Phase three – conceptualising a problem theme

From Table 3-1:

Research Process Techniques Analysis Outcomes Phase Three:

conceptualising a theme Activities

• _{researching key terms;} • conceptual modelling; • _{testing conceptual} models • critically reflecting in relation to model development Data Collection

Validation/ disconfirmation field data (organisation documents, email questions);

Data Analysis

Qualitative modelling

(constructs and relationships); IS modelling (data, process views);

Focus questions

Structured Data Products

1. Theme description; Boundary maintenance and Institutional broker constructs

2. Model one: nexus between accreditation and practice

3. Test DFD and E-R diagrams for IS 4. Model two: information orientations

for an integrated client record; Boundary maintenance construct

Interpretation and Discussion Table 4-1 and Table 5-1

The method for phase three is to research the problem theme and use it as a lens to develop a conceptual model of the BST situation to enable the researcher to answer the research questions.

3.4.1

Researching the theme

The following focus was adopted to facilitate the transition of the analysis from focusing on theme identification to conceptual model development. It also provided a guide further data collection and analysis:

Exploratory focus (Table 3-3)

What PPT-elements and activity sets of interactions are included in the problem theme [nexus between accreditation and practice]?

What constructs are available in the literature and what constructs grounded in the data can be used to describe the situation?

The process included an iterative series of analyses that fed into the conceptual modelling activity:

• Develop a classification scheme for ‘accreditation’ and ‘practice’ that reveal

different perspectives in the setting related to the nexus;

• Identify and articulate constructs for describing the _nexus (some PPT-constructs

were already mapped to the domain in phase two);

• Identify activities and roles which did not fit the constructs already mapped to the

domain;

• Articulate new constructs for such an activity (boundary maintenance,

institutional broker).

The researcher reviewed the data sets generated in phases one and two. The focus was on identifying assumptions and implicit perspectives controlling the meaning and significance of the terms accreditation and of practice when used in the BST context. The researcher also investigated the different meanings of ‘accreditation’ in the literature (Section 2.2.3). This multi-domain analysis formed the basis for defining the meanings of accreditation and practice for different perspectives in the setting.

The researcher used the construct ‘technological frames’ (Bijker et al., 1987) to analyse the different frames operating in BST for different actors’ perspectives on the purpose of accreditation, noting variations in perspectives associated with role in the

organisation and the unit of analysis (Table 3-2). An organisation-level analysis of perspectives on accreditation gave a different construction of accreditation to an individual-level frame (Table 4-6).

3.4.2

Conceptual Modelling

The conceptual modelling exercise used the key data elements and structural

relationships in the BST situation identified in phases one and two and the outcomes of an exploratory focus on the nexus between accreditation and practice. The modelling focus was on the following:

Conceptual Modelling focus (see Table 3-3)

What is the relationship between the conduct of the [breast screening] enterprise and the requirement to measure and report on the quality of the [screening] work done?

What are the differences between measuring the work done by an organisation and measuring the work done by an individual?

What are the influences and effects of the nexus in the research setting?

The key terms for the problem theme (accreditation and practice) were distinguished by meanings of the terms for different units of analysis (e.g. individual practice;

community practice; organisation practice; accreditation of individual; accreditation of profession and accreditation of organisation). This formed the basis for deciding the elements and relationships for the conceptual models.

The researcher iterated constructing prose descriptions of relationships between the constructs identified and diagramming models. Sociological literature was reviewed for additional conceptualisations of PPT interactions and useful constructs to inform this activity. Boundary infrastructure and naturalisation of artefacts into practice (Bowker & Star, 2000) were introduced to explain the canonical status of the NAS within the BSA Program of Service organisations.

The iterative analysis generated two conceptual models (Figure 1-1 and Figure 1-2) to facilitate describing, explaining and discussing the role and impact of the IS in the functioning of delivering and accrediting breast screening and assessment services in Tasmania. Model Two was developed following the process outlined in Section 3.4.3.

3.4.3

Testing the conceptual models

The two conceptual models were checked for validity across the spectrum of BST roles by specific (verbal and email) questioning of participants (Program Manager, Data Manager, Assistant Data Manager, Project Officer, Community Education and Recruitment Officer, radiographer, radiologist). The researcher also analysed BST documents (for e.g. BreastScreen Tasmania Business Case, 2003) and found that introductory comments or background remarks expressed perspectives in alignment with the rationale articulated in the NAS manual (National Quality Management Review Committee, 2002) for an accredited breast screening Program.

