Powerpoint slides
Knowledge sharing and institutionalism in the healthcare industry
Yong-Mi Kim, Donna Newby-Bennett and Hee-Joon Song
Abstract
Purpose – Knowledge sharing is recognized as one of the most important ways to improve
organizational performance. Organizations strive to facilitate knowledge sharing routines, yet these
attempts often fail. Although the successful deployment of knowledge sharing practices has been a
focus of knowledge management and organizational performance studies, little research has
considered the impacts of institutional structures. As such, the purpose of this study is to investigate the
extent to which institutional structures facilitate knowledge sharing practices and their impacts on
organizational performance.
Design/methodology/approach – Based on 220 usable survey responses, the authors applied
structural equation modeling (SEM) to observe the extent to which institutional structures enhance
organizational performance through knowledge sharing, and other important knowledge
sharing-related constructs (i.e. leadership and punitive behavior). The healthcare industry was used
as the research context as it is a knowledge-intensive industry.
Findings – The study finds that knowledge sharing practices were strongly influenced by institutional
structures, and together considerably enhanced patient safety. Furthermore, the institutional structures
had a high impact on leadership roles and the abatement of punitive behaviors, which in turn collectively
considerably enhanced patient safety.
Originality/value – This paper recognizes the power of institutional structures that successfully
facilitate knowledge sharing practices within an environment that is unfriendly to knowledge sharing
behaviors.
Keywords Knowledge sharing, Institutional structure, Leadership, Punitive behaviour, Healthcare industry, Knowledge management
Paper type Research paper
Introduction
Institutional theorists posit that external pressures are the major determinants of
organizational structures (e.g. Baum and Oliver, 1991; Scott, 1995; DiMaggio and Powell,
1983). This is because external pressures force ‘‘one unit in a population to resemble other
units that face the same set of environmental conditions’’ (DiMaggio and Powell, 1983).
Institutional theorists also suggest that new organizational forms will not emerge to fill
possible resource opportunities until organizations acquire legitimacy from the community
(Aldrich and Fiol, 1994). Legitimacy is a cognitive process through which an entity becomes
embedded in taken-for-granted assumptions (Suddaby and Greenwood, 2005). Gaining
legitimacy from the community is important because an organization’s survival and success
are largely contingent upon conformity to the norms of external environments (Meyer and
Rowan, 1977). Legitimacy elevates an organization’s status in the community, facilitates the
acquisition of resources, and endorses an organization’s rights and competencies to
provide specific products or services (Oliver, 1991; Meyer and Rowan, 1977; DiMaggio and
Powell, 1983; Scott, 1995).
PAGE 480 j JOURNAL OF KNOWLEDGE MANAGEMENT j VOL. 16 NO. 3 2012, pp. 480-494, Q Emerald Group Publishing Limited, ISSN 1367-3270 DOI 10.1108/13673271211238788
Yong-Mi Kim is an Assistant
Professor in the School of
Library and Information
Studies, University of
Oklahoma, Tulsa,
Oklahoma, USA.
Donna Newby-Bennett is
the Manager of the Quality
Resource Management
Department, Oklahoma
State University Medical
Center, Tulsa, Oklahoma,
USA. Hee-Joon Song is a
Professor in the Department
of Public Administration,
Ewha Womans University,
Seoul, South Korea.
Received July 2011 Revised December 2011 December 2011 Accepted December 2011
The authors are most grateful for the editing work of research assistant Emrys Moreau.
There are two viewpoints on institutional pressures. According to the first, organizational
structure changes are made in order to gain legitimacy and resources from the community,
but those changes are merely symbolical gestures made to acquire legitimacy. As such,
internal practices are not aligned with the intentions of institutional pressures (e.g. Meyer
and Rowan, 1977). In this case, internal practices and employees’ routinized behaviors are
different from the aims of external forces. The second viewpoint holds that since
organizations that grant legitimacy provide ‘‘guidelines for practical action’’ to other
organizations (Rao et al., 2003), those guidelines cause dramatic shifts in organizational
processes by changing members’ beliefs, logic, and sense-making (Suddaby and
Greenwood, 2005; Friedland and Alford, 1991; Ruef and Scott, 1998; Rao et al., 2000;
Lounsbury, 2001). More specifically, organizations conform to requirements imposed by
external forces on both structural and practical levels (Heugens and Lander, 2009; Chen and
Hambrick, 1995; Deephouse, 1999). As a result, the behaviors of employees are routinized
according to the aims of external organizations. It is not clear, however, why certain
organizations actively conform to external forces and routinize employees’ behaviors
accordingly, while others merely symbolically comply with external forces and do not change
employees’ behaviors. It is important to note that organizational structure and process,
which are observable from the exterior, are used as a formal response to institutional
pressures, while organizational members’ practices and behaviors are represented as an
organization’s internal practices in this paper.
