Knowledge Process Models in Health Care Organisations

Ideal-typical Examples from the Field

Lars Rölker-Denker and Andreas Hein

Department of Health Services Research, University of Oldenburg, Oldenburg, Germany

Keywords: Knowledge Processes, Organisational Learning, Learning Organisation, Modelling.

Abstract: This paper summarizes the recent work of analysing knowledge process in health care organisations with a

special focus on the geriatric disciplines. A study has been performed consisting of observations in the field

and interviews with the professionals. It is shown that knowledge processes have evolved over the past

years. New knowledge processes are introduced and modelled by using a combined method (3LGM

and

KMDL

). An outlook is given on measuring the dissemination of knowledge through the identified

processes in ongoing work.

1 INTRODUCTION

The increase of knowledge and information is a

general phenomenon and thus also applies to

healthcare. Emerging cooperation between health

care organisations (HCO) and in addition Mergers &

Acquisitions by highly integrated health care groups

extend the organisational knowledge base even

more. In addition medical schools and medical

university hospitals represent key actors in medical

knowledge development (Rölker-Denker and Hein,

2012b).

Organisational learning routines are key factors

for learning organisations. This applies to hospitals

in general (Pfaff, 1997) and individual departments

(Lipshitz and Popper, 2000) but also for larger

network structures (Rölker-Denker, 2010).

Organisational learning routines are key factors

for learning organisations. This applies to hospitals

in general (Pfaff, 1997) and individual departments

(Lipshitz and Popper, 2000) but also for larger

network structures (Rölker-Denker, 2010).

2 LEARNING ORGANISATIONS

Learning organisations can be described from

different viewpoints. In this paper the learning

organisation is analysed in sense of Wengelowski.

He defines three main areas: learning levels,

learning types and learning determinants, which all

can be practically mapped over an organisation for

analysing its accordance with the learning

organisation concept (Wengelowski, 2000).

Four learning levels can be distinguished:

individual learning, group (team) learning,

organisational learning and inter-organisational

learning. Individual learning means the changes in

behaviour, theories and concepts by an individual

whereas group learning means the same in a group

context. Organisational learning focuses on the

changes in organisational behaviour or theory. If

more than one organisation is involved in the

learning process then inter-organisational learning

can be identified.

Learning types can be differentiated into single-

loop learning, double-loop learning and deutero

learning (Hislop, 2009). Single-loop learning

focuses on incremental changes inside a constant

framework while double-loop learning focuses on

the framework. Finally, the process of learning and

extending an organisation’s awareness itself is in the

focus of deutero learning. The learning types are

based on each other. The abstract theories of

learning levels and types are brought together into

the organisation by the learning determinants. Three

determinants are discussed in literature:

organisational member, organisational structure and

organisational culture (Wengelowski, 2000). The

specific utilization and advancement of

competencies and qualifications among the

organisational members are fundamental tasks in

learning organisations. Each organisational member

has its unique setting of competencies and qualifica-

tions, e. g. professional or social competence.

312

Rölker-Denker L. and Hein A..

Knowledge Process Models in Health Care Organisations - Ideal-typical Examples from the Field.

DOI: 10.5220/0005192003120317

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2015), pages 312-317

ISBN: 978-989-758-068-0

 2015 SCITEPRESS (Science and Technology Publications, Lda.)

Important levers are human resource development

(further and advanced education) as well as staffing.

The formal organisational structure gives the

framework for all intra-organisational and partly

inter-organisational processes and sets the scope of

action for the organisational members. Following the

organisational view a differentiation can be made

between organisational structure, process

organisation, communicational / knowledge

organisation and informational organisation. The

organisational structure describes the long-term

primary organisation (functional, divisional, matrix

organisation) and flexible short-term organisation

(such as project organisation); the process

organisation describes how organisational tasks are

executed. The communicational / knowledge

organisation describes how knowledge is shared

inside organisations and which communicational

areas can be used. The informational organisation

contains written, spoken and IT-based information

systems. Organisational culture can be interpreted as

the informal organisational structure. In context of

the learning organisation three different types of

culture can be distinguished: learning culture,

communication culture and culture of trust (Rölker-

Denker, 2010). This definition of learning

organisations has been already used in previous

studies and ensures the comparability of actual and

future work with recent studies. As a result of this

recent work a method for modelling organisational

learning processes was declared to be useful

(Rölker-Denker et al., 2011).

3 MODELLING APPROACH

3.1 State of the Art

Modelling knowledge processes can be achieved

with different languages. UML (Unified Modelling

Language) is one approach which is used for this

purpose (Schreiber and Akkermans, 2000), other

approaches are EPCs (Event-driven process chains)

or petri nets (Fröming, 2009). These modelling

approaches have been developed without a guiding

knowledge management theory like the knowledge

management model from Nonaka and Takeuchi

(Nonaka and Takeuchi, 1995). This applies for the

Knowledge Modeling and Description Language -

KMDL

(Gronau and Fröming, 2006), see chap. 3.3.

