KNOWLEDGE MANAGEMENT OF HEALTHCARE

KNOWLEDGE MANAGEMENT OF HEALTHCARE BY CLINICAL-PATHWAYS
TOMOYOSHI YAMAZAKI
School of Knowledge Science, Japan Advanced Institute of Science and Technology,
Ishikawa Prefecture, Japan
E-mail: yamazaki-cp@jaist.ac.jp
KATSUHIRO UMEMOTO
School of Knowledge Science, Japan Advanced Institute of Science and Technology,
Ishikawa Prefecture, Japan
†E-mail: ume@jaist.ac.jp
Healthcare is a knowledge-intensive service provided by professionals, such as medical doctors, nurses, and pharmacists. Clinical pathways are used by many healthcare organizations (HCOs) as a tool for performing the healthcare process, sharing and utilizing knowledge from different professionals. In this paper, case studies were performed at two HCOs that use clinical pathways actively in the healthcare process. Theoretical model construction, sharing, utilization, and creation of the knowledge by different professionals, were tested by the case study of two HCOs which use clinical pathways actively. The theoretical model was a knowledge creation model which creates new knowledge continuously. In this theoretical model, clinical pathways are suggested to be an effective tool for knowledge management in healthcare.
1. Introduction
The current healthcare is asked to lower costs, and simultaneously is also required to improve the quality of continuous care. Furthermore, healthcare is a knowledge intensive service provided by professionals, such as medical doctors, nurses, and pharmacists. Therefore, in many HCOs, management based on knowledge management used in the industrial world is being carried out (Bose, 2003).
From the latter half of the 90s, clinical pathways began to be used as a tool for performing optimization of healthcare resources and enhancement of care quality by HCOs (Every, 2000). Now, clinical pathways are used as a tool for carrying out knowledge management in many HCOs. However, knowledge management used in many HCOs only shares and utilizes different professionals’ knowledge through information technology (IT). No concrete theoretical model of creation of new knowledge by health-care professionals using clinical pathways has been built. New knowledge needs to be created for continuous enhancement of quality of healthcare treatment, and a theoretical model for this is required. (Vanhaecht, 2006).
The aim of this research is filling in current gaps in this knowledge, through construction of a theoretical model of systematic knowledge creation in the healthcare process according to professionals' collaboration using clinical pathways.
2. Clinical pathways
Clinical pathway applies critical-path idea methods (used in process control in industry) to the healthcare process as a management tool, and was developed in the United States in 1985 (Zander, 1988). Clinical pathways have been designed as an approach to improve the quality of healthcare.
Such clinical pathways are structured instruments which lead to optimal interdisciplinary patient care. Practice of clinical pathways involves all healthcare professionals, physicians, nurse staff, physiotherapists, social workers, etc. Clinical pathways can offer everyday standard diagnosis and healthcare treatment. It can be thought of as a visualization of the patient healthcare process. The development and implementation of clinical pathways are multi-faceted and resource-intensive processes involving all concerned parties. Clinical pathways are used in healthcare in many countries (Campbell, 1998; Zander, 2002).
Sharing and integration of the knowledge of diverse professionals are important for implementation of a successful healthcare process using clinical pathways. Clinical pathways establish optimal resource utilization and improve communication among doctors, nurses, and other staff (Coffey, 2005). However, in the healthcare process using clinical pathways, it is difficult to respond to patients’ individuality (Kwan, 2003; Shi, 2008).
3. Knowledge management
Knowledge management is a business concept. The scope of knowledge management encompasses individual competence and organizational memory, knowledge creation from tacit to explicit knowledge, and includes the role of organizations in facilitating the creation of knowledge. New knowledge is created by the interaction of tacit knowledge and explicit knowledge. The interaction of different knowledge is performed "Ba." The setting of "Ba" is very important in knowledge management (Nonaka, 1995).
Another theory of knowledge-management is the "communities of practice." "Communities of practice" are phenomena said to: galvanize knowledge-sharing knowledge and change". They are defined as, "groups of people bound together by shared experience and passion for joint enterprise." This can be described as cross-functional terms-brought together to capture and spread ideas and know-how (Etienne, 2000). However, the disadvantageous of the "communities of practice" model is its informal nature.
