Interpretation – Nexus and Conceptual Models

The conceptual models (Figure 1-1 and Figure 1-2) are the outcome of the analysis in phase three (Section 4.5). They represent BST’s situation from the perspective of a problem theme: a nexus between accreditation and practice. The nexus is a

perspective of BST that identifies important aspects of a wicked problem situation faced by the organisation. This section interprets the nexus and the conceptual models developed from the analysis. The significance and meaning of the findings in the context of the literature is discussed in Section 5.4 – Discussion.

5.2.1

Meaning of the Nexus

The nexus between accreditation and practice is a relation embedded in the work practices and information system design of BST. The properties of the nexus are rooted in the combination of individual-situation data collection that is used for both individual-level patient centred clinical care and population-level organisation performance evidence. The nexus is characterised by tensions between two different forms of accreditation and three different meanings of individual client data. The work practice implications of the nexus are the role of institutional broker and the activity of boundary maintenance.

The nexus between accreditation and practice affects the actions and operations of BST activities in different ways. The effects of the nexus are highlighted by three foci, or units of analysis, in particular: 1) the client record artefact; 2) the technical

information system supporting the clinic and accreditation activities and 3) the socio- technical human activity system comprising BST as an accredited screening and assessment organisation to save women’s lives from breast cancer.

Considering the client record artefact, conflicts exist between how a clinician uses the client record to record data and what the data staff members require of data entry for accreditation purposes. The technical system output required of the client record is accurate and complete data records that can provide reliable measures of organisation performance. The social system output required of the client record is sufficient and relevant data that can provide the basis for multi-disciplinary collaboration and the endpoint: a definitive cancer diagnosis. The technical focus on data accuracy and completeness can be an irritation and unnecessary time waster for social actors in the clinic; the clinic staff members failure to adhere to technical standards wastes the time of data staff members who have to quality assure the data.

Changing the focus to thinking in terms of a technical information system (consisting of the client record, client information system, organisation documents setting out policies, procedures, performance standards etc) – the technical system is fully integrated to support both accreditation and practice activities. That is, data generated in the course of client service delivery is the data used to measure the organisation performance against specified standards. The client information system

is also used to provide radiologists with some aggregated client data related to their individual performance, confidentially, as feedback information to facilitate learning and developing practice.

However, widening the focus further still to consider the BST situation as an organisation-wide socio-technical system reveals a different integration story, in which the social system within BST works toward two dissonant outcomes:

measurement of the organisation for accreditation and membership of individuals in a multi-disciplinary screening community of practice.

The outcomes are mirrored in the different forms of accreditation in the nexus: organisation by measurement; individual by membership. They are also mirrored in information orientation requirements in an integrated client record that are in tension due to the difference between aggregated, population-level data (context free) and individual-situation data (context specific). A specific role (institutional broker) and a multi-dimensional activity (boundary maintenance) are required to manage different levels of meaning embedded in client record data that is designed for information integration to support both organisation accreditation and clinical practice.

5.2.2

Conceptual Models

MODEL ONE: NEXUS BETWEEN ACCREDITATION AND PRACTICE Conceptual model one: nexus between accreditation and practice (Figure 1-1) represents a situation where accreditation of an organisation is constructed as measurement by a data integrating artefact while accreditation of individuals is socially constructedby multi-membership. This highlights a wicked problem implication of an organisation priority of maintaining its accreditation status and prioritising qualities of activities that are measured. The two forms of accreditation can be dissonant and create tension at the point of delivering patient care, as

evidenced by the ongoing conflict in the BST setting between data staff members and clinicians.

In particular, the population-level requirements of BST clinicians’ work practice (focused on quantitative measures of performance) are dissonant with the individual clinician membership requirement to provide patient-centred health care to individual clients. The problems and tensions connected with radiographers could be interpreted as symptoms pointing to different levels of commitment or assent to accreditation- related assumptions underlying the BSA Program (Table 4-8). The organisation priority in that situation is for radiographers to change their practice to ensure population-level client data provided evidence of performance quality.

Population health care is a paradigm that logically entails optimising efficiency in client processing and focuses on number of clients processed; professional clinical health care for individual clients logically entails providing the time required for treatment on a case by case basis for each client and focuses on what the individual needs.

