zaheera seepye mba research report ver 2
TRANSCRIPT
i
Perceived factors promoting
knowledge transfer processes within
public hospital services in South
Africa
Zaheera Seepye
A research report submitted to the Faculty of Commerce, Law and
Management, University of the Witwatersrand, in partial fulfilment of the
requirements for the degree of Master of Business Administration
Johannesburg, 2014
i
ABSTRACT
Knowledge transfer processes are increasingly important in South Africa‟s
public healthcare industry for retaining scarce skills and facilitating a
collaborative learning approach amongst doctors which enhances patient care.
South Africa‟s public health sector faces many challenges, such as the shortage
of doctors. With these constraints, this study identifies the perceived factors that
promote knowledge transfer processes. A qualitative case study method
assisted with understanding knowledge transfer processes doctors utilise and
identified factors that promote and hinder these processes. The main findings
reveal that although doctors make the most use of the resources they have to
promote knowledge transfer, key components required to promote knowledge
transfer need to be implemented. The results of this study suggest a model
which illustrates requirements to foster an environment of knowledge transfer.
Leadership and management play an important role for implementing and
sustaining knowledge transfer.
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DECLARATION
I, Zaheera Seepye, declare that this research report is my own work except as
indicated in the references and acknowledgements. It is submitted in partial
fulfilment of the requirements for the degree of Master of Business
Administration in the University of the Witwatersrand, Johannesburg. It has not
been submitted before for any degree or examination in this or any other
university.
-------------------------------------------------------------
Zaheera Seepye
Signed at ……………………………………………………
On the …………………………….. day of ………………………… 2014
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DEDICATION
This research report is dedicated to my parents and my brother who we so
dearly miss. Your endless support, love and encouragement throughout my life
have always made me achieve my dreams and strive for more. Thank you for
all the sacrifices and always believing in me. I owe my success to you.
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ACKNOWLEDGEMENTS
Firstly, I would like to express my sincere gratitude to my supervisor, Prof. Rija,
your support and encouragement assisted me greatly with completing this
research report. I really appreciate your advice, time and inspirational lectures
while completing my MBA.
I would like to thank the doctors at the Helen Joseph hospital for taking time out
of their busy schedules to participate in interviews which assisted in completing
this research report. I really appreciate your time and assistance.
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TABLE OF CONTENTS
ABSTRACT ...................................................................................... I
DECLARATION ............................................................................... II
DEDICATION ................................................................................. III
ACKNOWLEDGEMENTS .............................................................. IV
LIST OF TABLES .........................................................................VIII
LIST OF FIGURES .......................................................................VIII
CHAPTER 1: INTRODUCTION ..................................................... 1
1.1 PURPOSE OF THE STUDY ............................................................................ 1
1.2 CONTEXT OF THE STUDY ............................................................................. 1
1.3 PROBLEM STATEMENT ................................................................................ 2
1.4 SIGNIFICANCE OF THE STUDY ...................................................................... 2
1.5 DELIMITATIONS OF THE STUDY..................................................................... 4
1.6 ASSUMPTIONS ........................................................................................... 4
CHAPTER 2: LITERATURE REVIEW ........................................ 5
2.1 INTRODUCTION .......................................................................................... 5
2.2 BACKGROUND DISCUSSION ......................................................................... 5
2.3 KNOWLEDGE ............................................................................................. 6 2.3.1 DEFINITION OF KNOWLEDGE .................................................................................... 6 2.3.2 KNOWLEDGE TYPES ................................................................................................ 7
2.4 TYPES OF HEALTHCARE KNOWLEDGE ........................................................... 7
2.5 DATA, INFORMATION, KNOWLEDGE AND WISDOM FRAMEWORK ...................... 8
2.6 KNOWLEDGE TRANSFER ............................................................................. 9 2.6.1 DEFINITION OF KNOWLEDGE TRANSFER ................................................................... 9 2.6.2 TRIGGERS OF KNOWLEDGE TRANSFER ..................................................................... 9 2.6.3 ENABLERS OF KNOWLEDGE TRANSFER .................................................................. 10 2.6.4 KNOWLEDGE TRANSFER PROCESSES ..................................................................... 11 2.6.5 BENEFITS OF KNOWLEDGE TRANSFER .................................................................... 16 2.6.6 BARRIERS TO KNOWLEDGE TRANSFER ................................................................... 16
2.7 CONCLUSION OF LITERATURE REVIEW ....................................................... 17 2.7.1 RESEARCH QUESTION 1: ...................................................................................... 17
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2.7.2 RESEARCH QUESTION 2: ...................................................................................... 18
CHAPTER 3: RESEARCH METHODOLOGY ............................... 19
3.1 RESEARCH METHODOLOGY ....................................................................... 19
3.2 RESEARCH DESIGN .................................................................................. 19
3.3 POPULATION AND SAMPLE......................................................................... 20 3.3.1 POPULATION ........................................................................................................ 20 3.3.2 CASE SITE ............................................................................................................ 20 3.3.3 SAMPLE AND SAMPLING METHOD ........................................................................... 21
3.4 THE RESEARCH INSTRUMENT .................................................................... 22
3.5 PROCEDURE FOR DATA COLLECTION .......................................................... 22 3.5.1 MULTIPLE DATA SOURCES ..................................................................................... 22 3.5.2 CASE STUDY DATABASE ........................................................................................ 23 3.5.3 CHAIN OF EVENTS ................................................................................................ 23
3.6 DATA ANALYSIS AND INTERPRETATION ....................................................... 23
3.7 LIMITATIONS OF THE STUDY ....................................................................... 24
3.8 VALIDITY AND RELIABILITY ......................................................................... 24 3.8.1 EXTERNAL VALIDITY .............................................................................................. 24 3.8.2 INTERNAL VALIDITY ............................................................................................... 25 3.8.3 RELIABILITY ......................................................................................................... 25
CHAPTER 4: THE CASE SITE .................................................... 27
4.1 INTRODUCTION TO THE HELEN JOSEPH HOSPITAL‟S DEPARTMENT OF INTERNAL
MEDICINE ................................................................................................ 27
4.2 ACADEMIC TRAINING PROCESSES .............................................................. 28 4.2.1 PEER-REVIEWED WARD ROUNDS (INTAKE, POST-INTAKE, GRAND WARD ROUND) ....... 28 4.2.2 MEDICAL UNIT MEETINGS ...................................................................................... 29 4.2.3 INTERNAL ACADEMIC MEETINGS ............................................................................. 29 4.2.4 SUBSPECIALTY CLUB MEETINGS ............................................................................ 30 4.2.5 EXTERNAL ACADEMIC MEETINGS ........................................................................... 30 4.2.6 EXTERNAL CONFERENCES .................................................................................... 30
4.3 INFRASTRUCTURE AND RESOURCES ........................................................... 30
CHAPTER 5: PRESENTATION, INTEPRETATION AND DISCUSSION OF RESULTS ......................................................... 32
5.1 INTRODUCTION ........................................................................................ 32
5.2 RESULTS PERTAINING TO RESEARCH QUESTION 1 ...................................... 32 5.2.1 STRUCTURED KNOWLEDGE TRANSFER PROCESSES ................................................ 32 5.2.2 UNSTRUCTURED KNOWLEDGE TRANSFER PROCESSES ............................................ 38
5.3 RESULTS PERTAINING TO RESEARCH QUESTION 2 ...................................... 38 5.3.1 FACTORS THAT PROMOTE KNOWLEDGE TRANSFER ................................................. 38 5.3.2 FACTORS THAT HINDER KNOWLEDGE TRANSFER ..................................................... 41
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CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS ........ 44
6.1 SUMMARY ............................................................................................... 44
6.2 PRACTICAL IMPLICATIONS ......................................................................... 46
6.3 RECOMMENDATIONS ................................................................................ 48
6.4 SUGGESTIONS FOR FURTHER RESEARCH ................................................... 50
REFERENCES .............................................................................. 52
APPENDIX A – INTERVIEW PROTOCOL .................................... 58
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LIST OF TABLES
Table 1: Interview Sample ................................................................................ 21
LIST OF FIGURES
Figure 1: Data, information, knowledge and wisdom framework (Bierly III et al.,
2000) .................................................................................................................. 8
Figure 2: Knowledge Transfer Process (Liyanage et al., 2009)....................... 12
Figure 3: Knowledge Transfer Process (Szulanski, 2000) ............................... 14
Figure 4: Requirements for promoting knowledge transfer .............................. 48
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CHAPTER 1: INTRODUCTION
1.1 Purpose of the study
The purpose of this research is to identify the perceived factors promoting
knowledge transfer processes within South African public hospital services. This
study investigates knowledge transfer processes utilised within South African
public hospital services and establishes factors that promote and hinder these
processes.
