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Purpose -The importance of networks in effecting the outcomes of change processes is wellestablished in the literature. Whilst extant literature focuses predominantly on the structural properties of networks, our purpose is to explore the dynamics of network emergence that give rise to the outcomes of process improvement interventions. Through the use of ActorNetwork Theory (ANT) we explore the dynamics in the implementation of a process improvement methodology in the complex organisational setting of a UK National Health Service Trust. The paper illustrates the utility of ANT in articulating the dynamic nature of networks underpinning socio-technical change, and our analysis provides insights for the management process change initiatives.Design/methodology/approach -This is a rich qualitative study in the Pathology Unit of a UK National Health Service Trust, using ANT as the theoretical lens for tracking the emergence and transformation of networks of individuals over the course of a management intervention to promote "Lean thinking" for process performance improvements.Findings -ANT is useful for explicitly tracking how organisational players shift their positions and network allegiances over time, and for identifying objects and actions that are effective in engaging individuals in networks which enable transition to a Lean process. It is important to attend to the dynamics of the process of change and devise appropriate timely interventions enabling actors to shift their own positions towards a desired outcome.Research limitations/implications -We make the case for using theoretical frameworks developed outside the operations management to develop insights for designing process interventions.Originality/value -By understanding the role of shifting networks managers can use timely interventions during the process implementation to facilitate the transition to Lean processes: e.g. using demonstrable senior leadership commitment and visual communication.Paper Type -Research paper.

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This paper demonstrates the value of Archer's morphogenetic approach (MA) in understanding and explaining the complexity of the broader context within which many developing country information and communication technology (ICT) projects are implemented. It does this by using MA's analytical and explanatory apparatus to examine the evolution of the context of public sector ICT provision in Kenya over the period 1963-2006. In addition to demonstrating the practical value of MA, the paper contributes to the Information Systems literature on ICT for development (ICT4D). The analysis identifies (1) global normative pressures, polity, the national socioeconomic base, disruptive technology, and the emergence of multistakeholder networks as key forces in shaping the evolutionary trajectory, (2) the explicit treatment of time and temporality as key for understanding mechanisms underpinning the evolutionary process, and (3) the difficulty of cleanly isolating the implementation of individual public sector ICT projects from the broader context and ICT4D agendas. The discussion elaborates on the features of MA found to be particularly valuable in this study. The paper concludes that explicitly attending to time and temporality, and to the broader context for ICT4D projects, would contribute to the development of more nuanced accounts of such projects and a more emancipatory outlook for ICT4D research.

BackgroundMany emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology - hand-held computers with computerised clinical decision support (CCDS) software - to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services.Methods/DesignPragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial.Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders.The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically.DiscussionSince the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services.In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen.Trial RegistrationISRCTN10538608