Knowledge Management and Learning in Healthcare
Revised September 23, 2002 (Reprint October 1, 2006) Abstract Many researchers and practitioners have developed models to discuss how organizations learn using concepts of learning, social theory, assembling and information transfer. The Organization Learning Systems Model (ALSO) provides a comprehensive framework for discussing how organizations Interact with their environments, reflect on information collected, disseminate knowledge to stakeholders and “make sense” with their culture through learning subsystems.
After reviewing Individual and organizational learning literature, I will reflect on a recent insulation at a major healthcare firm using this frame. This paper suggests that practitioners and managers can leverage this model to better manage learning, change, effectiveness and strategic planning. From Individual Learning to the Organizational Learning Systems Model In recent years the topic of organizational learning has been discussed In academia and the workplace with great interest.
In organizations, these discussions usually begin as the result of some cataclysmic event, strategic planning announcement, market change or dialogue on performance. Some see this subject as the integration or theft f many theories from sociology, psychology, management science and anthropology (Argils & Chon, 1978; Davis, 2001 ; Candlewick, 2000; Scanted & Marauded, 2000; discussed using “adaptation” language from sciences such as biology, physics and chemistry
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Regardless of the discipline, how individuals learn and the way this impacts the process by which organizations “learn” will continue to charge academic debates and consume practitioner resources. Linking theoretical constructs of organizational learning to the “real world” is a difficult challenge. In healthcare, researchers and practitioners have attempted to make this linkage by identifying learning conditions that must exist in order to generate, disseminate and use knowledge.
These include: 1) a shared vision of organizational goals and how learning can contribute to success; 2) leaders who ensure that opportunities, resources, incentives and rewards are provided to support learning; and 3) an organic structure with diverse communication channels that efficiently transfers information across organizational boundaries (Barley, Limited-Charles, & McKinney, 1998).
Others also suggest that understanding the environment, information processing functions and cognitive learning frameworks in health care organizations can boost the probability of building and maintaining intellectual capital (Granting, Nichols, & Schoenberg, 1997). One attempt to connect theory and practice is the Organizational Learning Systems Model (ALSO) (Scanted & Marauded, 2000).
This multi-disciplinary model developed at the Center for the Study of Learning at George Washington University is increasingly impacting the practice of organizational learning. This model is founded upon the writings of Tailcoat Parsons (Scanted & Marauded, 2000) and discussions of his organizational prerequisites of adaptation, goal attainment, integration and pattern maintenance functions in organizations. The structure of action provided by Parsons lends a powerful lens by which many organization processes and actions can be viewed (Lackey, 1987).
Scanted and Marauded (2000) expand on Parsons General Theory of Action by creating a model that explains organizational learning in the context of four learning subsystems: 1) environmental interface, 2) action/ reflection, 3) dissemination and diffusion and 4) meaning and memory. Equally as important, they depict interactions among these subsystems using the interchange media of information, goal reference knowledge, structuring and assembling. Many current management theories and models inadequately meet the special needs of the healthcare industry (Granting et al. 1997); however, the ALSO, can start a new, more comprehensive conversation regarding knowledge creation and organizational learning. Understanding the theoretical underpinnings of ALSO is the first step to appreciating its practical application in health care organizations. In this paper, horses of adult learning, social interactions and organizational learning are reviewed to provide perspective. I will discuss individual learning and learning in the social context before a discourse on organizational learning. This review will provide the learning foundation that establishes organizational learning as the theoretical basis for the ALSO.
After establishing the theoretical and practical applications of this model, I will use it to analyze an employee opinion survey with one of the nation’s leading healthcare providers. This will provide a bridge from theoretical construct to ragtime tool. In concluding, I will suggest that other healthcare organizations use this model to frame and facilitate future organizational learning and performance Individual Learning Learning takes place when individuals and organizations interact with their environments (Heeders, 1981).
Some researchers claim that learning is an on-going process of reflection and action where individuals ask questions, receive feedback, experiment and take action (Davis, 2001; Edmondson, 1999; Goby & Lewis, 2000; Kola, 1976; Leviathan & March, 1993). Gerber (2001) describes learning as a construct that involves a change in behavior or cognition (or both), relating to perceptions, affect, feelings, attitudes, and values. He continues by stating that learning occurs following, or as the result of experience, direction, thinking, and insight.
