managing knowledge in the healthcare sector. a review

International Journal of Management Reviews (2008)doi: 10.1111/j.1468-2370.2007.00219.x

International Journal of Management Reviews Volume 10 Issue 3 pp. 245–263 245

© 2007 The AuthorsJournal compilation © 2007 Blackwell Publishing Ltd and British Academy of Management. Published by Blackwell Publishing Ltd,9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

Blackwell Publishing LtdOxford, UKIJMRInternational Journal of Management Reviews1460-8545© Blackwell Publishing Ltd 2007XXXORIGINAL ARTICLESManaging knowledge in the healthcare sector. A reviewXXXX 2007

Managing knowledge in the healthcare sector. A reviewDavide Nicolini,1 John Powell, Paul Conville and Laura Martinez-SolanoOver the past decade, knowledge management (KM), as a concept and a set of practices,has penetrated into the fabric of organizational and managerial processes in the healthcaresector, which has been the site of numerous innovative KM practices. As a result scholarsfrom a range of academic (and non-academic) fields have begun to document how KM isconceived and practised in health care, what the recurrent issues are and how they can beaddressed. The purpose of this paper is to review the current literature on KM concepts,policies and practices in the healthcare sector. Based on the analysis of the most relevantcontributions in the last six years, three overarching themes that have occupied the interestsof authors are identified and discussed: the nature of knowing in the healthcare sector, thetype of KM tools and initiatives that are suitable for the healthcare sector, and the barriersand enablers to the take up of KM practices. The paper concludes with some considerationson what the literature tells us about the state of the art and the future of KM in thisimportant sector of Western economies.

Introduction

Over the past ten years, knowledge management(KM), as a concept and a set of practices,has penetrated increasingly into the fabric oforganizational and managerial processes inthe healthcare sector. This is hardly surprising,given that health care has become one of themost important economic sectors and a primarysource of employment in all the industrializedeconomies, generating on average 9% of theGDP in the EU zone and Canada and astaggering 15% in the US (Watson 2006).

As our goal was to adhere to the localparlance of healthcare practitioners, for thepurposes of this study we adopted the KM

definition currently used by the British MedicalAssociation and taken from the AmericanProductivity and Quality Centre: ‘The systematicprocess of identifying, capturing, and trans-ferring information and knowledge people canuse to create, compete, and improve.’

The wave of interest or, as some would say,fashion of KM has been accompanied byan increasingly sizeable body of literature,characterized by contributions from a range ofacademic and non-academic fields. However,as we shall show, most of this literature hasappeared in publications that do not usuallyfall within the areas of interest of manage-ment scholars and specialists, to the effect thatthe developments in this sector have remained

Managing knowledge in the healthcare sector. A review

246 © 2007 The AuthorsJournal compilation © 2007 Blackwell Publishing Ltd and British Academy of Management

mostly unnoticed and unaccounted for. In thispaper, we try partially to rectify this situationby providing an in-depth review and analysisof the current literature on KM in health care.We focused in particular on the productionfrom 2000 to the present, in both the business/management and medical literature. Based onthe qualitative synthesis of this large body ofresearch, we identify the main emerging themesand areas of interest. As a result, the paperboth provides an overview of the literatureand sheds light on the state of the art of KMtheory and practice in this important sector.

The paper is organized as follows. The firstsection provides some information on themethods used for reviewing the literature.Then the findings are presented, which suggestthat the interests of authors have been occu-pied by three overarching themes: the natureof knowing in the healthcare sector, the typeof KM tools and initiatives that are suitablefor the healthcare sector, and the barriers andenablers to the take up of KM practices. Thepaper concludes with some considerations onwhat the literature tells us about the state ofthe art and the future of KM in this importantsector of Western economies.

Methods and Review Boundaries

The literature review was performed in threestages. Stage 1 involved the collation andidentification of relevant literature. In healthcare, as in all other sectors, the discourse ofKM is bounded by a range of interrelatedterms which are often used interchangeablyand over which there is still some debate(Abidi 2001). Building on the definition ofKM identified above, we restricted our searchto formal methodologies and techniques tofacilitate the creation, identification, acquisi-tion, development, preservation, disseminationand, finally, the utilization of the variousfacets of healthcare knowledge. This definitionexcludes those informal practices within anorganization through which KM happens as anaturally occurring element of everyday work.Importantly, however, where in the literature

specific reference is made to the knowledgeenabling role of such processes, they wereincluded in the review.

The literature search was performed usingelectronic bibliographic databases coveringhealth and social sciences. The search termswere identified by the research team fromprevious reviews of the KM literature and byundertaking iterative scoping searches of data-bases. The terms used are shown in Table 1.

The databases searched included CINAHL(Allied health), Medline (Medicine), Embase(Medicine), Business Source Premier, ScienceDirect and ABI Inform (social science/businessand management). The searches were con-ducted in June 2006. From an original listof over 700 hits, we identified 178 articles forfurther examination in our scoping review.

In stage 2, two members of the researchteam created a thematic coding scheme basedon preliminary readings and discussion. Allcollaborators then met to discuss and agreethe coding of themes. The abstracts were thencategorized and coded in Nvivo7. This led tothe identification of overarching categories inthe existing literature.

Table 1. Search terms

HealthcareHospitalMedic$#1 or #2 or #3 (‘healthcare’ or ‘hospital’ or ‘medi$’)Knowledge captureKnowledge creationKnowledge diffusionKnowledge disseminationKnowledge exchangeKnowledge identificationKnowledge managementKnowledge retentionKnowledge translationKnowledge transferKnowledge utilizationKnowledge acquisitionOrgani$ational learningTacit knowledgeExplicit knowledge#5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 #4 and #20limit #21 to search in abstractslimit #22 to English language

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© 2007 The Authors 247Journal compilation © 2007 Blackwell Publishing Ltd and British Academy of Management

In stage 3, the literature in each of thethematic areas was analysed. Through thisprocess, we were able to identify a number offurther areas of debate and discussion. Theseareas are discussed in depth in the next sections.

Findings

Three features of the literature were immedi-ately striking and worthy of special mention.First, the literature was clearly segmented alongthree distinct disciplinary lines:

(1) information sciences(2) business and management(3) medical and allied health sciences.

It might be argued that, because the databasesselected were oriented toward the social, medicaland informational sciences, some selectionbias may have been at work. However, we triedto guard against this by including discussionswith stakeholders to ensure that we hadachieved a good coverage of the field.