BST is an evidence-based population-health service that is patient-centred when dealing with individual clients. The role of institutional broker and the activity of

boundary maintenance are important mechanisms in managing the implications of dissonance and tension between the two models for quality health service delivery. Client data used for both individual-situation and population-level contexts requires boundary maintenance as a mechanism to manage the meaning of client data at the boundaries of different contexts of use (Table 4-9).

MODEL TWO: INFORMATION ORIENTATIONS IN PATIENT CARE DECISIONS AND EVALUATION

In contrast to the sociological analysis indicating partial integration of the client record (with boundary maintenance occurring by data support staff members), a technical IS analysis indicated that the artefacts used in BST were fully integrated for supporting clinic practice and organisation accreditation. The research findings indicate that an information system that is fully integrated technically still has disjunctions at the level of meaning and requires human activity to coordinate, explain, align and prioritise meanings.

The boundary maintenance activity was not located in the data entry and data report generation work; rather in the translating, interpreting and keeping visible the meaning of individual situation-data generated in the clinics when aggregated to population-level measurements of health service delivery practice.

Thus, Model two: Information Orientations in Patient Care Decisions and Evaluation (Figure 1-2) represents the boundary maintenance implications of the integrated client record for the nexus between accreditation and practice structuring the problem situation in BST. It highlights the tensions between three information orientations required of a client record that is designed to integrate client information for

accreditation and supporting individual and multi-disciplinary team clinical practice. From a technical perspective, the client record is fully integrated to provide data that can be oriented to three different purposes: evidence of organisation performance, professional clinical judgment and client decision-making. However, the three orientations for data integrated in a single client record are not integrated at the level of meaning because there is an inescapable difference between the meanings of population-level, evidence oriented data, and the meaning of data in the context of a specific client receiving a health service. Boundary maintenance activity by the institutional broker in relation to the client record was primarily interpretation and alignment of meaning across contexts.

The problem situation in BST is linked to the healthcare system conflict between the model of population-level, evidence-based medicine to guide and control clinical practice and the model of clinical judgment that is built up case-by-case into expertise applied to individual client/patients. BST is a case illustrating that combining different models for assuring quality of health care services can have both negative effects of IS/ICT-enabled monitoring on professionalclinical autonomy and the positive effects of increased standards of care.

The cultural implications of using integrated information and standardised work practices to quality assure health services constitute a dilemma for organisation design and IS design. The nexus for BST uses standardisation and information integration as

a mechanism for controlling breast screening health service organisations that can be measured for cost-effectiveness and performance quality. However, a consequence of evidence-orientation dominance is that information for professional and client use can be distorted or neglected and that boundary maintenance is required to maintain the visibility of all three information orientations.

The dissonance in integration between technical (information systems) and social systems in the nexus cannot be eliminated by fully integrated computer-based information support systems and standardised work practices (from a technical perspective). One reason is the inescapable difference between the meaning

population-level, evidence-oriented data, and the meaning of data in the context of a specific client receiving a health service.

The ambition for evidence based clinical practice requires the collection of data that is in a form that enables aggregation of multiple instances of practice stripped of local context and can be used to measure outcomes and identify patterns that can be generalised. The information required for individual health service client care

includes the evidence base for best practice – but adapted and shaped by the wisdom, experience and skill to make judgments by an educated clinical professional who additionally is able to include client-specific information and communicate client- specific decisions for assessment.

Thus a critical healthcare system conflict is between the technical and social means of accreditation (measurement and membership) and the social and IS implications of the accreditation-practice nexus in any particular health care setting. Bringing into membership (educating and integrating clinical practice for standardised and multi- disciplinary work) is founded on having a mutually accepted basis of scientific evidence that is the basis of professional skills and knowledge of how best to approach delivering a health service.

However clinical practice is based on socialisation into a culture and practice that involves a long process of entering into and demonstrating continued commitment to membership as a competent trustworthy professional. The essence of

‘professionalism’ is the belief that the individual and their professional community has the skills, knowledge and commitment to make good judgments in particular situations based on the accepted body of knowledge of the profession and individual situation (See Section 2.2.3 discussion on accreditation). Such assumptions require information systems oriented to support the health professionals’ judgments on best decision for the individual client and providing an individual client with information for making good decisions.