The research will be undertaken within the Sydney South West Area Health Service (SSWAHS) which provides publicly-funded health care services for a population of 1.4 million people in central and south western Sydney. The population represents the most ethnically diverse Area Health Service in Australia. SSWAHS operates and manages 17 health care organisations with a workforce in excess of 17,000 people.
The information and communication technologies which will be the focus of this research are: computerised ordering systems; ambulatory electronic medical record systems; and emergency medicine information systems. All three ICT interventions present significant opportunities for work innovation. Figure provides details of these systems.
We will focus on the role of ICT to support five attributes of work practice innovation (see Figure , i-v):
Conceptual Research Design and Methods.
Objective 1 To investigate, measure and analyse the role of ICT in supporting work practice innovation
To determine the factors that enable or inhibit ICT-supported work innovation. Informed by the literature and our past research[38
] we have identified five areas which will be the target of investigation here (Figure , vi-x).
Objective 3 To quantify the impact of ICT-supported work innovation on organisational productivity, effectiveness, efficiency and cost (Figure , xi-xiv).
Objective 4 To apply the findings from objectives 1-3 to develop and test new models for the use of ICT to support innovative work practice change. These models may include, for example, methods for identifying opportunities for role responsibility changes using ICT and provision of tools for testing the impact of changes on service outcomes. We will test the effectiveness of these models in different settings using methods summarised in Figure .
The timetabling of interventions will allow for controlled before and after studies, case studies and longitudinal studies. Importantly, the interventions cover the wide breadth of services provided, from emergency to acute inpatient and outpatient care. We will be able to compare different organisations while keeping the ICT system and overall Area Health Service organisational factors constant. This will assist in isolating the effects of local team-based cultures on work innovation.
Data collection methods
Direct observations of practice in multiple sites will be undertaken to identify work role changes and innovation. This will be accompanied by video observation and interviews[27
]. These data will provide insights into changes in roles and responsibilities, team relationships, consumer involvement and factors identified by clinicians as supporting or preventing work innovation. The data will be combined with organisational document analyses, and non-participant observation of project steering and organisational committees. System functionality evaluations will be undertaken in conjunction with user feedback (via surveys, observations and interviews) about system performance, specifically in relation to integration of ICT with work practices. Observational studies and interviews will focus on identification of workaround procedures, as we have found[54
] these are often introduced to accommodate systems which fail to integrate with work practices, or where practices have not been changed to take advantage of work process efficiencies which ICT offer.
We will apply social network analyses, in which we have expertise,[56
] to examine social and communication networks. Drawing upon our past results we will focus on work task areas identified as opportunities for work innovation. The social network analyses will examine the extent to which participants across the enrolled organisations are linked and how discussions and ideas about work practice change are communicated between and across discipline areas, departments and services. The social network analyses will also investigate and provide a measure of team-based care. This will be quantified further using the Team Climate Inventory (TCI), a tool to gauge the extent of team cohesiveness and innovation. We have shown that teams with high TCI scores report more innovative use of ICT[47
]. The Organisational Culture Inventory (OCI)[48
], which we have demonstrated[58
] is able to discriminate between cultures in health organisations, will also be administered.
Quantitative changes in work patterns of clinicians will be calculated using our Work Observation Method by Activity Timing (WOMBAT), which we have developed and tested for reliability and validity [59
]. This method uses direct structured observations of individuals. The observer records information about what, with whom and how each task is undertaken, as well as interruptions and multi-tasking, using a personal digital assistant (PDA). The PDA automatically time stamps tasks and thus allows quantification of work patterns.
We will measure the effects of ICT-supported work innovation using a range of indicators including changes in:
1. organisational productivity measures such as number of patients treated and tests processed, lengths of patients' stays in hospitals, emergency department and outpatient visit length, and staffing levels and mix;
2. effectiveness and safety indicators such as changes in rates of medication error and unnecessary duplicate test orders; and
3. efficiency indicators such as turnaround time of test results, and staff time consumed by specific categories of work.
These data will be costed and combined with system implementation and maintenance costs to measure cost-effectiveness of ICT-supported work innovations. We will use both local financial data and costing data produced in previous studies[62
Findings will be tested as they emerge by soliciting feedback from stakeholder groups. Staff at the participating sites will be recruited as active contributors to the process of interpreting data and informing the research conclusions.
Ambulatory electronic medical record
As part of the rheumatology ambulatory electronic medical record (eMR), an electronic toxic drug monitoring system (eTDMS) has been developed to assist clinicians in monitoring rheumatology patients who are placed on toxic drugs, known as Disease Modifying Anti-rheumatic Drugs (DMARDs). The aims of this sub-study are to evaluate the effectiveness of the eTDMS in terms of: appropriate drug monitoring; time taken by nursing staff to monitor patients and the impact of the eTDMS on clinicians' work processes. Applying a before and after study design the first stage of this study will determine whether toxic drug monitoring has improved using the eMR. The sample size for this sub-study, based on power of 80% to detect a difference between pre and post intervention sample proportions at p = 0.05 is 60 patients in each study period. Work process changes will be identified using work process maps, interviews with clinicians, and time and motion work measurement studies of nurses in the clinic. The intervention will then be trialled at a second rheumatology clinic in another hospital and results of that trial compared.
Emergency medicine clinical information systems
A cross-sectional qualitative study, utilising interviews, focus groups, observation and video ethnography, will be conducted in the Emergency Departments (ED) of eight hospitals. Each technique will focus on eliciting information about clinicians' views and practices in relation to ICT systems used, how they have changed everyday work practices, specific effects on communication, professional roles and patient care outcomes. Interviews and focus groups will involve a sample of approximately 100 clinical staff. Further, a social network analysis to measure the ways in which senior emergency clinicians are connected across the eight hospitals will be conducted and the extent to which social networks influence the diffusion of new work practices with ICT assessed. This will involve a sample of approximately 70 senior emergency clinicians from across the eight hospitals.
Ethics approval for the overall study was granted by the Sydney South West Area Health Service Human Research Ethics Committee Multi-centre project No.09/CRGH/53, CH62/6/2009-046. This includes provision of informed consent where required by participants.