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Volume 15
Issue 1
Journal of the Association for Information
Abstract
Research Article
Sandra Richardson
University of Memphis
sandra.richardson@memphis.edu
William J. Kettinger
University of Memphis
wjkttngr@memphis.edu
The agility literature suggests a positive relationship between IT-investments, agility, and performance for firms
operating in turbulent contexts. However, agility studies have primarily focused on conceptual concerns,
leaving these relationships empirically unexplored. In addition, the literature has focused on for-profit firms
operating in commercial markets, thereby leaving other important organizational types unexamined; one such
type is the social enterprise (SE). SEs are entrepreneurial organizations with a mission to improve complex social
challenges (i.e., healthcare, hunger, education, etc) rather than profit maximization. This void leaves SEs in the
dark as to how they can leverage IT to become more agile and improve performance. We draw on the agility
perspective to examine how one exemplary SE operating in the context of pediatric global health utilized IT to
enhance its agility and improve performance. We identify how the SE’s IT-investment decisions resulted in an IT
platform that facilitated increased agility in launching new products aimed at improving survival rates of
children. Specifically, we analyze how the SE’s IT
platform positively impacted customer, partnering, and
operational agility, and demonstrate how this led to dramatic improvements in performance. Finally, we offer
evidence to support positive relationships between IT, agility, and performance in social sector contexts.
Keywords: Agility, Social Enterprise, Global Health, Health IT, Collaboration, Non-profit.
Volume 15, Issue 1, pp. 1-32, January 2014
IT and Agility in the Social Enterprise: A Case Study
of St Jude Children’s Research Hospital’s “Cure4Kids”
IT-Platform for International Outreach
* Varun Grover was the accepting senior editor. This article was submitted on May 20, 2010 and went through
four revisions.
Michael Shane Banks
University of North Alabama
mbanks@una.edu
Yuri Quintana
St. Jude Children’s Research Hospital
Yuri.Quintana@stjude.org
IT and Agility in the Social Enterprise: A Case Study of
St Jude Children’s Research Hospital’s “Cure4Kids”
IT-Platform for International Outreach
Journal of the Association for Information Systems Vol. 15, Issue 1, pp. 1-32, January 2014
2
1. Introduction
Firms invest in information technology (IT) with the hope of improving process efficiency, lowering
costs, gaining access to better information, improving relationships with customers and business
partners, and ultimately improving financial outcomes (Banker, Bardhan, Change, & Lin, 2006; Kohli
& Devaraj, 2003; Nazir & Pinsonneault, 2008). IT is increasingly viewed as a critical resource for
enabling firms to both sense and respond to threats and opportunities in turbulent and competitive
markets (Oosterhout, Waarts, & Hillegersberg, 2006; Overby, Bharadwaj, & Sambamurthy, 2006;
Sambamurthy, Bharadwaj, & Grover, 2003; Tallon & Pinsonneault, 2011). By applying agility
principles, IT facilitates the generation of digital options that can result in business infrastructure that
shapes a firm’s ability to launch frequent and varied competitive actions (Nazir & Pinsonneault, 2008;
Neumann & Fink, 2007; Oosterhout et al., 2006; Overby et al., 2006; Piccoli & Ives, 2005;
Sambamurthy et al., 2003, Tallon & Pinsonneault, 2011). Digital options are unique IT-enabled
capabilities in the form of flexible digitized enterprise work processes and knowledge systems that
can facilitate improved managerial insight, which lead to faster and higher quality decision-making
(Sambamurthy et al., 2003). Firms that integrate IT with strategies, processes, knowledge, and
relationships increase the potential for creating digital options, and, as such, are more likely to realize
increased IT value. This suggests that IT can be a digital options generator that serves as a strategic
differentiator between market competitors to enhance a firm’s competitive advantage and
performance (Sambamurthy et al., 2003).
Enterprise agility is a relatively new perspective that proposes a positive connection between a firm’s
IT-related decisions, level of agility, and business success (Sambamurthy et al., 2003). Agile firms
have been identified as those with the capability to recognize opportunities for leveraging IT in order
to rapidly sense and respond to market opportunities (Oosterhout et al., 2006; Overby et al., 2006;
Sambamurthy et al., 2003) by shaping digital options into competitive actions that result in improved
business outcomes (Sambamurthy et al., 2003). The current agility literature is largely theoretical.
Sambamurthy et al. (2003) introduce the notion of agility to the IS literature, refine the concept by
defining three types of agility (i.e., customer, operational, and partnering agility), identify the role of IT
as a strategic differentiator in competitive market environments, and offer a conceptual framework
that suggests a positive relationship between IT, agility, and firm performance. Overby et al. (2006)
differentiate agility from other related concepts by deconstructing enterprise agility into two core
components, sensing and responding, and offer a conceptual model that explains how specific IT
characteristics impact a firms’ sensing and responding capabilities. Oosterhout et al. (2006) offer a
conceptual framework that identifies specific environmental change factors that serve as drivers of
agility in competitive markets and demonstrate the role of IT as both an enabler or disabler of agility.
Hovorka and Larsen (2006) conduct an exploratory case study and demonstrate how the use of IT in
a distributed network-organization positively impacts a firm’s level of operational agility. More
recently, researchers have adopted the agility perspective to frame empirical investigations of the
relationships between IT and enterprise agility. For example, Tallon and Pinsonneault (2011)
empirically explored the relationship between IT strategic alignment and a firm’s level of agility and
found that alignment enabled agility. Collectively, the current body of knowledge begins to define
enterprise agility, identify drivers of agility, explores the link between organizational form and agility,
and demonstrates a relationship between IT alignment and agility in for-profit firms operating in
competitive markets.
To date, the agility literature has focused solely on for-profit firms operating in the boundaries of
commercial markets (Neumann & Fink, 2007; Oosterhout et al., 2006; Overby et al., 2006; Piccoli &
Ives, 2005; Sambamurthy et al., 2003; Tallon & Pinsonneault, 2011; Tseng & Lin, 2011), which has
left other important organizational types unexamined. One such type is the social enterprise (SE).
SEs are similar to commercial for-profit firms in that both utilize entrepreneurial practices to transform
materials and labor into products and services of greater value; therefore, similar organizational
functions are likely to be present in both (Bornstein, 2007; Collins, 2005). Unlike commercial for-profit
firms, SEs exclusively embrace a social mission in that they work to address complex social
challenges (i.e., healthcare, hunger, education, poverty, etc) rather than profit maximization. SE’s
Journal of the Association for Information Systems Vol. 15, Issue 1, pp. 1-32, January 2014
Richardson et al. / Agility in the Social Enterprise
3
strive to create social value. Social value results from SEs using and combining resources to produce
positive social change (Austin, Howard, & Wei-Skillern, 2006; Dees, 1998; Drayton, 2006) that
enhances the well-being of people and the planet (Brickson, 2007). SE’s operate in turbulent
environments characterized by unstable revenue mechanisms (i.e., fluctuating donation levels,
competition for grants, and the customer’s inability to pay for services) that make it difficult to match
market prices for labor, materials, and other assets. Complex government regulations and a heavy
reliance on a volunteer workforce also add instability to social sector environments. As a result, SEs
can benefit from understanding the relationships between IT, agility, and social value creation.
This paper offers contextually anchored contributions (Chiasson & Davidson, 2004) to the current
agility literature based on a longitudinal case study of IT-enabled agility in one SE, the International
Outreach Program (IOP) at St. Jude Children’s Research Hospital (SJCRH). The IOP strives to
improve diagnosis, treatment, and survival rates of children with cancer and other catastrophic
diseases worldwide, with a particular focus on low-income countries. The IOP is recognized as an
exemplary SE that has successfully used its Cure4Kids IT-platform to positively impact global health
(Quintana, O’Brien, Patel, Becksfort, Schuler, Nambayan, Ogdon, Chantada, Howard, & Ribeiro,
2008). We explore the differences between commercial for-profit contexts and social sector contexts,
and investigate the relationships between IT, agility, and success for SEs. To our knowledge, this is
the first study to use the agility perspective to investigate the relationship between IT investments,
agility, and the creation of social value.
This paper contributes to the literature by extending existing concepts of agility to the social sector
environment by conducting an empirical contextual case study analysis of how one SE’s IT-
investment decisions positively impacted agility and ultimately performance. In addition, this paper is
the first to use the Sambamurthy et al. (2003) agility framework to investigate the relationships
between a firm’s IT-related decisions, levels of agility, and performance outcomes. In doing so, we
demonstrate that the framework is beneficial for analyzing a firm’s tactics for agility, and, in the
context of our study, we identify examples of all three types of agility and demonstrate a link between
an SE’s IT-related decisions, agility, and improved performance. Finally, we identify a new set of
performance measures for social sector organizations. This paper proceeds as follows. First, in
Section 2, we offer a theoretical background related to both enterprise agility and social
entrepreneurism. Next, in Section 5, we demonstrate how the IOP leveraged IT to effectively respond
to the demands of the turbulent environment of global health outreach. In Section 5.4 we apply the
Sambamurthy et al. (2003) conceptual framework in an analysis of the IOPs IT-related decisions, the
resulting capabilities embedded in its Cure4Kids IT-platform, and increased levels of agility that
ultimately enabled the IOP to launch more impactful actions aimed at overcoming the limitations of
traditional outreach methods. Finally, in Section 6, we identify the IOP’s performance measures and
illustrate how its IT investments resulted in markedly higher levels of social value creation. In Section
7, we discuss our findings, possible future research directions, and the study’s limitations and
contributions.
2. Theoretical Background
2.1. Enterprise Agility
The concept of enterprise agility originated from concerns in manufacturing regarding the failure of
organizations to make internal changes fast enough to meet the evolving requirements of rapidly
changing markets and increasing customer demands (Dove, 1994; Youssef, 1992; Yusuf, Sarhadi, &
Gunasekaren, 1999;). Sambamurthy et al. (2003) introduced agility to the information systems
literature. They define enterprise agility as a firm’s ability to detect opportunities for innovation and
seize those competitive market opportunities by assembling the assets, knowledge, and relationships
necessary to react to these opportunities with speed and surprise. They also proposes a conceptual
framework that suggests the value of IT is in its role as a “strategic differentiator” and identifies agile
firms as those that utilize IT to identify and launch a variety of initiatives to gain competitive
advantage and improve performance.
In their conceptual framework, Sambamurthy et al. (2003, p. 256) define three separate dimensions
Journal of the Association for Information Systems Vol. 15, Issue 1, pp. 1-32, January 2014
Richardson et al. /Agility in the Social Enterprise
4
of agility: customer agility, partnering agility, and operational agility, and suggest that, by integrating
IT into each dimension, firms can develop unique IT-platforms that enable a “business infrastructure
that shapes the capacity of firms to launch frequent and varied competitive actions”, which results in
improved performance. Customer agility is defined as the involvement of customers in the exploration
and exploitation of opportunities for innovation and competitive actions (Sambamurthy et al., 2003). It
is proposed that a firm can enhance its customer agility by utilizing its IT platform to build and
enhance customer relationships and leverage the voice of the customer to gain market intelligence,
detect opportunities, inform product development, and conduct product testing. Partnering agility is
defined as the ability to leverage the assets, knowledge, and competencies of suppliers, distributors,
contractors, and logistics providers through partnerships that result in competitive opportunities for
innovation that are difficult for competitors to duplicate. It is possible for a firm to enhance its
partnering agility by utilizing its IT platform to enable greater inter-firm communication, collaboration,
knowledge creation, and sharing. Operational agility reflects the ability of a firm’s business processes
to develop speed, accuracy, and cost economy in the exploitation of opportunities for innovation and
competitive action. For example, a firm can enhance its operational agility by developing flexible,
reusable, IT-platform capabilities that facilitate cost reduction.