Second, there was a prevalence of contribu-tions from the medical sciences, a characteristicthat sets this literature aside from much of theprivate sector, where the main contributionshave been confined to information science andbusiness and management (Hazlett et al. 2005).This suggests that there is considerable interestin KM from within the medical sciences.Consequently, one of the primary producers ofthe literature was the healthcare sector itself.This was particularly the case for accounts ofspecific KM tools by practitioners keen topublish their own accounts and experiences.In addition to practitioner accounts, there wasa substantial ‘grey literature’, such as unpub-lished reports, policy documents, statements,strategies and frameworks. These tended to belargely supportive of, and optimistic about, thepotential of KM in the healthcare sector andoccasionally referred to specific KM initiativesunder way at a national level.

Third, most of the debate on KM in healthcare rotates around three main themes: thenature of knowing in the healthcare sector and

its consequences for its management; thebenefits and pitfalls of specific KM tools andinitiatives; and the barriers and enablers ofKM in the healthcare sector. These themes aresummarized in Table 2 and discussed in turnin the next three sections.

The Nature of Knowing in the Healthcare Sector

One of the more prevalent discussions withinthe literature on KM in the healthcare sectorwas around the distinctive ‘nature of knowing’in health care. The first recurring issue hereconcerned the highly fragmented and distrib-uted nature of medical knowledge in healthcareorganizations and the sector generally. Asecond major and recurring theme, particularlywithin the informatics oriented papers, wasthe reference to the proliferation of medicalknowledge within an ever expanding healthcaresector. Third, many authors were concernedwith the importance of local knowledge in themaking of medical decisions. Clearly, manyof the decisions made in this sector relate topeople’s health and well-being, and the cost ofpoor decisions can be immediately life threat-ening. In situations characterized by such highstakes, the literature reported a preferenceamong medical practitioners for knowledge ofa local nature.

Table 2. Main themes in the literature on KM in the healthcare sector

The nature of knowing in the healthcare sectorThe fragmented and distributed nature of medical knowledgeThe proliferation of medical knowledge, information and dataThe preference for local knowledge in the making of clinical decisionsKM tools and initiatives in the healthcare sectorInformation technology-based toolsSocial learning initiativesEducation and training initiativesThe barriers and enablers of KM in the healthcare sectorTools specific barriersOrganizational/external factors



The fragmented and distributed nature of medical knowledge. The literature on KM in thehealthcare sector is full of references to thehighly fragmented state of medical knowledgeand, crucially, the need for collaboration acrossorganizational and professional knowledgeboundaries (e.g. Meijboom et al. 2004). Althoughthe fragmented or ‘distributed’ nature of organ-izational knowledge is not unique to healthcareorganizations or the healthcare sector (Tsoukas1996), it seems to be particularly relevant in thiscontext. As Tagliaventi and Mattarelli (2006)suggest, healthcare settings are professionalizedinstitutions in which different groups withspecific rules, job representations, behavioursand values converge. Similarly, Paul (2006)asserts that healthcare delivery is fundamen-tally a collaborative process with both explicitand tacit knowledge aspects, where healthcareproviders work together to achieve outcomesin terms of access, quality and cost that theywould find difficult, if not impractical, to accom-plish on their own (Paul 2006, 144). Likewise,Aldred (2002) asserts that managing knowledgein the healthcare environment is like trying toknit with thousands of strands of knotted wool:data are held in a number of locations, man-aged by a variety of people and agencies, andstored in every imaginable format.

The fragmentation of medical knowledgeis also revealed in the presence of strong pro-fessional boundaries. Ferlie et al. (2005) arguethat social boundaries and cognitive or episte-mological boundaries between and within theprofessions retard the spread of innovations.Currie and Suhomlinova (2006) examine theimpact of both organizational and professionalboundaries on knowledge sharing within thecontext of the UK National Health Service,using a case study of an academic health centrewhich encompassed a university medical schooland a host of healthcare organizations, includ-ing commissioners and providers of health care.Their findings reveal that knowledge sharingis very difficult to realize in practice becauseof professional boundaries. Further, Guven-Uslu (2006) highlights the divide betweenclinicians and managers in clinical networks,

stating that ‘Each group coalesces arounddivergent orientations towards healthcare deliv-ery, with executive managers privileging costand clinicians privileging patient care’ (p. 99).

One of the repercussions reported in theliterature of these professional boundaries andthe fragmented nature of medical knowledgeis the gap between academic research evidenceand everyday practice in healthcare settings.Indeed, this is such an important issue that alively subfield known as knowledge transla-tion (KT) has emerged in response. Accordingto Ho et al. (2004), KT is defined as ‘theexchange, synthesis and ethically-sound applica-tion of researcher findings within a complexsystem of relationships among researchersand knowledge users’ (p. 91). In short, KTarticulates how new scientific insights can beimplemented efficiently into clinical practiceto reap maximal health benefits.

An additional difficulty arising from thedistributed nature of knowing in the health-care sector was discussed by Pope et al. (2006).They studied the early implementation ofTreatment Centres (TC) in the UK – designedto reduce waiting lists for elective caredramatically. In particular, they were interestedin exploring how meanings about TC werecreated and evolved, and how these meaningsaffected their subsequent development. Theirconclusions were that the meanings of TC were‘lost in translation’ between various layers ofinterlacing networks within and outside theNational Health Service.

The proliferation of medical knowledge, information and data. Ironically, the muchdocumented difficulty of getting new knowledgeinto practice may stem from an over abundanceof medical knowledge. Much of the literaturereferred to the increasingly saturated state ofthe healthcare sector, and individual practi-tioners in particular, with new information.Davenport and Glaser (2002) vividly portraythe situation with the real-life example ofDr Bob Goldszer who, according to the authors,must stay on top of approximately 10,000different diseases and syndromes, 3000

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medications, 1100 laboratory tests, and manyof the 400,000 articles added each year to thebiomedical literature.

The result, as Heathfield and Louw (1999)argue, is that medicine has reached a crisispoint. Doctors can no longer memorize oreffectively apply the vast amounts of scientificknowledge that are relevant to their clinicalpractice. Gray and de Lusignan (1999) echothe same concern by stating that modernhealthcare professionals have to resolve an‘information paradox’; they are overwhelmedwith information but cannot find particularinformation when and where they need it.

