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A positive deviance perspective on hospital knowledge management: analysis of Baldrige award recipients 2002-2008.

EXECUTIVE SUMMARY

Knowledge management (KM) is emerging as an important aspect of achieving excellent organizational performance, but its use has not been widely explored for hospitals. Taking a positive deviance perspective, we analyzed the applications of nine healthcare organizations (HCOs) that received the Malcolm Baldrige National Quality Award from 2002 to 2008. Baldrige Award applications constitute a uniquely comprehensive, standardized, and audited record of HCOs achieving near-benchmark performance. Applications are organized around leadership, strategy, customers, information, workforce, and operations. We find that KM is frequently referenced in all sections, and about two thirds of each application addresses KM-related issues. Many specific KM activities, such as strategic and action plans, communications, and processes to capture internal and external knowledge, are addressed by all nine applications. We present examples illustrating these frequently appearing KM concepts. Baldrige Award-recipient HCOs apply continuous improvement to KM processes, as they do to their organizations as a whole. We conclude that these HCOs have developed sophisticated, comprehensive KM processes to align both culture and specific procedures throughout the organization. KM in these organizations is a deliberate effort to keep all relevant knowledge at the fingertips of every worker, characterized by frequent communication, careful maintenance of content accuracy, and redundant distribution. We also conclude that the extent and rigor of their KM practice distinguish them from other U.S. hospitals.

INTRODUCTION

Modern healthcare practices require substantial use of knowledge management (KM). KM is a broader term than data management or information management. Whereas information or data is the qualitative or quantitative description, respectively, of an object, a concept, or a process, knowledge is the result of the evaluation, abstraction, or synthesis of information (Alavi & Leidner, 2001). Knowledge includes comparisons, opportunities for improvement (OFIs), and inferences about causes or corrections. For example, clinical care requires assessment of patient needs, coordination among a large number of providers, and the application of complex technologies. KM for care must manage information from ongoing patient assessments and treatment records (compare with Bohmer, 2009) as well as hundreds of professional guidelines and protocols integrated into lengthy, multi-step processes. KM involves not only the storage and use of information but also the evaluation, effectiveness, and continuous improvement of both the individual steps in care processes and their integration into treatment plans. Consequently, KM must go beyond data and information to include reporting structures, analytic processes, and strategic coordination.

More specifically, Alavi and Leidner (2001) define the four major elements in KM systems: knowledge creation--formal research, literature review, or field observation that leads to discrete statements of findings (consensus-building activity and the resulting agreement are part of knowledge creation); knowledge application--use of specific knowledge in an economically valued service or production activity; knowledge storage and retrieval--recording specific knowledge in a manner that captures its unique characteristics and supports its recovery; and knowledge transfer--communication of knowledge by voice, sign, or messaging system and by explicit training.

In this article, we examine these four elements of KM in high-performing healthcare organizations (HCOs). White and Griffith (2010) conclude that high-performing HCOs pursue consistent strategies that include measurement, benchmarking, and continuous improvement in all areas. These high-performing systems also empower their workers to challenge practices on subjective and qualitative grounds, and they monitor challenges and unexpected events. The combined information is used throughout the organization to forecast, analyze, and improve work processes. Hence, institutionalized mechanisms to support effective knowledge creation, application, storage and retrieval, and transfer are critical.

Positive Deviance

We identified the KM practices of nine healthcare recipients of the Malcolm Baldrige National Quality Award (refer to Table 1 for names, locations, and other organization information) using applications posted for public view (Baldrige Performance Excellence Program, 2002-2008). We employed a positive deviance approach that requires identifying (1) high-quality outcomes and (2) organizational practices key to those outcomes within a narrow set of high performers (Bradley et al., 2009).

The Baldrige review and award process fulfills this methodology. It relies on a detailed 50-page application in which applicants address about 30 questions in each of six dimensions of the organization (leadership, strategy, customers, human resources, information, and operations), plus a seventh section documenting performance against benchmark in each dimension (Baldrige Performance Excellence, 2009-2010). All applications receive comments and scoring from several trained examiners. Outlier scores are eliminated and the remaining scores are averaged. Final-round qualifiers receive a site visit to audit their application. The site visit team, composed of seven experienced examiners, spends five days on-site contributing a total of about 420 hours of effort and interviews with at least 10% of HCO staff to validate the results and the process described in the application (Baldrige Performance Excellence, 2012). The authors know of no comparably rich, rigorous, or validated source of information on the practices of high-performing HCOs.

We note that identifying organizational processes within high performers is often the first step in other research that explores firm-based strategic competitive advantages (e.g., Cremer, Garciano, & Prat, 2007) and the development of evidence-based management practices over time (e.g., Rousseau & Barends, 2011). In previous positive deviance studies, researchers have pursued narrow clinical areas, such as performance in care of patients with acute myocardial infarction, services for pregnant women, and preventive services for childhood nutrition (e.g., Bradley et al., 2009).

