Communities of Practice to Facilitate Successful Implementation of a Knowledge Management Project in a Complex Adaptive System

• Abstract
• Introduction
• Success Factors for Knowledge Management Systems in Healthcare Organisations
• A Knowledge Management System in ADHB
• Conclusion
• The Future of Communities of Practice in Knowledge Management Projects
• References
• Footnotes

Abstract
A knowledge management project implemented at Auckland District Health Board was initially only partially successful. Through the emergence of a Community of Practice, this implementation of a database which functions as an electronic clinical record was eventually adopted and, thus, the project considered successful. Some of the reasons for difficulties in implementing knowledge management projects in healthcare organisations are discussed as is the rationale for knowing what some of these difficulties are in order to overcome them.

Introduction
It is often difficult to successfully implement knowledge management systems in organisations. This is especially true in healthcare organisations:

Health care is one of the most complex systems known to contemporary society. Hospitals, in particular, are considered to be extraordinarily complicated organizations. Yet, when considered one element at a time, their complexity seems to fall away.^[1]

A health care organisation can be described as a complex adaptive system: "…a collection 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 actions change the context for other agents".^[2]

Healthcare organisations are made up of individuals with human attributes and this creates difficulty when adopting change. These individuals may choose if and/or when to adopt new practices such as information technology (IT) implementation.

One of the difficulties is that professionals ally themselves more readily to their professions or professional colleges than to the organisation in which they work. Professional allegiance often takes precedence over organisation alliance. The relationships between each of the professions existing in health care can be described as sometimes competitive, sometimes collaborative and sometimes interdependent. Individuals may pursue their own interests, or act as individual political agents, or may have their own individual strategies within the organisation’s internal politics.^[2]

Flanagan and Spurgeon^[3] highlight that people have various motivations and personality along with their training, skills, values and beliefs. Each individual in the organisation has a different mental model – attitudes, beliefs, and values – which can create tension, especially on interaction with other individuals.^[4,5] Recognising the mental models which individuals may operate from, can lead to transformation or assist in facilitating change.^[2] Thus, it is important to be aware of the various mental models and their interactions within an organisation when implementing projects.

Common perceptions of carefully managed healthcare organisations may further compound tensions by creating an environment of scarcity of resources, whereby individuals must work harder or fight for resources to perform their work. This mental model of carefully managed healthcare organisations has produced scant successful management strategies due to the use of business principles to bring everyone into line. Healthcare organisations are not machine bureaucracies, but labour intensive facilities dealing with complex issues of patient care and cure.

A further complication in healthcare organisations is that there is often inherent non-linearity and unpredictability. Inherent non-linearity describes the circumstance when, at times, large changes within a system may have little to no effect at all, whereas small changes can have a major impact on the system, also known as the butterfly effect. Emergence describes the situation when results or factors may emerge which were unforeseen or unpredicted.^[6]

This paper considers the role that a community of practice can play in facilitating an environment where innovative approaches, such as knowledge management projects, can flourish and become successful in the complex environment of a healthcare organisation. It reviews success factors for implementation of knowledge management systems in healthcare organisations, with a focus on communities of practice, and explores the role that communities of practice played in the implementation of HCC (Health Care Communities) – a database which functions as an electronic clinical record – within the Community Health and Mental Health departments in the Auckland District Health Board.

Success Factors for Knowledge Management Systems in Healthcare Organisations
Healthcare organisations rely heavily on knowledge. "Knowledge should be made so readily accessible that it can’t be avoided."^[7] Knowledge management systems, where knowledge is managed and successfully diffused throughout an organisation, requires facilitation via a comprehensive infrastructure, which may be absent in healthcare settings. This infrastructure depends on technical and organisational initiatives being aligned and integrated because they have been largely ignored in business strategies. This is an important concept because attempting to implement knowledge management systems has often failed, particularly in healthcare organisations.^[8]

All of the agents within a health care organisation rely on the ability to access, utilise, and disseminate useful and timely information.