1.2 Context of the study
Healthcare in South Africa is provided for by two systems, the private sector
and the public sector. The majority of the population use the public sector. In a
study Strachan, Zabow, and Van der Spuy (2011) showed that in 2009 the
medical specialist-to-population ratio is estimated to be 0.36 per 1000 in the
public sector. This indicates medical professionals in South African public
hospitals gain valuable knowledge as they treat and diagnose high volumes of
patients daily. This knowledge and current medical information are some of the
valuable assets in the healthcare industry (Stroetmann & Aisenbrey, 2012).
Therefore knowledge transfer processes can assist with retaining and
transferring these assets to newcomers (Argote, 2013).
Knowledge transfer processes involve a collaborative approach to expand and
distribute knowledge (Chen, McQueen, & Sun, 2013). In the healthcare
industry, collaboration amongst specialised medical experts in knowledge
transfer processes facilitates learning, which increases skills (Kühne-
Eversmann & Fischer, 2013). This is required for professional practice to assist
with diagnosing and the treatment of patients (Kraft, Blomberg, & Hedman,
2013). Also evidence-based medicine involves combining expertise and current
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medical information to diagnose and treat patients (Zidarov, Thomas, &
Poissant, 2013).
South Africa‟s public sector consists of academic hospitals that teach and train
undergraduate and postgraduate medical students. In addition, medical
graduates serve compulsory internships or compulsory community service in
public hospitals. Knowledge transfer enables learning from the experience of
others (Argote, Ingram, Levine, & Moreland, 2000), therefore transferring
knowledge from senior medical professionals to junior medical professionals
needs to be effective to increase skills and competence in junior medical
professionals.
Transferring knowledge improves performance and productivity (Denicolai,
Zucchella, & Strange, 2014) as medical professionals can utilise knowledge
transfer processes to assimilate knowledge to complete tasks. Also the
dissemination and application of knowledge creates new knowledge which can
lead to medical innovations (Graham & Logan, 2004).
Hospitals in South Africa‟s public sector are knowledge-intensive. Knowledge
transfer processes are required for retaining skills, learning, increasing skills,
increasing performance and medical innovations which enhances patient care
(Qatawneh, Yousef, & Shirvani, 2013). Therefore knowledge transfer processes
need to be promoted within South Africa‟s public hospital services.
1.3 Problem statement
Identify the perceived factors promoting knowledge transfer processes within
South African public hospital services.
1.4 Significance of the study
The next decade of medical advances will accelerate towards personalised
medicine which requires closer collaboration amongst doctors (Stroetmann &
3
Aisenbrey, 2012), therefore knowledge transfer processes are required to
create a collaborative approach to learning.
The importance of knowledge transfer in the healthcare industry can be
highlighted by the fact that in 2000, the Canadian parliament repealed the
Medical Council of Canada Act and created the Canadian Institutes of Health
Research (CIHR) to ensure knowledge creation and translation to improve the
health of Canadians (Joseph, 2013). The CIHR refers to “knowledge transfer”
as “knowledge translation” (Joseph, 2013). Oborn, Barrett, and Racko (2010, p.
5) cites, the World Health Organisation who adapted the CIHR‟s definition and
defined knowledge translation as “the synthesis, exchange, and application of
knowledge by relevant stakeholders to accelerate the benefits of global and
local innovation in strengthening health systems and improving people‟s health”.
The study fills a gap in that much of the theory for knowledge transfer focuses
on business firms. Relatively little study has been performed on knowledge
transfer in the public sector for healthcare and even less in third world countries.
The study may provide guidance to South Africa‟s Department of Health to
promote a culture of knowledge transfer and to establish knowledge transfer
processes to assist with the Human Resources Health Strategy of 2012/13 –
2016/17 to increase productivity and revitalise learning (Department of Health,
2011).
The study may assist Human Resource Managers and Managers of medical
units in public hospital to implement knowledge transfer processes to foster an
environment of learning and development among health professionals.
The study highlights the importance of knowledge transfer processes in South
African public hospitals, and as a result, health professionals may adopt
knowledge transfer processes to acquire knowledge from other health
professionals.
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1.5 Delimitations of the study
This study was confined to one South African public hospital.
This study focused on explicit knowledge and not other types of
knowledge since explicit knowledge is tangible, a common type of
knowledge found in organisations and it can be easily distributed, given
the time constraints doctors have in the public sector to transfer
knowledge.
The population of this study was limited to doctors in the Department of
Internal Medicine at three organisational levels, Interns, Registrars, and
Consultants.
Knowledge transfer occurs at all organisational levels in business firms
(Chen et al., 2013). However, Oborn et al. (2010) identifies that
knowledge transfer occurs at the individual and group levels in health
services research. The scope of this study focused on knowledge
transfer at the individual and group level and knowledge transfer from
individual to individual, individual to group, group to individual and group
to group.
1.6 Assumptions
The following assumptions have been made in this study:
a) Doctors usually work together to collaborate and share information as a
team.
b) Explicit knowledge forms are continuously shared in hospitals, mainly
amongst doctors.
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CHAPTER 2: LITERATURE REVIEW
2.1 Introduction
This chapter contains a literature review on the key themes in knowledge
transfer research. It begins with a background discussion on knowledge transfer
which discusses the continuous research of knowledge transfer to provide
organisational success for evolving business environments. This is followed by
a discussion on knowledge, including the different types of knowledge that can
be transferred in organisations. Thereafter, key concepts of knowledge transfer
are discussed, including knowledge transfer triggers, enablers, processes,
benefits and barriers. Finally the key learnings of knowledge transfer are
discussed within the context of South African public hospitals which provides a
basis for the research questions that are presented at the end of this chapter.
2.2 Background discussion
The importance of knowledge transfer has been widely discussed in the
business environment. Organisations have implemented knowledge transfer
processes to promote learning which leads to improved performance,
productivity, innovation, increased skills and retained skills which allows
organisations to compete (Garvin, 1993; Nonaka & Takeuchi, 1995; Senge,
1990). Furthermore, studies have evolved to show the importance of knowledge
transfer in the changing business environment, such as, acquisitions (Kosonen
& Blomqvist, 2013), multinationals (Kumar, 2013), and offshore sites (Chen et
al., 2013).
The success of knowledge transfer in firms can be applied to the public sector.
Recent studies focus on the importance of knowledge transfer in the public
sector within different industries such as education (Fullwood, Rowley, &
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Delbridge, 2013), police (Seba, Rowley, & Delbridge, 2012) and healthcare
(Mabery, Gibbs-Scharf, & Bara, 2013).
The benefits that firms receive from implementing knowledge transfer can be
applied to hospitals. Qatawneh et al. (2013) developed a model for total
knowledge transfer to diffuse innovation in the public healthcare industry.
2.3 Knowledge
The study of the theory of knowledge is called epistemology. Michael Polanyi, a
popular philosopher, developed a theory of knowledge in the late 1940s and
early 1950s. In his theory, knowledge has two dimensions, namely, tacit and
explicit. This forms the basis for defining knowledge types found in
organisations.
2.3.1 Definition of knowledge
Sveiby (1996, p. 2) cites Polanyi, “Knowledge is an activity which would be
better described as a process of knowing”.
Davenport and Prusak (1998, p. 5) provides a definition of organisational
knowledge, “Knowledge is a fluid mix of framed experience, values, contextual
information, and expert insight that provides a framework for evaluating and
incorporating new experiences and information. It originates and is applied in
the minds of knowers. In organizations, it often becomes embedded not only in
documents or repositories but also in organizational routines, processes,
practices, and norms”.
Nonaka (1994, p. 15) states there is a clear distinction between information and
knowledge, “information is a flow of messages, while knowledge is created and
organised by the very flow of information, anchored on the commitment and
beliefs of its holder”.
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2.3.2 Knowledge types
Nonaka (1994) describes two types of knowledge found in organisations,
namely tacit and explicit. Tacit knowledge is intangible, it is expertise and
experience (Borges, 2013) that “indwells” in the human mind (Polyani, 1966)
which makes it hard to communicate and deeply rooted in action, commitment
and involvement (Nonaka, 1994). Explicit knowledge is tangible, knowledge is
codified, transmittable and can be articulated to other people, using IT and
media it can be transmitted across organisational boundaries (Nguyen, 2013).
Lam (2000) identifies four types of knowledge: embrained knowledge
(individual-explicit knowledge is dependent on the individual‟s skills and
abilities), embodied knowledge (individual-tacit knowledge built upon practical
experience), encoded knowledge (collective-explicit knowledge in written rules
and procedures) and embedded knowledge (collective-tacit knowledge which
resides in organisational routines and norms).
van den Berg (2013) discusses three types of organisational knowledge,
namely, tacit, codified and encapsulated and describes encapsulated
knowledge as knowledge embodied in physical artefacts.