The focus of this paper will be on the routinization of knowledge sharing as employees’
behaviors. Knowledge sharing is selected because it has been noted as one of the most
important practices for organizational performance (e.g. Mathieu et al., 2000; Smith-Jentsch
et al., 2005; Wegner, 1987; Srivastava et al., 2006; Stasser and Titus, 1985). Although the
benefits of knowledge sharing are widely recognized among organizations and in academic
literature, not all organizations utilize it to enhance performance. Thus, it is timely to investigate
whether institutional pressures facilitate a knowledge sharing culture within an organization.
Recognizing the importance of knowledge sharing and externally-imposed institutional
pressures on an organizations’ survival, this study attempts to discover the conditions under
which external pressures and institutional processes can facilitate organizational knowledge
sharing practices. The premise of this paper is that organizational knowledge sharing will be
effectively formed in an organization when external pressures are expected to enhance
performance through a knowledge sharing practice. This argument is based on existing
literature stating that organizations are likely to comply with external pressures when those
forces facilitate performance (Heugens and Lander, 2009; Chen and Hambrick, 1995;
Deephouse, 1999; Westphal et al., 1997; Baum and Oliver, 1991).
This paper further acknowledges the role of leaders because the behaviors of leaders and
employees cannot be understood outside of the larger institutional framework (Krasner,
1988; Scott, 1995). Leaders can create an environment in which employees feel safe to
share knowledge (Kim and Newby-Bennett, n.d.; Edmondson et al., 2001). Additionally,
leaders signal the importance of certain behaviors, such as knowledge sharing, through
reward and encouragement. The role of leadership is further pronounced when conflicting
institutional values compete with each other, or when an organization shifts from a
knowledge sharing threatening culture to a knowledge sharing friendly culture. In such a
case, a leader will choose strategies that can enhance performance (e.g. Heugens and
Lander, 2009), thereby routinizing or destroying institutional practices through their
leadership roles.
Based on the importance of institutional pressures on organizational practice, the role of
leadership in conforming to or resisting institutional pressures, and the importance of
routinizing knowledge sharing practices within an organization, the purposes of this
research are three-fold: first, to what extent do institutional structures, which are formed in
response to external institutional pressures, impact organizational knowledge sharing
practices and the role of leadership?; second, to what extent does the role of leadership
facilitate knowledge sharing practices?; third, to what extent do institutional structure and
employees’ behaviors as a whole impact organizational performance?
VOL. 16 NO. 3 2012 jJOURNAL OF KNOWLEDGE MANAGEMENTj PAGE 481
The organization of this paper is as follows. The subsequent section explicates the research
context. The third section includes a literature review and hypothesis developments. The
fourth section offers research methods that include the treatment of the sample, common
method variance, and data analysis strategies. The fifth section contains the report of the
findings followed by discussion. This paper concludes with the implications for academia
and practitioners.
Healthcare industry as the research context
This paper uses the healthcare industry as a research context for three reasons. First,
legitimacy is critical for acquiring the symbolic resources necessary for a hospital’s survival
and success. This is because patients lack knowledge about services and prices, and thus
they rely on legitimacy (Fennell, 1980). The healthcare accreditation agency, The Joint
Commission (2011), supplies such legitimacy. The Joint Commission’s website states that
‘‘achieving accreditation makes a strong statement to the community about an
organization’s efforts to provide the highest quality services’’ (www.jointcommission.org/
benefits_of_joint_commission_accreditation). Therefore, accreditation signifies and
strengthens community confidence in the quality of patient safety, care, treatment, and
services. Because accreditation is a critical symbolic resource for the healthcare industry,
the industry is expected to conform to the rules and policies required by The Joint
Commission.
Second, the healthcare industry consists of knowledge-intensive organizations that should
constantly learn from mistakes and make improvements (Adler, 2003; Stead and Lin, 2009).
Most medical errors are due to a failure to learn from mistakes (Department of Health, 2000),
which is attributed to a punitive culture. Healthcare employees are blamed for errors,
punished harshly, and possibly subjected to public humiliation, and are therefore hesitant to
report errors or reveal problems (Hohenhaus et al., 2006; Reason, 2000; Department of
Health, 2000; Silen-Lipponen et al., 2005). Because errors are hidden, the industry lacks
sufficient error-related data to improve patient safety. Subsequently, faulty processes are
blamed for the majority of medical errors (IOM, 2000; Reason, 2000; Department of Health,
2000; Silen-Lipponen et al., 2005). Even if error-related data is collected, it is not used for the
improvement of patient safety structure due to a lack of learning mechanisms. For example,
only 10 percent of collected error-related information is used for learning (Tucker and
Edmondson, 2003), and 50 percent of adverse events could have been prevented if there
had been a learning mechanism in place (Chuang et al., 2007). It is clear that the inability to
learn from mistakes and improve patient safety processes has been a root cause for the
majority of recurring errors. Recognizing these problems in the healthcare industry, The Joint
Commission analyzes hospitals’ patient care structures and processes based on whether
they strive to improve patient safety by preventing recurrent errors. Without knowledge
sharing practices and the collection of error-related information, improving patient care
process is not realistic.
