Collaborative Learning Processes

Concept of work and how appliedKnight and Pye (2005):Operational network learning involves both behavioral and cognitive learning:

1. Developing meaning: shared values, identity, and frameworks between firms2. Developing commitment: the network-level implications of changes must be

considered, for example effects on patient community or region3. Developing method: putting into place necessary technologies, structures,

relations, routines, resources, etc. (“innovating and reorganizing) These three, especially “developing commitment and method” have network-level

consequences but are not network level processes Learning itself must become a “normal process”, with network members willing

and committed to learning Learning is not necessarily associated with performance improvement, however

changes will still make firms feel as though progress was made

Knight (2002): There are three views regarding organizational learning:

o Individual-Centered View: Learning takes place inside “individual human heads”, however human learning is influenced by the organization (Simon 1991)

o Group-Centered View: focus is on the top management team (“dominant coalition”

These two views depend on BOTH cognitive and behavioral learning

o Organization-Centered View: learning outcomes are changes in properties of organizations such as systems, structures, procedures, and culture resulting in changing patterns of action

Cognitive and behavioral learning is sustained despite personnel changes

Payton (2002):Implementation must consider:

1. push/pull factors : government, competition, economy2. behavior factors : support from stakeholders, political factors, autonomy3. shared systems topologies : information sharing/quality

Provans et al (2007): This study looked at the effectiveness of four mental health network sites: Providence, RI, Tuscon, AZ, Albequerque, NM, and Akron, OH.1. Providence:

Highly stable, resulting in little uncertainty Core agency had a historical and direct relationship with the state Integration occurred through this core agency High quality care due to a high level of state funding

2. Tuscon: Least effective system, undergoing substantial changes at the time of the study Community health system was new Newly formed core agency was responsible for case management, but did not

provide mental health services on its own Money went from the state to the local funding entity (a private not-for-profit)

and then to mental health institutions This system operated largely on the goodwill and professionalism of those who

operated individual agencies These individual leaders were good friends and were willing to work with each

other Additionally, a local advocacy group (Alliance for the Mentally Ill- AMI) was

highly visible with several powerful board members, and was thus able to organize local provider agencies and client families into an effective lobbying force

Decentralized integration was necessary to maintain minimal levels of acceptable services, as the Tuscon system was underfunded and lacked central guidance

3. Albequerque: despite weak funding, surprisingly effective Great levels of integration through centralization (“between Providence and

Tuscon”), however decentralized links between providers Effectiveness was also intermediate Four different agencies performed case-management

o One “core agency” served 90% of the system’s adult population, however the other three agencies developed their own subnetworks of linkage partners

o This core agency was also unresponsive to the community State funding was direct to agencies, but also fragmented into three funding

sources The system was well understood by clients, families, and professionals Professionals knew how to “work around” the system and the core agency

4. Akron: structurally similar to Providence with service linkages centralized through a core

agency Munificent resource environment Highly ineffective according to family assessments The community mental health system was new (like in Tuscon) An “Alcohol, Drug Abuse, and Mental Health Board” (ADM) acted as the

middle-man between the state and institutions in regard to fundingo The ADM was publico Its president was an eccentric, who stopped all government funding to two

of the three mental health centers present The system is confusing and hard to navigate due to recent changes Despite adequate funding, changes made it difficult for clients to find services

they needed

Havens et al (2006):A service-research partnership between 6 community hospitals was implemented using “appreciative inquiry” (AI). AI asks organizational members to find what’s working, and how to do more of what is working as a foundation for change. AI focuses on the positive rather than fixing the negative.

SOAR (strengths, opportunities, aspirations, results) vs. the more negative SWOT (strengths, weaknesses, opportunities, threats) model

“The AI approach to strategic planning starts by focusing on the strengths of an organization and its stakeholders’ values”

Kraatz (1998): This study examined 230 private colleges over 16 years.

Goals and outcomes to be achievedKnight (2002):

Strategic institutional alliances require:o Each firm receiving individual benefit, regardless of joint learningo The behavior of the institutional alliance must be reformedo Shared cognitive structures (e.g. norms and interpretations)o Collective or coordinated practices across the network

Kilo (1999):Motivations for collaborative improvement models include:

1. Reducing the gap between current knowledge and the actual provision of care2. Reducing the broad variation in the provision of care for comparable patient

populations3. Disseminating and describing examples of improved practices between

organizations; not only what should or should not be done, but also how to do or not do those things

4. Creating the possibility of professionals with diverse yet synergistic skills to work together; doctors often have a poor understanding of other professions and therefore undervalue the contribution of nurses ,P.A.s, and others.

