LARAMEE, ANN S. MS, APRN; BOSEK, MARCIA DNSc, RN; KASPRISIN, CHRISTINA A. EdD, RN; POWERS-PHANEUF, TERRY BSN, RN
Communication is the key to patient-centered, efficient and safe care. While the exchange of information often occurs verbally, the majority of healthcare communication requires some form of written statement ("if it isn't documented, it didn't happen") to convey the patient's plan of care, coordinate services between various healthcare professionals and offices, and document patient data as well as services rendered. Traditionally, this written documentation was entered into a "paper charting system," but at the beginning of the 21st century, the process of documentation is being transferred to an electronic health record (EHR). The move to an EHR is being driven by a variety of forces. The Institute of Medicine1-3 has proposed that having an effectively structured EHR can improve clinical efficiencies, patient safety, and quality of care. Globalization of healthcare requires that a patient's healthcare records be available electronically to facilitate telemedicine and coordination of care as well as promoting interdisciplinary communication. In addition, an EHR is perceived to be "greener"-more environmentally friendly.
As members of the Evidence-Based Practice Nursing Committee at a rural academic medical center, we questioned what evidence was present to support the hospital's EHR initiative. Knowing that specific departments within the hospital previously adopted discipline-specific EHRs, we began to wonder if the healthcare professionals in these departments could teach us something about their previous experiences. We hypothesized that learning about the facilitators and barriers to implementing these earlier EHRs could assist the current EHR implementation team to maximize the forthcoming EHR implementation. Thus, learning from within our own organization has the advantage of applying information and strategies that match our hospital's unique culture.
Electronic Health Records
The Health Information Management Systems Society defines EHRs as "a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface-including evidence-based decision support, quality management, and outcomes reporting."4(p1) In 2006, RNs were surveyed across the United States to determine their use of an EHR system. Only 17% reported that all major components (information about patients including problem list, demographics, ordering, notes, access to test results, decision support including guidelines and pathways, knowledge sources, reminders, and alerts) of an EHR were in routine use in their organization.5 In 2008, the American Hospital Association surveyed 3049 acute care hospitals with a 63% response rate. At that time, less than 2% of hospitals had a comprehensive EHR, 8% to 10% reported having a basic EHR system, and only 17% of hospitals had a physician ordering system.6 Because few hospitals have transitioned to an EHR, many nurses will undoubtedly be involved in future EHR transition projects. Therefore, the way in which nurses respond and adapt is an important focus as a new EHR is implemented.
Understanding how nurses feel about computers can enable the implementation team to structure communication, reframe misconceptions, and offer possible new perceptions. A variety of concerns held by nurses about impending EHR system implementations have been described: use of a computer is boring and repetitive and increased risk to patient confidentiality; workload would be increased; there would be more regulatory monitoring; and nursing professionalism is not enhanced by computers.7 As many as 50% of information system projects fail because of these fears.7 These concerns encountered before or during implementation are primarily organizational in nature and may be attributed to either attitudes toward the use of an EHR/computer or failure of the implementers to seek input from potential users. The willingness of nurses to adopt EHR systems is a major determinant of system implementation success,7 especially because nurses compose the largest workforce within a hospital. Without an assessment of concerns toward computers or EHRs followed by a plan to address misperceptions that in turn helps guide the planning, communication, and education of the implementation process, the project stands a chance of not succeeding.
A nurse's attitude is also a key factor influencing transition to an EHR. Multiple studies have evaluated nurses' attitudes toward computers or EHRs.7-23 Attitude is the predisposition to respond in a consistently favorable or unfavorable manner. Attitude is a determinant for the intention to adopt or use an information system. The majority of these studies show that nurses' computer- or EHR-related attitudes are generally positive.7-9,13-15,18,19,22 Dillon et al8 constructed a model that conceptualizes variables, which predict nurses' adoption and use of an EHR. These variables include demographic characteristics such as age, sex, and education level; self-reported computer use; and image profile (impressions of computer systems, personal experiences, information communicated by others), which all affect attitude and ultimately EHR adoption. There is no consensus on how computer or EHR attitude and multiple variables interact.7-9,13-15,18,19 Research highlighting nurses' attitudes and perceptions are important features to consider when implementing an EHR and continue to be prominent and active areas of study.