Third, the organizational leader’s role is critical in the healthcare industry (e.g. Heugens and
Lander, 2009). It is because institutional pressures can be conflicting, and employees are
receptive to the role of leadership. More specifically, hospitals have two conflicting
practices: one is a dominant culture of punitive behavior and the other is a recently emerging
knowledge sharing practice. In a strongly hierarchical culture like the healthcare industry,
the role of leadership is highly influential to employees (Kim and Newby-Bennett, n.d.). A
leader’s behavior signals the importance of certain behaviors (Vera and Crossan, 2004;
Edmondson, 2003). In the healthcare industry, junior doctors or nurses do not effectively
communicate with senior doctors or managers for fear of appearing incompetent (Reader
et al., 2007). To correct this, the leader (usually the senior doctor) can create an environment
wherein junior doctors and nurses feel they may ask questions freely. In this type of
environment, employees tend to learn more effectively about patient care and feel
psychologically safe when following the leader’s directions (Edmondson, 1999; Edmondson
et al., 2001). As such, leadership can facilitate or disrupt the stabilization of the institutional
practices in the healthcare industry.
PAGE 482jJOURNAL OF KNOWLEDGE MANAGEMENTj VOL. 16 NO. 3 2012
Theoretical backgrounds and hypothesis development
Figure 1 shows the proposed research model, which has five constructs from institutional
theory. The patient safety structure construct measures the organizational process reflecting
the accreditation agency requirement. Leadership captures the extent to which the leader
conforms or rejects institutional pressure and influences employees’ behaviors. Punitive
action is the existing, prevalent practice in the healthcare industry, and knowledge sharing is
the new practice that is necessary for the development of patient safety structure. Patient
safety is the performance measurement. The hypotheses of the constructs are organized
based on the flow of the discussions.
Punitive action
Punitive action has long been a dominant institutional practice in the healthcare industry. It is
defined as a set of recognizable behavioral patterns characterized by an unwillingness to
take responsibility in order to avoid blame or punishment for mistakes; and, as a
consequence, staff members are hesitant to report problems or potential dangers (Khatri
et al., 2009). Because knowledge resides in individuals, the success of organizational
knowledge is based on individuals’ willingness to share their knowledge, and is contingent
upon the recognition and acknowledgement of knowledge sharing (Jiacheng et al., 2010;
Srivastava et al., 2006). A punitive practice for knowledge sharing activities could be
detrimental to the development of an organizational knowledge sharing culture.
Punitive action has a negative relationship with patient safety (e.g. Chuang et al., 2007;
Kalisch and Aebersold, 2006). Medical residents often refrain from asking questions in case
their comments are incorrect or cause senior doctors to appraise them as incompetent
(Tangirala and Ramanujam, 2008). Similar behaviors are reported between nurses and
doctors (Tucker et al., 2007). As a result, employees are hesitant to speak up or ask
questions for fear of displaying a lack of knowledge or causing embarrassment (Khatri et al.,
2009; Hellings et al., 2007). Therefore, employees often withhold important patient
information (Tangirala and Ramanujam, 2008; Silen-Lipponen et al., 2005; Hellings et al.,
2007; Khatri et al., 2009). This causes problems regarding knowledge sharing (Detert and
Edmondson, 2007; Khatri et al., 2009). Considering all discussions collectively, one can
propose hypotheses as follows:
H1. Punitive practice will negatively relate to knowledge sharing.
H2. Punitive practice will negatively relate to patient safety.
Figure 1 The proposed model
VOL. 16 NO. 3 2012 jJOURNAL OF KNOWLEDGE MANAGEMENTj PAGE 483
Knowledge sharing
Knowledge sharing is a relatively new practice that hospitals are striving to institutionalize. It
is defined as ‘‘team members sharing task-relevant ideas, information, and suggestions with
each other’’ (Srivastava et al., 2006). This concept of knowledge sharing is based on the
premise that knowledge is not an object that resides outside of context; instead, it is an
individual’s interpretation of an object, and therefore individuals possess knowledge that
must be codified and shared (McInerney, 2002; Nonaka and Takeuchi, 1995; Liebowitz,
1999). Knowledge sharing is a critical team process because if knowledge is not shared,
then the cognitive resources available within individuals remain underutilized (Argote, 1999).