So prevalent is the challenge of ‘informationoverload’ in the everyday work of healthcarepractitioners (O’Brien and Cambouropoulos2000) that some of the literature has movedpast mere descriptions of the problem towardslengthy accounts of origins and solutions (Halland Walton 2004). Indeed, the emergence ofMedical Informatics could be seen as directlylinked to the current crisis of informationoverload. As is discussed below, one of themost prevalent tools for KM in health careis data mining, an advanced informationtechnology for searching and analysing massiveamounts of data.

The preference for local knowledge in the making of clinical decisions. A third theme fromthe literature concerned the various differentsources and types of knowledge that formedthe basis of medical decisions. The suggestionhere is that healthcare professionals value andpursue local and tacit knowledge, so that attemptsat managing health care knowing through themobilization of explicit and codified knowledgeare unlikely to succeed. Clarke and Wilcockson(2002), for example, show that this issue is atthe core of the debate around evidence-basedmedicine and the implementation of research-based knowledge. The authors make an importantdistinction between knowledge for practice(or distal knowledge) and knowledge frompractice (proximal knowledge). Distal knowl-edge was derived from outside a specific careenvironment and was thus seen as relatively

prescriptive and not owned by practitionersthemselves. Proximal knowledge was derivedfrom within a specific practice care environmentand, therefore, was dependent on the contextualissues within that environment such as staffinglevels and the nature of the service. Crucially,for Clarke and Wilcockson, this meant knowl-edge from practice (proximal knowledge) didnot meet many of the criteria used to judgethe quality of knowledge, such as its abilityto be generalizable in traditional ways. To berelevant to other care environments, proximalknowledge must be decontextualized, coreelements identified, transferred to another careenvironment, and recontextualized in the newcare setting. As a result, they feared, proximalknowledge would be excluded from the systemssupporting evidence-based practice. It is worthquoting Clarke and Wilcockson’s (2002)conclusion at length:

Whilst a great deal is expected of evidence-basedpractice, it is no panacea. Evidence and distalknowledge may be a tool ... but it is the proximalknowledge that allows practitioners in health andsocial care to know whether it is the right tool forthe job, whether it is the right knowledge for theneeds of their service users ... Consequently, clinicaldecision-making is located, or ‘situated’, in thecontext of proximal knowledge, changing as thatcontextual knowledge fluctuates in time and betweenplace and person. (Clarke and Wilcockson 2002, 398)

The importance of local context was also amajor finding of Gabbay and Le May (2004)and Dawes and Sampson (2003). The formerinvestigated how general practitioners andnurses derive their individual and collectivedecisions. Conducting an ethnographic studyover two years in general practices in England,Gabbay and Le May found that cliniciansrarely accessed and used explicit evidencefrom research or other sources directly, butrelied instead on what the authors termed‘mind lines’ (collectively reinforced, internalized,tacit guidelines). Although informed to anextent by the result of scientific research, thesemind lines were constructed mainly on thebases of the clinicians’ own and their colleagues’



experience, their interactions with each otherand with opinion leaders, patients and phar-maceutical representatives, and other sourcesof largely tacit knowledge. These findings arecorroborated by Dawes and Sampson (2003),who discuss the information needs andinformation-seeking behaviour of clinicians.Their research found that, after desk text sources,the second most frequent source of informa-tion was simply asking a colleague. Significantly,they found only one instance where electronicdatabases were the primary resource.

Finally, the critical importance of social andphysical proximity in knowledge exchangeswas convincingly highlighted by Tagliaventiand Mattarelli (2006). Taking a qualitativeand longitudinal approach, they investigatedthe processes of knowledge sharing betweenindividuals in different professional groupsand discovered that ‘operational proximity’ (thedegree to which professionals were co-located)was a major determining factor in the flow ofknowledge, with those working side-by-sideexhibiting the strongest tendency to shareknowledge. Their conclusion was that thecirculation of knowledge in healthcare networkshappens mainly within tightly knit networksof practice where operational proximity, incombination with value sharing that acts as aleveraging tool, allows for the circulation oftacit and embodied ways of knowing.

KM Tools and Initiatives in Health Care

While great attention in the analysed literaturewas devoted to the specific nature of knowledgein a healthcare setting, another major themewas the analysis and discussion of specifictools or initiatives for managing knowledge.Not surprisingly, this area is characterizedby less theoretical discussion and more interestfor the illustration and analysis of tools andpractices. In general, the KM initiatives describedin this type of literature could be categorizedas belonging to one of three types: IT-based,socially based and human resources driven, thelatter being focused on issues such as continuingprofessional development and education. Although

this pattern is quite common in the KM liter-ature and practice of other sectors, we foundthat in health care there is a visible prevalence– and probably a preference – for the secondtype of initiatives, a state of affairs that some-what sets the healthcare sector apart from otherindustries.

IT-based KM tools. A distinctive characteristicof the literature on KM in health care is thefocus on electronic libraries and repositoriesof scientific information in the form of articles,guidelines and clinical protocols (Kronenfeldand Doyle 2003). Building on the continuedgrowth of evidence-based medicine, electroniclibraries are seen as an important way of sup-porting the clinical decision-making process(Turner et al. 2002). According to Gray andde Lusignan (1999), these initiatives go someway to solving the healthcare sector’s infor-mation paradox discussed above, that is, thedifficulty in finding relevant information whenand where it is needed, despite an abundanceof information. Plaice and Kitch (2003) andWales (2005) describe the central role of thee-libraries as system-wide technology infra-structures facilitating management of bothexplicit and tacit knowledge. They argue that,in the UK, libraries and librarians have beenparamount to making KM a reality, in such away that KM, far from marginalizing thisgroup of professionals, reinforced the centralrole of the library as key information servicesand helped to recognize librarians for theirreal worth to their organizations.

Together with e-libraries, another typicalarea in the literature is data-mining tools. Theinterest in this type of tool can be linked tothe rapid expansion of medical knowledgeand information discussed above, althoughthe characteristics of the sector’s organizationalso seem to play a central role (Berger andBerger 2004). In fact, most of the literature oninformation and communication technology(ICT) application comes from US-based authors(Garg et al. 2005), who face the challenges ofoperating in a highly complex, highly fragmentedsector, and high pressure environment.