Learning through experiences and reflecting on actions has its formal grounding in the works of Dewey, Lenin and Pigged (Nineteen, 1998). Kola (1976) defines learning as a process whereby knowledge is created through the transformation of experience. Parsons identifies learning as cognitive processes that are required by organisms’ (and organizations) deed-fulfillment to complete actions (Lackey, 1987). Most modern theorists share the similar premise that experience plays a significant role in learning (Drunkards, 2000; Gerber, 2001; Goby & Lewis, 2000; Kola, 1976; Nineteen, 1998).
Gerber (2001) has posited that learning can be viewed in four categories aligned into two classes. The first class (two categories) is based on the research of Skinner and Pavlov. The Skinner model suggests that individuals are subjected to a stimulus that causes a response (traditional S 0 R). This response and stimulus interaction is called Association Learning. Reinforcement Learning is similar, but the learning is “reinforced” with another stimulus in close proximity (S 0 R 0 S). The second class of learning assumes that a process occurs within the subject that impacts the response produced by the stimulus (Gerber, 2001).
This class is represented as S 0 0 R, where “O” symbolizes the role of the subject in producing the response. In this category, termed Cognitive-perceptual Learning, learning is a mental process that considers varying perceptual “frames” until one corresponds to a universal structure. Past perceptual “Gestalts” are stored in memory and become data for future sections. Theorists such as Rogers, Moscow and Lenin are considered the founders of this type of learning. Cognitive-Rational/Linguistic Learning is the second category in this class and builds on the Cognitive-perceptual Learning.
Here, learning is based on experiences that can be coded and remembered through language; it permits higher levels of structuring that can be conferred to create new knowledge. In Cognitive-Rational/Linguistic Learning, the subject is using language (not necessarily words) as a means to collect data, enhance information analysis and communicate it to others. Information precedes thoughts, thought precede actions. Behavior results from cognitive analysis of data and decision-making (Gerber, 2001) based on individual experiences/action.
One view of what is happening at “O” is that the subject is using dimensions of learning to “frame” the stimulus (Kola, 1976) to create understanding. Wick (1993; 2001)) describes the formation of frameworks as important to helping people identify meaning. As will be viewed later, the ALSO provides a framework for this data-information-knowledge-meaning relationship. As individuals create frameworks, language (not necessarily words) may be used a means to create “schemas” and “narratives” that are used to interpret and catalogue frameworks by reflecting on experiences and through a process called “dialogue. Dialogue means that assumptions are suspended as individuals “think together” (Sense, 1990). Dialogue in the form of face-to-face communication is a process where one builds on the concepts in collaboration with others. Individuals in groups can enrich knowledge transfer and help to construct and reconstruct collective frameworks. It allows for people’s hypothesis to be tested (Monika, 1994). Frameworks, fed by experiences, knowledge and dialogue, are accumulated by individuals and allow for and are developed in a social context (Casey, 1997; Wick, 1993).
Scanted and Marauded (2000) discuss this framework building as critical to learning. Monika (1994) states that groups provide a “shared context” where ideas can be dialogue and reflected upon to impact performance. Social Context and Learning At the Rational/Cognitive Learning level, language, through dialogue becomes the facilitator of knowledge creation and new learning in a social setting. Therefore, learning occurs in the social context (Gerber, 2001). Learning is not the same for individuals alone as it is for individuals in groups or teams.
Some theorists contend that to isolate learning from the “social context” in which it occurs is counter productive (Gerber, 2001). Individual learning is necessary for survival; however, transference of learning requires “social systems” (Allele, 2000; Gardner & Short, 1998; Heeders, 1981; Scanted & Marauded, 2000; Sparrows, Elide, Kramer, & Wayne, 2001). Sense (1990). Teams, not individuals, are the fundamental learning unit in modern organizations and that if teams cannot learn, organizations will not (Sal, Marxism, & Decant, 1997). Learning in teams becomes complex (Gibbons, 1999).
