Title: Mutual Empathy, Ambiguity and the Implementation of Electronic Knowledge Management within the Compl
1Mutual 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
2Introduction
- 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
3Introduction
- 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
4Field 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
5Field 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)
6Problem
- 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
7Methodology 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
8Brief 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
9Brief 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
10Hierarchy 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
11Closing 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
12Visual and Mnemonic ModelsCrossing the
Acceptance Gap.
13Evolvement 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
14Evolvement 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?
15Acceptance 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.
16Health 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
17The 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
18Mutual 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?
19Emergent 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.
20Catalyst 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
21REFLECT
- 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 -
22Reflection1AR 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
23Control, 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
24Similarities 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
25Decision 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.
26Mutual 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
27NZ 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