Entrepreneurial alertness is a critical capability for developing agility. Entrepreneurial alertness is a
firm’s ability to recognize and respond to opportunities to detect market ignorance and identify
appropriate actions that result in improved competitive actions. Sambamurthy et al. (2003)
characterize entrepreneurial alertness by a firm’s strategic foresight and insight. Strategic foresight is
a firm’s ability to identify threats or opportunities in the market, including potentially disruptive actions
by its competitors. Strategic insight is a firm’s ability to visualize connections between digital options,
capabilities, and emerging opportunities.
The agility perspective highlights the role of digital options in building agility. Firms that integrate IT-
assets with existing processes, knowledge, and relationships can develop an IT infrastructure that
facilitates the creation of digital options. Any one digital option may support one or more of the three
dimensions of agility, resulting in higher-order capabilities that enable quick adaptation to changing
market conditions and the development of innovative inimitable products that differentiate a firm in the
market and result in a competitive advantage (Overby et al., 2006; Piccoli & Ives, 2005;
Sambamurthy et al., 2003; Tallon & Pinsonneault, 2011). Digital options extend the reach (breadth of
information) and richness (quality of information) of a firm’s knowledge and processes (Overby et al.,
2006; Sambamurthy et al., 2003; Tallon & Pinsonneault, 2011). For example, Amazon.com originally
constructed its IT platform to support online book selling. The platform included the IT infrastructure
necessary to support Amazon’s book-selling business (networking hardware, web servers,
databases, etc) and customized software (customer feedback systems, shopping carts, one-click
ordering). Systems that were optimized for web-based retail became digital options embedded in the
IT platform and were utilized by Amazon to reconfigure its resources and launch competitive actions
aimed at new markets (e.g., digital books, music, tablets, and other goods). Digital options enabled
Amazon.com to apply innovative customer focused services (e.g., recommendation and feedback
systems) to new markets, and to offer new services including application hosting, web services, and
cloud-based computing. While for-profit firms such as Amazon utilize digital options to improve
profitability, we propose that SEs can benefit from using digital options in the pursuit of a different
mission—the creation of social value.
2.2. The Social Enterprise
What is a social enterprise? The ongoing discussion concerning this question has resulted in several
definitions (see Appendix A). For the purposes of this research, we adopt the position of Peredo and
McLean (2006). To clarify their definition, they first conceptualize SEs on a continuum ranging from
organizations whose mission is exclusively focused on addressing a social need (SEs) to
organizations whose primary mission is profit maximization but who may also engage in some form of
social responsibility. As Table 1 illustrates, elements of social entrepreneurism and social
responsibility can be found in traditional for-profit organizations, but few definitions of SEs are so
broad as to include commercial for-profit organizations that engage in corporate social responsibility
activities (Martin & Osberg, 2007).
Journal of the Association for Information Systems Vol. 15, Issue 1, pp. 1-32, January 2014
Richardson et al. / Agility in the Social Enterprise
5
Table 1. Range of Social Entrepreneur Actions (Adapted From Peredo and McLean (2006))
Mission
Role of commercial
exchange
Example
Social
enterprises
Exclusively social
No commercial exchange
SJCRH (IOP)
Exclusively social
Some commercial exchange,
but profits are directed
exclusively at addressing
social goals
Newman’s Own
Social
responsibility
Socially focused business
goals, but not exclusively
Commercial exchange, profits
in part benefit entrepreneur
Tom’s Shoes
Social goals are prominent
among other goals
Commercial exchange, profit-
making is a prominent goal
Ben & Jerry’s
Social goals are subordinate to
other goals
Commercial exchange, profit
maximization is primary goal
Coca-Cola
Therefore, following Peredo and McLean (2006), we define the social enterprise as an organization:
(1) whose primary mission is the creation of social value, (2) that demonstrates a capacity to
recognize and respond to opportunities to create social value, (3) that employs innovation in creating
and/or distributing social value, (4) that accepts a degree of risk in creating and disseminating social
value, and (5) is unusually resourceful in dealing with the scarcity of assets that is unique to the social
sector context. In summary, SEs apply the entrepreneurial practices of business to the pursuit of
opportunities for social value creation and social transformation rather than for traditional profit
maximization (Dees, 1998; Mair & Marti, 2006; Martin & Osberg, 2007; Murphy & Coombes, 2009;
Zahara, Gedajlovic, Neubaum, & Shulman, 2009).
SEs are somewhat unique in the non-profit sector because they specifically focus on entrepreneurial
actions and the development of innovative solutions aimed at addressing pressing and complex
social needs (Bornstein, 2007; Dees, 1998), and because they typically strive for large-scale social
transformation that reaches well beyond the confines of a single disadvantaged community (Drayton,
2006; Martin & Osberg, 2007; Murphy & Coombes, 2009). This focus on large scale change in
disadvantaged populations differentiates SEs from other non-profit organizations that primarily focus
on providing a social benefit for a local or specific community.
The markets that SEs service can also differentiate them from commercial firms. Commercial firms
are organized to service markets that can comfortably afford new products or services and, as a
result, are designed to create financial profits (Martin & Osberg, 2007). In contrast, SE’s target social
needs, and, to do so, they purposefully locate their activities in contexts in which commercial markets
function poorly (Dees, 1998; Zahara et al., 2009). Their “customers” are aid recipients who do not
have the luxury of market choice (Beamon & Balick, 2008) and often cannot pay for products and
services (Oloruntoba & Gray, 2006).
SEs operate in extremely turbulent environments that may be even more susceptible to
macroeconomic instability than for-profit organizations due to their reliance on donations, grants,
government funding, and the intense competition for these limited funding sources (Austin et al.,
2006). These resource constraints make it difficult for SEs to pay market rates for labor, which results
in a reliance on a largely volunteer workforce characterized by high turnover. In addition, SEs often
operate in areas of the world with limited infrastructure and unstable governments that present
additional challenges. We propose that SEs provide a valuable context for extending our knowledge
of the relationships between IT, agility, and performance.
3. Research Design
The primary motivation for this study is theory elaboration, a process of comparing pre-existing
Journal of the Association for Information Systems Vol. 15, Issue 1, pp. 1-32, January 2014
Richardson et al. /Agility in the Social Enterprise
6
understandings with observed events in an effort to extend existing theory (Lee, 1999). We chose to
conduct a qualitative, contextually anchored longitudinal case study (Miles & Huberman, 1994) with
an exemplary organization (Yin, 2003)—St Jude Children’s Research Hospital’s (SJCRH)
International Outreach Program (IOP) based in Memphis, Tennessee. Qualitative methods are helpful
when extending theory because they provide rich descriptions of phenomena and events in
organizational contexts (Langley, 1999). Contextually anchored research is commonly conducted in
industries unexplored in IS research, and it facilitates the interweaving of existing IS research with
novel contexts (Chiasson & Davidson, 2004). The case study method provides an opportunity to
explore significant phenomena in a unique context in which existing theory only provides a partial
explanation and descriptive data can be especially revelatory (Eisenhardt, 1989; Eisenhardt &
Graebner, 2007; Walsham, 1995; Yin, 2002). Case studies that explore exemplary organizations take
advantage of rich, yet rare, instances of a phenomenon that has not previously received contextually
sensitive research attention (Yin, 2002). For these reasons, we found a longitudinal case study fitting
for understanding how the IOP’s IT decisions determined its agility and associated success.
3.1. Research Site
St. Jude Children’s Research Hospital (SJCRH), located in Memphis, Tennessee, was founded by
Danny Thomas in 1962 with the mission to “find cures for children with cancer and other catastrophic
illness through research and treatment” (www.stjude.org). SJCRH is internationally recognized for its
pioneering work in both treatment and research related to cancer and other catastrophic pediatric
diseases. It freely shares its research and medical discoveries, and its research has led to
discoveries that have increased survival rates for pediatric cancer patients worldwide (Howard,
Metzger, Williams, Quintana, Pui, Robinson, & Ribero, 2008). SJCRH has over 3300 employees and
operating expenses of over $1.4 million per day that are primarily covered by donations from
individual contributors. SJCRH is unique in that patients or their families are never asked to pay for
treatment. They currently treat, on average, 250 patients per day and support 5400 patients in active
status. After treatment, patients transfer to the After Completion of Therapy Clinic and receive annual
evaluations until they are 18 years of age or for 10 years after diagnosis.
SJCRH estimates that 160,000 children worldwide are diagnosed with cancer each year. The number
of annual cancer-related childhood deaths is rapidly increasing in low-income regions of the world
(Howard, Marinoni, Castillo, Bonilla, Tognoni, Luna-Fineman, & Antillon, 2007). An estimated 20
percent of newly diagnosed children are fortunate enough to live in the United States, Europe, or
other parts of the developed world where the cure rates currently approach 80 percent. The outlook is
much bleaker for the remaining 80 percent of these children. Effective treatments for children in
resource-poor countries are often unavailable in their community, limiting treatment to those with the
resources to travel abroad (www.stjude.org/international). In response to this disparity, SJCRH
established its IOP in 1993. Initially, the IOP relied solely on traditional methods of healthcare
outreach. However, in 2002, the IOP launched its Cure4Kids IT platform, which transformed the way
the IOP pursued its mission. We selected the IOP for our case study because it is an internationally
recognized SE that has won several awards for its use of its Cure4Kids IT platform to positively
impact pediatric healthcare and survival rates in the complex and turbulent environment of global
health (Quintana et al., 2008).
Our case study is revelatory in nature (Yin, 2002); it was designed to examine how the IOP took
advantage of its IT capabilities, and how these capabilities shaped its relationships and operational
processes in a way that increased its agility in launching new products that dramatically improved
performance. We were offered virtually unlimited access to the firm, which made it possible to
investigate the context in detail by observing the processes involved in the continual shaping of the
Cure4Kids IT platform.
3.2. Data Collection
Data collection occurred over a four-year time period between January 2008 and June 2012. Our
primary sources of data include unstructured and semi-structured interviews, non-participant
observations, direct interaction with the Cure4Kids IT platform, and organizational documents. In
order to become familiar with SJCRH, the IOP, and Cure4Kids, we began our data collection process
Journal of the Association for Information Systems Vol. 15, Issue 1, pp. 1-32, January 2014
Richardson et al. / Agility in the Social Enterprise
7
with four general data gathering meetings. Participants included an IOP physician, the IOP
Administrative Director, the IOP Director of Education and Informatics, and the Coordinator of
Content Development. At the end of each meeting, the IOP Director of Education and Informatics
provided us with a number of organizational documents (e.g., strategic plans, financial data, etc). We
then made specific requests for interviews with the principle stakeholders associated with the IOP
including managers, IT staff, education coordinators, users, volunteers, and IOP and SJCRH
physicians. The Director of Education and Informatics agreed to our requests and facilitated access to
these individuals. In all, we conducted 59 interviews. Table 2 summarizes the types and number of
interviews conducted (see Appendix B for the interview protocol). In addition to our specific interview
requests, the Director of Education and Informatics also invited us to a number of Cure4Kids planning
meetings so that we could interact with additional physicians, fellows, and volunteer consultants. He
also provided access to the Cure4Kids IT platform, and invited us to attend (as a non-participant
observer) weekly “feedback and improvement” meetings with two clinics in Central America
(participants included physicians, nurses, hospital administrators, and data entry personnel). During
these meetings, we learned how the physicians at these clinics used the Cure4Kids IT platform to
help make treatment decisions for their patients, interact and collaborate with physicians at other
clinics, exchange patient and clinic related experiences, structure and conduct clinical trials, develop
standardized treatment protocols, and improve internal clinical processes. In addition, we learned
how clinic administrators used Cure4Kids to develop patient medical records, track patient data, and
improve information flow.