In this study, we apply the positive deviance method at a broader level, seeking to understand how successful HCOs use knowledge to align, deploy, integrate, and improve these specific processes. The next step in a positive deviance approach is to test for the importance of these characteristics in achieving quality outcomes in larger population-based samples. While we plan to conduct this next step, it is beyond the scope of this article.

METHODS

Data Sources

We identified common KM strategies using qualitative analysis of the applications of nine HCOs receiving the Baldrige Award between 2002 and 2008 (Table 1). The recipients operate a total of 39 acute care hospitals across a range of locations, from extremely rural to densely urban communities, generally in competitive situations, with extensive ambulatory and post-acute operations. In total, they expend about $8 billion annually. The recipient set is small, which may reflect some advantageous environmental factors, such as monopolies or particularly supportive economies. However, we argue that the characteristics described in Table 1 fairly reflect a broad spectrum of American communities and hospital market conditions.

Baldrige applications devote four pages to a general description of the business, its location, and its unique characteristics and about 35 pages to addressing the organization's work processes in the areas of leadership, strategy, customer focus, human resource focus, information management, and operations. The remaining pages document results. Scoring is weighted 45 percent to results, with no other section earning more than 12 percent (Baldrige Performance Excellence, 2009-2010).

In the results section, applications typically report values for several dozen outcomes and major process measures. The recipients report results that are almost always in the top quartile and often top decile of comparison populations. In the published applications, the recipients are allowed to redact information that might impair their competitive position. Healthcare recipients have been quite forthcoming, apparently altering little. No applications are published except those of award recipients.

The authors conducted a content analysis of the HCO Baldrige Award-winning applications facilitated by NVivo qualitative data analysis software (QSR International, 2010). The content analysis identified key passages reflecting the four KM elements proposed by Alavi and Leidner (2001) and, through an iterative process, developed a classification scheme of the concepts at a fine level of granularity.

The authors marked passages that directly referenced knowledge creation, application, storage/retrieval, and transfer. They were at liberty to define the passage length, and they could identify more than one code for a given passage. While each Baldrige application was analyzed by a single researcher, the team met regularly to discuss the results and to develop consensus on ambiguities. We then tallied the coded data to identify frequently recurring KM processes.

RESULTS

Table 2 shows the results of our analysis. The counts of coded passages are displayed in the right-hand column of Table 2. We also tracked the number of applications in which a given category was referenced (column 2).

As expected, we found that KM is a ubiquitous theme. The four major categories are addressed multiple times in every application reviewed. Most subtopics are addressed by all or nearly all nine applicants. The mode of the sources counted at the lowest level is 9; the median is 7. The 15 detailed code topics that all healthcare Baldrige recipients have addressed are shown in Table 3.

To put these findings into context, each 50-page application contains about 300 to 350 paragraphs. The nine applications in total have about 2,800 paragraphs. We identified 2,170 paragraphs addressing KM-related issues--more than three fourths of the total. Almost half of the references address knowledge creation; one quarter of the references discuss knowledge application; another quarter address knowledge transfer; and less than 10 percent of the references pertain to storage and retrieval. In other words, these HCOs focus strongly on how to create, apply, and transfer knowledge among their associates. The mechanics of storing and retrieving information receive relatively less emphasis than other elements of KM.

Examples of High-Frequency KM Elements

In Table 3, we present descriptions of KM activities universally adopted by all nine Baldrige Award-recipient HCOs. In this section, we present quotes from the applications addressing each KM element--creation, application, storage and retrieval, and transfer.

Knowledge Creation

Recipients use a systematic search for information outside the applicant organization, such as benchmarks and best practices. Mercy Health System, for example, identifies 16 external sources, including commercial companies, such as satisfaction surveyors, and numerous government sources. Poudre Valley Health System identifies 14 sources. Both note that they must overcome serious difficulties in applying these data: time lags, inconsistent definitions, and representativeness of sample.

Many formal structures and processes are used to maintain control over information and decision processes. For example:

[T]he independent Board Audit Committee ... is chaired by a non-Board member and meets annually with an external auditor, in the absence of the senior management group.... Board members sign [a] Code of Conduct and Conflict of Interest statement; receive annual compliance training [and] training on how to structurally prevent unethical business practices.... On average, the Compliance Department performs five internal monitoring audits a month ... based on high-risk areas.... (Poudre Valley Health System, p. 3)

The Corporate Responsibility Process goes beyond compliance with the Office of Inspector General's model plan to ensure that SSMHC values are reflected in all work processes. Employees, physicians, volunteers, and key vendors are empowered through training and a confidential Helpline to raise questions about any part of their job. All reported issues are investigated and appropriate action taken in a timely manner. (SSM Health Care, p. 5)

