A COMPLEXITY INSPIRED A COMPLEXITY INSPIRED APPROACH TO APPROACH TO

Vincent ShawVincent Shaw

CO-CO-EVOLUTIONARY EVOLUTIONARY

HOSPITAL HOSPITAL MANAGEMENT MANAGEMENT INFORMATION INFORMATION

SYSTEMS SYSTEMS DEVELOPMENTDEVELOPMENT

Overview of Overview of PresentationPresentation

1.1. Research aim and questionsResearch aim and questions

2.2. Defining a HospMISDefining a HospMIS

3.3. The challenge of HospMIS Design and The challenge of HospMIS Design and ImplementationImplementation

4.4. Theoretical framework:Theoretical framework:– Complexity and Complex Adaptive Complexity and Complex Adaptive

SystemsSystems– Organizational learningOrganizational learning

5.5. Research methodsResearch methods22

Overview of Overview of Presentation 2Presentation 2

6.6. ContributionsContributions– Context as extreme heterogeneityContext as extreme heterogeneity– Managing heterogeneity with Managing heterogeneity with

flexible standards and flexible standards and – Flexible implementation processesFlexible implementation processes– Sustainability as co-evolutionSustainability as co-evolution

7.7. Concluding remarksConcluding remarks

33

1. Research Aim1. Research Aim

To develop complexity inspired To develop complexity inspired conceptual models to conceptual models to – understand the design, understand the design, – development and development and – implementation of implementation of

• sustainable and scalable hospital sustainable and scalable hospital management IS management IS

In resource constrained contextsIn resource constrained contexts44

What are my Research What are my Research Questions?Questions?

Given the Given the complex naturecomplex nature of the hospital of the hospital environment, what are the environment, what are the socio-technical socio-technical considerationsconsiderations that contribute to the that contribute to the design of sustainable and scalabledesign of sustainable and scalable hospital management information systems hospital management information systems in resource constrained settings?in resource constrained settings?

How can the How can the implementation processimplementation process be be designed to accommodate designed to accommodate unexpected unexpected contradictionscontradictions that arise between the that arise between the different realities of original intent and different realities of original intent and changing needs in the implementation changing needs in the implementation process?process? 55

2. Defining a HospMIS? 2. Defining a HospMIS?

Clinical information Radiographic information

Laboratory information

Traditional information needs of clinicians

Final Diagnostic information

Pharmaceutical information

Admission Separation Patient demographics

Billing information Throughput information

Traditional information needs of managers

Financial information HR information

Group 1

Group 3

Group 2

66

The Components of the The Components of the HospMISHospMIS

77

88

99

3. The Challenge in 3. The Challenge in HospMIS Development HospMIS Development 11 Fitting together:Fitting together:

– Clinical workClinical work– The organization that supports the The organization that supports the

clinical workclinical work– ICT’s used to manage information ICT’s used to manage information

(Aarts, Peel et al, 1998)(Aarts, Peel et al, 1998)

Organisational complexities of the Organisational complexities of the hospital context hospital context (Hanseth and Lundberg (Hanseth and Lundberg 2001; Lundberg and Tellioglu 1999)2001; Lundberg and Tellioglu 1999)

1010

The Challenge in The Challenge in HospMIS Development HospMIS Development 22

Heterogeneous and semantic Heterogeneous and semantic interoperabilitiesinteroperabilities

Difficulty of achieving a balance between Difficulty of achieving a balance between loose and tight integration of sub-systems loose and tight integration of sub-systems (Monteiro 2004). (Monteiro 2004).

Frequent changes in reporting Frequent changes in reporting requirementsrequirements

Pressure to “go big” and adopt global Pressure to “go big” and adopt global solutions solutions (Ellingsen and Monteiro 2003)(Ellingsen and Monteiro 2003)

1111

The Challenge in The Challenge in ImplementationImplementation Addressing design-reality gapsAddressing design-reality gaps

– Negotiating standardsNegotiating standards Skills to support the Skills to support the

implementation processimplementation process– Identification of skills required for Identification of skills required for

supportsupport– Development of appropriate skillsDevelopment of appropriate skills

1212

4. Theoretical 4. Theoretical framework 1framework 1

Drawn from Complexity Theory, and in Drawn from Complexity Theory, and in particular complex adaptive systemsparticular complex adaptive systems