Table 2. Summary of Interviews Conducted
Position
Number of
interviews
Type Time Context
Director Education & Informatics
for IOP
4
Semi-structured
2 hours ea.
SJCRH
12
Unstructured
1-3 hours ea.
SJCRH
5
Unstructured
1 hour ea.
Cure4Kids (online)
Director of IOP (Physician)
1
Semi-structured
2 hours
SJCRH
Director of Medical Informatics
& Clinical Trials (physician)
3
Semi-structured
2 hours ea.
SJCRH
5
Unstructured
1-3 hours ea.
SJCRH
Administrative Director IOP
2
Semi-structured
2 hours ea.
SJCRH
Programmer (lead)
1
Semi-structured
2 hours
SJCRH
2
Unstructured
1-3 hours ea.
SJCRH
5
Unstructured
1-3 hours ea.
Cure4Kids (online)
Educational Outreach
Coordinator
2 Unstructured 1 hour ea. SJCRH
Content Development Coord.
2
Semi-structured
2 hours ea.
SJCRH
SJCRH IOP Physician
2
Unstructured
1 hour ea.
SJCRH
Live Events Coordinator
1
Unstructured
1 hour
SJCRH
C4K User - Clinic Physician
(Central America)
5
Unstructured
1 hour ea.
Cure4Kids (online)
1
Unstructured
1.5 hours
SJCRH
C4K User – Clinic Administrator
(Central America)
5
Unstructured
1 hour ea.
Cure4Kids (online)
Research Fellow (Central
America)
1
Unstructured
1.5 hours
SJCRH
Total:
59
Journal of the Association for Information Systems Vol. 15, Issue 1, pp. 1-32, January 2014
Richardson et al. /Agility in the Social Enterprise
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4. Data Analysis
Data analysis was conducted by each of the four researchers (three had process analysis experience
and the last had contextual expertise). Our interpretation of how the IOP’s iterations of IT-investment
decisions resulted in specific IT capabilities that influenced agility, and ultimately performance,
evolved through data analysis and discussions among the researchers. These discussions were
fueled by iterative analysis of the interview transcripts, field notes, and other data sources. Our
interpretations were then validated with IOP management and technical staff. Our analysis occurred
in four steps.
First, we developed a timeline to facilitate the identification of relevant antecedents and outcomes of
IT-enabled agility in the IOP (Yin, 2002). The timeline offered a general chronology of events
associated with iterations of the IOP’s recognition of opportunities and its IT-related decisions that
influenced its agility and shaped its outreach actions.
Second, we created a preliminary list of pattern codes to help identify the relationships among
concepts found in the textual data (Miles & Huberman, 1994). First, we identified instances of the
IOP’s entrepreneurial alertness (strategic insight and foresight) and the associated decisions to
reconfigure, modify, or create specific IT-capabilities on the Cure4Kids IT platform. Using these as
pattern codes, we manually coded the transcribed interviews and other data sources to identify
evidence of how the IOP recognized opportunities and responded by investing in IT, creating digital
options, and configuring its IT platform and infrastructure.
Third, we established a connection between the Cure4Kids’ IT platform and specific instances in
which the IOP rapidly reconfigured its IT capabilities, knowledge, and other assets to launch new
products. These connections are evidence of the relationship between the IOPs IT-investment
decisions, the creation of specific IT capabilities, and increased agility.
Fourth, we analyzed how the IOP’s increased agility positively impacted performance outcomes. We
identified relevant performance indicators associated with each of the three dimensions of agility
(customer, operational, and partnering) identified by Sambamurthy et al. (2003) to demonstrate
evidence of the relationships between IT, agility, and performance in the context of the IOP.
Performance indicators were compared with those proposed in the agility literature to illuminate any
differences associated with the social sector context.
5. Results
5.1. A Technical Response to International Outreach
Since 1962, sick children from around the world have traveled to SJCRH’s Memphis, Tennessee
campus for treatment. However, travel logistics and related expenses made it difficult for families
without adequate resources to travel what were often great distances, leaving many children outside
of the US without access to appropriate treatment. Limited numbers of physicians and available
hospital beds further restricted the number of children that SJCRH could treat. These constraints
remained consistent for roughly 30 years until one patient’s case sparked SJCRH to recognize an
opportunity to positively impact treatment and survival rates in resource-poor countries.
In the early 1990’s, the mother of a SJCRH patient returned from Memphis to her home to El Salvador
and asked, “What happened to all of the other kids who were diagnosed at the same time as mine, but
didn’t have the money to travel, a visa, and connections?”. Concerned about the lack of treatment
options in her community, she established a partnership with a local doctor and together they started a
small foundation. They approached SJCRH to ask for assistance. One Director recalls, “She said we
have a little money, a doctor, and a place for kids, now we need technical advice”. In response, SJCRH
established a formal program to address the need for medical information and expertise in clinics
located in resource-poor countries. In 1993, SJCRH established its IOP as “a strategic approach to put
some effort and value into treating children in other countries that are poor” (Director 2). The IOPs
mission is “to improve the survival rates of children with cancer and other catastrophic diseases
worldwide, through the sharing of knowledge, technology, and organizational skills”.
Journal of the Association for Information Systems Vol. 15, Issue 1, pp. 1-32, January 2014
Richardson et al. / Agility in the Social Enterprise
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Initially, the IOP adopted traditional “twinning” methods for its outreach efforts. Twinning involves a
dedicated partnership between institutions in both high-resource and low-resource contexts and is
widely recognized as an effective method for healthcare outreach programs (Ribeiro, Steliarova-
Foucher, Magrath, Lemerle, Eden, Forget, Mortara, Tabah-Fisch, Divino, Miklavec, Howard, & Cavalli,
2008). Twinning programs in healthcare contexts are aimed at establishing basic clinical
infrastructures, education, and community involvement, and at improving healthcare in resource-poor
countries (Ribeiro & Ching-Hon, 2005). The IOP focused its efforts on developing local-level
relationships with a few clinics like the one in El Salvador, each located in a low- or middle-income
country. To ensure sustainability, the IOP also established relationships with local fundraising
organizations. In six years, the IOP developed twinning programs with roughly 18 clinics mostly
located in Central and South America. The IOP developed relationships through regular visits by an
IOP physician to a clinic, typically two or three times per year. Between visits, communication
continued via mail and phone, a slow and time consuming process by today’s standards. In addition,
the IOP hosted “fellows” from the clinics at the SJRCH and provided them with an opportunity to
observe and learn.
The IOP’s twinning programs facilitated the successful transfer of knowledge and processes to its 18
associate clinics and resulted in improvements in clinical infrastructures, medical treatment, and
survival rates at the local level. However, the twinning program required high levels of financial and
human resources, which restricted the impact of the IOP’s efforts. Director 2 said:
The way we impacted those sites was through frequent travel, we had a St. Jude expert
go to a country and say, ‘I’ll provide you with some information, and I’ll stay here for a
few days, we can treat these kids and develop a protocol and some internal processes
for data tracking and record keeping’...It was really effective, but resource intensive, and
still limited in the number of kids that were impacted...it wasn’t the biggest bang for the
buck.
In 1999, the Director of the IOP observed a number of visiting fellows photocopying medical books
while at SJCRH. The experience led the Director to recognize an opportunity to invest in IT in order to
improve access to medical research, educational materials, and expertise at the associate clinics:
It all started when we noticed that the Fellows visiting us spent a lot of time copying
materials before they returned home...the communities didn’t have access to
information…I even questioned them, saying listen, you are copying the book that is
four or more years delayed...but they preferred to have old information than not to have
anything… one idea came, how can we use technology to make relevant, current
information available to these individuals at home?
It was a “eureka moment” for the Director. He recognized that IT was rapidly becoming more available
globally, and recalled that “At that time, we [the IOP] were betting that the technology in other
countries was going to improve. It had in so many countries already—very abruptly, so we bet it
would get to these countries too.”. The IOP acted quickly and, in 1999, hired a contractor to create a
web-based digital library to be shared with its 18 associate clinics: “The idea in the beginning was to
have information, books, etc. that would be accessible by them [clinics] when they needed it.”.
Unfortunately, while the IOP recognized the potential of embedding its knowledge resources into a
web-based system, the contractor did not have the necessary insight to effectively integrate the
knowledge base into the web-based digital library. As a result, the digital library “didn’t make the
information available to the clinics...it just didn’t meet the needs of web-based education” (Director 1).
Next, the IOP hired a director to oversee the development of the digital library. The director developed
a website1 that had both a digital library and cancer registry capabilities to support research. However,
once again the technology was not well integrated into SJCRH’s knowledge base. He had developed
the correct technical solution, but he did not foresee the need for the knowledge base to mature and
1 Note that, although we use the term “website” here, the director more aptly developed the beginnings of an overall IT infrastructure.
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“it just didn’t grow in terms of content or features” (Director 1). Following the second failure, there was
a period of lapse without a director and high employee turnover. The IOP hired a part time
programmer to maintain the site and the clinics continued to use the digital library, but usage levels
were low.
In 2002 the IOP tried again. It hired a new director who recognized the potential of integrating the
IOP’s digital library with SJCRH knowledge resources. He quickly targeted a weekly SJCRH seminar
series. Each week, SJCRH hosted an expert speaker (some of them SJCRH physicians) to present
current topics and teaching cases. The result was a sustainable source of content that would promote
growth for the newly named “Cure4Kids” IT platform. Director 1 said:
We have a regular series of presentations here [SJCRH] and I thought of that as a
source for high quality content, and it was new every week... I thought that we could
record the seminars, along with the PowerPoint slides, and add that content and make it
available...so we captured those on video and leveraged that content first...we
revamped the website, it still had the digital library, but now it also had seminars.
In October 2002, Cure4Kids went live with a “handful of documents” and 5 online seminars. The IOP’s
Central American associate clinics and clinics in Brazil and Morocco were provided access to
Cure4Kids and customer support. A director recalled that “We picked our closest partners at the time
to help us with operationalizing and improving Cure4Kids”. In 2003, content reached 40 seminars and
Cure4Kids began to “fundamentally change the face of how the IOP did business” (Director 2).
Director 2 said:
The result was there were answers to questions [for the clinics]… We also started to
use email to talk... The need for travel decreased and the [IOP] physicians could answer
questions on a much more time-sensitive basis. This worked so well that we were able
to expand into more countries and create new ways to provide information.
Cure4Kids enabled the associate clinics to access current medical information that was previously
unavailable to them. As a result of this success, the IOP increased its focus on using Cure4Kids as a
foundation for recognizing and responding to new opportunities to develop new programs and further
improve the transfer of knowledge, technology, and organizational skills. Director 3 said:
Cure4Kids is the starting point for any initiative now, that is a given... Cure4Kids isn’t just
a platform to build solutions anymore...it is part of the process to even start talking about
any possibility or solution now.
5.2. Entrepreneurial Alertness, Entrepreneurial Actions, and Cure4Kids
In 2003, the IOP increased its focus on Cure4Kids as a platform for launching new initiatives. In
constructing Cure4Kids, the IOP created digital options in the form of a customized IT infrastructure
including hardware, telecommunication systems, open-source operating systems and applications,
specialized custom-developed code, and the knowledge and expertise necessary to integrate the
various components into effective solutions. In this section, we describe iterations of the IOP’s
entrepreneurial alertness and resulting entrepreneurial actions that led to the creation of specific IT
capabilities that shaped the IOP’s Cure4Kids IT platform. Table 3 summarizes the recognition of
specific needs and opportunities, and how the IOP responded by developing unique IT capabilities
that resulted in effective solutions embedded into its Cure4Kids IT platform.
