaluators. A three-year evaluation of TQM in the National Health Scheme (NHS) indicated that there were clear factors which predicted successful implementation, the most important of which was the need to have a structured, pre-planned approach based on a thorough understanding of alternative approaches (Joss, 2004). Moreover, a recent study from the UK (OSullivan, 2005) demonstrated how one NHS Trust achieved continuous quality improvement through determination, education, and implementation, supported by visionary and involved leadership in all areas, a multi-talented enthusiastic clinical audit department, and a high-quality dedicated staff.Nabitz and Walburg (2000) suggested that possible solutions to quality problems might lie in the approach promoted by the European Foundation for Quality Management (EFQM). The EFQM has developed a model to structure and review the quality-management processes of organisations. Self-assessment, benchmarking, external review, and quality awards are essential elements of this model and, as reported by Sanchez (2000), this approach represents an important means of achieving excellence in health care. Within the literature there are also many studies showing the benefits of applying models of quality implementation in health-care organisations (Naylor, 2005 Ruiz et al., 2005). Such studies have pointed to the real benefits that accrue to organisations which have used such approaches (Pitt, 2005).Business excellence methodology for quality improvementThe introduction of internationally respected quality frameworks the Malcolm Baldrige National Quality Award (MBNQA) in 2003, followed by the EFQM in 2005 has provided an opportunity for organisations to self-assess, using the models of TQM and business excellence which underpin these frameworks. In this process of self-assessment, an opportunity exists to identify the strengths and weaknesses in the current management of operations. In the USA, the effectiveness of the Baldrige process has been lauded by many (Gaucher and Coffey, 2000) who have indicated that organisations can learn about best practices from Baldrige-winning companies, and will thus be assisted in developing a composite for excellence.Although the Baldrige criteria were developed for commercial institutions, there has been keen interest in the adaptation of the model within health-care organisations in the USA following a pilot health-care project in 2005. To date, no health-care entity has yet achieved Baldrige-winner status, although Gaucher and Coffey (2000) have asserted that it is only a matter of time before there is a health-care winner. Moreover, these authors went on to say that the true benefit of the Baldrige process is not about winning an award. Rather, it is about the provision of a road map for a journey a framework for both incremental and breakthrough improvement and business excellence.Within the European context, since its introduction in 2001, the EFQM model has been attracting considerable interest across all sectors, and has become a well-recognised quality-management framework. Stahr et al. (2001) concurred with Gaucher and Coffey (2000) in stating that the model provides a means by which organisations can assess their paths and develop solutions to achieve excellence. Other authors have espoused the model as being surprisingly effective, with awards being presented to those firms considered to be the most accomplished exponents of TQM in Europe (Wilkes and Dale, 2005).Across European health care at an institutional level, an increasing number of organisations are making direct investments in the training of staff in the concepts of business excellence (Stahr et al., 2001 Jackson, 2001). The NHS Executive in the UK has provided a central lead in endorsing the model as an important framework for delivering on the clinical governance agenda. Furthermore the British Association of Medical Managers (BAMM) has promoted its use as a tool for organisational self-assessment (Stahr et al., 2001). Its use and adoption has been further supported by the British Quality Foundation which provides a major educational and support rol e in the use and adoption of the model in health care and other sectors across the corporate landscape.Without doubt, the future performance of health-care organisations will be assessed against wider goals than previously. There will be a greater emphasis on measuring organisational performance and, if performance is below par, rapid investigation and appropriate intervention will ensue (Naylor, 2005). Moeller (2001) concurred with this, and identified evaluation of health services as a prerequisite. However, Zairi et al. (2005) warned that measuring organisational effectiveness in the delivery of health care is a challenging task.Joss and Kogan (2005) strongly recommended that a comprehensive set of criteria should be included, against which to evaluate progress. This should be based on the main requirements of TQM, supplemented by other organisational criteria thought to be important by the evaluators. A three-year evaluation of TQM in the NHS indicated that there are clear facto rs which predict successful implementation including awareness of the need to have a structured, pre-planned