Knowledge Management in the NHS ... - Wiley Online Library

HLR286.fm Page 136 Tuesday, August 22, 2000 1:21 PM

Knowledge Management in the NHS: positioning the healthcare librarian at the knowledge intersection Blackwell Science, Ltd

Carole Keeling* & Sian Lambert†, *Project Officer, Graduate School of Science, Engineering & Medicine, University of Manchester, †Course Leader/Senior Lecturer, Department of Information & Communications, Manchester Metropolitan University, Manchester, UK

Abstract This paper defines what is meant by Knowledge Management, investigates how it interlinks with new ways of delivering health care and gives a synopsis of a study that investigated issues around implementation of Knowledge Management across a sample of healthcare librarians. Areas of investigation that are related to Knowledge Management include: HSG(97)47, evidence-based medicine, clinical governance, information and communication technologies, and the changing role of the healthcare librarian. A diagram is included in this paper which illustrates how the healthcare librarian interacts with resources, staff and practices, so contributing to the knowledge base of health care. The paper concludes that Government policy, new technologies and the push towards the practice of information age medicine are forcing changes throughout the NHS. Recognition of Knowledge Management is still in its infancy in the NHS —it calls for major change in organizational thinking and acceptance by the librarian that their service must also be subject to continuous improvement.

Introduction The Government has set the NHS the task of becoming an information-led industry; if this is to be achieved then innovations in management are needed. By positioning healthcare librarians at the intersection between people and resources and empowering them to take on a Knowledge Management role, the NHS has the potential to realize this aim. This paper defines what is meant by ‘Knowledge Management’, investigates how it interlinks with new ways of delivering health care, and gives a synopsis of a study that investigated the

Correspondence: Carole Keeling, Project Officer, Graduate School of Science, Engineering & Medicine, University of Manchester, Roscoe Building, Brunswick St., Manchester M13 9 PL, UK. E-mail: [email protected]

136

implementation of Knowledge Management by a sample of healthcare librarians. Information-intensive initiatives such as telemedicine (NHS Direct), evidence-based medicine (EBM), clinical governance, and the roll-out of the private Internet network NHSnet, are changing the ways in which health care is provided and medicine is practised within the NHS. In combination with the implementation of HSG(97)47,1 their effects have helped to create a climate where ‘the amount of health information is now huge and growing uncontrollably’.2 This scenario formed the basis of a recent smallscale study, undertaken as the subject of an undergraduate degree thesis in Information and Library Management,3 which looked at a range of issues connected with the implementation of Knowledge Management (KM) by healthcare librarians:

© Blackwell Science Ltd 2000 Health Libraries Review, 17, pp.136 – 143


Knowledge management in the NHS, Carole Keeling and Sian Lambert

• management structure and funding of healthcare libraries, • access to and training in Information and Communication Technologies (ICTs), • hospital culture and library interaction with other departments, • understanding of and participation in KM initiatives by healthcare librarians.

Background to Knowledge Management Definition To help understand the definition of ‘Knowledge Management’ it is essential to differentiate between data, information and knowledge. Information uses data as its raw material and is informationsystems centred; whilst knowledge is used to activate information by application of a range of skills and experiences, ‘the major steps that occur in the transforming of information into knowledge are learning, knowing, filtering, evaluating and balancing’.4 Objectives The primary objective of KM is to utilize the experience and understanding of individuals within an organization with the aim of enriching its intellectual capital. Thus, KM is primarily a personcentred process, concerned with extracting value from knowledge that exists in two different formats: tacit knowledge refers to personal expertise that is not shared on a formal basis, i.e. through discussion or documentation. Explicit knowledge refers to knowledge that has been recorded in a media allowing it to be shared by others, e.g. newsletter, Website, database. Origins KM originated in the late 1980s as a Japanese-led organizational discipline—following on from and complementary to—Total Quality Management (TQM) and other lean manufacturing strategies (e.g. Kaizen, Just-In-Time). Whilst TQM concentrates on breaking down an activity into its constituent parts, analysing them to define where improvements could be

made and introducing change accordingly, Kaizen takes the TQM philosophy one stage further by demanding continuous change—either by adapting an existing product or creating a new one in order to stay ahead of the market. All three strategies (TQM, JIT, Kaizen) rely on KM principles and practices, for example: • sharing of tacit and explicit knowledge, • teamworking, • management of change, • exploitation of knowledge as a capital asset. Whilst employment of such strategies have been linked traditionally with industry, it is accepted that ‘information’ is now one of the most important assets to any type of organization. The NHS is a prime example of this, it therefore seems reasonable to suggest that those at the forefront of information provision within the NHS should be taking a close look at what KM can do to help them improve their service.