Subsequently, knowledge sharing is a core element for the enhancement of performance
(Mathieu et al., 2000; Smith-Jentsch et al., 2005; Wegner, 1987; Srivastava et al., 2006;
Stasser and Titus, 1985).
Knowledge sharing is especially critical in hospitals because individuals in a team have
different backgrounds, perspectives, and observations (Dougherty, 1992). Identifying the
importance of knowledge sharing, the Institute for Healthcare Improvement urged hospitals
to create ‘‘an atmosphere of mutual trust in which all staff members can talk freely about
safety problems and how to solve them, without fear of blame or punishment’’ (Institute for
Healthcare Improvement, 2005). Facilitation of knowledge sharing activities is expected to
enhance patient safety because the majority of medical errors are derived from a lack of
learning combined with punitive behavior. Therefore, H3 is as follows:
H3. Knowledge sharing practice will positively impact patient safety.
Leadership
The role of the leader is believed to be instrumental for disrupting or strengthening
institutional practices. In a highly hierarchical culture such as a hospital, a leader can
significantly impact employees’ behaviors (Kim and Newby-Bennett, n.d.). Hospital
employees are highly receptive to the signals and behaviors of those in a position of
authority or power (Tyler and Lind, 1992), and employees depend on them for recognition
(Depret and Fiske, 1993). A leader can create a knowledge sharing practice by establishing
environments where employees feel safe asking questions and discussing concerns
(Edmondson, 1999). Leaders can further coach employees in providing clarification and
feedback, seeking the input of team members, listening to concerns, and being accessible
and receptive to the ideas and questions of others (Edmondson, 2003). The willingness of a
leader to discuss suggestions about patient safety can signal to employees the importance
of communication as well as enhance information sharing (Flin and Yule, 2004; Reader et al.,
2007; Manser, 2009). Leadership in the hospital setting has been found to significantly
influence employees’ learning behaviors because employees interpret the leader’s signals
and respond to those signals (Edmondson et al., 2001; Edmondson, 1999; Tucker et al.,
2007).
Different staff members in a hospital team have very distinctive backgrounds, training, and
special knowledge that enable them to observe different problems concerning patient care
(Dougherty, 1992). In this context, leaders view themselves as knowledge sharing facilitators
and partners in decision making. Leaders who facilitate knowledge sharing also enhance
patient safety (Edmondson et al., 2001), and therefore it is logical to propose that a leader is
likely to advocate knowledge sharing practices (e.g. Tucker and Edmondson, 2003; IOM,
2000):
H4. Good leadership will negatively relate to punitive action.
H5. Good leadership will positively relate to knowledge sharing.
H6. Good leadership will positively relate to patient safety.
Learning structure for patient safety
A learning structure for patient safety consists of the hospital rules, policies, and processes
for patient safety that are observable to external evaluators, such as the accreditation
PAGE 484jJOURNAL OF KNOWLEDGE MANAGEMENTj VOL. 16 NO. 3 2012
agency. The accreditation agency analyzes the learning structure because serious adverse
events do not have a single and isolated cause; rather, faulty processes are the root causes
for recurring similar errors (Department of Health, 2000). According to the Department of
Health, as many as 70 percent of adverse incidents are preventable if hospitals have sound
patient care structures, and the majority of medical errors are attributed to faulty structures
(Hohenhaus et al., 2006; Reason, 2000; Department of Health, 2000; Frankel et al., 2009).
In order to establish a learning structure, a hospital needs accurate error-related data. The
accreditation agency examines the errors and then analyzes whether patient safety
structures are designed to prevent the errors. Error-related data can only be effectively
collected in a knowledge sharing culture, therefore establishing a learning structure for
patient safety is dependent upon the knowledge sharing behaviors of leaders and
employees. Institutional pressures from the accreditation agency are expected to be
accepted because hospitals can enhance patient safety by complying with the agency’s
requirements, and an empirical study based on the hospital setting supports this argument.
At the time of the introduction of the electronic patient record (EPR) system, treating patients
was considered the role of doctors and entering patient information was considered the role
of support staff (Jensen et al., 2009). However, when doctors learned that the EPR would
enhance patient safety by directly transmitting accurate information to other caregivers and
pharmacies, they integrated entering patient information in to their tasks (Jensen et al.,
2009). This finding shows that leaders are likely to practice knowledge sharing in order to
enhance patient safety. Furthermore, the adoption of a new knowledge sharing practice is
likely to be further enhanced by pressures from the accreditation agency, which emphasizes
organizational learning at the structure level. As a consequence, H4, H5, H6, and H7 are as
follows:
H7. A learning structure for patient safety is likely to improve patient safety.
H8. A learning structure for patient safety is likely to influence leader’s behavior.
H9. A learning structure for patient safety is likely to improve knowledge sharing
activities.