5.2.1. Cure4Kids
Prior to 2002, travel demands and limited communication between site visits restricted the impact of
the IOP’s outreach activities to its 18 partner clinics. Director 2 said:
When you look back to the early 90’s you really had three ways to communicate; the
phone, mail, and air travel... The reality was that these are poor countries and they can’t
make that phone call, even that simple technology was expensive and limited what we
could do.
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With the introduction of Cure4Kids in 2002, the associate clinics could access current treatment
information. At that time, the IOP did not track usage data (e.g., site visits, downloads, etc); however,
they received regular feedback that indicated the information on Cure4Kids was beneficial to the
clinics. As the IOP Director stated, “They [clinics] would tell us that they read a lot, and the books and
seminars really helped them with the treatment of patients”. The feedback indicated that Cure4Kids
was enabling the IOP to respond quickly and effectively to address the information needs of its
associate clinics. “It was clear that we were able to use this technology to extend our knowledge...to
help the clinics in a meaningful way” (Director 3). By 2003, content had grown to over 40 seminars
and an increasing number of articles. Figure 1 summarizes the evolution of Cure4Kids between 2002
and 2012.
Table 3. Entrepreneurial Actions & IT Capabilities
Entrepreneurial
alertness
Entrepreneurial actions ( IT capabilities)
Cure4Kids
application
Recognized need for low
cost IT solution to
address medical
information deficits in low-
income countries
Developed web-based knowledge repository and digital
library IT-capabilities that support creation of, and access
to, codified knowledge, enabling quick reaction to
opportunities for knowledge transfer and sharing among
stakeholders (extends knowledge reach)
Cure4Kids
IT platform
Identified an opportunity
for virtual meeting
capabilities on Cure4Kids
to extend knowledge
exchange and facilitate
collaboration
Developed virtual meeting rooms, meeting management
tools, and document sharing IT-capabilities that support
collaboration and enable quick reaction to opportunities
to support sharing of expertise, tacit knowledge,
perspectives, and resources among shareholders
(extends knowledge richness)
Cure4Kids
live meetings
Recognized a need for an
IT solution to address
workflow and informatics
deficits in clinics
Developed a clinical repository, electronic medical record
capabilities, workflow process support tools, and analytic
tools that support the collection of clinical information,
analytics, and information transfer to support clinical
decision making. Enables quick reaction to opportunities
for information use and process reengineering (extends
process richness)
POND4Kids
Identified an opportunity to
capture content from live
meetings to make case
information available to the
public
Developed knowledge management, relationship
management, and messaging capabilities facilitating the
integration of teaching cases with the process of
providing expert consultations. Enables quick response
to opportunities to facilitate the flow of clinical expertise
and teaching cases among stakeholders across a variety
of geographical regions (extends process reach)
Consult4Kids
Recognized opportunity for
an IT solution to support
exchange of case
information
Developed wiki and knowledge management capabilities
to support the collection, validation (peer-review), and
distribution of case-based (patient cases) information.
Enables quick reaction to opportunities for perspective
sharing, and the development and dissemination of tacit
knowledge among stakeholders (extends knowledge
richness)
Oncopedia
Recognized a need for IT
solution to support
community based cancer
education
Developed collaboration tools and web-based
capabilities to support communities of practice focused
on education. Enables quick reaction to opportunities for
focused web-based education programs (extends
knowledge reach and richness)
Cure4Kids for
Kids
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Figure 1. Cure4Kids Evolution
In 2003, the IOP Director attended a conference and while there met with a well-known physician
from Italy who had conducted outreach in Nicaragua for over 30 years. The discussions sparked the
Director’s entrepreneurial energy again, which resulted in the addition of “live meeting” capabilities to
the Cure4Kids platform. Director 1 said:
They had a great meeting, discussing clinical cases and outreach, and when he [IOP
Director] returned he asked, “can’t we use Cure4Kids now to continue the discussion?”
This is really how our international presence was established, but we didn’t know it at
the time, we were just looking at how to keep the communication going.
At the time, social networking technology was not widespread and the Director of Cure4Kids
envisioned adding virtual meeting-room capabilities into Cure4Kids. As a technical solution, the IOP
created “working groups” and document sharing capabilities with low bandwidth requirements.
Registered users could form groups, set up either public or private meetings, and gather in virtual
meeting spaces on Cure4Kids. An online meeting management software product that the IOP had
previously purchased was integrated so that users could organize meetings (e.g., scheduling,
announcements, invitee lists, etc) and share documents. Director 1 said:
We had our first meeting with Dr. M in Italy, our Central Americans and us all logged into
a virtual conference room...they [clinics] presented their first case in PowerPoint...I can
tell you the first year was quite a challenge in terms of getting people to use the
technology...the audio quality was poor...but they were getting to know each other and
really wanted to have these meetings and they put up with a lot of discomfort to get this
off the ground.
The IOP started to track usage related to site visits, downloads, number of groups, and meetings.
Between 2003 and 2006, Cure4Kids had moderate growth in terms of groups, meetings, and
downloads. By 2007, word began to spread and there was rapid growth of groups and meetings
between 2007 and 2008. By 2012, Cure4Kids had 32,554 users in 185 countries with over 6,000,000
items downloaded (e.g., documents, seminars, etc). A Director recalled that, “Usage grew from about
200 people using per year to several thousand, the growth was phenomenal”. In addition, Director 1
said:
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Everybody was hearing about it at conferences, international meetings, and from local
communities, the growth was exponential, we went from about 200 people to about
10,000 that year, we hit about 14,000 the following year, and about 20,000 in
2009...that’s a lot of meetings, collaboration, discussion and knowledge sharing, and
good will...we were having a much broader impact.
The introduction of live meetings triggered rapid growth, established an international presence for the
IOP, and dramatically improved the depth and breadth of knowledge exchange to levels that surprised
even the IOP. They discovered that “the same set of strategies was useful over and over again… if
Cure4Kids helps poor kids with cancer in the Philippians then it is probably going to help poor kids
with cancer in India—most of our strategies, based on poor kids in Brazil and Central America, just
got imported over” (Director 4). Evidence that Cure4Kids had extended the depth and breadth of the
IOP’s impact began to emerge. Director 4 said:
I can think of a case, a doctor from India said “the things that I saw with your patients is
probably the same as in my patient profile so I changed treatment”, it was a toxicity
issue, it makes you wonder how many die from toxicity that could have been prevented
if they were just in the US…through Cure4Kids we were able to help that child in India.
The IOP discovered a dramatic increase in the number of independent working groups that often
formed around geographic location and time zones. The groups met regularly on Cure4Kids (at least
once a month) to sustain their own local collaborations. Director 1 said:
India is a good example...we have no partners there, haven’t worked in these
communities...but many people in India know about and use Cure4Kids...it’s basically
social networking at work, people found out about it and word spread.
In the midst of rapid growth, the IOP continued to emphasize the importance of its close relationships
with the original associate clinics. They established weekly meetings on Cure4Kids and realized
dramatic improvements in communication and information exchange. Collaboration with the associate
clinics was no longer restricted to two to three clinical site visits a year. The impact was illustrated by
an unexpected decrease in international children coming to SJCRH for treatment. Director 2 said:
Because of the IOP, those international children, their stays here have decreased
dramatically...I think a major contribution of that reduction is Cure4Kids and the access
to information and live meetings...so the kids that you see here at SJCRH now are not
necessarily here because they don’t have treatment options in their home countries, but
because they can come here and help us to research, it’s a win-win opportunity.
The IOP continually utilized its relationships with the associate clinics to identify new opportunities for
outreach, to test new products launched on Cure4Kids, and to provide feedback for improvements.
The associate clinics proved to be a valuable asset as the IOP heightened its focus on using
Cure4Kids as a platform for developing new outreach efforts.
In 2008, the IOP discovered that physicians in other U.S. institutions were using Cure4Kids as a
resource for information exchange and collaboration. A Director described one such user: “it was
great, Washington D.C.’s Children’s hospital was using it...we were excited about this and created a
formal relationship with them”. Many organizations would view the independent use of its IT-based
products by another organization in the same industry as a threat to its uniqueness or its competitive
advantage. The IOP viewed it as an opportunity for collaboration:
I have never been afraid to share or collaborate… well that may not have been true the
first year or two...but I credit him [Director of IOP] with this...when we were partnering
with some groups I thought that is going to take away from the uniqueness of what we
are doing...if we share content...he said don’t worry about it, they want to help kids,
that’s our mission too, collaborating is consistent with our mission (Director 1).
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The IOP viewed collaboration with like-minded institutions as essential to achieving a meaningful
impact on global health, specifically in the context of pediatric oncology.
These programs [healthcare outreach] will have to be interoperable, there is not enough
money or knowhow to solve these problems in the care of complex chronic disease,
multiple diseases...those who realize it earlier will move toward success faster than
those who try to do it alone because…it’s too complex (Director 3).
The Director of Cure4Kids had a vision: he wanted to collaborate with other global health outreach
institutions by sharing content across websites to increase the information available to clinics and the
overall impact for the IOP and other like-minded organizations. The IOP viewed collaboration as a
way to “help anyone who wants to help kids”. The Director of Cure4Kids described the potential of
collaboration:
We have a mission to share; it is part of our ethic, part of our DNA...what we are doing
here is too big for one organization to change alone...if we collaborate we are all
working toward our mission and having a bigger impact on the lives of children.
The IOP focused on systematically promoting collaboration; however, they quickly met with resistance.
Many similar organizations held a competitive mindset similar to those in for-profit firms. Director 1
said:
I have to be convincing of this collaboration, some others [outreach organizations] are
still very territorial, they have the mindset that “we want all of our content on our site just
for our users”, but you know if their site doesn’t grow then they aren’t meeting their
mission, and if they falter then that is another avenue for content that is closed to clinics
who need it, no one meets their goals in the long-run.
The IOP developed a “branding” strategy that would allow each organization to retain ownership of
their content by providing a link to its content (e.g., seminars, papers, etc) to be posted on the partner
institution’s website. When a user clicks on a link, regardless of where the content was hosted, the
originating organization’s brand (name and logo) appeared. Eventually, through branding, the IOP
successfully developed collaborations. Director 1 said:
We respect branding so these situations are doable, they work and we will all be
stronger if we collaborate, we can help more kids working toward our missions
together...and in the end no one cared if one site had more visits.
The IOP’s insight into how it could make use of Cure4Kids to engage in web-based collaboration with
other outreach institutions enabled both the IOP and the other institutions to achieve a greater impact.
Director 1 said:
It worked extremely well, those seminars have been viewed 150,000 times and half of
the traffic comes from their site and half from ours, it was a win-win...and if one ends up
with more traffic on their site that’s ok, the impact on the kids is the important thing and I
hope we helped them with that.
5.2.2. Pond4Kids
Prior to 2002, Cure4Kids did not support capabilities for workflow processes or basic informatics.
Clinical registry capabilities, designed as a database to support statistical research, had been
developed during one of the two failed pilot tests, but the associate clinics had not used these
functions and, as a result, the clinical registry remained in the background. Then, in late 2002, an IOP
physician returned from a site visit. Programmer 1 said:
He [IOP physician] saw a need for improving workflow processes and support for
informatics at the clinic...what we had didn’t really support that, but we could definitely
see an opportunity to help clinics with more of an electronic medical record approach.
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The IOP responded by reconfiguring the original cancer registry functions to develop IT capabilities
with a clinical interface, similar to electronic medical records, as a way to support everyday workflow
solutions that would meet the needs of the clinics. POND4Kids (Pediatric Oncology Networked
Database) was launched in 2003 and represented a hybrid solution situated between a medical
record and clinical registry. POND4Kids includes capabilities to support workflow processes and data
exchange functions to support information exchange. Programmer 1 said:
When you share data through it, POND will automatically remove the names and
identifying information of the patient...it removes birthday and name, but provides
access to age...so you have relevant information, you can get an age of a person at
diagnosis, just not the ability to identify the original patient...it’s HIPAA compliant, but still
holds some of the useful data sharing components.
