Knowledge Management Concepts and Processes in Healthcare

Research Plan for Doctoral Thesis

Helvi Nyerwanire

, Erja Mustonen-Ollila

, Antti Valpas

and Jukka Heikkonen

Department of Software Engineering and Information Management, Lappeenranta University of Technology,

Lappeenranta, Finland

Department of Obstetrics and Gynaecology, South Karelia Social and Health Care District, South Karelia, Finland

European Commission Joint Research Centre, Unit JRC.G1 Scientific Support to Financial Analysis, Ispra, Italy

1 STAGE OF THE RESEARCH

This study presents a research plan for a doctoral

thesis about Knowledge Management in Healthcare.

It outlines objectives, research problems, state of the

art, methodology and expected outcome. The study

introduces current knowledge management concepts,

the research questions, and a conceptual framework

of knowledge management processes. It also

outlines data collection methods and data analyzing

methods. In this study both qualitative analyzing

methods with the grounded theory approach and

quantitative data analysis with novel intelligent

computing and analyzing methods are applied.

This doctoral study is planned to take a total of

five (5) years (January 2012- January 2017) in

which the output will be five (5) conference articles,

and one journal article. Furthermore, a relevant

introductory section of the thesis will be written in

this period. One conference article has been

accepted in 2012, another conference article was

submitted for reviewing purpose in 2014, and one

journal article is in preparation.

2 OUTLINE OF OBJECTIVES

It has been claimed that knowledge is

conceptualized from different disciplines

(Hernández and Noruzi, 2010). For instance

accountants measure it on the balance sheet;

information technologists want to codify it on

systems; sociologists want to balance power with it;

psychologists want to develop minds because of it;

human resource managers calculate a return of

investment on it; and training and development

officers want to make sure that they can build it. An

individual can decide on where and when to apply

knowledge in order to get the best results

(Hernández and Noruzi, 2010). Among health care

practitioners, knowledge is captured in social

interaction, e.g. when physicians and nurses meet

patients. Physicians transfer their knowledge and

expertise in meetings and consultations sessions, and

they can express and interpret diagnosis reports,

create new expert knowledge by reading, by learning

in traineeship, and having discussions (Nonaka,

1994; Alavi and Leidner, 2001). Collective

knowledge exists in networks in organizations, and

knowledge is internally ingrained in people (Alavi

and Leidner, 2001), and people learn in the practice

community through participation with each other,

e.g. cardiologists can belong to a community of

practice transferring and receiving knowledge on

best practices (Grover and Davenport, 2001).

In this study, the primary objectives and goals

are to discover and conceptualize knowledge

management concepts and processes in healthcare,

specifically in a hospital environment, by combining

information systems science, knowledge

management science, medical science, nursing

science, sociology of knowledge, management

science, and computational intelligence (Polanyi,

1966; Nonaka, 1994; Nonaka and Takeuchi, 1995;

Nonaka and Konno, 1998; Alavi and Leidner, 2001;

Dalkir, 2005; Mustonen-Ollila, 2005; Raitoharju et

al., 2007; Oinas-Kukkonen et al., 2008; Mustonen-

Ollila and Heikkonen, 2008a, 2008b, 2009; Oinas-

Kukkonen et al., 2009; Lahtiranta, 2009; Koskinen,

2010; Greig et al., 2012).

3 RESEARCH PROBLEM

The research problems, research question (RQ) and

related studies and theories of knowledge

management processes are shown in Table 1 below.

Thus, the research questions (RQ) to be

answered are as follows. RQ1) How do nurses and

physicians acquire for new knowledge at the

Nyerwanire H., Mustonen-Ollila E., Valpas A. and Heikkonen J..

Knowledge Management Concepts and Processes in Healthcare - Research Plan for Doctoral Thesis.

 2014 SCITEPRESS (Science and Technology Publications, Lda.)

Table 1: Knowledge management processes, research problems, research question (RQ) and related studies and related

theories.

Knowledge

management

processes

Research

problems

Research question (RQ) and related studies Related theories

Knowledge

acquisition (1)

Acquisition

mechanisms

RQ1) How do nurses and physicians acquire

for new knowledge at the research site?

