A COMPLEXITY INSPIRED APPROACH
TO
CO-EVOLUTIONARY
HOSPITAL
MANAGEMENT
INFORMATION
SYSTEMS
DEVELOPMENT
Vincent Shaw
Overview of Presentation
1.
2.
3.
4.
Research aim and questions
Defining a HospMIS
The challenge of HospMIS Design and
Implementation
Theoretical framework:
– Complexity and Complex Adaptive
Systems
– Organizational learning
5.
Research methods
2
Overview of Presentation 2
6.
Contributions
– Context as extreme heterogeneity
– Managing heterogeneity with flexible
standards and
– Flexible implementation processes
– Sustainability as co-evolution
7.
Concluding remarks
3
1. Research Aim

To develop complexity inspired
conceptual models to
– understand the design,
– development and
– implementation of
• sustainable and scalable hospital
management IS

In resource constrained contexts
4
What are my Research
Questions?


Given the complex nature of the hospital
environment, what are the socio-technical
considerations that contribute to the design of
sustainable and scalable hospital management
information systems in resource constrained
settings?
How can the implementation process be
designed to accommodate unexpected
contradictions that arise between the different
realities of original intent and changing needs in
the implementation process?
5
2. Defining a HospMIS?
Traditional inf ormation needs of managers
Financial information
Group 3
HR infor mation
Billing information
Group 1 Admission
Patient demographics
Clinical information
Group 2
Throughput information
Separation
Radiographic
information
P harmaceutical
information
Traditional inf ormation needs of clinicians
Final Diagnostic
information
Laboratory
information
6
The Components of the
HospMIS
7
8
9
3. The Challenge in
HospMIS Development 1

Fitting together:
– Clinical work
– The organization that supports the clinical
work
– ICT’s used to manage information
(Aarts, Peel et al, 1998)

Organisational complexities of the
hospital context (Hanseth and Lundberg 2001;
Lundberg and Tellioglu 1999)
10
The Challenge in HospMIS
Development 2


Heterogeneous and semantic
interoperabilities
Difficulty of achieving a balance between
loose and tight integration of sub-systems
(Monteiro 2004).


Frequent changes in reporting
requirements
Pressure to “go big” and adopt global
solutions (Ellingsen and Monteiro 2003)
11
The Challenge in
Implementation

Addressing design-reality gaps
– Negotiating standards

Skills to support the implementation
process
– Identification of skills required for support
– Development of appropriate skills
12
4. Theoretical framework 1


Drawn from Complexity Theory, and in
particular complex adaptive systems
Four key concepts:
– CAS as agents with schemata adapting to
the environment
– Non-linearity resulting in unpredicatble longterm outcomes
– Self-organizing groups and networks
displaying emergent behaviour
– Co-evolution at the edge of chaos
Defintions of Complexity

A complex system is made up of a large number of parts that
have many interactions (Simon 1969).

Complexity in organisations has three dimensions:
– vertical - the number of activities or subsystems (the number of
hierarchies),
– horizontal - the number of job titles, or departments and
– third - the spatial dimension or the number of geographical locations in
which the organization operates
(Daft (quoted in Anderson 1999)) .

Complex systems “are typically organisations made of many
heterogenous parts interacting locally in the absence of a
centralised pacemaker and control” (Fontana (1999) pg 14).
14
Agents with schema adapting
to the environment:


A CAS is a system of individual agents,
who have the freedom to act in ways
that are not always totally predictable,
and whose actions are interconnected
such that one agent’s action changes
the context for other agents.
Stock market, colony of ants, weather
system, immune system
15
Non-linearity resulting in
unpredictable long-term
outcomes



The sand pile example
“Self-organizing criticality” = small
adjustments result in large-scale changes
Non-linearity and indeterminate outcomes
evolve as a result of both negative and
positive feedback
16
Self-organizing groups and
networks displaying emergent
behaviour


The ability to self organize is a
characteristic of systems where
independent agents behave according to
a set of rules and not due to external
control.
Feedback loops modify the behaviours of
agents
17
Co-evolution at the edge
of chaos
18
Theoretical framework 2
Individual
Group
Organizational
Feed forward processes
Exploration
Intuiting
Individual
Interpreting
Group
Feedback processes
Understanding
technological
change as
organizational
learning
Exploitation
Integrating
Organizational
Institutionalizing
19
Aborptive Capacity and
Systems capabilities




The policies, procedures, and manuals that
are used to integrate explicit knowledge.
Ensure “behaviors are programmed in
advance of their execution”.
Support knowledge absorption, but tend to
be limited in scope and flexibility
Negative overall effect on “absorptive
capability”
20
Aborptive Capacity and
Co-ordination capabilities




The ability to communicate between
members of a group, and between groups.
e.g. self-organizing groups which cut across
layers of authority (hierarchy) and
functional groupings.
Less efficient in effecting knowledge
absorption, but have an ability to be flexible
and cover a broad scope of knowledge
absorption
Positive effect on absorptive capacity.
21
Aborptive Capacity and
Socializing capabilities




Ability to create a corporate identity as well
as a collective interpretation of reality.
Socialization capabilities are path dependent
and shaped by the history of the
organization, and tend to foster
isolationism.
Organizations with strong socialization
capabilities tend to reject outside knowledge
that is different to their organizational code.
Negative effect on absorptive capacity
22
5. Research Methods 1


