Work Flows and Data Flows

There aretwo distinct work activities within BST performed by different groups of staff members, working in separately located areas. The client record (paper) is the artefact linking the two activities and is physically moved between different locations.

Workflows in BST are dominated by the data collection and processing requirements for the client record (paper and electronic versions). Workflows related to delivering the screening and assessment service cannot progress until data from the paper client records has been manually entered onto the client information system. (See Figure 4-4)

Figure 4-4 BST Hobart office – focus of interactions for different work areas

In Figure 4-4 the darker area corresponds to the secure data and administration area; the lighter area is the clinic area. Batches of client records (grouped by appointments for a clinic) are transported by trolley (or couriered from mobile and Launceston clinics) to and from the data area and the different clinic areas (Figure 4-5). Client records that are identified by data support staff as incomplete, have inconsistent data or indicate a failure in quality of service are given to the Assistant Data Manager (data quality issue), Data Manager (unexpected data value) or Designated Radiologist (clinical practice quality, data completeness).

Figure 4-6 is a human activity model of BST activities for a standard client trajectory. Clients either experience one or two cycles of interactions: routine screening clinic and (if they have a ‘suspicious’ x-ray) attend a ‘further assessment’ clinic, concluded with a ‘definitive diagnosis’.

Figure 4-6 Activity system representing PPT-interactions between clients and BST

The BST information system supporting clinic activities is focused on the paper client record. The client record artefact enables the multi-disciplinary team of clinicians to record client data and clinical outcomes in a single location (paper client record). The client record is the focus of discussion and clinical judgment by clinicians during an assessment clinic. Clinically interesting or problematic client records are discussed in multi-disciplinary professional development meetings.

A major task for data support staff members is manually entering client data from the physical client record onto the electronic client information system. Each

synchronisation interaction is potentially an occasion for work system breakdowns involving individuals, work teams and the management staff of BST: breakdowns which prompted problem-solving discussions in staff meetings and reports related to accreditation compliance.

All clients participate in the routine screening activity and screening capacity is a major bottleneck for the other activities that flow into and out of a routine clinic. Several radiographers took stress and holiday leave in response to pressure to screen clients more quickly. This flowed through to affect the work of data support staff members responsible for client bookings.

[Name] asked a data staff person how she was going. [The person] was upset because they had to do 160 rebookings because of changes in the radiographers’ work shifts, which put them behind and was also very hard to do: “One lady’s appointment had to be changed twice!”

Field notes, Data support staff observation

The information support for non-clinic staff members’ activities is provided by the client information system (electronic client record). The client information system enables data support staff to directly enter client data for clients booking an appointment or print clinic appointment lists. Management staff members (data, clinic and

administration managers) use the client information system to monitor and report BST performance against the NAS set for organisation accreditation.

The central activity in BST is delivering routine screening and follow-up assessment services and occurs in the clinics. There are several PPT-interactions that connect at the boundaries of clinic activity and flow on to other activities, on which clinic activities subsequently depend. Other activities are primarily processes focused on the client record: client records must be prepared for a clinic (before routine or assessment clinic); prepared for radiologists to read films (after routine clinic) and prepared for data

support staff (after films are read) to enter data on the client information system. Thus, at the finish of ‘in-person’ PPT-interactions with a client (in the clinics), the focus of BST work activities switches to the client record. The activity of recording client data is the second major activity in BST. This activity involves clinical staff members recording data onto theclient record and data staff members working in data staff area transferring the data onto the client information system, “quality assuring” the data entry and producing reports against NAS. Artefacts related to complying with the BSA Program’s NAS were integral to this system of work practice.

Organisation performance outcomes are used to evaluate client experience of interactions with the service organisation in relation to:

• education and information; • initiating appointments; • participation in the Program; • interactions during a clinic; • communication;

• time frames; • clinical outcomes.

Data reports are constructed in relation to appointments, participation, time frames (for various steps in the clinical pathway) and clinical outcomes. In particular the NAS standards check timeliness of communication and quality of diagnostic tests and (based on outcomes of surgery) correctness of diagnosis. Organisation performance

measurement is primarily from client record data and ‘non data’ NAS are audited on the occasion of an accreditation site visit. The client information system database is queried to generate reports on organisation performance against the metrics defined in the NAS. From an organisation perspective, BST’s accreditation relies on the accuracy and completeness of each client record, as well as the quality of the judgments made by

clinicians. The data area staff members are focused on the client record as the primary artefact for demonstrating compliance with the NAS. It is important for data support staff and the assistant data manager that each individual client record is accurate and complete.

Her current problem was that she was trying to quality assure (QA) data entry from a client file … the Assistant Data Manager told me QA is difficult because in a data job, “the data has to be good, especially in a place like BreastScreen, where your data is scrutinised minutely, and if something is wrong, the first question they ask is, ‘What else is wrong?’ and you don’t want to go there”.

Field notes, Assistant Data Manager observation, August 2005

The NAS requirements for clinicians to fill out forms in the client record completely are not always congruent with the clinician’s personal information requirements to record the data that is necessary for clinical judgments. The designated radiologist is

responsible for individual client record clinical data entry and client records with missing or inconsistent data are delivered to his office each week by the assistant data manager for correction before the data is entered onto the client information system.

