Collaborative Learning Processes

Concept of work and how applied

Knight and Pye (2005):
Operational network learning involves both behavioral and cognitive learning:
1. Developing meaning: shared values, identity, and frameworks between firms
2. Developing commitment: the network-level implications of changes must be
considered, for example effects on patient community or region
3. Developing method: putting into place necessary technologies, structures,
relations, routines, resources, etc. (innovating and reorganizing)
These three, especially developing commitment and method have network-level
consequences but are not network level processes
Learning itself must become a normal process, with network members willing
and committed to learning
Learning is not necessarily associated with performance improvement, however
changes will still make firms feel as though progress was made


Knight (2002):
There are three views regarding organizational learning:
o Individual-Centered View: Learning takes place inside individual human
heads, however human learning is influenced by the organization (Simon
1991)
o Group-Centered View: focus is on the top management team (dominant
coalition
These two views depend on BOTH cognitive and behavioral
learning
o Organization-Centered View: learning outcomes are changes in properties
of organizations such as systems, structures, procedures, and culture
resulting in changing patterns of action
Cognitive and behavioral learning is sustained despite personnel
changes

Payton (2002):
Implementation must consider:
1. push/pull factors: government, competition, economy
2. behavior factors: support from stakeholders, political factors, autonomy
3. shared systems topologies: information sharing/quality

Provans et al (2007): This study looked at the effectiveness of four mental health
network sites: Providence, RI, Tuscon, AZ, Albequerque, NM, and Akron, OH.
1. Providence:
Highly stable, resulting in little uncertainty
Core agency had a historical and direct relationship with the state
Integration occurred through this core agency
High quality care due to a high level of state funding
2. Tuscon:
Least effective system, undergoing substantial changes at the time of the study
Community health system was new
Newly formed core agency was responsible for case management, but did not
provide mental health services on its own
Money went from the state to the local funding entity (a private not-for-profit)
and then to mental health institutions
This system operated largely on the goodwill and professionalism of those who
operated individual agencies
These individual leaders were good friends and were willing to work with each
other
Additionally, a local advocacy group (Alliance for the Mentally Ill- AMI) was
highly visible with several powerful board members, and was thus able to
organize local provider agencies and client families into an effective lobbying
force
Decentralized integration was necessary to maintain minimal levels of acceptable
services, as the Tuscon system was underfunded and lacked central guidance
3. Albequerque:
despite weak funding, surprisingly effective
Great levels of integration through centralization (between Providence and
Tuscon), however decentralized links between providers
Effectiveness was also intermediate
Four different agencies performed case-management
o One core agency served 90% of the systems adult population, however
the other three agencies developed their own subnetworks of linkage
partners
o This core agency was also unresponsive to the community
State funding was direct to agencies, but also fragmented into three funding
sources
The system was well understood by clients, families, and professionals
Professionals knew how to work around the system and the core agency
4. Akron:
structurally similar to Providence with service linkages centralized through a core
agency
Munificent resource environment
Highly ineffective according to family assessments
The community mental health system was new (like in Tuscon)
An Alcohol, Drug Abuse, and Mental Health Board (ADM) acted as the
middle-man between the state and institutions in regard to funding
o The ADM was public
o Its president was an eccentric, who stopped all government funding to two
of the three mental health centers present
The system is confusing and hard to navigate due to recent changes
Despite adequate funding, changes made it difficult for clients to find services
they needed


Havens et al (2006):
A service-research partnership between 6 community hospitals was implemented using
appreciative inquiry (AI). AI asks organizational members to find whats working, and
how to do more of what is working as a foundation for change. AI focuses on the positive
rather than fixing the negative.
SOAR (strengths, opportunities, aspirations, results) vs. the more negative
SWOT (strengths, weaknesses, opportunities, threats) model
The AI approach to strategic planning starts by focusing on the strengths
of an organization and its stakeholders values

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

Goals and outcomes to be achieved
Knight (2002):
Strategic institutional alliances require:
o Each firm receiving individual benefit, regardless of joint learning
o The behavior of the institutional alliance must be reformed
o Shared cognitive structures (e.g. norms and interpretations)
o Collective or coordinated practices across the network