Four key concepts:Four key concepts:– CAS as agents with schemata adapting to the CAS as agents with schemata adapting to the

environmentenvironment– Non-linearity resulting in unpredicatble long-Non-linearity resulting in unpredicatble long-

term outcomesterm outcomes– Self-organizing groups and networks displaying Self-organizing groups and networks displaying

emergent behaviouremergent behaviour– Co-evolution at the edge of chaosCo-evolution at the edge of chaos

Defintions of Defintions of ComplexityComplexity

A complex system is made up of a large number of A complex system is made up of a large number of parts that have many interactions parts that have many interactions (Simon 1969). (Simon 1969).

Complexity in organisations has three dimensions: Complexity in organisations has three dimensions: – vertical - the number of activities or subsystems (the number of vertical - the number of activities or subsystems (the number of

hierarchies), hierarchies), – horizontal - the number of job titles, or departments and horizontal - the number of job titles, or departments and – third - the spatial dimension or the number of geographical third - the spatial dimension or the number of geographical

locations locations in which the organization operates in which the organization operates

((Daft (quoted in Anderson 1999)) . Daft (quoted in Anderson 1999)) .

Complex systems “are typically organisations made of Complex systems “are typically organisations made of many heterogenous parts interacting locally in the many heterogenous parts interacting locally in the absence of a centralised pacemaker and control” absence of a centralised pacemaker and control” (Fontana (1999) pg 14). (Fontana (1999) pg 14). 1414

Agents with schema Agents with schema adapting to the adapting to the environment:environment:

A CAS is a system of individual A CAS is a system of individual agents, who have the freedom to act agents, who have the freedom to act in ways that are not always totally in ways that are not always totally predictable, and whose actions are predictable, and whose actions are interconnected such that one agent’s interconnected such that one agent’s action changes the context for other action changes the context for other agents.agents.

Stock market, colony of ants, weather Stock market, colony of ants, weather system, immune systemsystem, immune system

1515

Non-linearity resulting in Non-linearity resulting in unpredictable long-term unpredictable long-term outcomesoutcomes

The sand pile exampleThe sand pile example ““Self-organizing criticality” = small Self-organizing criticality” = small

adjustments result in large-scale adjustments result in large-scale changeschanges

Non-linearity and indeterminate Non-linearity and indeterminate outcomes evolve as a result of both outcomes evolve as a result of both negative and positive feedback negative and positive feedback

1616

Self-organizing groups and Self-organizing groups and networks displaying networks displaying emergent behaviouremergent behaviour

The ability to self organize is a The ability to self organize is a characteristic of systems where characteristic of systems where independent agents behave independent agents behave according to a set of rules and not according to a set of rules and not due to external control. due to external control.

Feedback loops modify the Feedback loops modify the behaviours of agentsbehaviours of agents

1717

Co-evolution at the Co-evolution at the edge of chaosedge of chaos

1818

1919

Theoretical framework Theoretical framework 22

Organizational

Organizational

Group

Group

Individual

Individual

Fe

ed

back

pro

cess

es

ExploitationExploration

Feed forward processes

Intuiting

Institutionalizing

Interpreting

Integrating

UnderstandinUnderstanding g technological technological change as change as organizationorganizational learningal learning

Aborptive Capacity Aborptive Capacity and Systems and Systems capabilities capabilities The policies, procedures, and manuals The policies, procedures, and manuals

that are used to integrate explicit that are used to integrate explicit knowledge. knowledge.

Ensure “behaviors are programmed in Ensure “behaviors are programmed in advance of their execution”.advance of their execution”.

Support knowledge absorption, but tend Support knowledge absorption, but tend to be limited in scope and flexibilityto be limited in scope and flexibility

Negative overall effect on “absorptive Negative overall effect on “absorptive capability”capability”

2020

Aborptive Capacity Aborptive Capacity and Co-ordination and Co-ordination capabilities capabilities The ability to communicate between The ability to communicate between

members of a group, and between groups. members of a group, and between groups. e.g. self-organizing groups which cut across e.g. self-organizing groups which cut across

layers of authority (hierarchy) and layers of authority (hierarchy) and functional groupings. functional groupings.