Strategies/Observations for EHR Implementation
In multiple studies, authors have retrospectively evaluated EHR implementation processes and suggested strategies to assist other institutions toward a successful EHR implementation7-9,24-40 (Table 1). A systematic review of EHR implementation studies found that the main predictors of an effective implementation included management support, financial resource availability, implementation policies, practices, and climate.25 Essential components of the management support category included strong commitment that is broadly communicated and an inspiring champion. The initial and ongoing maintenance financial costs including reductions in productivity during and after EHR implementation were cited as a major barrier. In the policies and practices category, eight themes arose: (1) Training should be adequate, timely, tailored, and available and include simulated patient encounters; (2) protected time for training; (3) assess expectations and address unrealistic expectations, conveying clear goals and anticipated benefits; (4) ongoing, onsite technical support; (5) lack of incentives and rewards is a barrier; (6) appropriate individuals must be included in the design of the EHR system and implementation planning process with physician buy-in; (7) the EHR must be accessible and efficient and not interfere with the patient encounter; and (8) redundancy and technical backup are critical. Finally, organizations that have a culture of change and who value innovation may have a greater likelihood of being successful.25 Overall, the implementation experience of most of the North American and international studies done in a variety of settings from hospitals to clinic practices were positive,7-9,26,30,33,35,36 although there were a few less positive experiences.27,29,34,38
When an institution is about to embark on the implementation of an institution-wide EHR, can previous organizational experiences inform the process? Two departments have already successfully implemented an EHR documentation system. Can the successful unit-based implementation experience inform future adoption of the institution-wide EHR?
1. What factors do interdisciplinary healthcare team members at a rural academic medical center perceive led to a previous successful implementation of an EHR?
2. What strategies do interdisciplinary healthcare team members at a rural academic medical center perceive as being effective in overcoming barriers, addressing expectations, quelling fears, and helping to create positive attitudes and perception during a previous transition to an EHR?
The setting is a rural academic medical center with a trauma I emergency department (ED) and a dialysis department (DD) composed of one acute dialysis unit in the hospital and five satellite dialysis centers throughout the state. The DD began using the CyberRen (Cybernius Medical Ltd, St Albert, AB, Canada) system 10 years ago. In a separate initiative, 5 years prior to the beginning of this study, the ED adopted the T-System (T-System, Inc, and T-System Technologies, Ltd, Dallas, TX) EHR. Current members of the interdisciplinary teams employed in these two departments who were present during the prior EHR implementation were invited to participate. Table 2 contains descriptive data about these individuals.
Forty participants were self-selected and participated in 11 focus groups. Focus groups were organized by department and held at various times during a 6-week period, from September through October 2008. Focus groups allowed participants to hear and respond to issues raised by members of their own disciplines as well as those of other health professionals. While focus groups were interdisciplinary, efforts were taken to separate supervisors from staff to promote candidness of responses. A conference call option allowed two participants to be included when distance and scheduling constraints arose.
A descriptive exploratory qualitative research design was used, specifically, semistructured focus group interviews with content analysis and evaluative surveys. The focus group questions are listed in Table 3.
Focus group interviews were conducted with early EHR adopter interdisciplinary staff using semistructured questions. Each focus group was audiotaped, and field notes were kept. After the analysis of the focus group data, a seven-item questionnaire was developed and distributed to the staff of these units to validate the themes identified in the focus groups. These items are listed in Table 4.
The potential participants were invited to participate in this research project by a written invitation from the principal investigator (PI) sent via the medical center's e-mail system as well as a hard copy delivered by interdepartmental mail to their hospital mailbox. Potential participants responded directly to the PI via e-mail to volunteer for a specific focus group session. At the beginning of each focus group, the potential participants were provided an "information sheet" in addition to having the purpose and goals of the study reviewed verbally. The employee's decision to stay and participate in the focus group served as their implied consent. Participants were free to withdraw from the study at any point during the interview and to request that their data be removed from data analysis.
The study was approved by the organization's Committee on Human Subjects Protection.
Face-to-face interviews in addition to the participating on "work time" do not allow for anonymity, but a variety of actions were taken to promote the confidentiality of the participants and the data generated. First, no demographic data were collected from the participants. Second, the participant list was kept separate from the focus group data and locked in the researcher's office. Third, participants were read a confidentiality statement at the beginning of each focus group, emphasizing each participant's responsibility to treat the focus group session as a confidential activity. Finally, audiotapes were destroyed at the completion of the study.