4. Healthcare knowledge
Within modern healthcare discipline, emphasis was placed on formalized. Evidence based medicine (EBM) provide a tool for communicating the relative effectiveness of health interventions where quantitative data exists. Many regard the evidence-base as not really telling the whole story. Many Healthcare professionals can not manage their patients simply as biomedical models, and that there is often another dimension to disease and management of patient-care. The failure to recognize the limitations of EBM leads to tension being created when can not be implemented. Healthcare professionals often lack a language with which to communicate important knowledge for patient, by which there is no evidence base. The recognition of this limit is important for many healthcare professionals (Simon, 2002).
Clinical guidelines have been defined as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.” Clinical guidelines are created based on EBM (Schneider, 2006).
5. Knowledge management in healthcare
Knowledge management is used in many HCOs, because, healthcare is a knowledge intensive service provided by professionals. When healthcare organization (HCO) introduces knowledge management into their process management, it is important to take into consideration the culture inherent to each expertise (Russ, 2005).
In knowledge management, sharing and utilizing scientific evidence of explicit knowledge is required for implementation of evidence based medicine (EBM). However, there is no combination with a scientific basis about explicit knowledge acquired by clinical experience which each professional has accumulated, so, carrying out effective clinical practices is difficult. Therefore, knowledge management which can share and utilize, both explicit and tacit knowledge is required by HCO (Sandars, 2006).
In modern health care systems, healthcare providers face ever new challenges with regard to quality and cost of care, as well as to satisfaction and training of professionals. In order to solve these challenges, the introduction of knowledge management in healthcare process management is effective (Kitchiner, 1996).
The core of a team working in modern healthcare is changing from the doctor to the patient. Accordingly, within a team, knowledge management which can create the optimal healthcare process for the patient by various professionals will be required (Metaxiotis, 2006).
Knowledge management of HCO must provide (Wahle, 2008).
(i) Framing of the standardized healthcare process, and support of the optimized clinical practice.
(ii) Effective and efficient management of health-care professional employment.
(iii) Better quality care offered to the patient, and related provision of information.
6. Knowledge management by clinical pathways in healthcare
Clinical pathways are developed through collaborative efforts of doctors, nurses, pharmacists, and others to improve the quality and value of patient care. Clinical pathways are prepared using clinical guidelines’ based on EBM of the visualized knowledge. But, healthcare professionals' context knowledge is essential in using a clinical guideline. The production process of a clinical guideline is based on agreement formed by this discussion, so, the care team can provide optimal healthcare treatment. Clinical pathways are a tool for utilizing diverse knowledge (Mitton, 2007).
A typical healthcare process can be managed by clinical pathway. However, clinical pathway is not suitable in some complicated cases. (Cardoen, 2008).
7. Research approach
We carried out the case studies in two hospitals, Saiseikai Kumamoto Hospital and Fukui General Hospital, which use clinical pathways activity for healthcare process management.
Case studies were performed from May-06 to October-07. Methods of research included analysis of documents relevant to clinical pathways activity, and interviews with clinical pathways administrators. The purpose of the interviews was to obtain information about the intentions and interpretations of clinical pathways activity which was not obtained from document analysis. By analysis of the data obtained from our investigation, it is possible to observe the healthcare process using clinical pathways common to two hospitals. The extraction of the knowledge process from these clinical pathways is our main goal.
8. Research result
8.1 Case 1: The clinical pathway activity of Saiseikai Kumamoto Hospital
8.1.1 The background and the characteristics of Clinical pathway activity
In 1996, clinical pathways were introduced at this hospital. The main reason for introducing it was for patients to understand the outline of healthcare contents by clinical pathway. The introduced clinical pathway was a tool which promoted communication between healthcare professionals and patients. The administrators of this hospital considered the new use of clinical pathway. The chief hospital administrator understood that clinical pathway was an improvement tool of healthcare quality after participating in a clinical pathway seminar held in 1998 in Boston. Especially, the chief hospital administrator noted that clinical pathways were effective in the collaborative work in healthcare by professionals. As a result, clinical pathway activity rule of this hospital is that all the staff members participate.
8.1.2 Details of Clinical pathway activity
Clinical pathway activity is a healthcare process constituted of production, implementation, and improvement process.
