PLAN DE MANEJO DE DESECHOS

Over 100 rich pictures were iteratively constructed during phase one, drawing on observation field notes, organisation documents and trajectories data to express different aspects of the BST situation. Rich pictures were sketched consecutively in Visual Art diaries, dated and numbered to form a chronological record of the evolution of the researcher’s knowledge and understanding of the PPT-elements, perspectives and relationships connected to trajectories of client interactions with BST-people and BST- artefacts.

The researcher drew different kinds of rich pictures, depending on the purpose. Initial rich pictures aimed to put down everything the researcher ‘knew’ from the fieldwork. They were unstructured, messy and focused on noting any social, geographical, political and technical elements of the situation and relationships between people, place and things. They indicated gaps in knowledge requiring further data collection.18

Figure 4-1 is an early rich picture of BST as a unit within the Public and Environmental Health Service (PEHS) for Tasmania. Elements include: the geographical distributions of BST work with Tasmanian women (Hobart clinic, Launceston clinic, mobile clinic and locations for recruitment activities); some situations of client interactions with BST staff members (being educated about the service, booking an appointment, having a routine mammogram); the primary artefacts used in client interactions; communication with clients (letters, telephone, face-to-face); staff interactions with each other and the artefacts used in their work; political and social factors present.

18 _{A consequence of the ‘quick and dirty’ nature of rich picture drawing is that the products are generally} low quality for reproducing as evidence in the context of reporting on research findings: they do not scan well into electronic format. The researcher acknowledges that Figures 4-1, 4-2, 4-3, 4-8, 4-12 and 4-13 are difficult to read: the originals are pencil drawings and thus the quality cannot be sufficiently improved for the purpose of readability, even by enlarging. The purpose of including them in Chapter 4 is to provide an indicative sample of the analysis products from this research from using the ‘rich picture’ technique.

Figure 4-1 Geographical, social, technical and political elements/relations BST context

Figure 4-2 highlights the primary groups of people engaged in different activities and that the client record data is the link between their activities. Clinic based activities are separate from data area, administration and recruitment activities. Clinic based activities (delivering the health service) and recruitment activities (promoting the health service) revolve around personal interactions with a client. Clinic activities also revolve around recording and using data on a paper client record. Data area and administration

activities revolve around the data on the client record in both paper and electronic forms. The Program Manager, Data Manager and Designated Radiologist jointly interact to monitor and manage the implications of aggregated client data reports for organisation accreditation. (Model two is recorded in this rich picture; was added during phase threeanalysis.)

Figure 4-2 Rich Picture: BST data flows

No single rich picture represented all the details and insights into the organisation situation arising from the fieldwork but repetition of concepts and relationships for different levels of analysis and for different perspectives was an indication that the researcher had a sufficient appreciation of the situation. At this point, a summary rich picture was constructed to conclude phase one (see Figure 4-3). The summary rich picture expressed the researcher’s understanding of the key aspects of the problem situation for BST and was done to aid transition into phase two and identifying a key problem theme for BST.

Figure 4-3 Rich Picture: key aspects from phase one

Figure 4-3 represented the people and things interacting in the course of conducting the BST enterprise. It shows different roles in the organisation and data flows for

interactions and activities (involving clients, data area, clinic area, and management staff) and onto BSA. The rich picture expressed the conflicts evident in the research data particularly from analysis of problem-focused recurring conversations (see Table 8-5).

This rich picture highlighted that the client record was a key artefact to support client- staff interactions in the clinic. After each clinic, the client records were transported to the data area and used as a key artefact for work in measuring organisation performance and supporting meeting standards. Client record use in the clinic affected its use in the data area and vice versa. In addition, the effects of problems in either area extended beyond the boundaries in which teams worked to affect the ability of BST to conduct its enterprise of saving women from breast cancer and stay accredited.

