A Complexity Inspired Approach to

1. A Complexity Inspired Approach to Co-evolutionary Hospital Management Information Systems Development Vincent Shaw

2. Overview of Presentation • Research aim and questions • Defining a HospMIS • The challenge of HospMIS Design and Implementation • Theoretical framework: • Complexity and Complex Adaptive Systems • Organizational learning • Research methods

3. Overview of Presentation 2 • Contributions • Context as extreme heterogeneity • Managing heterogeneity with flexible standards and • Flexible implementation processes • Sustainability as co-evolution • Concluding remarks

4. 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

5. 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?

6. 2. Defining a HospMIS?

7. The Components of the HospMIS

10. 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)

11. 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)

12. 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

13. 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 long-term outcomes • Self-organizing groups and networks displaying emergent behaviour • Co-evolution at the edge of chaos

14. 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).

15. 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

16. 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

17. 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

18. Co-evolution at the edge of chaos

19. Theoretical framework 2 Understanding technological change as organizational learning

20. 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”

21. 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.

22. 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

23. 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

24. 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

25. 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

26. Formal Doctoral studies Med officer Queenstown Act Director Hospitals - Province HISP-SA Manager and team member Malawi Hosp Zambia PHC PHC Info systems ECP Hosp Information systems ECP ECPHosp Nigeria PHC 1992-97 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Paper 1 1 2 Paper 2 3 Paper 3 Paper 4 4 Paper 5 5 Paper 6 6 7 Paper 7 Legend Research / period covered in paper Publication date Research related to thesis Employment / Role

27. 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

29. 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

35. This Malawian Hospital had • A touch screen EPMR for Paediatric patients • The DHIS as the HospMIS • This filing system for patient records

37. Managing heterogeneity through flexibile standards: a) Adaptable paper tools

38. The EDS as a Flexible Standard • Total deliveries • Deliveries mothers under 18 • Deliveries mothers over 18 • Deliveries under 2500g • Deliveries over 2500g

39. Gateways as flexible standards

40. The DHIS as a flexible standard

41. Managing heterogeneity through flexibile implementation processes: CEOC • Principle of integrated independence BEOC BEOC BEOC BEOC 24/7 HF 24/7 HF 24/7 HF 24/7 HF

42. Process for accommodating non-linearity

43. 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 inter-dependencies • Development of the Health Information Practitioner • Introduction of redundancy

44. 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).

45. Co-evolutionary model for sustainable HIS Development

47. 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 inter-organizational dimensions

48. 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

49. Thank you