In complex work settings the design of a system, including the associated work practices, must be completed in use to derive full benefit from the system. We investigate the introduction of an electronic whiteboard throughout a hospital in which management substituted a local design-in-use process, driven by super users, for a centrally organized implementation process. The aim of this study is to investigate the design-in-use approach to systems implementation with respect to the tension that ensued between hospital management’s expectations to the process and the goals pursued in the individual departments. On the basis of interviews we find that many users, including some super users, were skeptical toward design in use, that the process was better suited for intra- than interdepartmental change, and that simultaneous evolution in management’s expectations and the locally pursued goals aggravated the tension. We discuss the circumstances under which a local design-in-use process may, partly, replace conventional systems implementation.