1.1 Background

The concept of a VUCA world, characterized by volatility, uncertainty, complexity and ambiguity that emerged after the Cold War, has given way to the notion of a BANI world (introduced by the Covid-19 pandemic), which highlights the brittleness, anxiety, non-linearity and incomprehensibility of our times. This change underlines how reality is currently unpredictable and that the only certainty we have is change (“change is the new normal” [1]) [2].

The accelerated urbanization of the global population poses considerable challenges to conventional health systems, making the task of meeting citizens’ needs progressively more challenging [3]. Thus, Health 4.0 is emerging as a crucial element in future socio-economic planning, promoting multiple benefits for the health system [4].

In the European context, and particularly in Portugal, digitalisation is being promoted as a solution to make the health sector more efficient and accessible, potentially generating significant economic benefits [5]. However, Huaytan et al. [6] point out that any digital transformation strategy must be comprehensive and coordinated, encompassing technological, regulatory, educational and financial aspects. The accomplishment of smart health depends on various components, such as smart ambulance systems, smart hospitals, wearable devices and emergency response [7], enabling connected medical devices and smart systems to promote diagnostics, health monitoring and well-being [3].

Thus, digitalisation has emerged as a promising “remedy” for increasing efficiency and accessibility in the health sector. However, it is necessary to digitise healthcare without losing humanity. According to Chaabi [8], the focus of Industry 4.0 is the automation of processes and the integration of new technologies, but in contrast, Industry 5.0 shifts the emphasis to a human-centred model, repositioning human workers at the centre of the production process [9].

As Feki and Boughzala [10] state, “digital transformation is more than just technological change”. Digital transformation in healthcare is therefore a phenomenon that goes beyond mere technological change; it is a reconfiguration of the practices and structures that form the heart of healthcare. We are witnessing an evolution that changes the way healthcare is designed, delivered and managed. The Covid-19 pandemic has accelerated this process, highlighting the urgent need for innovation and the adoption of new ways of providing health services, facilitating diagnoses and ensuring data analysis, as the studies by Dal Mas et al. [11] and Megawati et al. [12] illustrate.

Furthermore, Wanasinghe et al. [13] discuss the concept of human-centred digital transformation, emphasizing the importance of prioritizing the humanisation in digital initiatives. These insights highlight the need to incorporate human-centred principles on the path to digital transformation in healthcare to ensure that the needs, competencies and perceptions of healthcare professionals and stakeholders are adequately addressed throughout the process [14]. In line with this topic, research by Jarva et al. [15] highlights the importance of healthcare professionals’ perceptions of digital health competence, emphasizing the importance of understanding and addressing the skills and competences required for a successful digital transformation.

The centrality of the human being in digital transformation is not only an ethical issue, but also a strategic one. Cutting-edge technologies, no matter how advanced, need a human touch to ensure that they are effectively adopted and that they really add value to processes in the specific context of healthcare. This means creating systems that are intuitive, accessible and that improve interaction between healthcare professionals and patients. Thus, this balance between technology and humanity is fundamental to building trust and for digitalisation to be truly transformative. Adopting practices that promote digital inclusion and ensuring that all healthcare professionals have the necessary skills to use the new technologies, are crucial steps in this process [16]. In this way, it can be ensured that hospital digital transformation is carried out in an inclusive and equitable manner, paving the way for more personalized and patient-centred healthcare [17–19].

We are moving towards a Society 5.0, which aims to address social issues to raise people’s standard of living. Achieving this goal will be facilitated by technology and the transition to a socio-economic system that prioritizes the recognition and appreciation of human and environmental capital, to the detriment of the constant search for profits [20]. As mentioned by Ciasullo et al. [4] the concept of Health 4.0 establishes a model for the provision of health services that is consistent with the principles underlying Society 5.0. In this context, Health 4.0 aims to involve professionals and users in making the most of the intellectual capital available to healthcare organisations, with the aim of structuring health promotion and risk prevention services that are consistent with a patient-centred approach to care [21]. To achieve this goal, hospitals must adapt to this paradigm shift, and it is crucial to understand how the challenges associated with adopting new technologies in the hospital environment can be mitigated.

Angerer et al. [22] state in their study that for this paradigm shift to digital in the hospital context to be successful, close collaboration between managers and technology specialists is essential, focusing not only on technology, but also on its implications for the strategic and operational management of healthcare entities. As a result, it was concluded that hospital digital transformation requires a holistic approach that transcends the simple implementation of new technologies. A well-defined approach that integrates technological innovation with healthcare processes, organisational culture and the patient experience itself is essential.

1.2 Study motivation

As we have seen so far, it is common sense that digital transformation brings benefits in general to all areas, especially in the health sector, not only for the patients themselves, but also for health organisations (both on the “demand” and “supply” side).

The results of a previous study based on interviews with 11 health professionals [23] reinforced the importance of this research, contributing to the motivation behind this study. In that study, health professionals stated:

• that resistance to change on the part of health professionals and low digital literacy are the most common challenges that usually prevent technological adoption in the health sector; this is also argued by several other studies [16,18,24];
• for the digital transformation to be successful, it is imperative to have multidisciplinary collaboration between the various health professionals and IT professionals, to optimize the use of these technologies in the provision of healthcare, thus emphasizing the importance of people, as it is recognized by [25]; and
• correctly identifying the problems to be solved implies working on processes to develop robust and effective technologies from the point of view of improving health outcomes and the efficiency and effectiveness of services.