Further, recipient HCOs sustain their culture with specific education and policies that they have developed ("original development"). For example:

Ethical practices are first communicated ... in the orientation of new employees [and are] reinforced by system policies such as the Standards of Ethical Behavior, Conflict of Interest, Corporate Responsibility, Equal Employment Opportunity/Affirmative Action, Confidentiality of Information, Sexual and Other Harassment, ... Staff Rights to Refuse to Participate in Aspects of Patient Care, Corporate Responsibility Process, confidential Helpline and employee grievance process, which encourages reporting of unethical behaviors by management or others.... Ethics committees in all the hospitals and nursing homes offer a forum for patients and their families and caregivers to discuss and review clinical/ethical issues, including patient rights. (SSM Health Care, p. 7)

The Baldrige Criteria emphasize the importance of identifying best practices and, with them, realistic benchmarks, or known best values of performance measures (Baldrige Performance Excellence, 2009-2010). The applicants use their systematic search for external knowledge as a foundation for benchmarking. For example:

The System Leadership Team, Senior Leadership Team and department heads, with assistance from the outcomes managers, operations improvement department, clinical outcomes department and clinical quality department search their respective sources for world-class benchmarks. (North Mississippi Medical Center, p. 11)

Understanding what customers want has become an ongoing endeavor supported by trained professionals. The description in Sharp HealthCare's application is representative of market research and surveys conducted by Baldrige Award recipients:

[O]n an annual and ad hoc basis, Sharp assesses key customer groups, competitor activities, market share distribution, population health indicators, demographic data, customer group feedback, and industry trends data.... Sharp's marketing plans incorporate situational and SWOT analyses; focus group, and Awareness/Perception/Utilization research; and [a proprietary] life-stage segmentation system. Customer satisfaction priorities also are assessed annually and integrated into the planning process.... (Sharp HealthCare, p. 12)

Knowledge Application

Recipients follow an annual cycle of planning, goal setting, implementation, and preparation for the next cycle (White & Griffith, 2010). The following quotes illustrate the rigor and extent of the planning process ("action plans"):

Based on the [board] approved strategic objectives and long-term action plans, senior leaders further develop long-term action plans. Senior leaders identify those key service initiatives to be completed within the next fiscal year and incorporate them into the system dashboard. VP owners develop appropriate system-level action plans. (Mercy Health System, p. 9)

To support system-wide goals, team members meet with directors in patient care units/departments and use the Avatar priority matrix to identify improvement opportunities, set goals for department and write unit improvement initiatives. For transparency, system, facility and unit patient satisfaction results are posted monthly on the intranet. Units use these data to gauge progress toward their improvement goals and make adjustments. (Poudre Valley Health System, p. 12)

Recipients also uniformly pursue a culture of empowerment and responsive (or "servant") leadership (White & Griffith, 2010). Large flows of knowledge come from the activities supporting this culture. For example:

The core values are integrated into the ... hiring process ... and are published on the WP Card. The card is distributed to all employees and contains SLH'S mission statement, vision, core values, hospital strategic goals, performance improvement, and customer contact requirements. (St. Luke's Hospital of Kansas City, p. 10)

The Sharp Experience infuses Sharp's Mission by reconnecting the hearts, minds, and attitudes of its almost 14,000 team members, 2,000 volunteers, and 2,600 affiliated physicians to purpose, worthwhile work, and making a difference. (Sharp HealthCare, p. i)

Further, recipients document specific plans for compliance with federal and state regulations. They approach their own bylaws and internally created standards with similar rigor. For example:

Orientation also addresses, in addition to HIPAA requirements, requirements for employee and workplace safety, hazardous materials, risk management, OSHA, AIDS education, infection control, corporate compliance, ethics, and many other issues. (Baptist Hospital Inc., pp. 24-25)

Cross-functional committees identify and address workplace health, safety and security. The Safety Committee maintains the Environment of Care Plan and implements rite Hazardous Material, Emergency, Safety, Fire Prevention, and Security Management Plans. The Wellness Committee promotes programs that encourage healthy lifestyles and help prevent injuries on the job. (Mercy Health System, p. 27)

Finally, performance improvement teams play a key role in performing KM functions in recipient HCOs. These teams range widely in size and formality, but they always have an assigned agenda, membership, and timetable (White & Griffith, 2010). For example:

PVHS has seven multidisciplinary performance excellence teams ... to function as system-wide oversight committees.... These teams have defined roles in: 1) the annual performance excellence cycle; and 2) monthly monitoring of key performance measures. Process Improvement staff belong to each team and coordinate improvement efforts between the teams, as well as quarterly learning opportunities.... (Poudre Valley Health System, p. 5)