2.4 Types of healthcare knowledge
Abidi (2008) identifies eight different types of knowledge found within
healthcare. However, only the explicit types are discussed below:
Patient Knowledge - This refers to the patient‟s medical history, test results,
diagnosis and treatment plan that Doctors capture in the medical record.
Medical Knowledge- This contains medical theories such as textbooks and
journals, also documented healthcare delivery models and processes.
Resource Knowledge- This refers to the resources and infrastructure available
in the hospital for doctors to provide patient care. This is more like an inventory
8
list which is necessary for doctors to know which medical diagnostic devices,
drugs, etc. are available when making decisions for treatment plans.
Process Knowledge- These are the standardised workflows the hospital
follows to treat patients.
Organisational Knowledge- This contains the hospital‟s organisational
structure and policies.
2.5 Data, Information, Knowledge and Wisdom Framework
Bierly III, Kessler, and Christensen (2000) defines the Data Information
Knowledge Wisdom (DIKW) framework for learning which contains the following
four levels:
Figure 1: Data, information, knowledge and wisdom framework (Bierly III
et al., 2000)
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Firstly, data is raw facts. This level involves learning about data which is the
process of accumulating facts.
Secondly, information is meaningful and useful data. This level involves
learning about information which is the process of giving form to data.
Thirdly, knowledge is obtained by understanding information and its associated
patterns.
Fourthly, wisdom is the ability to apply knowledge. This level involves making
sharp judgments and action based on knowledge.
2.6 Knowledge transfer
The identification of organisational knowledge types forms the basis to discuss
knowledge transfer theory.
2.6.1 Definition of knowledge transfer
Argote and Ingram (2000) describe knowledge transfer in organisations as a
process through which one unit is affected by the experience of another. This
can be applied across organisations, as Argote (2013) discusses, an
organisation learns from the experience acquired at another. Chin (2013)
mentions that the speed, and quality of learning, is often increased by
transferring knowledge from one situation to another related situation. Al-Kwifi
and Ahmed (2013) maintain that knowledge transfer is a collaboration among
individuals and groups within organisations and across organisations.
2.6.2 Triggers of knowledge transfer
Rana, Goel, and Rastogi (2013), in a study, describe the biggest challenge of
the human resource department in any public organisation is talent
management. The study also describes knowledge transfer methods, such as a
10
knowledge base website on the intranet for sharing best practices, technology
and product knowledge, to ensure transfer of skills for developing talent.
Knowledge transfer is crucial for succession planning as valuable knowledge is
lost when staff leave (Esmyol & Jonasová, 2013).
Knowledge transfer is essential for transferring skills from experts to
newcomers. Guechtouli, Rouchier, and Orillard (2013) identify codified
knowledge as one of the mechanisms for transferring knowledge to newcomers.
2.6.3 Enablers of knowledge transfer
Al-Gharibeh (2011) defines knowledge enablers as organisation elements that
consistently help foster knowledge transfer within organisations. Studies identify
that organisational culture is the most important enabler for knowledge transfer,
followed by information technology (Al-Gharibeh, 2011; McNichols, 2010; Syed-
Ikhsan & Rowland, 2004).
Schein (1984, p. 3) defines organisational culture, “is the pattern of basic
assumptions that a given group has invented, discovered, or developed in
learning to cope with its problems of external adaptation and internal
integration, and that have worked well enough to be considered valid, and,
therefore to be taught to new members as the correct way to perceive, think,
and feel in relation to those problems”. Mannion and Davies (2013) cite this
definition and state that many authors discuss culture as operating at three
levels, artefacts, beliefs and values and assumptions. Certain factors in
organisational culture, such as trust, communication, information systems,
rewards and organization structure are positively related to knowledge transfer
in organisations (Al-Alawi, Al-Marzooqi, & Mohammed, 2007).
Organisations should implement Information Technology (IT) infrastructures that
provide a seamless flow of the organisation‟s explicit knowledge which enables
the capturing and transfer of the organisation‟s knowledge and expertise (Zack,
11
1999). Information Communications Technology (ICT) tools such as discussion
forums and shared workspaces encourage employees to communicate and
transfer knowledge (Eze, Goh, Goh, & Tan, 2013).
2.6.4 Knowledge transfer processes
According to Chen and McQueen (2010), knowledge transfer can be divided
into two groups, namely structured and unstructured. Structured knowledge
transfer processes are formal, planned and intentional. This is an ordered step
by step process. Unstructured knowledge transfer processes are informal,
unplanned and spontaneous. In this technique, a step in the process can be
jumped to without following previous steps.
a. Structured knowledge transfer processes
The structured knowledge transfer processes will take into account tacit and
explicit knowledge but focus only on explicit knowledge transfer stages.
i. Liyanage et al knowledge transfer process
Liyanage, Elhag, Ballal, and Li (2009) describe a one-way, six step knowledge
transfer process (shown in Figure 2):
1. Awareness - involves identifying the appropriate or valuable knowledge.
2. Acquisition – knowledge is acquired, provided that both the receiver and
source have the capability to do it.
3. Transformation – refers to the process the receiver uses to convert the
acquired knowledge into useful knowledge.
4. Association – involves associating the transformed knowledge to the
internal needs of the organisation.
5. Application – value is created when knowledge is applied where it is
needed.
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6. Knowledge Externalisation / Feedback – refers to transferring
experiences or new knowledge created by the receiver to the source
using a feedback loop.
The process also describes prerequisites required for knowledge transfer, such
as modes of knowledge transfer and performance management, and takes into
account factors that influence knowledge transfer. Also close and tight
interactions between individuals, teams and organisations are required for
knowledge transfer to occur at these three levels.
Figure 2: Knowledge Transfer Process (Liyanage et al., 2009)
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ii. Guzman and Trivelato’s codified knowledge
transfer process
Guzman and Trivelato (2008) describe an explicit knowledge transfer process
with three stages:
Knowledge codification - involves the articulation and formalisation of
knowledge. This stage contains tacit elements such as extracting tacit
information from the person holding it and writing it up.
Mechanisms use to transfer knowledge - may include technology-based
mechanisms.
Knowledge assimilation and application- is the decodification of
knowledge to understand, interpret and comprehend it and apply the
newly assimilated knowledge.
Ernst & Young uses a similar approach for intra-organisational explicit
knowledge transfer. This involves removing client-sensitive information from
documents and developing „knowledge objects‟ by pulling key pieces of
knowledge out of documents, such as market segmentation analyses, bench
mark data, etc., and storing them in the electronic repository for people to
assimilate and apply (Hansen, Nohria, & Tierney, 2000).
iii. Szulanski’s knowledge transfer process
Szulanski (1996) describes the transfer of best practice in the firm which can be
seen as an unfolding knowledge transfer process that consists of four stages
(shown in Figure 3):
Initiation – A transfer begins when both a need, and the knowledge to
meet that need, is identified. This stage is completed once the required
knowledge is found.
14
Implementation – The source and recipient establish social ties to
engage in knowledge transfer which is adapted to the needs of the
recipient.
Ramp-up – The recipient begins using the acquired knowledge and
identifies and resolves unexpected problems that hamper the application
of knowledge.
Integration – The recipient achieves satisfactory results with the
transferred knowledge and makes it a routine. The transferred
knowledge can be institutionalised into explicit knowledge forms, for
example, manuals and databases (Sutrisno, Pillay, & Hudson, 2012).
Figure 3: Knowledge Transfer Process (Szulanski, 2000)
iv. Dixon’s knowledge transfer processes
Dixon (2000) describes five knowledge transfer processes, serial transfer, near
transfer, far transfer, strategic transfer and expert transfer. Explicit knowledge is
transferred using the near transfer and expert transfer processes.
Near transfer refers to transferring knowledge from a team that has gained
experience from performing a repeated task to other teams that are performing
similar tasks. This process involves two stages: firstly, disseminating knowledge
15
electronically and secondly, supporting the knowledge transfer process with
personal interaction. Dixon (2000) uses Ford‟s Best Practice Replication system
as an example to describe the near transfer process. Each of Ford‟s vehicle
operations plants located around the world exchange best practices amongst
each other that have reduced their own costs and increased productivity. Every
week a few practices are published on the intranet. Integral to this system is a
report that is generated which shows how many practices each plant has
contributed and adopted. If a regional manager notices that a plant in their area
has contributed a few practices, pressure is put on that plant to increase its
submissions.