(Huber, 1991; Mustonen-Ollila and

Heikkonen, 2003; Dalkir, 2005; Mustonen-

Ollila, 2005; Whelan et al., 2009)

Organizational learning (Dalkir, 2005;

Huber, 1991; Morr and Subercaze, 2010)

Knowledge

creation and

construction (2)

Social

construction

knowledge

RQ2a) How do nurses and physicians create

and construct knowledge at the research

site? (Huber, 1991; Nonaka, 1994; Alavi

and Leidner, 2001)

RQ2b) What impact has organizational

learning, unlearning and internal learning on

knowledge creation and construction at the

research site? (Hsiao and Chang, 2011)

Latour, 1991

Organizational learning (Huber, 1991; Morr

and Subercaze, 2010). Learning in

organizations (Ferriani et al., 2005; Morr

and Subercaze, 2010). Organizational

unlearning (Venable et al., 2010)

Knowledge

transfer (3)

Knowledge

transfer,

transfer

problems

RQ3a) How do nurses and physicians

transfer knowledge at the research site?

(Wang and Lu, 2010; Lauder et al., 1999;

Dalkir, 2005)

RQ3b) What are the knowledge transfer

problems at the research site? (Mustonen-

Ollila and Heikkonen, 2003; Morr and

Subercaze, 2010; Ferlie et al., 2012)

Knowledge sharing and communities of

practice (Dalkir, 2005; Eppler, 2007).

Learning and knowledge transfer (Lauder et

al., 1999; Wang and Lu, 2010; Morr and

Subercaze, 2010; Ferlie et al., 2012)

Knowledge

storage (4)

Knowledge

management

systems,

information,

data

RQ4) How do nurses and physicians store

knowledge at the research site? (Hanvanich

et al., 2006).

Organizational memory (Paoli and Prencipe,

2003).

Knowledge management processes and

management systems (Alavi and Leidner,

2001; Gold, 2001; Nonaka and Konno,

1998; Nonaka and Takeuchi, 1995)

Knowledge

application (5)

Application

mechanisms

RQ5) How do nurses and physicians apply

knowledge at the research site? (Huber,

1991; Dalkir, 2005; Morr and Subercaze,

2010)

Knowledge application (Huber, 1991;

Dalkir, 2005; Morr and Subercaze, 2010)

Organizational

learning,

unlearning and

internal

learning (6)

Learning

and

unlearning

mechanisms

RQ6) How do nurses and physicians learn

from existing knowledge and new

knowledge at the research site? (Hsiao and

Chang, 2011)

Organizational learning (Huber, 1991; Morr

and Subercaze, 2010). Learning in

organizations (Ferriani et al., 2005; Morr

and Subercaze, 2010). Organizational

unlearning (Venable et al., 2010)

research site? RQ2a) How do nurses and physicians

create and construct knowledge at the research site?

RQ2b) What impact has organizational learning,

unlearning and internal learning on knowledge

creation and construction at the research site? RQ3a)

How do nurses and physicians transfer knowledge at

the research site? RQ3b) What are the knowledge

transfer problems at the research site? RQ4) How do

nurses and physicians store knowledge at the

research site? RQ5) How do nurses and physicians

apply knowledge at the research site? RQ6) How do

nurses and physicians learn from existing knowledge

and new knowledge at the research site?

4 STATE OF THE ART

Different types of knowledge have been identified

and integrated into existing and emerging healthcare

information management practices (Alavi and

Leidner, 2001; Lahtiranta, 2009; Gold et al., 2001;

Nonaka and Konno, 1998). We have expanded Alavi

and Leidner’s study (2001) to cover new theoretical

knowledge concepts found in earlier research

(Nyerwanire and Mustonen-Ollila, 2012) (See Table

2).

First, clinical medical expert knowledge is

IC3K2014-DoctoralConsortium

bounded to physicians' medical knowledge and

expertise both in practice and theory (Iwai and

Ishino, 2009; Hill, 2010; Morr, 2010). Second,

collective knowledge means that organizations learn

from internal and external sources of organizations

and sub-networks (Morr, 2010). Finally, knowledge

is embedded in the members, tools, and tasks of the

organization (McGrath and Argote, 2000; Wegner,

1986) and the knowledge of these three sub-

networks and their combinations is important to find

out what kind of knowledge the organization, and in

our case especially the healthcare environment needs

to be able to accomplish their work properly.

Healthcare practitioners use their experience by

applying it in medical practice. Evidence-based

medicine is a form of organizational learning in the

knowledge management context (Morr and

Subercaze, 2010).

4.1 Conceptual Framework of

Knowledge Management Processes

Knowledge management processes are

conceptualized in Figure 1.

In Figure 1, the research context is the Central

Hospital of South Karelia Social and Healthcare

District, and the unit of analysis is a department or

several departments at the hospital. The processes in

Figure 1 are shown as ellipses with a number

ranging from 1 to 5 (knowledge acquisition,

knowledge creation and construction, knowledge

transfer, knowledge storage, and knowledge

application) or with dashed arrows (internal

learning, organizational learning, and organizational

unlearning).