Therefore, for the digital transformation to take place in the best way, a balance is needed between three essential pillars: people, processes and technology, guided by cultural aspects, which also reinforces the importance of studying culture. As highlighted by Gomathi & Mishra [18] in their study, the interaction between humans and technology aims to improve the efficiency and effectiveness of production processes. Furthermore, according to Paul & Zhou [26], “Having the right balance of people, process, and technology has always been the key to the success of any transformation and the core of company competitiveness, as well as the innovation capability”.

People and processes are often (mistakenly) “neglected” during this shift to the digital, despite being crucial elements of this transformation, as highlighted by the healthcare professionals interviewed. So it is in this area that this article aims to contribute, with a tool that makes it possible to manage the digitalisation process while keeping people at the heart of development. In line with this thinking, Gilli et al. [27] state in their study that, more than technology, people and their culture drive digital transformation. Furthermore, according to Konttila et al. [28], health sector organisations must focus on social dynamics in the workplace and foster a positive environment to improve their adaptability to digital transformation.

Thus, there is a need for a guide to support hospitals in planning and implementing digital transformation initiatives, focused on people and leveraged by processes, can facilitate the adoption of and adaptation to new technologies in the hospital environment, and this challenge is the subject of this study (see Fig 1).

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Fig 1. Study motivation.

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2.1 Organisational culture management and organisational behaviour

Organisational culture, defined as a system or set of values, beliefs and behaviours (feeling, thinking, acting, etc.) that shape the way members of an organisation interact with each other and with the outside world, is a crucial factor in operational success [29–31]. “Culture is to the organisation what personality is to the individual” [32].

On the other hand, everyone brings with them a set of beliefs, which are shared between different individuals through social interaction Castellano as cited in [33]. These beliefs may or may not be shared by everyone, however; according to Grabovetter as cited in [33] individuals are predisposed to change their minds if a larger group around them holds that other belief.

Furxhi [34] points out that employees’ reactions to change are fundamental, since they are the ones who implement it. On the one hand, a (negative) culture that shows readiness for change or resistance to change and remains attached to outdated procedures can hinder the process of change in the organisation. Some authors argue that resistance to change can be as much an organisational and group issue as an individual one and is caused by factors such as: fear of the unknown, lack of communication and involvement, and bureaucratic organisational structures [34,35]. On the other hand, a positive organisational culture, which values continuous improvement, innovation and collaboration, can facilitate the implementation of practices that lead to desirable operational outcomes, such as the efficiency and effectiveness of operations [30].

Organisational culture influences employee motivation and satisfaction, organisational performance and cognitions, and has a direct impact on organisational behaviour [33,36]. Organisational behaviour can be defined as: the field of study in which the aim is to investigate how the individual behaviour of each individual impact’s behaviour within the organisation, in order to increase operational efficiency [37,38]. The dedication and involvement of people within an organisation is crucial for operational excellence, so it is important to create a work environment that motivates employees [39]. Thus, it is important to develop a culture that values not only social aspects, but also cognitive ones, creating an environment that encourages positive and productive behaviours, such as: helping colleagues, being punctual, and following company rules in a way that promotes a positive and efficient work environment [33,36,38].

The effective management of organisational culture is a complex and multidimensional challenge faced by leaders and managers. With the growing understanding that an organisation’s culture can be a catalyst or inhibitor to its success, the need to adopt robust cultural management models has become imperative.

Van Der Post et al. [32] identified 15 culture constructs in their study which allow it to be measured: conflict resolution; culture management; customer orientation; disposition towards change; employee participation; goal clarity; human resources orientation; identification with organisation; locus of authority; management style; organisation focus; organisation integration; performance orientation; reward orientation; task structure.

There are several models in the literature that measure organisational culture. However, the literature points to several difficulties in measuring it, as it is complex and multifaceted. These include: the concept of organisational culture being made up of a huge set of interrelated norms; the lengthy process due to having several levels; that selection bias can occur, triggered by the attempt to convey a positive image of the company (even if it is not entirely true); and the lack of construct validity of existing scales [33,40,41]. Table 1 shows some of the organisational culture management models in the literature.

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Table 1. Organisational culture management models.

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In addition to these four models, there are many others, such as: culture audit (an assessment method that can include workshops, interviews and questionnaires, among others, to understand organisational culture); Hofstede’s cultural dimensions theory (a model that helps to understand cultural differences within the company); and the organisational culture assessment instrument (OCAI); among many others [52,53]. These models make it possible not only to identify and understand the underlying values and rules that guide and influence people’s behaviour in an organisation, but also to offer a strategy for involving people and applying changes that bring the culture into line with corporate goals.

The assessment and management of organisational culture in hospitals is an essential part of the healthcare system [54]. This is a crucial process for understanding how current beliefs and behaviours reinforce or hinder the achievement of patient care goals and operational efficiency. This cultural assessment, more than a measurement of employee satisfaction, is a comprehensive diagnosis that seeks to align daily practices with the goals of the health service. By identifying behavioural patterns and underlying values, hospital leaders can implement changes that not only improve the patient experience, but also optimize processes, leading to improvements in performance and organisational performance [29,55]

2.2. Outcomes in health and organisational culture

The quality of healthcare is a constant concern around the world, due to the need to ensure sustainability, control costs, and promote effective, safe and patient-centred care. These measures aim to increase transparency and accountability and improve health outcomes and patient satisfaction [56,57].