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Importantly, unlike in other industries, inhealth care the data to be mined can be of avery different nature. At least three types ofdata are relevant in the conduct of activities inhealth care: patient-centred data, that is, the datarelative to the state and history of individualpatients; service data, that is, data regardingthe operation and management of healthcareservices; and scientific or epidemiologic data,that is, data on how to address specific diseasesand conditions (including information on avail-able drugs and their effects). Each type of datarequires a different approach, highlighting thatin health care the distinction between infor-mation and knowledge is highly problematic.

The attempt at improving the managementof patient-centred data has given rise to avast area of research and business focused ontechnologies such as electronic patient records,telemedicine services and other devices orinfrastructures for sharing diagnostic data (seeDelpierre et al. (2004) and Ross et al. (2003)for a review). While these technologies areseldom considered as KM tools, there is anemerging consensus that an efficient manage-ment of knowledge in the healthcare sectorrequires the integration of this class of toolswith more proper KM technologies, such asscientific repositories, e-libraries and clinicaldecision support systems, discussed below.The idea is that, by allowing a fast, effectiveand automated cross-referencing between patientdata and clinical resources, it is possible tostreamline the clinical process, with obviousbenefits for both the patient and the wider system.

Starting from the observation that the sectoris highly complex and therefore overloaded withoperational information, other authors discussthe potential value of data-mining tools forimproving the quality of service and safety inthe healthcare sector. Abidi et al. (2005) advo-cate the use of data-mining techniques for theoperational management of healthcare enter-prises. Their paper is based on the argumentthat, despite generating massive amounts of‘knowledge-rich’ healthcare data, modernhealthcare systems do not use these data toimprove the management and delivery of

healthcare services. They provide details onan ‘info-structure’ that uses data mining toacquire, share and operationalize healthcareknowledge. Similarly, Wickramasinghe andSchaffer (2006) highlight the growing dis-crepancy between the revolutionary changesin medicine and the minimal changes inhealthcare processes which leads to inefficientand ineffective healthcare delivery. They arguethat healthcare organizations must use data-mining techniques to maximize the data andinformation generated by them and whichflow through ICTs if they are to improveaccess to and quality of their services.

Finally, great interest in the literature ispaid to the tools which promise to support theclinical process by allowing faster and moreeffective access to the vast scientific literature.Tools discussed under this heading includecomputerized decision support systems, com-puterized clinical guidelines and web-basedtechnologies for supporting the circulationand take-up of healthcare-related knowledge.

Clinical decision support systems are toolsdesigned for improving clinician’s decision-making (Kawamoto et al. 2005; Miller 1994).The literature abounds with examples andmodels (see Bali (2005) and Bali et al. (2005)for a recent review) which include computer-assisted diagnosis, drug dosing and prescrip-tion, and electronic reminders. However, arti-cles and papers often refer to pilot projects orsystems implemented and tested in single sitesand assessed by their promoters. Accordingly,the utility and safety of these tools is highlydisputed. Garg et al. (2005) recently reviewedabout 100 clinical trials and found that lessthan half produced any sort of improvement.As Wears and Berg (2005) note, this is hardlysurprising, given that these systems are toooften conceived and developed without thedue consideration of their implication for thedaily practices of their users.

Besides tools which aim at automatingclinical activities, the literature discusses adifferent way of using ICT tools for support-ing KM processes. Many authors thus discussthe use of web-based technologies for supporting



the circulation and take-up on healthcare-related knowledge. As we shall see shortly,this literature implicitly recognizes that, inmany countries, clinical professionals arestill somewhat diffident towards advanced ICTapplications and favour the use of ICTs forenhancing traditional ways of sharing know-ledge. A number of authors thus claim thatintranet and web-based solutions hold a highpotential for social and cognitive knowledgeprocesses, thanks to their capacity to enhancethe existing relationships and the social capitalthat goes with it (Aidemark 2005).

Finally, IT can support virtual communitytools to support collaboration, communitybuilding and learning between clinicians(e.g. Falkman et al. 2005) and also with patients;for example, Koumpouros et al. (2006) describea ‘Health Community KM System’ in thefield of cardiology. Koumpouros et al. arguethat healthcare organizations can promoteknowledge creation and utilization by chronicpatients through the introduction of a virtual,private, disease-specific patient community(see also Winkelman and Choo 2003).

Social learning initiatives. The emphasis on‘social ware’ is a prevalent theme in the liter-ature, and our review indicates that there is awidespread acknowledgement that the know-ledge challenges facing the healthcare sectorcannot be resolved by the use of IT-basedKM tools alone. In fact, by a sizeable margin, theliterature on KM in health care focused ontwo social mechanisms: communities ofpractice and network modes of organizing as analternative to IT-based KM tools. This is atheme that mirrors the development of KMdiscourse in non-healthcare fields where thetechno-enthusiasm of the 1990s was replacedby the current focus on community andnetwork-based approached to managing know-ledge (Newell et al. 2002).

As mentioned above, a number of authors,such as Lathlean and Le May (2002), Gabbayand Le May (2004) and Tagliaventi andMattarelli (2006), highlighted the importantrole of informal networks and communities in

conveying evidence to clinicians, nurses,technicians and other healthcare personnel. Forall these authors, the circulation of knowledgeamong healthcare practitioners relies heavilyon professional networks and communitiesof practice, which can therefore be used as amechanism for enhancing the ways in whichhealthcare organizations leverage their know-ledge bases. Accordingly, Lathlean and Le May(2002) and Gabbay et al. (2003) reported theencouraging results of an attempt at usingcommunities of practice as a way of improvinginter-agency working. They found that,under specific circumstances and conditions,communities of practice are a very usefulmechanism for the development of servicesthat span different professional perspectives andinvolve consumer interests.

Donaldson et al. (2005) provide an alternativereading of communities of practice. In theirstudy of the UK charity Macmillan CancerRelief, the authors relate how the organizationis learning from its work with groups andcommunities as well as patients and carers inorder to benefit people living with cancer.In essence, it is suggested, the charity hascreated and supported a number of groups andcommunities that ‘float’ around its organiza-tional structure and extend its reach far beyondits formal boundaries. Because these groupsare not part of the formal structure, they can-not be ‘managed’ like normal organizationalteams. Nonetheless, the conversations andstories shared in them generate new ways ofthinking and practising, and may also result intangible ‘products’ such as documents, stand-ards or major programmes.

