Strategic Plan

A managerial view of the knowledge flows of a health-care system

Harri Laihonen1

1Tampere University of Technology, Tampere, Finland

Correspondence: Harri Laihonen, Department of Information Management and Logistics, Tampere University of Technology, PO Box 541, FI-33101, Tampere, Finland. E-mail: [email protected]

Received: 26 September 2011 Revised: 6 September 2013 Accepted: 14 February 2014

Abstract A health system has various knowledge structures enabling its knowledge resources to be efficiently applied. The literature has covered the management of clinical health information fairly extensively, but less is known about manage- rial knowledge flows. To address this knowledge gap, a regional health system in Finland is studied and managerial knowledge flows categorized in order to provide a better understanding of the inter-organizational knowledge networks of a health system. The paper contributes by illustrating and concretizing the knowledge dynamics of a health system. The empirical examination reveals the complexity of managerial knowledge flows and identifies three main categories of these: (1) national information steering, (2) regional information steering, and (3) internal control information. These categories are further elaborated with the data gathered through observation, interviews, and process modelling. A better understanding and management of knowledge flows is expected to have a positive effect on the performance of the health system. Knowledge Management Research & Practice (2015) 13(4), 475–485. doi:10.1057/kmrp.2014.3; published online 17 March 2014

Keywords: knowledge transfer; knowledge flows; knowledge management; health management

Introduction This paper studies the managerial knowledge flows of a health-care system. A focus on knowledge dynamics is required because modern health- care organizations and systems are very dynamic; system structures are in a continuous state of change and individual organizations compete, co-operate, and create value in close interaction with their customers (cf. Porter & Teisberg, 2006; Nordgren, 2009; Laihonen, 2012). The paper contributes with its empirical approach, its focus on managerial knowledge, and by studying knowledge flows from the system perspective. Previously, the focus has been markedly on organizations and the integration of information systems into clinical work (Bose, 2003; Berg, 2004) and only few attempts have been made to analyse knowledge transfer from the perspective of managing the service system (cf. Edwards et al, 2005; Laihonen, 2012). This brings in the need for understanding inter-organiza- tional knowledge transfer and knowledge networks (Easterby-Smith et al, 2008; Van Wijk et al, 2008; Phelps et al, 2012). Finally, the knowledge transfer literature has also been criticized for a lack of empirical research (Nissen & Levitt, 2002; Riege, 2007). The managerial perspective is essential because health-care organizations

store vast amounts of data but often lack the means and/or the will (Sveiby, 2007) to analyse and refine it for purposes of managing and developing their operations (Delesie & Croes, 2000; Berg, 2004). The role of informa- tion technologies and information systems in decision-support is a widely

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studied area (e.g., Williams et al, 2006; Avillach et al, 2008; Lemire, 2010; Lloyd-Bostock, 2010), likewise the role of knowledge transfer in building expertise of health- care professionals (see Pentland et al (2011) for an exten- sive review). What seems to be missing is a more general and strategic understanding of the knowledge structures that enable the development and renewal of the health- care system. To address this knowledge gap, the paper studies the managerial knowledge flows of the health-care system and aims to create a basis for more effective utilization of knowledge resources in health care. This is expected to lead in the long run to more effective health services. The paper focuses on knowledge transfer because this

has been widely recognized as a critical success factor for modern organizations. In order to respond to changes in the environment, to innovate and achieve competitive success, organizations have to be able to transfer knowl- edge effectively (Cohen & Levinthal, 1990; Grant, 1996; Szulanski, 1996; Albino et al, 1999; Riege, 2007; Easterby- Smith et al, 2008; Meier, 2011). Nevertheless, it is easy to stress the importance of knowledge transfer in general but what does it mean in practice? This paper offers some answers to this question by building on the knowledge transfer literature and studying knowledge flows in health- care management. The viewpoint is managerial – the empirical part of the paper seeks answers to the following research question: What knowledge flows create a basis for management in a regional health-care system? The remainder of the paper is organized as follows. The

next section reviews the literature on knowledge transfer and knowledge flows. From the literature, four critical components of knowledge transfer are identified that form the basis for the empirical analysis. Then the empirical research methods are described. The empirical section maps the managerial knowledge flows of the health-care system studied and categorizes them on the basis of the literature. The discussion section follows the empirical section. Finally, the concluding section summarizes the key findings of the paper and suggests directions for further research.

