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Mutual Empathy, Ambiguity and the Implementation of Electronic Knowledge Management within the Compl

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Title: Mutual Empathy, Ambiguity and the Implementation of Electronic Knowledge Management within the Compl


1
Mutual Empathy, Ambiguity and the Implementation
of Electronic Knowledge Management within the
Complex Health System
  • Dr Martin Orr
  • Specialist Psychiatrist
  • Clinical Director Information Systems Waitemata
    District Health Board
  • Auckland New Zealand
  • DBA Student Southern Cross University Australia
  • A/Prof Shankar Sankaran
  • Director College of Action Research
  • Graduate College of Management
  • Southern Cross university

2
Introduction
  • Healthcare complex adaptive system
  • Non linear dynamics and sensitivity to initial
    conditions is inherent and small changes in one
    part of system or embedded system can change the
    context and outcome of another part ,leading to
    significant variability and emergence in health
    outcomes
  • New Zealand has one of highest rates of
    enmeshed clinical information and communication
    technology within this complex system

3
Introduction
  • Implementation of an integrated series of
    electronic Clinical Knowledge management systems
    in a large New Zealand District Health Board
  • Team utilised Action Research (iterative cycles)
    reflective learning approach to enhance their
    capability to deal with emergent issues and plan
    for each subsequent project stage
  • The emergent focus on process issues of
    connectedness, competency and control were not
    the technical concerns initially expected
  • Mutual empathy for both self and others was
    identified as a core capability requirement to
    cope with the inherent ambiguity within complex
    systems

4
Field Situation
  • Multiple ongoing IS projects to improve KM of
    DHB organisation and community
  • DHB Region 3500square KM 450,000 people
  • 4500 staff , All Government funded Primary (GP)
    and Secondary (Hospital) Care
  • This presentation focuses on a Clinical
    Electronic Health KMS Implementation project
    facilitated by an Action Research Methodology
  • Bringing togetherall patient specific knowledge
  • Sharing across regional primary (GP) /secondary
    (hospital) spectrum
  • Multiple modules requiring implementation into
    multiple services and multiple processes and
    requiring input/resource from multiple teams from
    clinical to vendors to IT services
  • Core team of 12 Seconded Clinicians/IS
    specialists

5
Field Situation
  • A single login interface from which all patient
    demographics, medical alerts, past treatment
    events and investigations (blood tests, xrays
    etc) can be viewed
  • An electronic medical document repository
    (Including migration of 250,000 historical
    documents)
  • A real time patient tracking system for the
    Emergency Care Centre
  • A surgical audit system
  • Electronic referral status messaging and
    discharge summaries for primary care (GPs)
  • Electronic sign off of laboratory results
  • Integrated into work flows and directly impacting
    on multiple services and at least 2500 hospital
    staff and 130 primary care practices (320 GPs
    and staff)

6
Problem
  • How can the implementation of electronic Health
    Knowledge Management systems be enhanced (in the
    Waitemata DHB) ?
  • What are the key variables/issues?
  • Initial Proposition
  • By iterative process of action and reflective
    learning
  • By the development of a model/s that seek/s to
    identify and convey key issues in the
    implementation of eHKM that may be of some
    utility as an intervention in moving stakeholders
    from pre-contemplation---contemplationto
    increasingly effective action

7
Methodology Outline
  • Action research method stage
  • Iterative Cycles of Plan, Act, Observe, Reflect
  • Data collection
  • Participant observation
  • Action research group and individual feedback
  • Convergent interviews
  • Triangulation
  • Continuously seeking for disconfirming evidence
  • Preliminary Conceptual stage
  • Literature review
  • Communication with experts
  • Interests and experience

8
Brief justification for Focus on Implementation
  • Health IS implementation failure norm
  • Full, partial, sustainability, replication
  • Culture change failure to recognise, adapt and
    cope with complex social system
  • Failure to recognise complexity or attempts to
    control complexity via increasing data collection
    and Inflexible mandated protocol- a linear
    solution in a complex non-linear environment that
    fails to recognise and accommodate complexity,
    variability and emergence
  • Concept-reality or Acceptance gap

9
Brief justification for AR methodology
  • Primary goals action or change, and research or
    understanding, and synergy between the action and
    research
  • Cycles of action and critical reflection
  • Plan, Act, Observe, Reflect cycle
  • Exploratory theory building emphasis, responsive
    and flexible to complex changing situations,
    accommodates participant observation.
  • AR and Reflective Practice integrated into fabric
    of daily practice of project