As continuous quality improvement has become a cultural norm, SSMHC has been transformed into a team-driven organization.... Use of teams gives SSMHC the flexibility to pull together individuals with special expertise to quickly address changing customer, operational, and health care service requirements. (SSM Health Care, p. 24)

Knowledge Storage and Retrieval

While the mechanics of knowledge storage and retrieval are not covered in the applications in great detail, our content analysis results show that recipients use electronic records, intranets, forums, electronic newsletters, and message systems extensively. For example:

Over the past five years, BMH has doubled the percentage of the organization's operating budget specifically devoted to IT in order to improve access and availability of data and information.... Technologies include: picture archiving and communication system in radiology and cardiac catheterization labs, electronic medical record, document imaging, BIOID (a fingerprint identification system for safe medication administration), secure Internet-enabled physician access to patient records and diagnostic images ... from offsite locations, email and Internet access for all staff, [and] corporate-wide intranet for communication and knowledge sharing. (Bronson Methodist Hospital, p. vi)

Knowledge Transfer

Recipients invest in staff training at levels unheard of in healthcare until 2001. For example, Bronson Methodist Hospital (p. 4) provides more than 100 hours of training per full-time equivalent employee per year. Other applications note training that explicitly addresses behaviors as well as processes. For example:

The Performance Management Process (PMP) produces a set of specific, measurable behaviors that exemplify the core values for each and every SLH employee. These behaviors are documented on a PMP form, which is developed collaboratively by supervisors and employees. Performance reviews and developmental objectives are included in the process so that all employees are measured on their effectiveness in implementing the core values and continually learn and develop the behaviors that are consistent with them. (St. Luke's Health System, p. 9)

Approximately 285 BHI leaders attend quarterly sessions designed to facilitate skill acquisition or improvement, personal development, and teamwork. Past session topics have included management versus leadership, time management, stress management, effective communication, employee retention strategies, effective meeting skills, giving and receiving feedback, and the use of 360[degrees] feedback reports. (Baptist Hospital Inc., p. 24)

Medical executive committee members receive training based on a nationally recognized methodology for medical staff governance, and medical staff offices attend annual training conferences [and] a four-day training related to medical staff governance, which includes topics such as disciplining and leading committees. For the Medical Staff Quality Committee, new members receive training from the Quality Resources departments and conferences on physician peer review. (Poudre Valley Health System, p. 23)

All recipients emphasize individual training, evaluation, and coaching, but they also give careful attention to publishing newsletters, updating websites, and developing helpful signage. Bronson Methodist Hospital's "Plan for Excellence" is representative:

This one page document is distributed to all employees and contains the hospital's MW [mission, values, and vision], strategic objectives (three Cs) [clinical excellence, customer and service excellence, corporate effectiveness], philosophy of nursing excellence, commitment to patient care excellence, PDCA [Plan-Do-Check-Act] model for improvement, and Customer Service Standards and Expectations. In addition, it includes other tools focused on service excellence such as service recovery, interaction process, scripted phrases, and telephone answering. On a daily basis, all employees have visibility to the Plan for Excellence, which is a constant reminder of the principles critical to BMH in the delivery of high quality care and excellent service. (Bronson Methodist Hospital, p. 1)

Knowledge transfer also includes disseminating status reports on performance. All recipients use balanced scorecard assessments, with about 30 measures at the strategic or enterprise level and a dozen or more for each first-line operating unit. Sharp HealthCare's approach describes the basic process of reporting, which emphasizes frequent, open, and specific communication:

Goals use targets derived from national, state and regional benchmarks, or internal benchmarks when external comparisons do not exist or are not available. The Report Card is a subset of a broad number Of measures contained in Pillar and departmental dashboards. (Sharp HealthCare, p. v)

Analyses are made available to employees via presentations, administrative teams, and Sharp's Strategic Planning Intranet site, which links to community/industry resources, research studies, and over 500 data reports. (Sharp HealthCare, p. 12)

Person-to-person communication is also universal. Senior managers at award recipient sites are expected to spend at least five hours per week in direct contact with frontline workers. For example:

Leaders, preceptors, and educational instructors are formally charged with reinforcing the use of knowledge and skills on the job ... through direct observation, immediate reinforcement of specific skills, annual competency assessment, and performance appraisal. A hey role of the preceptor is to mentor and reinforce skills of new employees on a daily basis. (Bronson Methodist Hospital, p. 22)

The senior leadership team also ... rounds in work areas and lounges where physicians congregate. Not only are SLT [Senior Leadership Team] members visible, they are accessible as well. (North Mississippi Medical Center, p. 3)

Leaders model desired behaviors daily through their interactions with employees and customers. (North Mississippi Medical Center, p. 22)

DISCUSSION

We examined the characteristics of KM in high-performing HCOs. Our analysis yielded the following conclusions, which may be helpful for other hospitals and health systems.