An interesting albeit scarcely known wayof leveraging the power of networking formanaging knowledge is the establishment ofmanaged clinical networks. This approach,which was piloted in the UK in the late 1990s,can be considered a healthcare-native way ofaddressing the knowledge needs of the sector.

According to Conner (2001) networks basedon informal relationships are not new in thehealthcare sector, but rather it is the formal-ization of these networks and the recognition

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of their potential that is new. They provide theexample of the UK Northern and YorkshireLearning Alliance (NYLA), which was estab-lished as part of an effort radically to improvecare. They describe how the NYLA operatesas a network, with a small team of changeexperts working to develop change managementand service improvement capacity across 10,000square miles. Edwards (2002) puts forwardthe view that formal networks offer a way ofmaking the best use of scarce specialist exper-tise, standardizing care, improving accessand reducing any ‘distance–decay’ effects thatcan result from the concentration of specialistservices in large centres. They can create systemsto ensure that patients receive a standardinvestigation and are referred on rather thanbeing held in a local service that may nothave the full range of expertise. As a result,networks should be able to exploit any rela-tionships between quality and volume andenable a faster spread of innovation. Briceand Gray (2003) add that managed clinicalnetworks streamline care across boundariesand diffuse evidence and ‘best practice’ acrossthe whole health economy.

Although Edwards (2002) reports emergingevidence that managed networks do providebenefits, a number of recent studies take a morecritical and less optimistic view of this way ofaddressing KM in the healthcare sector. Forexample, Addicott et al. (2006) point out that,in spite of the supposed greater capacity ofnetworks to support the transfer of evidence-based or ‘best’ practices across boundaries andaccelerate organizational learning, very littleof this was achieved in the UK case. In theirstudy of the managed Cancer Network inLondon, they found that, while networks didassist structural reconfiguration, their KM roleremained marginal. They argue that this wayof promoting the development, circulation andutilization of health-related knowledge washampered by the political constraints imposedon these networks. In spite of being estab-lished in view of explicit KM objectives, theUK-managed clinical networks were increas-ingly expected to deliver centrally established

targets (for example reducing waiting times),which were monitored through performancemanagement indicators. The pursuit of thesepolitically sensitive targets ended up margin-alizing the original knowledge-sharing objec-tives, reducing these networks to yet anothertype of delivery system. Addicott et al. (2006)conclude that, when discussing KM matters, itis necessary to distinguish between managedand organic professional networks. Crucially,they found that an excessive or misplacedlegitimization and formalization of emergentcommunities and networks can in fact disrupt,rather than support, their knowledge-sharingcapacity. Finally, as we shall discuss moreextensively in the next section, authors such asFerlie et al. (2005) highlight that communitiesand networks in health care are responsiblenot only for the spread but also for thenon-spread of knowledge, as individual pro-fessionals operate within mono-disciplinarycommunities of practice.

Education and training initiatives. This is afinal theme related to the place of KM inprimary and continuing professional education.Antrobus (1997) and Kenner and Fernandes(2001) approach the issue of KM as an advancedtopic in nursing education. They lament that,for most graduating nurses, KM as a conceptor set of practices is foreign. The authorsadvocate the introduction of KM into the cur-riculum, claiming that KM is an approach thatprepares the advanced practice nurse for theever-changing healthcare environment. It is atool, they argue, that will help a nurse to workmore smartly, efficiently and cost-effectively.Similarly, Martins et al. (2005) also suggestthat education in KM would provide a positivecontribution to professional development,though, as they point out, it is scarcely appre-ciated at present.

Other authors focus on the capacity of KMto sustain the recruitment and retention ofhealthcare professionals, especially in thenon-medical professions. Kenner and Fern-andes (2001) argue that an increased focuson the knowledge import of healthcare work



could help to improve the capacity of the sectorto attract new and brighter recruits. Ralph andOrtega (2006) report on the operationalizationof this idea and the attempt to use a range ofhuman resources (HR)-based practices forretaining and attracting knowledge workersat a US hospital. The HR practices weredesigned as part of a scheme intended toretain loyal personnel, establish organizationknowledge and contribute to the quality of thepatient experience.

It is worth noting that, because of therelatively recent adoption of the KM discourseby the healthcare sector organizations, severalinitiatives that in other sectors might well fallunder the conceptual umbrella of KM, in thissector were developed under different agendas.Two are worth mentioning here.

First, nursing professionals and academicshave long established a line of research andpublication around the topic of work-basedand organizational learning through reflectionon practice (Clarke et al. 1996; Johns 1994;Page and Meerabeau 2000). As suggested bySandars (2004), work-based learning in healthcare responds to almost the same demandsaddressed by KM initiatives. Many of theauthors addressing this issue argue that thepromotion of the systematic processes of reflectionon practice could constitute an opportunity forsustaining both the professional developmentof individual nurses as well as for increasingthe knowledge base of the organization. Accord-ing to Lockyer et al. (2004), for example, pro-cesses of systematic reflection allow for thetransformation of ideas and experiences intonew knowledge and action. Their paper arguesthat educational programmes can encouragereflection through the judicious use of case-based discussion, formal and informal needsassessments, and commitment to change exer-cises. Nicolini et al. (2004) describe a structuredinitiative for fostering organizational changeand learning in health care based on the use ofreflection on action. Building on the traditionof Action Learning, they argue that it is possibleto establish larger organizational reflecting struc-tures. which, in the right condition, allow for

the translation of personal and group reflectioninto sustainable organizational learning.

Second, as mentioned above, there existsa vast literature on the topic of KT whichaddresses the transfer of research-based know-ledge from the research community to thecommunity of potential users (see Estabrookset al. (1996) and Thompson et al. (2006) fortwo recent reviews). Most of this literature(and related initiatives) addresses the topic ofhow evidence from research could be effectivelyshared and circulated among the end usercommunity. Although the problem is framedusing a localized vocabulary and, as such, itmight escape the attention of KM scholars,many of the topics addressed in this literature,from how to improve the utilization of newresearch or practice-based knowledge to howto share service and clinical best practices, fallsquarely within the remit of what outside thissector would be considered KM.