The IOP worked with one of its associate clinics, located in Brazil, to test POND4Kids. Director 1 said:
We worked with Brazil to test a new version of POND...the main thing was
operationalizing our processes...we set up a team to help set up their medical
records…we made some modifications and it turned out to be a nice solution for
them...after they helped us test it we launched POND for all Cure4Kids users...and it
grew considerably in content and access.
From a technical perspective, the IOP carefully integrated POND4Kids’ capabilities with those on the
overarching Cure4Kids IT platform. Director 1 said:
They share the same architecture at the core...this was important, so whenever we do
an improvement for Cure4Kids it can be migrated over to POND, they are linked at the
hip...for example, we did a help system for Cure4Kids because it is a knowledge base,
so you can search for information...and then we just moved that help software into
POND and now you have a help management system in there too.
POND4Kids provided workflow solutions for the clinics and also enabled the IOP to capture, cleanse,
and integrate all of its data for other users to access.
5.2.3. Consult4Kids
By 2003, Cure4Kids supported information exchange, collaboration, workflow processes, and clinical
registry capabilities for its rapidly growing user base. However, Cure4Kids did not have capabilities to
connect users in need of specialized advice to experts in the field. The IOP saw an opportunity and, in
2004, it developed Consult4Kids to connect users with experts to facilitate case consultations. The
IOP envisioned a system that would bring experts together with healthcare providers seeking advice
and facilitate the discussion of treatment options in a Cure4Kids virtual meeting room. Since the
information on Consult4Kids would be case specific, the IOP kept Consult4Kids data separate from
the main Cure4Kids system to ensure that identifiable information was not improperly shared.
Consult4Kids was designed with separate accounts, user names, and passwords from those on
Cure4Kids. Director 1 said:
So here is an example where we weren’t too happy with the result...our mission here
was secure consultation and quick timing, two things that didn’t happen...so we made
entry a single form, but people don’t like to do it because they have to log in, scroll
multiple boxes, and compared to the immediacy of email where you don’t log on or
select anything, it didn’t work...they just found it easier to email each other once they
were in contact and circumvent the system and we couldn’t capture that content...they
just didn’t use it so it didn’t grow the way we had thought it would.
Consult4Kids experienced slow growth from 2004 to 2007. In 2008, to address the usability issues,
the IOP integrated Consult4Kids into the Cure4Kids platform and introduced single password
capabilities for both. To address the tendency of users to rely on email to circumvent the system, they
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developed message board capabilities. In addition, they used POND4Kids capabilities to remove
identifiable information. Director 1 said:
It has grown a little faster since 2008, but we are still working on it...so we won’t be
sharing patient data, and the actual recommendation doesn’t have the name of the
patient, it just gives advice...it’s working now and people are finding each other and
using it more.
5.2.4. Oncopedia
Onocopedia was launched in 2007 as a reaction to the exponential growth in the number of meetings
on Cure4Kids and growing use of Consult4Kids. Oncopedia is a wiki-style system that enables users
to upload patient case-based information for sharing. The patient cases are peer reviewed by a team
of volunteer physicians who confirm information accuracy and HIPAA compliance. Director 1 said:
Both because of Consult4Kids and because of live meetings we saw an issue and
thought, “there are a lot of good teaching cases out there that aren’t being
captured”...we started talking and we thought about Wikipedia which was really growing
then, and we said “couldn’t there be a way in which you could submit an online case?”
We then thought about adding a formal peer review, quality check, and make sure it’s
accurate information and we started working on Oncopedia.
In addition to hosting case information from experts, the IOP recognized that local communities, often
in resource-poor countries, had unique cases or solutions. They envisioned Oncopedia as a way to
support the exchange of case-based information among users who could benefit from the experience
of others in similar communities. Director 2 said:
There was an issue regarding the diversity of pediatric cancer in the world...we know it
[cancer] from the US and Europe, but not other places in the world, maybe it’s the same,
but maybe it’s different...people were discussing cases that we had never really seen
here...so we decided to create something like Wikipedia to encourage people from other
countries to report very interesting cases and open them up for discussion to a much
larger community.
The IOP looked to the IT capabilities on Cure4Kids to develop Oncopedia. Programmer 1 said:
We reuse architecture as much as we can, and often the merging of capabilities from
different systems on Cure4Kids...so with Oncopedia we were able to easily swallow it up
as a Cure4Kids service...most of the functionality was already there so it [Oncopedia]
didn’t need a lot of additional work, or an additional log-in for the users...the main thing
there wasn’t technical, it was really more the peer review process and that has to do
with our volunteers not the technology.
In early 2007, the IOP piloted Oncopedia with one of its associate clinics and then tested the system
with all of its Central American associate clinics. Oncopedia went live in late 2007 and, by 2008, there
had been 20,000 items downloaded by 3,000 different users. The impact of Oncopedia is illustrated
by a post from a user who adjusted the treatment of a child as a result of accessing a case titled
“Cheek Mass for a Non-Hodgkin Lymphoma Case” that was posted on Oncopedia by Dr. X. The user
said:
I tried it with two girls of 18 and 24 months with this tumor, with LNHP 2000 Protocol
[and] excellent response to three years of survival at the moment, no express Medullary
disease or required RXT.
5.2.5. Cure4Kids for Kids
Launched in 2009, and piloted in Memphis, TN, Cure4Kids for Kids was aimed at developing
capabilities to support local-level outreach efforts and positively impact treatment and survival rates
by offering tools to support cancer education and prevention. Memphis was a logical choice for the
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pilot program because the city of Memphis has a number of grim health statistics related to obesity,
diabetes, and cancer that are well above the national average. The IOP developed partnerships with
local schools in the Memphis City Public School System, and, as part of the program, IOP physicians
visited the pilot schools to teach students about the biology of cancer, healthy lifestyle choices (e.g.,
smoking, diet, exercise, sun exposure, etc), and science. In addition, video games and educational
content designed for children, teachers, and parents were hosted on Cure4Kids for Kids. The IOP
leveraged Cure4Kids to develop new capabilities to support the Cure4Kids for Kids program. For
example, at one point, the IOP recognized a need for teachers to be able to create individualized
websites, and Cure4Kids did not have the web-hosting capabilities. Rather than developing or buying
the needed capabilities, the IOP utilized the group functions on Cure4Kids to support webpage
capabilities. Director 1 said:
So for Cure4Kids for Kids we took the idea of groups and we were able to create self-
contained sites...so for the teachers, they will have their own website, but what it
[website] really is, is a group.
At the time of our research project, Cure4Kids for Kids was still in the pilot phase. The IOP’s goal was
to develop a program that includes organizational processes and technical capabilities on Cure4Kids
to support users in developing collaboration with local schools aimed at cancer education and
prevention.
In this section, we describe our interpretations of how the IOP’s IT-investment decisions resulted in
the specific IT capabilities on its Cure4Kids IT-platform. In addition, we describe how the IOP reused,
modified, and reconfigured existing knowledge, processes, and assets to improve its outreach efforts,
which thereby extended the depth and breadth of impact. In Section 5.3, we describe the Cure4Kids’
IT characteristics that facilitated these actions.
5.3. IT-Platform Characteristics to Support International Outreach
In this section, we address the key IT characteristics of the Cure4Kids platform, which was driven by
an open access strategy that enabled the IOP to quickly react to new opportunities.
5.3.1. Open Access Strategy
The IOP pursued an open access strategy, evidenced by its philosophy to freely share its content,
processes, and technology with any organization or individual that shares its mission. The IOP
provided technical advice and guidance to help others use Cure4Kids to support their own IT
infrastructure, content, workflow processes, and knowledge sharing capabilities. To support these
activities, the IOP focused on developing IT-capabilities to enable open access to information and
facilitate the transfer to knowledge to clinics globally. This open access philosophy facilitated
“branding” and collaboration with other outreach organizations and led the IOP to adopt open source
tools to develop an adaptable IT-platform. Director 1 said:
Open access is fundamental to us...it’s in our organization’s DNA to share...the
distinguishing factor between Cure4Kids and similar sites, like WebMD, is that we are
providing free or open access...open access is critical for “branding” and collaboration...
we are encouraging other similar organizations to do that too...but, even within other
institutions, such as universities, and even other outreach programs, they have inflexible
internal systems that highly restricts the impact of their content.
5.3.2. Open Source
The IOP elected to develop Cure4Kids with open source tools for two primary reasons. First, it
determined that proprietary software was prohibitively expensive. Programmer 1 said:
If we didn’t use open source this wouldn’t be possible, it would cost too much, so it is
open source all of the time...for example, the entire operating system is open source –
Linux...the web server, Apache...the database system, if we had to buy it all the IOP
could not have created Cure4Kids as we know it.
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Second, the open source architecture provides stability since the IOP has access to all of the code. It
is also easier to find volunteers, collaborators, and new employees, who are familiar with open source
tools. Programmer 1 said:
The cost of a Visual C++…development environment… is huge stuff, you can do it, but
it costs $5,000 a seat...so just having that in mind I think there would be a lot less Visual
C++ developers than there are PHP developers...and it [open source] is easier to
integrate, and I would say that there are readily a lot of people available out there...if I
have a question or problem I can post a question online and you may get 10 answer
and a discussion going, so it’s an advantage to have all of those points of view rather
than a contract with a company and sitting on the phone with tech support.
5.3.3. Simple & Adaptable IT Platform
The IOP recognized the need for a simple and flexible platform that could be easily adapted for clinics
with unpredictable IT infrastructures, modified for varying levels of technical experience, and quickly
reconfigured to support the IOP’s outreach actions. The open source architecture helped achieve a
simple and adaptable IT-platform. Programmer 1 said:
We emphasize modularity, extendibility, and scalability and most of those right now are
in the open source arena...plus open source is cheaper and more flexible and can
match the different environments we work in around the world.
Adaptability is a key Cure4Kids characteristic: it is critical in supporting rapid growth of users, content,
and the ability to quickly launch new applications to meet the needs of users in very different areas of
the world in terms of technological infrastructure, language, and culture. Director 1 said:
We are providing access to knowledge at no cost, and everything that we have done
here with technology is to make the content available and accessible by low income
countries with low bandwidth connections, with technology that isn’t proprietary, its
modifiable and flexible, so we can meet their needs [users] very quickly.
The development of Oncopedia is an example of the adaptability of Cure4Kids. The IOP created
Oncopedia almost entirely by reconfiguring capabilities already embedded in Cure4Kids. The simple
and adaptable Cure4Kids platform enabled the IOP to integrate POND4Kids and live meetings to
capture and share content on Consult4Kids; content that had previously been lost at the end of each
consultation. Programmer 1 said:
We try not to reinvent the wheel, we think of how we can take our existing resources, it’s
like Lego’s, how do we take our existing technical assets and modify them so that we
can reuse them as much as possible.
By embracing the concepts of open access, open source, and simplicity, the IOP realized its vision of
creating a simple and adaptable platform that can quickly and effectively respond to new opportunities
and challenges. Director 1 said:
Open source, open access, the software is open source and our people also share their
knowledge freely and completely, so it’s almost as if it reflects the personality of the
people involved...open, agile, flexible, describe the platform, as well as the people.
5.4. Developing IT-Enabled Agility
In this section, we use the Sambamurthy et al. (2003) agility framework to analyze how the IOP’s IT-
investment decisions, and the resulting IT capabilities on Cure4Kids, impacted agility. Table 4
summarizes how the three dimensions of agility apply to the IOP and Cure4Kids.