Knowledge acquisition involves searching for

valuable knowledge, and external knowledge may be

acquired by importing knowledge components

directly or by depending on intermediaries (Huber,

1991; Mustonen-Ollila and Heikkonen, 2003;

Mustonen-Ollila, 2005). Whelan et al. (2009) argue

that an organizational gatekeeper is the key

individual who connects the organizational members

to the external sources of information, and the

organizational members are kept up-to-date with the

outside information by communicating with the

gatekeepers.

Learning influences knowledge creation, and

according to Oinas-Kukkonen et al. (2009),

knowledge provided by evidence-based medical

guidelines and drug information databases help

physicians to learn new things. Raitoharju et al.

(2007) state that an electronic patient record enables

creation of organizational knowledge, and it is a

useful tool to survive in everyday work in primary

care. According to Dalkir (2005), in decision-

making and clinical practice knowledge is

transferrable through individual learning for

example by observation (Hall and Walton, 2004). It

is also possible that knowledge transfer can occur

without the individual being aware of it happening

(Dalkir, 2005). Learning in groups occurs through

discussions, meetings and lecture sessions in which

people share their experiences (Dalkir, 2005).

Table 2: Knowledge concepts, definitions, examples, and past research.

Knowledge concepts Definitions Examples Past research

Clinical medical expert

knowledge

Knowledge dwells on the

healthcare practitioners’ medical

degree, skills and experience

Expertise on diagnosis of patient

needs

Iwai and Ishino, 2009;

Hill, 2010; Morr, 2010

Collective knowledge Knowledge exists in organizations

and their sub-networks

Organizational learning Morr, 2010

Member-member

network knowledge

Knowledge is embedded in

network members

Members are the human

components of the organization

McGrath and Argote,

2000

Task-task-network

knowledge

Knowledge is embedded in tasks Reflects the organization’s goals,

intentions and purposes

McGrath and Argote,

2000

Tool-tool network

knowledge

Knowledge is embedded in tools,

such as information systems

Tools are the technological

components (hardware, software,

and systems)

McGrath and Argote,

2000

Member-task network

knowledge

Knowledge about who knows

certain tasks

Members are allocated to certain

tasks

McGrath and Argote,

2000; Wegner, 1986

Member-tool network

knowledge

Knowledge about who knows

certain tools

Members are allocated to certain

tools

McGrath and Argote,

2000; Wegner, 1986

Member-task-tool

network knowledge

Knowledge about who knows

certain tasks with certain tools

Members are allocated to certain

tasks with certain tools

McGrath and Argote,

2000; Wegner, 1986

Task-tool network

knowledge

Knowledge about what tasks are

performed with what tools

Tasks are performed with certain

tools

Wegner, 1986

KnowledgeManagementConceptsandProcessesinHealthcare-ResearchPlanforDoctoralThesis

Figure 1: The conceptual framework of the study.

Lauder at al. (1999) state that knowledge transfer is

the ability to apply knowledge gained in one

situation in another similar situation, or to use

metacognitive strategies to act in a novel situation.

New knowledge is generated by the influx of

information into an individual’s mind, combined

with the existing knowledge of this individual, and

then communicated further and made explicit

(Blumenberg et al., 2009). After knowledge

creation, it needs to be transferred throughout the

healthcare organization. The knowledge that is

relevant and right to be transferred needs to be

determined as well (Dalkir, 2005). The formal

communities of practice include meetings, and the

informal communities of practice will include

discussion groups, study groups and online

communities (Wang and Lu, 2010). The more

knowledge is shared between individuals, the more

opportunities there are for knowledge creation

(Dalkir, 2005). Due to the reason that communities

are formed with different ways of working and

adoption of different vocabularies, they may not

understand each other (Dalkir, 2005). For example

human actors in IT and the business domain often

speak different technical and procedural languages

(Blumenberg et al., 2009). For instance one domain

can articulate requirements, goals and constraints

that another domain can think of as being

unreasonable and uncooperative (Blumenberg et al.,

2009).

Knowledge storage can be defined as the

organization’s memory which comprises the

knowledge and information that the people working

in the organization possess through their skills and

experiences. The collective memory of the

organization is the organizational culture expressed

through the routines and attitudes inhabiting in

groups and networks (Paoli and Prencipe, 2003).