Less efficient in effecting knowledge Less efficient in effecting knowledge absorption, but have an ability to be absorption, but have an ability to be flexible and cover a broad scope of flexible and cover a broad scope of knowledge absorptionknowledge absorption

Positive effect on absorptive capacity. Positive effect on absorptive capacity. 2121

Aborptive Capacity Aborptive Capacity and Socializing and Socializing capabilities capabilities Ability to create a corporate identity as well Ability to create a corporate identity as well

as a collective interpretation of reality. as a collective interpretation of reality. Socialization capabilities are path dependent Socialization capabilities are path dependent

and shaped by the history of the and shaped by the history of the organization, and tend to foster isolationism. organization, and tend to foster isolationism.

Organizations with strong socialization Organizations with strong socialization capabilities tend to reject outside knowledge capabilities tend to reject outside knowledge that is different to their organizational code. that is different to their organizational code.

Negative effect on absorptive capacityNegative effect on absorptive capacity

2222

5. Research Methods 15. Research Methods 1

Longitudinal case study approachLongitudinal case study approach Member of the HISP action Member of the HISP action

research networkresearch network– As an empowering process, seeking As an empowering process, seeking

local solutionslocal solutions– Within an iterative cycle of action, Within an iterative cycle of action,

reflection and learningreflection and learning

2323

Research Methods 2Research Methods 2

Primary data collection throughPrimary data collection through– Field notes and a personal diary, and Field notes and a personal diary, and

reflections on various data sourcesreflections on various data sources– Camera for documentationCamera for documentation– Recorded interviews and meetings – some Recorded interviews and meetings – some

transcribedtranscribed– Filed visits and direct observationFiled visits and direct observation

Secondary data sources throughSecondary data sources through– Official documents, reports policies, Official documents, reports policies,

guidelines, etcguidelines, etc

2424

Research Methods 3Research Methods 3

Data analysis through interpretive Data analysis through interpretive research methods using research methods using – first and second-level analysisfirst and second-level analysis– analysis as part of my doctoral studiesanalysis as part of my doctoral studies– Co-evolutionary growth processCo-evolutionary growth process

Theory used to inform data analysis Theory used to inform data analysis and as a final product of my and as a final product of my researchresearch

2525

12

3

4

5

67

Publication date

1997 2000 2003 20061998 1999 2001 2002 2004 2005 2007 2008 2009

Paper 1

1992-97

Paper 2

Paper 3

Paper 4

Paper 5

Paper 6

Paper 7

Med officer Queenstown Act Director Hospitals - Province HISP-SA Manager and team member

Formal Doctoral studies

PHC Info systems ECP Hosp Information systems ECP ECPHosp

Malawi Hosp

Nigeria PHC

Zambia PHC

Research / period covered in paperResearch related to thesisEmployment / Role

Legend

6. Contributions 1 6. Contributions 1 Understanding the context as Understanding the context as extreme heterogeneityextreme heterogeneity

Extreme heterogeneity Extreme heterogeneity manifested in hospitalsmanifested in hospitals– Differences between departmentsDifferences between departments– Differences between hospitalsDifferences between hospitals– Different professional groups, Different professional groups,

staffing levels, and skills basestaffing levels, and skills base Extreme heterogeneity creating Extreme heterogeneity creating

nested effectsnested effects2727

2828

Complexity of the Complexity of the environment characterised environment characterised byby

A broad range of challengesA broad range of challenges Limited control over information Limited control over information

production activitiesproduction activities Other complexities impinging on Other complexities impinging on

HospMISDHospMISD As unanticipated non-linear As unanticipated non-linear

effectseffects

2929

V Shaw 26 June 2009 Trial DefenceV Shaw 26 June 2009 Trial Defence

V Shaw 26 June 2009 Trial DefenceV Shaw 26 June 2009 Trial Defence

V Shaw 26 June 2009 Trial DefenceV Shaw 26 June 2009 Trial Defence

V Shaw 26 June 2009 Trial DefenceV Shaw 26 June 2009 Trial Defence

V Shaw 26 June 2009 Trial DefenceV Shaw 26 June 2009 Trial Defence

V Shaw 26 June 2009 Trial DefenceV Shaw 26 June 2009 Trial Defence

This Malawian This Malawian Hospital hadHospital had

A touch A touch screen EPMR screen EPMR for Paediatric for Paediatric patientspatients