The literature on knowledge transfer and knowledge flows Knowledge transfer has been one of the main research fields of knowledge management ever since the early 1990s (e.g., Cohen & Levinthal, 1990; Grant, 1996; Szulanski, 1996). The increased complexity of modern business environments has further increased the impor- tance of and interest in the phenomenon, not only within organizations but also between different agents (e.g., Inkpen & Tsang, 2005; Easterby-Smith et al, 2008; Khamseh & Jolly, 2008; Van Wijk et al, 2008; Hutzschenreuter & Horstkotte, 2010; Phelps et al, 2012). The essence of knowledge transfer is emphasized in knowledge-intensive organizations, and its value is primarily determined by their knowledge assets

(e.g., Alvesson, 1993; Blackler, 1995; Miles et al, 1995; Løwendahl et al, 2001; Käpylä et al, 2011). Knowledge transfer is defined as the transfer of knowl-

edge from one unit to another (e.g., Cutler, 1989; Albino et al, 1999; Hendriks, 1999; Argote & Ingram, 2000; Bender & Fish, 2000; Kalling, 2003; Kumar & Ganesh, 2009). It is a process involving two actors – the sender and the receiver (individuals or organizations), and occurs through different media. Thus, when analysing knowledge trans- fer, it is important to understand: (1) who transfers knowl- edge to whom (actors), (2) what is transferred (content), (3) in which context (context), and (4) which medium is the most suitable in a given context (media) (Albino et al, 1999; Jasimuddin, 2005). To distinguish this key concept from its very closely related concept ‘knowledge sharing’, this paper follows a definition stating that ‘trans- fer implies focus, a clear objective, and unidirectionality, while knowledge can be shared in unintended ways multiple-directionally without any objective’ (King, 2006, p. 493). From the actors’ viewpoint, several factors affect the trans-

fer. The roles of openness or willingness to share knowl- edge, trust, and previous knowledge have been recognized as important characteristics (Wathne et al, 1996; Cruz et al, 2009). Each of these characteristics correlates posi- tively with knowledge transfer (e.g., Cohen & Levinthal, 1990; Dodgson, 1993; Wathne et al, 1996). The cognitive capabilities of the actors, and especially the absorptive capacity of the recipient, also influence the success of transfer (e.g., Cohen & Levinthal, 1990; Gupta & Govindarajan, 1991, 2000; Szulanski, 1996; Simonin, 1999; Tsai, 2000; Foss & Pedersen, 2002). Further, Ko et al (2005) emphasize the important role of the sender (i.e., credibility and intrinsic motivation) for the success of inter-organizational knowledge transfer. Easterby-Smith et al (2008) continues the list with the characteristics of a firm and points out absorptive capacity, motivation or learning intent, power issues, risk taking, and geographic location. Concerning the content of the transfer, it is more

challenging to transfer tacit knowledge than explicit knowledge (e.g., von Hippel, 1994; Simonin, 1999; Argote & Ingram, 2000; McEvily & Chakravarthy, 2002). Explicit knowledge can be more easily articulated and is often transferred by information systems, whereas storytelling (e.g., Swap et al, 2001) is a commonly used method for transferring tacit knowledge. The ambiguous nature of knowledge hampers the transfer (e.g., Zander & Kogut, 1995; Szulanski, 1996, 2000; Stein & Ridderstrale, 2001; Simonin, 2004; Coff et al, 2006; Van Wijk et al, 2008). In addition, the value of the information transferred makes a difference – the more valuable the information, the more interested the receiver is in receiving it (Gupta & Govindarajan, 2000). The context of the transfer can be distinguished into

internal and external (Albino et al, 1999). Internal context refers to organizational culture. External context refers to the circumstances in which inter-organizational