To effectively evaluate organisational change, it is crucial to measure health outcomes, which can be classified into different groups. The WHO [58] identified six key dimensions for assessing hospital performance: clinical outcomes; production outcomes; patient centredness; responsive governance; staff orientation; and safety. Table 2 below shows these same groups and the type of metrics that can be measured in each of them. This data allows adjustments to be made on an ongoing basis to enhance the quality of health services.

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Table 2. The six key dimensions of hospital performance.

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As seen above, organisational culture is crucial within an organisation and plays a critical role in determining health outcomes (key performance indicators) [61]. A strong culture that values collaboration, innovation and commitment can positively influence operational efficiency, patient satisfaction and staff motivation. Furthermore, it can be stated that in environments where transparent communication, mutual support, and continuous learning are encouraged, there is a greater likelihood that processes will be optimized and errors minimized, thus improving clinical outcomes. [29,61–64]. Mannion & Davies [29] even point out that organisational culture is often cited as the culprit when health scandals arise, and cultural change is also prescribed as a remedy to solve the problems.

Therefore, investing in organisational culture not only boosts overall performance, but also promotes an environment where professionals feel valued and patients consequently receive higher quality care. For this very reason, organisational culture is a crucial vector for driving significant improvements in overall health and well-being [29,63–66].

Thus, it can be concluded that understanding and shaping organisational culture is essential for healthcare leaders seeking to improve operational results and promote a more effective and safer work environment. Braithwaite et al. [65] suggest that healthcare administrators and policymakers should focus on cultivating and promoting positive organisational cultures to improve hospital performance.

2.3 Change management

Change management is the method adopted by an organisation with the aim of recognizing new demands and/or limitations imposed by the external environment and adapting to them. It also involves determining the strategic and operational initiatives considered crucial to optimizing organisational performance. It encompasses planning, executing and evaluating appropriate initiatives to ensure the continued success of the organisation [67].

Lichem-Herzog & Sorko [68] argue that without a well-defined plan, companies have difficulty in change processes. Gilli et al. [27] state in their study that the digital transformation is no different from other changes at the organisational level, arguing that existing knowledge about change management is applicable to the introduction of the digital paradigm.

Hubbart points out that an organisation’s culture significantly influences its agility and ability to adapt to changing operations, which are crucial to operational success, further stressing that resistance to change is not only a barrier, but also an instinctive reaction that can be mitigated through proactive leadership and inclusive practices [35].

It is therefore essential to understand the causes of employee resistance so that managers can design effective change processes that achieve the desired results. In this context, according to Prosci, a global organisation specialized in change management, organisational culture is one of the main causes of resistance to change, including aspects such as risk-averse cultures, past negative experiences with change, and issues of mistrust between departments and hierarchical levels [69]. Furthermore, as stated by Hubbart [35], the sources of resistance to change among workers include scepticism and insufficient confidence, emotional reactions, apprehension of failure, ineffective communication and time constraints. More are identified: expectations generated from previous experiences, leaving the comfort zone which can generate discomfort, and fear of change [1,70].

The literature presents a series of strategies aimed at developing the culture of organisations, reducing resistance to change and, consequently, improving operational results [34,35]. These techniques involve both the understanding and harmonization of corporate values and practical measures for the continuous improvement of operational processes. Thus, effective strategies for overcoming this resistance and managing change emphasize the importance of transparent communication, the participation of all people in decisions related to change, the alignment of organisational culture and structure with the desired change, and an active leadership role to mitigate employee resistance to change [69]. Below are different strategies for successful change:

• Effective communication: It is essential to clearly communicate the purpose, benefits and expected impacts of the changes to be implemented, as this can help align employees with organisational objectives and reduce resistance to change (an inhibiting factor). Furthermore, according to Lichem-Herzog & Sorko [68] “70% of all change processes fail due to the lack of a clear goal and a systematic approach to change” [35,67].
• Participation and involvement: It is crucial to involve employees in the change process, from planning to implementation, so that acceptance and commitment to the proposed changes can be increased. Involving employees in change initiatives can lead to a greater sense of ownership and stronger alignment with organisational goals. Collaboration and cooperation between people is essential for change to be successful, and the transition must take place in an environment of dialogue, trust and reciprocal agreement, rather than being unilaterally imposed on the members of the organisation [35,71–74].
• Training and development: Training and development serve to empower employees with the skills necessary for change, enabling people to be effective in the workplace. Providing adequate training can help people feel less threatened and more prepared for change, facilitating this transition [72,74].
• Supportive leadership: Leaders who demonstrate support during the change process and who are committed to continuous improvement can positively influence organisational culture, encouraging acceptance and adaptation to new practices [27,35,73,74].

When organisations are successful in their change processes, they see effort and dedication from their people to the new guidelines, experience fewer fluctuations in productivity throughout the implementation phase, and achieve the completion of changes in considerably shorter periods of time [67]. We can therefore conclude that there is a relationship between effective change management and health outcomes.

