CHAPTER 4 DATA COLLECTION AND ANALYSIS
4.5 Phase Three: Conceptualising the theme
4.5.1 Problem Theme – Key Terms
Phase two analysis identified that the nexus between accreditation and practice in BST is characterised by a construction of accreditation in which the processes and structures for organisation-level and individual-level accreditation are fundamentally different (Table 4-6). Organisation-level accreditation is measurement by artefact and individual-level accreditation is a social construction by membership of a professional group.
ACCREDITATION AND PRACTICE
Definitions for the terms ‘accreditation’ and ‘practice’ were synthesised from the literature (see Section 2.2.3) including from the websites of associations of health professionals. The definitions were constructed to express the concepts’ meaning, independent of context. However, the researcher identified that in the context of health professional work, particularly in BST, both terms varied in meaning,
depending on unit of analysis. Table 4-7 is the schema for accreditation and practice from analysing the BST data at the level of individual, community of practice, profession, organisation and enterprise, where ‘enterprise’ is the collective national
BSA Program aiming to provide Australian women with a breast-screening and assessment health service. (See Table 8-11 for the extended analysis).
‘Accreditation’ can be a social construct, by membership or a technical construct of measurement by an artefact. ‘Practice’ is essentially a social term involving
individuals or communities of people working. However, there is a meaning of practice at organisation-level in which managers responsible for quality and standards compliance engage in activities intended to influence individual/team practice and also activities aiming to justify or explain organisation performance. The different meanings for accreditation and practice were built into the problem theme and with the PPT-constructs used in developing Model one.
Construct
unit of analysis
Meaning
ACCREDITATION: Conferred status and authority to act in a domain based on evidence, reputation and /or credit for capacity to act competently and independently
Individual - professional
Accreditation to work by membership of profession. Authority and status to enter into membership of specific community of practice or service organisation. (Artefact proof = credential; social proof = personal reference).
Community of Practice (CoP)
Accreditation by membership of an organisation. Socially constructed by engaging in a practice: developing reputation and trust of other CoP members as use and develop skills and knowledge.
Organisation Accredited to organise and coordinate PPT- interactions to conduct a given enterprise. Authority and status conferred = objectively measured as competent to best practice quality standard
(Artefact proof = NAS data report, accreditation site visit report, letter of accreditation)
Enterprise Accredited by quantitative measure providing proof that cost-effectively saving lives and that member organisations accredited using objective standards
(Artefact proof = aggregated data reports across member service organisations)
PRACTICE: Customary way of exercising knowledge and skills in an occupation
Individual - Professional
Practice profession within an organisation-defined framework and to professional membership standards. Continuing professional membership mandatory (CPD record). Radiologists’ performance feedback on practice for NAS compliance and skills/knowledge improvement. Multi-disciplinary meetings to collaborate and share knowledge
Network of Practice - Professional
Practice as a member of a professional community. Identity includes possession of a repertoire of knowledge and skills and competence to use them (in multi- disciplinary context);
Community of Practice
Socially constructed membership via exercise of personal competencies, skills and knowledge in CoP work. Trust (demonstrate that competent in practice); Responsibility (trusted to act); Authority (natural authority, power to negotiate)
Organisation Accrediting organisation (BSA) determines framework of standards of best practice for organisation (BST) to operate within.
Negotiation of meaning of NAS data reports (explanation of NAS data /
justification of practice); Individual representatives on BSA committees (influence organisation directives). NAS compliance mandatory; philosophy of quality improvement framework and population screening ethos
Table 4-8 is analysis in relation to: 1) assumptions about accreditation in the interview and organisation documents data; 2) agreement with those assumptions indicated in interview and documents data and observations and 3) sub-themes related to reasons for assent or dissent to the accreditation-related assumptions underlying the
establishment of the BSA Program.
The data indicates that accreditation is linked to social concepts of trust and reputation as well as technical concepts of monitoring and measuring. The organisation-level assumption that accreditation is necessary and the NAS is the appropriate mechanism for ensuring high quality health care service delivery is not completely assented to within the BST context at the level of individual staff members and professionals employed under contract.