H10. A learning structure for patient safety is likely to reduce punitive behaviors.
Research methods
This study used an existing instrument developed by the Agency for Healthcare Research
and Quality (AHRQ), which this organization has utilized in patient care-related research and
which has been adopted by other researchers (e.g. Schutz et al., 2007; Kalisch and
Aebersold, 2006; Hellings et al., 2007). The items in the questionnaire were not pre-tested
and pilot tested as it is common practice to elect not to go through such practice if items
were already validated (Kim, 2009). This section includes the sample, the treatment of
common method variance (a main concern for psychometric research), the treatment of
missing variables, and confirmatory factor analysis.
The sample
Patient safety can be best measured through staff members’ perspectives (Pinkerton, 2005).
Following this recommendation, we surveyed hospital staff members who had direct contact
with patients. The finalized questionnaire was distributed in a metropolitan hospital located
in the Midwest United States in 2008. A total of 317 questionnaires were distributed and 249
responses were collected (a 78.6 percent response rate), of which 220 were usable for
analysis. Responses are representative of the various hospital units. Approximately 50
percent of the staff members had worked in the hospital for one to five years, and 17 percent
had worked in the hospital for six to ten years, statistics indicating that respondents
understand existing routines and serve as good informants for this research.
VOL. 16 NO. 3 2012 jJOURNAL OF KNOWLEDGE MANAGEMENTj PAGE 485
Addressing common method variance
Common method variance is a major concern for social science research as it could lead to
false conclusions because researchers could incorrectly conclude that there is a genuine
relationship when there actually is not. The original instrument has a quality combination of
formative and reflective items, a method commonly used to treat this problem.
Subsequently, formative and reflective items were identified and analyzed accordingly.
The reflective measure is that a construct influences the items and, therefore, the items are
claimed to be reflective of the construct. For example, employees in a punitive culture fear
that their mistakes are held against them, that records of mistakes are kept in their file, and/or
they are afraid to ask questions for fear of punishment. Because punitive action makes
employees fearful, items within the punitive culture should have a high common variance,
inter-correlations, and internal consistency (Diamantopoulos and Siguaw, 2006), which is
commonly measured as Cronbach’s a. Formative measures, on the other hand, represent
those items of a construct that are hypothesized to cause changes in the construct;
therefore, the direction of causality is from the items to the construct (Jarvis et al., 2003). As
an example, if a team constantly discusses ways to improve patient safety, and staff
members are informed about errors, those are two independent activities that improve
knowledge sharing; however, both together enhance knowledge sharing. Since these two
activities are distinctive behaviors, one cannot anticipate a high correlation among the items
within the construct. As a consequence, nomonological validity and confirmatory factor
analysis (CFA) (changes in validity) are used as ways to assess validity (Diamantopoulos
and Siguaw, 2006).
Identifying reflective and formative measures is extremely challenging because the
measures are not always straightforward (Diamantopoulos and Siguaw, 2006; Jarvis et al.,
2003). Consequently, scholars have proposed using a theoretical argument (or
nomonological validity) for the determination of formative measures (Jarvis et al., 2003).
Another method used for determination recognizes that because reliability estimates (e.g.
Cronbach’s alpha) among the formative items are assumed to be low, the construct validity
should not be significantly changed when a single indicator is removed (Diamantopoulos
and Siguaw, 2006). The finalized items in the appendix went through all these steps.
The treatment of missing variables
As noted, 220 out of 249 responses were usable. Missing variables for reflective measures
were treated in a conservative way by substituting the mean of the variables within the same
construct of the respondent (Miranda and Kim, 2004). This treatment is more valid than other
methods, such as the mean from all responses, because the same respondent is likely to
answer items within the same construct similarly. If a respondent answered less than half of a
construct, the construct was treated as missing. Because formative items are deemed to
have a low reliability among items, missing variables are not treated for formative items.
Confirmatory factor analysis
Confirmatory factor analysis (CFA) rigorously tests convergent and discriminant validity
(Diamantopoulos and Siguaw, 2006). Convergent validity is achieved when indicators are
loaded according to the purported constructs and are significant. Discriminant validity is
assessed by constraining the estimated correlation parameters (e.g. learning culture and
punitive culture) to 1.0, and then performing a chi-square difference test on the values
obtained for the constrained (i.e. set to 1) and unconstrained models (Kim, 2010).
Discriminant validity is claimed to be achieved when the chi-square value between the
constrained and unconstrained models is significantly different (Kim, 2010). The entire
constructs in the proposed model demonstrated convergent validity for all constructs at
p , 0.001 and achieved discriminant validity at p , 0.001.