2.3.1 Main change management models.

Change management is therefore a methodology that combines strategies and tactics to promote and facilitate effective change processes [75]. There are various methods used to facilitate change in an effective and sustainable way. Errida & Lotfi [76] analysed 37 organisational change models in their study. Table 3 below gives three example models.

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Table 3. Change management models.

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Other change management models include: the change formula of Beckhard and Harris; McKinsey’s 7-S framework; Bridges’ model of transition; Garvin and Roberto’s change model; General Electric’s change model; and many more, many of which are combinations of each other [76,82].

2.3.2 The ADKAR model.

Among the several change management frameworks identified in the literature, the ADKAR model was selected for this study because it offers a practical and people-centred structure that directly aligns with the human dimension of digital transformation. While other organisational approaches such as Kotter’s 8-Step model or Lewin’s three-stage process place greater emphasis on organisational structures, leadership or strategic alignment, ADKAR is specifically designed to support change at the individual level [83,84].

By emphasising individual behavioural progression through the sequential stages of Awareness, Desire, Knowledge, Ability and Reinforcement, ADKAR provides a clear and operational tool to understand how people adopt and sustain new practices. This characteristic makes the model particularly suitable for contexts in which the success of digital initiatives depends heavily on human factors. Given that the successful adoption of digital technologies in hospitals depends strongly on staff engagement, readiness and capability building, ADKAR provides a clear and actionable lens for analysing the human side of transformation.

In healthcare, change management is even more crucial due to the specialized nature of clinical work and the complexities inherent in the sector. This area is fundamentally about people, from healthcare professionals to users, which further exacerbates issues of resistance to change and sometimes, given the diversity of people involved, a lack of digital literacy. Digital transformation requires adapting traditional methods, which can be a challenge as it not only alters the provision of care, but also requires new skills. Therefore, the adoption of change management methodologies is essential to facilitate a smooth transition to these new practices and to fully reap the benefits of digitalisation.

In his study, Chaabi [8] used the ADKAR methodology, combined with another, to establish a roadmap for implementing I5.0 in the context of industry. Also, in a study by Babin & Ghorashy [85], the authors conclude that incorporating the ADKAR model into the change management process significantly improved the success of their innovation initiatives. Specifically, they found that integrating structured change management using this model during the implementation of digitalisation initiatives led to better acceptance and understanding of the change by the entire organisation, highlighting the importance of addressing the human side of change to ensure the successful adoption and sustained benefit of new technologies. The author of the model himself writes in his book: “the model provides a framework and sequence for managing the people side of change”.

ADKAR, a model developed by Hiatt [78] is an acronym representing a structured approach for organisational change management, guiding individuals, and teams through five sequential phases: awareness, desire, knowledge, ability, and reinforcement, facilitating a gradual and successful transition to desired changes within a company or project [77]. According to Paul & Zhou [26], the ADKAR approach serves as an effective strategy for managing changes within organisations, offering a roadmap to assess and rectify resistance, with a focus on planning and executing tailored actions that underpin effective change and ensure the achievement of goals. According to Boca [77] the aims of the five phases are:

• Awareness – Understanding the need for change and the benefits of this change;
• Desire – Fostering a personal commitment to support and get involved in change, creating the desire to change;
• Knowledge – Providing the information and training needed for change, understanding the needs of professionals;
• Ability – Developing the skills and behaviours needed for change to take place;
• Reinforcement – Ensuring that change is sustained through positive reinforcement and support, i.e., providing support during the new stage.

Fig 2 shows each of the phases of the ADKAR methodology.

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Fig 2. ADKAR methodology.

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Digitalisation is accepted by healthcare professionals when they understand that it helps to improve the quality of care and supports workflow processes. However, negative experiences, together with a lack of competence, cause frustration and a lack of desire to integrate the digital transformation process [28]. Effectively managing the complexity inherent in digital transformation requires focusing on the mindset and skills of employees. The necessary changes in processes, technologies and strategies can be achieved through training and professional development initiatives, internal communication, and systems that recognize and reward achievements [86].

Organisational culture, change management and healthcare outcomes are interconnected elements that jointly shape the success of digital transformation in hospitals. A supportive organisational culture creates the conditions for openness, collaboration and readiness for change. Change management provides the structured processes, such as communication, training and engagement, needed to translate this cultural foundation into the effective adoption of new technologies. When these two dimensions work together, digital initiatives are more likely to enhance both operational efficiency and human-centred care delivery. Thus, the interaction between culture and change management acts as a catalyst for improved healthcare outcomes in digital health initiatives. [87–91]

Building on this interaction, the balance between humanisation and digitalisation is also central to the theoretical foundation of this study. In this context/study, humanisation refers not only to empathy, communication and dignity in patient care, but also to the support, wellbeing and meaningful engagement of healthcare professionals who must adopt and work with new technologies. Digitalisation, in turn, focuses on efficiency, automation and data-driven processes. Rather than being opposing forces, these dimensions complement each other when digital tools are implemented through approaches that prioritise staff engagement, adequate training, and patient-centred and staff-centred workflows. This perspective underpins the contribution proposed in this study, illustrating how technology can enhance both patient care and the professional experience when supported by effective change management.