Longitudinal case study approach
Member of the HISP action research
network
– As an empowering process, seeking local
solutions
– Within an iterative cycle of action,
reflection and learning
23
Research Methods 2

Primary data collection through
– Field notes and a personal diary, and
reflections on various data sources
– Camera for documentation
– Recorded interviews and meetings –
some transcribed
– Filed visits and direct observation

Secondary data sources through
– Official documents, reports policies,
guidelines, etc
24
Research Methods 3

Data analysis through interpretive
research methods using
– first and second-level analysis
– analysis as part of my doctoral studies
– Co-evolutionary growth process

Theory used to inform data analysis
and as a final product of my research
25
Formal Doctoral studies
Med officer Queenstown
Act Director Hospitals - Province
HISP-SA Manager and team member
Malawi Hosp
PHC Info systems ECP
1992-97
1997
Hosp Information systems ECP
1998
1999
2000
2001
Zambia PHC
ECPHosp
2002
2003
Paper 1
2004
Nigeria PHC
2005
2006
2007
2008
1
2
Paper 2
3
Paper 3
Paper 4
4
Paper 5
Paper 6
5
6
7
Paper 7
Legend
Employment / Role
2009
Research related to thesis
Research / period covered in paper
Publication date
6. Contributions 1
Understanding the context as extreme
heterogeneity

Extreme heterogeneity manifested in
hospitals
– Differences between departments
– Differences between hospitals
– Different professional groups, staffing
levels, and skills base

Extreme heterogeneity creating nested
effects
27
28
Complexity of the
environment characterised by




A broad range of challenges
Limited control over information
production activities
Other complexities impinging on
HospMISD
As unanticipated non-linear effects
29
V Shaw 26 June 2009 Trial Defence
V Shaw 26 June 2009 Trial Defence
V Shaw 26 June 2009 Trial Defence
V Shaw 26 June 2009 Trial Defence
V Shaw 26 June 2009 Trial Defence
This Malawian
Hospital had



V Shaw 26 June 2009 Trial Defence
A touch screen
EPMR for
Paediatric
patients
The DHIS as
the HospMIS
This filing
system for
patient
records
V Shaw 26 June 2009 Trial Defence
Managing heterogeneity
through flexibile standards:
a) Adaptable paper tools
37
The EDS as a Flexible Standard
Total deliveries
Deliveries mothers under 18
Deliveries mothers over 18
Deliveries under 2500g
Deliveries over 2500g
38
Gateways as flexible
standards
FMS database
Paper
printout of
financial data
from two
accounts
Accounts
combined
into single
values for
hospital
Data
physically
captured in
DHIS
(Fin database)
Exported to
stiffy disk,
flash, or
emailed as
comma
delimited file
Imported into
DHIS
(Hospital
database) and
included in
integrated
management
report
39
The DHIS as a flexible
standard
40
Managing heterogeneity through
flexibile implementation
processes:

Principle of integrated independence
CEOC
BEOC
BEOC
24/7
24/7
HF
HF
24/7 24/7
HF
HF
BEOC
BEOC
41
Process for accommodating
non-linearity
High
Data
Volume
Low
Use of
information
Poor
Technical
aspects
Well
developed
Weak
Human
resources
Strong
42
Flexible implementation
processes contd





Mindful innovation
(Swanson and Ramiller 2004,
Weick, Sutcliffe et al. 1999)
Attractors as growth points (Braa et al 2007)
Creation of networks and interdependencies
Development of the Health Information
Practitioner
Introduction of redundancy
43
The Challenge of
Sustainability

Sustainability is “…the challenge to make
an information system work, in practice,
over time, in a local setting. This involves
shaping and adapting the systems to a
given context, cultivating local learning
processes, and institutionalizing routines of
use that persist over time (as well as when
the researchers leave and external funding
is over).” (Braa, Monteiro et al. 2004) (p. 338).
44
Co-evolutionary model for
sustainable HIS Development
Feed forward processes
Exploration
Feedback processes
Exploitation
Hospital co-evolving
in response to
changes in the health
sector and in
response to
interaction with HISP
HISP co-evolving
in response to
changes in the ICT
sector and in
response to
interaction with
hospital
Hospital management
information system coevolving in response to
inputs from both
partners
45
Deepening of
geographic scale
to new levels in the
HS hierarchy
Widening of
geographic scale
across new
geographic areas
Geographic
scaling
Widening of scope by
adopting new
functionality
Scaling the
scope of the
system in use
Deepening of
scope as
evidenced by
increased user
maturity
46
7. Concluding remarks 1

Limitations in this thesis can be
identified related to:
– Relative short periods of study of
HospMIS
– Limited focus on cultural diversity and the
impact of this on HospMIS
– Lack of depth regarding interorganizational dimensions
47
Concluding remarks 2

Contributions can be defined in terms of
development of ICT’s:
– Locally appropriate solutions in the “south” for the health
sector
– Development of local capacity
– Development of sustainable organizations and processes



Research in resource constrained contexts
Research on FOSS
Methodological issues such as:
– Longitudinal action research projects
– Multi-level focus for data analysis
48
Thank you
49