Goodness of a model is assessed using various indices. The most commonly used indices
are x 2, Normed x 2, comparative fit index (CFI), and root mean square error of approximation
(RMSEA) (Hair et al., 2010). Insignificant values of x 2 value indicate a good fit between the
data in the analysis and the proposed theoretical model, prompting researchers to look for
PAGE 486jJOURNAL OF KNOWLEDGE MANAGEMENTj VOL. 16 NO. 3 2012
insignificant values. Its p-value is 0.076, which is significant. However, it is recommended to
consider the value with Normed x 2 because x 2 is more sensitive to the number of
observations than Normed x 2. Normed x 2 is a measure of a ratio of x 2 to the degrees of
freedom (df) for a model. Generally, x 2: df ratios on the order 3:1 or less are associated with
better-fitting models. Normed x 2 value is 1.332, which is considerably lower than the cutoff
value. CFI is an improved version of the Normed Fit Index and is insensitive to model
complexity; consequently, it is the most widely used model index (Hair et al., 2010). Its cutoff
value is 0.90, and the CFI value is 0.982. RMSEA is another widely used model fit for how well
a model fits the population. A low value represents a good model fit, and the recommended
cutoff value is between 0.03 and 0.08 (Hair et al., 2010). The value of RMSEA is 0.039, which
is considerably lower than the proposed cutoff value. Considering all these model fit indices,
the fit of the proposed model is satisfactory.
Reports of findings and discussion
The finding of data analysis is graphically presented in Figure 2. Notably, the learning
structure for patient safety has high impacts on knowledge sharing, leadership roles, and
punitive behaviors. In order to facilitate the discussions of the finding, Table I provides the
results of the hypotheses.
Figure 2 Report of findings
Note: *p < 0.1; **p < 0.05; ***p < 0.001
R2 = 0.411
-0.471** -0.293***
0.513*
-0.339*
-0.482***
-0.325*0.0060.640***
0.864***
R2 = 0.616
R2 = 0.327 R2 = 0.405
Significant path Insignificant path
-0.260**
Table I Summary of findings
Hypothesis Finding
H1. Punitive practice will negatively relate to patient safety Supported H2. Punitive practice will negatively relate to knowledge sharing Supported H3. Knowledge sharing practice will positively impact patient safety Supported H4. Good leadership will negatively relate to punitive action Supported H5. Good leadership will positively relate to knowledge sharing Not supported H6. Good leadership will positively relate to patient safety Reversed H7. A learning structure for patient safety is likely to improve patient safety Supported H8. A learning structure for patient safety is likely to influence leader’s behavior
Supported
H9. A learning structure for patient safety is likely to improve knowledge sharing activities
Supported
H10. A learning structure for patient safety is likely to reduce punitive behaviors
Supported
VOL. 16 NO. 3 2012 jJOURNAL OF KNOWLEDGE MANAGEMENTj PAGE 487
The first set of the hypotheses deals with punitive behavior, which is an existing
institutionalized practice that has been noted as a root cause for medical errors. The findings
show that punitive behaviors are highly and negatively related to patient safety and
knowledge sharing. The relationship between knowledge sharing and punitive behaviors are
in a direct inverse relationship and significant at 99.99 percent, and thus H1 and H2 are
supported.
The second set of the hypotheses concerns how the new institutional behavior, which is a
knowledge sharing practice, impacts patient safety. The newly formed institutionalized
practice has a positive impact on patient safety, and its statistical strength is strong enough
to support this conclusion, and therefore H3 is supported.
The third set of the hypotheses deals with the role of leadership in institutional pressures. The
role of the leader is found to be very important in terms of reducing punitive behaviors. It was
significant at 99.99 percent, and thus H4 is supported. The role of leadership is highly and
significantly related to patient safety, but not in the expected direction as the role of
leadership is negatively related to patient safety, and thus H6 is reversed. Also, leadership is
not found to have positive impacts on knowledge sharing practices, and H5 is not supported
in this dataset. The last set of the hypotheses relates to how the hospital safety structures
impact leadership, knowledge sharing, punitive behaviors, and patient safety. The
structures highly impacted the role of the leader and explained 33 percent of the
leadership roles in hospitals. It is significant at 99.99 percent, and thus H8 is supported.
The hospital structure for patient safety also had high impacts on punitive behaviors and
knowledge sharing. More specifically, the patient safety structures directly and significantly
enhanced a knowledge sharing practice while considerably abating punitive behaviors.
Their significant levels are very high, and thus H9 and H10 are supported. The hospital
structures for patient safety also had very strong impacts on patient safety. Its statistical
significant level is very high, and thus this dataset strongly supported H7.