To make this concept operational within the roadmap and its measurement layer, “humanisation” is defined through observable dimensions at two levels: (i) patient experience (dignity, communication, autonomy, trust, and relational continuity) and (ii) staff experience (wellbeing, perceived workload, meaningfulness of work, psychological safety, and participation in decision-making). In this study, digitalisation is considered aligned with humanisation when it reduces administrative friction and supports more time and higher-quality clinical interaction, supports coordination, and strengthens autonomy and digital inclusion/capability without increasing inequalities or excluding groups.

3.1. Aims and goals

The aim of this article is to propose a roadmap to support the planning and implementation of hospital digital transformation, with a focus on the human dimension and organisational culture. Positioned as a change-management tool, it helps hospitals managing the transition towards digital transition through cultural adaptation and stakeholder engagement. The roadmap sets out a sequenced set of actions and associated KPIs to guide implementation and monitor progress, while foregrounding humanisation, staff engagement and cultural alignment. Its use requires local tailoring to organisational context and digital maturity.

To address this aim, the following research question was defined:

(RQ): Which elements should a human-centred roadmap include to support the planning and implementation of hospital digital transformation, considering organisational culture and change management?

Subsequently, and to ensure a more structured research process, the main research question was divided into two sub-questions:

1. i. RQ1 (theoretical and contextual): Which roadmap elements are supported by the literature and enriched by contextual expert inputs (observations and informal discussions)?
2. ii. RQ2 (empirical): How do Portuguese hospital managers’ insights refine or reprioritise these elements?

3.2 Methodology

To achieve the study objective, a mixed-method research design was adopted, integrating both theoretical and empirical approaches (see methodology in Fig 3).

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Fig 3. Methodology.

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In the theoretical approach, the essential components for defining a digital transformation roadmap with a focus on the human dimension were identified. This stage combined (i) a structured literature review of change management, digital transformation, and organisational culture frameworks and (ii) practical observation in real organisational settings and informal conversations with domain experts involved in digital transformation projects.

This combined analysis allowed the initial version of the roadmap to be structured, outlining the fundamental pillars for successful and human-centred digital transformation in the healthcare sector.

The empirical approach aimed to refine the preliminary framework with insights from practice. To do this, eight semi-structured interviews were conducted with hospital management professionals involved in digital transformation in Portuguese hospitals. These interviews offered a practical view of ongoing initiatives and allowed the analysis of different digital transformation approaches. The findings helped identify best practices, barriers, and lessons learned, which supported the refinement of the theoretical model and the development of the final roadmap.

Thus, the final version of the roadmap emerged from the triangulation of evidence drawn from multiple sources: theoretical foundations, expert knowledge, and empirical evidence. This process helps to ensure that the model is conceptually grounded and contextually informed, reflecting implementation considerations reported in Portuguese hospitals while maintaining theoretical robustness.

For clarity, the methodology is presented in two parts: first, the development of the initial roadmap (based on the structured literature review and contextual inputs), and second, the development of the final roadmap (refined through semi-structured interviews with hospital managers).

3.2.2 Final roadmap refinement: Semi-structured interviews with hospital managers.

3.2.2.1 Data collection procedures: Only after the theoretical and contextual foundation was established were semi-structured interviews conducted to complement and refine the preliminary framework.

To refine the roadmap with a practical perspective, a qualitative approach was chosen, which included semi-structured interviews with a group of experts, various hospital management professionals from various regions from the north to the south of Portugal. These interviews were carried out between May and June 2024, following pre-designed questions according to the established objective and the different phases of the ADKAR methodology, resulting in an interview script with ten questions. In addition to these questions, those introducing the interviewee and those dealing with consent to confidentiality and anonymity were also asked. Table 4 shows the objectives of each group of questions, distributed according to the ADKAR methodology.

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Table 4. Objectives of each group of questions according to ADKAR methodology.

https://doi.org/10.1371/journal.pone.0344555.t004

Since the study focused on hospital managers’ perceptions of change management practices and did not involve patients, clinical data, or any sensitive personal information, formal ethics approval was not required under institutional guidelines. The study protocol was reviewed and confirmed as exempt from full ethical review by the Ethics Committee of University of Aveiro, in accordance with national and European data protection regulations (GDPR, Regulation (EU)). All participants received written information about the study’s objectives and procedures before the interviews. Informed consent was obtained from each participant prior to participation, and their consent was verbally confirmed and audio-recorded at the beginning of each interview. Participation was entirely voluntary, and confidentiality and anonymity were assured throughout the process. No identifiable personal data were collected, and all records were anonymised prior to analysis.

3.2.2.2 Data analysis: The interview data were analysed, ensuring practical alignment with real hospital contexts.

To ensure transparency and methodological rigour, the analysis followed a structured coding process. The transcripts were coded using an initial deductive codebook informed by the theoretical roadmap, while additional codes were added inductively during the close reading of the interviews. The final themes and categories resulting from this coding process are summarised in Table 5.

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Table 5. Themes and categories identified through thematic content analysis of the interview transcripts.

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In order to draw conclusions from the information obtained from the practical perspective, a thematic-categorical content analysis of the transcribed interviews was carried out. The aim of this analysis technique is to extract meaning from texts that deal with a particular subject under study. Thus, the usual stages of content analysis were followed, which consist of: organizing the material and defining the pre-analysis procedures; identifying emerging concepts through textual interpretation during the exploration phase; and finally processing and interpreting the results. Thematic saturation was reached after the sixth interview, as no new themes or categories emerged thereafter.