First, KM is ubiquitous. The capture, transfer, and application of knowledge are important in every aspect of the organization. Many messages, particularly those relating to the culture, are delivered repeatedly and in multiple ways. Baldrige recipients directly or indirectly reference their KM practice when describing every aspect of their organizations. KM practices are deeply embedded throughout these organizations, touching every aspect from culture to process improvement to information technology. They are fundamental to management success.

Second, KM is planned and precise. Recipients clearly work on dual concepts: (1) How should this task be done? and (2) How should we deliver the knowledge necessary to do the job? The answers to the first question are protocols or work processes. These are captured, studied, and improved. In high-performing organizations, "How we do it here" is not a tradition, shared through word of mouth, or left to the individual worker to determine. Rather, it is a specified, uniform process, easily retrievable and shared by all who contribute to it. Many of these processes involve several groups--suppliers, doers, followers, and so on. Standardization puts them all on the same page. It reduces errors, delays, and rework that generate excess cost. Eliminating them is a major factor in the recipients' documented financial success (Griffith, 2009).

Delivering knowledge is also a planned activity. Careful programs for KM development, emphasizing the multiple factors driving success (Smaltz et al., 2005; Kamal et al., 2008), have been recognized as essential. Training programs are extensive in recipient organizations, as they put both process-specific and patient-specific information at the fingertips of their caregiving teams. At the patient's side, team members know the patient's needs and the processes to use in fulfilling those needs. They have the supplies they need and the instruments required to check, complete, and record the treatment. This utility is where electronic health records (EHRs) will pay off for organizations, as it will allow them to overcome the difficulties encountered in early EHR applications (Committee on Patient Safety and Health Information Technology, 2011).

Third, KM drives process improvement. The Plan-Do-Check-Act (PDCA) model is used repeatedly by these high-performing HCOs to analyze and improve work processes. To execute PDCA cycles requires teams that are supported with measures, statistical analyses, benchmarks, best practices, and often trials. The process improvement systems create extensive KM requirements for internal and external knowledge. The systems are expensive because workers are pulled off their jobs, so team efficiency is required to ensure that participants find the right knowledge in a timely manner.

Fourth, KM explicitly and carefully reinforces the organizational culture. Recipient organizations emphasize a culture of empowerment, encouraging all workers to contribute to mission achievement (White & Griffith, 2010). Every worker's question must receive a constructive answer. Baldrige recipient organizations communicate and re-communicate their mission; adopt explicit policies for handling a wide variety of worker input; and develop sophisticated, information-based systems to achieve both financial and psychological rewards. These extensive KM systems coordinate responses, track performance, support coaches, and train supervisors.

KM is itself subject to continuous improvement. M1 KM activities are assessed in terms of cost, effectiveness, accuracy, and users' satisfaction. Benchmarks are established and OFIs are identified and pursued. The expectation is that next year's KM performance will be better than this year's.

Finally, the most striking components of Baldrige recipient hospitals' KM are its precision, uniformity, and extensiveness in application. We found that Baldrige recipients directly or indirectly reference KM practice when describing every aspect of their organization, much beyond the scope of Application Section 4.2, "Information and Knowledge Management" (Baldrige Performance Excellence, 2009-2010). The section covers several important topics: ensuring accuracy, confidentiality, timeliness, security and safety, emergency backups, and KM planning. Our analysis shows that many recipients have mastered these concerns and moved beyond them.

CONCLUSION

Taking a positive deviance perspective, we conclude that Baldrige Award-recipient HCOs have developed sophisticated, comprehensive KM processes to align both the organization's culture and the specific procedures it manages throughout their organization. We believe this study offers strong evidence that KM is deeply and universally woven into the recipients' operations and is critical to their documented excellence. KM in these organizations is a deliberate effort to keep all relevant knowledge at the fingertips of every worker, as demonstrated through frequent communication, careful maintenance of content accuracy, and redundant distribution. We conclude that the extent and rigor of recipients' KM distinguish them from other U.S. hospitals.

Our conclusions are subject to two limitations. First, we cannot rule out the existence of "something better." An HCO may be able to document superior performance using different approaches than those described in the Baldrige application. Second, we cannot argue that replicating these practices will always produce comparable results. There is an "omitted variable" problem: Despite the rigor of the Baldrige Criteria, application, and site visit, these organizations may have some hidden advantage that allows them to excel. Because of this uncertainty, we cannot guarantee that simply emulating recipients' processes will yield recipients' results.

For more information about the concepts in this article, contact Mr. Griffith at jrg@umich.edu.

REFERENCES

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American Hospital Association (AHA). (2010). 2009 Annual Survey of Hospitals. Chicago, IL: AHA.

