Theme: Nexus between Accreditation and Practice

use to support their activities as part of the BST health service delivery enterprise. It highlights that the actors’ focus is on organisation-level accreditation or on

developing professional practice (individual work practices or the clinical team practices). The Designated Radiologist’s focus is on the interplay between

organisation accreditation and work practices in the clinics – creating an environment in which clinic work practices are equivalent to NAS best practice standards.

Different BST activities exhibit different ways of using the client record data and different perspectives on the purpose of the client record (either as a physical artefact and/or in its digital form on the client information system). In particular there is a different focus when using the client record for staff members engaged in client data analysis from an organisation management perspective (Data Manager, Program Manager and Designated Radiologist) in contrast to other work within the

organisation, particularly use of the client record in clinics (radiographer, radiologist, surgeon, pathologist, clinic support staff).

HUMAN ACTORS ACTOR ACTIVITY FOCUS BST SUPPORTING ARTEFACTS

Client My experience and

expectations of health service delivery

Client Record (partial); telephone; letter

Data support staff members

Accreditation (organisation) Client Records; Client Information System; telephone

Data Manager and Assistant Data Manager

Accreditation (organisation) NAS manual; NAS Data Dictionary; Client Information System; problem Client Records

Clinic staff members

Professional practice (individual, member of team)

Client Record;

Designated Radiologist

Best practice; standard practice

Adjusting clinic practice so that maintain accreditation (organisation)

NAS manual; Client Record

Data Manager; Program Manager; Designated Radiologist

Monitoring and reporting outcomes of practice (individual, team)

Measuring practice against accreditation standards

Client Record; Client Information System; NAS manual; BSA reporting tools.

Education and recruitment officer

Client participation

Accreditation (organisation)

Recruitment Plan; Client Information System – overall participation rate only

Table 4-5 showed that accreditation and practice were two preoccupations in the setting that were mutually constituted, such that the requirements of accreditation had strong implications for how work activities were designed and conducted; the

everyday realities of screening and assessing women for breast cancer had strong implications for the organisation’s performance standards compliance.

Thus, the BST work practice context is dominated by an externally imposed system for organisation-level quality assurance and quality improvement that includes “a formal accreditation program” (National Quality Management Review Committee, 2002).

“A population-based screening program like BreastScreen Australia must be implemented with stronger control and guidance than is customary in health service development. The report of the AHMAC Breast Cancer Screening Evaluation Steering Committee emphasised the need for a highly integrated, systematic and coordinated quality improvement program, which includes standardised accreditation processes, evaluation, and national and state-level coordination mechanisms” … “The focus of the quality improvement program is to ensure that minimum standards are maintained and to pursue excellence by continually developing strategies to review and improve care. The Program strives for continual improvement through self-review, feedback, acquisition of new knowledge and skills and change in practice. As part of its overall approach to quality improvement, BreastScreen Australia also includes a formal accreditation program.” (National Quality Management Review Committee, 2002: 1)

National Accreditation Standards Manual “Um, the great advantage of having standards is that you have well, more call it control in breast screen than in, well in any other medical situation that I know. There’s over control, far too much of it. Um, but it’s like everything else if you have far too much you get just enough.” Interview transcript, Clinician The NAS is very expensive and arduous on staff, but necessary: prompts improvements and “keeps people from going feral”.

Field Notes, Data Manager comment Role of the NAS

The Program Manager believes that: 1) the population health model for health service is incompatible with the acute diagnostic model where the focus is on the individual. In population health you care for the individual in the context of “we need them in the door to deliver the population health benefit” but the focus is on the wider population, and 2) the NAS drives the BST program.

She “lives with the NAS everyday” and “cracks the whip” because at the level of people doing their job: they are following NAS defined policies and procedures but they do not think about the NAS and/or are not aware of the NAS as the driving force for why they do what they do. She believes she has to drive it because the culture of BST includes people not connecting their work to others; people resisting work and putting energy into complaining when they could just do it.

Researcher memo, post interview Program Manager

This assumption is operationalised in a ubiquitous barrier question applied to every BST decision-making activity involving changes to work practices or client data and information support: “Will the decision outcome comply with the NAS?” This barrier was applied to the recommendations from a Business Analysis Project in 2005 that was conducted in order to prepare requirements for a new client information system. The recommendations were intended to deliver improved work processes and suggested some changes to the client data collected. The client information system, particularly the database of client records, is essential to the operation and

accreditation of a screening and assessment service and suggestions that did not comply with the NAS were rejected.

Role of the Client Information System

“Unfortunately I think what has not occurred is an understanding of how the database links directly to our accreditation performance and there have been a number of things that just haven’t been captured because that understanding isn’t there. That this isn’t just about something we measure because we want to, but we have to perform against these boundaries and so that’s why theres these requirements. And we have to report against it and no you can’t get rid of making appointments and reporting against each examination being done with individual machines because that’s a method of measuring the performance of the machine. So, yes, there are a number of issues actually about the grass roots operation that I think have been lost in the overall business case [for the new client information system].”

Interview transcript, Program Manager

The conflicts between data-oriented staff members and clinic-oriented staff members and the breakdowns in coordinating their work outputs are connected to the different methods and requirements for maintaining accreditation (see Table 8-9). Data support staff members are only required to think about measurement of the organisation using the client record data entered onto the client information system: BST measurement is affected by how quickly or accurately client data is entered onto the system and processed. The data managers are concerned with data quality (complete and accurate) and NAS compliance.

“So, for [the data support staff] to do their job, what they need to know is what the operational manual says, not that the NAS says we have to have that because we want to ensure quality and consistency of service, standards and outcomes etcetera, etcetera.”

“ … in the data area, their role is to enter bookings and data. How what they do impacts on the clinic, for most of them, does not enter their consciousness. But you would know, if they double book, or if they incorrectly enter data, it has huge impacts on the clinics: their operation, their efficiency, and from a management perspective, it means that the data that we’re extracting is dirty. Sometimes we pick it up; sometimes we don’t.”

Interview transcript, Program Manager

Clinicians are focused on delivering client/patient-centred care from a clinical perspective. However, they do not always demonstrate commitment to the technical information priorities of accurate and complete client records or the BSA work standards of best practice clinical guidelines. A particular issue for the “Designated” BST clinicians the social context of professional membership and respect for clinical autonomy of fellow members of a specialty. “Collegial persuasion” is difficult to achieve and other social solutions to introducing the NAS into the practice of clinicians (using the counsellors) have emerged.

“For instance, the pathologists have contacted [deleted] pathologists when there’s been a discrepancy between their histological findings and the final open biopsy finding. And the surgeon, [name], who is the designated surgeon, has undoubtedly had contact with his fellow surgeons, um, about things. And there is an awareness, but you certainly can’t- what you can do is- I think the counsellors have an enormous role in this respect- what you can do is follow every case up so that the result is the best available. If at the same time you don’t change the ways of the surgeon, tough, because changing the way people work is often very difficult and not everyone works to quite the same standards. But, if from a BreastScreen point of view you nag like the girls [counselors] do, then for an individual BreastScreen patient there are enough layers of safeguards with the safety net finally being the counsellor, that the surgeon or pathologist knows that they’ve made a mistake, not made a mistake, should have done it this way, should have done it that way.”

Interview transcript, Clinician