Saturation was assessed during coding by tracking the emergence of new codes and themes across consecutive interviews. After interview 6, no new themes were identified and subsequent interviews (7–8) served to confirm the stability of the thematic structure. Stability was evaluated based on (i) repetition of previously identified categories, (ii) absence of novel conceptual dimensions relevant to the roadmap components, and (iii) convergence in reported barriers/enablers across participants from different regions and regimes.

Table 6 summarises thematic stability by indicating when each ADKAR pillar first emerged and illustrating that later interviews reiterated the same pillars. In line with our analysis, no qualitatively new thematic directions were observed after the sixth interview, and the final interviews primarily reaffirmed previously identified perspectives.

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Table 6. Evidence of thematic stability across interviews (ADKAR pillars).

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3.2.2.3 Sample characterization: In this subsection, we present only the characterisation of the interview sample. Analysing the profile of the eight interviewees, we can see a diversity of occupational, institutional and geographical profiles. Starting with the demographic data, the predominant age range of the interviewees is between 40 and 60, suggesting solid professional experience accumulated over the years. Concerning professions, we noted a variety of leadership positions in healthcare organisations, both public and private. The presence of interviewees from both public and private institutions suggests a comprehensive view of the practices and challenges faced by the healthcare sector in Portugal, providing a solid basis for comprehensive analyses and insights into the country’s healthcare system. In terms of geographical distribution, the interviewees are spread across different regions from the north to the south of Portugal, such as Porto, the Algarve, Coimbra, Lisbon and Braga, reflecting a representative sample of the country’s regional diversity. Additionally, the interviewees were chosen because of their existing experience in digital transformation, helping to provide valuable insights into the challenges and best practices in this process. The sample was selected for convenience. Table 7 shows the profile of each of the interviewees.

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Table 7. Profile of the interviewed individuals in general management positions.

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Although the study involved eight interviews, we observed thematic saturation by the sixth interview, with the final two interviews serving to confirm the stability of the identified themes. Participants were selected based on their managerial roles and direct involvement in digital transformation initiatives, ensuring information-rich cases relevant to the study objectives.

A small, information-rich sample was considered appropriate because the study was to refine a preliminary roadmap using expert managerial insights rather than to estimate prevalence or produce statistical generalisation. Participants were selected to maximise heterogeneity across regions and governance regimes (public/private), ensuring exposure to varied implementation realities”.

4.1 First roadmap for digital transformation with human focus based on theoretical and contextual research

As mentioned above, to establish a roadmap for digital transformation, it is crucial to recognize the pivotal role of human resource practices in planning and implementing digital transformation initiatives.

A fundamental component of digital transformation is establishing, enhancing and nurturing a digital culture “understood as a set of values and characteristic behaviours, at personal and organisational levels, driving new digitally enabled ways of thinking, working and interacting with the customer, among employees and business units, and with new digital tools” [86]. So, it is necessary to be careful about people and their feelings regarding this transition.

Taking into account the insights gleaned from the literature, it was possible to come up with a preliminary version of a roadmap for digital transformation focusing on the human component, which includes six phases (see Table 8).

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Table 8. Roadmap phases.

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Fig 4 shows the proposed change management tool, based on the theoretical research, which was the basis for the empirical study.

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Fig 4. Initial roadmap for planning and implementing digital transformation with a human focus.

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4.2 Final roadmap for digital transformation with human focus based on empirical component

This section presents a revised version of the roadmap introduced in Section 4.1, now strengthened by the insights obtained from interviews with hospital management professionals.

4.2.1 Experts’ perception of a possible roadmap for digital transformation in healthcare.

The interviews with hospital managers provided a practical understanding of the digital transformation initiatives implemented in Portuguese hospitals, helping to refine and adapt the roadmap initially developed.

In general, the professionals agreed with the approach taken to the roadmap, highlighting and valuing the stages presented, the techniques used in each stage and the consideration of the human component. In addition, several professionals reported positive previous experiences with the lean methodology, highlighting how its application had contributed to the mapping and optimization of processes. They also emphasized that the digitalisation process was tackled efficiently within the hospital, indicating that applying these practices was perceived as beneficial for the institution. The interviewees’ feedback reinforces crucial elements for the success of digital transformation in the hospital environment: the importance of managing organisational culture and continuous communication. Below are some of the topics highlighted by the managers regarding the roadmap, and the improvements/opinions they suggested.