Kilo (1999):
Motivations for collaborative improvement models include:
1. Reducing the gap between current knowledge and the actual provision of care
2. Reducing the broad variation in the provision of care for comparable patient
populations
3. Disseminating and describing examples of improved practices between
organizations; not only what should or should not be done, but also how to do
or not do those things
4. Creating the possibility of professionals with diverse yet synergistic skills to
work together; doctors often have a poor understanding of other professions
and therefore undervalue the contribution of nurses ,P.A.s, and others.
5. Removing practitioners from their profession-based silos, changing a
practitioners focal plane to the overall system
The benefits of collaboration include:
1. Total knowledge and understanding greater than when work is done separately
2. Increased probability of successfully discovering solutions to problems
3. Solutions focus on systems of care, not individuals
4. Integrative solutions
5. Increased acceptance of solutions due to participation in problem-solving
6. Meaningful relationships built, serving as the key to future improvement

Havens et al (2006):
The objectives of the AI partnership were:
1. to improve communication and collaboration among nurses and other healthcare
professionals
2. to enhance staff nurse involvement in organizational and clinical decision making
3. to enhance cultural awareness and sensitivity toward patients, families, other staff
disciplines, and departments


Examples of processes that have been successful
Knight (2002):
Examples of organizational learning within other industries:
1. Industry Recipes (Spender 1989)
a. Management adopts perspectives widely shared within their industry,
conforming general prescriptions to their firms needs
b. Common organization-level practices exist, but are not coordinated
between firms
2. Emergency Services Networks
a. Interorganizational changes are accompanied by intraorganizational
changes (e.g. new training policies and practices, new equipment) due to
inquiries regarding efficacy of a particular industry or service
b. Collaboration within the network already exists, but not true integration
3. Managing product tampering crises (Nathan and Mitroff 1991)
a. Within a fragmented network, during a crisis organizations must subscribe
to a single negotiated order if they are to respond appropriately
b. No clear, shared network identity exists
4. Toyotas knowledge-sharing network (Dye and Nobeoka 2000)
a. Key suppliers adopt the Toyota production system to improve their
processes
b. Individual firms improve processes through learning from other firms
c. Shared cognitive structures and coordinated practices develop

Berwick (2003):
Seven recommendations to leaders regarding how to accelerate the rate of diffusion of
innovations:
1. Find sound innovations
2. Find and support innovators
3. Invest in early adopters
4. Make early adopter activity observable
5. Trust and enable reinvention
6. Create slack for change
7. Lead by example

Payton (2002):
Health Network implementation success depends on:
Systems planning: determines direction and scope, while identifying solutions
Organizational readiness: requires efficient internal organizational processes in
order to manage IOS technology
Needs assessment: fundamental in gaining endorsement

Pollard et al (2004):
Explored students attitudes to recently implemented modules which required
collaborative learning and working between adult nursing, childrens nursing, learning
disabilities nursing, mental health nursing, midwifery, social work, occupational therapy,
physiotherapy, diagnostic imaging, and radiotherapy students
Found that students were inclined towards interprofessional learning, but against
interprofessional interaction
o The latter effect was especially seen in mature students with work
experience

Provan et al (2007):
Network effectiveness could be explained by: network integration, external control,
system stability, and environmental resource munificence. A high amount of any of
these aspects leads to success with integration.
1. network integration: there must be centralized links between providers; each
individual within a network cannot be an island
2. external control: a centralized core agency is helpful to coordinate integration of
services between hospitals
a. this makes the system easy to navigate, and doesnt require that users be
familiar with loopholes and workarounds
3. system stability: changing funding, government regulations, and leadership can
hinder the effectiveness of a health network
4. munificence: more money and resources, more effective; every member of the
network must see benefits from membership
Overall findings:
A positive tie between network integration and coordination is most likely when
integration and coordination occur from the top down, but not when agencies take
it upon themselves to integrate their services
A centralized entity must be present to help coordinate integration

Havens et al (2006):
The six participating hospitals saw increased nurse retention and improved quality of care
due to the use of AI. The effectiveness of AI has yet to be tested in other studies.
AI is a strategy for unleashing and sustaining positive organizational
change

Kraatz (1998):
Colleges that were members of smaller, older, and more homogeneous
intercollegiate consortia were more likely to undertake fundamental
curriculum changes
Colleges tended to imitate similar consortium partners that were
performing well rather than larger, more prestigious partners
Colleges tended to adopt programs that had previously been adopted by
other members of the consortium (imitation was more common than
innovation)