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relationships take place. A shared context (i.e., similarities in organizational culture, values, and technical skills) expedites the transfer by reducing the ambiguity. Finally, the transfer media or the actual means for the transfer have a significant role. The success of the transfer is dependent on the capacity and richness of the media (Albino et al, 1999). The qualitative aspect of capacity concerns the ability for noiseless transfer, while the quan- titative aspect refers to the redundancy of the transferred information. Richness refers to the possibility to exchange mental representations (Daft & Lengel, 1986). Another closely related concept describing an exchange

of knowledge is knowledge flow (Kumar & Ganesh, 2009). It occurs quite frequently in the knowledge transfer litera- ture (e.g., Appleyard, 1996; Preiss, 1999; Argote & Ingram, 2000; Dixon, 2000; Spencer, 2000; Swap et al, 2001; Foss & Pedersen, 2002; Bontis et al, 2003; Cantwell & Mudambi, 2003; Snider & Nissen, 2003; Nissen, 2006; Mu et al, 2008). Nevertheless, the concept as such has been the prime focus of research in only a few studies despite its potential as a more precise expression related to the phenomenon of knowledge transfer. The literature so far has approached knowledge flows

mainly as a part of a particular knowledge management process, such as knowledge creation. The most familiar approach to the flow of knowledge is Nonaka’s (1994) view of knowledge creation. Nonaka studied four different types of knowledge flows that are illustrated by the SECI model (Nonaka & Takeuchi, 1995). The SECI model has been criticized for its conceptual focus and it has been claimed that the model does not provide any prac- tical way of analysing knowledge flows (Nissen & Levitt, 2002). This criticism reflects the practical need for empiri- cal studies to concretize the conceptual approaches and to enhance the current understanding about the flow of knowledge (cf. Simonin, 2004; Riege, 2007). Later on Nonaka et al (2008) discuss ‘process theory’, in an attempt to open up the black box of knowledge creation. They state that it always deals with ‘the process in which individuals with different values and perspectives relate with each other and with the environment’. Thus, in addition to a more practical theory, the role of the environment and inter-organizational knowledge flow have also been emphasized more recently (cf. Bell & Zaheer, 2007; Easterby-Smith et al, 2008; Van Wijk et al, 2008; Phelps et al, 2012). Defining knowledge flows exhaustively is not straight-

forward. In their definition Mu et al (2008) state that knowledge flow comprises the set of processes, events, and activities through which data, information, and knowledge are transferred from one entity (person or system) to another. This definition is still quite abstract and requires concretization. It does not specify how the knowledge actually flows. The next section aims to bridge this gap between existing theory and practice by illustrating the concrete embodiments of knowledge transfer from the health-care system management viewpoint.

Research methods The paper reports the findings of a 3-year case study of managerial knowledge flows in a regional health-care system in Finland. The study was conducted between 2005 and 2007. A case study approach (e.g., Stake, 1994; Yin, 1994) was appropriate to obtain detailed information on the conditions, critical events, and processes of a single entity (Jensen & Rodgers, 2001). It was expected that this in-depth understanding would also have theoretical impli- cations (cf. Eisenhardt, 1989; Stake, 1994). The Health Care District of Forssa (FSTKY) was the subject of the research, a federation of five municipalities that started as a joint municipal health-care authority at the beginning of 2001. The population in the area is about 35,000. The federation provides primary health care, specialized health care, mental health care, environmental health care, and A-clinic services (operations to reduce alcohol, drug, and other addiction problems) for the inhabitants of its area in southwestern Finland. The federation employs about 700 people. The qualitative data was gathered in three phases in

order to gain a wide perspective on the phenomenon (cf. Eisenhardt, 1989). After each phase, a summary report of the findings was provided for the organization in order to foster continuous interaction between practitioners and the researcher, and to validate the relevance of the inter- pretations made. In the first phase, the author observed the management group meetings for a period of 7 months. During this period a total of nine meetings were held and their durations varied from 1.5 h to 3.5 h. All the meetings were tape-recorded and transcribed. On the basis of this data, preliminary categorizations of managerial knowledge flows were formed. In the second phase, the knowledge flows of one treat-

ment process (i.e., neurological treatment chain/diagnosis of dementia) were modelled. In this phase, four interviews with the key participants (i.e., chief physician, health centre physician, system support specialist, and quality and development manager) were conducted. This phase of the study provided valuable insights into the accumula- tion of internal control information and the status of knowledge-based decision making in FSTKY. In the third phase, after the analysis of the preceding phases, the leading office holders of the FSTKY were interviewed (n = 7). During these interviews conceptualizations of the earlier phases were discussed and iterated. The interviews focused on both the current knowledge-related challenges and the future knowledge needs of the interviewees. The overall purpose of the empirical phase was to

identify the knowledge structures and respective flows that managers utilize in their knowledge formation, and there- fore only leading office holders were interviewed. The data provides a many-sided picture of knowledge flows in health-care system management, although the target group somewhat limits the generalizability of the results. The analysis is based on the theoretical setting described in the previous section and the four aspects of the actors, content, context, and media.