Audiotapes from each of the focus group sessions were analyzed utilizing the intuit, analyze, and describe method.41 The intuiting step involved various members of the research team observing the focus group sessions and listened to the audiotapes to become familiar with the participants' perceptions and experiences when an EHR was implemented in their department. Intuiting requires the researcher to be open to the uniqueness of the participants' experience with the research phenomenon. The intuiting process required the researchers to confront their expectation that education was the key to the successful implementation of an EHR when participant after participant failed to identify education as fundamental to their adaptation to using an EHR. In addition to identifying repetitive ideas, the researchers were listening for contradictory ideas or experiences.
The analyzing process involved identifying from the participant narratives the various characteristics that they viewed as essential to successful implementation. The final step of describing the process of successfully implementing an EHR occurred when commonalties or themes between the various characteristics were identified.
Trustworthiness (reliability and validity) of the qualitative data analysis was promoted by several actions.42,43 Triangulation of multiple data sources (interdisciplinary team and two different clinical departments) increased the breadth of the data collected by providing multiple perspectives and contexts. At least two researchers analyzed the data from each focus group. Data saturation was noted during focus group 9. Two additional focus groups were held to ensure saturation. Investigator debriefing sessions were used to challenge the emerging characteristics and themes. An initial member check was performed via an anonymous electronic survey with the population from which the participants were obtained to validate the accuracy of the four major themes.
The participants described four major themes as being fundamental to the successful transition to an EHR based on the participants' previous experience with initiating a departmentally based EHR.
Theme 1: It Will Take One Hundred Charts
"It will take one hundred charts" is the slogan participants used to realistically communicate expectations about when an employee would start to feel comfortable using the EHR. An ED RN explained, "We were told right from the beginning, it would take 100 patients, and they were right, that is what it took." The use of the number "100" is large without being overwhelming and focuses the employee's attention forward to a not-so-distant expectation of accomplishment. An ED physician explained that when converting to an EHR, there is a need to "emphasize the benefits." The "It will take one hundred charts" slogan assisted the participants to address and remove barriers related to:
1. Unrealistic expectations and fears related to individual competency when initially beginning to work with the EHR:
Attending physicians have taken on more and more of the tasks so our days are eaten up …every time a new technology which has potential to make things better for patients and the healthcare system, we are all in favor of it, but I am personally afraid that it will be one more thing, one more piece put on us…. I feel same way about any new system, there is a work shift… so it is a strain on us." [Dialysis physician]
Get message across that this will be difficult in the beginning, but you are going to love it as you discover what it will do for you. [Dialysis RN]
The T-System is great for ordering and having other departments see what is happening, but you are seeing all the patient stuff makes you wonder about patient confidentiality. [ED unit secretary]
2. Lack of preparation for change:
You should not be at your normal staff level if you normally have a six-patient assignment you better have a three-patient assignment on the go-live date. [Dialysis RN]
3. Perceived limited information
4. Perceived lack of feedback as employees began to use the EHR
Theme 2: Self-discovery
Self-discovery notes that each employee needs to be encouraged and facilitated in their individual pursuit of learning about the EHR and their skills in using the system. Participants repeatedly discussed needing to be given permission to work the system and the need to be empowered to learn. Participants found the ability to use a CD tutorial with case study scenarios that can be worked through during a training session or individually at home essential to their self-discovery process. An ED unit secretary reflected, "I was worried that my lack of computer skills and that I am older than anyone else and only work per diem meant that the transition would be hard for me." The participants also perceived that their self-discovery process was encouraged when managers created an open learning environment by inviting employees to come into the clinical department with financial compensation to gain further clinical experience with using the EHR or for additional tutorial time during the first week the EHR was implemented. The process of self-discovery assisted the participants to address and/or remove barriers related to the following facts:
1. Learning occurs sequentially and requires repetition.
We got permission to come in extra to explore and chart on pretend patients. [ED RN]
If those first people get it down while you are on for 3 days, you learn how to do it and then you can teach the next person that is coming on and be a resource. [Dialysis RN]