Expert transfer is the process where a team faces a technical question that it
cannot solve and seeks the expertise of others in the organisation. This process
involves locating knowledge resources and using online technologies such as
email and forums to transfer knowledge. Dixon (2000) uses Chevron‟s Best
Practices Resource Map (BPRM) as an example to describe expert transfer.
This map displays the contact names and numbers for the functional areas
within Chevron‟s network to assist employees in locating expertise and skills
which is published on the intranet for easy access and retrieval.
v. Nonaka’s modes of knowledge transfer
Nonaka (1994) describes four modes of knowledge transfer, Socialisation,
Externalisation, Combination and Internalisation. The combination mode
transfers explicit knowledge. This involves using social processes, such as
contacting people, to collect explicit knowledge held by them which is
reconfigured through sorting, adding, re-categorising, and re-contextualising
into new explicit knowledge and disseminated amongst members of the
organisation. Formal courses and seminars are examples of the combination
process (Stevens, Millage, & Clark, 2010).
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b. Unstructured knowledge transfer processes
Chen and McQueen (2010) identify three unstructured knowledge transfer
types, unstructured copy, unstructured adaption and unstructured fusion.
Unstructured copy is mainly explicit which involves using pre-existing
knowledge sources, such as document repositories, to „copy‟ or imitate
someone‟s way of performing a task. The other two types are mainly tacit.
2.6.5 Benefits of knowledge transfer
Knowledge transfer facilitates learning. Organisational performance is
improved by sharing best practices to complete tasks (Palacios-Marqués, Peris-
Ortiz, & Merigó, 2013).
A criterion for organisations to gain a competitive advantage is to have
resources and capabilities that are superior to its competitors (Hinterhuber,
2013). Knowledge transfer develops resources and capabilities which may be
achieved using a codification strategy (Ding, Liu, & Song, 2013).
Knowledge transfer leads to innovation. Drucker (1999, p. 22) states, “If we
apply knowledge to tasks we already know how to do, we call it 'productivity'. If
we apply knowledge to tasks that are new and different we call it 'innovation'”.
2.6.6 Barriers to knowledge transfer
The following factors hinder knowledge transfer:
Resistance –Staff may be reluctant to share their expertise because they
perceive their expertise as a source of survival in the organisation.
Communication developed through organisational culture is one of the key
elements that enables knowledge transfer (Aziz, Gleeson, & Kashif, 2013).
17
ICT Competencies - Knowledge stickiness refers to the inability to transfer
knowledge. ICT competency is a factor that could mitigate knowledge stickiness
and enhance knowledge transfer (Sheng, Chang, Teo, & Lin, 2013) .
Cultural Differences– Knowledge transfer can be difficult between people with
different national cultural norms. Therefore trust, cultural alignment and
openness to diversity influence knowledge transfer (Boh, Nguyen, & Xu, 2013).
Additionally, A. Riege (2005) identifies thirty-five knowledge sharing barriers.
2.7 Conclusion of Literature Review
Knowledge is one of the most valuable assets of an organisation. Knowledge
transfer processes allow organisational members to collaborate and transfer
knowledge. South African public hospitals have a shortage of health
professionals, therefore codifying knowledge retains knowledge in the hospital
as it is available at all times for reuse. This is necessary for succession planning
as scarce skills need to be identified and transferred. This also assists with
transferring skills to newcomers.
The use of knowledge transfer processes in hospitals facilitates learning
amongst health professionals which increases skills and competence. The
dissemination and application of knowledge for new tasks creates new
knowledge. The ability to create new knowledge leads to innovation. A
competitive advantage is gained when knowledge is transferred to create
superior resources and capabilities. The availability of explicit knowledge forms
improves performance, therefore knowledge transfer processes need to be
effective within South African public hospital
2.7.1 Research Question 1:
What processes do doctors follow in public hospitals to transfer knowledge?
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2.7.2 Research Question 2:
What promotes the effectiveness of knowledge transfer processes?
19
CHAPTER 3: RESEARCH METHODOLOGY
This section outlines the research methodology used in this study. Firstly, the
motivation for a qualitative research methodology is discussed, followed by the
research design and rationale for a single case study approach. Thereafter, the
Helen Joseph South African public hospital case is introduced. This established
the discussion for the sampling method, research instrument and procedure for
data collection and analysis. Then, the limitations of the research are discussed.
Lastly, methods used to increase validity and reliability in this study is described
to ensure quality data is obtained from this research.
3.1 Research methodology
The purpose of this study is to identify the perceived factors promoting
knowledge transfer processes utilised by doctors. The purpose is to gain a
better understanding of these processes by asking how and why questions
which involves building theory. Therefore, qualitative research would be more
useful than quantitative research for collecting data, analysing data, and
presenting findings.
3.2 Research design
The single case study was the preferred method for the research design of the
study. The rationale for choosing this methodology is based on the following
characteristics of a qualitative single case study discussed by Robertson,
McKagan, and Scherr (2013) which can be used to generalise findings: Single
cases,
a) retain necessary complexity – The study includes phenomena that can
be interpreted in the context of the study which may identify or explain
issues in the case.
20
b) connect to the theory – This allowed for the comparison of the literature
reviewed with data gathered in the study.
c) illustrate theories and broaden awareness – Focusing on one hospital
allows understanding a situation and gathering and interpreting complex
data.
d) address specific research goals - The researcher has a goal of
identifying factors that promote the effectiveness of knowledge transfer
processes within South African public hospitals and highlighting the
importance of knowledge transfer.
The qualitative single case study research has a limitation of reliability and
validity, which is defined in section 3.8, together with methods this study
utilised to ensure reliability and validity.
3.3 Population and sample
3.3.1 Population
The population for this study is defined as doctors working in South African
public hospitals.
3.3.2 Case site
The case chosen for this study is the Helen Joseph South African public
hospital. The hospital consists of two divisions, Internal medicine (non-surgery)
and External medicine (surgery).
The rationale for choosing Joseph South African public hospital:
It is an academic hospital, therefore, knowledge transfer processes that
facilitate learning can be identified.
21
It is a large hospital and has organisational levels.
Doctors exist at different organisational levels, therefore knowledge
transfer processes can be identified at the junior levels and senior levels.
3.3.3 Sample and sampling method
The interview sample chosen was a representative of doctors at three
organisational levels (interns, registrars, and consultants) from the Internal
Medicine division. Interns are graduates that are completing internship.
Registrars have completed internship and have begun to specialise.
Consultants are specialised physicians. The sample consisted of fourteen
respondents who are listed in Table 1. This represents the purposive sampling
method which samples cases in a strategic way by ensuring those sampled are
relevant to the study and the researcher samples with a specific goal in mind
Bryman (2012). Therefore, this sample and method represents doctors at three
organisational levels from the Internal Medicine division which is necessary to
obtain data to comprehensively identify the perceived factors promoting
knowledge transfer processes at the individual to individual and individual to
group, group to individual and group to group levels.
Table 1: Interview Sample
Level Number to
be
sampled
Consultants 4
Registrars 5
Interns 5
Total 14
22
3.4 The research instrument
The research instrument for the study consisted of conducting semi-structured
interviews with a standardised questionnaire listed in Appendix A. This
improves validity and reliability of the research as a standardised questionnaire
ensures consistency for data interpretations and a semi-structured interview
makes interviews flexible to capture important data by getting respondents to
expand further on their answers (Bryman, 2012).
Yin (2009) recognises that a pilot study assists with refining data collection with
the content of the data and the procedures to be followed. The study began with
a pilot study to refine and clarify the standardised questionnaire.
3.5 Procedure for data collection
Yin (2009) identifies three principles for data collection:
Use multiple sources of evidence.
Create a case study database.
Maintain a chain of evidence.
The next sections discuss how the study addressed these principles.
3.5.1 Multiple data sources
Bryman (2012) defines triangulation as the use of multiple sources of data in a
study to cross-check findings. This strengthens generalisability of the study. The
following sources of data will be used during this research:
Interviews: This is the main source of data collection for this study. The
interviews were conducted with doctors described in section 3.3.2. Firstly, the
researcher visited the Helen Joseph hospital and discussed with doctors the
nature of this research. Secondly, interviews were scheduled with doctors.
23
Interviews lasted for a maximum of thirty minutes, given the time constraints of
doctors, if more interview time was required, another interview was scheduled
or more information was telephonically obtained.
All interviews were recorded and transcribed, as well as hand written notes
taken during the interview were used to capture important points.
Direct Observation: The researcher observed the environment at the hospital.
This assisted with cross-checking the interview data with the observations.
3.5.2 Case study database
A case database in the form of hard copy notes and computer recordings was
created. The raw data was organised chronologically and processed data was
organised according to the layout of the research report. This allowed a third
party to verify the research findings.