approach based on a thorough understanding of alternative approaches (Joss, 2004). Moreover, as demonstrated by OSullivan (2005), successful implementation requires the support of visionary and involved leaders in all areas, together with dedicated and educated staff.Examining organisational effectiveness in Irish health careAs suggested by Nabitz and Walburg (2000), the solution to quality problems might lie in the approach promoted by the EFQM. As reported by Sanchez (2000), this approach represents an important means of achieving excellence in health care which concurs with earlier descriptions by Gaucher and Coffey (2000). Self-assessment can examine current practice and establish capability, thus driving improvement rather than a reaction to weaknesses in the current system (Russell, 2005).There are also many studies in the literature which show the benefits of applying the business excellence model for quality implementation in health-care organisations (Naylor, 2005 Jackson, 2005a Nabitz and Klazinga, 2005 Arcelay et al., 2005). Such studies have pointed to real benefits that have accrued to organisations using such an approach. Furthermore, Jackson (2005a) demonstrated that the adoption of the principles of self-assessment and business excellence can lead to the achievement of a culture of continuous improvement.Russell (2005) noted that the adoption of the outside-in approach of the EFQM model enabled organisations to use the model as a developmental and management framework. For Arcelay et al. (2005), the model provided a global, systematic regular analysis of the activities and results by comparing them with the criteria of the excellence model. Moreover, the process made it possible to make comparisons with other private and public organisations.Using a systems view of an organisation enables managers to focus on the processes between the p arts of an organisation, rather than on the parts themselves, which is similar to physicians using a systematic model in which to analyse signs and symptoms, and thus make a diagnosis. An effective organisation is one in which the total organisation, through its significant subparts and individuals, manages its work against goals and plans with a view to achieving these goals within an open system. Methods of management that have been developed in manufacturing environments are naturally regarded with scepticism in non-manufacturing sectors.However, according to West (2001), studies that have been conducted on the link between the organisation and management of services and quality of patient care can be criticised both theoretically and methodologically because of the many different mechanisms that may be operating at once to produce the relationship between volume and quality. West (2001) asserted that a more rigorous body of work exists on the performance of firms in the private sector, often conducted within the disciplines of organisational behaviour or human resource management.Ireland and the International ICT SystemDublin has, in the 2000s, carved out several niche international functions for itself, one of which, call centre activities, has been the principal focus of this study. According to a report in The Irish Times (August 20, 2003), Ireland accounts for 30% of all international call centres located in western Europe. The great bulk of these are to be found in Dublin. The central role of ICT in call centre activities has facilitated their centralisation in Ireland, from where markets spread across Europe and even further afield can readily be served. As Sassen (2005, p. 56) has observed Information technologies, often thought of as neutralising geography, actually contribute to spatial concentration.Call centre activities, therefore, have helped Ireland to escape the bounds of geographical peripherality, thereby contradicting Wegeners (2005) gloo my prognosis which visualised cities in the periphery as inevitable losers from growing inter-urban competition in Europe. This has been cleverly portrayed in an IDA advertisement which shows Ireland at the centre of a surrounding group of disembodied European countries ( Fig. 1). These latter are no longer seen as being more or less distant from Ireland, but as constituting a set of different language and market territories, all equally accessible from Ireland.However, Dublins growing international reach and the growing technological sophistication of its economic base should not mask the fact that, structurally, it retains a dependent position within the international division of labour. Its rapid recent economic expansion has been largely based on the attraction of branch plant operations which remain poorly embedded in the local economy (Breathnach, 2005). nd, while the rising skill levels associated with recent inward investment have facilitated substantial improvement in livin g standards generally, in the specific case of the call centre sector, much of the employment which has been created remains relatively poorly paid a fact which is directly linked with the high proportion of women workers in the sector, despite their high skill levels.Furthermore, the rapid growth of the call centre sector in the 2000s looks increasingly unsustainable as the