Interpretation of the findings
This study revealed the significant roles of institutional structure that has high impacts on
leadership, employees’ behaviors, and patient safety. The findings show that knowledge
sharing practices can be effectively practiced and impact organizational performance with
the aid of institutional structure. We further interpret that the hospital structures and
processes, which are congruent with the intention of external institutional pressures,
successfully impact leadership and knowledge sharing practices. This may be because
the intents of the external organization and the objectives of the healthcare industry
complement each other. More specific discussions based on the research questions are
provided below.
The first research question was: to what extent do institutional structures, which are formed in
response to external institutional pressures, impact organizational knowledge sharing
practices and the role of leadership? Patient safety structure highly impacted the
routinization of knowledge sharing practices in the healthcare industry, perhaps due to the
accreditation agency. In order to improve patient safety process, the hospital must have a
learning system in place, which in turn is achieved through collecting error-related data and
knowledge sharing. The opposite side of knowledge sharing is punitive behavior as
knowledge sharing cannot thrive in a punitive environment. This research finding empirically
supports the theoretical argument that they are in a direct inverse relationship, and the
structure can play an important role. Knowledge sharing cannot flourish without addressing
punitive behavior first, and this finding clearly shows that a good hospital structure has the
capability to combat punitive behaviors. Although these findings are expected based on
existing literature, this study adds value by empirically reporting the power of institutional
structures on knowledge sharing and punitive behaviors.
The institutional structure is the single most important factor for facilitating knowledge
sharing while diminishing punitive practices in the healthcare industry, which is interpreted in
two ways. First, while hospitals may have known the harmfulness of punitive behaviors, it
PAGE 488jJOURNAL OF KNOWLEDGE MANAGEMENTj VOL. 16 NO. 3 2012
may not be feasible to reverse the dominant institutional practice without the aid of
institutional structure and the external pressures. Second, hospitals have suffered from a
poor reputation regarding the mismanagement of patient care since 2000, when the Institute
of Medicine (IOM) reported that 44,000 Americans die each year as a result of medical
errors, making it the eighth leading cause of death (IOM, 2000). A majority of these errors
have been blamed on faulty processes. This has caused the healthcare industry to seek
ways to improve patient safety process, which in turn allows the accreditation agency to
serve its purpose as an external pressure.
The second part of the first research question concerns the relationship between the
institutional structure and the role of leadership, which is found to have a high correlation due
to three main reasons. The first reason is that, consistent with existing studies (e.g. Scott,
1995), the role of a leader is enabled or constrained by institutional contexts. This influence is
especially strong when the pressure is from an authoritative organization, such as the
accreditation agency. Hospital leaders may need to conform to guidelines for legitimacy,
even if conformation is symbolic. The second reason could be signaling a new view of
patient safety. It is widely acknowledged that hospitals’ faulty processes are responsible for
the majority of medical errors and that deaths result from those errors. Thus, hospitals have
suffered from bad reputations regarding patient care. The symbolic meaning of complying
with improving patient safety processes through knowledge sharing may shift the old view of
error-prone management to a new image of patient safety improvement. The third reason
that leaders may comply with the patient safety system is based on the perspective of
performance scholars (Deephouse, 1999; Westphal et al., 1997). This perspective indicates
that hospital leaders may be highly motivated to comply with knowledge sharing practices
because such practices grant them legitimacy and allow for enhancing patient safety. As
such, the new institutional structures allow hospital leaders to enjoy both symbolic resources
and practical benefits.
The second research question was: to what extent does the role of leadership facilitate
knowledge sharing practices? As noted, a leader can choose to conform to or abate the
adoption of an institutional force. The research finding showed that leaders have the
capabilities to disrupt established institutional punitive behaviors, and leaders are in fact
responsible for the culture in this study context. By refraining from punitive practices,
leaders can create non-threatening environments that promote communication. However,
the role of a leader has an unexpectedly weak impact on knowledge sharing. This is
surprising given that leaders had already eased punitive behaviors, yet employees are still
hesitant to speak up. We speculate that knowledge sharing cultures are not quite stabilized
in the healthcare industry, and thus employees are still afraid of their mistakes being
recorded in their personnel file. This is an important finding in that punitive behavior is so
deeply ingrained in the hospital safety culture that it continues to interfere with knowledge
sharing and patient safety, despite the fact that leaders had already shifted their leadership
styles.
Unexpectedly, leadership had a negative impact on patient safety. This may be because
good leadership allows employees to report errors and mistakes more freely, thereby
causing positive relationships between good leadership and reported error rates
(Edmondson, 2003). A leader who creates a knowledge sharing environment may
encourage employees to report errors and mistakes for the purpose of learning and the
improvement of patient safety structures. Employees are likely to know more about the
number of the mistakes under this type of leadership as compared to punitive
environments.