3.5.3 Chain of events
A record was kept for the chain of events that occurred during the research
process. This began from the time the research proposal was approved to the
final completion of the research report. The chain of evidence collected during
the study increased reliability and supported the conclusion which allows a third
party to verify the findings of the research.
3.6 Data analysis and interpretation
The study used analytic techniques described be Yin (2009) for case study
analysis:
Pattern Matching – The study compared empirically based patterns with
the predicted ones identified in the literature review.
24
Explanation Building – The study constructed explanations based on the
research questions and data collected. The case database assisted with
this.
3.7 Limitations of the study
The study has the following limitations:
The study is limited to the Helen Joseph Hospital, Department of Internal
Medicine.
It is unknown whether the findings of this study can be generalised to
other industries in the public sector due to the limitation of the case study
methodology.
3.8 Validity and reliability
Validity and reliability is necessary to ensure quality data is obtained. Firstly,
this section discusses the limitations of validity and reliability in a qualitative
case study research. Secondly, the methods this study adopted to ensure
validity and reliability are described.
3.8.1 External validity
External validity is the extent to which the results of the study can be
generalised to other contexts (Bryman, 2012). The case study research is
inherently limited in terms of generalisability, as it represents one sample of a
population (Bryman, 2012).
This study used techniques identified by A. M. Riege (2003) to increase external
validity in a case study research, such as:
The definition of the scope and boundaries in the research design phase
assists in achieving reasonable analytical generalisations rather than
25
statistical generalisations. The choice of the Helen Joseph hospital was
partially for the reason of generalisabilty. This case represents a large
knowledge-intensive South African tertiary hospital with the evaluation of
knowledge transfer processes that represents a substantial population
(doctors at three levels (interns, registrars and consultants) in the internal
medicine division).
The data analysis phase compared evidence or findings with existing
literature to generalise aspects within the scope and boundaries of the
research.
3.8.2 Internal validity
Internal validity refers to the soundness of casual relationships between two or
more variables or cause-and-effect relationships discovered in the study
(Bryman, 2012). Internal validity in qualitative research matches researchers‟
observations with the theoretical ideas they develop (Bryman, 2012). This is a
limitation in a case study research as a good match is required.
This study used techniques identified by A. M. Riege (2003) to increase internal
validity in a case study research, such as:
Within-case analysis was used in the data analysis phase which involved
writing up a case study and identifying key themes in the data for
preliminary theory generation (Eisenhardt, 1989).
Internal coherence of findings was achieved by cross-checking results
against interviewees by asking them if the conclusions are accurate.
3.8.3 Reliability
Reliability refers to obtaining the same results when the study is repeated
(Bryman, 2012). The qualitative case study research has a limitation on
26
reliability since this study involves conducting interviews which entails
interpreting verbal data.
This study used techniques identified by A. M. Riege (2003) to increase
reliability in a case study research, such as:
The development and refinement of the case study protocol was
achieved by conducting a pilot interview to test the questionnaire for the
interviewees‟ understanding and completeness. Based on the result, the
standardised questionnaire was refined and clarified to obtain the
appropriate data from interviewees.
Interviews were recorded and transcribed, observations were also
recorded. This developed the case study database to organise and
document data collected.
The theoretical framework resulting from the literature review is used to
interpret responses from interviewees to assure meaningful parallelism of
findings across multiple sources of data.
27
CHAPTER 4: THE CASE SITE
This chapter provides a description of the case site that was used to conduct
this study. The discussion begins with a background of the Helen Joseph
Hospital. This is followed by a description of academic training processes
implemented by the Department of Internal Medicine. Lastly, infrastructure and
resources are discussed.
4.1 Introduction to the Helen Joseph Hospital’s Department of
Internal Medicine
The Helen Joseph Hospital is a South African public hospital which is located in
Auckland Park, Johannesburg. It provides medical services to the public and it
also serves as a teaching hospital.
Helen Joseph‟s Department of Internal Medicine focuses on the prevention,
diagnosis and treatment of diseases. The department provides accredited
subspecialty training for Nephrology, Pulmonology, Cardiology and Neurology.
Also additional subspecialty services are available for Gastroenterology,
Endocrinology, Rheumatology, Haematology and Infectious Diseases.
The department consists of four general medical units. Each medical unit
comprises Interns, Registrars, and Consultants. Interns are recently qualified
doctors that serve a compulsory two year internship at a designated hospital
practicing under medical supervision. This requirement is defined by the Health
Professions Council of South Africa (HPCSA) which is a statutory body
established in terms of the Health Professions Act 56 of 1974. All doctors have
to register with the HPCSA as a pre-requisite for professional practice. After
completing the two year internship, Interns are qualified general practitioners
and can practice medicine without medical supervision.
28
Registrars have completed the Internship programme and train to become
specialists in various disciplines. The period of training is three years for a
speciality and two years for a subspecialty. During this time the Registrar is
employed at the hospital to provide clinical services, supervise and teach
interns, and rotate through subspecialties and hospitals to gain practical
knowledge in a chosen discipline. Once a Registrar successfully completes the
training programme and examinations, he/she are qualified to register with the
HPCSA as a specialist physician.
Consultants or physicians have completed the Registrar training programme
and all speciality training in a chosen discipline. The Consultant‟s post at the
hospital is permanent or contract based, and they are responsible for the care
of all patients, supervising and training of Interns and Registrars, and other
managerial tasks.
4.2 Academic training processes
Helen Joseph‟s Department of Internal Medicine implements the following
academic training processes:
4.2.1 Peer-reviewed ward rounds (intake, post-intake, grand ward
round)
Each medical unit is schedule to operate on specific days for patient intake.
During this process an Intern will examine a patient, take blood tests, etc. in the
presence of a Registrar, who reviews the Interns management of the patient. If
there is something that an Intern has missed, the Registrar will give a tutorial at
the patient‟s bedside.
Registrars also teach medical procedures to Interns, to test the Interns‟
understanding of what they have learnt, and Interns conduct the medical
procedure on a patient while being observed and corrected by the Registrar.
29
The day after the patient is admitted, post-intake ward rounds occur. During this
process, Registrars present the patient cases and a Consultant reviews the
management of the patient with the Registrar. Consultants also give tutorials at
the patient‟s bedside if there is more that can be done for the patient.
Grand ward rounds occur weekly. Each medical unit performs their own grand
ward rounds. During this process, the entire medical unit visits all of their
patients in the wards during which Registrars present the patient‟s cases at the
patient‟s bedside.
During ward rounds, Interns and Registrars take notes for their own reference.
Ward rounds are a peer-reviewed process.
4.2.2 Medical unit meetings
Each medical unit has bi-weekly meetings, also known as Mobility and Mortality
meetings. Consultants, Registrars and Interns are involved in these meetings. It
is an open discussion, where the cases of patients who are very ill or who have
passed away are discussed, and methods of improvement for patient
management are considered.
4.2.3 Internal academic meetings
All medical units in Internal Medicine meet weekly. These meetings are
attended by Consultants, Registrars and Interns. During these meetings,
Registrars prepare and present interesting patient cases or a patient condition.
At the end of the presentation, there is a question and answer session where
Consultants are available to answer questions from the audience.
30
4.2.4 Subspecialty club meetings
The subspecialty departments in Internal Medicine have weekly journal club
meetings. During these meetings, Consultants and Registrars that practice and
train in a specific subspecialty, meet to discuss interesting articles and new
research on a relevant topic. This is compared with current methods of practice
that they use to check feasibility of practice. This also keeps Consultants and
Registrars updated with new research.
4.2.5 External academic meetings
Once a week, general practitioners and physicians from South African public
hospitals are invited to an academic meeting hosted at another South African
public hospital to transfer knowledge on interesting patient cases or to attend a
lecture on a specific topic.
4.2.6 External conferences
Internal Medicine general practitioners and physicians attend the yearly
Physicians Update Meeting. This is a local conference where guest speakers
present the latest medical research. Physicians also attend subspecialty
conferences hosted by South African Medical Association (SAMA). Attending
international conferences depends on budget approval from the hospital.
4.3 Infrastructure and resources
Helen Joseph‟s Department of Internal Medicine consists of eleven wards, of
which two are admission wards with in-patient facilities for about 350 patients
(Wits, 2013).
Each medical unit in the department consists of approximately 4 consultants, 5
registrars and 5 interns. There are four medical units in the department of
Internal Medicine. Each department is scheduled to operate on specific days for
31
patient in-take. The average medical intake is forty-five patients per day (Wits,
2013). During patient in-take, Interns and Registrars work approximately 16
hours per day.
There is one computer per clinic. The computer is outdated and it takes a while
to process and retrieve information. Doctors queue to use the computer to
access patients‟ test results. Most of the time, doctors have to use their own
smartphones or tablet devices to retrieve information and collaborate with each
other.