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Results – knowledge flows in health-care system management

Knowledge structures of a regional health-care system A general description of Finnish public health care and its knowledge flows is provided in Figure 1. The figure illus- trates how knowledge flows can be categorized into sub- categories by posing simple questions: who, what, and to whom (cf. Albino et al, 1999; Jasimuddin, 2005). This conceptualization already helps managers in assigning responsibilities and communicating the importance of different knowledge-related tasks. In the figure the arrows represent the three main cate-

gories of knowledge flows identified during the first empirical phase (observation): (1) national information steering, (2) regional information steering, and (3) internal control information. The steering is two-way at all levels: health-care organizations are steered but at the same time they are also able and expected to participate in the steering through their feedback and opinions. Information steering in the Finnish context refers to

a public policy instrument, the purpose of which is to provide information for service producers to develop their own operations (cf. Vedung & van der Doelen, 1998; Syväjärvi et al, 2007). Despite the usage of the term ‘information steering’, this policy instrument also includes the application of methods that refer more to data and also knowledge. This relates to a more general issue concerning the Finnish language, which has no separate

words equivalent to English ‘data’, ‘information’, and ‘knowledge’. ‘Knowledge’ can refer to any of these depend- ing on the context. Here, the term ‘knowledge flow’ is preferred because the aim of these flows is to improve managers’ decision-making capabilities, which always requires interpretation. Thus in the following discussion and analysis, knowledge flows contain data, information, or knowledge, depending on the situation. For practical purposes, this definition had to be made. During the interviews it was fairly easy to distinguish whether the interviewee was referring to data, information, or knowl- edge. When an interviewee talked about operational infor- mation systems s/he was referring to data, in the case of reports and research publications the focus was on information and if the source was a meeting with a colleague it was reasonable to consider this as a transfer of knowledge. The above description provides a good starting point for

analysing the knowledge structures of the health-care system, but a more detailed analysis is needed when seeking the concrete bottlenecks in knowledge transfer. However, it is also important to picture each organization within a wider system in order to ensure that all the important stakeholders are taken into account.

Knowledge flows in national information steering Each upper-level knowledge flow illustrated in Figure 1 can be further categorized in several ways by asking the

Regional health care systems

Interest groups

- Political parties

- Media

- Elected officials

- Customers

- Other opinion leaders

Regional information steering

Feedback

National information steering Health care programs

Quality guidelines Handbooks

Performance indicators

In h a b ita

n ts

o f m

u n ic

ip a lit

ie s

National health care system

Health care organization

Public Private 3rd sector

Patient work

Admin./Health care specialists

Figure 1 Knowledge structures of a regional health-care system. Source: Laihonen (2012).

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same questions as above: who, what, and to whom. In the case study the process was continued with a more detailed analysis of the actors (who and to whom). However, it became evident that this approach was closely connected to the analysis of the content of knowledge flows (what), and the selection of an appropriate context and media for transferring the knowledge. The chosen approach enabled, for example, a more

detailed analysis of national information steering. This led to the separation of knowledge flows that relate to a certain health-specific area of expertise from the more general information steering (i.e., health care in general, or further, a certain specialty area, like surgery). Profession- based information steering represents the other end of the continuum. This steering relies on personal interaction and the exchange of tacit knowledge. It is also important to note that doctors and other health-care specialists are typically steered by the experts of their own specialty area as one of the interviewees pointed out:

Professional steering is strongly based on collegial discus- sions – knowledge seeking and sharing, different opinions – that finally lead to or crystallize into a shared understanding and vision

Advances in medical science are likewise typically dis- cussed together with the specialists from a certain area and these knowledge flows are clearly distinguishable from the administrative steering that concentrates on very different issues and is operationalized in very different terms:

Administrative steering represents quite an opposite type of steering – it is very black and white. Letters, instructions, and orders are delivered in a very simple form. The message is inserted into a conduit and the rest is up to the receiver. There is very little room for discussion.