(i) Production process;
Clinical pathways are produced in workshops (WS) in which all professionals related to a specific disease participate. In WS, the healthcare target "outcome" is set up as a milestone of the patients' condition. Accordingly, in the WS, discussions by diverse healthcare professionals to agree about the formation regarding "outcome." The expression of diverse ideas from many participants is important in clinical pathways production. In addition, guidelines and the medical records are referred to in clinical pathway production.
(ii) Implementation process;
Many clinical business routines using clinical pathways are assessed by healthcare professionals for "outcome." The objective assessment of "outcome" is important in the implementation process of clinical pathways. The condition of a patient whose "outcome" assessment is different from the usual case is called "variance." In using clinical pathways, response of "variance" by healthcare professionals adapts for a patient's individuality. It is important to necessarily write down the medical records of a patient's condition which cannot be assessed by "outcome." The intuition obtained by observation by professionals is also recorded.
(iii) Improvement process;
All the related professionals gathered as in the production process, and used statistical analysis of "variance" to improve the clinical pathways. Based on the analysis of "variance" the diverse healthcare professionals involved discussed the issues. The responses led to setup of new "outcome." Clinical pathways administrator said that the healthcare process using clinical pathways verifies healthcare contents. Setup of the subjective hypotheses by specialists was effective for the creation of new "outcome." Professionals' new knowledge is required for creation of new "outcome."
8.2 Case 2: The clinical pathway activity of Fukui General Hospital
8.2.1 The background and the characteristics of Clinical pathway activity
In 1999, the healthcare professionals of ophthalmology referred to clinical pathways of other hospitals, and produced their own. In 2000, the chief hospital administrator, who considered standardization of services for patients, determined to make clinical pathway activity into a tool of the healthcare process management at the hospital.
The concept of clinical pathway activity is a tool which makes possible the sharing of medical records among patients and healthcare professionals.
8.2.2 Detail of Clinical pathway activity
Clinical pathway activity is a healthcare process consisting of production, implementation, and improvement process. And so, a system which decreases the user load in all the processes was built.
(i) Production process;
Although the related professionals produced the clinical pathway using collaboration, it was carried out based on the clinical pathway production manual. The method of setting concrete "outcome" was written down in the manual. The agreement formation by discussion of diverse professionals was essential to setting the "outcome." Clinical pathways administrator said, "different professionals' diverse knowledge is visualized in setting "outcome" by free discussion, the environment for this is important." In addition, guidelines and medical records are referred to in clinical pathways production.
(ii) Implementation process;
Assessment of "outcome" was considered to be important in the implementation process. Furthermore, response and record when "variance" occurs in the condition of patients were also considered to be important. The healthcare professional needs observation of a patient's new condition which could not be assessed by "outcome." The professional necessarily writes down new patient information in medical records. And, the professional’s subjective judgment using patient's medical record is also important.
(iii) Improvement process;
"Variance" was totaled and statistical analysis conducted. The improvement of "outcome" was made from analysis of data using "variance" analysis table. However, the agreement formation by discussion of the related professionals was necessary for the improvement of "outcome." The clinical pathway administrator said, "By conducting factor analysis using "variance," the quality of the healthcare treatment offered to a patient can be improved." In addition, setting a new "outcome" of a patient's new condition which could not be assessed by "outcome" is important in this process. Setting a new "outcome" needs a lot of patient information which was written down the medical records. Therefore, patient information was collected in the process of implementation.
8.3 The healthcare process in common clinical pathways activity
The outline of the research result is shown in Table 1.
The clinical pathways activities of two hospitals consisted of processes of "production," "implementation," and "improvement." And each process was connected to the next continuously.
Table 1: Research result of Cases study

Case 1 Case 2
Production Process All the related professionals' participation were indispensable Although a setup of "outcome" was the purpose, the production manual existed.
The Purpose of this process is the setup of "outcome" The related professionals' participation were desired
The environmental setting which extracts diverse knowledge was important. Most important was expressing diverse ideas
The guidelines and medical records were referred for The guidelines and medical records were referred for
Implementation process Clinical business routine was the assessment of "outcome" Assessment of "outcome" based on a manual was clinical routine
The responses and records of "variance" were important The responses and records of "variance" were important
Subjective records were also important. The intuition of professional wrote down medical records
Improvement process Improvement of "outcome" based on "variance" Improvement of "outcome" based on "variance" analysis table produced by the total of "variance
This process should be essential to enhancement in quality This process should be essential to enhancement in quality

The common elements acquired from the contents of each process are as follows.
