Summary:

Background

Lancaster General Hospital is located in Lancaster City, Pennsylvania and provides tertiary care to its patients. In Lancaster General Hospital training and development, clinical education and performance improvement are not coordinated under one entity. Because of this, they have different approaches to solving a performance or education problem. This often leads to lack of organizational focus and efficient utilization of resources.

Focus

The case focuses on the Trauma Department of Lancaster General Hospital, specifically that involving the care of spinal cord injury (SCI) patients. In this department, two individuals, the director of Continuing Medical Education (CME) and the trauma case manager and educator assumed the roles of Chief Learning Officer since the hospital has no one assigned for this position.

Trauma Care

By nature, trauma care is multidisciplinary. Health-care providers from physicians, to nurses, to other support staff are involved through the whole process of caring for trauma patients. The process begins at the time the injury was incurred, throughout treatment until recovery and return to normal function of the patient. Because of the nature of trauma care, knowledge is abundant however there is a need to manage this in order to ensure that learning occurs not only on the individual level but also in all the different levels of the organization.  As emphasized by Berwick and Nolan (1998), knowledge is available in medicine, yet much of it fails to enter patient care to a daily basis. Ensuring the distribution of knowledge throughout the different levels would lead to providing their patients with the optimal care they deserve.

The SCI Task Force

A change in hospital improvement processes and the transition of trauma leadership, the Trauma Department identified several clinical areas of focus for improvement. Task forces were created to address the issues identified. The SCI task force was created to address the issues of involving the care provided to SCI patients. This is composed of the trauma medical director, an orthopedic surgeon, a neurosurgeon, an emergency department (ED) physician, a radiologist, and a nursing case manager. Initial action plans included the need for training of physicians and the nursing staff as well as a few specific processes and planning interventions.

The SCI task force received request for training and they conducted a review of issues related to previous training requests. The following conclusions were drawn from this review:

1. Fundamental process and system change were needed to improve performance.
2. Knowledge to achieve this improvement was not available within the organization.
3. Knowledge would need to be infused and utilized at the process level along with supporting structures to achieve improvement.

Identified Objectives of the SCI Task Force

1. Validate current data collection methodologies and variables.
2. Develop standards of care for sentinel care providers through the following tools:

a. protocols
b. standing orders
c. nursing and physician patient assessment guides
3. Incorporate evidence-based research and current literature into practice.
4. Develop guidelines for transfer of patients to regional SCI centers for advanced care.
5. Provide education for multidisciplinary trauma staff concerning changes in SCI management.
6. Develop a comprehensive and consistent educational system for patients and their families.
7. Feed relevant information back to key individuals in the process.

To promote knowledge infusion, relationships with external sources have to be built and sustained in order to ensure continuity in the improvement process. Communications were made with a regional SCI center, Thomas Jefferson University Hospital, whose expertise in trauma care the SCI of Lancaster General solicited. This hospital was identified because SCI believed that they have the knowledge needed to promote the initial boost in the process as well as the ability to sustain a long-term relationship to maintain the continual flow for knowledge management. On the other hand, Thomas Jefferson receives some of the advanced SCI patients from Lancaster General Hospital.

An SCI team from Thomas Jefferson went to Lancaster General Hospital for a site visit. The SCI team is made up of: an orthopedic surgeon, rehabilitation physician, nurse SCI research associate, and a nurse coordinator.

The two individuals who assumed the role of CLO, the SCI task force, and the Trauma Department administration undertook significant planning to design interventions that would help address the identified objectives.

Phases of the SCI Knowledge Infusion Process

1. Entry phase: this began with a visit of a Jefferson team to Lancaster General Hospital. The visit began with a lecture for the physicians to review related cases pertaining to SCI management. This was followed by a tour of the facility to give the team insights of the current practice and processes in Lancaster General Hospital. An invited multidisciplinary SCI team conducted a case review session of current and previous cases. This review helped orient the Jefferson team to key issues. Work groups made up of surgeons, rehabilitation and nurses were formed to assess current tools, review evidence-based methodology, begin work on the identified objectives, and establish a long-term knowledge and information links with the expertise from Jefferson. A lecture to the nursing and technologist staff concluded the visit.
2. Assessment phase: Various methods are used to assess the process and objectives and goals are determined. In this phase, the collaborative efforts of the Lancaster General and Jefferson Teams determined that an infusion of knowledge was needed to improve care of SCI patients.
3. Planning phase: interventions and systems were planned to have an impact on the SCI process.
4. Implementation phase: this involves implementation of the outputs of the planning phase.
5. Management phase: continual outcome is expected at this stage. During this phase, discovery of other opportunities may occur, triggering various parts of the cycle to augment the improvement process.

Results

1. Data analysis of the C-spine clearance management guidelines revealed 85% compliance in the 1st year and 92% compliance in the 2nd year.
2. The SCI Task Force continues to discuss revisions on the basis of its findings and literature reviews.
3. A spine call study demonstrated 80% overall compliance with utilization of the spine call physician.
4. Review of SCI patients treated has demonstrated improvement in documentation of care.
5. The standard of care was followed 100% of the time for identified SCI patients.
6. Many caregivers credit the standing order sheet as making the whole process easier.