end of the decade approaches. Growing labour shortages are driving up labour costs which, in conjunction with increasing housing and transportation problems, are beginning to attenuate Dublins attractiveness as a call centre location according to a 2005 survey of call centre locations in Great Britain and Ireland, reported by Allen (2005), Dublin had fallen to the 29th position of 46 locations surveyed, having been in the top 10 in 2006.The response of the IDA has been to devote additional resources to promoting non-Dublin locations for call centre projects. However, even if this is successful in the short run, in the longer term the future of call centre employment will be increasingly threatened by technological developments, such as speech recognition technology and especially the rapidly growing use of the internet for making reservations, placing orders and seeking information.The IDA has justified its promotion of the call centre sector, despite the inferior nature of much of the employment involved, largely on the grounds that it provides an initial base upon which more sophisticated forms of employment can be built. Its long-term strategy, in other words, is to encourage firms which have established call centres in Ireland to add on additional functions, such as financial management and software development, to these initial operations. Already there has been some success in this area of shared services back-office activities by mid-2003, some 25 such operations had been established, and were projected to employ over 3000 people by the year 2000 (information supplied by Forfs).Ult imately, however, all of these activities remain as back-office activities, whose essential linkages are external to the Irish economy. In other words, their Irish location is not crucial to the parent companies of these operations rather, it is contingent on the availability of certain attractions which may either be transient or reproducible elsewhere (Allen, 2005). As Wilson (2005) has noted, call centres are essentially a highly footloose sector, with few local economic linkages and little fixed investment in machinery and equipment they therefore can be relocated quite readily in the light of changing comparative factor conditions.The National Health Service (NHS) in the UK published its NHS Plan in July 2000 (http//www.nhs.uk/thenhsexplained), saying that patients and people were central to its radical reform of healthcare and that although this included more hospitals and beds, shorter waiting times and improved care for older people, an essential element was that patients sh ould have more power and information. As Grimson et al. (2000) rightly comment, healthcare is an information-intensive business, with data on an enormous scale gathered by way of hospitals, clinics, laboratories and primary care surgeries.Central to any information-intensive business is, naturally, the effective sharing of that information and, in order to empower and better engage the patient, how best that can be done. Funded by the UKs Department of Health, the British Librarys integrated Telemedicine Information Service (TIS), described in the latest edition of the NHSMagazine (http//www.nhs.uk/nhsmagazine), is to improve the take-up of telemedicine technology in the UK, reinforcing the importance that information and communication technologies (ICTs) are seen to have in the sharing of information and the engagement of patients in their healthcare.By way of explanation, the word telemedicine has been coined as a way of capturing, in only one word, how ICT is being used in health care. However, as Curry et al. (2003) rightly comment, terms such as telemedicine, teleconferencing, health informatics and medical informatics seem to be used interchangeably, and that there is some confusion as to what is, and is not, involved, citing various studys, including those of Preston at al. (2002) and Mark and Hodges (2001) to support their claim. As there is some disagreement with the term, we use in this study the meaning assigned by Perednia and Allen (2005), that is, the use of information technologies in helping to provide medical information and services in healthcare. Whatever its name, or its definition, it concerns, in one way or another, the mediating role that technology plays in the interaction between humans, whether patient or healthcare professional.At the time of writing, there are 138 telemedicine projects in the UK (http//www.tis.port.ac.uk/tm/owa/projects.allUK), and they cover aspects of healthcare as diverse as mental health, diabetes, foetal monitor ing and accident and emergency care. Indeed, it points to one of the advantages of telemedicine its applicability across a wide range of clinical issues. However, while these projects certainly cover a diversity of issues, they have something in common, that is, they address only one of these clinical matters. Each system is designed differently, is unlikely to be compatible with another, and needs different technical support and user training.Whilst such individual systems have proved useful in a particular context (see, for example, Gilmour et al., 2005 Jones et al., 2006 Lesher et al., 2005 Loane et al., 2005 Lowitt et al., 2005 Oakley et al.,