Patient files are manually (non-computerised) created, updated and stored in a
filing cabinet.
32
CHAPTER 5: PRESENTATION, INTEPRETATION AND
DISCUSSION OF RESULTS
5.1 Introduction
This chapter combines the presentation, interpretation and discussion of results.
The responses obtained from the semi-structured interviews described in
Chapter 3, are themed and explained in relation to the literature review
discussed in Chapter 2.
5.2 Results pertaining to Research Question 1
This section discusses the results pertaining to the first research question:
What processes do doctors follow in public hospitals to transfer
knowledge?
All of the respondents interviewed contributed to identifying and describing
processes doctors follow to transfer knowledge.
Chen and McQueen (2010) consider that knowledge transfer processes can be
categorised into two groups, structured or unstructured. The results are
organised according to these groups.
5.2.1 Structured knowledge transfer processes
According to Chen and McQueen (2010), structured knowledge transfer
processes are formal, planned and intentional. All of the responses from the
interviews indicate that the Helen Joseph hospital‟s academic training
processes can also be categorised as structured knowledge transfer processes
as they are formal (academic training processes consist of formal academic
meetings), planned (academic training processes are scheduled) and
intentional (the purpose of academic training processes is to facilitate learning).
33
a. Academic training processes
The Helen Joseph Hospital implements the following Academic training
processes:
b. Peer-reviewed ward rounds
All of the respondents shared the view that the most amount of knowledge
transfer occurs during the peer-reviewed academic ward rounds which are
patient intake, post intake and grand ward rounds. The description they
provided for the transfer of knowledge that occurs from Registrars to Interns
during the patient intake ward can be related to the knowledge transfer process
Szulanski (1996) describes, which consists of the following four stages:
Initiation (tacit or explicit) – A transfer begins when both a need and the
knowledge to meet that need is identified. During the patient intake ward
round, Interns are practicing under the supervision of Registrars in which
Registrars identify the need to transfer knowledge to Interns, Interns may
need to be corrected during the examination, diagnosis or treatment of a
patient or require more knowledge on the medical condition. This stage is
mainly tacit, but when practicing evidence-based medicine, explicit forms
such as medical journals, are used to acquire knowledge about a
medical condition.
Implementation (tacit or explicit) – The source and recipient establish
social ties to engage in knowledge transfer. The Registrar is the source
and the Intern is the recipient. They are acquainted with each other as
they are scheduled to perform patient intakes. The transfer of knowledge
occurs at the bedside of the patient. This is mainly tacit but Interns take
notes in an explicit form.
Ramp-up (tacit) – The recipient begins using the acquired knowledge.
After a Registrar demonstrates a medical procedure to the Intern, the
34
Registrar observes the Intern perform the same procedure and corrects
the Intern if necessary.
Integration (tacit or explicit) – The recipient achieves satisfactory results
with the transferred knowledge and makes it a routine. The Intern
performs more procedures without the Registrar having to correct them
or provide them with more information. This stage is mainly tacit, but
according to Sutrisno et al. (2012), the transferred knowledge can be
institutionalised into explicit knowledge forms.
The respondents describe post intake ward rounds which occur the day after
patient intake in which Consultants peer-review the Registrar‟s diagnosis and
treatment plan that was established during patient intake. From the responses,
the transfer of knowledge for post intake ward rounds follows a similar process
as described for patient intake except the source is the Consultants and the
recipients are the Registrars and Interns.
The majority of respondents conveyed that they learn about interesting cases
during grand ward rounds. They indicated that grand ward rounds involve
visiting all the wards where Registrars transfer knowledge by presenting patient
cases to all the staff in the medical unit at the patient‟s bedside. The transfer of
knowledge that occurs during ward rounds can be linked to the codified
knowledge transfer process Guzman and Trivelato (2008) describes:
Knowledge codification – This stage involves extracting tacit information
from the person holding it and writing it up. Patients transfer knowledge
to doctors and doctors record this in the patient file together with the
patient‟s diagnosis and treatment plan. Registrars transfer explicit
knowledge recorded in patient files to the entire medical unit.
Mechanisms to transfer knowledge – Registrars present the patient‟s
case from the patient‟s file and the medical unit uses explicit methods to
take notes. This is similar to a workshop mechanism to transfer
knowledge where ideas are discussed and questions asked.
35
Knowledge assimilation and application –This refers to the decodification
of knowledge to understand, interpret and comprehend it and to apply
the newly assimilated knowledge. The majority of the respondents
expressed that by learning about medical conditions they have not
treated, or interesting patient cases, it makes them more aware of how to
treat a similar case when they encounter it. The respondents take notes
in an explicit form during this process and use it as a reference.
c. Medical unit meetings
Most of the respondents shared the view that knowledge transfer occurs during
the medical units internal Mobility and Mortality workshops where patient cases
are discussed with methods for improving the management of patients. During
this process the respondents indicated that they take notes in an explicit form
which they use as a reference.
The respondents‟ explanation for the transfer of knowledge that occurs during
these meetings can be described according to Szulanski (1996)‟s knowledge
transfer process but only the first two stages of this process are implemented.
Firstly, in the initiation stage, doctors identify relevant patient cases to discuss.
Secondly, in the implementation stage, Consultants discuss methods for
improving the management of patients with all of the staff in the medical unit.
d. Internal academic meetings
According toDixon (2000), explicit knowledge is transferred using the near
transfer process which refers to transferring knowledge from a team that has
gained experience from performing a repeated task to other teams that are
performing similar tasks. The description provided by the respondents‟ indicated
that a similar process is followed during internal academic meetings, Registrars
36
from different medical unit‟s present patient cases encountered, or a medical
condition, using explicit forms such as visual presentations on computer to staff
from all medical units in the Department of Internal Medicine.
However, the knowledge transferred may not only be about experienced gained
from performing a repeated task but the treatment plan of an interesting patient
case. Also, knowledge is not disseminated electronically as all of the
respondents indicated that they take notes in an explicit form for future
reference. A few respondents indicated that sometimes Registrars have the
presentations on a USB memory stick which can be copied from them.
e. External academic meetings
According to Argote (2013), an organisation learns from the experience
acquired at another. Similarly, most of the respondents indicated knowledge
transfer occurs during external academic meetings. These meetings are held at
different public hospitals and general practitioners and specialists from other
public hospitals attend these meetings. During these meetings interesting
patient cases are presented or a lecture is given on a specific topic. Explicit
knowledge types, like lecture notes, are given to attendees, and attendees take
notes.
The description provided by the respondents for the transfer of knowledge that
occurs during external academic meetings can be related to the knowledge
transfer process Szulanski (1996) describes. Firstly, in the initiation stage,
doctors identify relevant medical topics to discuss or patient cases. Secondly, in
the implementation stage, doctors transfer knowledge on a medical topic based
on research and experience.
37
f. External conferences
A few respondents indicated that they attend conferences held locally to acquire
new knowledge. This is related to the examples of formal courses and seminars
Stevens et al. (2010) provides, for the combination process Nonaka (1994)
describes for explicit knowledge transfer, in which explicit knowledge is
collected and reconfigured into new explicit knowledge and disseminated
amongst members of the organisation.
g. Subspecialty clubs
Most of the respondents shared the view that knowledge is transferred during
subspecialty journal club meetings. The respondents‟ description of this transfer
of knowledge can be described according to Szulanski (1996)‟s knowledge
transfer process but only the first two stages of this process are implemented.
Firstly, in the initiation stage, doctors identify relevant journal articles to discuss.
Secondly, in the implementation stage, knowledge contained in explicit forms is
shared and discussed amongst colleagues. This is an open discussion where
current practices are compared with new research to determine whether it is
feasible to implement these at the hospital.
h. Expert transfer
Most of the respondents that are consultants indicated that when they
encounter a patient‟s case that is complicated, they contact other specialists
either via email containing the patient‟s case details or identify the subspecialty
department in the hospital that can assist with the case and share and discuss
the patient‟s file with them. This is similar to the expert knowledge transfer
Dixon (2000) describes, in which explicit knowledge is transferred by locating
38
knowledge resources, that can assist with solving a problem that a team faces,
using online technologies, such as e-mail or forums, to transfer knowledge.
5.2.2 Unstructured knowledge transfer processes
Unstructured knowledge transfer processes are informal, unplanned and
spontaneous (Chen & McQueen, 2010).
a. Unstructured copy
Most of the respondents indicated that each subspecialty department
implements their own method of technology for sharing guidelines, interesting
medical articles and patient scans. They further indicated that this provides all
staff with information as they do not get to see each other daily as they work in
different medical units. The sharing of guidelines using this method is similar to
the unstructured copy knowledge transfer process described by (Chen &
McQueen, 2010) in which explicit knowledge is obtained from document
repositories to „copy‟ or imitate someone‟s way of performing a task.