More detailed analysis of administrative steering revealed that it is possible to separate the central govern- ment’s information steering from other administrative guidance. The former happens, for example, through formal written communications from the ministries, offi- cial statistics, national development programs, and the communication of health policies. These flows dissemi- nate strategic information and it was found that the citation above refers more to this steering by the govern- ment agencies. Other administrative steering relates more to tactical and operational management and is based more on interaction but also involves the dissemination of instructions and guidelines. The former can be considered as vertical steering, whereas the latter typically concen- trates on horizontal steering and concerns more practical and local issues of public administration. Table 1 cate- gorizes national information steering into three categories and also presents some examples of such steering. The categories also differ regarding the content of steer-

ing. The emphasis is on different types of knowledge, that is, data, information, or knowledge. The categories are also differently positioned on the tacit–explicit continuum, which imposes various requirements on the contextual

setting of knowledge transfer and also on the mechanisms and methods used. Thus, content analysis relates closely to the selection of the most appropriate transfer media. For example, profession-based steering is typically based on face-to-face interaction, which is needed for transfer- ring highly specialized tacit knowledge. This emphasizes the richness of the media. In the case of administrative steering, such as statistical data or other explicit material, the capacity of the media is more important. The selection of the appropriate media and context also represents a strategic choice between codification and personaliza- tion strategies (cf. Hansen et al, 1999).

Knowledge flows in regional information steering Similar categorizations can be conducted at the various levels of the system. The earlier literature and public discussion in Finland have focused on information steer- ing at the national level because at this level it constitutes an official policy instrument. However, the role of infor- mation steering and the respective knowledge flows is not restricted to national level. In the case study, a similar analysis was conducted at the regional level, where regional information steering was categorized into sub- categories of regional governance, regional development, and regional operations management (see Table 2). Again, the categories were formed on the basis of the

participating actors. Concerning regional governance, the actors were the five municipalities, as the owners of the FSTKY, and at the other end the management of FSTKY. This category concerns strategic management and top-level regional decision making. FSTKY as a federation of municipalities constitutes its own political system and therefore knowledge transfer among the governing parties plays a significant role in regional development. Interviewees highlighted the reciprocal nature of knowl- edge transfer in this context. Leading office holders have a major role in the preparation of upcoming major decisions, especially when these are expected to have a significant financial impact. Thus, these knowledge flows cover more than mere information provision. In general, regional processes were regarded as more inter- active than governmental steering, which was mostly due to the spatial proximity of the actors and the trust accumulating over years of continuous face-to-face inter- action at the local and regional level. Knowledge flows of regional development were consid-

ered to be extremely important components of a system’s knowledge structures because they encapsulate opinions and knowledge arising bottom-up. These flows are impor- tant constituents of tactical steering because it is through these that the best possible approaches and operating methods are developed for this particular area. Further- more, knowledge flows related to regional operations management address the knowledge needs of operative guidance and continuous development. Together these two latter categories form knowledge structures that enable top management and various functional units to

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Table 2 Categorization of regional information steering

Regional governance Regional development Regional operations management

Sender Owners (five municipalities and their administrative bodies), Federation council

Employees, inhabitants of the owner municipalities

Management group, top management, divisional management

Receiver Management group Owners (five municipalities), management group, top management

Functional units

Context/content Strategic management Tactical management Operational management and development Examples of the steering parties and content of the steering

Guidelines and recommendations from the county administration

Assimilation of external knowledge Control and process information provided by the patient information system

Self-assessments Regional (internal) development projects, regional co-operation

Information from administrative information systems (HR, finance, etc.)

Regional development projects and evaluations Development initiatives from the personnel, feedback from the customers

Framework agreements and purchasing contracts

Table 1 Categorization of national information steering

Central government’s information steering Administrative information steering Profession-based information steering

Sender Governmental agencies Administrative specialists Medical/nursing professionals Receiver Municipalities, federation council and

executive board, management group Administrative specialists based on functional responsibilities Medical/nursing professionals

Context/content Health policy, strategic management Administrative guidelines, tactical/operational management Professional development and knowledge sharing Examples of the steering parties and content of the steering

Guidelines and recommendations from the ministries and county administration

Administrative guidelines, evaluations, and education from the Finnish Local and Regional authorities

National institute for health and welfare

National statistics Administrative guidance from the hospital districts Care guidelines by the Finnish Medical Society Duodecim National development projects and evaluations

Framework agreements and purchasing contracts Professional Interest groups (medical and nursing associations, training, publications, visits, seminars)