ASSENT/COMMITMENT (implicit or explicit)
ACCREDITATION ASSUMPTIONS
Organisation level
Individual level Professional level Sub themes (assent/dissent) Accreditation is necessary for legitimate practice
Yes Yes Yes Trust
Reputation Evidence base Membership Monitoring No proof that accreditation improves patient care To be successful, breast screening must be done according to ‘best practice’ population screening principles Yes (Explicit premise of national Program) Variation (related to role and network/ community of practice membership) Variation (employed or contracted within the Program or clinician referral)
Patient centred care
Patient centred care (individual, diagnostic focus vs population focus) Clinical professional independence / autonomy Continuous quality improvement is a necessary goal for health care service Yes (Explicit premise of national Program) Variation (related to individual motivation and training) Yes (condition of employment, professional membership) Continuing professional development
Driving the NAS into everyday practice (naturalisation) Unreasonable: staff overload, external constraints Objective standards and metrics are necessary Yes (‘gold standard’ focus) Yes (qualified- subjective measures important too) Yes (qualified- subjective measures important too) Measuring competence Bench marking
Too many standards Non-data standards (subjective assessment) Integration of information and work practice standardisation are necessary Yes (national Data Dictionary and NAS) Variation (related to role and network/ community of practice membership) Yes (as impacts multi- disciplinary practice)
Consistent quality and equity for clients of health care service
Tailored patient care Translation problems across contexts
CONSTRUCTING ORGANISATION ACCREDITATION AND INFLUENCING PRACTICE
The requirements of BSA for BST to maintain its accreditation within the NAS regulatory framework have both positive and negative effects. Positive effects include introducing ‘best practice’ standards into the everyday practice of individual health professionals. This extends, beyond clinicians working in the context of BST, to clinicians within the specialties of practice that apply to breast cancer diagnosis and treatment (pathology, surgery, radiology).
The Designated Radiologist was a senior clinician who had been involved in the BST Program from its inception. He believed that the NAS was a significant factor in raising the standards of clinical practice in Australia. His observation was that the NAS directly affected clinicians involved in the BSA Program, and also indirectly (by its existence) influenced the practice of clinician members of specialist networks of practice using their skills and knowledge outside the BSA context, for example in private practice.
“I think NAS as a whole it wouldn’t be an exaggeration to say that the NAS system in BreastScreen has contributed largely to the very great betterment of women with breast problems in every field, ah, because the very fact it was so closely monitored meant that um, surgeons and other people had to start to think on the same lines. ... it’s not an exaggeration to say the NAS aspect of BreastScreen has affected medicine as a whole, um and it has affected diagnostic mammography immensely. ... there is the awareness that it is being done in a highly regulated fashion by BreastScreen and that therefore they have to come up to scratch with it.”
Interview transcript, clinician
Negative effects observed in BST were related to the interactions between the two different forms of accreditation (Table 4-6). Effects included tensions arising from conflicting perspectives on the implications for clinical practice of the NAS and requirements for BST to allocate human and other resources to manage the tensions. Tensions were between staff members whose role focused on use of client record for accreditation purposes and those whose role focused on delivering a health service for whom the client record provided information support for clinical practice. Evidence of tensions included staff members’ complaints; resistance to changing work practices, “collegial persuasion” by ‘Designated’ clinicians and social alternatives to persuasion where recalcitrant clinicians were unwilling to submit to NAS requirements for data recording or clinical practice.
BOUNDARY MAINTENANCE ACTIVITY AND THE NEXUS
BST employs individual staff members in roles that demarcate them from
membership of the BST screening community of practice. Their work tasks are at the intersections between organisation-level activities related to maintaining BST’s accreditation and individual-level activities related to the practice of screening women for breast cancer.
This work occurs at the boundary between the clinic area and the data area. It is an activity focused on the client record and was described by the term boundary
maintenance by the researcher. From the initial analysis in this phase, the construct was defined as:
Boundary maintenance is the human activity required to create and maintain connections between groups of people working together across and within organisation boundaries (Kelder & Turner, 2007).
For the specific activity of data support staff members entering the data from the paper client record onto the client information system and the Data Manager generating data reports, boundary maintenance was described as:
Boundary maintenance is the activity set required within the organisation to convert the information artefacts used for practice … into information artefacts for organisation accreditation (Kelder, 2007).
This definition was proved incorrect by an IS analysis of the client record and client information system, resulting in modification of Model one (Section 4.5.5) and development of Model two.
Table 4-9 sets out different occurrences of boundary maintenance activity that occurs when there is a disjunction between different domains of BST operations. In Table 4-9, the term, ‘ΣCR’ refers to NAS data reports generated from aggregated client data records for different fields on the client records (CR) held in the digital Client
Information System (CIS):
DISJUNCTION BETWEEN BOUNDARIES BOUNDARY MAINTENANCE
BST level of compliance to NAS
Organisation level
BSA requirements for data and practice
Enterprise level
• Explanation of unmet standards • Proposed changes to practice to
increase compliance
NAS requirements for practice
Organisation level (ΣCR)
Actual practice
Organisation level data implications for individual practice
• Feedback to CoP and individual staff
members on performance (radiologists only)
• Education of clinical professionals on
NAS best practice
Meaning of NAS data reports Organisation level (ΣCR) Meaning of individual CR Individual level (single CR)
• Correction of incomplete or inaccurate
CR
• Explanation of clinic practice for an
individual client situation that created unmet standard but kept principle of individual care
Table 4-9 Boundary maintenance and different kinds of disjunctions
INSTITUTIONAL BROKER ROLE AND THE NEXUS
Data reports and ‘Explanation of Unmet Standards’ reports were constructed by the Data Manager in consultation with the Program Manager and Designated Radiologist. The role of the Designated Radiologist in this activity was to make explicit the
the clinics and translate its meaning in relation to organisation performance against the NAS, including any local contextual factors constraining the ability of BST to comply. The role also was to translate the aggregated client record data numbers and make explicit any changes to practice required in the clinics to improve standards compliance.