When setting the stage for ALSO, Scanted and Marauded (2000) stats that learning is an individual process that involves the accumulation of knowledge that accommodates benefit to a larger collection of individuals. Edmondson (1996) states that this type of learning for collections of individuals is possible, but the collections must be defined as part of a larger organization. Members must have a shared culture, clearly defined membership and shared responsibility for outcomes. This culture along with other factors will affect learning (Heeders, 1981; Wick, 1993; Wilson & Wilson, 1998).
Group learning and performance are more than the some of individual parts (Edmondson, 1996; Sparrows et al. , 2001). “Learning in teams is an attempt to articulate behaviors through which such outcomes as adaptation to change, greater understanding or improved performance can be achieved” (Edmondson, 1999). This is Rational/Cognitive Learning at the group level is the “O” processes required for the group to respond to the environment and learn together. In healthcare, targeted learning in teams produces benefits for individuals and organizations (Gibbons, 1999; Wick, 1993).
Learning in groups has proven useful in problem solving, product development, leadership development, quality implementation and transitioning theory into action (Gibbons, 1999; Scanted & Marauded, 2000; Sparrows et al. , 2001; Wilson & Wilson, 1998). To achieve higher performance and to better understand what happens in organizations, individuals form in groups to learn, create knowledge and communicate (Sal et al. , 1997). Through social learning, knowledge is created and legitimated. Informal communities become “communities of practice” (Allele, 2000) that create knowledge and transform it (Sparrows et al. 2001). Klein and Roth (1997) describe a similar concept of “learning histories” where teams of people create narratives to identify and share organization learning. The ability to frame, airframe, learn and unlearn can be enabling devices for organizations (Heeders, 1981; Monika, 1994). In healthcare settings, training and education programs are powerful tools that are usually undervalued at the team level, therefore reducing the potential for building collective frames and effective learning integration.
To make matters worse, in health care, employees are often segregated into classes of physicians, nurses, administrators and others. Collective frames are then occupational specific. This does not contribute to organizational learning and may lead to conflicting learning and performance goals. To have an impact, organizations must first begin the conversation of how they organize learning, how they evaluate and monitor learning and how they share learning and key messages among stakeholders.
Framing and re-framing will need to take place if teams are to learn and be effective as they network and connect (Gibbons, 1999; Nineteen, 1998; Wick, 1993). Healthcare leaders must develop opportunities for learning to be connected and networked to other parts of the organization and to the environment (Souses & Poster, 1995). Organizational Individual learning, particularly Cognitive/Rational-Linguistic learning, and collective learning comprise the foundation of organizational learning.
Organizational learning, as a discipline, is formed by concepts from psychology, sociology, education, anthropology and management science (Argils & Chon, 1978; Davis, 2001 ; Candlewick, 2000; Scanted & Marauded, 2000; Sense, 1990). Such an interdisciplinary construct allows application to organizational actions that include organizational behavior, team development, knowledge management, leadership development and others. The interaction between the collective and the individual (Argils & Chon, 1978; Monika, 1991; Sparrows et al. 2001), application of learning theories (Gerber, 2001; Kola, 1976; Kemp, 1999) and the understanding of a “whole systems” approach (Danville & Jacobs, 1992; Katz & Kahn, 1966; Sense, 1990) are key to how knowledge is shared throughout organizations. Scanted and Marauded (2000, peg 22) refer to organizational learning as “an intricate and complex relationship among people, actions, symbols and processes. Practicing Organizational Learning For good reasons, practitioners in organizations are investing in ways to harness this new discipline (Argils & Chon, 1978; Bland et al. 2001; Duffy, 2000; Marauded, 1996; Giggler, 1999; Stewart, 2000; Warhorse, 2001). Some have suggested that the future of many organizations is directly related to how well they transition individual learning and experiences into collective knowledge. Others support this by positing that contentiously managing effective learning, knowledge sharing and change implementations will be major competitive factors (Allele, 2000; Davis, 2001 ; Candlewick, 000; Marauded, 1996; Scanted & Marauded, 2000; Sense, 1990).