Customer agility occurs when a firm utilizes the voice of its customers as a source for ideas for
innovation, as co-creators in the development of new products, and as product testers (Sambamurthy
et al., 2003). The IOP enhanced customer agility by responding to customer ideas and feedback in
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pursuing new opportunities for value creation, and engaging with them in the ongoing development
and testing of new products. For example, through this process, the IOP discovered some users were
reluctant to criticize or provide constructive criticism for fear of losing the service. The IOP addressed
this by reassuring the users and explaining that constructive criticism and feedback are critical to the
future success of Cure4Kids. As Cure4Kids matures, more users are providing feedback that will be
incorporated into future actions.
Partnering agility is a firms’ ability to leverage the assets, knowledge, and competencies of suppliers,
distributors, contract manufacturers, and logistics providers through alliances, partnerships, and joint
ventures (Sambamurthy et al., 2003). Partnering agility enables a firm to build a network of strategic,
extended, or virtual partnerships that facilitates the exploitation of new opportunities and
enhancement of its own capabilities (Sambamurthy et al., 2003). IT improves communication and
enhances collaboration across firms. As such, it serves as a strategic differentiator that distinguishes
a firm from its competitors, which leads to improved performance. The IOP focused on using IT to
develop partnerships with like-minded global health outreach organizations in an attempt to extend
the impact of its outreach actions. To support these partnerships, the IOP used IT to facilitate the
integration of knowledge through collaboration with the aim of extending the reach and richness of
each organization’s actions. For example, the IOP successfully partnered with organizations such as
Medpedia, the American Cancer Society, the International Society of Pediatric Oncology, the United
Nations, and others. The IOP recognized that, by breaking down silos and collaborating with
institutions with similar missions (i.e., to improve healthcare), together they could overcome
knowledge and resource constraints and collectively achieve a more significant impact.
Table 4. Examples of IT-enabled Agility in the IOP
Key
applications
Type of
agility
Example
Cure4Kids
POND4Kids Customer
agility
Associate clinics served as the “go-to” testers for all new
Cure4Kids programs prior to going live for all users.
Users served as a source for ideas for the development of new
programs. For example, a physician at a clinic expressed concern
about a lack of process workflow capabilities; the IOP saw this as
an opportunity to address a clinical need and developed
POND4Kids in response.
Cure4Kids
Oncopedia
Consult4Kids
Cure4Kids for
Kids
Partnering
agility
Cure4Kids served as a “strategic integrator” by facilitating
“branding” and outreach collaborations that resulted in the
integration of resources among like-minded organizations (i.e.,
American Cancer Society, etc.) aimed at achieving a greater
collective impact on global health.
The IOP partnered with local school administrators to launch
Cure4Kids for Kids, an outreach to school children focused on
cancer education and prevention.
Cure4Kids
POND4Kids
Oncopedia
Consult4Kids
Cure4Kids for
Kids
Operational
agility
Oncopedia is an integrated system that allows users to upload
case related content onto Cure4Kids thereby expanding the depth
and breadth of knowledge exchange.
Cure4Kids’ open source architecture provided a simple and
adaptable platform that facilitated rapid reconfiguration and
reorganization of assets to extend the impact of the IOP’s outreach
efforts from 18 associate clinics to over 35,000 users worldwide.
Cure4Kids resulted in reduced costs, improved communication,
and improved clinical outcomes.
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Operational agility reflects the ability of a firm’s business processes to achieve speed, accuracy, and
cost economy, which ensures that it can rapidly redesign existing processes to exploit opportunities
and gain a competitive advantage in commercial markets (Sambamurthy et al., 2003). The IOP
concentrated its efforts on developing a simple, flexible, and modifiable IT-platform. The choice to use
almost exclusively open source tools was a low-cost alternative that made it possible for the IOP, with
its operating budget supported primarily by donations, to create the robust Cure4Kids IT platform. The
IOP was continually able to utilize the digital options built into the platform to reconfigure resources
and quickly react to new opportunities.
The IOP’s IT investments led to increases in all three dimensions of agility. As a result, the number of
users grew exponentially and more clinics could access content. Collaborative partnerships with other
global outreach organizations resulted in a greater depth and breadth of knowledge exchange with
communities in need. Operational costs decreased while knowledge transfer increased.
6. Performance Measures-Social Value Creation for Internernational
Outreach
Identifying meaningful performance metrics was was difficult for the IOP. The organization
repeatedly emphasized the importance of idenitifying meaningful success metrics to determine
the efficacy of its existing activities in order to effectively guide future strategy. Director 2 said:
“Measurement, we struggle with what meaningful [success] indicators are”.
In the previous section, we use the Sambamurthy et al. (2003) conceptual model of agility to analyze
the positive impact of the IOP’s IT-decisions on customer, partner, and operational agility. In this
section, we examine the relationship between increased agility and performance outcomes. We found
that the performance measures in the existing agility literature (e.g., return on investment, revenue,
market share, etc) did not translate well to the context of the IOP. As Director 2 said:
So, ROI...there are many ways that we can calculate this, do a cost benefit analysis
from let’s say 10 years ago to today, so you provide a seminar on Cure4Kids vs. having
to send all of those people on a plane trip somewhere, it’s simple, and it tells us
something about ROI...but I always go back to—it is the “unknowns”…that are more
important to us, it’s not so much the monetary as providing access on demand and that
unknown impact that occurs somewhere...that is the important thing, the real value, and
we can’t capture that with ROI.
To examine how agility impacted performance, we identified performance measures that the IOP used
to determine success, which allowed us to examine the relationship between agility and performance
in the context of a SE. We identified the following performance measures: impact on a social need,
empowering the user, resource integration through collaboration, facilitating clinical data and process
standardization, dissemination of information, and improved operational processes.
6.1. Impact a Social Need
The most important indication of success was a positive impact on survival rates:
The ultimate metric is a higher survival rate...which we have in our partner cities; we’ve
gone from 30 percent to 70 percent (Director 1).
The IOP’s annual reports indicate that at an associate clinic in Recife, Brazil (regular users of
Cure4Kids), the cure rates for childhood cancer went from 29 percent to 60 percent. In addition, the
probability of 4-year survival for El Salvadoran children with acute lymphoblastic leukemia increased
from 10 percent to 60 percent over an eight-year period. A study conducted at another associate clinic
determined that survival rates for Acute Lymphoblastic Leukemia (ALL) had risen to 70 percent. The
IOP also found that the clinic had realized improvements in survival rates across all diseases: “It
turned out that everything got better; it wasn’t just ALL [Acute Lymphoblastic Leukemia]” (Director 4).
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6.2. Empower Users
The IOP recognized success when the exchange of knowledge, technology, and organizational
processes enabled users to improve treatment and increase survival rates in their own communities.
Before Cure4Kids, the transfer of knowledge, technology, and organizations processes was restricted
to its associate clinics and was a one-way flow of information. Access to Cure4Kids empowered local
healthcare providers and communities, extended the impact, and improved sustainability of the IOP’s
outreach efforts. Collaboration among communities on Cure4Kids, independent of the IOP, is a
powerful success indicator for the IOP. Director 3 said:
There are so many communities that need help...and we can’t help everyone...you can’t
have one doctor going to Morocco, and to Central America, and the Middle East, and
then back here to treat patients...there is just a finite amount of resources…so
Cure4Kids helps us reach other places that need access to the expertise at St Jude...we
give them that expertise so they can help themselves.
One example occurred in response to a shortage of specialists in Central America. There are roughly
20 pediatric oncologists in all of Central America (SJCRH has over 40). These 20 oncologists are
trained as generalists; however, to meet the needs of their patients, each one must become a
specialist in a variety of cancers without the necessary resources and training. A group of Central
American oncologists used Cure4Kids to develop a solution. As Director 4 said:
They worked out a system in Central America where they assigned each doctor to a
specialty…for example, they said for Burkett Lymphoma this doctor in Honduras is going to
be in charge of that…So all seven countries use the exact same treatment, review all the
patients, and have meetings weekly, and every Friday afternoon is “Burkett Lymphoma
happy hour”...the doctor from Honduras sets up the meetings …what is interesting is that
this guy had no specific training in this area…he was a pediatric oncologist who saw every
kind of patient, and now he has developed into an expert.
Another example occurred when a group used Cure4Kids to share resources and provide desperately
needed medicine to a patient:
[Cure4Kids] is enabling people to help people…basically using the technology to
communicate their knowledge and help out in material ways...one example, we were
having a meeting of the Central American group…they were discussing a patient, the
treatment plan, how they were using the protocol, and what needed to be modified in
the future. Someone typed a comment that they had a patient with a certain type of
cancer. For this cancer there is a medicine that increases survival rates by 30 percent,
but they were out of the medicine. So they said…does anyone have any that they could
loan us? The chat started going back and forth…by the end of the conversation
someone from a neighboring country that had the medicine had made arrangements to
put the medicine on a bus and ship to the physician who requested it…they said it will
be put on a bus at 2pm and the bus will be there by 6pm…the patient got the medicine
that day…that was really, really good, because the whole point is St. Jude can’t help
everyone, so we try to help people help each other (Director 4).
6.3. Integrating Resources through Collaboration
No single organization could meet the challenges of treating children with cancer in resource-poor
countries. As a result, the IOP viewed collaboration and the integration of resources among global
outreach institutions to be essential to achieving a meaningful impact. Director 1 said:
So, with the “Y” society, one of their sites wasn’t growing, I proactively said “we will give
you some links to our content that you can access freely”...it helped them, they grew,
and could sustain their site...and you know if their site doesn’t grow then they aren’t
meeting their mission—right? There is no one to drive traffic if their site falters...we don’t
want that to happen because that avenue for content would be lost to someone who
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needed the information...it wouldn’t benefit the treatment of a child somewhere in the
world...so I am glad that we were of help to them and their site grew...we have had more
downloads too because others share content links on Cure4Kids...collaboration is
critical and everyone benefits.
6.4. Data Process Standardization
The IOP emphasized the importance of helping clinics develop standard protocols with data analysis
capability and performance metrics. Prior to Cure4Kids, clinics often did not have adequate workflow
processes or medical record capabilities. Cure4Kids facilitated the transfer of both knowledge and
processes that enabled the clinics to launch new standardization processes to improve treatment and
outcomes. For example, when clinics adopt POND4Kids, they immediately engage in processes that
support data standardization, which results in improvements in tracking treatment-based outcomes.
Director 4 said:
When you have a pull down menu that has five items on it people are forced to put their
data into this framework and in a way this forces a level of quality of thinking...I don’t
know how to quantify the benefit exactly, but eventually I can imagine that POND is the
only way that childhood cancer information is collected and stored there and this would
make it possible to do some better analysis on clinical outcomes.
The IOP later examined the impact of POND4Kids at an associate clinic and found that POND4Kids
facilitated standardization that resulted in improved treatments and survival rates:
If they are tracking, and they know the protocol, then they think “If we are going to
deviate from the standard plan there should be a reason why”...We studied this impact
in Brazil, and we clearly saw that their ALL results had improved...there were also things
done to make that improvement, like to reduce abandonment, improve transportation,
housing, job training, a lot of different things...later we studied the effect of this on all of
the other diseases and it turns out everything got better, it wasn’t just ALL (Physician).
6.5. Dissemination of Information
Sharing knowledge, technology, and organizational skills is at the core of the IOPs mission. Before
Cure4Kids, the IOP only shared information with its associate clinics. Since launching Cure4Kids, the
IOP’s ability to share knowledge, technology, and organizational processes expanded dramatically,
reaching over 35,000 users worldwide. One IOP Physician said:
You can’t substantiate the impact on these poor countries...you know, access to
information about medicine, treatment and plans, how to decrease infections in the
hospital environment...even as basic as the benefits of washing hands.