The DHIS as The DHIS as the HospMISthe HospMIS

This filing This filing system for system for patient patient recordsrecords

V Shaw 26 June 2009 Trial DefenceV Shaw 26 June 2009 Trial Defence

Managing heterogeneity Managing heterogeneity through flexibile standards: through flexibile standards:

a) Adaptable paper toolsa) Adaptable paper tools

3737

The EDS as a Flexible The EDS as a Flexible StandardStandard

Total deliveries

Deliveries mothers under 18

Deliveries mothers over 18

Deliveries under 2500g

Deliveries over 2500g

3838

Gateways as flexible Gateways as flexible standardsstandards

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

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

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

3939

The DHIS as a flexible The DHIS as a flexible standardstandard

4040

Managing heterogeneity Managing heterogeneity through flexibile through flexibile

implementation processes: implementation processes:

4141

Principle of integrated Principle of integrated independenceindependence

CEOC

BEOCBEOC BEOC BEOC

24/7HF

24/7HF

24/7HF

24/7HF

Process for Process for accommodating non-accommodating non-linearity linearity

4242

Data

Volume

Low

High

Strong

Weak

Human resources

Technical aspects

Poor

Well developed

Use of information

Data

Volume

Low

High

Strong

Weak

Human resources

Technical aspects

Poor

Well developed

Use of information

Flexible Flexible implementation implementation processes contdprocesses contd

Mindful innovation Mindful innovation (Swanson and Ramiller (Swanson and Ramiller 2004, Weick, Sutcliffe et al. 1999)2004, Weick, Sutcliffe et al. 1999)

Attractors as growth points Attractors as growth points (Braa et al 2007)(Braa et al 2007)

Creation of networks and inter-Creation of networks and inter-dependenciesdependencies

Development of the Health Information Development of the Health Information PractitionerPractitioner

Introduction of redundancyIntroduction of redundancy4343

The Challenge of The Challenge of SustainabilitySustainability Sustainability is “…the challenge to Sustainability is “…the challenge to

make an information system work, in make an information system work, in practice, over time, in a local setting. practice, over time, in a local setting. This involves shaping and adapting the This involves shaping and adapting the systems to a given context, cultivating systems to a given context, cultivating local learning processes, and local learning processes, and institutionalizing routines of use that institutionalizing routines of use that persist over time (as well as when the persist over time (as well as when the researchers leave and external funding is researchers leave and external funding is over).” over).” (Braa, Monteiro et al. 2004) (p. 338).(Braa, Monteiro et al. 2004) (p. 338).

4444

Co-evolutionary model for Co-evolutionary model for sustainable HIS sustainable HIS DevelopmentDevelopment

4545

Fe

ed

back

pro

cess

es

Exploitation

ExplorationFeed forward processes

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 co-evolving in response to

inputs from both partners

Deepening of geographic scale

to new levels in the HS hierarchy

Widening of geographic scale

across new geographic areas

Deepening of scope as

evidenced by increased user

maturity

Widening of scope by adopting new functionality

Scaling the scope of the

system in use

Geographic scaling

4646

7. Concluding remarks 7. Concluding remarks 11

4747

Limitations in this thesis can be Limitations in this thesis can be identified related to:identified related to:– Relative short periods of study of Relative short periods of study of

HospMISHospMIS– Limited focus on cultural diversity Limited focus on cultural diversity

and the impact of this on HospMISand the impact of this on HospMIS– Lack of depth regarding inter-Lack of depth regarding inter-

organizational dimensionsorganizational dimensions

Concluding remarks 2Concluding remarks 2

4848

Contributions can be defined in terms of development Contributions can be defined in terms of development of ICT’s:of ICT’s:– Locally appropriate solutions in the “south” for the health Locally appropriate solutions in the “south” for the health

sectorsector– Development of local capacityDevelopment of local capacity– Development of sustainable organizations and processesDevelopment of sustainable organizations and processes

Research in resource constrained contextsResearch in resource constrained contexts Research on FOSSResearch on FOSS Methodological issues such as:Methodological issues such as:

– Longitudinal action research projectsLongitudinal action research projects– Multi-level focus for data analysisMulti-level focus for data analysis

4949

Thank you