In the area of modelling clinical IT

infrastructures a key concept is a conceptual

architecture showing the included systems and areas

(Locatelli et. al., 2012). These approaches lack a

detailed technical view, e.g. showing tasks and

subtasks. This applies to the Three-Level Graph-

Based Meta Model for the Management of Hospital

Information Systems - 3LGM

(Winter and Haux,

1995), (Winter et. al., 2003), see chap. 3.2.

For the description and modelling of

organisational learning routines these two well-

proven concepts have been selected and combined

for the first time to meet the demand for modelling

organisational learning routines in health care

organisations. Both concepts are introduced in brief,

for more details see (Rölker-Denker and Hein,

2012a).

3.2 3LGM

3LGM

is used for modelling hospital information

systems and architectures. Models build with

3LGM

use a simple intuitive notation. It can not

only be used for modelling hospital information

system but also connections to hospital’s

environment like physicians, care-givers and other

HCOs. 3LGM

is based on three layers: domain

layer, logical tool layer and physical layer. The

domain layer describes typical tasks and subtasks in

a HCO like patient scheduling or radiological

reporting. The logical tool layer comprises concrete

systems like hospital information systems (HIS),

radiology information systems (RIS) or picture

archive and communication systems (PACS).

Finally the physical layer describes physical

hardware (PCs, server, switches) and social-

technical elements (mail in-trays, archive) and the

connections between these elements. The physical

layer is left out at the moment due to its subordinate

relevance in analysing knowledge processes (Winter

and Haux, 1995), (Winter et. al., 2003).

3.3 KMDL

KMDL

is used for modelling knowledge processes

in organisations. It is based on the knowledge

management model from Nonaka and Takeuchi

(Nonaka and Takeuchi, 1995) with its four phases of

socialisation, externalisation, combination and

internalisation. KMDL

is divided into process layer

and activity layer. Tasks, the order of tasks,

information systems, functions (provided through

information systems), roles and persons are part of

the process layer. Objects of the activity layers are

information and knowledge objects, single persons

(or teams), requirements and the different

transformations between the four knowledge

management phases (Gronau and Fröming, 2006).

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3.4 Consolidation

On the functional layer 3LGM

solely describes

typical hospital task and is not process-oriented.

However KMDL

describes processes and focuses

on information systems, roles and especially tasks

on the process layer. The connection of both

concepts can be achieved by mapping 3LGM

‘s

domain and logical tool layer and KMDL

‘s process

layer. The result is a fourth layer above the

functional layer of 3LGM

and can be understood as

a knowledge layer. The knowledge layer is

connected to the domain layer by tasks and roles and

to the logical tool layer by information systems.

Using the knowledge layer it is possible to map

knowledge processes into a HCO and identify key

success factors for these processes (Rölker-Denker

and Hein 2012a).

3.5 Graphical Representation

The following symbols are used in this work:

 Conversion: A knowledge conversion

following Nonaka/Takeuchi, e.g. externalisa-

tion or internalisation.

 Knowledge Object: A complex object of

knowledge, describing how knowledge is

acquired for the organisation e.g. creating a

sophisticated report or staffing well-educated

personnel.

 Information Object: A simple information

object, e.g. letter, x-ray image or laboratory

report.

 Requirement: A functional or technical

requirement, e.g. a software system to be used

 Person: A person taking part in the process

 Team: Multiple persons forming a durable

team

Figure 1: Key (activity view).

4 MODELLED LEARNING

PROCESSES

In a first step the learning processes were identified

in field studies by shadowing the daily work in

different clinical departments (acute geriatric,

neurology, stroke unit, neurosurgery, and

nephrology) in two hospitals, one municipally and

one confessionally owned. Each department was

visited for one to two days (depending on the unique

work flows) by one observer, afterwards draft

models were developed and in the end discussed in

semi-structured narrative interviews with selected

professionals involved in the processes (Rölker-

Denker and Hein, 2012b).

The following organisational learning routines

have been identified and observed (Rölker-Denker

and Hein, 2014):

 Physician rounds

 Reflection meetings

 In/after surgery meetings

 Staff meetings

 Consultation

 Early Stand-up Meeting

 Multi-professional geriatric team session

 Interdisciplinary clinical case conferences

 Discharge management

These learning routines have been identified in

all clinical departments except the multi-professional

geriatric team session which is specific to geriatrics.

The learning routines have been also validated by

expert interviews in a research project for building a

health services research network (Rölker-Denker et.

al., 2014). These interviews have been conducted

with the medical and/or economic management of

more than 20 hospitals in the northern part of

Lower-Saxony, Germany. Some of these learning

routines (physician rounds, reflection meetings,

in/after surgery meetings, staff meetings) have been

already discussed in literature (e.g. Lipshitz and

Popper, 2000) and have been confirmed during this

study. Some of the new identified organisational

learning routine will be described in the next

paragraphs.

Each routine will be introduced by a so-called

storyboard, derived from clinical practice. Based on

these storyboards the routines are modelled and

described in detail.