• Inclusion of health professionals (M1, M2, M4, M5, M6, M7): The importance of including healthcare professionals from the start of the project and throughout is highlighted as an important component of the roadmap. This is intended to foster stakeholder acceptance and support, improve understanding of the objectives, and strengthen their sense of involvement in the project. This initial involvement is crucial to the roadmap’s success. [“In the human component there are two crucial aspects - the involvement of the people who are going to benefit from TD is essential and we must allow these people to be on the ground and build the transformed process. They must feel that the work is well done and that they have contributed to the process; another important issue is the involvement of top management” (M4).
• Promote the action plan (M2, M5, M6): It is important to “sell” the action plan as part of the change to guarantee results. [“You must have the ability to influence, to make people see what they haven’t seen yet” (M5)].
• Organisational culture management (M3, M4, M5, M7): It is suggested that the change in organisational culture occurs throughout the process, with the dissemination of positive results to facilitate the acceptance of new technologies. Bottom-up implementation can be more effective by sharing successes and improvements achieved, to trigger change in the top healthcare management in Portugal. [“It is crucial that the Ministry of Health recognizes and supports the importance of digitalisation to facilitate a broader transformation” (M3). “Organisational culture is difficult to change quickly and cannot be imposed externally. Small changes can be introduced gradually but will take years to be recognized. The advent of technologies can help, but cultural change is more about the essence of the organisation. The transformation of culture must be gradual and not just focused on digitalisation, to avoid bigger problems” (M2). “An organisational culture medication component is needed” (M7)].
• Roadmap format (M3, M4, M6): The format of the roadmap should evolve from linear to circular, allowing for a more effective representation of the idea of continuous improvement. This circular approach highlights the importance of constant adjustments, ensuring that the digital transformation process continually adapts to the needs and feedback of those involved, promoting a culture of innovation and efficiency within the institution. [“I wouldn’t change anything in terms of content, but I would give it a more circular note, as a result of the dynamism that the plan has to have” (M4). “Continuous feedback from professionals should be incorporated in order to adjust and improve the stages of the roadmap. In addition, allow the process to be circular, so that it can be revisited somewhat frequently, to enable changes, adjustments and corrections to be made to certain steps” (M6)].

It was proposed that the roadmap be restructured into a production chain flow format, which includes input, processing and output stages. “At first it will be ADKAR itself and the assessment of the organisational culture as an initial diagnostic factor to assess where that organisation, those people are at, before entering the processing mechanism, in order to have a direct output of what can be my KPIs. In other words, understanding what they need, understanding how they are, understanding how we are going to involve them?” (M7). At the processing point, people’s culture and what they need is modelled, and the entire process is carried out. KPIs should be measured both in the intermediate phase and at the end to monitor and evaluate the progress of the digital transformation.

• Value in healthcare (M7): It is necessary to define what is value in health, value-based healthcare in the light of Michael Porter’s writings. In his book [100], he proposes a transformation in the healthcare system, arguing that competition should be based on creating value for patients, defined as the relationship between health outcomes and costs. They argue that the quality of health outcomes should be the focus, promoting a shift from volume-based to value-based competition. This involves a paradigm shift aligning all agents in the healthcare system, including providers, payers and patients, to prioritize efficiency and effective results.
• Internal communication (M6): Effective internal communication is fundamental to the success of the digital transformation, and there must be communication between all levels of the organisation, ensuring that everyone involved is informed, committed and aligned with the project’s objectives. All of this promotes collaboration and strengthens cohesion between teams. [“It’s essential to include an internal communication component to ensure that everyone involved clearly understands the advantages of joining the digital transformation. The more effective this communication is, and the better-informed people are about the benefits of the action, the less resistance they will have” (M6).]
• KPIs and health outcomes (M5, M7): It is important to note that KPIs and the measurement of health outcomes are essential for the continuous management and updating of the digital transformation project over time. Knowing the state of the process is crucial; ultimately, it is always necessary to measure everything possible. Table 9 shows the KPIs mentioned by the managers interviewed.

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Table 9. KPIs for evaluating the success of digital transformation mentioned by interviewees.

https://doi.org/10.1371/journal.pone.0344555.t009

With these suggestions, the roadmap was revised to incorporate the suggestions of the managers interviewed, considering their needs and good practices. Section 4.2.2 will explain the final roadmap.

4.2.2 Final roadmap.

Taking the interviewees’ inputs into consideration, the model was updated to a circular version (with the same steps described above in Table 8), incorporating concepts of managing and measuring organisational culture, as well as change management with continuous evolution, reflecting the main focuses of the professionals involved. Measuring organisational culture is crucial for selecting appropriate actions to support staff and teams in achieving the intended goals. In addition, the model was given the structure of a production flow that includes input, processing and output stages. Special focus was given to KPIs as metrics for evaluating the success of the digital transformation. In addition, the concept of value in healthcare was defined as explained by Michael Porter.

To this end, as mentioned by several interviewees, it will be important in this transformation process to build one or more teams focused on digital transformation, empowered and multidisciplinary teams that have the autonomy to make decisions and implement solutions.

Fig 5 shows the final version of the roadmap for the hospital’s digital transformation, with a focus on the human component, a change management tool.

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Fig 5. Final version of the planning and implementation roadmap for digital transformation with a focus on the human component.

https://doi.org/10.1371/journal.pone.0344555.g005

To strengthen the operationalisation of humanisation within the roadmap, we make explicit how key roadmap elements can support human-centred outcomes through plausible mechanisms. Table 10 maps selected roadmap elements to the intended humanisation dimensions (patient and staff experience) and to example indicators, clarifying that these represent measurable targets for monitoring and future evaluation rather than empirically confirmed effects.

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Table 10. Mapping of roadmap elements, mechanisms, humanisation dimensions, and example indicators.

https://doi.org/10.1371/journal.pone.0344555.t010

Table 11 gives a brief explanation of the different phases of the final version of the roadmap, with some specific KPIs to assess progress and performance of the implementation in each phase, covering both operational outcomes and human-centred dimensions (patient experience and staff experience).

