Findings – Substantive Domain

The information support provision for BST embedded principles of information integration and work practice standardisation into the design of BST and its

provisions for information support. More specifically the BST situation combined two models for assuring the quality of a health care service that were integrated in the design of the client record/client information system.

The system analysis of interacting social and technical arrangements making up the nexus between accreditation and practice in the BST situation demonstrated that the client record was fully integrated for organisation accreditation and supporting health service delivery in the clinics. The use of a client information system to store and manipulate client data resulted in an artefact construction of accreditation by measurement for the BST organisation. This construction aligned well with

population-level data processing capabilities of computer-based information systems and an EBM model for quality assured health service delivery.

However, the accreditation by measurement construction aligned only partially with a model for quality assurance that dominated in the clinics. In the clinic context, accreditation for health service delivery practice relied on individual clinicians’ membership of a community of practice or network of practice. The social

construction of accreditation by membership focuses on individual-situation data and relies on social mechanisms for strengthening members’ clinical practice within the context of patient-focused health service delivery in which measurement is used to inform and improve practice.

The client record/client information system provided a technical source of information support for the organisation activity of screening and assessing women for breast cancer. The primary focus of the technical system was measurement: measurement for judgment of organisation performance and, to a lesser extent, measurement to inform improvements to clinical practice.Social sources of information support were provided within the clinic community of practice, particularly by the role of

The information support provided in the BST setting included an institutional broker role. This role involved a multi-dimensional activity of boundary maintenance. For the BST organisation, boundary maintenance required skilled judgement to interpret and translate the meaning of individual-situation data (in a client record) across different orientations associated with use of the client data for different purposes, scales of activity and contexts. This was because failed standards in terms of BST organisation-level performance did not always mean a failure to deliver quality patient-centred care. Boundary maintenance reports were populated by sentences that referred to individual client or local situation data/information that mitigated or explained a failed standard.

There are several points to make in answering the research question: What is the role of the information system in the functioning of a breast screening and assessment health service and what is its impact?

The role and impact of the information system in BST is intimately connected to the nexus between accreditation and practice embedded in its work practice and

information system design. Its role is to support data collection, processing and interpretation requirements that enable the organisation staff members to deliver a screening and assessment health service and the quality of that service to be measured for accreditation.

The measurement function of the information system is provided by artefacts, in particular a client information system that has embedded principles of standardised ‘best practice’ work and integrated information that can be used in multiple contexts and for different purposes. The client information system prioritises measurement for judgment, and only provides limited measurement information supporting improving clinical practice.

The principles, standards and metrics for measurement are articulated in the BSA documents (BreastScreen Australia, 2005; National Quality Management Review Committee, 2002) and its Data Dictionary. These artefacts are mandated for use by all Service organisations in the BSA Program and the expectation is naturalisation, such that the artefacts function as boundary infrastructure (Bowker & Star, 2000). The information support function for clinical practice (delivering the health service) is provided by artefacts (paper client record, policy and procedure manuals) and by social arrangements for information use. The role of institutional broker and the activity of boundary maintenance are integral to the information support needs of BST to facilitate the model for quality assurance based on strengthening members engaged in clinical practice and using measurement information for improvement in the local community of practice context.

Information support provisions in BST have had both positive and negative effects. Standards for health care practices have been raised and best practice guidelines naturalised into everyday ways of screening and assessing women for breast cancer. The clinic staff members work together and exhibit the properties of a learning and developing community of practice (Wenger, 1998), and use some of the outputs of the IS/ICT as measurement for improvement of clinical practices. However, the dominant model for quality assurance in BST is EBM, and measurement for judgment. The

capability of IS/ICT to readily generate and process population-level data that can be used as information of measurement for judgement has increased pressure on certain staff members to change their practices in ways that are not always acceptable to their membership in clinical communities or networks of practice.