2. Adult learners need motivation to change their behavior.
3. How to individualize documentation using drop-down menus.
Drop-down menus for signs and symptoms are never complete…. I have my own template, and this makes it so much easier. [Dialysis physician]
4. The use of computers and the EHR are not intuitive.
People who were not computer knowledgeable were more concerned. [ED unit secretary]
5. Participants reported experiencing "self-blame" by information services when the EHR did not work correctly.
Through the process of self-discovery, the employees may feel empowered when they can accurately identify EHR "glitches" and help to describe desired modifications. One ED participant summarized the idea of self-discovery as: "We knew we needed it. It was in our best interest, and we believed it would make life better."
Theme 3: Clear Processes
Clear processes for using the EHR are needed and need to be communicated to prevent employees from creating "workarounds." Written instructions need to be developed that are easily accessible by employees (ie, cheat sheets summarizing documentation pathways, backup processes, how to correct an error, how to transcribe physician orders, etc). Participants preferred written assist devices rather than computer "help" functions. In fact, participants described contacting peers to develop "workarounds" rather than attempting to navigate computer helps. A dialysis RN noted, "Hard to say if (company) knew that we were having problems, upgrades (to the system) affect other parts… they just don't think it through, so workarounds helped." Clear processes will address and/or remove barriers related to the following four types of workarounds:
1. Software workarounds occur when employees create their own system for documenting when the "real" method was unknown or not intuitive. Software workarounds create problems with data communication and retrieval.
Most important thing before it is launched is really make sure that as many I's are dotted and T's are crossed, if people start having glitches, then you don't trust the system, then you are not going to use the system as it is meant to be used, and this is exactly the way it was for us, took us a long time to trust the system. [Dialysis dietitian]
2. Paper workarounds occur when employees perform duplicate documentation and keep backup files or handwritten notes. Duplication is time consuming and slows down acceptance of the new EHR system.
I wasn't worried about being computerized, but we did need paper backup. [Dialysis RN]
3. Environmental workarounds occur when the employee has no acces to a computer terminal to document or perceives the computer in the patient's room as being unsafe, unprofessional (eg, employees have to stand with their back to the patient when documenting), or an infection control risk. Participants described not having sufficient numbers of computers located adjacent to patient rooms to meet the needs of the interdisciplinary staff. Allowing the employee to sit while documenting was perceived as desirable by some employees. Insufficient access can create power struggles and territorialism, especially related to computer terminals.
4. Staff workarounds occur when one employee asks another employee to document for him/her. This workaround may be associated with power hierarchy (physician asks the nurse to document) or related to perceived knowledge/comfort with the EHR.
I don't have a natural feeling for technology… cumbersome tasks like entering new drugs…. I tended to put off on the nurses whenever I could rather than do myself because I was busy… didn't take the time to learn." [Dialysis physician]
Theme 4: Make the EHR Support a Customer-Focused Service
"Make the EHR support a customer-focused service" is the final theme discussed by the participants. Several participants specifically stated that to be successful, the support service must mimic the hospital's Provider Access Service (PAS) used throughout the hospital and outpatient settings to facilitate and coordinate paging and information access. Thus, the participants believed that for an EHR to be successfully implemented, the employees must perceive the support services as mimicking the PAS customer-focused service. Electronic health record support individuals must be accessible 24/7 as an ongoing service. Initial on-site presence of support individuals was perceived as desirable by the ED employees. An ED RN described, "We had lots of support at first in the beginning, and then slowly, there were less folks to help." In addition, a dialysis RN explained, the technical team "has to know all the programs" and "how they each affect other abilities." Thus, support persons must be perceived to be knowledgeable, caring, and respectful by the hospital employees. Support individuals need to understand not only the system, but also the clinical significance of the data that are being documented. When questions are posed, answers need to be forthcoming. If the first support individual does not know the answer, then the support person should have ready access to a supervisor, who can determine the answer/solution for the problem. Making the EHR support a customer-focused service will address and/or remove barriers related to the following:
1. Gatekeepers (persons who might prevent employees from finding solutions and/or asking questions)
Have to go through that one person and that's a big block. [Dialysis RN]
2. Lack of technical support
How do you get help when you need it…. There is always a little help button, the help button never gives you what you need… no info at all… only way to find help is to find a person. [Dialysis RN]
3. Expectations/fears related to losing data or making a misentry
Can someone outside the unit mess things up for us? [ED unit secretary]
Making the EHR support a customer-focused service will ultimately promote a positive attitude by the hospital employees regarding the EHR and promote an institutional culture where employees are expected to ask questions and make suggestions for improving the use of the EHR.
