Communities of Practice and Innovation Diffusion in UAE Healthcare

Introduction and Statement of the Problem

"None of us is as smart as all of us." — David R. Bender, 2000, p. 5

Today, healthcare organizations are typically characterized by complexity, an enormous investment in infrastructure, and a multidisciplinary cadre of clinicians. These clinicians may or may not be receptive to innovations in technology and product development, depending in some measure on how their colleagues view those innovations. When efficient networks exist among healthcare practitioners, the data-sharing practices needed to communicate this type of information are improved and innovations may be more readily adopted on a widespread basis. According to Rogers (2003, p. 5), diffusion is the process by which an innovation is communicated through certain channels over time among the members of a social system. Communities of Practice are an example of such social systems.

For the diffusion of innovation to be effective in any Community of Practice (CoP) network, the synchronization of the factors of communication channels, rate of adoption, and characteristics of the social system—from both a social and communication structure perspective—must be taken into account. To the extent that these factors are in alignment with each other is the extent to which there is an effective diffusion of innovation (DoI), optimization of resource allocation, and the stability to create an ethical framework. When a CoP has attained this level of efficiency across these three dimensions, the tendency of its structure to create a learning ecosystem also begins to emerge (Chang & Harrington Jr., 937). Learning ecosystems help to minimize resistance to change by concentrating on assimilating knowledge through reciprocal sharing of insights, the creation of process-based taxonomies, and the development of governance frameworks for continual improvement and growth (Grossmeier, 346).

The main purpose of this dissertation was to develop timely and informed answers to the following guiding research question and sub-questions concerning the diffusion of innovation and its application in the UAE healthcare system:

RQ: Do social networks and communities of practice (CoP) exist in the UAE healthcare system, and can leaders be identified?

Sub-question 1: How can CoP data be used to improve the diffusion of new innovation between healthcare professionals?

Sub-question 2: How can pharmaceutical companies activate CoP networks to improve their resource allocation?

Sub-question 3: How can pharmaceutical companies harness the benefits of CoP within their ethical framework?

Improvements in the competitiveness and productivity of nations today depend on the introduction and diffusion of innovation among firms (Vazquez-Barquero, 2002). The diffusion of innovation throughout healthcare organizations often begins in the knowledge management, support services, and decision support systems areas, due to these processes having a direct impact on quality of care (Wong, Legnini, Whitmore, & Taylor, 2000, p. 249). Moreover, researchers, theorists, and practitioners from many fields are interested in and affected by the diffusion of innovations within and across organizations, including organization development, education, management, healthcare and public health, information technology, and sociology. Many of these fields share an interest in organizational improvement, yet there is evidence that innovations often are not diffused within and across organizations to achieve that improvement (Lundblad, 2003, p. 50).

A few examples illustrate the issue and provide background for why diffusion of innovation is an important topic from both theoretical and practice perspectives. In healthcare settings, new clinical and process advancements are continuously developed in research and practice, yet these innovations often take years, if not decades, to spread into wide use (Lundblad, 2003). Process innovations are often low- or no-cost changes that a healthcare delivery organization can make—such as reminder systems, care pathways, and clinical guidelines—yet they still do not find their way into routine practice (Lundblad, 2003).

The propensity of a CoP to serve as the catalyst for creating greater levels of knowledge transfer and corresponding trust is also a key determinant in the productivity of healthcare communities throughout regions (Fuentelsaz, Gomez, & Palomas, 1172). From a more pragmatic perspective, in order for the UAE healthcare community to nurture and grow CoPs, there must be a concentration on knowledge sharing, the evaluation of new medical products (Carter, 20) to more efficiently and completely treat patients, and a recognition that continual improvement will require continual measurement as well (Inamdar, Kaplan, & Reynolds, 179).

Any CoP must also be outward-centered, attending to the unmet needs of professionals in the UAE healthcare community who seek to continually improve and learn. Any CoP, to stay relevant, must maintain this outward-facing set of priorities—not only regarding recently introduced medical technologies (Carter, 20) and their implications for broader technology acceptance and adoption (Bernstein, McCreless, & Cote, 17), but more importantly regarding their diffusion through the UAE medical community (Huesch, 1270). There must also be an element of environmental scanning for best practices and approaches that drive the greatest increases in efficiency in critical healthcare processes if the CoP is to grow in its value to members. In this regard, Lee and Valderrama (2003) note that "CoPs are created to connect individuals with a common interest, so they can exchange knowledge objects, best practices, and lessons learned" (p. 29).