The social Insurance Institution of Finland Best practices concerning human resources management, financial management, and information management

Research, pharmaceuticals (international and domestic)

A m a n a g eria

l v ie w

o f th

e k n o w le d g e flo

w s o f a h e a lth

-ca re

syste m

H arriLaih

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K n o w led

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interact and guide the organization towards the pre-set objectives. The health-care system studied relies heavily on

the mere existence and transfer of information; it does not systematically accumulate this information into valid control information as described by one of the interviewees:

We don’t have shared data warehouses that would enable the combination and collation of data from different sources. Combination is done in Excel, some information taken from the patient information systems, some from the financial systems.

This also illustrates the interconnectedness of knowl- edge flows; data and information about operational pro- cesses should create the basis for tactical and strategic decision making. This is a bottleneck also recognized in the literature on health-care knowledge management. Information systems provide an efficient method for transferring patient-related information within opera- tional processes (cf. Williams et al, 2006; Avillach et al, 2008; Lemire, 2010; Lloyd-Bostock, 2010), but the man- agerial perspective has not received enough attention. Knowledge flows smoothly in clinical care pathways, especially within an organization, but does not accumu- late into strategic insights. Problems arise when patients cross organizational boundaries and when the discussion turns to the effectiveness of cross-organizational services.

We don’t have such tools that would enable us to evaluate certain customer processes. We don’t have tools for analyz- ing service processes, we are able to monitor outputs and financial issues, but we don’t get any direct feedback about the actual processes – to illustrate the quality and effective- ness of our services.

The last two quotes also exemplify a wider technical issue concerning several more or less unconnected infor- mation systems. The fragmentation of data and informa- tion between information systems and expertise between professionals challenge the seamless flow of knowledge, which results in breaks in service processes.

Discussion: knowledge flows in health-care system management

Contribution to the knowledge management literature This study contributes to the knowledge management literature and to the discussion on knowledge transfer in particular by illustrating a practical way of analysing knowledge flows. This has been noted as a deficiency in the knowledge transfer literature (Nissen & Levitt, 2002; Riege, 2007). It has been argued that the literature focuses more on factors impeding or stimulating transfer than on empirically tested solutions (Riege, 2007). To help bridge this knowledge gap, the paper studied knowledge transfer as an underlying phenomenon and knowledge flows as its practical manifestation. In light of the empirical experiences, the added value of the approach proposed

originates from its practical focus on the concrete flows that transfer knowledge and generate value from organizations’ knowledge resources (cf. Løwendahl et al, 2001; Schiuma et al, 2007; Schiuma, 2009). The existing approaches highlight the dynamic nature of knowledge, but remain at a fairly general level concerning the ways in which value creation actually takes place. The empirical evidence implies that practitioners ana-

lyse knowledge transfer in small and concrete parts, and that ‘knowledge flow’ offers them a conceptual tool for communicating this abstract issue. Consequently, knowl- edge flow can be defined as the concrete process in which certain knowledge is transferred from the sender to the receiver. This definition is consonant with various defini- tions of knowledge transfer (e.g., Cutler, 1989; Albino et al, 1999; Hendriks, 1999; Argote & Ingram, 2000; Bender & Fish, 2000; Kalling, 2003) but also adds an important practical aspect by focusing on individual trans- fer processes. A particular knowledge flow can serve as a primary impulse for interaction or as feedback on a preceding knowledge flow. The literature seems to provide a good basis for the

empirical analysis of knowledge flows despite the criti- cism; the empirical examination revealed aspects very similar to those reported in the literature. The roles of openness and willingness to share knowledge, trust, and previous knowledge that have been recognized as the drivers of knowledge transfer in literature (Wathne et al, 1996; Cruz et al, 2009) were also deemed important in practice. However, before actors can engage in interac- tion, a strategic decision needs to be taken on how this interaction is supported by the health-care system and the individual organizations. Depending on the content (explicit or tacit) either technical tools or a physical location for the knowledge transfer must be provided (cf. von Hippel, 1994; Simonin, 1999; Argote & Ingram, 2000; McEvily & Chakravarthy, 2002). It is also important to engage the right people and to select the right content for this audience (cf. Ko et al, 2005). Currently, a lot of information (e.g., from research institutes, various non- profit organizations, and even governmental institutions) is merely fed into all possible channels and steering parties simply hope that this information will reach the right people and influence their behaviour. The suggested four- fold approach (i.e., to actors, content, context, and media) is also applicable as a managerial tool. Another contribution of the paper originates from its