Another example occurred after an IOP Physician visited a non-associate clinic in Africa. He recalled
his observation of the availability of information at the clinic before and after Cure4Kids:
Before Cure4Kids we would go to a center in Zimbabwe...even in the year 2000 they
were still using information from the 1970’s because that is what they had access
to...now that is not true today, because of Cure4Kids.
For the associate clinics, Cure4Kids significantly impacted the timely availability of clinical information.
Before Cure4Kids, there were long periods of time between site visits and communication with the
associate clinics, sometimes with negative consequences. Director 4 said:
Communication and collaboration is the most important thing…and we didn’t even know
that five years ago…in retrospect we see it…five years ago a physician from the IOP
would personally visit each partner site, read everything, meet all of the people, look at
the hospital, data, train people…it was very time and labor intensive…and even more
sad, sometimes after a year and a half passed and you realized something came up
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right after the last visit…so for a year and five months something that could easily be
addressed was not…by having weekly meetings on Cure4Kids everybody is there…it’s
informal and things are solved casually, fairly informally, and timely.
The IOP measures the impact of Cure4Kids on the dissemination of information by tracking usage
data. In 2002, there were 35 registered users on Cure4Kids, all of whom were located at an associate
clinic. In November 2011, there were 29,000 registered users in 178 countries, over five million items
had been downloaded, and over 18,000 seminars were hosted on the site. By June 2012, Cure4Kids
had 32,633 registered users with six million downloaded items.
6.6. Organizational Improvements
Internal process improvements were an important indicator of success for the IOP. Cure4Kids
enabled the IOP to facilitate internal organizational process improvements not only in the IOP, but
also in the entire SJCRH organization. This included improved efficiency, decision-making, and
managerial foresight. The use of Cure4Kids by SJCRH increased exposure for SJCRH, and facilitated
greater fundraising opportunities and results for SJCRH. Director 1 said:
We share our podcasting and knowledge of the technology with the IT Department on
the St Jude side...more St Jude employees use Cure4Kids and that’s important, we
want to add value to St. Jude too.
Cure4Kids increased awareness, recognition, and associated fundraising for SJRCH. As a result,
SJCRH recruited several high-profile visitors that have generously supported SJCRH. Director 1 said:
When those high profile visitors come here they often donate $5,000 or $10,000
dollars...the recognition that they bring also helps with fundraising campaigns... so,
because of our success we are able to contribute to fund raising efforts at SJCRH.
Before Cure4Kids, the IOP simply focused on fulfilling the original expectations of extending the
impact of SJRCH beyond its Memphis hospital campus. Cure4Kids enabled the IOP to “give back” to
SJCRH in terms of improved processes, improved information and collaboration resources, and
improved fundraising capabilities.
7. Discussion
Our case study, conducted over a four-year period (2008-2012), has documented the linkage
between entrepreneurial alertness, IT-investment decisions, agility (customer, partnering, operational),
and performance in the social sector context. Our analysis clearly shows that such a linkage can be
found where the overarching goal of the firm is the creation of social value rather than obtaining a
competitive advantage and securing higher profits. These findings also provide empirical support for
the agility perspective as proposed in prior literature. (Nazir & Pinsonneault, 2008; Neumann & Fink,
2007; Oosterhout et al, 2006; Overby et al., 2006; Piccoli & Ives, 2005; Sambamurthy et al., 2003;
Tallon & Pinsonneault, 2011). In this section, we discuss our findings and contributions, and offer
propositions to guide future research related to IT-enabled agility.
Our study provides contextually sensitive contributions (Chiasson & Davidson, 2004) that extend our
existing understanding of IT-enabled agility (Oosterhout et al., 2006; Overby et al., 2006,
Sambamurthy et al., 2003; Tallon & Pinsonneault, 2011) to the social sector context by showing how
IT helped the IOP become more agile and how increased agility resulted in improved performance.
Social sector organizations, such as the IOP, operate in turbulent environments and adopt
entrepreneurial business practices to guide the transformation of materials and labor into products
and services of greater value (Austin et al., 2006). This study illustrates that SEs can benefit from
improved agility. Traditional healthcare outreach methods restricted the ability of the IOP to achieve a
positive global impact on the treatment of children with cancer outside of its direct relationships with
associate clinics. In response, the IOP invested in IT and developed specific IT capabilities to extend
the breadth of its impact; these included a web-based digital library, live meeting capabilities, workflow
process capabilities, and a wiki-style resource for user generated case based knowledge exchange.
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We documented that these capabilities resulted in increased customer, partner, and operational agility,
which lead to improved performance. As a result of these innovations, we found that, in the case of
the IOP, the flow from turbulence to success through agility held true. Specifically, we found that, for
the IOP, agility was manifest in specific IT platform-related decisions. For example, the decision to
develop an IT architecture with open source tools provided cost savings and direct access to the code,
which resulted in a simple and adaptable platform that supported rapid reconfiguration and the
addition of new features, which, in turn, lead to increased operational agility. The platform improved
the IOP’s ability to meet the needs of its international users with varying levels of IT infrastructure in
over 180 countries. Therefore, we propose that:
P1a: The use of open source tools to develop an IT platform lead to quicker
development of new IT capabilities.
P1b: Quicker development of new IT capabilities leads to higher levels of operational
agility.
P1c: The use of an open source architecture leads to fewer conflicting standards.
P1d: The use of an open source architecture leads to higher levels of flexibility resulting
in higher levels of international access.
P1e: Higher levels of international access leads to higher levels of partnering agility.
The IOP incorporated mechanisms to support user-generated content that increased customer agility.
For example, Oncopedia facilitated user contributions that resulted in an increase in knowledge
exchange related to unique, locally relevant treatment contexts. Therefore, we propose:
P2a: Open source architectures that incorporate mechanisms for user generated
content lead to higher levels of flexibility in establishing an information portfolio.
P2b: Flexible, IT-enabled user-generated content information mechanisms, lead to
increased customer agility.
Earlier agility studies (Neumann & Fink, 2007; Oosterhout et al., 2006; Overby et al., 2006; Piccoli &
Ives, 2005; Sambamurthy et al., 2003; Tallon & Pinsonneault, 2011; Tseng & Lin, 2011) propose that,
for agile firms, “IT serves a strategic differentiator” that provides a competitive advantage in the
boundaries of for-profit organizations operating in turbulent markets. Our study differed from these
conceptions of agility in one important way; we observed that, for SEs, IT serves as a “strategic
integrator” that increases social value creation by decreasing differentiation in turbulent social sector
contexts by facilitating resource integration among SEs working toward similar social missions. Our
results demonstrated how the IOP successfully used Cure4Kids to launch its “branding” program to
effectively integrate resources across like-minded organizations and thereby extending the impact of
all participating organizations on global health outcomes. This differs significantly from the context of
for-profit organizations that could potentially be accused of price fixing or other anti-competitive
practices if they engaged in this degree of collaboration. Our study extends current agility concepts by
demonstrating how the IOP’s decision to create a program to link and share content across websites
facilitated resource integration among like-mined organizations and resulted in increased partnering
agility and improved performance. In the case of the IOP, the Cure4Kids IT platform served as a
strategic integrator that facilitated higher levels of partnering agility and improved performance.
Therefore, we propose:
P3a: In turbulent social sector contexts, IT serves as a strategic integrator that leads to
the integration of resources among SEs with similar social missions.
P3b: A higher level of resource integration among SEs with similar social missions
reduces differentiation among SEs in the social sector market.
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P3c: Reduced levels of differentiation among SEs in the social sector market results in
increased enterprise agility.
Finally, existing agility studies propose a positive relationship between agility and success in the
context of commercial markets (Overby et al., 2006; Piccoli & Ives, 2005; Sambamurthy et al., 2003;
Tallon & Pinsonneault, 2011). Common across all of these studies, improved financial performance is
the ultimate performance variable of interest. The impact of agility on performance has been
measured in terms of return on investment (ROI), increased market share, return on assets, and net
margins (Overby et al., 2006; Sambamurthy et al., 2003; Tallon & Pinsonneault, 2011). In the case of
the IOP, these financial performance indicators were not meaningful. Our study extends the current
understanding of the relationship between agility and success by documenting meaningful
performance measures for social sector contexts. In the context of the IOP, we found evidence of a
positive link between increased agility and increased performance in terms of the following measures:
positive impact on a social need, empowering users, facilitating collaboration and resource integration,
dissemination of information, data and process standardization, and improved internal processes. We
observed that, in turbulent social sector contexts, meaningful performance measures differ from those
commonly used to determine success in for-profit organizations. Therefore, we propose:
P4: In the social sector context, key performance indicators include non-profit related
outcomes such as: a positive impact on a social need, empowering users,
integration of resources through collaboration, dissemination of information, data
and process standardization, and improved internal organizational processes.
Prior to 2000, the IOP had developed an effective international outreach program focused on
improving the treatment and survival rates of children with cancer and other catastrophic pediatric
illnesses through the exchange of knowledge, technology, and organizational processes. The IOP
had demonstrated, with twinning programs at its associate clinics, the ability to sense opportunities to
address clinical needs in resource-poor countries and seek appropriate organizational responses.
This existing entrepreneurial alertness (Overby et al., 2006; Sambamurthy et al., 2003) shaped the
IOP’s IT-related decisions that led to the creation of digital options and the development specific IT-
capabilities on the Cure4Kids platform between 2000 and 2012. The IOP’s ongoing experience with
Cure4Kids resulted in a learning process that emphasized continuous entrepreneurial alertness
(sensing and responding) for using IT to effectively address new opportunities and perceived needs.
As a result, the IOP emerged a more agile organization adept at using Cure4Kids to strengthen its
customer, partner, and operational agility, enabling the organization to quickly launch new initiatives.
Our study offers evidence of the relationships between IT, agility, and success. Specifically, we
demonstrate that, in the context of our study, manifestations of IT-related decisions are related to
increased agility, and we observed increases in each of the three types of agility. In addition, we offer
evidence that increased agility resulted in improved performance. Finally, we provide evidence for
new success measures that are more relevant in the social sector context of our study.
7.1. Future Research
Our findings have implications for future research into IT-enabled agility. In this project, we documented,
in the context of our study, a positive link between entrepreneurial insight, a firm’s IT platform, enterprise
agility, and increased performance outcomes. We also demonstrated how the Sambamurthy et al.
(2003) conceptual model can inform the investigation and analysis of IT-enabled agility in different
organizational contexts. Future studies could further develop existing conceptual agility models by
examining IT-enabled agility in additional organizational types and contexts where there are differences
in managerial competence. Second, we suggest that IT can serve as a strategic integrator that can
positively impact agility and performance outcomes. Further studies could empirically validate this
insight and investigate the relationship between IT, agility, and value creation in the context of new
market environments such as emerging markets centered on social networking technology (e.g.,
Facebook, Twitter, etc). Finally, we document that existing financially focused measures of performance
do not adequately address the idiosyncrasies of some specific contexts, such as those found in the
social sector. Future studies can extend this insight by exploring the relationship between IT, agility, and
performance in different contexts including other social sector environments, non-profits, health care
contexts, governmental organizations, and emerging organizational forms.
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7.2. Limitations
As with any research, there are several limitations that should be considered in interpreting the results
of this study. While we have conducted a rigorous and in-depth longitudinal case study, our sample is
limited and specific in context (healthcare outreach). Therefore, we must be cautious when
considering transferring these findings to additional contexts. In addition, our research is interpretive
in nature and we recognize that the inherent biases of the researchers influenced our interpretation of
the data and the presentation of the results.