5.3 Results pertaining to Research Question 2
This section discusses the results pertaining to the second research question:
What promotes the effectiveness of knowledge transfer processes?
The majority of respondents interviewed contributed to identifying factors that
promote the effectiveness of knowledge transfer processes and factors that
hinder knowledge transfer processes.
5.3.1 Factors that promote knowledge transfer
The results uncover the following factors that promote knowledge transfer
processes:
39
a. Interesting patient cases
All of the respondents shared the view that interesting patient cases promotes
knowledge transfer. They indicated that they notify each other when interesting
patient cases are encountered which allows them to examine the patient or
obtain knowledge about the patient‟s medical condition from the patient‟s file,
research the medical condition and discuss the patient‟s case with colleagues.
The respondents further indicated that interesting patient cases are also
discussed during academic training processes.
These findings are supported by Becheikh, Ziam, Idrissi, Castonguay, and
Landry (2010, p. 11), who state that an “attribute of the knowledge that could
have an important impact on the effectiveness of its transfer, is its relevance.
Relevance means that knowledge should be interesting, credible and produced
at the opportune time”.
b. Smartphone and tablet capabilities
All of the respondents confirmed that that they use their own smartphones or
tablet devices to collaborate, share information, research medical conditions
and retrieve patient test results. The respondents described that they use apps
available for smartphone and tablet devices, mostly free-service apps are used
like messaging services, which allows them to setup chat groups to share
information, notify each other of interesting patient cases and discuss medical
conditions. Also file hosting service apps are used to share guidelines and
interesting articles.
All of the respondents indicated that they use the web functionality of the
smartphone and tablet devices to access medical journal articles to research
medical conditions and retrieve patient test results. Also, the portability of the
devices allows them to retrieve information at the patient‟s bedside.
40
These findings are concur with Eze et al. (2013), who states Information
Communications Technology (ICT) tools encourage employees to communicate
and transfer knowledge.
c. Continuing Professional Development (CPD) Points
A few respondents indicated that CPD promotes the transfer of knowledge.CPD
was introduced by the Health Professionals Council of South Africa (HPCSA)
for health professionals to acquire new knowledge and keep up to date with
medical research. The respondents indicated that CPD points are earned by
participating in academic training processes, online CPD events such as
completing online CPD courses and CPD events such as presenting at
conferences. These findings are in agreement with Kayhan (2014), who
identifies that CPD is used for individual learning to keep up to date with
medical research and to maintain the highest standard of professional practice.
d. Self-interest to learn
Most of the respondents discussed that their own interest to learn and keep
updated with current medical research promotes the transfer of knowledge.
They discussed that they read medical journal articles in their own time to learn
about medical conditions and keep updated with current medical research. A
few respondents indicated that when they read interesting articles, they will
discuss these with colleagues.
One respondent, who is an Intern, described that they read textbooks and when
they come across a patient case with a medical condition they have read about,
they will ask the Registrar that is supervising them to explain the medical
condition, which provides a better understanding.
The results match views expressed byBierly III et al. (2000), a passion to learn
is one of the drivers for organisational wisdom and individual wisdom is
41
transformed into organisational wisdom using knowledge transfer as one of the
methods. Also,Inkpen and Tsang (2005) describe social capital dimensions of
networks, such as network ties, facilitates knowledge transfer.
5.3.2 Factors that hinder knowledge transfer
The findings reveal that the following factors hinder knowledge transfer
processes:
a. Lack of time to transfer knowledge
All of the respondents shared the view that time constrains them in transferring
knowledge and teaching Interns. They indicated that although Helen Joseph is
an academic hospital, they also provide service delivery. This was also
observed by the researcher as some of the respondents were interrupted during
interviews to take urgent calls or to attend to patients.
Most of the respondents who are Registrars indicated that the role of a
Registrar working as a general physician, ward consults, follow-up rounds, post-
intakes, supervising interns, training to become a specialist, and academic
meetings coupled with the amount of patients they treat daily is sometimes
overwhelming. However, most of the respondents acknowledge that they have
to transfer knowledge to Interns as next year the Interns will become Registrars
and they require knowledge to train the new Interns.
A few of the respondents who are Interns indicated that sometimes Registrars
and Consultants are too busy treating patients and they cannot ask them for
assistance.
These findings agree with A. Riege (2005, p. 23) who identifies that a “general
lack of time to share knowledge, and time to identify colleagues in need of
specific knowledge” is a potential barrier for individuals to transfer knowledge.
42
b. Lack of information technology systems
Frustrating to get patient records
All of the respondents shared the view that the manual (non-computerised)
patient file makes it difficult to learn about the patient and to discuss the
patient‟s case with other doctors. They indicated that the file contains the
patient‟s medical history, test results, diagnosis and treatment plan. They further
indicated that patient files get lost, it takes a long time to find files, handwriting
in files is illegible, and test results are loosely kept in files and sometimes get
lost and has to be repeated.
These findings are aligned to Zack (1999) who states organisations should
implement IT infrastructures that provide a seamless flow of the organisations‟
explicit knowledge which enables the capturing and transfer of the
organisations‟ knowledge and expertise.
Frustrating to get patient test results
A few respondents indicated that the IT system does not allow them to view the
history of patients‟ test results.
A few respondents who are Registrars indicated that there are two labs in the
hospital and it is difficult to track test specimens and results as sometimes
specimens get lost and tests have to be repeated.
It is evident that these findings are in agreement with A. Riege (2005, p. 29),
that the “lack of integration of IT systems and processes impedes on the way
people do things” is a potential technology barrier for transferring knowledge.
43
c. Lack of infrastructure
Most of the respondents indicated that there is no computer lab or facility setup
for them to learn, read journal articles or research medical topics. This agrees
with A. Riege (2005, p. 26) who states that “shortage of formal and informal
spaces to share, reflect and generate (new) knowledge” is a potential
organisational barrier for knowledge transfer.
Majority of the respondents indicated that there is one computer in a clinic and
doctors queue to use it to retrieve patient test results or research information.
This confirms research by A. Riege (2005, p. 25) who states that “shortage of
appropriate infrastructure supporting sharing practices” is a potential
organisational barrier for knowledge transfer.
d. Lack of awareness of the benefits of knowledge
transfer practices
A few respondents mentioned that knowledge transfer is not formalised as the
teaching processes and the environment is fast paced, so it depends on an
individual whether they want to share or not.
A few respondents who are Registrars shared the same view that it is difficult to
teach Interns who show a lack of interest in learning.
The findings were initially identified by A. Riege (2005, p. 24) as the “lack of
leadership and managerial direction in terms of clearly communicating the
benefits and values of knowledge sharing practices” and were categorised as a
potential organisational barrier for knowledge transfer.
44
CHAPTER 6: CONCLUSIONS AND
RECOMMENDATIONS
6.1 Summary
The findings from this study identified processes doctors follow to transfer
knowledge. The results revealed that there are no formal processes
implemented for knowledge transfer and mainly academic training processes
are used to transfer knowledge. The analysis of these academic training
processes indicated that knowledge is assimilated and disseminated during the
peer reviewed patient intake and follow up ward rounds. However the analysis
of the other academic training processes only described the acquisition of
knowledge. It is important to note that the literature review illustrates that value
is created when knowledge is applied, which is implemented in stages of
knowledge transfer processes (Guzman & Trivelato, 2008; Liyanage et al.,
2009; Szulanski, 2000).
The results linked the process of sharing guidelines with the unstructured copy
knowledge transfer process of Chen and McQueen (2010), the internal
academic meetings with the near transfer process of Dixon (2000) and the
seeking of medical expertise with the expert transfer process of Dixon (2000).
The literature mentions that these explicit knowledge transfer processes are
used to transfer technical expertise. The findings indicated that a small amount
of knowledge transfer occurs using these processes. These processes require
technology mechanisms, such as online forums, which enable doctors to locate
each other to collaborate and transfer knowledge. The results revealed that
there are no formal technology mechanisms implemented for this to occur.
Instead, doctors use their own smartphones or tablet devices and use free
service apps to collaborate, but each subspecialty department implements their
own technology mechanism for sharing information which complicates the
45
integration of information when Registrars move to other subspecialty
departments during their training.
This study identified interesting patient cases promote the effectiveness of
knowledge transfer processes as doctors notify each other when they encounter
interesting patient cases. Also interesting patient cases are discussed during
academic training processes and the earning of CPD points. Other factors that
promote knowledge transfer are smartphone and tablet devices which enable
the retrieval of medical information at the patient‟s bedside, assist with
practicing evidence based medicine using journals, medical apps and web
searches, using file sharing services to share interesting articles amongst
doctors and message services which allows doctors to collaborate. A self-
interest or passion to learn also promotes knowledge transfer as doctors
discuss articles they read or patient cases they encountered with colleagues.