The discussion on KT and the ‘gap’ betweenacademic research and everyday practice isworth considering also for the insight it canprovide into the interests associated withspecific modes of knowledge production andcirculation. For example, authors such asWood (2002) and Ferlie and Wood (2003)raised the possibility that the gap could bemore than a delivery error or a ‘lost in trans-lation’ effect. When observed through an interestand power lens, the separation betweenknowledge production and consumption seemsto be inextricably tied to the attempt of theproducers (usually academics) to retain con-trol over the process of knowledge legitimiza-tion and the power that goes with it. Far fromundermining this situation, the notion of KTas seen, for example, in the evidence-basedmedicine movement, reiterates the division oflabour, providing a more subtle defensive strategyfor the basic academic disciplines.

The Enablers and Barriers of KM in the Healthcare Sector

Besides addressing the nature of knowing andthe tools and initiatives utilized, a small but

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important section of the literature discuss theenablers and barriers of KM in the healthcareorganizations. These themes are discussedrespectively in the following sections andsummarized in Table 3.

Enablers of KM. Several authors such as Booth(2001), Sensky (2002) and Sandars (2004)suggest that most of the enablers of KMin health care are not different from thoseidentified in different industries. Sensky (2002)argues that KM will not happen in healthcareorganizations unless leadership, culture, HRMpractices and IT infrastructure and skillsare in place. In a similar way, Booth (2001)identifies ten building blocks for the successof KM. He argues that it is not sufficient toaddress merely content and technology – anempowering culture is also required. Thisincludes executive level support and creationof an environment where sharing of goodpractice is encouraged. Above all, KM shouldbe integrated with the business objectivesof the organization and managed in a waythat is comparable with management ofother commodities within an organization.Finally, Koumpouros et al. (2006) researchedthe critical success factors for establishinga multidisciplinary health community KMsystem using Internet-based ICTs. Some ofthe major success factors they found included:knowledge critical mass, political commitmentand endorsement, well-structured ontology,multilingualism of the content and timelessprocesses and patient- and problem-orientedKM system.

These claims are substantiated by a varietyof in-depth studies which explored more indetail the conditions that are conducive to thevarious dimensions of KM processes. Edmondson(2003) investigated the behaviours promotinglearning in interdisciplinary clinical actionteams, particularly in the operating room.Edmondson sets the thesis up by arguing thatmembers of these teams must coordinate actionin uncertain, fast-paced situations, and theextent to which they are comfortable speakingup with observations, questions and concernsmay critically influence team outcomes. Againstsuch a context, she found that the most effectiveleaders helped teams learn by communicatinga motivating rationale for change and byminimizing concerns about power and statusdifferences to promote speaking up in theservice of learning.

Based on their study of practice-sharingin a network of practice mentioned above,Tagliaventi and Mattarelli (2006) find that,when professional groups share commonvalues, such as the centrality of the patient,exchange of knowledge is greater. Also, andas discussed earlier, they found that knowledge-related interactions were greater amongprofessionals that were in close operationalproximity. Similarly, Russell et al. (2004) exploredthe process of knowledge exchange in aninformal e-mail network for evidence-basedhealth care. The informal e-mail network helpedto bridge the gap between research and practiceby serving as a rich source of information,providing access to members’ experiences,suggestions and ideas, facilitating cross-boundary

Table 3. Major enablers and barriers of KM success in healthcare organizations

Enablers Barriers

Shared common values and culture Over management and interference from political sphereMinimizing concerns about power and status differences Clinical managerial conflictInterdisciplinarity (broad-based membership) Professional barriersClose proximity (operational) Lack of trustSalient topics Poor quality relationshipPolitical commitment and endorsement Insufficient technology skillsLoose structure Lack of strategic breadth and leadership



collaboration, and enabling participation innetworking at a variety of levels. Ad hocgroupings and communities of practice emergedspontaneously as members discovered com-mon areas of interest. Critical success factorsinclude a broad-based membership from boththe research and service communities, a looseand fluid network structure, tight targetingof messages based on members’ interests,the presence of a strong network identity andculture of reciprocity, and the opportunity fornew members to learn through passive partic-ipation. Finally, Bowen and Martens (2005)focused on KT within a community of practice.They took as their point of departure anapparent gap in the literature around personalfactors in KT. On this line of investigation, theyfound that the ‘quality of relationships’ and‘trust’ connected many different components ofKT, and were essential for collaborative research.

While most of the literature on the enablersof KM in health care is aligned with what hasbeen found elsewhere, a typical element ofthis sector is the claim that KM must betightly coupled with and support what hasbecome known as ‘clinical governance’ (Scallyand Donaldson 1998). Clinical or healthgovernance is the attempt at integrating withina single strategy all the activities that have animpact on patient care. This involves improvingthe quality of information, promoting col-laboration, implementing evidence derivedfrom research, as well as auditing clinical andservice results in view of promoting thecontinuous improvement of quality of care andpatient safety. Many authors, especially in theUK, argue that clinical governance is no morethan a specific application of KM or that KMis the keystone for governance to succeed. AsBooth aptly puts it, seeing clinical governancein terms of KM helps to stress the vital impor-tance of appropriate methodologies and tech-nologies, rather than seeing these as luxuriesor ‘add-ons’ (Booth 2001, 7). In fact, one ofthe most successful KM initiatives in theUK (the collection and dissemination of short,structured accounts of local improvementsknown as ‘Eureka’) was promoted by the

Clinical Governance support team and notby a KM task force (Wall 2006).

Barriers to KM. As in the case of enablers,many of the barriers to KM in health careresemble the factors identified in other indus-tries, although some exceptions apply. Sensky(2002), for example, suggests that the absenceof a clear KM strategy and leadership (e.g. nothaving a Chief Knowledge Officer), the lackof an appropriate culture, and a poor IT infra-structure are all potential barriers to KM inhealth care. His findings echo those of Riege(2005) who, investigating other industries,found three dozen barriers to KM falling underthe general headings of individual, organiza-tional and technological barriers.

Focusing on the problems encountered inbringing about effective ‘team-working’ inoperating theatres, Finn and Waring (2006)found that ‘architectural knowledge’ (know-ledge that connects and integrates the specializedcomponent knowledge of team members) wasfundamental to effective team practice and thedelivery of safe, efficient patient care. Importantly,however their research found that the creation of‘architectural knowledge’ was inhibited bythe organizational context. More specifically,they found that the need for flexibility in termsof changing personnel during surgery in theoperating theatre militated against the creationof architectural knowledge which required adegree of continuity.