Organizational memory can be mental abilities and

issues inside the organizational members, but also

the information possible to retrieve, such as copies

of memos, letters, spreadsheets, and data stored in

computers constitute organizational memory (Paoli

and Prencipe, 2003). Alavi and Leidner (2001) claim

that knowledge management systems are a

supporting class of systems to the organizational

processes of knowledge management and knowledge

storage. The organization’s computer-based

communication and information system applications

contain databases, repositories, directories, and

networks.

Knowledge application is the ability to use the

learned material in new and concrete situations by

applying rules, methods, concepts, principles, laws,

and theories (Dalkir, 2005), and knowledge is shared

from different sources. The use of external

knowledge will create new knowledge (Huber,

1991).

Internal learning has two modes of knowledge:

tacit and explicit knowledge. Tacit knowledge is

Knowledge creation&

constructio

(2)

Central Hospital

Knowledge transfer (3)

Organizational

unlearning

Internal

learning

Knowledge

acquisition (1)

Knowledge

application (5)



Organizational learning

Knowledge

storage (4)

Department

IC3K2014-DoctoralConsortium

gained through clinical and practical experience

(Dalkir, 2005). Räisänen et al. (2010) argue that the

use of healthcare information systems has enhanced

individual learning and group learning, and the

physicians can achieve and create new knowledge

by using information systems. A physician will

require also other knowledge than medical and

clinical knowledge, such as technical skills,

academic knowledge, a hospital’s and healthcare

organization’s cultural knowledge, management

know-how, and administrative skills The knowledge

of healthcare organizations can be transferred to an

individual, a group or a system (Willams and Baláž,

2008). According to Oinas-Kukkonen et al. (2008), a

patient relationship management system is affected

by the impact of the knowledge work performed by

the physicians in a hospital, and the use of the case

system seems to enhance knowledge creation. The

knowledge transfer barriers are lowered between the

physicians and the patients by enhancing

communication through a follow-up system (Oinas-

Kukkonen et al., 2008).

In organizational learning, knowledge is stored

in databases in documents, and the learning entities

are both the individual and organization (Mustonen-

Ollila and Heikkonen, 2003; Morr and Subercaze,

2010). This kind of organizational learning is ‘old

organizational learning’. On the other hand, new

organizational learning means discovering new

theories, practices and innovation and then

distributing or transferring that new knowledge to

the organization (Mustonen-Ollila, 2005; Morr and

Subercaze, 2010).

Organizational unlearning means that old

organizational knowledge is disregarded. The

knowledge considered for elimination is the same

knowledge that led the organization to its previous

success (Turc and Baurnard, 2007), and there is a

need to remove or reject previously used practice

from the organization (Mustonen-Ollila, 2005).

Therefore, change and learning theories are relevant

and should be included in a framework in order to

draw a comprehensive image of processes at work in

the changing organizations (Turc and Baurnard,

2007; Venable et al., 2010).

5 METHODOLOGY

5.1 Data Collection

The case study approach (Yin, 2003) has been

chosen for this study. The primary data sources are

both open-end and structured interviews conducted

at South Karelia Social and Health Care District’s

Central Hospital. Furthermore, archival records are

used as secondary data sources. The interviews are

transcribed and sent to the interviewees to be

checked and corrected. The open-end interviews

create the possibility for individuals or groups to

express themselves freely questionnaires.

First, a pilot study was carried out in the

Obstetrics and Gynecology department of South

Karelia Social and Health Care District’s Central

Hospital in January - March 2013. After the pilot

study, four other departments were included in the

research, and new interview rounds have been and

will carried out in the following order: in January -

April 2014, a second round of interviews was carried

out in the Obstetrics and Genecology department.; in

March - May 2014 the first interview round was

carried out in the Paediatric department.; in March -

June 2014 the first interview round is carried out in

the Paediatric Neurology department.; in May - June

2014 the first interview round will be carried out in

the Surgical department.; and finally in May 2014

the first interview round will be carried out in the

Anaesthesia and Surgery department.

The interview questions have been improved

after each interview round to match the healthcare

organization's knowledge management base better.

The interviews have been and will be tape-recorded

and transcribed. Before the interview, permission is

asked from the interviewee to use the tape recorder.

In the interviews, a predesigned interview protocol

is used, called structured interview, and the

interview questions are sent to the interviewees in

advance (Creswell, 2007).