Changing role of the librarian in an information-intensive NHS The shift towards multidisciplinary library provision, as set out in HSG(97)47,1 will of course increase the quantity of information passing through the library. When combined with other information-intensive practices, as mentioned above, it becomes apparent that healthcare librarians need to look at new methods of managing and exploiting these resources in ways that contribute to the strategic aims of the organization. This new climate of information-led health care has given librarians the opportunity to enhance their role and provide not just an information service, but a KM service to the rest of the hospital community. In so doing, they create an opportunity to strengthen the strategic input of the library service, and moreover promote it to those staff who have not been frequent users—particularly Trust and Health Authority managers. KM has received an encouraging press from within the library and information community, where it is seen by its advocates as being the catalyst to increased recognition for the librarians’ skills at board level. Writing in 1997, Lopatin and Blagden5 were pressing the case for healthcare librarians to become involved in KM:

© Blackwell Science Ltd 2000 Health Libraries Review, 17, pp.136 –143

137


138


Figure 1 Positioning the healthcare librarian at the knowledge intersection

‘… It seems that both clinicians and managers have forgotten, or are unaware of, the skills of librarians. But we come equipped with critical appraisal skills and a great deal of knowledge of the new technology. Librarians are knowledge managers par excellence’. However, as in other sectors where the image of the librarian’s role is undervalued, the healthcare librarian could be left behind in terms of involvement in KM. Establishment of favourable relationships with hospital managers and other influential departments who would be major movers in KM (e.g. IT, Clinical Audit, R&D) is crucial, as is the creation of library-led ‘quick-win’ KM initiatives, prior to a fully integrated hospitalwide approach to adoption. In line with the ethos of a multidisciplinary service, librarians need to adopt an holistic viewpoint—which could be facilitated by conducting an audit of the research interests of appropriate staff—by developing systems that allow the results of information searches to be shared by other clients working in similar fields. However, the librarian’s technical skills alone are not enough to power successful KM; acceptance as a facilitator to

such a diverse range of staff groups as found in the NHS could only be achieved by exposure to training in KM techniques, empowerment and public relations. In KM terms, this would necessitate making connections between the knowledge assets of one employee and the knowledge deficits of another. The healthcare librarian appears to be the logical choice to lead such a project, for example: • they are often the first port of call for staff who are undertaking research projects; • they are aware of (and often well-trained in) the use of information technology; • they are skilled in presenting and targeting information; • they have developed good networking skills through their training and experience in customer care. Figure 1 presents a model of how healthcare librarians might interact with resources, staff and practices by positioning their service at the intersection between information sources feeding in (e.g. from NeLH) and feeding out (e.g. library participation in promotion of EBM). At the centre is the healthcare librarian, reprocessing what comes in and re-routing it to




others in the hospital community, where in context, it becomes part of the knowledge base of patient care. The diagram also depicts that KM does not work in isolation, it has partners such as TQM and Clinical Governance and utilizes the tacit/explicit knowledge of the hospital community and its external contacts. Culture change Whilst acquisition of appropriate skills could enable the healthcare librarian to activate this model, it is recognized that KM cannot be achieved without acceptance of change in working cultures. The NHS is no stranger to change, more often as the reactive recipient, rather than a trailblazer of its own accord when faced with cultural change. Embracing KM is likely to be no different. The introduction of KM would require new ways of working in order to extract optimum value from the knowledge held within the organization. For example, on an individual level it demands sharing of ideas to achieve organizational objectives at the expense of personal power; and organizationally, the creation of flatter management structures to encourage teamworking wherever possible. The following ‘test questions’, devised by management consultant Sandra Ward,6 make a useful framework for librarians to build on when thinking about a KM approach and could be used as a basis for discussion with other senior managers: • Can we transfer knowledge easily to new employees? • Is ours an information/knowledge sharing culture? • Do we know what and where our knowledge assets are? • Is knowledge organized and easy to find? • Do we capture and share best practice? • Do we learn from mistakes? • Do we reward knowledge-sharing? • Are we exploiting knowledge effectively and strategically? • Does our knowledge walk out of the door as staff leave?