system perspective. When seeking system-level productiv- ity improvements (cf. Lönnqvist & Laihonen, 2012), inter- organizational cooperation increases the complexity of knowledge transfer (Easterby-Smith et al, 2008; Van Wijk et al, 2008). This was clearly also detected in the empirical study and was one reason why external steering was divided into national and regional information steering and why internal control information was separated from the external knowledge sources. Depending on where the boundaries are drawn, the nature of knowledge transfer changes, for example, due to cultural differences as well as

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trust, power, and credibility issues among system mem- bers, which are all also affected by the geographical posi- tion of organizations (cf. Easterby-Smith et al, 2008; Van Wijk et al, 2008; Phelps et al, 2012). These clearly also have managerial implications. The paper presents as evidence the diversity of actors participating in health-care manage- ment and various knowledge flows disseminating knowl- edge within the system. It also dispels the ambiguity of knowledge in health-care management and enhances the understanding about the mechanisms of knowledge transfer in this particular context. Related to the systemic analysis of knowledge flows, the

paper also raises an important issue concerning the pro- blems in process-specific approaches presented in the earlier knowledge transfer literature. Focusing exclusively on a certain process (e.g., knowledge creation or learning) may lead to an incomplete understanding of knowledge transfer and cause sub-optimization or bottlenecks in knowl- edge transfer, either within an organization or between the actors of the health-care system. The approach proposed aims to overcome these problems by stressing that the efficiency of knowledge transfer should be a central con- cern not only for individual organizational functions (e.g., clinical care pathways, human resources, or customer relationship management). The mapping and analysis of knowledge flows should also be approached from the perspective of the health-care system as a whole. The understanding of the health system as a knowledge system builds up gradually from individual patient encounters, but the most influential effects are achieved when this information is compiled and analysed in larger parts; this alone reveals the true effectiveness of health services. Finally, an important lesson from the empirical study

relates to the often irrational and ad hoc nature of knowl- edge flows. Whereas the literature considers knowledge transfer and knowledge flow more or less as a rational and intended process, in practice it often occurs in a haphazard manner, that is, without being planned and without a clear purpose. This irrational aspect of knowledge trans- fer has not been very thoroughly discussed, although sudden and ad hoc knowledge processes spring up con- tinuously. This notion turns the focus from the strictly defined transfer processes to the enabling structures that make it possible for the participants to become engaged in the transfer in the first place. The managerial implica- tion of this is to concentrate on building those enabling structures instead of controlling and planning each and every single transfer process. Institutional structures and predefined knowledge flows can promote knowledge transfer, but this is not the whole truth about knowledge management in health care.

Managerial implications The implications of the study for health-care management originate first from its managerial and second from its system perspective. The literature has focused more on the application of information technologies and systems

to clinical work (e.g., Williams et al, 2006; Avillach et al, 2008; Lemire, 2010; Lloyd-Bostock, 2010) and the role of knowledge transfer in building up the expertise of health-care professionals (Pentland et al, 2011). To break free from organization-specific and technology-oriented thinking, the paper utilized the concept of ‘knowledge flow’ as a research instrument and studied how knowledge flows within a health system. The viewpoint was manage- rial; the aim was to understand how managers perceive their knowledge environment. Empirical experiences suggest that the categorization of

knowledge flows helps practitioners to gain an improved understanding about their knowledge environment. Cate- gorization offered a structured way to understand how the knowledge resources are combined and transformed (cf. Laihonen & Lönnqvist, 2010). Practitioners found the knowledge flow analysis to be a simple and practical way of enhancing their understanding of the knowledge dynamics of the health-care system. According to the empirical findings, inter-organizational knowledge flows and external knowledge seem to play an important role in the renewal of the health-care system. Thus, internal information about the efficiency of services needs to be complemented with the external perspective. An analysis of who transfers knowledge to whom, what is transferred, in which context, and through which media (the transfer happens) (Albino et al, 1999; Jasimuddin, 2005) offered a practical way to analyse the surrounding knowledge environment:

This kind of thinking and theoretical approach offers a method for understanding and simplifying the overwhelm- ing amount of knowledge – which is valuable.