Baldrige Performance Excellence Program. (2002-2008). Award recipients' contacts and profiles. Accessed November 11, 2011. http://www.baldrige.nist.gov/Contacts _Profiles.htm

Baldrige Performance Excellence Program. (2009-2010). Health care criteria for performance excellence. Accessed November 11, 2011. http://www.nist.gov/baldrige /publications/archive/2009_2010 _business_nonprofit_criteria.cfm

Baldrige Performance Excellence Program. (2012). Examiner Resource Center. Accessed March 5, 2013. www.nist.gov/ baldrige/examiners/resource_center/

Bohmer, R. M. J. (2009). Designing Care: Aligning the Nature and Management of Health Care. Boston,/vIA: Harvard Business Press.

Bradley, E. H., Curry, L. A., Ramanadhan, S., Rowe, L., Nembhard, I. M., & Krumholz, H. M. (2009). Research in action: Using positive deviance to improve quality of health care. Implement Science, 4(25).

Committee on Patient Safety and Health Information Technology, Institute of Medicine. (2011). Health IT and patient safety: Building safer systems for better care. Washington, DC: National Academies Press.

Cremer, I., Garciano, L., & Prat, A. (2007). Language and the theory of the firm. Quarterly Journal of Economics, 122(1), 373-407.

Griffith, l. R. (2009). Finding the frontier of hospital management. Journal of Healthcare Management, 54(1), 57-72.

Kamal, J., Silvey, S. A., Buskirk, J., Ostrander, M., Erdal, S., Dhaval, R., ..., Payne, P. R. (2008). Innovative applications of an enterprise-wide information warehouse. AMIA Annual Symposium Proceedings, 6, 1134.

QSR International. (2010). NVivo qualitative data analysis software. Doncaster, Australia.

Rousseau, D. M., & Barends, E. G. R. (2011). Becoming an evidence-based HR

practitioner. Human Resource Management Journal, 21 (3), 221-235.

Smaltz, D. H., Callander, R., Turner, M., Kennamer, G., Wurtz, H., Bowen, A., & Waldrum, M. R. (2005). Making sausage--effective management of enterprise-wide clinical IT projects. Journal of Healthcare Information Management, 19(2), 48-55.

White, K. R., & Griffith, J. R. (2010). The Well-Managed Healthcare Organization, 7th ed. Chicago, IL: Health Administration Press.

RELATED ARTICLE: Practitioner application.

Sherry Mazer, FACHE, corporate regulatory officer, Temple University Health System, Philadelphia, Pennsylvania

Applying for the Malcolm Baldrige National Quality Award helps frame an organization's approach to quality improvement and represents its commitment to providing high-quality care. The Baldrige journey involves a rigorously disciplined process, but one that can align the entire organization and move it to world-class status. The use of a knowledge management (KM) system is part of this framework and provides the tools necessary for healthcare organizations (HCOs) to achieve and sustain excellence.

The Baldrige Award focuses on results, which are monitored over time through a performance improvement process. KM is an important component in the performance improvement methodology chosen by the HCO, whether it is Plan-Do-Check-Act or another process. The review conducted by the authors demonstrates the appropriateness of this approach. As one would expect, knowledge creation was cited by the HCOs studied more frequently than were the other three elements--knowledge application, knowledge storage and retrieval, and knowledge transfer. Identifying the priorities, benchmarking them against the literature and the field, and making sure they are appropriate for the organization's needs should be the most time-consuming activity an organization undertakes during the Baldrige application process. In addition, a similar time commitment should be expected when operationalizing the results and communicating those results.

The regulatory and accreditation requirements in healthcare require organizations to have many of the structures in place dictated by the Baldrige Criteria. As the Baldrige website states, responding to the Criteria helps an HCO to marshal its resources; identify strengths and opportunities for improvement; improve communication, productivity, and effectiveness; and achieve strategic goals. It requires organizations to measure and improve many areas, both clinical and administrative. Those HCOs that have undertaken the Baldrige journey, whether they won the award or not, have built structures and processes that engaged all levels of and all stakeholders in the organization.

As noted by the authors, the transparency of information provided by Baldrige Award-recipient organizations was striking. The staff, physicians, and others understood what the organization wanted to achieve and their role in helping the organization be successful.

I served as a senior examiner for Quality New Jersey, the organization that oversaw the New Jersey Governor's Award for Performance Excellence using the Baldrige Criteria. I followed the progress of HCOs that won the gold award in New Jersey and went on to win the national Baldrige Award. The energy, enthusiasm, and engagement at every level were palpable in those organizations.

The Baldrige Criteria do not tell leaders how to implement the process. Instead, the criteria allow each organization the flexibility to choose their own tools and methods. HCOs that have taken the journey have improved the quality and safety of the patient care they deliver; increased the efficiency with which they provide care, treatment, and services; and improved patient satisfaction. The Criteria are worth reviewing for any organization, regardless of whether it plans to apply for the Baldrige Award. This framework helps organizations become successful with value-based purchasing efforts and other aspects of the Affordable Care Act and will enable them to prosper.

