Proactive management of knowledge is today seen as a key strategy to ensure the performance and success of organizations or systems. [1] In a 2020 systematic review conducted by Hill, Stephani, Sapple and Clegg [2] where continuous quality improvement appeared effective, collaboration and communication between health care professionals appeared important. A major challenge to integrating evidence into practice for conditions such as heart failure (HF) is that it involves a complex process of acquiring and converting both explicit and tacit knowledge into clinical activities. Explicit knowledge is codified information such as peer-reviewed articles, rules and guidelines, which can be readily shared through written documents and other communication channels. [3] Tacit knowledge, in contrast, requires intensive social interaction and exchange. Although both forms of knowledge are critical for effective professional practice and health care delivery, most policy, practice and research activity to improve quality of care emphasizes explicit knowledge. Recent interest and expanded research activity examining Communities of Practice (CoPs) and related concepts are beginning to redress this imbalance, however.
The focus of this article is a CoP known as the “Heart Failure (HF) Provider Network” in the United States Department of Veterans Affairs (VA) Health Care System. Specifically, we describe the formation of this CoP, who participates, and how the CoP works including its various activities. The overarching goal of the HF Network CoP has been to improve the quality of care for HF patients in the VA Health Care System. The method to achieve this is by actively involving a significant number of members from different disciplines across all VA sites. As a CoP, the HF Network is designed to facilitate networking, information dissemination, and collaboration among members.
Communities of Practice (CoPs)
Communities of practice (CoPs) have been used in the health sector to support professional practice change. [4] They enable the diverse wealth of knowledge embedded in people, local conditions and special circumstances to flow from practice domain groups to program and service areas, and into the larger system where it can effect organizational change.[5] In 1991 Lave and Wenger [6] developed the concept of the CoP. They suggested that learning takes place in social relationships rather than through the simple acquisition of knowledge. These informal communications became the means for sharing information for improving practice and generating new knowledge and skills. In 1998, Wenger [7] proposed three CoP dimensions: mutual engagement (the interaction between individuals that leads to the creation of shared meaning), joint enterprise (the process in which people are engaged and work together towards a common goal), and a shared repertoire (the common resources and jargon that members use to negotiate meaning within the group). Later in 2002 Wenger, McDermott and Snyder refined the description of CoPs as 'groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis. [8] They identified three essential characteristics of CoPs: 1) the 'domain' creates common ground (i.e. the minimal competence that differentiates members from non-members), and outlines the boundaries that enable members to decide what is worth sharing and how to present their ideas; 2) the 'community' creates the social structure that facilitates learning through interactions and relationships with others; and, 3) the 'practice' is the specific knowledge that the community shares, develops, and maintains. Wenger et al. purported that a well-developed CoP group (i.e. when the three elements work well together) provides an environment that facilitates learning and knowledge development. [8]
Li has argued [9] that the literature is less clear on how to foster the three CoP elements, especially at the early stage. To improve their understanding about the use of the CoP concept, they conducted a research synthesis project to explore how the concept was operationalized in the business and health sectors. Findings showed that among shared characteristics of CoPs in business and health care, learning and sharing information through socialization appeared to be the central characteristic of the CoP groups. To varying degrees, all CoPs demonstrated four characteristics: social interaction among members (interaction of individuals in formal or informal settings, in person or through use of communication technologies); knowledge sharing (process of sharing information that is relevant to the individuals involved); knowledge creation (process of developing new ways to perform duties, complete a task, or solve a problem); and identity building (process of acquiring a professional identity, or an identity of being an expert in the field).
Wenger and colleagues suggested that an ideal CoP group should include a leader(s)/champion(s), a facilitator(s), a core group of experts who regularly interact with the group, and a dedicated group of members with varying levels of expertise. [8] Their work suggested that organizations can engineer and cultivate CoPs to enhance their competitiveness. According to Bertone and colleagues [1] CoPs represent a potentially valuable tool for producing and sharing explicit knowledge, as well as tacit knowledge and implementation practices.
CoPs have been described as a type of informal learning organization are gaining popularity in the health sector. Some CoPs resemble an informal network, where the goal and structure of the group is loosely defined, and others are similar to support groups, where the main goal is to enhance self-efficacy. [9] One version of a CoP, known as a clinical community, is an emerging approach to quality improvement (QI) to which several largescale projects have attributed some success. [10]
Health Impact of CoPs
While there is evidence for improved process of care, there is limited evidence to show that CoPs affect health care outcomes. In their 2009 literature review from 1991–2005, Li and colleagues [11] found no studies to show improvements in health outcomes of CoPs in the health sector. In another comprehensive review of studies from 1990–2009, Ranmuthugala [12] noted that little is known about the organizational processes that lead to successful creation of knowledge-based structures such as CoPs.
Medical Education
In terms of its implications for medical education, Cruess and colleagues [13] stated that CoPs can serve as the foundational theory, and other theories can provide a theoretical basis for the multiple educational activities that take place within the community, thus helping create an integrated theoretical approach. CoPs can guide the development of interventions to make medical education more effective and can help both learners and educators better cope with medical education's complexity.
Heart Failure (HF) Provider Network
In July 2006, VA’s Chronic Heart Failure (CHF) Quality Enhancement Research Initiative (QUERI) established a CoP consisting of VA members to improve the quality of care provided to HF patients throughout the VA Health Care System. This multidisciplinary CoP is called the Heart Failure (HF) Provider Network.