Clinical Governance: TQM for clinicians? EBM and Clinical Governance are disciplines that promote the ethos that medical practice must be

based on proven research, adhere to quality-driven standards and focus on a continuous improvement process in the provision of patient care. As a consequence, they have generated a huge increase in the quantity of information now available—for example through electronic resources such as the Cochrane Library and EBM databases—so making it imperative that skills in information retrieval and interpretation become common amongst healthcare practitioners, if such resources are to be fully exploited. Knowledge Management appears to be a perfect partner to drive Clinical Governance—both need to share the same criteria in order to operate: ‘A working environment which is open and participative, where ideas and good practice are shared, where education and research are valued … The challenge to the NHS is the active creation of such cultures in most hospitals and primary care groups of the future’.7

Information & Communication Technologies KM is as much about valuing the information an organization possesses as it is about exchanging information over the intranet. This process has started to occur within the NHS. Its recent information strategy document8 signalled that the NHS had begun to understand the value of its information resources and had placed their exploitation at the centre of its strategic forward planning. Its private network, NHSnet, was designed to facilitate this. The business-end of NHSnet is NHSweb, which acts as ‘a private intranet for the NHS’ providing ‘rapid access to a vast range of information resources both on NHSweb itself and on the public Internet.’8 NHSweb has the potential to become a key tool in assisting the healthcare librarian to provide a KM-based service, by providing content for the creation of a knowledge network, personalized to the specialities represented in their hospital and the areas of research pertinent to their users. For example, the NHS Information Zone Website, which acts as a homepage to NHSweb, has been designed as a one-stop-shop for harvesting the latest health-related news from a variety of sources (e.g. mainstream media, Department of Health, NHS Information Management Group) as well


139


140


as hosting a number of specialist ‘zones’, such as The IM&T Zone designed to disseminate information to ‘any professional in the field of IT or information management’.9 In addition, the National Electronic Library for Health (NeLH), currently under construction, shares the same potential. It will host full text versions of 300 medical journals and comprehensive collections of knowledge, based around medical specialities (e.g. primary care, oncology, mental health).10 In the NHS the information infrastructure is clearly being installed—but is the information culture keeping pace? This question formed the basis of a hypothesis for investigating knowledge and uptake of KM by healthcare librarians.

Study of KM in NHS libraries A sample of 100 NHS healthcare libraries at various locations within England, Scotland and Wales, were selected by purposive sampling methods in order to investigate whether librarians were applying KM principles in their work, or were receptive to—and prepared for—a KM approach. Three criteria were used in their selection: • Geographical spread in order to obtain a ‘snapshot’ of activity, however the sample was too small to illustrate any reliable geographical trend related to uptake of KM. • Twenty per cent of the sample were chosen because articles relating to their library had appeared in the LIS press. • Eighty per cent of the sample were chosen according to their characteristics (e.g. size of stock > 2000 units; had Internet access) as entered in the directory, Guide to Libraries and Information Sources in Medicine and Healthcare.11 This sample received a postal questionnaire, containing 49 questions, together with a covering letter explaining the reason for contact. The questionnaire was designed to encourage respondents to express their opinions, seeking both qualitative and quantitative answers and provided tick boxes to collect data on factual questions. A 3-week period was allowed for reply and a response rate of 51% was achieved. Questions were allocated under three subject headings: Management structure and funding;

ICTs: access / training; Knowledge Management and the healthcare librarian. Management structure and funding The largest single classification of management responsibility for the library was still held by the Clinical Tutor (34%); Chief Executives came in at 12% whilst a range of functions appeared under ‘other’ (54%), such as Human Resources Manager and Directors of IT and Finance. This trend towards involvement of senior trust managers may be advantageous to the librarian, in that a number of respondents indicated that the role of Clinical Tutor was more concerned with issues connected with medical education for junior doctors than with library management during their typical time input of two ‘sessions’ per week. Thus, it might be fair to assume that a manager —rather than a medic—would be more in tune with the ‘big picture’ as libraries aimed to fulfil their role as multidisciplinary units, leaving behind their old image as a service dedicated to medical staff only. Furthermore, hospital managers might also have KM on their own agendas and be receptive to the idea of KM-based projects involving the librarian. A number of comments centred on the premise that where there was an absence of a fully committed manager—who was part of the hospital management hierarchy—this reinforced the division between the library and the rest of the hospital community. Funding streams to healthcare libraries remained complicated; only two respondents received funding from one source, whilst the average number was three. Apart from the practical difficulties in managing a number of funding streams, the lack of one central source also created lines of demarcation, for example respondents reported restrictions on transferring money belonging to one staff group to supplement resources for other groups. Complexity or lack of funding was cited as a barrier to involvement in interdepartmental projects, as was the library’s lack of status, for example: ‘I am funded through 7 different sources but have no Trust funding…. I cannot neglect my medical work for wider Trust work. If I was funded I could co-ordinate across the Trust.’ Anonymous