John R. Griffith, LFACHE, Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor; Kathleen M. Fear, School of Information Science, University of Michigan; Eric Lammers, PhD, Mathematica, Inc., Princeton, New Jersey; Jane Banaszak-Holl, PhD, Department of Health Management and Policy, School of Public Health, University of Michigan; Christy Harris Lemak, PhD, FACHE, Department of Health Management and Policy, School of Public Health, University of Michigan; and Kai Zheng, Department of Health Management and Policy, School of Public Health and School of Information Science, University of Michigan

TABLE 1
Characteristics of Healthcare Baldrige Award Recipients, 2002-2008

                                                    2009
                                     No. of     Expenditures
Name,                                 Acute         (in
Award Year           Location       Hospitals    millions)

SSM Health           St. Louis,        17         $2,277 *
Care                 MO; OK;
(SSMHC),             WI
2002

Baptist              Pensacola,         2           $314
Hospital Inc.,       FL
2003

St. Luke's           Kansas City,       8           $887
Hospital of          MO, metro
Kansas City,         area
2003

Robert Wood          Mercer             1         $1,088
Johnson              County, NJ
University
Hospital Hamilton,
2004

Bronson              Kalamazoo,         1           $507
Methodist            MI
Hospital, 2005

North Mississippi    24 counties        1           $567
Medical              in
Center, 2006         Mississippi

Mercy Health         Janesville,        3           $350
System, 2007         WI

Sharp Health-        San Diego,         4         $1,419 *
Care, 2007           CA

Poudre Valley        Ft. Collins,       2           $494
Health System,       CO
2008

                         Market
                      Description;
Name,                   Reported
Award Year            Market Share         Scope of Services

SSM Health           "Very            "Hospitals, nursing
Care                 competitive in   homes, physician
(SSMHC),             SSMHC's          practices, clinics,
2002                 major            managed care organizations
                     markets"; 19%    (where existing), and
                                      other business units";
                                      home care

Baptist              Primary          Acute care, ambulatory
Hospital Inc.,       competitors:     care, home health
2003                 Sacred Heart
                     and HCA West
                     Florida; 40%

St. Luke's           "Two major       "8 hospitals, 14 primary
Hospital of          systems have     care facilities, 5
Kansas City,         evolved in the   behavioral health clinics, 7
2003                 ... area: [St.   employee assistance
                     Luke's Health    program locations, 3
                     System] and      wellness/fitness locations,
                     HCA"; 26%        5 home health/hospice
                                      locations, and 4 affiliated
                                      health care facilities"

Robert Wood          "Four acute      Tertiary acute care
Johnson              care hospi-
University           tals within a
Hospital Hamilton,   fifteen mile
2004                 radius"; share
                     is not given

Bronson              Nine counties    "[An acute hospital], an
Methodist            in southwest     inpatient rehabilitation
Hospital, 2005       M1, five major   hospital, 20 physician
                     competitors;     practices, a healthcare
                     51%              staffing service, lifestyle
                                      improvement and
                                      research center, athletic
                                      club, outpatient radiology
                                      center, health plan"

North Mississippi    "The nearest     "A continuum of high
Medical              hospitals of     quality and safe health
Center, 2006         comparable       care services.... home/
                     size, and ...    hospice or long-term
                     services, are    care."
                     at least 100
                     miles away";     Cost per adjusted
                     76%              discharge was lower than
                                      100 top 25th percentile
                                      and lower than all of its
                                      identified "comparable
                                      hospitals"

Mercy Health         "Largest of      A 240-bed hospital, two
System, 2007         6 hospitals      critical access hospitals,
                     within 30        38 clinics, long-term
                     miles"; 30%      care, hospice, home care,
                                      health insurance (pp. i,
                                      iv)

Sharp Health-        San Diego        "Four acute-care hospitals,
Care, 2007           County,          three specialty
                     population       hospitals, three affiliated
                     450,000; 27%     medical groups, a health
                                      plan, four long-term care
                                      facilities, a liability
                                      insurance company, and two
                                      philanthropic foundations"

                                      Primary and specialty
                                      outpatient care, mental
                                      health, home, hospice,
                                      rehabilitation, and long
                                      term care

Poudre Valley        500,000          Acute care
Health System,       people in CO,
2008                 WY, NE; 62%

* Expenditures are for the system to which the recipient hospital
belongs.

Source: Applications of healthcare Baldrige Award recipients; AHA
(2010).