5. Removing practitioners from their profession-based silos, changing a practitioner’s focal plane to the overall system

The benefits of collaboration include:1. Total knowledge and understanding greater than when work is done separately2. Increased probability of successfully discovering solutions to problems3. Solutions focus on systems of care, not individuals4. Integrative solutions5. Increased acceptance of solutions due to participation in problem-solving6. Meaningful relationships built, serving as the key to future improvement

Havens et al (2006):The objectives of the AI partnership were:

1. to improve communication and collaboration among nurses and other healthcare professionals

2. to enhance staff nurse involvement in organizational and clinical decision making3. to enhance cultural awareness and sensitivity toward patients, families, other staff

disciplines, and departments

Examples of processes that have been successfulKnight (2002):Examples of organizational learning within other industries:

1. “Industry Recipes” (Spender 1989)a. Management adopts perspectives widely shared within their industry,

conforming general prescriptions to their firm’s needsb. Common organization-level practices exist, but are not coordinated

between firms2. Emergency Services Networks

a. Interorganizational changes are accompanied by intraorganizational changes (e.g. new training policies and practices, new equipment) due to inquiries regarding efficacy of a particular industry or service

b. Collaboration within the network already exists, but not true integration3. Managing product tampering crises (Nathan and Mitroff 1991)

a. Within a fragmented network, during a crisis organizations must subscribe to a single negotiated order if they are to respond appropriately

b. No clear, shared network identity exists4. Toyota’s knowledge-sharing network (Dye and Nobeoka 2000)

a. Key suppliers adopt the Toyota production system to improve their processes

b. Individual firms improve processes through learning from other firmsc. Shared cognitive structures and coordinated practices develop

Berwick (2003):Seven recommendations to leaders regarding how to accelerate the rate of diffusion of innovations:

1. Find sound innovations2. Find and support “innovators”3. Invest in “early adopters”4. Make early adopter activity observable5. Trust and enable reinvention6. Create slack for change7. Lead by example

Payton (2002):Health Network implementation success depends on:

Systems planning: determines direction and scope, while identifying solutions Organizational readiness: requires efficient internal organizational processes in

order to manage IOS technology Needs assessment: fundamental in gaining endorsement

Pollard et al (2004):Explored students’ attitudes to recently implemented “modules” which required collaborative learning and working between adult nursing, children’s nursing, learning disabilities nursing, mental health nursing, midwifery, social work, occupational therapy, physiotherapy, diagnostic imaging, and radiotherapy students

Found that students were inclined towards interprofessional learning, but against interprofessional interaction

o The latter effect was especially seen in mature students with work experience

Provan et al (2007):Network effectiveness could be explained by: network integration, external control, system stability, and environmental resource munificence. A high amount of any of these aspects leads to success with integration.

1. network integration : there must be centralized links between providers; each individual within a network cannot be an island

2. external control : a centralized core agency is helpful to coordinate integration of services between hospitals

a. this makes the system easy to navigate, and doesn’t require that users be familiar with loopholes and “workarounds”

3. system stability : changing funding, government regulations, and leadership can hinder the effectiveness of a health network

4. munificence : more money and resources, more effective; every member of the network must see benefits from membership

Overall findings: A positive tie between network integration and coordination is most likely when

integration and coordination occur from the top down, but not when agencies take it upon themselves to integrate their services

A centralized entity must be present to help coordinate integration

Havens et al (2006):The six participating hospitals saw increased nurse retention and improved quality of care due to the use of AI. The effectiveness of AI has yet to be tested in other studies.

“AI is a strategy for unleashing and sustaining positive organizational change”

Kraatz (1998): Colleges that were members of smaller, older, and more homogeneous

intercollegiate consortia were more likely to undertake fundamental curriculum changes

Colleges tended to imitate similar consortium partners that were performing well rather than larger, more prestigious partners

Colleges tended to adopt programs that had previously been adopted by other members of the consortium (imitation was more common than innovation)

Lessons learnedLeathard (2003):Barriers in joint working and planning across health and social services (Hardy et al, 1992):

o Structural issues: service fragmentation and gaps in serviceso Procedural matters: different budgetary and planning cycles and

procedures hindering joint planningo Financial factors: different funding mechanisms and flows of financial

resources, administrative and communication costso Status and legitimacy: elected agencies vs. private agencieso Professional issues: competitive ideologies and values, professional self-

interest, competition for domains, conflicting views about patients, and differences between specialties, expertise, and skills

Additional interprofessional pitfalls include:o Different values and languages between professional groupso Separate training backgroundso Time-consuming consultation and trainingo Conflicting professional and organizational boundaries nad loyaltieso Isolated practitioners with little management supporto Inequalities in status and payo Differing leadership styles

o Lack of clarity about roleso Latent prejudices

Often, when significant moves are made toward interprofessional groupings, everyone pulls back into specialty-specific in-groups

o Doctors are seen as “professionals”, with nurses and social workers regarded as “semi-professionals”

o Organizational mergers can create a power base difference wherein weaker agencies/professions do not have adequate power to defend professional interests

Other issues include confidentiality (how much about patients should extend between organizations), professional loyalty, and accountability.