“They’ve [client records] been filled in, but they haven’t been filled in properly. You see, it’s very, very easy to miss bits and pieces as you’re going through. … I mean it sounds a bit daft to do all this. The last lass who was doing [the assistant data manager] job used to do it for us, because most of them are obvious, but [name] basically says, ‘It’s your job; I don’t want to enter stuff without (XXX) ((spoken very quietly)). … It drove me nuts initially, but I think its crap in, crap out isn’t it? And if you don’t put the right stuff in, mind you, we’re not getting much out either are we?”

Interview transcript, Designated Radiologist

The Designated Radiologist is the leader and a member of the clinic community of practice in BST. He also uses his skills and knowledge in other health service delivery contexts and communities of practice due to his membership of the network of practice for accredited radiologists.He has a brokering role as part of his employment as

Designated Radiologist. This role is an element of the BSA requirements for its member organisations. Embedded in the NAS, it is a mechanism for assuring that the ‘best practice’ clinical guidelines are part of the everyday practice of clinicians working for BST. The Designated Radiologist is also expected to decide on and communicate changes to clinic work practices. He is the liaison person for coordinating the use of the client records between the data and clinic areas and between the administration and clinic areas.

It is important for the Data Manager and the Program Manager that the aggregated client record data demonstrates compliance with standards. There are 176 NAS standards. Most of the NAS are measured using data elements in the client record (which comply with the Data Dictionary defined by BSA). Accredited organisations must supply an annual data report that is calculated using approved algorithms. The Data Manager continuously monitors the data on the client information system for evidence that BST is continuing to meet standards and particularly to identify standards that are not met, or where compliance is trending downwards.

“NAS data reports involve a hell of a lot more than simply generation of database reports - all the exceptions/oddities are individually examined, files are hand checked, and occasionally results are sent to the multidisciplinary committee for review and action. For instance, if we record a positive core biopsy result but enter that the client did not receive surgery, this comes up in the NAS report query as a false positive due to limitations in the database and algorithms. An alternate algorithm might show such cases as ‘incomplete’; however this might still not be correct.”

Email to researcher from Data Manager

The Designated Radiologist, Data Manager and Program Manager work together to monitor and take action on organisation performance standards. Standards compliance is treated as a risk management issue and client record data can be investigated both at the level of individual records and aggregated client data for a specific data element. They meet frequently (as needed) and formally (each month) to discuss the details of individual client records that are negatively contributing to a standard compliance measure. The meetings are also used to generate explanations for unmet standards to be presented in reports (initially to the SAC and then the National Quality Management Committee heading BSA). The SAC consults with the Program Manager and approves or recommends actions to improve the ability of BST to meet standards that are trending down or failed. Actions can involve decisions to change clinical practice, data

management processes or the format of the various forms that comprise the client record.

When working together, the Designated Radiologist, Data Manager and Program Manager do not have the properties of a community of practice. The activity is one of brokering, of engaging in discussion and negotiation that results in transferring elements of practice from one community to another. Thus, they make decisions affecting how work practices of other staff members and teams are organised. These decisions are imposed on members of the clinic community of practice and other staff members (data support, clinic and recruitment). All decisions are predicated on the expectation of enabling or ensuring compliance with the NAS.

In this context, the NAS is a technical structure in the setting that constrains these staff members as leaders to collaboratively develop and actively implement a system of work activity to: Monitor activity outcomes; Evaluate outcomes against the metrics in the NAS; note and respond to any trigger to take Action and Report NAS compliance, remedial actions and outcomes (see Table 4-2).

Monitor Evaluate Action Report

Individual client record quality and aggregated client record data measured against NAS metrics

Compliance with NAS or specific NQMC directives. Identify causes and control actions that can be taken to facilitate compliance; construct explanations for situations where action problematic. Change work processes or policies; instruct staff members about NAS implications for current work practices Formal reports to Tasmania’s State Accreditation Committeee and to BSA’s National Quality Management Committee. Table 4-2 BST activities focused on the National Accreditation Standards

The analysis shows the priority of accreditation-related data collection and analysis for the organisation. At the level of the national breast-screening enterprise, BST is part of an accrediting system for over forty breast screening service organisations; its

membership in this system determines the data it collects from clients and the focus of data collection and information management is ensuring compliance with BSA requirements. Client interactions are done in accordance with NAS specifications and measured via data collected on the client information system. Performance reports to government departments are based on and adapted from information gathered for BSA accreditation. This data analysis contributed to the insight that a nexus between

accreditation and practice as an organisation-wide theme.

Figure 4-7 represents the data flow for BST from a data flow (process) perspective. BST (viewed as a breast-screening information system) interacts with external entities in its environment. BST exchanges information with individual CLIENTS,

BREASTSCREEN AUSTRALIA and the Tasmanian State and several Federal

GOVERNMENT DEPARTMENTS. Organisation reports are generated from aggregated client data and letters to individual client are generated from the client record held in the client information system database.

BreastScreen Tasmania (BST) CLIENT

GOVERNMENT DEPARTMENT BREASTSCREEN AUSTRALIA

Cancer status report

Com plianc

e re port

Accred itation sta

tus rep ort

Performance and co mpliance Reports Registratio_{n and app}

ointment

Figure 4-7 Information System view of BST context level data flow diagram (DFD)

From the information system (data processing) perspective the client is ‘outside’ the BST boundary. However, client trajectories data indicated a social system in which the client is an integral member of the screening and assessment process, cooperating with BST staff members and participating in (sometimes challenging) decision-making (Wales et al., 2002), particularly in the assessment clinic context (see Figure 4-3).