Knowledge is "…information that has been combined with experience, context, interpretation, and reflection."^[9] Thus, knowledge relies on information. Information is data that is useful or relevant. Clinicians compile data into information. This information is only useful if the clinician can access it in a timely and useful context.^[10-12] Polanyi notes that knowledge is a process of knowing.^[12] Knowledge builds on previous knowledge. Therefore, one must first have knowledge. Information can be communicated through various channels – orally or in written formats, but information must be put into context within an individual’s mind to become knowledge.

Knowledge management systems create the infrastructures that assist in facilitating the creation, accessibility, utilisation and dissemination of knowledge.

Social networks or communities of practice within an organisation cross traditional hierarchical boundaries and form useful networks for the dissemination, transfer, and capture of knowledge. This concept was founded by Lave and Wenger (1991), Brown and Duguid (1991) and Chaiklin and Lave (1993) with the addition of Boland (1994), who said that there are multiple communities within an organisation who may be dealing with a problem but because of their social network foundation, they find ways to communicate across traditional boundaries, and "…interact to create the patterns of sense making and behaviour displayed by the organisation as a whole".^[13]

The Institute for Research on Learning "…notes that it is the informal, socially constructed communities of practice that form within organisations that are the true mechanisms through which people learn and through which work gets done.^[14]

Communities of practice also work to diffuse some of the barriers or resistance to change.

Peter Senge^[15] believes that in order for organisations to survive, they must become "learning organisations". He says to overcome built in learning disabilities of operations in traditional organisational structures, organisations must adopt, understand and navigate through five disciplines, including Systems Thinking, Personal Mastery, Mental Models, Building a Shared Vision, and Team Learning. Such learning organisations aid in fostering innovation, and innovation is necessary to promote new ways of coping to become or remain successful.

"One of the by-products of the complexity of health care organizations is their remarkable resilience in the face of pressure; even when that pressure is one for positive change."^[2] One of the barriers is making time for individuals to develop ideas for innovative means to affect positive changes. Often, making time for individuals to reflect and brainstorm, or foster innovative practices or methods, is considered to be a rare luxury rather than an efficient use of time and engagement of individuals to affect a positive influence for change.

Social networks or communities of practice offer one means of overcoming these traditional barriers. They can diffuse some of the barriers and/or resistance to change because individuals are able to interact on their own terms and feel more in control with the processes of change, rather than being forced through traditional hierarchical authoritarian directives or coercive methods. This is especially true when individuals have greater autonomy and therefore may feel more inclined to affect changes to maintain social status within their informal networks. Innovation is a key success factor and yet, change or implementing changes necessary for innovation to thrive is difficult within complex healthcare organisations. Communities of practice can serve as an important lever for this critical innovation.

A Knowledge Management System in ADHB
The recent knowledge management project in ADHB began with the implementation of HCC (Health Care Communities), which is a database that functions as an electronic clinical record. HCC was rolled out into Community Health and Mental Health departments across ADHB.

The implementation was only partially successful initially as there was a department within Mental Health that was reluctant to take up the new system. There were numerous attempts to engage the department in scheduled open courses and one-on-one training sessions. Although many completed the training, resistance continued because of multiple organisational difficulties within the department, creating a lack of time to engage and a reluctance to add to staff’s overburdened workloads. Additionally, many project members moved on to other projects, leaving a gap in complete uptake of utilisation of HCC at ADHB.

As the project neared completion, the project manager handed over the project to operational staff and the author took over the operational support role from a position in Information Systems. A friend and colleague of the author who is a clinician in Mental Health requested that the author give one-on-one instruction on the HCC system. This effectively created a community of practice or social network through which traditional hierarchical organisational boundaries, between Information Services and Mental Health, could be crossed."

Until this point, the mental health clinician had little experience with computers and viewed the use of HCC as a further task that would be added to an already overburdened clinical workload. It was felt that utilisation of HCC was considered more of an administrative duty rather than a clinical asset.

However, through the opportunity provided within the community of practice, the clinician began to understand the added value of utilising this application through somewhat innocent conversations that arose between the author and the clinician regarding the application’s abilities and functions.