Knight (2002): “Particularly in the area of community-based health and social services… effectiveness must be assessed at the network level, since client well-being depends on the integrated and coordinated actions of many different agencies” (Provan and Milward, 1995)

Unlike within the individual firms, the lack of overarching authority structures means that learning processes cannot be traced and tracked

Kilo (1999):This is a review of the “Breakthrough Series” (BTS), developed by the Institute for Healthcare Improvement in 1995

Cooperative and collaborative behaviors are often lacking within healthcare networks

Information is not shared Help is not requested Communication skills are poor Anger is not uncommon Physicians often act independently, and are trained to be fully independent in

thought and action. Heated competition and productivity pressures, as well as lack of time and few

opportunities to meet exacerbate the lack of collaborative opportunity in health care.

Link to a PowerPoint regarding IHI’s “Breakthrough Series”:http://www.google.com/url?sa=t&source=web&cd=5&ved=0CDEQFjAE&url=http%3A%2F%2Fwww.nnphi.org%2FCMSuploads%2FThe-Olympic-Team-Trials-18129.ppt&ei=lvJJTN2dNY38nQfHmflX&usg=AFQjCNH1bod7s0u1HxED3T-VESbbU0eRJA

Payton (2002):Across case findings:

Government policies slow implementation Hospitals need to see cost/benefit analysis before this will be implemented Local hospital associations’ support was not important Physicians played the most significant role in the implementation process (also

important are vendors and end-users such as nurses and administrators)

Patient support was found to be unimportant to these systems, as they figured patients did not understand health care delivery

Information quality and sharing require process improvement and reengineering at the intraorganizational level

Vendor “turf wars” generated technological issues during network implementations (political issues)

o Analogy: unlike banks, hospitals cannot easily share data due to multiple platform technologies that cannot communicate

Health networks must create PERCEIVED value and benefits: Political issues and behavioral constraints must be overcome for implementation

success Health care reform will most likely hinder network implementation Careful planning is essential to the success of netowrks Identifying and engaging key players is vital as US health organizations migrate

toward Web-based mechanisms for care delivery Individual organizations should assess their processes to ensure mechanisms are

in place to support network The REAL customer is not the patient, but rather the physician Competition between participating hospitals will be problematic if who is paying

is not established early Failure to have top management teams of hospitals supporting intraorganizational

project managers = failure of networko Management from different institutions must be willing to reach a

consensus

Pollard et al (2004):Findings:

Educational level and perceptions of disparity in academic ability influences interprofessional education

o Nurses linked differences in entry qualifications with inequality between professions, with nurses and radiography students retaining a low opinion of other students’ academic abilities, and skepticism that learning with other disciples enhanced their own learning

Learning together before qualification may influence professional socialization (biases do not have a chance to become ingrained)

Occupational therapy and social work held negative views of interprofessional interaction upon entry to their professional program

o Social workers saw themselves as having “broader life experiences”o Occupational therapists rated themselves as “superior in practical skills”

Kraatz (1998):1. Strong ties to other organizations can mitigate uncertainty and promote adaptation

by increasing communication and information sharing2. Networks can promote social learning of adaptive responses, rather than other,

less productive forms of interorganizational imitation

BibliographyBerwick, DM. (2003). Disseminating innovations in health care. JAMA, 289(15), 1969-75.

Havens, DS, Wood, SO, and Leeman, J. (2006). Improving nursing practice and patient care: building capacity with appreciative inquiry. The Journal of Nursing Administration, 36(10), 463-470.

Kilo, C. (1999). Improving care through collaboration. Pediatrics, 103(1), 384-393.

Knight, L. (2002). Network learning: exploring learning by interorganizational networks. Human Relations, 55(4), 427-454.

Knight, L, & Pye, A. (2005). Network learning: an empirically derived model of learning by groups of organizations. Human Relations, 58(3), 369-392.

Kraatz, Matthew S. (1998). Learning by association? Interorganizational networks and adaptation to environmental change. Academy of Management Journal, 41(6), 621-643.

Leathard, A. (2003). Interprofessional collaboration: from policy to practice in health and social care. Bruner-Routledge.

Payton, FC. (2000). Lessons learned from three interorganizational health care information systems. Information and Management, 37(6), 311-321.

Pollard, KC, Miers, ME, & Gilchrist, M. (2004). Collaborative learning for collaborative working? Initial findings from a longitudinal study of health and social care students. Health Soc Care Community., 12(4), 346-58.

Provan, KG, Fish, A, & Sydow, J. (2007). Interorganizational networks at the network level: a review of the empirical literature on whole networks. Journal of Management, 33(3), 497-516.