Page - 182 - in Applied Interdisciplinary Theory in Health Informatics - Knowledge Base for Practitioners

2.2. Evaluating implementationof anew electronic preoperative information system within a surgical pre-assessment clinic. Surgical pre-assessment clinics (PACs) evaluate whether patients may be suitable for day case surgeryor 23-hour care,or may require a longer in-patient stay. These have been introduced in Scotland as a result of policy recommendations intended to reduce unnecessary burden on services, and reduce surgical mortality rates [12]. PACs act as a gateway to surgical services from a wide range of referral pathways, involving multiple information flows. The PAC design evaluated by Bouamrane and Mair (2014) incorporated development and implementation of an electronic pre-operative information management system, to facilitate information sharing among members of the multidisciplinary PAC team. Development occurred iteratively by PAC staff in collaboration with the local NHS Health Board Information Technology team. In this article, the authors focus on one site (Dumfries and Galloway Royal Infirmary - DGRI) from a national study in Scotland.The authors modelled clinical processes using process- mapping techniques, and conducted 10 semi-structured interviews with five participants across four visits to the clinic site [12]. NPT was used in analysis of results from both process mapping and qualitative interview data. The rationale for the clinic was found to be well established at DGRI, supported by previous institutional experience of problems with traditional in-patient routes lacking pre-assessment. In addition, the importance and relevance of the service was reinforced by national policy initiatives that incorporated performance targets. Coherence of the PAC in terms of overall relevance to strategic objectives of the institution was therefore well established. Coherence wasalso found to be high within the pre-assessment clinic, but less so at points of contact with other services. This was attributed in part to the number of different possible pathways to the PAC which were observed to be confusing to staff within the clinic, in addition to the fact that junior doctors involved in various routes to the PAC were not routinely involved in the clinic’s assessment processes. The collaborative design of PAC implementation and development, particularly with respect to the pre-operative information management system, was reported as a strength of the project. The authors report a ‘teething period’ of 12 months, after which specialist nurses leading PAC development were ‘entirely satisfied’ with information management practices. The combination of leadership from experienced pre-surgical nurses, and collaborative ongoing development with local NHS IT services ensured that key people relating to both clinical and health informatics aspects of the project were working together to drive forward development (an aspect of Cognitive participation). Staff within the multi-disciplinary team (MDT)were found to behighly experienced in care and management of day-case patients. This foundation allowed PAC staff to effectively define their roles in relation to the new clinic, and build both individual and collective understandings of accountability (collective action). At the level of the wider institution however, participants expressed concerns with respect to replication by the PAC of information available through other sources (i.e. primary care). Here, the authors note that such concerns may in principle be addressed through improvements to integration of existing information systems. In the context of Collective action, such a development would require extending professional relationships through which roles are defined to encompass inter-departmental working (i.e. who is responsible for which tasks within an overall care pathway). Finally, although the prior experience of PAC staff was important in the success of the nurse-led clinic design process, there were no formal processes for continuing professional development or training at the PAC (reflexive M.BracherandC.R.May / ImplementingandEmbeddingHealth InformaticsSystems182