BST – Client interactions

BST interactions with clients are structured by the NAS requirements, which control the activities, sequence and timeframes of staff member actions as well as measuring the outcomes via the client record/client information system. The NAS requirements are designed to deliver a client/patient-centred health care service at population-level. The view of the client is tightly defined from both a social and technical viewpoint.

Table 4-3 summarises different perspectives on BST clients considering the BST organisation as: 1) a social system and 2) a technical information system for screening women for breast cancer. It also summarises 3) client behaviours that challenge the organisation viewpoint on the attributes of their clients and what is best for clients.

The social system organisation view is based on data collected using a range of analytic lenses for observing activity involving PPT-interactions including a client record/ client information system, analysed using qualitative sociological techniques. The information system organisation view is based on data collected with a focus on the information system that supports the screening and assessment health service enterprise, analysed using SSM techniques and IS data modelling techniques. Trajectories data and

observation/participant observation data was the basis of identifying client perspectives (indicated by behaviours that challenge the organisation system views).

Perspectives on Client-Organisation Interactions Organisation View: Social System for screening women for breast cancer

• Individual clients requiring “further assessment” interact by telephone with

counsellors and then in person at the clinic as participant decision maker with a multi-disciplinary clinical team;

• personal interactions with radiography staff are highly constrained by the

requirement of structured tasks (breast x-ray and recording client data) to be performed in short time frames;

• The clinical pathway for an individual called back for further assessment is

structured and has routine elements, but the clinic staff members’ perspective of clients is focused on individual care and informed decision making. [ ‘inside a bubble of care’];

• _{Individual pathways are situated in the psychosocial status of the client as}

well as the clinical data collected by various diagnostic tests.

• _{There are two primary and distinct social groups in BST (clinic staff and data}

staff)

• There are two distinct systems of activity in BST (clinical service to clients

and management of client data);

• _{The work synchronising data on the physical client record with the digital}

client record is done manually by data support staff and their workload is affected by the clinic activities;

• The client record data is monitored by data managers and clinic managers

against organisation standards performance requirements (NAS);

• Organisation standards performance (status and trends) is discussed with

the Program Manager and changes in work practices negotiated.

Organisation View: Information System to support screening women for breast cancer

• Clients eligible for registration with the Program are well-defined and no

exceptions are allowed;

• Client interactions at the organisation boundary occur via letters generated

by client information system and then telephone call for a screening appointment taken by a data staff member responsible for entering client data onto the client information system;

• The clinical pathway for a routine breast-screen and possible further

assessment is a well-defined process and highly constrained by the requirement of structured tasks to be performed according to best practice guidelines within defined time frames;

• The data collected is defined by the National Accreditation Standards (NAS)

and the National Data Dictionary;

• The physical client record data must be synchronised with the data on the

client information systemand quality checked for accuracy and completeness. Client View: Client behaviour challenging the organisation view on screening

• Turning up for a breast screen without an appointment;

• _{Taking an inter-state holiday immediately after a routine screen (not}

available for further assessment) in Tasmania’s capital city, Hobart;

• Asking for a screening appointment because of symptoms (BST is for

asymptomatic women);

• _{Client complaints (phone calls and letters) when did not get service}

expected.

The social system for conducting the BST enterprise is configured as multiple social groupings engaged in different, occasionally competing, but interdependent activities (with breakdowns, bottlenecks, ‘work arounds’). Different social configurations of work groups have different characteristics: some work groups are defined organisationally as teams (data, administration, recruitment, clinic support, radiographers); some work groups have the properties of a learning community of practice, and members of an organisation team can also be members of the community of practice (all staff members who take part in multi-disciplinary assessment clinics). Multi-membership was a

property of the screening community of practice as each clinician was also an accredited member of a profession (Brown and Duguid’s (2000) network of practice).

The technical information system supporting BST purposes and activities consists of structures and processes that include standards for work practices, information support for the BST enterprise and performance measurement of the organisation: all linked to the client record.

Clients exhibit challenging behaviours that indicate expectations of the BST health service that are not met. Many of these expectations cannot be met because of the structural requirements of the NAS, for example the client records is owned by BST, although clients can apply for a copy of their record under freedom of information legislation. Client records must be kept for accreditation purposes; clients’ data is not readily or completely transferable to other jurisdictions. If a client transfers to another jurisdiction (e.g. NSW) she must be discharged from BST, registered with BSNSW and start a new client record. If her previous films are needed for comparison with current x- rays, they must be copied and couriered to the requesting screening organisation.