4.1 Multi-professional Geriatric Team

Session

Storyboard

In the morning, Doctor A, an assistant

geriatrician, is updating the EHR of his/her

geriatric patients. He/she uses the GERDA

(Geriatric Database), a software component

integrated into the HIS. He/she updates his/her

observations on the patient regarding the general

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state, his/her interpretation of laboratory values

etc. He/she also sees the entries of the members

of the multi-professional geriatric team. In the

afternoon he(she meets with the other members

and discusses the patient development. As the

patient’s discharge is planned for end of the week

the medical social worker reports the current state

of negotiations with an ambulatory care service in

the city which will take care of the patient after

discharge.

The multi-professional geriatric team session

process is shown in figure 2, particular process steps

are:

 MGT - Multi-professional Geriatric Team: The

team consists of doctors, nurses, logopedics,

physiotherapeutists, occupational therapeutists

and medical social workers.

 Updating EHR: All team members update the

EHR with the relevant professional

information. Each profession has its own input

fields. This is the externalisation step.

 Team Session: The MGT meets and discusses

all patients on the basis of the information

within the EHR. This includes the current state,

future developments and treatments as well as

all other business regarding the patient. This is

the combination step.

 Treatment: With the combined information out

of the team session all members can continue

with the coordinated treatment.

4.2 Interdisciplinary Clinical Case

Conferences

Storyboard

The internist Doctor A has a patient with an

unclear oncological diagnosis. He/she decides to

sign on this case for the clinical conference. All

oncologist of the hospital meet at weekly basis

and discuss patients with difficult/severe

diagnoses. The conference participants examine

the documents (reports, medical images) and give

a recommendation and report. The assistant of a

doctor attending writes the final report and

updates the EHR. In the end Doctor A reads the

updated EHR and the report and can use this for

the further treatment of his/her patient.

The clinical conference is shown in figure 3,

particular process steps are:

 Sign on Case: Doctor A signs up his/her

patient for the clinical conference to be

discussed.

 Analyzing Case: All attending doctors,

including Doctor A, analyse the provided

information objects (e.g. images, reports;

internalisation step) and discuss

recommendations for further treatment

(internalisation). The result is a consolidated

recommendation (combination) as new

knowledge object.

 Writing Report: The assistant writes a report

containing the recommendation, resulting in a

new information object.

 Updating EHR: The assistant loads the report

into the EHR.

 Reading: Doctor A reads the updated EHR

and can use this knowledge for the further

treatment of his/her patient.

4.3 Discharge Letter

Storyboard

Doctor A, a senior geriatrician, starts writing the

discharge letter for his/her patient. When he/she

has finished his/her draft the discharge letter is

corrected by the chief geriatrician Doctor B.

Doctor A can finalise the discharge letter. The

discharge letter is forwarded to the department

assistant who sends to letter by regular mail to the

family physician of the patient.

The discharge letter (DL) process is shown in figure

4, particular process steps are:

 Writing DL: Doctor A writes the DL draft by

using the updated EHR with images, reports

etc. This is the externalisation step.

 Correcting DL: Doctor B corrects the draft

DL, the result is the corrected DL. This is the

combination step.

 Finalising DL: Doctor A finalises the

corrected DL and forwards it to the

department assistant.

 Sending DL: The department assistant sends

the DL to the family physician in charge. This

is the step where the sector boundaries are

overcome.

 Receiving DL: The family physician in charge

receives the DL and updates the patient EHR

in his/her office. Reading the patient’s DL is

the internalisation step.

5 CONCLUSION AND OUTLOOK

5.1 Conclusion

Health care has evolved in the recent years and this

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also applies to organisational learning routines.

Emerging specialisation in medicine regarding more

specialised disciplines (e.g. geriatrics as a

specialisation of internal medicine) or occupational

profiles (e.g. case management, palliative care

nurses) and enforced inter-profession cooperation

between physicians, nursing and other professions

have changed organisational learning routines like

the multi-professional geriatric team session. The

scope of organisational learning has also changed,

starting from learning routines inside hospital

boundaries up to inter-organisational (between

several hospitals) and even inter-sectoral (between

hospitals, rehabilitation organisation and ambulatory

actors).

Well-described learning routines have been

proven in the field but also new ideal-typical

organisational learning routines have been identified

and have been introduced in detail. The

demonstrated organisational learning routines have

been modelled from field observations and can be

stated as ideal-typical routines.

5.2 Outlook

In a next step the velocity of knowledge

dissemination will be measured and factors

influencing the velocity will be identified, e.g. how

long does it take to use the knowledge from a

consultation report in the patient treatment process.

These measurements and influencing factors will

be the basis for remodelling proposals. These

proposals could focus on remodelling the learning

routine itself by rearranging the process steps,

eliminating negative influencing factors, or

reinforcing positive influencing factors. New

process steps or links between actors are possible.

ACKNOWLEDGEMENTS

The authors would like to thank the Metropolregion

Bremen-Oldenburg (reference number: 23-03-13)

for partly supporting this work.

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APPENDIX

Figure 2: Multi-professional Geriatric Team Session (activity view).

Figure 3: Clinical conference process (activity view).

Figure 4: Discharge letter (activity view).

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