We chose to conduct this case study at St. Jude Children’s Research Hospital’s International
Outreach Program because it provided a unique opportunity to examine a context not previously
explored in the agility literature. SJCRH, and its IOP, are leaders in the field and the exemplary nature
of the organization presents some limitations. Some of the strategies and actions captured in our
interpretation may not work as well for SEs with more limited resources. In addition, the leadership
and philosophy of the IOP may be very idiosyncratic to the personality, confidence, and competence
of this unique SE. As a result, it should be acknowledged that the solution that provides agility for the
IOP may not translate well to smaller, less-progressive organizations that do not have the same level
of technical capability.
8. Conclusion
We applied the Sambamurthy et al. (2003) conceptual model for agility to help explain how a SE
operating in the turbulent context of global health outreach leveraged IT to overcome the limitations of
traditional outreach models by developing specific IT capabilities that resulted in greater depth and
breadth of impact on the treatment of children with cancer. From a practical point of view, these
findings can provide a template that can inform practitioners about how to structure similar programs.
Our research contributes to the understanding of the relationships between IT, agility, and success by
demonstrating how IT can help organizations sense and responds to new opportunities to improve
performance (Overby et al., 2006; Sambamurthy et al., 2003; Tallon & Pinsonneault, 2011). We
examine these relationships in the previously unexplored social sector context by analyzing how one
SE’s IT decisions to develop specific IT capabilities enabled it to become more agile in the pursuit of
its mission. We identify specific decisions that enabled the SE to sense opportunities and challenges
in the environment and to respond by reconfiguring its resources to develop specific IT capabilities
that increased customer, partner, and operational agility. We demonstrate how the SE developed
digital options that were used to shape new capabilities that positively impacted performance. We
illustrate that existing financially focused performance measures did not adequately translate to the
SE context and we identify new measures of success that are more relevant to social sector
organizations. Finally, we discover that, in the context of this study, the value of IT emerged from its
role as a strategic integrator that facilitated the integration of resources among like-minded outreach
organizations, increasing performance outcomes relevant to the social sector context.
Acknowlegements
We wish to thank the anonymous reviewers for offering their insights which were very helpful to us
with each revision. We would also like to express our thanks and gratitude to Varun Grover for his
guidance and support throughout the review process.
Journal of the Association for Information Systems Vol. 15, Issue 1, pp. 1-32, January 2014
Richardson et al. / Agility in the Social Enterprise
27
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Appendices
Appendix A.
Table A. Definitions of Social Enterprises from Existing Literature
Source
Definition
Leadbetter
(1997)
Engaging in entrepreneurial behavior for social ends rather than for profit objective, or
alternatively, that profit generated from market activities are used for the benefit of addressing
social needs
Dees (1998)
Being a change agent in the social sector by a) adopting a mission to create and sustain social
value (over private value), b) sensing and relentlessly pursuing opportunities to serve that
mission, c) engaging in a process of continuous innovation, adaptation and learning, d) acting
boldly without being limited by current resources, and e) exhibiting heightened accountability to
the constituencies served and outcome created
Drayton
(2006)
A major change agent, whose core values center on identifying, addressing, and solving societal
problems
Mort et al.
(2002)
A multidimensional construct involving the expression of entrepreneurially virtuous behavior to
achieve a social mission…the ability to recognize social value creating opportunities and key
decision-making characteristics of innovation and risk-taking
Pearce (2003)
Non-profit organizations that pursue social objectives through the sale of goods or services
Alford et al.
(2004)
Creates innovative solutions to social problems, mobilizes ideas, capacities, resources, and
social arrangements required for social transformation
Dart (2004)
A strategic response to many of the varieties of environmental turbulence and situational
challenges that nonprofit organizations face
Tan et al.
(2005)
Making profits by innovation in the face of risk with involvement of a segment of society in need,
where benefits accrue to that same segment of society
Mair & Marti,
(2006)
...creating value through the innovative use and combination of resources…explore and exploit
opportunities to create social value by catalyzing social change or addressing social needs
Harding
(2006)
businesses trading for a social purpose…an organization with social objectives who surpluses
are reinvested for that purpose in the business or in the community, rather than being driven by
the need to maximize profit for shareholders an owners
Peredo &
McLean
(2006)
Aimed at creating social value…shows a capacity to recognize and take advantage of
opportunities…employ innovation…accept and above average degree of risk…unusually
resourceful…in pursuit of a social mission
Martin &
Osberg (2007)
Social entrepreneurship is the: (1) identification of an unjust equilibrium that causes the
exclusion, marginalization, or suffering of a segment of humanity that lacks the financial means
or political clout to achieve any transformative benefit on its own; (2) identification of an
opportunity in this unjust equilibrium and developing a social value proposition to challenge the
equilibrium; and (3) forging a new equilibrium that alleviates the suffering of the target group
through imitation and the creation of a stable ecosystem that ensures a better future for the
targeted group and society
Certo & Miller
(2008)
Social entrepreneurship involves the recognition, evaluation, and exploitation of opportunities that
result in social value—the basic and longstanding needs of society—as opposed to personal or
shareholder wealth
Zahra et al.
(2009)
Encompass activities and processes undertaken to discover, define, and exploit opportunities in
order to enhance social wealth by creating new ventures or managing existing organizations in
an innovative manner.
Faminow et
al. (2009)
Innovative learning organizations with a mission to create social value in risky adverse
environments characterized by one or more market failures
Murphy &
Coombes
(2009)
A venture intended to promote a specific social purpose a context of mobilization or a shared
orientation about a social purpose which can transcend the boundaries of a venture and
subsume many constituents.
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Appendix B.
Table B1. Interview Protocol
1. Who am I interviewing?
a. What is their role?
b. What is their relationship to Cure4Kids?
c. What is their educational/experiential background?
2. General Information about Cure4Kids?
a. How does Cure4Kids fit into the overall SJCRH/IOP?
b. Why was the Cure4Kids program established?
c. Why was the Cure4Kids program established?
d. What is the Mission of the Cure4Kids program?
e. Is the contribution of C4K partitioned from the overall IOP?
3. How is Cure4Kids funded?
a. How does the funding structure impact decisions about growth strategies?
b. What types of “failures” have resulted in the flow of resources away from C4K and toward
another IOP project?
c. What role do your customers play in obtaining funding?
d. What role do your strategic partners play in obtaining funding?
4. Who are your customers?
a. How do they become customers?
b. How do they know about Cure4Kids?
c. How do they use Cure4Kids?
d. How do they integrate Cure4Kids services into their organization?
5. Who are your partners?
a. How do choose a strategic partner?
b. Who are your strategic partners?
c. How do strategic partnerships evolve?
d. How is the Cure4Kids IT-platform leveraged to enable strategic partnerships?
e. What is the goal of strategic partnerships?
6. Who do you consider your competition?
a. How is the Cure4Kids IT- platform leveraged to deal with competition?
b. How does Cure4Kids differentiate itself from the competition?
c. How do competition organizations fit into Cure4Kids’ strategic planning?
7. Describe the Cure4Kids IT-platform/architecture?
a. Software (purchased, built in-house, etc?)
b. How did you decide on the individual elements of the IT-platform?
c. How did the your “customers” shape your choices in developing the IT-Platform?
d. How did your strategic partners shape your choices in developing the IT-Platform?
e. How did your competition shape your choices in developing the IT-Platform?
f. What are the most important characteristics you considers when building the C4Ks
platform? (ease of use, scalability, etc.)
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Table B1. Interview Protocol (cont.)
8. How do you decide to build new products or services?
a. Triggers for new products/services
b. Triggers for improvements
c. Problems/failures
d. Successes
e. Any surprises?
f. How do you discover new opportunities to develop products and services?
g. How does C4Ks leadership shape the technical IT platform?
9. How do you go about researching new products and services?
a. Where do the ideas come from?
b. How do you leverage the Cure4Kids IT-platform when developing new products and
services?
c. How does the IT platform provide a foundation for new services or solutions?
d. How does Cure4Kids handle speed to market (prioritize)?
e. In what ways have you had to be innovative and agile in developing solutions based on
community need?
f. How does the C4Ks IT platform allow you to be creative with limited resources and
employing current capabilities to address needs/solutions?
g. Percentage of solutions that are improvisational vs. planned (strategic)
10. When a solution or service isn’t working?
a. How do you know?
b. What do you do?
c. An example of dropping a program or service?
d. An example of reacting to fix a problem?
11. What is success for Cure4Kids?
a. How is Cure4Kids evaluated by the IOP/SJCRH?
b. Success Measures?
c. What is a good outcome?
d. How do you know you’ve been successful (even if you aren’t measuring?)
e. What changes do you see in the communities, or feedback do you get?
f. How do you know when you have implemented something, but could do better?
g. What would be a good success measure that you are not currently collecting data on?
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About the Authors
Sandra M. RICHARDSON is an Associate Professor of Management Information Systems in the
Fogelman College of Business and Economics at the University of Memphis. Dr. Richardson’s
research focuses on the development and implementation of IT strategy, inter-organizational
collaboration, IT management, and the implications of IT on organizations, individuals, and society.
Her research focuses on IT use in three contexts; general organizations, healthcare organizations,
and social entrepreneurism. Her general organizational research focuses on interorganizational
collaboration, project management, and IT strategy. Related to healthcare, her research primarily
focuses on the impact of information systems on global medical education, improving patient
outcomes, and facilitating patient decision support. In the social sector context, her research
investigates how social enterprises leverage information technology to offer goods and services to
address the social needs of a community and society (i.e., healthcare, hunger, education, disaster
recovery, etc.). He holds a PhD in Management Information Systems from the University of Central
Florida and a master’s degree in Management Information Systems from Texas Tech University.
M. Shane BANKS is an Assistant Professor in the Department of Computer Science and Information
Systems at the University of North Alabama. He received his Ph.D. in Management Information
Systems from the University of Memphis. His research has appeared in the Journal of Information
Technology Management and the proceedings of the Americas Conference on Information Systems.
His research interests include IT-enabled value creation, online social media, healthcare information
systems, and IT-enabled social enterprises.
William J. KETTINGER is Professor and the FedEx Chair of Excellence in MIS at the Fogelman
College of Business and Economics at the University of Memphis. He formerly held the position as
Professor and Moore Foundation Fellow at the University of South Carolina. He has also regularly
taught in the MBA programs at IMD in Lausanne Switzerland, Wirtschaftsuniversität Wien, Vienna
Austria and at the Tecnologico de Monterrey in Mexico. He has over 100 publications including four
books, over 65 refereed journal articles in such journals as ISR, MIS Quarterly, EJIS, JMIS, JAIS, ISJ,
Decision Sciences, and Sloan Management Review. He currently serves as a Senior Editor of MISQ
and MISQ Executive. He also serves, or has served, as an Associate Editor of MIS Quarterly,
Information Systems Research and JAIS, and has twice served as a special senior editor for JMIS.
He received the Society of Information Management's best paper award and directed a SIM APC
study on IT value. His research seeks to offer rigorously derived strategic answers for practicing
managers.
Yuri QUINTANA is the Director of Education and Informatics in the International Outreach Program at
St. Jude’s Children’s Hospital. He has led the development of several international online projects,
including www.Cure4Kids.org, a pediatric cancer education website used by thousands of health
professionals in over 180 countries. Prior to joining St. Jude, He was a principal investigator in the
Canadian HealNet Research Network focusing on consumer health informatics; while there, he
designed breast cancer decision support systems for the Canadian Cancer Society. Formerly a
faculty member at the University of Western Ontario, Quintana also served as director of the New
Media Research Lab. He has held high-tech positions at IBM Canada Limited, Watcom Inc., WATFAC,
and the University of Waterloo, and has chaired four international conferences on medical informatics,
Quintana earned master’s and doctoral degrees in systems design engineering and an
undergraduate degree in electrical engineering and computer science, from the University of Waterloo.
Quintana’s research focuses on the development of innovative Internet technologies that empower
communities of health care professionals and consumers to communicate, learn, and collaborate
worldwide.