Lorence and Churchill (2005), examined theuptake of computerized patient record systemsas a means of clinical KM. Overall, they founda non-uniform diffusion of computerized healthinformation technology, due in part to culturalfactors, mistrust of computerized data andlack of technology training and knowledge.

The issues of mistrust in computerized datawas also raised by Guah and Currie (2004) andBower et al. (2001), who studied the use ofICTs as a way of building cross-professionaland cross-disciplinary boundaries. They foundthat the uptake and application of such ICTswas fundamentally affected by a range of socialand operational issues, such as fears over a

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new formalization and traceability of previouslyinformal conversations, a rebalancing of powerrelationships (between professionals using theICTs and between doctor and patient), pres-sures on social/cultural and procedural alignmentbetween participants, and personal attitudesto the technologies, i.e. a general dislike of ICT.Bower et al. (2001) argued that ICTs were severelycompromised by an inability to deal with thetacit nature of communications and knowledge.This issue was touched upon previously by,among others, Bower et al. (2000). They foundthat professionals in the healthcare sector oftenresisted ICT innovations which they perceivedas having the potential to disrupt crucial pro-cesses, especially when these processes involveda substantial tacit knowledge component.

While lack of time to share knowledge,culture, leadership, lack of transparent rewardsand recognition systems, hierarchical organi-zation structure, lack of integration of ITsystems and processes and reluctance to useIT systems are all barriers that the healthcaresector share with other industries, two specificaspects of healthcare work pose specific chal-lenges to the success of KM practices on thisenvironment: the strong professionalization ofthe sector and the influence from other areasof society, namely, the political sphere.

Professional divisions have long been re-cognized as barriers to the circulation of innov-ation and knowledge in health care (Ferlie et al.2005; Swan and Newell 1995). Ferlie et al.(2005) studied multiple innovations and foundthat the tendency of professionals to operatewithin mono-disciplinary communities of practicecreated social and cognitive boundaries which,in turn, hampered their circulation. This studyis particularly interesting in that it problema-tizes the distinction between formal method-ologies and informal practices in the flow ofknowledge. In healthcare, professional rela-tionships are often highly institutionalized, sothat the resistance of doctors to KM initiativescan be understood in terms of the struggle forseizing control of the knowledge processesand the conflict of alternative ways of govern-ing knowledge. This is well documented by

Currie and Suhomlinova (2006), who exam-ined the impact of both organizational andprofessional boundaries on knowledge sharingwithin the context of the UK National HealthService. The authors studied an academic healthcentre that encompasses a university medicalschool and a host of National Health Serviceorganizations, including commissioners andproviders of health care. They found that specificgovernmental regulations actually strengthenthe boundaries within the field and run againstthe logic of cooperation essential for know-ledge sharing. In particular, government-setperformance indicators cause the activity ofhealthcare organizations and those in highereducation to diverge so that research andpractice are uncoupled. Similar cultural factorsare picked up by Dean (2002), who exploredbarriers to learning from errors. Dean (2002)found that barriers to learning from prescrib-ing errors include the non-discovery of manyprescribing errors, lack of feedback to theprescriber when errors are discovered by otherhealthcare professionals, and a culture thatdoes not encourage reflection on errors togetherwith why they occurred and how they can beprevented. The author concludes by callingfor changes in both systems and culture so asto provide an environment in which lessonscan be learnt from errors and put into practice.

From their investigation into the value ofthe UK National Health Service CancerNetwork mentioned above, Addicott et al. (2006)found that over-management and politicalinterference in clinical networks were majorbarriers to knowledge processes. Clinical net-works, originally established with knowledge-sharing intent, quickly became just anothertool for achieving government goals, with theresult that knowledge concerns were margin-alized by the demands of achieving performancetargets and following government protocols.Clinical and managerial networks were alsoconsidered by Guven-Uslu (2006), who arguethat, despite government encouragement forclinicians and managers to work together innetworks to improve performance, this type ofnetworking is difficult to realize in practice.



The major barrier identified in the study wasclinical–managerial conflict, as each group isguided by diverging priorities towards health-care delivery: while managers privileged cost,clinicians tend to give priority to patient care.Additionally, the study found that top-down‘managerialist’ approaches to the implementa-tion of benchmarking initiatives within networksset clinicians against managers.

Concluding Remarks

The main aim of this paper was to reviewthe recent literature on KM in health care.Although this industry was relatively slow inboarding the KM bandwagon, our reviewshows that there has been a growing interestin this issue in recent years.

Our comprehensive scoping review indicatesthat three related themes are central in the KMdebate in health care: the nature of knowingand the proliferation of data in the healthcaresector; the interests for social vs ICT-basedinitiatives for supporting KM processes; andthe discussion of the enablers of and barrierto KM. As we have seen, the complex, multi-professional and multi-level nature of thesector is reflected in the fragmented anddistributed nature of healthcare knowledge.Our review suggests that the major issue facinghealthcare professionals is not the lack ofas much as the overabundance of informationand knowledge. At the same time, however, thepresence of a variety of stakeholders, scientificand occupational communities, and hencedifferent vocabularies, makes the resultingdissonance almost irreducible. While sensitizingus to the risk of information overloads facinghealthcare professionals, the literature alsoreminds us that any tool or technology whichdoes not actively acknowledge and engagewith such complexity is bound to fail.

In the first place, one may note that itsextended ‘isolation’ allowed health care todevelop some native approaches and themesthat set this literature apart from that devel-oped in other sectors. Instead of knowledgetransfer, social capital and community of prac-

tice, in health care one finds practitioners andresearchers discussing forms of evidence, KTand managed networks. The fact that healthcare has not endorsed (yet) the standarddiscourse on KM should not be mistaken forlack of interest or initiatives. On the contrary, ourreview suggests that, because of its nature, thehealthcare sector reflects all the time on thenature and ways of managing what is known,albeit this discussion is conducted in ways thatare not immediately recognizable by externalobservers. While this ‘ecological segregation’has created some obvious barriers, so that theindustry has been slow in taking advantage ofthe experience and wisdom developed elsewhere,it has also given rise to some interesting devel-opments that should be considered with attention.