Barriers to the Knowledge-Infusion Process

1. Many physicians, nurses, and other health-care professionals still want and feel comfortable with the traditional lecture when the term learning is mentioned or required.
2. When performance problems are encountered, the first request is usually for a lecture or training to change behavior.
3. Health care is heavily divided, with political lines existing among departments, specialties, organizations, and institutions.
4. Typically in multidisciplinary care such as trauma, various physician specialists may have differing opinions on the optimal methods for treating certain injuries. This disagreement may stem from such varied sources as financial, professional organization, ego, training, and local turf battles. Management of this disagreement can play a large factor in accomplishing improvement and opening up the flow of knowledge and information in the process.
5. Division in health care builds inefficiencies, impediments to process learning, and compartmentalization of care for patients.
6. There is lack of experience with performance improvement, workplace learning, and knowledge management. Health-care professionals are not trained in these fields and often do not understand the requirements for these activities. Emphasis is placed on technical competence in the profession, not on performance improvement, management, learning, or other process support tools.
7. Financial resources are most often designated for technological improvements, not process or learning improvements.
8. Increasing pressures to control costs in the health-care environment often result in human resource downsizing, leaving clinical professionals with no assistance for process improvement and development.
9. There are significant amounts of organizational and accreditation structure that exist within the health-care environment. Processes, procedures and decisions are subject to many committee reviews, approvals, and signatures, all of which slows or limits improvement and learning as well as creates a pyramid organizational structure.

1. Working with individuals or departments outside of a learning, education or training department requires a knowledge champion. This individual must understand basic values to process or performance improvement, systems overview and essentials of learning.
2. Narrowly focused projects allow for initial success, prevent broken promises, keep consultant and client goal oriented, and permit trial and error.
3. Working with departments, individuals, and processes that are friendly to process learning or performance improvement assists in early improvement and learning process.
4. Identification of limitations and realistic goals helps clients gain confidence in the improvement and learning process.
5. Learning at the process level does not necessarily guarantee performance or process improvement. Management and implementation of that knowledge are required to apply the learning to the process for realized performance results.
6. Each performance or learning situation may require different approaches. Adaptability, creativity, questioning, and research are important to assess approaches early in the process. What may work in one organization may not work in another, even though the situation may be similar.
7. Knowledge required may be found in unlikely places at reasonable costs.
8. Process outcomes, alone and compared with benchmarks, are a good measure of the level of knowledge that exists within that process.

1. The site visits conducted resulted in the building of lasting relationships among the experts who provide one another with knowledge. Sharing of process, common issues and problems, examination of data, and research of better methods occur through this exchange. What occurred in this relationship is implicit, or informal, knowledge sharing.
2. A process has been established for infusion of knowledge into various processes within the Trauma Department. The focus is on process needs, desired outcomes, and the methodology to import knowledge into the process.
3. Collaboration of care with providers within Lancaster General Hospital has increased to ensure each SCI patient receives the optimal care. Clemmer, Spuhler, Berwick and Nolan (1998) recommend five principles for fostering cooperation in a health-care setting:

a. Develop a shared purpose.
b. Create an open, safe environment.
c. Include all those who share a common purpose and encourage diverse viewpoints.
d. Learn how to negotiate agreement.
e. Insist on fairness and equity in applying the rules.
4. Through the knowledge management process, these principles helped foster internal collaboration between the various specialties of health-care professionals.
5. Through the infusion process, other needs were identified. During many of the intervention phases, discoveries were made that were not apparent during initial needs assessment or planning stages. Flexibility was required to alter the direction, table the issue for a later project, or immediately address the issue.

Dede Bonner. “The Knowledge Management Challenge: New Roles and Responsibilities for Chief Knowledge Officers and Chief Learning Officers.” Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 3-19.

Adam Gersting, Bill Ives and Cindy Gordon.  “A Human Performance Approach to Knowledge Management: Andersen Consulting”. in: Jack J. Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 23-38.

Nick Milton.  “Managing Knowledge in an Oil Exploration Office”. in: Jack J. Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 39-53.

Verna J. Willis and Gary L. May. “Strategy and the Chief Learning Officer”. in: Jack J. Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 55-70.

Michael H. Mitchell and Nick Bontis. “Aligning Human Capital with Business Strategy”. in: Jack J. Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 73-86.

Case Study in Online Knowledge Exchange Community: Entovation International Ltd. (Debra M. Amidon. “Leading through Strategic Conversations”. in: Jack J. Phillips and Dede Bonner, editors. In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 101-114.

Gary Jusela and Nick Nissley. “Action Learning and Organizational Design”. in: Jack J. Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 133-145.

Lynne Hambleton.  “Supporting a Metamorphosis through Communities of Practice”. in: Jack J. Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 147-156.

Michael Horst adn Theresa Snavely. “Assuming the Role of CLO in a Hospital Setting”. In: Jack J. Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 189-203.

Ruth Ash and Maurice Persall: The School Principal as Chief Learning Officer: Seven Exemplary Schools” in: Jack J. Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 205- 220.

Robin Lackey and Richard Brehler: “Dismantling and Rebuilding Learning Processes” in: Jack J. Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 221-233.

Dave Snowden.  “Storytelling and other Organic Tools of Chief Knowledge Officers and Chief Learning Officers”. in: Jack J. Phillips and Dede Bonner (editors). In Action: Leading Knowledge Management and Learning. American Society for Training and Development, 2000.  pp. 237-252.