Knowledge management in the NHS, Carole Keeling and Sian Lambert Table 1 Feedback from users of Cochrane Databases. Comment

Score

Difficulties with interface Content not comprehensive Content difficult to understand Cannot print out easily Used infrequently OK after training

23 10 6 3 7 9

Response rate: 48 (94%).

Figure 2 Staff training

‘The main barrier is that the library is seen by many to be peripheral to the organization.’ North Tees General Hospital These reasons alone suggest that many librarians would encounter obstacles in initiating a KM approach—which requires collaboration rather than competition—moreover it suggests that the healthcare library function might benefit generally if funding and management were standardized. ICTs: access/training Respondents were asked to indicate whether they and/or their staff had received formal training in various skills and techniques, as illustrated in Fig. 2. Eighty per cent of respondents had at least one member of staff who had received formal training in navigating the Internet, although there was a paucity of skills in using HTML or a Web page editor. Given that intranets are KM-enablers and that intranet content is dependent on HTML, healthcare librarians need to be receptive to learning this skill, particularly as editing functions can now be performed easily through word processing packages, such as MS-WORD 97. All respondents had access to the Cochrane Library and greater numbers of staff had received formal training in using it compared to any other skill mentioned in the questionnaire, however this did not signify that this resource was highly valued.

A range of difficulties with the interface and content were reported by respondents and on behalf of their users (see Table 1). If such negative views are representative of the population as a whole, then it might be fair to assume that the practice of EBM cannot be successfully developed until such errors are rectified by the Cochrane Team, given that the databases are acknowledged as the ‘principal source of evidence’12 and have the potential to assist in what Muir Gray terms ‘the move from information to knowledge and eventually to wisdom’.13 Responses illustrated that connection to NHSnet was patchy, with almost equal numbers of hospitals enjoying connection throughout the site compared to hospitals with no connection at all, moreover a significant proportion had limited connection to NHSnet which excluded the library. Where connection had been provided, librarians were using NHSweb for a variety of functions, for example to access official documents, to gather information from NHS Information Zone, and to trial-run assorted databases. However, access to NHSweb was a fairly recent event for most respondents who, generally, were disappointed with its content so far. The most eagerly anticipated resource was the introduction of the NeLH. Knowledge Management and the healthcare librarian Whilst the majority of respondents indicated that they were aware of the objectives of KM, few had received any formal training specifically labelled as KM (see Fig. 2), whilst three respondents indicated that their Trusts had employed a designated


141


142


Chief Knowledge Officer, in all cases a very recent appointment, yet to produce any results. Evidence was sought of KM on the hospital agenda—whether library-led or otherwise. The majority of respondents indicated that they were not aware of any KM initiatives taking place or planned, but where positive responses were made, these centred on intranet content developments. Respondents were asked a series of questions to ascertain their understanding of KM and their attitudes and intentions towards instigating a KM approach. In answer to a question that asked respondents to comment on the extent of research they had done on KM, 12% had undertaken extensive research on the topic, 64% had undertaken a limited amount, and 24% had not done any. Whilst some indicated scepticism towards the value of KM, the majority acknowledged that it was an area they felt they ought to investigate, but perceived there to be barriers such as lack of time, money and encouragement and lack of recognition of professional credibility from management in order to do so.

Table 2 Hospital culture and Knowledge Management. Reason given

Score

Hospital culture against KM Library not preferred choice Librarian lacks skills Librarian lacks time Library not integrated Not the Librarian’s role

9 19 7 22 13 1

Response rate: 51 (100%).

‘I know KM is important but I really do not have the time to think about it.’ Anonymous Figure 3 Could KM be implemented in your hospital?