HF Network Goals
The overarching goal for the HF Network is facilitate knowledge exchange of EBPs and strategies for improving quality of care for HF patients. The specific Network goals are:
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Share evidence-based HF programs.
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Understand and help resolve barriers and facilitators to implementation.
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Establish collaborations/networking.
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Disseminate findings and implement quality improvement projects.
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Provide opportunities to identify/involve opinion leaders and/or local champions.
Creation of HF Network
The HF Network involves HF members at all VA sites (sites) interested in improving HF care. It was rolled out at the national level and initiated with a single email to all known Chiefs of Medicine and Chiefs of Cardiology at the VA sites. They were asked to forward the invitation to all interested VA staff. Those expressing interest are sent an e-mail invitation describing the HF Network, including its purpose, opportunities to present, and next scheduled meeting. Membership grew based on peer/provider recommendations, VA newsletters and VA websites. Existing members may discontinue their membership at any time.
Activities of the HF Network
For our purpose, we chose to map Li’s four characteristics of CoP groups [11] work to the four categories of the HF Network activities: shared ways of engaging, resources, research/QI activities and relationships.
Table 1
Mapping of Li’s Characteristics of CoP Groups to HF Network Activities
HF Network Activities
|
Li’s Characteristics of CoP Groups
|
Social interaction
|
Knowledge-sharing
|
Knowledge-creation
|
Identity-building
|
Shared Ways of Engaging
|
Bi-monthly web-based meetings with conference calls
|
X
|
X
|
X
|
X
|
Annual in-person meeting
|
X
|
X
|
X
|
X
|
Surveys – e-mail text and web-based links
|
|
|
|
|
Email exchange
|
X
|
X
|
X
|
|
Non-mandated forum of VA SharePoint site to exchange ideas
|
X
|
X
|
X
|
|
Revise CHF QUERI Strategic Plan
|
|
X
|
|
|
Networking
|
X
|
|
|
X
|
Resources
|
HF Programs
|
|
X
|
X
|
|
HF Provider Toolkit
|
|
X
|
X
|
|
HF Tools
|
|
X
|
X
|
|
Patient and caregiver education materials
|
|
X
|
X
|
|
Funds for projects
|
|
X
|
X
|
|
Research/QI Activities
|
Expand research activities
|
X
|
X
|
X
|
X
|
Expand QI initiatives
|
X
|
X
|
X
|
X
|
Recruit sites to conduct research and/or QI initiatives
|
X
|
X
|
X
|
X
|
Formative evaluation of HF Network
|
X
|
X
|
|
X
|
Relationships
|
Collaborations
|
X
|
X
|
X
|
X
|
HF experts
|
X
|
X
|
X
|
X
|
New local opinion leaders and champions
|
X
|
X
|
|
X
|
Development of sub-specialty networks
|
X
|
X
|
X
|
X
|
We have used the HF Network to disseminate results of randomized trials (e.g., clinical reminders for beta-blocker use) and to facilitate the implementation of the national quality improvement (QI) initiatives such as the Hospital To Home (VA H2H) initiative to reduce readmissions for Veterans with heart failure. [14] In collaboration with the members we also developed an online HF Provider Toolkit for better management by members. [15]
We have tracked four specific activities to determine members’ “active” participation in the HF Network. The first, and most attended, is the bi-monthly web-based meetings with conference calls. During the web-based meetings the moderators share announcements and updates which are typically followed by two presentations made by members of the HF Network, guests (both VA and non-VA). The second is an annual in-person meeting. The third tracked activity is a periodic online survey to HF Network members. These surveys have queried sites on the presence of local QI projects and members’ views on VA goals related to the care of Veterans with heart failure. The fourth tracked activity is soliciting members of the HF Network to apply for funding for implementation projects from the VA’s QUERI Program funding as well as CHF QUERI’s core funds.
Assessment of the HF Network
Our evaluation of the HF Network can be considered a formative evaluation. Stetler [16] defined formative evaluation as “a rigorous assessment process designed to identify potential and actual influences on the progress and effectiveness of implementation effort. Formative evaluation enables researchers to explicitly study the complexity of implementation.”
Conceptual Frameworks for the Evaluation of CoPs
McKellar [17] reviewed evaluation frameworks for CoPs. It was found that strong claims about generalizability could not be made with limited applications of the frameworks. Richard developed a conceptual model to evaluate an initiative based on a CoP strategy. This model was based on theories of work-group effectiveness and organizational learning and can be adapted by evaluators who are increasingly called upon to illuminate decision-making about CoPs. [18] This model took its strength from two improvements over the traditional input-process-output models. First it used the term “mediation” to explain the transformation of its inputs into outcomes. Further, due to the feedback loops, it depicted that outcomes will have an impact on organizational learning and practices that will necessarily affect individual and group characteristics.
Conceptual Framework for the Evaluation of the HF Network as a CoP
Based on McKellar’s approach [17] we have conceptualized the formative evaluation of the HF Network. Figure 1 highlights the HF Network’s conceptual framework for the evaluation in terms of its various activities (inputs), proximal impacts (mediators) at the individual-level, and its distal and ultimate impacts (outcomes) on implementation of new/improved EBPs at the sites and system-wide level.