La profundización de las uniones aduaneras

This research did not begin with a focus on accreditation. However, the outcome of the research was a lens for investigating the relationship between the way people do their work in an organisation setting and the measurement of that work: a nexus between accreditation and practice. This nexus highlighted a ‘wicked problem’ for the organisation and the conceptual models and constructs provided a language and framework for understanding important elements and relationships in the setting. The different aspects of roles, activities, processes, and structures in the setting, and importantly from and IS discipline perspective, the role and impact of the information support provisions, particularly the computer-based information system.

This research could be extended in all three areas that a research project contributes to knowledge: substantive, methodological and theoretical.

6.5.1

Substantive

The research project in BST was a single case. There are over forty Service organisations accredited as members of the BSA Program. A research project repeating the methodology in other Service organisations would be useful to assess generalisability of the case to other Service organisations in the Program, particularly if the problems experienced in BST were similar or different; if the nexus between accreditation and practice was evident and had similar or different properties; if the conceptual models applied.

The researcher is aware that there are several dimensions of difference between Service organisations including: size of target population; whether full service is provided or clinical services are outsourced; location (urban areas have concentrated population and rural / remote areas have dispersed populations, needing mobile services) and level of accreditation awarded to the Service organisation (4-year, 2- year, 2-year with high priorities, provisional accreditation and dis-accreditation). The National Accreditation Standards and the Data Dictionary, and the responsibility for meeting standards and managing the client data are common.

Additional case studies covering the range of key differences would provide a range of empirical data that could then be analysed in a meta-case study to identify if the nexus had similar or different qualities and effects and what those were. For example, in its decade-long history had operated under three business models: outsourced clinical services; partially outsourced and full-service model. The interview data had interesting commentary from staff members who had worked within all three models. The full-service model in the BST context facilitated the development of a community of practice in the clinics that was entirely lacking when clinical services were

provided by a private radiology firm. This raises a question:

What factors affect the role and impact of the information system in the functioning of screening and assessment organisations?

What factors affect the quality of screening and assessment services that their computer-based client information system does not support?

How is the role and effectiveness of the ‘institutional broker’ affected by factors (dimensions of difference) such as models of service delivery and information provision to clinicians for improving their practice?

This research project has implications for current research focused on health service delivery quality and safety. The value of accreditation and whether it is causally linked to high quality health care is an area of research that is being examined theoretically in Australia by a research team at the Centre for Clinical Governance Research in Health.20 Braithwaite et al. (2006) noted that the belief that accreditation

was a valid indicator of high quality health service had been validated by very few empirical studies and proposed aresearch approach to examine the validity, impact and value of accreditation processes in health care. However, the model hypothesising interrelationships between organisational characteristics does not include information support systems and none of the six research objectives in the proposed “prospective, multi-method, multilevel, multi-disciplinary approach” consider the role and impact of the information support arrangements on the quality of clinical practice and health service delivery.

Research questions in relation to the research proposed in (Braithwaite et al., 2006) include:

How is the culture in the organisation shaped and influenced by the information support provided (particularly computer-based information systems)?

What are the relationships between information support arrangements that support measuring the work done in the course of clinical practice and those that support interactions between clinicians and clients associated with high quality care? In 2007, the Department of Health and Ageing initiated a multi-project evaluation of all aspects of the BSA Program, including the accrediting system21. The request for tender (RFT) for evaluating the “accrediting system” (Review of the BreastScreen Australia Accrediting System)had five objectives:

1. identify national and international best practices for accrediting healthcare services and determine core criteria for a robust accreditation system;

2. benchmark the current system for accrediting BreastScreen Australia services against national and international best practices and the determined criteria; 3. identify the strengths and weaknesses of the current accreditation system;

4. identify suitable options, consistent with current Australian accreditation reforms, for ensuring the safety and ongoing quality improvement of the screening and

assessment services provided by the Program;

5. assess whether the current accreditation system meets its aims, through independent review, to strengthen and sustain the quality of service provision, proving it worthy of public confidence.

In the view of the researcher, the outcomes of this doctoral research raises several questions regarding the relationships between models for assuring the quality and efficiency of health service delivery in the BSA Program and the design of the

computer-based client information systems to comply with the National Accreditation Standards Manual and the Data Dictionary. One of the weaknesses of the current accrediting system is the design of information support for accreditation that prioritises State and Territory autonomy (a political structure) and also prioritises population-level data used as measurement for judgment.

21 _{This RTF is now closed and the results are currently unavailable. See}

https://tenders.gov.au/?event=public.advert.showClosed&AdvertUUID=8A7CF462-0515-EE2F- 8309C313BE78743B last accessed 29/01/2009.

The BST case could be mapped to the outcomes of the BSA evaluation report and any outcomes of the research Program outlined in (Braithwaite et al., 2006).

6.5.2

Methodology Development

A limitation of the research was that the engagement with the substantive setting ceased once the conceptual models had been developed and validated by participants. This was a function of the findings – the nature of the wicked problem situation was articulated, but the organisation had little power to influence significant contributors to the stress: standards that must be met but were not possible to meet for human resource reasons.

The researcher would like to develop the methodology to include an action research expectation such as assumed in SSM (Checkland & Scholes, 1999), in which the researcher as active participant facilitating change and increasing capacity within the organisation to manage ‘wicked problems’.

The researcher will continue to reflect on the actual steps taken during the process of inquiry with a view to identifying problems with the method (particularly in deciding an appropriate level of data collection and analysis to achieve understanding without overburdening participants or the researcher).

6.5.3

Theoretical Development

The conceptual models need to be tested in other situations to determine to extent to which they can generalise to, for example:

• other Service organisations within the BSA Program;

• other health service organisations under an accreditation regime for assuring

quality

• information system support arrangements that prioritise different measurement

purposes (e.g. measurement as feedback to facilitate improvement of practice). The models can be developed or added to in order to think about different structural arrangements for information support and possible effects of alternative information support arrangements.

In (Kelder, 2007), the researcher explored the idea of developing a model to express ‘a continuum of integration’ that would enable removal of boundary maintenance activity and increase effectiveness of information flows. This line of analysis was temporarily abandoned when the IS analysis of the client record/client information system demonstrated that the client record was fully integrated for the purposes of organisation accreditation and supporting clinical practice. However, there are theoretically other possibilities for transformational IS/ICT design involving the removal of boundary maintenance, which could be fruitful to study further and model.