The empirical examination also revealed the well-known distinction between two dominant knowledge strategies: personalization and codification (Hansen et al, 1999). Typically these two strategies are considered from the viewpoint of one organization, but the study showed that these are also highly relevant for system-level analysis and management. There is a clear need to contemplate information steering also from this perspective. Defining and concretizing knowledge strategies not only clarifies the roles of different steering parties but also helps practi- tioners to identify the most valuable steering for their particular area. The main question that arises concerns who bears or could bear the responsibility for the whole service system, who is responsible for balancing the var- ious information steering activities at the national level, and how the regional-level steering can be coordinated. An important practical observation also relates to the differ- ence between knowledge transfer and knowledge sharing. To improve the effectiveness of information steering, a distinction should be made between an intended and focused knowledge transfer and unintended knowledge sharing (cf. King, 2006). For some knowledge, sharing is satisfactory, but, as the empirical examination pointed out, there are numerous occasions where sharing is not enough; a more focused and decisive approach is needed.

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Considering the self-organizing nature of modern health- care systems and their knowledge processes (Laihonen, 2006, 2012), these questions are difficult political issues. Codification strategy applies well to some kinds of

steering. From the viewpoint of an individual health-care organization the management challenge then concerns the integration of external knowledge, and the first task is to recognize the most important information sources and to build knowledge structures and practices that support efficient knowledge transfer. However, there are numerous situations requiring a more personal approach. Trust and motivation to learn also improve when steering is interactive and personal. Thus, a personalization strategy should be preferred especially in the case of extremely ambiguous and tacit knowledge. This is important to bear in mind to balance the general dominance of technical approaches in the area of health knowledge management. The categorization proposed helps to understand the scale and complexity of the knowledge management of the health-care system – it is not just about the clinical information systems and explicit knowledge. In addition, individuals’ attitudes, capabilities and tacit knowledge, working methods and knowledge networks at each sys- tem level should be taken into account in the pursuit of productivity improvements and appropriate ways to orga- nize future health care.

Concluding remarks In light of the foregoing discussion, it is proposed that a knowledge flow approach provides a practical way for understanding the dynamics of a health-care system. By analysing knowledge flows, managers can get a concrete grasp of the phenomenon of knowledge transfer and target their management efforts at the most meaningful knowl- edge-based activities. It is also argued that the approach has theoretical value – it is a step towards a more practice- oriented theory of knowledge transfer. A special focus on knowledge flows helps in identifying

concrete activities where the sender delivers knowledge

to the receiver. As the paper illustrated, the transfer of certain knowledge from the sender to the receiver often necessitates not only the usage of a different context and medium, but also reciprocal interaction and conversa- tion. From the theoretical perspective, this paper contri- butes to the discussion on the phenomenon of knowl- edge transfer. Despite the wide variety of knowledge transfer literature, it seems that the practical applications still lack those groundbreaking ideas and examples that would explain how the theoretical principles could be put into specific terms and utilized in practice. The knowledge flow approach proposed offers a concrete method for practitioners at the various levels of the health-care system to recognize, understand, and, above all, concretize such phenomena that might otherwise go unrecognized. The practical relevance of the analysis presented is

significant because it disengages from the prevailing tech- nology-oriented approaches and seeks answers to more profound questions about the role of knowledge in health- care management. This is a timely issue because modern health-care systems are dynamic and evolving structures for which knowledge is a critical resource. For practi- tioners, the paper provides a simple way to proceed. First, it stresses the recognition of the actors (sender and recei- ver). This helps in classifying the knowledge flows used for the actual knowledge transfer. Second, the content of the transfer should be taken into account when selecting the context and media for knowledge transfer (e.g., face-to- face or technical solutions). These fairly simple managerial guidelines originate from the theoretical discussion on knowledge transfer but are not yet fully implemented. The categorization of knowledge flows proposed illustrates the range of knowledge that needs to be taken into account and managed in the Finnish context. Failure to identify the variety and range of knowledge flows may be one reason why practitioners are still struggling with their transfer processes despite the richness of the existing knowledge transfer literature.

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About the Author Harri Laihonen is a Research Fellow at the Department of Information Management and Logistics, Tampere Univer- sity of Technology, Finland. His research focuses on

knowledge-based value creation and the management of service performance.

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