TABLE 2
Knowledge Management References in Healthcare Baldrige Applications,
2002-2008

                                     Number of     Number of
Knowledge Management Element        Applications   References

All knowledge management                 9           2,140
Knowledge creation                       9             907
External knowledge                       9              95
  Organizational internalization         9              95
Externalization                          9             392
  Combination                            7              34
  Formal structures and processes        9             160
  Organizational development             9             173
  Socialization                          4               7
  Other                                  3              18
Incentives                               7              22
  Knowledge retention                    7              25
  Sources and tools                      9             373
    Benchmarking systems                 9              60
    Data from competitors                8              34
    Management rounding                  4               9
    Market research                      9              37
    Surveys                              9              97
    Tracking systems                     8              71
    Other                                3              65
Knowledge application                    9             549
Forms of applications                    9             197
  Action plans                           9              71
  Other                                  2               3
  lob descriptions                       8              16
  Mission statements                     6              27
  Performance projections                7              40
  Strategic plan                         8              40
Types of applications                    9             347
  Cultural                               9              67
  Directives                             9              99
    Externally imposed                   8              22
    Internally created                   9              77
  Self-contained task teams              9              69
  Other                                  1              13
Not classified                           1               5
Knowledge storage and retrieval          9             141
Forms                                    8              41
  Formal                                 8              33
  Individual                             5               8
  Transient                             n/a              0
Information tools                        9              99
  Knowledge repository/databases         9              69
  Training materials                     8              23
  Other                                  2               7
Not classified                           1               1
Knowledge transfer                       9             543
Interactive                              9             137
  Lectures                               4              10
  Luncheon meetings                      5              13
  Rounding                               6              10
  Training sessions                      9              70
  Workshops                              4              17
  Other                                  4              17
Passive                                  9             117
  Newsletters                            6              15
  Posters                                8              28
  Reporting                              7              71
  Other                                  3               3
Other                                    3              22
Personal versus impersonal               9              93
  Impersonal                             9              47
  Person-to-person                       9              45
  Other                                  1               1
Planned versus unplanned                 9              97
  Planned                                9              88
  Unplanned                              5               8
  Not classified                         1               1
Potential occasions for transfer         5              34
Communication and interactions           5              25
  Other                                  3               9
Who to transfer to                       7              24
  Suppliers and external partners        7              20
  Other                                  1               4
Knowledge transfer not classified        5              19

TABLE 3
Knowledge Management Activities Noted in All 9 Baldrige Healthcare
Applications, 2002-2008

                                                            References
                                                 Total          per
KM Element             Description             References   Application

Creation      Efforts by the organization to       95          10.56
              draw insights from external
              sources of knowledge

Creation      The conversion of individual        160          17.78
              or group tacit knowledge into
              explicit knowledge via
              established processes for
              process design, evaluation,
              and improvement

Creation      The conversion of individual        173          19.22
              or group tacit knowledge into
              explicit knowledge by an
              organization's own efforts;
              may be "one-off" or informal
              processes (e.g., a one-time
              survey)

Creation      Tools or information sources         60           6.67
              allowing the hospital to
              compare its performance on
              various metrics with others'
              performance

Creation      Tools or information sources         37           4.11
              allowing the hospital to
              develop knowledge of its local
              market and competitors

Creation      Surveys used to create               97          10.78
              knowledge for various
              purposes; can include internal
              surveys (e.g., of physicians)
              or external surveys (e.g., of
              customers)

Application   Action plans as systematic           71           7.89
              responses to short-term
              strategic or improvement goals

Application   Efforts by the organization to       67           7.44
              define and support a specific
              organizational culture

Application   Specific set of rules,               77           8.56
              standards, procedures, and
              instructions developed through
              the conversion of specialists'
              tacit knowledge to explicit
              and integrated knowledge for
              efficient communication to
              nonspecialists

Application   Teams of individuals with            69           7.67
              prerequisite knowledge and
              specialty formed for problem
              solving

Storage and   Use of a specific information        69           7.67
retrieval     system (e.g., knowledge base,
              intranet) to store
              externalized knowledge

Transfer      Transfer of knowledge via            70           7.78
              direct, formal training
              sessions specifically focusing
              on management training

Transfer      Transfer of knowledge via            47           5.22
              methods that do not involve
              person-to-person interaction
              (e.g., booklets, training
              manuals)

Transfer      Transfer of knowledge via            45           5.00
              methods that involve person-
              to-person interaction (e.g.,
              meetings, presentations); can
              also be informal meetings

Transfer      Transfer of knowledge via            88           9.78
              methods that involve
              scheduled, designated time and
              activities; contrast to
              unplanned or spontaneous
              knowledge transfer

Sum (%) references                               1,225           57%

Median and mean references/application            7.78          9.08
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Article Details
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Author:Griffith, John R.; Fear, Kathleen M.; Lammers, Eric; Banaszak-Holl, Jane
Publication:Journal of Healthcare Management
Geographic Code:1USA
Date:May 1, 2013
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