SOCIAL SYSTEM ANALYSIS

Model one was developed using sociological techniques and methods, focusing on BST as a social system supported by a technical system, including information support. The researcher tested the constructs and model of their relationships with targeted

ethnographical observations, including email questions. Role-specific elements of the models were discussed with individual participants across the range of roles in BST for agreement of fit with everyday real-world experience.

In particular, Model one was shown to the participants engaged in boundary maintenance for comment. The Program Manager disliked the term but, with some

qualifications and caveats, agreed with the structural description of the constructs and their relationships. Participant agreement and disagreement with the models was analysed for bias due to technological framing associated with an individual’s role and membership.

INFORMATION SYSTEM TECHNICAL ANALYSIS

Model one had implications for interpreting the technical system (in particular the client record) in BST. To test the claims represented in Model one, the researcher undertook an IS analysis of the BST information artefacts. The National Accreditation Standards manual, the Data Dictionary for the BSA Program, BST’s Business Process Analysis Project Report (“current state” business processes, work flows and information flows) and the BST Policy and Procedure manual were analysed. The focus of the

investigation was the data elements required in the client record and also standards for work practices measured by data recorded in the client record and/or documented in other places.

The researcher then used the data for an information systems analysis to see how client record data elements were used at various stages on its trajectory through BST and beyond to other entities, particularly the accrediting organisation, BSA. The analytic focus was the relationships between different types of data in the breast screening system from the perspective of the nexus between accreditation and practice.

The Business Process Analysis project provided models of all the workflows and data flows. The researcher developed a series of nine Entity-Relationship (E-R) diagrams to reveal the underlying technical perspective of the organisation. Combined, the data flow diagrams (DFDs), business processes and E-R represented the system architecture for BST.

E-R diagrams were developed for the artefacts used in activities related to accreditation and/or practice: the client record, client information system, NAS manual, BSA’s Data Dictionary and BST’s Policy and Procedure manual. The E-R diagram was drawn to show the relationships between the different types of client data and was focused on the client record. The researcher had access to the Business Process Analysis document showing how information flowed through the system for breast screening at BST. The context level diagram for BST of actors and their roles was revised to identify major functions of the accredited breast screening enterprise, viewed as a system (See Figure 4-11).

E-R diagrams were developed to identify the content of data flowing through BST. E-R diagrams were constructed for the client record first (Figure 4-12). The qualitative data was revisited to identify additional artefacts for data records that were significant for accreditation-related activities and screening practice activities (Table 4-11). It was not possible to relate all the entities in the current system, and the researcher noted islands of disconnected entities (see Figure 4-13).

The researcher analysed the relation between the data collected onto the client record and any other information collected in the course of BST work activities to support: 1) practice; 2) individual accreditation and 3) organisation accreditation.

3.4.4

Critical Reflection

The researcher reflected on the implications of the nexus between accreditation and practice that incorporated non-alignment of the social and technical systems for delivering the screening and assessment health service in the BST setting. The researcher adopted a distinction between social systems and technical systems (see Section 2.4.1) and drew on literature from qualitative health research discussing the role and impact of information in health service contexts to answer the following questions:

1. What are the social consequences of the nexus between accreditation and practice?

2. What are the technical consequences of the nexus between accreditation and practice?

3. What are the implications of the insight that the social system for BST indicates partial integration of accreditation and practice (organisation and individual level) while the technical system indicates full integration such that client record data used to support clinical practice is the data used for organisation

measurement and evaluation?

The second conceptual model was constructed to capture the insights/findings from phase three critical reflection. This model drew on the insights from a literature survey that identified the work of Mol (2006) and Berwick (2002) challenging technical and population-level conceptions of information purpose and use-in-practice.

3.4.5

Conceptual Models – end Phase three

The models were constructed using a social system and information system analysis followed by critical reflection on the implications of the nexus. The modelling process was iterative and kept open to different units of analysis by the PPT-heuristic. The second conceptual model was constructed in response to understanding that the client record was an important unit of analysis and that the IS analysis did not accord with the sociological analysis. Model two reframes the analysis to focus on the meaning of the client record data. The models together represented the outworking of the nexus

between accreditation and practice embedded in the organisation design (work practice and information system implications).

Phase three concluded with an explication of the two conceptual models; the PPT- constructs adopted from different theoretical frameworks and the boundary

maintenance and institutional broker constructs. The interpretation drew on the SSM principle of representing both social and technical (socio-technical) structures from a declared perspective.