In sum, for any CoP to be effective, there must be constant attention to learning and to allowing for the gradual diffusion of innovation based on the level of acceptance to change within the CoP itself. Inherent in this gradual diffusion of innovation is also the concept of a maturity model. Therefore, for any CoP to continually meet the needs of its members, a maturity model of diffusion must be created and fine-tuned over time so that the CoP will stay relevant, continually accumulating and sharing knowledge with its members.

Etienne Wenger provides a useful definition of communities of practice as groups of people who share a concern or a passion for something they do and want to learn how to do it better through regular interactions with each other. Communities of practice can provide the framework in which group members interact effectively with peers through rapid, technology-enabled communications to discuss timely issues of mutual concern in a collaborative effort to solve problems and obtain recommendations (Hemmasi & Csanda, 2009, p. 262). Consequently, mature communities of practice are capable of assisting organizations in making the transition from a traditional multidivisional, or M-form, organization into a more competitive learning, or L-form, organization (James, 2002).

According to Wenger (1991) and Hemmasi and Csanda (2009), the primary characteristics that identify a group as a community of practice include: (a) a recognized domain of interest that group members share and commit to, (b) relationships between group members that allow them to engage in joint activities, share information, and help each other, and (c) the development of a shared practice consisting of experiences, stories, tools, shared resources, and so forth. Likewise, Wesley and Buysse (2001) emphasize that, "Compared to other collaborative research-practice approaches that appear in the literature—such as action research or professional development schools—communities of practice may offer the most promise for altering the linear relationships through which information is handed down from those who discover the professional knowledge to those who provide and receive services" (p. 114).

Literature Review: Communities of Practice in UAE Healthcare

The ability of practitioners to develop shared knowledge in these environments is not an automatic process; rather, it requires that community members actively engage in information-sharing processes that help consolidate and use available information in ways that define sets of best practices. Since the goal of such communities of practice is not static or restricted to a single area of investigation, the development and maintenance of communities of practice tends to forge enduring relationships among their membership, resulting in viable networks characterized by solid relationships and trust (Buysse, Sparkman, & Wesley, 263).

Moreover, CoPs develop their practice by improving the diffusion of innovation within their active networks; the benefits of such interactions are countless, especially in the field of healthcare. Specialty physician communities present an exemplary case for CoPs because they share the same practice, interest, and professional ethos. It is therefore instructive to study whether those CoP networks exist in the United Arab Emirates, whether they are active, and whether leaders can be identified. Collecting such data enables this project to measure whether the rate of diffusion of new innovations can be improved and, hence, be used by pharmaceutical companies in the UAE to improve their resource allocation—all within healthcare's ethical framework.

The UAE currently has 40 public hospitals, a number that represents a major increase from just seven in 1970 (UAE country profile, p. 7). Moreover, the UAE Ministry of Health has launched a multimillion-dollar program to enlarge the country's existing health facilities and hospitals and medical centers to serve all seven emirates (UAE country profile, p. 7). An ultra-modern general hospital has been constructed in Abu Dhabi with a projected bed capacity of 143, including a trauma unit, and will serve as the framework for the development of a home healthcare program in the UAE. In addition, in an effort to attract affluent UAE nationals and expatriates who have traditionally traveled abroad for their healthcare services, Dubai is also developing Dubai Healthcare City—a facility that will offer state-of-the-art, evidence-based private healthcare services to UAE consumers as well as serving as an advanced academic medical training center (UAE country profile, p. 7).

There is also a growing need for heart specialists in the UAE, with the current principal cause of death being cardiovascular disease, accounting for fully 28% of all deaths in the country (UAE country profile, p. 7). Additional significant causes of death include accidents and injuries, malignancies, and congenital anomalies (UAE country profile, p. 7). In addition, the UAE launched a national initiative in 1985 designed to prevent transmission of acquired immune deficiency syndrome (AIDS) and control its entry into the country—an initiative that has proven effective. According to World Health Organization estimates, in 2002–2003 there were fewer than 1,000 people in the UAE infected with the human immunodeficiency virus/AIDS (UAE country profile, p. 7).

A brief overview of healthcare metrics for the UAE is provided in Table 1 below.