To be more effective, learning in organizations must maximize the interactions among individuals so that knowledge creation is continuous, fostered by the leadership (Sal et al. , 1997; Monika, 1991) and structured in a way that permits flexibility. Opportunities to create created can be applied to linear and nonlinear learning environments Amazonian, 2000; Monika, 1994; Scanted & Marauded, 2000; Wick, 2001). Practitioners need a model based on compelling research, theory and practice that considers the ragtime needs of organizations to maximize learning.
The Organizational Learning Systems Model provides these elements necessary to fully consider what is occurring in organizations as they learn. Organizational Learning Systems Model (ALSO) Introduction to Organizational Learning Systems Model Many components, subsystems and “disciplines” of organizational learning have been identified so that theorists and practitioners can discuss learning environments and systems (Marauded, 1996; Monika, 1994; Scanted & Marauded, 2000; Sense, 1990; Giggler, 1999; Stewart, 2000).
The ALSO describes four subsystems of learning, eased on Parsons General Theory of Action and functional prerequisites. Parsons identified organizations as relationships among adaptation, goal attainment, integration and pattern maintenance functions (Scanted & Marauded, 2000) moderated by exchanges between influence, power, culture and resource allocation . This provides a basis to describe learning in terms of concrete organizational actions related to four learning subsystems. Scanted and Marauded (2000) discuss four subsystems that impacts organizations’ environments, actions, processes and cultures.
Based on Parsons model, they posit that relationships between organizations and their environments will control interactions between internal and external factors as they collect energy (information). The ALSO seems complex at first (See Figure 2) and it may be difficult to determine exactly what is occurring and how. In breaking the model down into four separate sections and explaining how interchange media interacts with the separate subsystems, I will attempt to make the model less complex and easier for the first-time viewer to interpret.
The Environmental Interface subsystem represents Parson’s adaptation function and describes how information enters the learning system. This subsystem requires “imported energy and information to survive” (Scanted and Marauded, pegs 88, 1 15). The Action/Reflection subsystem represents the goal attainment function and describes the learning needs of the system. In this subsystem, mechanisms are engaged to transfer information to knowledge (Scanted and Marauded, pegs 88, 152). The Dissemination and Diffusion subsystem represents the integration function and describes coordination within the learning system.
This subsystem (Scanted and Marauded, peg 63) refers to the procedures that allow the organization to ordinate elements of the learning system such as communication, leadership and internal modifications. Finally, Scanted and Marauded (2000) develop the Meaning and Memory subsystem to represent the pattern maintenance function. They describe the maintenance of a learning system’s pattern of action. This may also be interpreted as the culture subsystem where organizations enact the assembling process to maintain “the way we do it here. Each of these subsystems is required to fully understand how organizational learning occurs and each will be discussed in more detail. Environmental Interface In learning systems, new information is the “energy’ required for survival. New information becomes the interchange media that relates the Environmental Interface interact with their environments can have power over how they learn and use information (Daft & Wick, 1984; Monika, 1994). Other authors have supported this view (Allele, 2000; Bland et al. , 2001; Gardner & Short, 1998; Science, 2001; Sense, 1990; Warhorse, 2001).
Scanted and Marauded (2000) describe the Environmental Interface (See Figure 3) subsystem as the portal for new information. As information is introduced into health care organizations, it must be transformed through recesses that lead to new knowledge (Limited-Charles, McGuire, & Blinder, 2002) and action. The ability of leaders and employees to adapt through rapid information processing can speed or slow learning. Leviathan and March’s (1993) discussion of adaptation among multiple actors offers an explanation for how organizations have a tendency to look into their own network for answers as opposed to relying on new provided data.
While acknowledging and reflecting upon internal information is important, failure to accurately “scan” the environment for new information will limit knowledge creation (Daft & Wick, 1984; Wick, 1993). By not considering external systems and engaging stakeholders, organizations will not learn effectively. Without relevant environmental information, the ability to link knowledge to action (in the Action/Reflection subsystem) will be seriously degraded. Thus learning, and indeed action, will be compromised.
Employees and leaders must scan the environment constantly to determine what information is “out there” and the potential impact it may have on their networks. In planning for the interface between the environment and other learning subsystems, organizations must take into consideration how they identify new information, employ mechanisms to engage the environment and determine how to control the interaction with the environment. Again, information is the energy. It is collected from the environment and shared with the Action/ Reflection subsystems where attempts to formulate actions and goals are made.