Three of the four themes uncovered in this study are not unique and corroborate the findings in other previous published research.25 "Clear processes" where detailed instructions for using the EHR are communicated to prevent employees from creating "workarounds" is the only new theme. The participants in our study believe the chief strategies that lead to a successful implementation of an EHR include making expectations and benefits explicit, addressing fears and concerns about implementation, allowing for individualized learning, being well staffed during "go-live" period, and having a 24/7 technical resource support during go live and for the duration, and finally giving clear, concise instructions on how to use the EHR system to avoid workarounds. Almost every single focus group and several studies made it very clear that failure to convince the users of the relative merit by clearly describing the benefits and expectations of an innovation such as the EHR could prevent adoption.7,30,35
Some general key concerns around EHR implementation that were mentioned in every focus group sessions were also cited in the literature, such as skepticism and suspicion for the handling of clinical information, confidentiality and privacy issues, and the inability to capture the essence and complexity of a caring practice such as nursing.7,25,27,30,37 Technical computer issues were also prevalent concerns in focus groups as well as in the literature such as slow response time, printer problems, system downtime, need to have paper backup, patients' rooms being too crowded, having too many disruptions, and not enough computers.9,30,35 Interestingly, staff identified territorial issues and becoming frustrated and upset when someone else was in their space using their computer. To utilize some of the intended safety features of an EHR, there is an expectation that staff will document in "real time" or soon after doing the intervention. Little is known about nurses' perceptions of computer availability and expectation of real-time documentation.
A prominent theme in our study was to have topnotch timely customer service support when computer or EHR issues arose. Having onsite technical advice from a clinically based support person who was there when needed was the most often described solution in the literature.31,33 Staff support particularly during the go-live period was also unequivocally suggested by focus group participants and suggested in the literature including decreasing nurse-patient or physician-patient ratios and increasing the number of staff during implementation.27,31,33 Like our study, support and resource issues were acknowledged in most studies as barriers to a successful implementation.25-28,30,33
The need to manage the stressors that inevitably occur in the transition from a paper-based system to an EHR is recommended in the literature, yet no specifics were offered.34 However, the focus group participants were quick to identify stress reducers (food especially chocolate, massage, and other tangible "perks" or positive reinforcements) that were effective for them and recommended for the next implementation process.
Surprisingly, little mention of the perception of the relationship between EHRs and quality outcomes for patient care was noted in this study and the literature.30,37 Even though some of the participants had used department EHR for 10 years, subjects did not mention that patient outcomes had improved. A few studies, mostly conducted in single-site academic medical centers, have demonstrated evidence that the EHR positively affects patient outcomes and quality of care in a meaningful way,44,45 and more information is being published as more EHRs are implemented. In the implementation studies reviewed, there was a discrepancy in the perceptions and recognition that the quality of patient care was improved with the presence of an EHR by the users.7,25,26,30,35-37 Some studies found improvements with efficiencies or a greater sense of professionalism, while in others, the perception of improvements never materialized. Despite the lack of quantifiable outcomes, the overall consensus from studies in the literature was that users expressed optimism that eventually the EHR would improve outcomes and ultimately be worth the cost investment.30,35,37 As well, even though our participants did not verbalize concrete patient benefits, none wanted to revert back to a paper-based system. The relationship of EHRs and quality outcomes merits further investigations.
Interestingly, even though our study participants had been through earlier EHR implementations that were described as successful, participants verbalized similar fears and concerns in anticipation of implementing a new hospital-wide EHR. This signifies that change is change, and attention should be given to cognitive or psychological variables that are involved in the change process. Rogers' Theory of Diffusion of Innovations and Lewin's Change Theory have been models used in the EHR implementation literature.24,35,46,47 The principles of change and how the innovation is diffused are essential to the successful implementation of an EHR. No matter how perfect the preparation plan for the implementation process, change can be a painful process. A successful change requires clear goals, realistic milestones, efficient delivery and coordination, and attention to follow-through, all well established change principles.