10
Hierarchy of making senseData management to
Wisdom management
  • Clinicians and their communities relate within a
    system characterised by complexity, variability,
    ambiguity, emergence, human emotion and dynamics
    and require electronic systems that enhance their
    capacity to care by recognising and embracing
    these realities
  • Repeatedly found the need to move our
    terminology and management focus up the
    hierarchy of making sense of our world from
    data to information to knowledge to next wisdom
    to repeatedly recapture the focus on people
    context and process
  • Wisdom application of knowledge with common sense
    and insight
  • Systemic wisdom development-Move from a focus on
    data to people connecting within a context

11
Closing The C.A.R.E. G.A.P.S. F.I.R.S.T.
  • Clinical
  • Administration
  • Research
  • Education
  • GP
  • Allied Health Services
  • Patient
  • Supports
  • Fast
  • Intuitive
  • Robust
  • Stable
  • Trustworthy
  • A Health Knowledge System should aim to
  • close the communication loop
  • Integrate
  • Optimise key stakeholders Capacity to C.A.R.E.
  • Develop a culture and supporting systems that
    Respect Value and Protect the creation,
    acquisition and sharing of health information

12
Visual and Mnemonic ModelsCrossing the
Acceptance Gap.
13
Evolvement of Gap Metaphor
  • One leap-crash and burn
  • Need to Incrementalise- foundation
    blocks/stepping stonesbuild a detailed content
    picture
  • versus
  • Youre weaving fibres together to create a
    beautiful rug, not stacking cans in a
    supermarket

14
Evolvement of Gap Metaphor
  • What was the supporting ecosystem and passion
    required to build and hold it together?
  • How could you get everyone to cooperate across
    multiple systems with different cultures,
    languages and priorities?
  • How should and could the building stones link,
    who should design build or own them?
  • What was optimal stone size or gap?
  • Was incrementalism always right did it not just
    encourage inertiawas it not better sometimes
    just to make a leap of faith, do something
    radical and force system to change?

15
Acceptance gap metaphor as a projective technique
  • Major value not in creating time intense detailed
    content pictures of every specific step
  • Instead served better as brief projective
    technique for mixed groups (representative of key
    interdependent systems and agents), surfacing the
    assumptions and perceptions and values ,and
    setting a basis for moving towards the desired
    shared language, understanding, significance and
    hope.

16
Health Knowledge Ecosystem
  • the life cycle of a piece of paper touches
    multiple layers
  • its like pebbles skipping off the waterneed to
    understand not real for them, not the same
    urgency until impacting on their world
  • Innovation, Innovators, Implementors,
    Individuals, Invironment, Investors,
    Informaticians, and Integrators
  • Need to align and invest in all components

17
The Learning Curve and Coping with Ambiguity
  • as move through learning curve, more focus on
    walking the boards than documentationstill on
    the rollercoaster but see things differently and
    know will cope
  • Its not what you know, its who you know

18
Mutual Empathy
  • Emotion How do the key stakeholders feel about
    an issue their sense of control, competency,
    connectedness?
  • Motivation what drives them values, reason,
    emotion, self-interest?
  • Pressures What are the pressures impacting on
    their behaviour/decisions?
  • Attachments What are the key attachments or
    networks for stakeholders?
  • Trouble What issues trouble each stakeholder
    group most?
  • Handle How do stakeholders cope/adapt/learn from
    experience/utilise supports?
  • You What part do you play in each stake holder's
    conceptualisation of an issue?

19
Emergent Demands and Concerns
  • Moving from email/word/internet use to
    Integrating technology into daily care systems
  • Project management creates an important framework
    to drive process along
  • However with a complex system, it is difficult
    and of limited utility to fix scope and timelines
    in concrete, and not allow for the wider and
    enduring systemic issues, ambiguities, emergent
    phenomena, challenges and opportunities that have
    to be dealt with as they arise.