The third research question was: to what extent do institutional structure and employees’
behaviors (i.e. knowledge sharing and punitive behaviors) as a whole impact organizational
performance? This research question investigated the collective impacts of the
institutionalized structure, leadership, and employees’ behaviors on patient safety. The
explanatory power of the model was very high as over 40 percent of patient safety was
explained by the constructs in the proposed model, and all constructs in the model
significantly contributed to patient safety. Among them, the institutional structure has the
VOL. 16 NO. 3 2012 jJOURNAL OF KNOWLEDGE MANAGEMENTj PAGE 489
strongest impact on patient safety. Similar impacts of knowledge sharing and punitive
behaviors were observed in this finding. Although the healthcare industry has successfully
formed a knowledge sharing practice, punitive practice is still deeply rooted in the culture.
As noted, a leader is in a position to influence employees’ behaviors and to leverage
knowledge sharing practices to further improve patient safety.
Conclusion and managerial implication
This study’s finding answered important issues in the healthcare industry. Knowledge
sharing practices can be effectively institutionalized within an organization with the aid of
institutional structures. This finding further implies that a leader serves as a champion who
institutionalizes new practices if those practices enhance their performance. Furthermore,
this dataset found that the role of leadership was critical for a successful transition of
behavioral actions.
This study has multiple implications for practitioners and academia. For academia,
knowledge management scholars are encouraged to consider institutional logics when
they deal with organizational knowledge management successes or failures.
Organizations often fail to form a knowledge sharing practice because institutional
structures are incongruent with the practices for knowledge sharing (e.g. punishment for
errors, individual-based recognition and award systems, etc.). It is also recommended
that the organizational type be considered with regards to the success of a knowledge
sharing practice. For example, the healthcare industry is a knowledge-intensive industry
that could potentially greatly benefit from a knowledge sharing practice. External
institutional pressures also need to be considered for the success of organizational
knowledge sharing practices. If the logics of the external pressures and the benefits of
knowledge sharing in an organization are congruent, it is highly likely that the organization
will comply with the external pressures and thus knowledge sharing practices are likely to
be successful. For hospital leaders and managers, it is proposed that individuals’ errors
that are derived from faulty processes should be protected in order to create an
environment where employees safely discuss and report problems. It is further
recommended that individual employees be recognized for contributing insightful
knowledge that results in increased patient safety.
This study is slightly limited as the measure of the institutional structure is based on the spirit
of the accreditation agency. Therefore, for the future studies it is recommended that
respondents be directly asked whether the structures were designed to meet the
requirements of the accreditation agency. In this way, one can further ascertain the influence
of the accreditation agency on the healthcare industry.
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Appendix
About the authors
Yong-Mi Kim is an Assistant Professor in the School of Library and Information Studies at the University of Oklahoma. Her research includes web site utilization, IT outsourcing, knowledge management, and research methods. Her work appears in MIS Quarterly, Information Systems Research, Journal of the American Society for Information Science and Technology (JASIST), Journal of Information Science, Library & Information Science Research, Journal of Academic Librarianship, International Journal of Electronic Customer Relationship Management, International Journal of Organization Theory and Behavior, and Journal of Advances in Information Technology, among other journals. Yong-Mi Kim is the corresponding author and can be contacted at: yongmi@ou.edu
Donna Newby-Bennett is the Manager of the Quality Resource Department at the Oklahoma State University Medical Center. She has responsibilities for improvement of performance and patient safety at the Medical Center. She has been leading an improvement team to address team, leadership and communication functions to reduce errors and improve patient safety.
Hee-Joon Song is a Professor in the Department of Public Administration at Ewha Womans University, Seoul, South Korea.
Table AI Operationalization
Constructs Items Reliability
Patient safety Please give your work area/unit in this hospital an overall grade on patient safetya
NA
Leadership (formative measures) My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures
NA
My supervisor/manager seriously considers staff suggestions for improving patient safety
Knowledge sharing (formative measures) We are given feedback about changes put into place based on event reports (formative) We discuss ways to prevent errors from happening again (formative) We are informed about errors that happen in this unit (formative) Staff will freely speak up if they see something that may negatively affect patient care (reflective)
a¼0.73
Staff feel free to question the decisions or actions of those with more authority (reflective)
Punitive practice (reflective measures) Staff feel like their mistakes are held against them (reflective) a ¼ 0.78 Staff worry that mistakes they make are kept in their personal file (reflective) Staff are afraid to ask questions when something does not seem right (reflective)
Learning structure for patient safety After we make changes to improve patient safety, we evaluate their effectiveness (formative)
NA
Our procedures and systems are good at preventing errors from happening (formative)
Note: aFailing, poor, acceptable, very good, excellent; The remaining items were measured with the five-point Likert scale ranging from strongly agree to strongly disagree Source: Agency for Healthcare Research and Quality (2007)
PAGE 494jJOURNAL OF KNOWLEDGE MANAGEMENTj VOL. 16 NO. 3 2012
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