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Table 11. A brief explanation of the final version of the roadmap and some KPIs associated with each task.

https://doi.org/10.1371/journal.pone.0344555.t011

Overall, despite some variations in focus, participants shared a common understanding that digital transformation in hospitals must be carefully planned and implemented to balance technological efficiency and humanisation. A general consensus emerged around the importance of leadership, communication, and staff engagement as key enablers of successful change.

6.1 Conclusion

For hospital digital transformation to be successful, it is essential to follow a clear organisational direction, and set priorities, and adopt an integrated approach that considers technology, processes, people and organisational culture.

The centrality of human beings in digital transformation is not only an ethical issue, but also an organisational and operational imperative one, and the need to develop a roadmap for digital transformation with a focus on the human component was recognized and was considered an essential aspect by the interviewees. The roadmap was adjusted to the needs of the hospital managers interviewed, as illustrated in Fig 5. This approach is in line with what Gilli et al. [27] state in their study, that people, rather than technology, drive digital transformation. The importance of developing the roadmap presented above is therefore clear.

As mentioned earlier, people are central to the success of the digital transformation, and this success is measured through KPIs. One of the key conclusions drawn from the interviews was: To guarantee the effectiveness of the KPIs and obtain satisfactory values for them, it is essential to keep people: involved, informed, inspired, innovating, interconnected, inclusive, influential, interactive, intuitive, and invested. In this digital transition, human capital has come to be seen as an enabler and catalyst for innovation. Fig 6 shows a playful diagram of this conclusion.

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Fig 6. The human factor as a crucial element in the success of KPIs.

Adapted from: Robertson Hunter Stewart.

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• Involved: “Keep People Involved” – Keeping people involved in all phases of the digital transformation process to foster commitment and active participation.
• Informed: “Keep People Informed” – Ensuring that everyone is up to date with the latest digital trends and practices for an informed transition.
• Inspired: “Keep People Inspired” – Constantly encouraging the team with visions of the future and innovations that show the positive impact of digitalisation.
• Innovating: “Keep People Innovating” – Stimulating creativity and experimentation to find new and improved digital solutions.
• Interconnected: “Keep People Interconnected” – Ensuring that communication and collaboration networks are optimized in the digital age.
• Inclusive: “Keep People Inclusive” – Promoting a culture of diversity and inclusion in the digital environment.
• Influential: “Keep People Influential” – Empowering employees to be agents of change and positively influence the direction of digitalisation.
• Interactive: “Keep People Interactive” – Providing digital interfaces and experiences that promote continuous interaction and involvement.
• Intuitive: “Keep People Intuitive” – Developing systems that are easy to understand and use, keeping the user experience at the heart of digital innovation.
• Invested: “Keep People Invested” – Cultivating a sense of ownership and commitment to the organisation’s digital goals.

Furthermore, this study clarifies that the balance between humanisation and digitalisation is not a conceptual abstraction, but a practical principle incorporated throughout the roadmap. Each phase of the proposed model operationalises this balance, linking technological initiatives to cultural diagnostics, team involvement, communication, training, and continuous measurement of results. By integrating human-centred indicators alongside operational KPIs, the roadmap provides a structured basis to assess whether digital transformation remains aligned with humanisation goals in hospital settings. This addresses the study’s initial intent by offering a feasible way to support and monitor this balance in real hospital contexts.

Accordingly, the roadmap should be interpreted as a proposal designed to support humanisation through measurable indicators, while further piloting is needed to assess real-world effects.

6.2 Contributions and implications

• Theoretical implications:

This paper contributes to the literature by presenting an implementation-oriented roadmap for digital transformation, grounded in theory and empirically refined, with a focus on the human dimension. Proposed as a change-management support tool, it is intended to inform implementation planning rather than to report a tested intervention, as it has not yet been piloted or validated in real-world settings. By addressing a recognised gap, the study advances research on change management and digital transformation in healthcare and highlights priorities for future empirical validation.

• Practical implications:

By incorporating human component perspectives into an implementation roadmap, healthcare institutions may better navigate the organisational complexities of digital transformation while maintaining a focus on humanisation. The roadmap supports the structuring and sequencing of initiatives, stakeholder engagement, and monitoring through KPIs. However, implementation outcomes, adoption at the practice level, and effects on patient and staff experience require local tailoring and should be assessed through piloting and evaluation in real-world settings.

6.3 Limitations and future work

• Limitations:

The study relies on a small qualitative sample of Portuguese hospital managers (n = 8), so findings primarily reflect managerial perspectives within a specific context and may not represent frontline staff, patients, or other stakeholders; transferability requires local tailoring. Interview-based analysis may be affected by participant/researcher bias and by evolving policy and technology conditions. The roadmap is a theoretically informed and empirically refined planning proposal, not a tested intervention: it has not been piloted or compared with existing frameworks, so future evaluation is needed to assess effectiveness and comparative value.

• Future work:

Future work would include interviews with other stakeholders, such as doctors, nurses and patients, to get a more holistic view of digital transformation in the healthcare sector. In addition, we plan to implement/pilot the roadmap in a real-world context, conducting longitudinal studies to assess the roadmap’s long-term impact on healthcare institutions and adjusting approaches as necessary. Future work also plans to digitise the roadmap, as well as develop and document metrics and performance indicators to assess the effectiveness of digital transformation initiatives and the impact on the quality of healthcare services and patient satisfaction. In addition, the intention is to define a set of KPIs that should be measured as an “output” of the roadmap.