CHAPTER 4 DATA COLLECTION AND ANALYSIS
4.5 Phase Three: Conceptualising the theme
4.5.4 Boundary Maintenance Construct Reconsidered
Boundary maintenance activity in BST is focused on client data. It occurs at the boundary of client data use between the clinic and data area. It also occurs at the boundary of client data use between BST and BSA for organisation performance evaluation. The Designated Radiologist acting as institutional broker is the key actor involved in boundary maintenance in both use contexts.
Boundary maintenance activity involves collaboration between the Designated Radiologist and different staff members, particularly the Data Manager and Program Manager. This collaboration is focused on negotiating shared understanding and reconciling the meaning of client record data for and across different contexts, in particular the meaning for organisation accreditation and the meaning for an
individual’s or for a team’s practice. The Designated Radiologist is responsible for the clinic staff, aided by the Designated Surgeon and Designated Pathologist. The Data Manager is responsible for data area work performance in terms of its impact on data quality. The Program Manager has overall responsibility for BST’s implementation and compliance levels regarding the NAS. Boundary maintenance has different objectives depending on the problem being addressed and the boundary that client data/information is crossing.
The boundary between the clinic and data areas involved a change from professional- use orientation of individual-situation client data for diagnosis in the clinic to
evidence-orientation using population-level aggregated client data for data managers to monitor and report BST’s performance. The inter-organisation boundary between BST and BSA required the population-level performance measurement data to be interpreted and explained in terms of the local BST organisation context. This was especially important for Service organisations like BST operating in a State
jurisdiction with a population that is small such that one client with a ‘false positive’ cancer diagnosis results in failing a NAS.
Table 4-12 sets out different occurrences of boundarymaintenance in the BST context and the outcomes:
Boundary Maintenance Occurrences Outcomes
1. The meaning of each NAS standard must be articulated and explained to every member of BST: data staff members and clinic staff members. The implications of each NAS standard are formalised into the policy and procedure manuals governing how each role is to be performed and the measurements to indicate the level of compliance are monitored and acted on. Individual mentoring of clinical staff members and multi- disciplinary team meetings provide a ‘no blame’ context for learning from failure or problems. The accreditation site visit assesses the understanding and commitment of individual staff members to the NAS.
NATURALISATION OF STANDARDS
2. An ‘unmet standard’ outcome of a client information system data report measured against a NAS metric requires translation of its meaning from the clinic context. Boundary maintenance is needed to identify when a failing standard is due to work practices in the data area, the clinic area or ineffective interactions between the two areas. The tight coupling of the client trajectory and client record trajectory means that bottlenecks in the data area may be caused by practices in the clinic area and vice versa. The translation results in a decision on if, what and how to change clinical practice to improve the quality of client service measured by that metric (and reverse a trend of failing a NAS).
WORK PRACTICE REDESIGN: DATA OR CLINIC
3. A client complaint needs to be set in the context of the level of organisation compliance with any NAS standard that is related to the complaint. Boundary maintenance is needed to evaluate the validity of a complaint (some complaints are due to client expectations for individual service that a population health service like BST is not required to meet); to identify desirable changes in work practices and to direct the changes to be made.
POPULATION- LEVEL VS. INDIVIDUAL SITUATION DATA JUDGEMENT
4. (Model two): The meaning of a data element on a client record from an accreditation compliance perspective can differ from the perspective of what was best for the individual client from the perspective of a professional clinician and/or from the perspective of an individual client on what constitutes patient-centred care. Boundary maintenance is necessary to preserve all perspectives, particularly in the context of a failing standard from population-level data where patient-centred care for an individual actually occurred.
PRESERVING MEANING IN CONTEXT
Table 4-12 Boundary maintenance occurrences and outcomes
The sociological data on conflicts and tensions connected to the artefacts functioning as boundary objects in the setting was analysed to determine different meanings of client data in the different contexts of use. Table 4-13 summarises the analysis which indicates that boundary objects are used in BST for different purposes, moderated by three information orientations. Table 4-13 is slightly modified from the version in (Kelder & Turner, 2008).
BOUNDARY OBJECT EVIDENCE ORIENTATION PROFESSIONAL ORIENTATION CLIENT DECISION ORIENTATION Digital client information system
Aggregated client record data used to measure organisation
performance. Evidence base for quality of organisation practice relative to standards.
Potential contribution to EBM clinical guidelines.
Aggregated data on individual and team performance supplied as feedback to inform decisions on how to improve practice. EBM clinical guidelines add to an individual professional’s body of knowledge.
Aggregated client data (interpreted by academic community) provides evidence for benefit of proposed clinical decisions on treatment
Individual Client Record
Discussion with client of situation in relation to evidence base (informed consent).
Adding data for shared information and understanding within multi-disciplinary team.
Discussion with client of situation in relation to clinical diagnosis from data recorded. National
Accreditation Standards manual
Sets out standards for breast screening practice and metrics for meeting standards based on evidence of ‘best practice.’
‘Designated’ broker uses NAS to educate
individuals and his professional network on ‘best practice’ standards.
Information for clients on what can expect of a quality health service (client letters,
brochures).
Data Dictionary
Sets out required data elements for collection and algorithms for measuring standards compliance.
Requirements for data onto client record: broker ensures members share understanding of meaning of terms
Data collection requirements of client information system do not always support individual client expectations of health service.
Table 4-13 Information orientations and boundary objects, adapted (Kelder & Turner, 2008)
In addition, reports to BSA are prepared using a template required for use by all accredited Service organisations and sent to BSA. The Data Manager populates reports with information from the client information system; the Designated Radiologist and the Program Manager provides contextual information from the organisation situation (e.g. not enough radiographers constraining ability to meet participation rate NAS). The information is presented in the required format and in order to communicate BST’s compliance with the accrediting organisation standards (the NAS) and provide explanations and plans for improvement where they are not met. These reports function as boundary objects for sharing information between the two organisations and have an evidence orientation.