20
Catalyst Projects
  • Each step or project can act as a catalyst toward
    getting the attention and a greater understanding
    of the complexity, needs and attractors of
    interfacing systems aligning and altering if
    necessary one piece at a time as build capacity
    for more fundamental change

21
REFLECT
  • Review -thoughts, feelings, behaviour in regards
    previous plan/actions/unplanned
    action/non-actions/observations--and key
    themes/examples emerge-both positive and negative
    particularly- Confusing/Unpredictable or
    unexpected/Troubling-threatening/Suppressed
  • Exceptions sought if apparent agreement (between
    key informants/documents/observations)
  • Future impact considered --on what should be done
    for next step of project--considering
    opportunities threats and identified strengths
    /weaknesses
  • Learning---opportunities considered in terms of
    model building /but also opportunities for skill
    improvement--focus on the CUTS--not least the
    suppressed --issues noted not addressed or
    suppressed and consider how addressing might have
    facilitated project
  • Explanations sought if apparent disagreement
    between key informants/documents/observations  
  • Challenges to assumptions sought--both own and
    also those noted by participants--in terms of
    model/principles underpinning actions/project 
  • Troubles--what still troubles you /puzzles you
    /nagging doubts--gaps in data /methodology/directi
    on--just wish to jot down which may form up in
    future to key themes
  •  

22
Reflection1AR and Double Loop Learning 2 I-Mail
and Chaotic Loop Learning
  • Action Research and Double Loop Learning (Argyris
    and Schon)
  • Potential for Critical analysis and appropriate
    changing of fundamental assumptions or governing
    values can occurhowever requires skill and
    recognition risks/limitations
  • I-Mail building on Shankar Memo to Myself
  • Recording of reflections in electronic mail to
    self collected Handheld computer/PDA
  • Similar Schon Reflection in action and reflection
    on earlier reflection in action
  • Chaotic loop learning Free flow material and
    ideas or insights that just appeared to emerge
    role of subconscious, cognitive filters,
    governing assumptions and receiving and dealing
    with information non linear fashion
  • Constant search for disconfirming
    evidence/Triangulation

23
Control, Competency,Connectedness
  • Many of core issues focus on
  • Spectrum
  • Control versus loss/lack of control
  • Competency versus loss/lack of competency
  • connectedness versus loss/lack of connectedness
  • And how perceptions of loss/lack of
    control/competency/connectedness contributes to
    sense of chaos
  • Similar themes change, hierarchy of needs,
    leadership, systems, motivation, psychotherapy,
    grief literature

24
Similarities of AR Group Process to Psychotherapy
Process
  • Similar Group dynamics themes emerge
  • Control, competency, connectedness
  • Seeing process as cathartic,containing,
    nurturing-feeding
  • Forming storming norming and performing and
    termination issues
  • As a Psychiatrist, concerns when working with
    change leader with regards to the group dynamics
    and dangers of little knowledge when holding
    reflection/skills groups that are acting as form
    of group therapy even if not recognised as such
  • Kurt Lewin Father of both Action Research and
    Group Dynamics
  • Similar supervision dynamics
  • Fluctuating between panic where is it all going
    dealing with ambiguity to wonderment of how all
    slots together
  • Despite being a Specialist Psychiatrist,
    questioned appropriateness and my level of
    training for dealing with such dynamic issues and
    raised question should Action Researchers have at
    least a minimal level of competency and
    supervision to recognise and deal with group
    dynamic issues

25
Decision making in the complex Zone
  • Wilson et al 2001 (adapting the work of Zimmerman
    et al 1998) suggest some principles to facilitate
    decision making in the "Complex Zone".
  • These are using intuition, experimenting, minimum
    specification, chunking, using metaphors and
    asking provocative questions.
  • All these principles or techniques evolved within
    the team as a natural consequence of the action
    research reflective learning process, adding some
    empirical support to its perceived utility within
    complex environments.

26
Mutual Empathy
  • Mutual empathy emerged as a core capability to be
    identified and nourished, to help build a shared
    language, understanding, significance and hope
    and thrive within a complex environment of
    inherent ambiguity and variability, and issues of
    control, competency and connectedness

27
NZ Focus on Enhancing Core Clinician Patient
Interface
  • Focus on informing and connecting rather than
    controlling or significantly changing traditional
    clinical processes or systems
  • Embracing complexity and chronicity as well as
    individual and group needs and value
  • Networking the knowledge of key stakeholders so
    that better questions can be formulated, rather
    than the focus being on attempting to provide
    mandated answers
  • Incrementally building capacity for more
    fundamental change
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