Although training related to the EHR was discussed in all focus groups, training was not described as a main concern, which challenged our initial presumptions that education was the key resource for a successful change. As adult learners, participants may have felt empowered to learn at their own pace and had the majority of their educational needs met. Computer training and informatics competency education48-50 have, however, been prominent topics in many of the studies,25-28,30-33,51 and lack of training in computer and EHR competencies was identified as a barrier to successful EHR implementation.30 The literature recommended that early plans to train multiple users should be a priority and tailored to varying degrees of user knowledge, skill, and motivation. Training should also be ongoing well after deployment of the EHR.26,33
The implementation processes described by both the DD and the ED participants were overall positive similar to most other studies.7-9,26,30,33,35,36 Although the experiences were different for each department, the ED participants' comments were qualitatively more positive as they reflected on their experience compared with the comments made by DD participants. There could be a number of reasons for this; the DD implemented their EHR 10 years earlier at a time when computer skills may have been less advanced, and staff had less exposure to computers. In addition, the DD was a beta testing site for the CyberRen system, which may have had an impact on the smoothness of their implementation. Also, hospital management may have learned from the earlier DD experiences, which facilitated the later ED implementation. The fact that the ED staff were involved in the planning process for their EHR implementation may have promoted a more positive implementation experience.
Recommendations to Future EHR Implementation
1. Begin every-other-week updates with all employees and informally query employees about the project's progression, including communication of benefits of EHR.
2. The use of a FAQ on the hospital Web site or a "Just Ask" newsletter might also be a format to encourage employee questions and understanding.
3. Develop a designated contact e-mail or phone number where employees can go to communicate conceptual or process questions and/or suggestions.
4. 24/7 Live access for specific end-user issues for a specified period on every unit. Pager access after the live implementation phase is completed.
5. Stress reducers and perks during initial rollout, for example, food, massages, personalized M&M's with "It takes 100."
6. Debriefing with staff at end of shift.
7. Individualized employee feedback regarding quality of data documentation.
8. Monitoring for workarounds.
9. Skills checklist/competency related to EHR (not just computer skills).
10. Unit-specific case studies for education.
11. Survey patient satisfaction with personalization of care after EHR implementation.
12. Formally pairing a more technically savvy individual with a less technically savvy individual as a mentor or resource.
The ability to generalize the findings from this study to other organizations involved in implementing an EHR may be limited. The two independent EHR implementations promote confidence in the ability to generalize these findings to other units and organizations. In addition, the use of rich narratives illustrating the themes and associated barriers is designed to provide the reader with a source of comparison for evaluating the generalizabilty of these findings. Because the previous EHR implementations occurred over 5 years ago, the use of computers and electronic systems (such as e-mail and the Internet) for both personal and professional use has increased and may be a positive difference between today's healthcare workforce and our sample. Finally, this study's results are based on participant perception and recall. The possibility exists that the passage of time as well as anticipation of the impending EHR implementation may have impacted the participant's perceptions and recall.
FUTURE RESEARCH QUESTIONS
1. What impact does the implementation of an EHR have on patient care outcomes?
2. What is the perception of nurse satisfaction associated with a transition to an EHR over time?
3. What resources do nurses actually consult during the initial transition to an EHR?
4. Do nonnursing members of the healthcare team have different needs and/or fears associated with transitioning to an EHR?
5. What educational and/or orientation strategies are most effective in preparing various members of the interdisciplinary healthcare team to transition to using an EHR?
To effect major change in an organization, it is essential that sufficient preparation be done to maximize the potential for successful adaptation. In this research study, we report on staff's perceptions of implementation of an EHR at a rural academic medical center. In addition to a thorough investigation of the literature addressing the key factors, we sought help from early implementers of unit-specific EHR implementation. Using qualitative research methodology, four themes were identified. Three were previous reported in the literature ("It will take 100 charts," self-discovery, and customer service). The fourth theme, clear processes, emerged from the focus groups as the participants spoke about difficulties in navigating the systems and their own creative solutions. This research supports that, in addition to evidence-based practice reported at other institutions, data should be obtained from within the organization. This "learning from within" facilitates implementation within the organization's unique culture.
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