Putting the focus back on knowledge

Knowledge may be the primary currency of health systems, but its value has been neglected by policymakers and management, says health management consultant Dr Gray Southon.

That neglect, he says, is compromising health-sector performance. Not that he can promise an easy fix.

For starters, it would mean breaking away from a fixation on things that can be measured, to delve into the much less tangible realm of knowledge dynamics.

That involves analysis of how the chunks of professional, individual or community knowledge floating about the health sector are structured, used, communicated externally and shared internally.

Understanding that, says Southon, "would produce a health system that helps clinicians to be better supported and helps managers to provide the necessary support".

New Zealand-born Southon, who teaches at the Sydney University of Technology, was speaking at a Waikato Management School seminar on ways to deal with some of the organisational discord generated by health-sector reform.

Your average large hospital is now far too complex for traditional forms of management, he says.

"People cope with complexity by narrowing it down. Management cannot possibly understand the diversity of clinical activities - so they function with a grossly simplified view."

That can lead to one-size-fits-all solutions that may ease problems in one area, only to create them in another.

The system is also stuck in what management guru Peter Drucker has described as a "production framework" rather than a "knowledge framework", says Southon.

In other words, the focus is on what people do - how many widgets are produced, or hip replacements done - rather than what they know.

"Current policy and management philosophies focus on finance and process, largely neglecting the dynamics of knowledge," says Southon.

Meanwhile, the people who claim to have an overview are principally economists and politicians, who have little understanding of how the system works.

"Those who make the system work all have their own territories so there is incredible fragmentation," says Southon. "The challenge is to understand that fragmentation and get the system working for you."

A failure to recognise the complexity of health service organisations has, he says, "enabled a shift in power from clinicians to policymakers and managers, which will detract from our long-term ability to make the best decisions for use of health resources".

His recipe for improvement includes moving away from efficiency-focused hierarchical structures to knowledge-sharing networks.

"As long as the focus is on one institution or one health district, then it is too narrow to solve problems."

Cross-institutional initiatives have already been applied successfully in Australia, says Southon.

"There is one called the health roundtable in which institutions across Australia ... meet regularly and address specific issues - such as how to best run a cardiac suite.

"Expertise is pooled, and that suggests what further work needs to be done to improve things."

While that's a valuable process, it's too slow, says Southon, addressing just one issue every six months. He suggests encouraging informal communications to enable people to share ideas and experience and form "communities of practice".

Specialised service providers could hook into each other's knowledge bases through a system of "networked programme management".

"You look at the national picture and ask: how do you run cardiac services or mental health services throughout the country?"

Some of those links already exist through professional organisations, but it would make sense to strengthen and extend them. System-wide decision-making, says Southon, promotes common practice, increasing the ease of coordination and the ease of adapting to new technologies or practices.

"A hospital board is then dealing with a mental health service that knows what it is doing, that gets input from its network that has developed real national standards into which the community and Government has had input."

Wouldn't this approach risk having specialty providers stuck in their own silos, with no crossover to other disciplines?

"That is a problem and a challenge," says Southon, "but it is a coordination task. Management is then not accountable for basic services but it is accountable for getting them working together."

Not, he admits, a simple task.

Three of the primary knowledge realms - community and personal, clinical, management and policy - may overlap but have separate reference centres. Even within specialties, the knowledge base is wide.

"With cancer, for instance, you have different medical specialties - oncology, radiation therapy, surgery - all with different mindsets. With good leadership, you can get very integrated centres, but there are not many."

On top of that, when you look at the care of cancer patients, there are various community organisations, community nurses, general practitioners, the Cancer Society and so on.

"And that's just one health speciality," says Southon. "It's a highly complex system."

He suggests stronger links with professional colleges because they represent a key knowledge base. Suppliers such as pharmaceutical companies also have extensive knowledge of health practices and needs.

"The more they can be engaged as cooperative partners in providing the best possible service for the community," says Southon, "the more beneficial their influence will be.

But such engagement would involve "considerable transparency in the role of various parties".

Although the concept of knowledge management didn't rate a mention in management books a few years ago, there's increasing recognition that its role is central.

"It is something that needs to be handled as part of core corporate management - just as finance is. But it requires a different way of thinking about organisations."

* vjayne@iconz.co.nz