‘Librarians do not have a high profile. Managers do not generally use or know the library and its staff.’ Derbyshire Royal Infirmary However, a higher proportion reported that their skills in using ICTs—particularly with regard to intranet content—had raised their profile across the Trust: ‘Involved through intranet developments—KM is tailor-made for librarians.’ Royal Cornwall Hospital ‘IT have realized that we are the database experts and we can train others too.’ Bristol Royal Infirmary ‘KM is part of the new job description for our Electronic Librarian.’ St. James’s Hospital, Leeds Respondents were also asked to consider whether the culture at their hospital would be receptive to KM and whether they thought the library would be asked to lead KM projects (see Table 2). Figure 3

illustrates opinion on how extensively KM could be implemented. Targeting information to the right customer is a key attribute of KM and devising a system so that information is disseminated appropriately and quickly needs to be achieved to create a KMled environment. Only 6% of respondents had a system whereby checks could be made to ascertain if information retrieved for one user could also benefit others; whilst 8% offered this service to Consultants only. This lack of co-ordination may suggest that librarians see their users as individuals and that each search situation is therefore a one-off for that client. As installation of hospital intranets becomes more commonplace, it may become apparent that the costs of performing research audits could be quickly recouped if such information was available on a database, searchable by keyword and fully




accessible to other personnel from their desktop— one example of a library-led KM-based initiative.

Conclusion: does anything work if your Trust doesn’t own it? Government policy, new technologies and the push towards the practice of information age medicine have combined to force changes throughout the NHS, designed to maximize the effectiveness of their core competencies, which include research, innovation and knowledge. However, an environment of knowledge capture and sharing is needed if information overload is to be avoided and competencies are to be translated into the core product of providing first-class healthcare. It is acknowledged that the study described here could provide no more than a snap-shot of KM-related activity within healthcare libraries, however if respondents’ answers were typical of the rest of the population, then recognition of KM is still in its infancy within the NHS. Few respondents had looked at KM in depth or had undertaken any type of formal training. Furthermore, a significant proportion of respondents reported that senior managers were, at best, indifferent to the service they provided. However, there were also many examples of librarians taking on active roles in multidisciplinary teams, particularly connected to Clinical Governance and Internet-related projects—two areas where KM principles would be most relevant: ‘The KM function is being led by Clinical Effectiveness Division, we are part of that and are actively consulted.’ Salisbury Dist. Hospital ‘Library was invited to join intranet project team and took the lead on content decision process.’ Royal Preston Hospital As these quotes illustrate, new practices and ICTled projects have created new opportunities for librarians to interact with influential departments, sell their skills and bring in ideas for small-scale KM projects with ‘quick-win’ results. From this basis it would, potentially, be easier to gain the backing of senior managers to invest resources in a knowledge-enabling framework, such as that

devised by Ward,6 with the aim of making KM principles inherent within health service culture. Knowledge Management is a people-centred process that demands culture change and an investment in resources before pay-back can be achieved, making the backing of senior managers essential to its success—and as one respondent commented, ‘Does anything work if your Trust doesn’t own it?’. The challenge to healthcare librarians is to become involved in creating such an environment. That challenge has presented itself as KM, which requires a major change in organizational thinking and acceptance by the librarian that the service they provide must also be subject to continuous improvement.

References 1 NHS Executive. Health Service Guidelines: Library & Information Services. HSG(97)47, 6 November 1997. 2 Swaffield, L. Competition wasn’t healthy. Library Association Record, 1999, 101: 290–1. 3 Keeling, C. R. A study into the implementation of knowledge management by NHS health care librarians. BA Thesis, Manchester Metropolitan University (unpublished), 1999. Copies are available from the author. For details please contact . 4 Abram, S. Post-information age positioning for special librarians: Is KM the answer? Information Outlook, 1997, 1: 20. 5 Lopatin, W. & Blagden, P. Knowledge is power. Health Service Journal, 16 October 1997, 28–31. 6 Ward, S. Test for knowledge management. In: Webb, S. (ed.) Knowledge Management: Linchpin of Change. London: ASLIB, 1998: p. 12. 7 Scally, G. & Donaldson, L. J. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ, 1998, 317, 61–65. 8 NHS Executive. Information for Health: an Information Strategy for the Modern NHS 1998–2005. [online] . 9 NHS Executive. Welcome to the NHS Information Zone. Huntingdon, 1998. 10 Mitchell, P. Brought to book. Health Service Journal. 10 December 1998, 12. 11 Dale, P. (ed.) Guide to Libraries and Information Sources in Medicine and Health Care. London: British Library, 1997. 12 McGuiness, R. Discover health information. Managing Information, 1999, 6: 29–32. 13 Muir Gray, J. A. Knowledge Poverty and Knowledge Inequality. Proceedings of Conference ‘Operating with Knowledge’. Royal Society of Medicine, London, 6 November 1997.


143