Table 1: Healthcare Overview of the UAE

Birth rate, crude (per 1,000 people): 15.59 [121st of 195] | Children underweight rate: 3% [61st of 95] | Contraception: 28% [63rd of 89] | Dependency ratio per 100: 36 [167th of 166] | Drug access: 95% [50th of 163] | HIV/AIDS adult prevalence rate: 0.18% [104th of 136] | Hospital beds per 1,000 people: 2.2 [43rd of 149] | Life expectancy at birth, female: 78.56 years [74th of 226] | Life expectancy at birth, male: 73.35 years [69th of 226] | Life expectancy at birth, total population: 75.89 years [71st of 225] | Life expectancy at birth, total (years): 79.18 [23rd of 194] | Maternal mortality: 3 per 100,000 [135th of 136] | Physicians per 1,000 people: 2.02 [50th of 148] | Probability of not reaching age 40: 5.4% [97th of 111] | Probability of reaching age 65, male: 75.8% [35th of 159] | Smoking prevalence, males (% of adults): 17.3% [36th of 42] | Health spending per person: $1,428 [21st of 133] | Total expenditure on health as % of GDP: 3.1% [176th of 185] | Water availability: 58 cubic meters [168th of 169]

Source: NationMaster, 2010

The UAE is also considered to have the best telecommunications network in the entire Arab world, with the highest voice connection and broadband Internet connectivity capacity per capita; in addition, the UAE has the lowest mobile-phone rates in the Arab world (US$0.06 per minute) (UAE country profile, p. 19). According to U.S. government analysts, in 2005 the UAE had more than 4.5 million mobile cellular telephone subscribers, compared with 1.2 million landlines in use (representing penetration rates of 101 and 28 lines per 100 residents, respectively). Domestic lines use microwave radio relay, fiber optic, and coaxial cable technology (UAE country profile, p. 19). Furthermore, as of 2009, the UAE had almost 400,000 Internet hosts and nearly three million Internet users, clearly indicating the country's ability to facilitate the communication requirements for both traditional and virtual communities of practice.

One of the most developed and widely practiced models across many types of organizations today is the community of practice (Brown & Duguid, 2000). This is particularly true in process-intensive operations such as healthcare (Hemmasi & Csanda, 2009). According to Bounfour (2003), "The installation of 'communities of practice' has as its ultimate goal the organisation of a dynamic dialogue between the tacit knowledge of individuals and the formalised knowledge of the firm" (p. 164). The research to date suggests that communities of practice appear to be an evolution, continuation, and amplification of the team concept (Wenger et al., 2002).

Although conventional teams have been highly successful over the years, communities of practice appear to be particularly well suited to provide additional benefits by being more responsive to the opportunities and challenges of today's rapidly changing environment, growing global competition, and ever-advancing information technology. Moreover, communities of practice can provide organizations with the framework they need to ensure that the tacit or implicit knowledge present in an organization is not lost, by forging connections between individuals who share comparable interests in ways that help diffuse information to all community members (Hemmasi & Csanda, 2009). As Droege and Hoobler (2003) point out, CoPs are structures that can effectively prevent loss of tacit knowledge associated with employee turnover by providing the connections necessary for transfer and retention of knowledge.

One of the original groups consistently cited as being among the pioneers in the formation of communities of practice concerned machine repairmen for Xerox (Brown & Duguid, 2000). The results of a study of these community members showed that working in knowledge-sharing groups can help transform companies into learning organizations. A more recent study by Anand, Gardner, and Morris (2007) of consulting firms documented the efficacy of communities of practice as effective knowledge-based frameworks that help fuel innovation. Likewise, a review of communities of practice adoption by the government of the Netherlands conducted by Kranendonk and Kersten (2007) concluded that these groups represent viable ways to draw on the "wisdom of the crowd" to identify solutions to problems that could not be solved by single individuals. In this regard, McDermott (1999) suggests that there are three basic considerations an organization should address when designing a CoP:

1. The kinds of knowledge that will be shared in the group—i.e., explicit or tacit knowledge;
2. The group's sense of identity; and
3. The extent to which the knowledge shared is integrated into actual work (p. 26).

There have been some conflicting reviews concerning how communities of practice are created and sustained, with some authorities (Wenger, McDermott, & Snyder, 2002) suggesting that the majority of such groups are created voluntarily and informally and that this is a prerequisite for success; by contrast, other authorities (Perry & Zender, 2004) have found that it is possible for professional communities of practice to be formed in purposeful ways that contribute to their sustainability (Hemmasi & Csanda, 2009).