The analysis revealed that this may contribute to increasing organisational
wisdom.
The results of this study recognised the following factors that hinder knowledge
transfer: The lack of information systems makes it frustrating for doctors to
retrieve patient information from the manual (non-computerised) patient file and
to retrieve patient test results from the labs. This, together with the lack of
information technology infrastructure, which means that doctors have to queue
to retrieve information from the one computer per clinic takes up a lot of time
which affects doctors as they see numerous patients‟ daily and at the same
time, train to become specialists and train junior staff. Also it was established
during the analysis that the lack of awareness of the value and benefits of
knowledge transfer practices hinders knowledge transfer.
46
6.2 Practical Implications
The evidence from this study has the following important implications that key
stakeholders, South Africa‟s Department of Health and Public Hospital
Resources Mangers and doctors, should consider.
Leadership and management will play an important role in promoting
knowledge transfer. While this study was being conducted, the
researcher could not obtain any documented knowledge transfer
processes, the respondents acknowledged that there are no documented
knowledge transfer processes and academic training processes and
mechanisms differ amongst public hospitals. It is evident that adequate
leadership and management is required to drive the implementation and
sustainability of knowledge transfer processes.
The literature review identified organisational culture is the most
important enabler of knowledge transfer, followed by information
technology (Al-Gharibeh, 2011). Again, leadership is required to drive a
culture of knowledge transfer which entails creating awareness of the
benefits and value of knowledge transfer.
The benefits of implementing IT systems are significant:
o The current flow of knowledge occurs from individual to individual
during patient intake and post intake ward rounds, individual to
group during academic meetings, and group to individual and
group to group during expert transfer. The implementation of IT
systems will encourage the free flow of knowledge transfer
amongst all doctors.
o In addition, knowledge transfer will become self-directed as
doctors are empowered to learn.
47
o Furthermore, the study identified that standardised electronic
communication mechanisms such as online forums or
organisational social media sites are required for doctors to locate
each other and collaborate. This will promote expert transfer.
From the findings it can be deduced that by storing patient files
electronically in a central repository, not only will it promote knowledge
transfer and assist with reducing doctors‟ time constraints but will save
on costs for repeating patient tests which occurs when files are lost, test
results kept in files are lost, and when patients come from other hospitals
and their medical information cannot be retrieved.
With the implementation of IT system projects, it is important to note that
training will be required to build ICT competencies.
Investing in infrastructure will yield benefits. The study identified that
libraries are required to transfer and generate new knowledge. Building
knowledge libraries and developing learning centres will provide a space
for doctors to collaborate and transfer knowledge which may lead to
medical innovations. It will provide a space to inspire innovation and
creativity.
The implementation of both IT systems and infrastructure will provide
structure, space and speed for doctors to treat patients, given their time
constraints.
Implementing formalised knowledge transfer processes which require the
conversion of tacit knowledge to codified knowledge will assist with
retaining knowledge and the training of new recruits (Guechtouli et al.,
2013).
The implementation of knowledge transfer processes may affect other
functions of the hospital, e.g. Research and Development will be
empowered to publish more journal articles. Other hospital staff, such as
48
nurses, will be empowered to transfer knowledge. Specific coaching and
mentoring programmes can be designed to transfer scarce knowledge
and skills.
The overall impact of implementing standardised knowledge transfer
processes across South African public hospitals with the supporting
infrastructure and standardised IT systems will lead to the flow of
knowledge transfer across organisational boundaries which are the
transfer of knowledge amongst all doctors and staff across South African
public hospitals.
6.3 Recommendations
Based on the evidence from this study and implications identified in the
previous section, a model is established and depicted in figure 4, which
provides a holistic view of requirements that South Africa‟s Department of
Health and Public Hospital Human Resources Mangers should implement for
promoting knowledge transfer practices.
Figure 4: Requirements for promoting knowledge transfer
Knowledge Transfer
Leadership
Culture
IT Systems Infrastructure
49
Leadership and management play an important role in fostering an environment
of learning. It is required to create an organisational culture that encourages
knowledge transfer which entails creating an awareness of knowledge transfer
by clearly communicating its benefits.
The study reveals that it is evident that there is a great need for South Africa‟s
Department of Health to invest in providing information technology systems and
infrastructure in South African public hospitals.
A central repository is necessary to store medical records electronically,
which is easily integrated with lab systems to retrieve history information
and other hospital systems supporting supply chain processes, which
provide enhanced service delivery or patient care.
IT systems are required for knowledge to flow in all directions and across
organisational levels.
The implementation of knowledge transfer processes and systems that
support the transfer of tacit knowledge to explicit knowledge which
retains knowledge and assists with the training of doctors. It is important
to develop, implement and formalise knowledge transfer processes that
adds value. The literature review describes knowledge transfer
processes that contain stages where value is created (Liyanage et al.,
2009; Szulanski, 2000).
A standard technology communication mechanism is required to locate
doctors electronically, such as online forums or organisational social
media sites, to seek medical expertise, collaborate and share
information.
A learning facility or library is required which encourages self-directed
learning and collaboration amongst doctors.
50
Therefore, both IT systems and infrastructure are required to implement a
space for learning, creativity and innovation. Also, it is important to develop,
implement and formalise knowledge transfer processes that add value. The
literature review describes knowledge transfer processes as containing stages
where value is created (Liyanage et al., 2009; Szulanski, 2000).
With the implementation of any IT project, and the building of infrastructure,
leadership and management is required to oversee the successful and timely
completion of these projects and to ensure the organisation adopts these
system and facilities by influencing culture. When designing IT systems, it is
important to gather the input of the organisation as ease of use of the system
will encourage knowledge transfer. Also, when designing libraries or learning
and development centres, it is important to involve the organisation in the
design of these facilities to ensure all requirements are gathered.
The importance of leadership and management cannot be stressed enough as
leadership and management is required to sustain knowledge transfer, the bi-
directional arrows indicate aspects that influence knowledge transfer which
leaders and managers need to continuously monitor to promote an environment
of knowledge transfer and learning.
6.4 Suggestions for further research
Based on this study, the following opportunities for further research include:
Research to determine the value created through the knowledge transfer
processes identified in this study.
A quantitative study to determine a more comprehensive list of factors
that promote knowledge transfer and factors that hinder knowledge
transfer in South African public hospitals. These factors can be
measured or rated to identify areas that have an increased impact on
transferring knowledge.
51
Research can be conducted through multiple case studies across
different types of hospital to determine a more extensive list of
knowledge transfer processes doctors follow.
This study focused on a single case site. Research can be conducted on
another case site with a comparison study of the two case studies. This
will assist with generalising of the findings.
Research can be conducted at a public hospital in another third-world
country to determine similarities and differences. This may assist with
identifying processes for knowledge transfer with limited staff, technology
and time.
A study to determine technology mechanisms that will increase the
effectiveness of knowledge transfer processes within South African
public hospitals.
52
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APPENDIX A – INTERVIEW PROTOCOL
The following guideline was used to obtain data for this study. The interviews
begin with the researchers introducing themselves and getting to know the
respondents, this built the conversation for the interview questions, thereafter
respondents are thanked for their assistance and lastly methods for providing
feedback or results of this study are discussed.
1. Introduction
Personal introduction
Reason for the study
Sharing of results
Recording the interview
2. Get to know the respondent
Are you an Intern, Registrar or Consultant?
What are your work tasks?
How many years working experience do you have?
3. Interview Questions
The following interview questions are developed to provide consistency
for obtaining data.
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A semi-structured interview approach is followed which allows the
exploration of new ideas or to uncover findings.
Open-ended questions assist with discovering findings and avoid guiding
the interviewee to towards anticipated answers.
The interviewer should start with open-ended questions specified below
and refer to probing questions only if the response from the interviewee
does not focus on answering the research questions.
Questions relating to research question 1:
What processes do doctors follow in public hospitals to transfer
knowledge?
Open-ended questions:
1. What are the cases where the transfer of knowledge occurs?
Probing questions:
1. What are the stages in the knowledge transfer process?
2. How do you acquire patient information to complete work tasks?
3. How do you transfer patient information to other doctors?
Questions relating to research question 2:
What promotes the effectiveness of knowledge transfer processes?
Open-ended questions:
1. What promotes you to transfer knowledge to other doctors?
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2. What prevents you from transferring knowledge?
Probing questions:
1. How do doctors collaborate to share information?
4. Exit
Thank you for participation
5. Feedback
Results of the study