According to Creswell (2007), the individuals

considered for the interviews need to have

participated in the process or action, and they must

be given the time and place to be interviewed. Our

study is in line with this, because the hospital

arranges the place and time for the interviews, and

the Chief physician of the Obstetrics and

Gynecology department of the Central Hospital acts

as the research site coordinator. Creswell (ibid.) also

highlights the importance of type of sampling and

the number of interviews needed. In any needed

legal permission or arrangements inside the hospital,

the research coordinator is essential, because in the

hospitals and healthcare organizations in Finland the

national laws and regulations are very strict, and also

the interviews need a specific time table, because

they must not affect the patient care work.

KnowledgeManagementConceptsandProcessesinHealthcare-ResearchPlanforDoctoralThesis

5.2 Data Analysis

5.2.1 Qualitative Data Analysis with the

Grounded Theory Approach

This study is a qualitative inquiry based on the case

study approach (Yin, 2003; Creswell, 2007). This

method is best suited for social sciences, as it allows

the researcher to interact with the society through

interviews and observations for the purpose of

acquiring the desired data. The researcher will be

able to combine various data sources such as

archival records, interviews, observations, audio

recording, and even quantitative data for the analysis

without restricting the data formats (Joan and Pastor,

2007). The Grounded Theory (GT) approaches of

Glaser and Strauss (1967), Pawluch and Neiterman

(2010) and Corbin and Strauss (1990) are used in the

data collection and analysis. According to Corbin

and Strauss (1990), there are three levels of coding

in the Grounded Theory: open, axial and selective

coding. Open coding reveals similarities and

differences in the data so as to unveil the concepts,

classes and relationships between the concepts in the

data. Similar concepts will be put into the taxonomy

of categories. There is a need to set the dependencies

and relationships between concepts and classes thus

in axial coding categories are analyzed. Through this

the development of the relationships between

concepts will reveal new concepts and relationships.

Selective coding integrates and refines the fully

developed categories into theories. The main theme

of the research emerges from the data during this

phase, but after the main theory is established, the

researcher still refines the categories by trimming off

unwanted ones and filling in those still poorly

developed. In our study, a department in a central

hospital is the unit of analysis. The sample has not

been limited to a certain number of departments,

because the goal of the study is to achieve deep

understanding of the selected case departments and

to identify their knowledge management concepts,

relationships and processes.

Finally, when a research is a collective case

study by nature, it aims at creating a new theory.

The multiple case study approach is applied when

aiming at developing a new theory, and this study

will also utilize a new methodological approach

where both qualitative and quantitative research

approaches are applied. As the quantitative research

approach we use novel intelligent computing and

analyzing methods, which are described in the next

section. The theory creation should thus combine

both multiple data collection methods. The

triangulation will make it possible for the multiple

data collection techniques to provide stronger

substantiation of concepts. Collecting different types

of data by different methods from different sources

produces a wider scope of coverage and may result

in a fuller picture of the phenomena under study.

Especially Eisenhardt (1989) suggests that both

quantitative and qualitative data should be used in

any study. The flexibility given by GT makes it

possible for the respondents to express their views

and opinions easily and freely.

5.2.2 Quantitative Data Analysis with Novel

Intelligent Computing and Analyzing

Methods

As this is study also quantitative, a large sample of

data will be collected in order to carry out the

needed statistical analyses (Kohonen, 1989). The

exploratory data analysis approach is needed for

generating hypothesis due to weaker assumptions

and prior knowledge about the data. Classified

hypothesis testing is applied to reject or accept

hypotheses whenever available. Data mining

techniques are tools for exploratory data analysis.

These include clustering, regression, classification

and association analysis techniques. The goal of data

mining is to find unsuspected relationships and to

summarize the data in novel ways that are both

understandable and useful for the goals of the

project. Especially data visualization methods, such

as the Self-Organizing Maps (Kohonen, 1989,

1995), Bayesian networks (Heckerman, 1996),

multidimensional scaling and hierarchical clustering,

are needed for the understanding of deeper domain

and variable dependencies. For data regression,

linear and non-linear methodologies of classification

and association analysis, combined with variable

selection and uncertainty analysis are applied. As the

general framework, the Cross Industry Standard

Process for Data Mining (CRISP-DM) approach has

been selected. The modeling part includes the

methods mentioned above.

6 EXPECTED OUTCOME

The scientific contribution of the project will be to

create a new theory called knowledge management

life cycle in healthcare, based on the discovered

empirical findings. The practical and managerial

contribution will be helping physicians and nurses to

understand their own valuable knowledge capital

and practice, getting familiar with knowledge

IC3K2014-DoctoralConsortium

management practices in the hospital, and helping to

build up better healthcare information systems. The

methodological contribution will be using diverse

qualitative research methods such as the Grounded

Theory and novel intelligent computing methods

together.

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