The actions and goals processed must be shared throughout organizational networks via the Diffusion and Dissemination subsystem. The information is then sifted through the Meaning and Memory subsystem to determine how the culture will respond, and patterns maintained or modified. Action/Reflection Once data is collected through the scanning process, interpretation is used to give meaning to the data (Daft & Wick, 1984). The ALSO considers interpretation as key when organizations reflect on new information in processing new goals and actions.
Through action learning, collective learning and training, organizations transform data into information; information into knowledge. Daft and Wick (1984) support this need for organizations and individuals to interpret information entering the system before producing action. Knowledge creation and action are the result. The Action/ Reflection subsystem of the ALSO represents the actions that occur as organizations attempt to satisfy learning goals. Here, organizations experiment, test, and simulate with the information provided from the Environmental Interface.
In this subsystem (See Figure 4), organizations examine those mechanisms and actions that enable them to assign meaning to new information, thus creating goal reference knowledge. Wick (1993) and Monika (1994) support the ALSO proposition that frameworks are developed that allow this subsystem to interpret and share goal reference knowledge. Organizations may consider training, new technologies, processes and assimilation throughout the organization. They may ignore precedent, rules, and enact traditional expectations depending on interactions with the other subsystems, especially Meaning and Memory (Scanted & Marauded, 2000).
Without mechanisms to collect, analyze and compare new information and establish learning goals, health care organizations will experience dysfunction in their learning systems (Barley et al. , 1998; Limited-Charles et al. , 2002). Dissemination and Diffusion The Dissemination and Diffusion subsystem is concerned with coordinating elements of subsystems and “communicating. It deals with how organizations move knowledge and integrate it. Dissemination and Diffusion is the primary subsystem for moving, transferring, retrieving, and sharing information and knowledge (Scanted & Marauded, 2000).
This subsystem produces structuring activities such as leading, communicating and other mechanisms that shift information and knowledge throughout the system. This includes acts of networking, managing, coordination, and implementing roles and norms that facilitate movement of information and knowledge. Providing treatment to patients offers an analogy for information dissemination. The healthcare provider receives symptoms (information) from the patient (environment) which may dictate which prescription (action) is most appropriate.
Informal networking may be the prescription for certain types of dissemination, while a memo from management might serve as the best “medicine” to diffuse other types of knowledge. Like medical treatment, dissemination will vary among practitioners and result varying degrees of success. As in healthcare, some dissemination may be more preventative, some may require emergency application. Dissemination and Diffusion (See Figure 5) of knowledge is a key leadership role and ay determine how successful organizations are at integrating learning.
More importantly, it may determine the success by communicating key messages. The output produced from this subsystem is dynamic structuring that integrates organizational structure, roles, norms, processes, and objects. Giddiness (1979) describes “saturation as the production and reproduction of social systems through the application of generative rules and resources”. Saturation incorporates interactions within the system. By structuring knowledge and information, organizations can communicate and prepare networks to operate more effectively.
Processes, development activities and equipment such as computers may aid organization in storing, retrieving and facilitating knowledge. This dynamic interaction enables the Dissemination and Diffusion subsystem to integrate the other three subsystems. Memory and Meaning The final subsystem mentioned in the ALSO involves how organizations construct meaning and store artifacts and “memories. ” The essence of the learning system is its Meaning and Memory subsystem. It is from this learning subsystem that other subsystems draw guidance and control (Scanted & Marauded, 2000).
Referring to our previous patient treatment example, the symptoms (information) may suggest the provider offer specific protocol or medicine (action). The protocol requires a shot, followed by a prescription regimen and change in diet. If a new protocol (new information from the environment) is announced, the healthcare provider will attempt to make sense out of it in relationship to the patient being treated. Based on the patient the way “we have always done it” instead of using the new protocol. This subsystem is composed of interpretative assumptions that are intrinsically linked to the organizations’ culture.
It maintains the culture of organizations through language, symbols, norms and these assumptions (Scheme, 1992; Scanted & Marauded, 2000). It defines the ability of organizations to make sense of what is happening to them and remembers the knowledge that is critical to its survival. The Meaning and Memory function attempts to maintain organizations’ basic assumptions through assembling and the creation of learning controls. It creates barriers that maintain certain assumptions and patterns. This is the genesis of “resistance to change. ” This subsystem serves other subsystems through assembling.