Second, besides revealing a rich panoramaof initiatives and approaches, partly hidden bythe difference in language, the review alsosuggests that several segments of the health-care industry still favour KM initiatives basedon enhancing the existing ‘social ware’ insteadof trying to substitute it with some kind ofhardware or software. This derives in partfrom the nature of healthcare work, which is stilllargely based on tacit and sticky forms ofknowledge, and in part from the traditionallyIT adverse culture of many of the healthcareprofessionals. These data, however, need alsoto be interpreted against the differences in theorganization of healthcare systems. For exam-ple, most of the papers on computer techno-logy KM initiatives (about 60% according toGarg et al. 2005) originate in the US, a con-text marked by extreme fragmentation, whereintegration of data is paramount. Conversely,networking seems to be the privileged way ofaddressing the well-known weaknesses of large,centralized organizations such as the NationalHealthcare Services organizations of manyEuropean and non-US OECD countries.

Third, the literature indicates that the specificnature of the healthcare industry, which istraditionally located at the crossroads betweendiverging and even contrasting local and globalinterests, poses challenges to KM that set thissector apart from many others. For example,

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KM in health care has to face the fact thatprofessional boundaries and political interven-tions constitute both enablers of and barriersto the circulation of knowledge. At the sametime, in no other sector is politics played soclearly around what is known and what countsas evidence – probably because much morethan profit is at stake when it comes to clinicaland medical knowledge. While addressingknowledge and KM issues without sensitivityfor its power dimension is generally inadvisable,it is bound to create serious misperceptions inhealth care, which may generate more ill-fatedKM initiatives and projects.

The review also reflects the importantdifferences between healthcare systems, forexample between the US and the UK (Besleyet al. 1994; Davies and Marshall 2000; Ferlieand Shortell 2001). While the so-called managedcare system in the US puts a direct premiumon cost reduction and quality improvement, italso amplifies the fragmentation and increasesthe transaction costs involved in the deliveryof health care. As a consequence, the mainpriority in this type of system is the effectiveintegration of patient data and the use ofclinical decision support systems as a way ofboth optimizing the cost effectiveness oftreatments and creating a trail of accountabilitythat can be easily used for reimbursement pur-poses. By the same token, our literature reviewalso reflects the very different challenges posedby systems such as those of Canada, the UKand other European nations. The challenge isovercoming the rigidities and compartmentali-zation brought to bear by the bureaucraticstructures which govern these often very largeand highly centralized systems. It is notsurprising that several of the papers addressingsocial learning initiatives come from authorswho operate in this context.

The strong centralization of the UK systemis also somewhat mirrored in the literature.On the one hand, the contributions from UKauthors reflect the fact that this country is atthe forefront of actively promoting KMinitiatives, such as the creation of a NationalLibrary for Health and the introduction of

networks aimed at sharing knowledge andimproving service quality. At the same time,UK authors have produced an increasingnumber of critical papers which try to bringto the fore the possible shortcomings of the so-called ‘governance’ model and the counterin-tuitive reality that the strong centralized approachto managing learning promoted in this countrycan hamper, instead of sustaining, the effec-tive circulation of medical knowledge.

Although the literature is not necessarily adirect reflection of the state of the art in thefield, our review suggests that the interest inthis topic is on the increase and so will be therelated academic production. In particular, weshould expect a rise in papers investigating the‘social ware’ approach to KM in the health-care sector. This would partly reflect a generaltrend on the ground, where there is a cleargrowth of interest in networks and communi-ties but would also be in line with other fields,where authors documented a burgeoning interestin the use of communities of practice as waysof managing knowledge (Handley et al. 2006).Our review also suggests that, in the future,we should expect an increasing number ofpublications providing some insights into theeffective outcomes and benefits of KM initia-tives in this important sector. While there isan abundance of theoretical discussion and ofmodels, evidence of the results is still scarce.Finally, we should expect a steep increase inthe more critically oriented papers aimed atexploring the relationship between KM,governance and control.

The review suggests that at least three topicsremain substantially under-investigated and offerpromising opportunities for future research.First, in spite of the claims that the emergenceof the ‘expert patient’, relatively little atten-tion is paid to this topic in the KM literature.Most of the papers surveyed in this revieware focused upon practitioners. There is aneed to further the understanding of the roleof the patients in the process of knowledgeproduction and consumption in health care.Second, the lack of evidence on the effectivenessof KM tools and their capacity to address



some of the central concerns in health careis a promising topic for research. Finally, thetransfer of KM ideas and models from industryto the healthcare sector is an interesting objectof study. Recent work suggests that the travelof KM between sectors cannot be describedby a linear model of transfer and resistance.For example, Currie et al. (2007) found evidenceof subtle processes such as partial avoidanceand reappropriation, e.g. how cliniciansestablish local KM initiatives in competitionwith those promoted by managers.

The review is likely to be of use for bothresearchers and practitioners. Researchers shouldtake note of the fragmented and distributednature of healthcare knowledge, which mirrorsthe complex, multi-professional, and multilevelnature of the sector which sets it apart fromother industries. The main message for practi-tioners is that a linear transfer of KM model,processes and tools from other sectors is rarelylikely to be successful. In order to succeed inthe healthcare sector, any KM initiative needsto be reconciled with the specific nature of theprocesses at hand. While policy aspirationsare to be applauded, they need to be tailoredto the inherent professional and local natureof knowing in the healthcare sector, lest thepromotion of KM initiative becomes yet anotherarena for the clash of professional, managerialand economic rationalities.

Acknowledgements

The research on which this paper is basedwas supported by the Warwick InnovativeManufacturing Research Centre as part of thePhase 2 Scoping Initiative (Project PTOC 21).The WIMRC is funded by the UK Engineer-ing and Physical Science Research Council(EPSRC) with supplementary support fromcollaborating industrial partners.

Note

1 Author for correspondence: Davide NicoliniIKON Warwick Business School, University ofWarwick, Coventry, CV4 7AL, UK, Tel: +44247652 4282, e-mail: [email protected]

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Davide Nicolini is from IKON, Warwick Busi-ness School, University of Warwick, CoventryCV4 7AL, UK. John Powell is from WarwickMedical School, University of Warwick,Coventry CV4 7AL, UK. Paul Conville is fromWarwick Business School, University of War-wick, Coventry CV4 7AL, UK. Laura Martinez-Solano is from Warwick Manufacturing Centre,Warwick International Manufacturing Centre,University of Warwick, Coventry CV4 7AL, UK.

managing knowledge in the healthcare sector. a review

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