(i) Production process;
a) In this process, setup of "outcome" was important.
b) In setup of "outcome", participation was required of all related professionals.
c) The environment for discussion of professionals in setting the "outcome," for agreement formation is important.
d) The guidelines and medical records are referred to in production.
(ii) Implementation process;
a) The objective healthcare process (by assessment of "outcome") was recorded.
b) The response and record of "variance" showed the response of the patient individually to the health care process.
c) Record of the condition of patients could not reach desired "outcome" was also
considered as important.
d) Subjective judgment of professionals is also considered as important.
(iii) Improvement process;
a) "Outcome" was improved using statistical analysis of "variance" obtained in the
implementation process.
b) In the improvement process, participation was required of all related
professionals, as in the production process.
c) The quality of the healthcare treatment offered was upgraded by improvement of
"outcome."
d) Setting a new "outcome" by hypothesis based on observation of new patient's
condition is recommended.
9. Research findings
From the research result, a theoretical model which shows the knowledge process of clinical pathway activity using the concept of "outcome" and "variance" was built (Fig. 1). The theoretical model shows the interaction in the healthcare process of clinical pathways, tacit knowledge, and explicit knowledge. The tacit knowledge used in the healthcare process is context knowledge which each professional has, such as know-how and skill. The explicit knowledge used in the healthcare process is objective knowledge, such as the guidelines and the contents of medical records.
The characteristics of the theoretical model, including the interaction of tacit knowledge and explicit knowledge, include:
(i) Each healthcare process is shown "Ba" of Knowledge process which carries out the
interaction of different knowledge,
(ii) Each "Ba" are "Accept", "Integrate", and "Practice" and connected spirally,
(iii) "Accept" exists in the production process, and discussion is needed to set an
"outcome" by accepting the knowledge from different participant,
(iv) A contradiction model which can create new knowledge continuously was built
from case studies of two hospitals.
(v) "Integrate" exists in the processes of production and implementation, and through
participants’ discussion, integrates expertise into optimal whole knowledge,
and sets up "outcome.
(vi) "Practice" exists in the processes of implementation and improvement, and
practicing leads to optimal knowledge on the clinical side, and the professionals
acquire new knowledge.
(vii) Spiral risen "Accept" exists in the improvement process, the new knowledge
acquired by practice, and the result of "variance" analysis, setting a new "outcome"
by hypothesis is accepted, and the clinical pathway is improved.
In this model, if the process of improvement did not exist, dynamic knowledge creation difficult. Clinical pathway administrators also consider the process of improvement as very important.
10. Discussion
"Ba" of this theoretical model has the interaction of tacit knowledge and explicit knowledge. This differs a little from the "SECI" model (Umemoto, 2004). Using guidelines and medical records of explicit knowledge is essential for production of clinical pathway. Clinical pathway activity was no interaction between the tacit knowledge which exists in the "SECI" model, on these case studies. On healthcare process, explicit knowledge was suggested that it is an interface among the professionals from whom formal knowledge differs.
Sharing of different knowledge is important for continuous implementation of knowledge management. Accordingly, environmental structure of "Ba" which accepts different knowledge is knowledge management administrator's essential condition. The creation of new knowledge is possible because diverse knowledge is shared (Nomura, 2002). Clinical pathway administrators were doing their best to the environmental setting which diverse knowledge expresses for setup of "outcome." Environmental setting of "Ba" is suggested that it is required for knowledge management of clinical pathway activity.












11. Conclusion
The theoretical model which can create new knowledge continuously was built from case studies of two hospitals.
This study’s implications are as follows:

(i) Not only the healthcare work process, but, the knowledge processes are included in
clinical pathways.
(ii) "Ba" of this knowledge process consists of "Accept", "Integrate", and "Practice."
(iii) Each "Ba" is carrying out the interaction of different knowledge.
(iv) These “Ba” are organizational knowledge creation models connected spirally.
(v) However, if the process of improvement does not exist in clinical pathways, this
model does not function.
In future study, we will create a system to observe the process of Knowledge sharing. We plan to produce a system that supports clinical pathway activity.
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