Not only did the clinician ask to begin learning by one-on-one instruction, but has since learned the system and is now asking for further instruction. Other colleagues within that department noticed the uptake and began to realise the advantages of using the system. They initially queried their previously reluctant colleague about the added value in being able to access as well as create patient notes, as well as the experience of having one-one-one instruction which was deemed more useful than the prior attempts at training.

It could be argued that a case of inherent non-linearity has ensued in that the whole department is now using the system as well as advocating for other departments to begin using HCC. Members of the department requested further instruction in the utilising HCC so they can access more robust clinical information regarding patients, in particular those who cross services.

An emergent factor came about as word got out that the clinician and subsequently the department were utilising HCC; many clinicians in other Mental Health departments breathed a sigh of relief. Information in HCC is considered vital to continuity of care as patients often cross departments and/or clinicians, eg psychiatrists to psychologists, social workers, and mental health nurses, in their mental health journey. For example, the Crisis Team often had difficulty in accessing necessary patient information, especially out-of-hours when originating clinicians may be unavailable, as they provide 24-hour/7day a week care for many of the Mental Health department’s patients.

On the basis that all departments are now utilising HCC, the project has now been considered successful.

Another emergent factor has been the raising of the bar on the level of knowledge in utilising HCC throughout Mental Health. Prior to the complete uptake of the system, departments already using HCC considered themselves to have expert knowledge and experience in its use. Now that other departments are using HCC, these original users want to increase their level of knowledge and utilisation, in order to continue to be considered more expert users of the system – something of a competitive cycle, which is encouraged. These "super users" continually challenge current practices and known limitations of the system, asking for more functionality and instruction which they happily pass along to other users in their departments.

Conclusion
Communities of practice are based on informal relationships or social networks that are able to cross traditional hierarchical organisational boundaries, and extend into wider social circles. This is especially true when networked individuals belong to different professional bureaucracies and traditionally non-friendly organisational departments. This can have a domino or cyclical effect that continually raises the bar of knowledge and level of engagement. This may be due to the nature of friendship, which is based on a more solid, valued, and trusted foundation, as opposed to the basis of organisational relationships where authoritarian practices may prevail. The parties involved have a vested interest to achieve based on the success of the existing relationship. Thus, they are able to withstand more challenges and work through difficulties in order to maintain the relationship status. This is in contrast to some change management experiences such as implementation of knowledge management systems whereby the first obstacle may cause either a delay or total failure to adopt knowledge management systems. People may take stances in the coercive, directive methods of traditional hierarchical authoritarian organisational business practices. Oftentimes, these methods produce an environment whereby individuals may perceive these practices as threats to traditional ways of working – "it ain’t broke, so don’t fix it". However, through wider social networks, communities of practice can contribute to successful knowledge management projects.

The Future of Communities of Practice in Knowledge Management Projects
A new project, involving implementation of HCC across all Mental Health services in the three organisations in the Auckland region has begun. It is the author’s view that communities of practice will contribute to successful implementation of this project. To date, project members are currently engaged in strategic conceptualisation of the structures and details for implementation in 2007. Communities of practice have already eased cross-organisational communication and agreements for provisions of IT services in order to adopt use of HCC as an electronic clinical record for mental health patients in the Auckland region.

Project members who have first-hand experience from the previous HCC implementation have begun asking representatives from various services currently using HCC to communicate their experiences and expertise to a new wider community of practice – as representatives of various professional bureaucracies, and through social networks. This will assist in better communication through the region, the ability to cross organisational boundaries, and hopefully assist in breaking down traditional barriers. Many clinicians believe that the ability to access patient information across the region will assist in better patient management. And that is the overall goal of the latest Auckland region project.

References

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Footnotes
This paper was prepared by the author in her role as student of the POPLHLTH723 Health Knowledge Management course at the School of Population Health, Auckland University. As such the views expressed in the paper are those of the author and are not intended to represent the position of ADHB.