PROBLEM SITUATION APPRECIATION

BST is situated in the context of its role as a health service organisation delivering population-level screening and assessment for breast cancer; part of a national breast- screening Program overseen by BSA. Its purpose is cost-effectively saving women’s lives: both population-level and individual client/patient health service delivery is important, but prioritised differently within the organisation. Data collection is an integral part of clinic activities; data management is connected to the clinic work practices at several levels (data quality and completeness; data monitoring; data reporting) and dependent on them.

The constructs community of practice and broker (Wenger, 1998) represent social aspects of the clinic based activities (routine screen, further assessment and results clinics). Specialist clinicians (radiologists, surgeons, pathologists) are members of the screening and assessment community of practice. However, they have additional membership in their profession, requiring brokering activity to manage situations where the requirements for individual profession membership conflict with BST requirements for clinical practice specified or implied in the National Accreditation Standards (NAS). The Designated Radiologist, Designated Surgeon and Designated Pathologist are

particularly responsible to educate and persuade fellow clinicians to adopt the NAS into their practice. They do this primarily in the context of personal interactions (which they refer to as “collegial persuasion”) with fellow specialists (who, for example, may not be using ‘best practice’ techniques) and by a monthly multi-disciplinary meeting presented by the Designated Radiologist. This meeting is attended by BST clinical staff members, including counsellors, and is open to all medical doctors, not just those working for BST. Participants gain professional development points, which is a requirement of continuing membership in their clinical specialty.

The BST situation includes symptoms of stress and associated conflict issues. Stress symptoms include: certain staff members working chronically long hours; processing client record files in which backlogs is normal; radiographers taking workers’

compensation and stress leave; recurring conversations of complaint and resentment and difficult interpersonal relations. Conflicts are between clinic-located and data-located staff members or staff teams. Conflicts are expressed in making judgments about others’ work practices and work ethic.

The negative judgments are in the context of pressure for BST to meet the NAS and to continually improve performance standards for organisation accreditation. However, there are capacity issues for delivering clinical services and for processing client records within required time frames. Staff members frame breakdowns and bottlenecks in work processes in terms of the priority of individual client/patient care or the priority of ‘the greater good’ of a population-level client focus. Pressure on clinic staff members to increase screening and reading rates is met with clinician resistance on the grounds of requirements of belonging to a health service profession with its own standards for professional conduct: “we are not just technicians.” Table 8-9 is an example of a grouping of data related to perspectives and relationships between radiographer work practices and work practices of data staff and recruitment staff.

“It’s about how they do their screening and why they do their screening, and the objective of the program is to screen as many women as we can. … it is about an appropriate blend of providing an efficient service .... It’s not about looking after one woman’s individual needs; it’s about looking after all women’s mass needs.”

Interview transcript, Program Manager

Staff members who work in the data area have two main tasks: 1) ensuring that client data is accurately and completely entered onto the client information system on time (data support and assistant data manager) and 2) reporting the aggregate of client data against the NAS using BSA supplied report templates (data manager). Data support staff members’ work is negatively impacted by inaccurate data entry on individual client

records and delays in the progress of the client record through linked activities in the clinic setting.

The data support staff members are highly constrained in opportunities to develop their work practices. As a group they do not have a vision to improve their work in order to contribute to the organisation enterprise and resist changes to work practices imposed by the Data Manager. In contrast, the clinic support staff members (with similar skill and responsibility levels) work closely with the multi-disciplinary collective of clinicians. They actively adapt work practices in order to facilitate better work flows and client experience. BST staff members who work in the clinic context identify and engage with the concepts of continuous development of work practices in response to client expectations and to achieve best practice clinical outcomes.

The Data manager, Designated Radiologist and Program Manager have the task of monitoring and taking control actions to maintain BST performance outcomes measured against the NAS. They prepare and present reports to the State Accreditation Committee (SAC), which is a committee of expert professionals who are responsible to oversee BST at jurisdiction-level (State/Territory). The SAC reports to BSA, making

recommendations for accrediting BST based in the SAC’s assessment of the quality of BST performance from the data reports taking into account local contingencies outside the control of BST that affect performance.