Communities of general practice and healthcare service improvement: Boosting or blocking knowledge sharing? 6 th March 2012 Dr Roman Kislov.

Communities of general Communities of general practice and healthcare practice and healthcare service improvement: service improvement: Boosting or blocking Boosting or blocking knowledge sharing?knowledge sharing?

6th March 2012Dr Roman Kislov

OverviewOverviewWhat do we know from literature

◦Boundaries◦Communities of practice◦CoPs and service improvement

The Chronic Kidney Disease project◦Context◦Boundaries: professional, intra-

organisational, organisationalImplications for the use of the CoP

approach in service improvement

Literature: BoundariesProfessionalOrganisationalBetween communities of practice

(CoPs)

CoPs are work-related communities of individuals created over time through sustained collective pursuits of shared enterprises (Brown and Duguid, 1991; Ferlie et al., 2005; Wenger, 1998).

Literature: Communities of PracticeCoPs in healthcare are

predominantly uniprofessional and block knowledge sharing and innovation spread at professional boundaries (Ferlie et al., 2005).

In certain cases these boundaries can be successfully bridged through the formation of multiprofessional CoPs bringing together representatives of different professional groups (Gabbay and le May, 2011;

Gabbay et al., 2003).

Two perspectives on CoPs

Literature: CoPs and service improvementDeliberately constructed CoPs enhance

professional education, adoption of innovation and knowledge transfer (Li et al., 2009; Ranmuthugala et al., 2011).

Challenges to cultivating CoPs in service improvement:

time-limited nature of the projects top-down approach to change management preoccupation with performance measurement at the

expense of human and social aspects of change (Bate and Robert, 2002; Currie and Suhomlinova, 2006; Currie et al., 2007).

The impact of pre-existing professional and organisational boundaries on CoP cultivation seems somewhat underestimated (Kislov et al., 2011).

Research QuestionsResearch Questions

How do boundaries between CoPs existing within and across general practices influence the implementation of a primary care service improvement programme?

How do these boundaries affect the emergence of new multiprofessional and multi-organisational CoPs within and across primary care organisations?

The Chronic Kidney Disease The Chronic Kidney Disease projectproject

Practice A

Practice B

Practice C

Practice D

Professional boundaries‘…Here we work so much together on everything else because we are a practice. So, we have to share knowledge on everything else. So, doing it with the CKD, was nothing different to how we would generally. We were used to sharing that knowledge. We were used to interacting: the nurse with the doctors, the nurse with me. So, it didn’t cause any major disabilities that way because that’s how we work anyway, you know, we share.’ (A practice manager)

Professional boundariesProfessional boundaries

Practice A Practice

B

Professional boundariesNot a problem for the CKD projectPossible explanations:

◦Existing power structures not challenged◦Autonomy granted to nurses and

managers◦Complex nature of knowledge

(managerial, technical, clinical and other aspects)

◦A shared history of learning, working and sense-making

◦Operational proximity◦Sharing common values

Intra-organisational boundaries

‘…What happens is if you take up a thing, people tend to load all the results and everything onto you to take a decision about the patient… Not everyone was entirely keen, in the sense that they had lots of other things on their plate, with the QOF and other things, so they were more concentrating on other things.’ (A general practitioner)

Intra-organisational Intra-organisational boundariesboundaries

Practice A

Practice B

Practice C

Practice D

Intra-organisational boundariesMore pronounced in larger GP surgeries1) Between the multiprofessional team

and receptionists2) Between the multiprofessional team and other clinicians

May challenge sustainability of changeUnderlying factors:

◦ Lack of identification with the CKD work◦ Lack of identification with the organisation◦ Lack of organisational support for the CKD

project

Organisational boundaries‘…I think we’re very protective of what we’ve got, and I think that will always be a barrier because it’s always been. When I started working in primary care in ‘97, it was them and us. We didn’t share any information at all. It’s calming down now and it is getting better, but I think the only barrier will be “I don’t want them to know what we did well and them doing it and them being better than us.”’ (A practice manager)

Organisational boundariesOrganisational boundaries

Practice A

Practice B

Practice C

Practice D

Organisational boundariesMost problematicPossible explanations

◦ GP surgeries as competitive businesses◦ Strong organisational identification◦ Looseness of inter-organisational networks◦ Historical lack of collaboration

External facilitation and involvement of (external and internal) knowledge brokers were used to compensate for the lack of inter-organisational knowledge sharing

The developmental perspective on CoPs

Analytical perspective Analysing practice learning,

meaning, and identity in organic CoPs

A theoretical lens

Instrumental perspective Deliberate cultivation of CoPs

for knowledge management A managerial technique

Developmental perspective midway between the analytical and instrumental perspectives maximal utilisation of existing organic CoPs improving communication within and between them analysing the configuration of boundaries, roles and identities in

existing CoP landscapes increasing the permeability of CoP boundaries enabling development of these CoPs through participation in the

service improvement initiative

Applying the developmental perspectivePromoting co-production and shared

ownership of the initiative between the local CoPs and external facilitators

A nuanced and facilitative approach to implementation

Identifying and targeting actors with simultaneous membership in a number of intra- and extra-organisational CoPs

Developing knowledge and skills related to dealing with intra- and inter-organisational boundaries

Maximal utilisation of existing inter-organisational networks and channels of communication

ConclusionsConclusions Professional boundaries between doctors, nurses and

managers do not seem to complicate the process of service improvement in primary care settings

Knowledge sharing related to service improvement is impeded by intra- and inter-organisational boundaries

Development of multiprofessional communities of general practice is enabled by the nature of the primary care settings

Development of multi-organisational CoPs in the process of service improvement in primary care is highly problematic

Dialogue with existing communities of practice may be more beneficial for service improvement initiatives than attempts at the deliberate construction of new CoPs