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

Overview What do we know from literature ◦ Boundaries ◦ Communities of practice ◦ CoPs and service improvement The Chronic Kidney Disease project ◦ Context ◦ Boundaries: professional, intra-organisational, organisational Implications for the use of the CoP approach in service improvement

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

Literature: Communities of Practice CoPs in healthcare are predominantly uniprofessional and block knowledge sharing and innovation spread at professional boundaries (Ferlie et al., 2005). In certain cases these boundaries can be successfully bridged through the formation of multiprofessional CoPs bringing together representatives of different professional groups (Gabbay and le May, 2011; Gabbay et al., 2003).

Two perspectives on CoPs Analytical perspective CoP approach is used to analyse practice, identity, meaning and learning in various groups Mainly looks at organic CoPs which are informal and exist independently from formal organisational structures CoPs as a theoretical lens Instrumental perspective CoP approach is used as a knowledge utilisation tool enhancing innovation and joint working Attempts to deliberately cultivate CoPs in an organisation and use them for achieving organisational aims CoPs as a managerial technique

Literature: CoPs and service improvement Deliberately constructed CoPs enhance professional education, adoption of innovation and knowledge transfer (Li et al., 2009; Ranmuthugala et al., 2011). Challenges to cultivating CoPs in service improvement :  time-limited nature of the projects  top-down approach to change management  preoccupation with performance measurement at the expense of human and social aspects of change (Bate and Robert, 2002; Currie and Suhomlinova, 2006; Currie et al., 2007). The impact of pre-existing professional and organisational boundaries on CoP cultivation seems somewhat underestimated (Kislov et al., 2011).

Research Questions How do boundaries between CoPs existing within and across general practices influence the implementation of a primary care service improvement programme? How do these boundaries affect the emergence of new multiprofessional and multi-organisational CoPs within and across primary care organisations?

The Chronic Kidney Disease project Practice A Practice B Practice C Practice D

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

Professional boundaries Practice A Practice B

Professional boundaries Not a problem for the CKD project Possible explanations: ◦ Existing power structures not challenged ◦ Autonomy granted to nurses and managers ◦ Complex nature of knowledge (managerial, technical, clinical and other aspects) ◦ A shared history of learning, working and sense-making ◦ Operational proximity ◦ Sharing common values

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

Intra-organisational boundaries Practice A Practice B Practice C Practice D

Intra-organisational boundaries More pronounced in larger GP surgeries 1) Between the multiprofessional team and receptionists 2) Between the multiprofessional team and other clinicians May challenge sustainability of change Underlying factors: ◦ Lack of identification with the CKD work ◦ Lack of identification with the organisation ◦ Lack of organisational support for the CKD project

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

Organisational boundaries Practice A Practice B Practice C Practice D

Organisational boundaries Most problematic Possible explanations ◦ GP surgeries as competitive businesses ◦ Strong organisational identification ◦ Looseness of inter-organisational networks ◦ Historical lack of collaboration External facilitation and involvement of (external and internal) knowledge brokers were used to compensate for the lack of inter- organisational knowledge sharing

The developmental perspective on CoPs Analytical perspective Analysing practice learning, meaning, and identity in organic CoPs A theoretical lens Instrumental perspective Deliberate cultivation of CoPs for knowledge management A managerial technique Developmental perspective midway between the analytical and instrumental perspectives maximal utilisation of existing organic CoPs improving communication within and between them analysing the configuration of boundaries, roles and identities in existing CoP landscapes increasing the permeability of CoP boundaries enabling development of these CoPs through participation in the service improvement initiative

Applying the developmental perspective Promoting co-production and shared ownership of the initiative between the local CoPs and external facilitators A nuanced and facilitative approach to implementation Identifying and targeting actors with simultaneous membership in a number of intra- and extra- organisational CoPs Developing knowledge and skills related to dealing with intra- and inter-organisational boundaries Maximal utilisation of existing inter-organisational networks and channels of communication

Conclusions Professional boundaries between doctors, nurses and managers do not seem to complicate the process of service improvement in primary care settings Knowledge sharing related to service improvement is impeded by intra- and inter-organisational boundaries Development of multiprofessional communities of general practice is enabled by the nature of the primary care settings Development of multi-organisational CoPs in the process of service improvement in primary care is highly problematic Dialogue with existing communities of practice may be more beneficial for service improvement initiatives than attempts at the deliberate construction of new CoPs