Accreditation requirements vary within and between communities of practice in BST. The formal accreditation requirements (credentials to work, evidence of continuing professional development) varied for different staff members: data and administrative staff members did not have formal requirements to prove ongoing competence to work; accreditation requirements for staff members working in the breast screening community of practice were determined by requirements for maintaining membership of their profession (characterised by the researcher as network of practice).
In addition to being a member of the clinic community of practice and specialist radiologists network of practice, the Designated Radiologist has a formally instituted role of broker. The role of institutional broker carries the responsibility to introduce, and as far as possible enforce the adoption of, ‘best practice’ standards set out in the NAS to fellow clinicians.The purpose of instituting a brokering role in the clinical context is to ensure the introduction of desired work elements and practices into a community of practice and to encourage the introduction into local networks of practice.
At the organisation-level unit of analysis, institutional broker is a leadership role, formally institutedwithin the organisation design for ensuring work practice conforms to accreditation standards of clinical best practice.
• Within the community of practice the role is both leading by example and enforcing standards for practice based on institutional authority.
• Within the network of practice, the role carries no institutional authority and brokering is by education and persuasion.
4.5.2
Conceptual Modelling
SOCIAL SYSTEM ANALYSIS
The analysis using SSM and GTM was a sociological analysis, treating the technical elements as ‘things’ in the setting used by people, supporting and impacting their work interactions. The sociological analysis indicated the BST situation was structured by a nexus between accreditation and practice in which two forms of accreditation operated. Organisation-level accreditation was an artefact construction, by measurement; individual-level accreditation was a social construction, by
membership.
Client record data was collected and processed by clinical staff members for clinical judgment purposes. The client record functioned within the screening community of practice as a boundary object between members of the multi-disciplinary community of practice for coordinating activities and sharing understanding as well as boundary object between clinic-practice and data-accreditation activities.
Workflows and activities that focused on managing the transition of data from the paper client record to the client information system were described as boundary maintenance activities. Boundary maintenance in relation to the client record was understood as the result of a client record design that did not integrate data from clinical practice with data for organisation accreditation, requiring human intervention to convert it for a different use. This interpretation was tested by an IS analysis (data and process views – see Section 4.5.3) that demonstrated, from a technical system perspective, the client record was in fact fully integrated to provide data to support clinical practice and measure organisation performance for accreditation.
The technical analysis of the client record and its relation to other information artefacts in the setting led to revisiting the analysis of the boundary maintenance construct and modifying Model one. An additional conceptual model, Model two, was constructed to synthesise the interpretation of the social system analysis indicating partial integration and the technical system analysis indicating full integration of the client record/client information system to provide data to measure organisation performance for accreditation and data to support clinical practice.
MODELLING RELATIONSHIPS BETWEEN CONSTRUCTS
Figure 4-9 is an example of a preliminary conceptual model to express the impact of the NAS on the system of work practice in the clinic (imposed artefacts and
standards) and the dual memberships of clinic staff (working for BST; member of a professional network of practice).
Figure 4-9 Conceptual model: early version
Figure 4-10 is the published version of the model developed from the sociological analysis. It expresses the nexus between accreditation and practice for organisation- level accreditation constructed by artefact and individual accreditation constructed by membership. In this model, boundary maintenance was a construct to express the activity of transferring data from clinic practice onto the client information system and the activity of aggregating individual client record data to construct reports indicating the performance compliance of the screening organisation (enterprise organisation) against the standards required by the accrediting organisation.
Figure 4-10 Model one: pre IS analysis version (Kelder & Turner, 2007)
Figure 4-10 was developed before the IS analysis of the client record / client
information system and other information artefacts forming part of the wider technical information system supporting the BST enterprise.
The final version of Model one (Figure 4-14) incorporates the findings of the IS technical analysis of the client record (see Section 4.5.3) and further sociological analysis (see Section 4.5.4). Model two was constructed as a result of the combined analysis. It represents that the client record was fully integrated for organisation accreditation and supporting clinic practice purposes, but required boundary
maintenance to manage changes in meaning across contexts of use. The more nuanced understanding of the activity of boundary maintenance and the role of institutional broker was incorporated into Model one with the addition of boundary constructs boundary object and boundary infrastructure.
The two models, deploying constructs and relationships derived from the empirical data and drawing on constructs found in the socio-technical literature, are presented as findings for phase three of this research. Model one has slightly different published versions (Kelder, 2007; Kelder & Turner, 2008), having been adapted during the course of the research analysis.