Assembling is the primary interchange medium with the other subsystems and is represented by language, symbols, assumptions and values. It is the output that interprets interactions with the other subsystems (Giggler, 1999; Wick, 1993). Wick (2001) describes assembling as the process of assigning meaning to organizational actions. Wick (1993) indicates that assembling is necessary in organizations and without it, collapses in structure will occur. To affect assembling throughout the organization, a series of planned synchronized actions must be used. Education, communication and new technology can be useful.
These dissemination and diffusion actions can produce change in the Memory and Meaning subsystem while maintaining certain useful patterns and structural integrity of the system. Healthcare and ALSO: Employee Opinion Survey Example Kaiser Permanent People Pulse Kaiser Permanent of the Mid-Atlantic States (KEMPS) is a 6,000-employee health maintenance organization that serves more than 500,000 healthcare clients. It has a unique not-for-profit structure that combines characteristics of an insurance company with a practicing physician group to provide a unique health care delivery model.
Every year KEMPS conducts an employee opinion survey to measure satisfaction among employees. The leadership refers to this attempt to “take the pulse of the employees” as People Pulse. This thirty-two questions survey is categorized into eight dimensions including Work Unit, Leader Communications, Quality, Labor Relations, etc. It is a typical opinion survey In previous years, the leadership distributed surveys, analyzed the results and created reports that summarized the data. These reports were then provided to managers and supervisors to communicate the results of the survey throughout the organization.
In some cases, work unit managers, distributed the reports to their work units and some even established “People Pulse” committees to discuss the results. However, as in many firms, the reports were mentioned briefly at the end of staff meetings and then filed away. Some managers sent the reports directly to the filing cabinets without sharing the information. There was no systemic follow-up activities or support offered. Some attempted to impact employee satisfaction by engaging in a variety of actions. The number of managers taking this approach seemed insignificant for organizational change.
In fact, there is evidence that the majority of the managers actually did nothing with the results. Like many companies, the employee opinion survey seemed to be conducted in order to satisfy a commitment to “hear what the sponsor organization-wide discussions of the results or employee involvement. The information provided from the survey was never appropriately transitioned from data to knowledge. It was not clearly disseminated into the organization and not effectively incorporated into the culture. From the employees’ and managers’ perspective, People Pulse was Just another project that the senior leadership had initiated.
Lessons-learned from other projects and years past were not shared. Organization- wide did not seem to occur. KEMPS was basically experiencing what the majority of healthcare companies that conduct these types of surveys experiences – nothing. A Different Approach The leadership of KEMPS desired a different outcome that would permit more employee involvement in 2001. They decided to develop a process that would improve employee participation in completing the survey. The results would be analyzed, processed and via “action planning. ” Managers, employees, labor representatives and physicians would be involved.
The belief was that if employees were involved in collecting, analyzing, disseminating and developing actions from the data, that employees would take greater responsibility for general satisfaction in the workplace. They determined that a successful effort would be more employee driven and less manager directed. They also tasked the human resources vice president with facilitating a process that would be simple, would not require organization restructure and would consume minimal resources. The vice president delegated the project to the workforce and organization development department to integrate this onto other DO projects.
KEMPS was in the middle of a very tough year financially, and the market more competitive. Growth projections had not been met, competitors were looming, retention and recruiting efforts were not stellar and satisfaction of members needed improvement. In others words, KEMPS was experiencing what most other firms in healthcare was experiencing. KEMPS leadership had also been considering lessons learned from other organizations regarding the link between employee satisfaction, customer satisfaction and business performance (Km & Brooks, 1998; Keys, 2001;
Uric, Kirk, & Quinn, 1998; Science, 2001). People Pulse was positioned to provide information about employee satisfaction and other measures were employed to measure customer satisfaction and business performance. The real difference for 2001 was that the leadership was committed to change in employee satisfaction. The workforce and organization development department designed a process for interpreting data, creating ownership in the process, helping managers involve employees in decision-making and disseminating data from the external consulting firm throughout the organization.