Lessons learned
Leathard (2003):
Barriers in joint working and planning across health and social services (Hardy et al,
1992):
o Structural issues: service fragmentation and gaps in services
o Procedural matters: different budgetary and planning cycles and
procedures hindering joint planning
o Financial factors: different funding mechanisms and flows of financial
resources, administrative and communication costs
o Status and legitimacy: elected agencies vs. private agencies
o Professional issues: competitive ideologies and values, professional self-
interest, competition for domains, conflicting views about patients, and
differences between specialties, expertise, and skills
Additional interprofessional pitfalls include:
o Different values and languages between professional groups
o Separate training backgrounds
o Time-consuming consultation and training
o Conflicting professional and organizational boundaries nad loyalties
o Isolated practitioners with little management support
o Inequalities in status and pay
o Differing leadership styles
o Lack of clarity about roles
o Latent prejudices
Often, when significant moves are made toward interprofessional groupings,
everyone pulls back into specialty-specific in-groups
o Doctors are seen as professionals, with nurses and social workers
regarded as semi-professionals
o Organizational mergers can create a power base difference wherein
weaker agencies/professions do not have adequate power to defend
professional interests
Other issues include confidentiality (how much about patients should extend
between organizations), professional loyalty, and accountability.

Knight (2002): Particularly in the area of community-based health and social services
effectiveness must be assessed at the network level, since client well-being depends on
the integrated and coordinated actions of many different agencies (Provan and Milward,
1995)
Unlike within the individual firms, the lack of overarching authority structures
means that learning processes cannot be traced and tracked

Kilo (1999):
This is a review of the Breakthrough Series (BTS), developed by the Institute for
Healthcare Improvement in 1995
Cooperative and collaborative behaviors are often lacking within healthcare
networks
Information is not shared
Help is not requested
Communication skills are poor
Anger is not uncommon
Physicians often act independently, and are trained to be fully independent in
thought and action.
Heated competition and productivity pressures, as well as lack of time and few
opportunities to meet exacerbate the lack of collaborative opportunity in health
care.
Link to a PowerPoint regarding IHIs Breakthrough Series:
http://www.google.com/url?sa=t&source=web&cd=5&ved=0CDEQFjAE&url=http%3A
%2F%2Fwww.nnphi.org%2FCMSuploads%2FThe-Olympic-Team-Trials-
18129.ppt&ei=lvJJTN2dNY38nQfHmflX&usg=AFQjCNH1bod7s0u1HxED3T-
VESbbU0eRJA

Payton (2002):
Across case findings:
Government policies slow implementation
Hospitals need to see cost/benefit analysis before this will be implemented
Local hospital associations support was not important
Physicians played the most significant role in the implementation process (also
important are vendors and end-users such as nurses and administrators)
Patient support was found to be unimportant to these systems, as they figured
patients did not understand health care delivery
Information quality and sharing require process improvement and reengineering
at the intraorganizational level
Vendor turf wars generated technological issues during network
implementations (political issues)
o Analogy: unlike banks, hospitals cannot easily share data due to multiple
platform technologies that cannot communicate
Health networks must create PERCEIVED value and benefits:
Political issues and behavioral constraints must be overcome for implementation
success
Health care reform will most likely hinder network implementation
Careful planning is essential to the success of netowrks
Identifying and engaging key players is vital as US health organizations migrate
toward Web-based mechanisms for care delivery
Individual organizations should assess their processes to ensure mechanisms are
in place to support network
The REAL customer is not the patient, but rather the physician
Competition between participating hospitals will be problematic if who is paying
is not established early
Failure to have top management teams of hospitals supporting intraorganizational
project managers = failure of network
o Management from different institutions must be willing to reach a
consensus

Pollard et al (2004):
Findings:
Educational level and perceptions of disparity in academic ability influences
interprofessional education
o Nurses linked differences in entry qualifications with inequality between
professions, with nurses and radiography students retaining a low opinion
of other students academic abilities, and skepticism that learning with
other disciples enhanced their own learning
Learning together before qualification may influence professional socialization
(biases do not have a chance to become ingrained)
Occupational therapy and social work held negative views of interprofessional
interaction upon entry to their professional program
o Social workers saw themselves as having broader life experiences
o Occupational therapists rated themselves as superior in practical skills

Kraatz (1998):
1. Strong ties to other organizations can mitigate uncertainty and promote adaptation
by increasing communication and information sharing
2. Networks can promote social learning of adaptive responses, rather than other,
less productive forms of interorganizational imitation

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

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

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

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

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

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

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

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

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

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