Lave and Wenger (1991) are credited with introducing the term "communities of practice" in an attempt to better define the need for forging more cohesive communities and to help legitimize the practices of individuals. By and large, communities of practice concern a group of people who hold in common certain defined beliefs, practices, and understandings that extend over time in an effort to achieve a common goal (Wenger, 1998). Based on his review of recent trends, Roth (1998) believed that these emerging communities "are identified by the common tasks members engage in and the associated practices and resources, unquestioned background assumptions, common sense, and mundane reason they share" (p. 10). Lave and Wenger defined a community of practice as follows: "[Community does not] imply necessarily co-presence, a well-defined identifiable group, or socially visible boundaries. It does imply participation in an activity system about which participants share understandings concerning what they are doing and what that means in their lives and for their communities" (p. 98).

Definitions of communities, their characteristics, and an individual's participation in a community are all relevant to the manner in which innovation is diffused throughout the network of members. Table 2 below sets forth different types of communities and their corresponding features as identified through studies in anthropology, education, and sociology—features that are particularly relevant to communities of practice.

Table 2: Characteristics of a Community

Common Cultural and Historical Heritage: Communities go beyond simply coming together in response to a specific need. Successful communities have a common cultural and historical heritage that partially captures socially negotiated meanings, including shared goals, meanings, and practices. In communities of practice, new members inherit much of these goals, meanings, and practices from previous community members' experiences in which they were hypothesized, tested, and socially agreed upon.

Interdependence System: Individuals are part of something larger as they work within the context and become interconnected to the community, which is itself a part of something larger—the society through which it has meaning or value. This helps provide a sense of shared purpose as well as an identity for the individual and the larger community.

Reproduction Cycle: It is important that communities have the ability to reproduce as new members engage in mature practice with near peers and exemplars of mature practice. Over time, these newcomers come to embody the communal practice (and rituals) and may even replace longtime members.

Source: Jonassen & Land, p. 37

While every community of practice is unique, some shared fundamental features can help outsiders understand how the network operates and use these insights to gain access to the community in order to help diffuse innovative products and practices. Because there are important shared cultural and historical heritage issues involved in how members interact with each other, cross-cultural differences among community membership may constrain communication on the one hand, while also representing opportunities to forge new bridges that facilitate communication within the network on the other. For example, Day, Zaccaro, and Halpin (2004) emphasize that "Organizations may foster knowledge sharing by creating mechanisms—informal or formal, technological or nontechnological—for [members to] ask one another for advice and offer each other guidance. Knowledge-sharing mechanisms of this kind include communities of practice linking geographically dispersed individuals who share technical or professional skills" (p. 374).

Although cross-cultural in composition, the practices that emerge from these communities will likely be industry- or profession-specific, and may include both professional and social links such as membership in professional organizations, shared adherence to a code of professional conduct, or membership in the same social clubs—all with a primary focus on sharing information concerning issues of mutual interest. As Fincher and Tenenberg (2006) note, "Membership in communities of practice is enacted through the dynamic and continuous interactions on issues of shared interest and meaning" (p. 265). Without continuous interaction, communities of practice wither and die; they therefore require efficient communication networks to facilitate the sharing of all types of information, particularly information that members regard as important to their interests and professional development.

In the UAE, these burgeoning networks are by necessity being redefined as their membership ebbs and flows with differing cultural groups being represented in various proportions over time. As more and more non-UAE citizens become part of the communities of practice being developed in the country, there will be a corresponding need to reevaluate how these networks operate and what shared common features distinguish their interpersonal communication methods. This ongoing reevaluation is required to keep the marketing message fine-tuned to changing interests and needs—a requirement that applies to all organizations competing in the healthcare industry, but especially for pharmaceutical companies that may be struggling to grow their market share in a new region or promote innovative products in time to provide a decent return on investment.

In this regard, de Cagna (2001) notes that "Communities of practice do not form and exist according to the command-and-control model of Industrial Age organizations. Instead, these learning communities are truly organic, energized primarily by a generative blend of individual identity and shared passion" (p. 6). As a hallmark of successful communities of practice, this "shared passion" is part of the quid pro quo involved in how members perceive the time and effort required for their active participation. As de Cagna points out, "Communities of practice combine social capital with intellectual capital and with structural capital, so that the skills of people, the relationships they build with each other, and the tools and documents that they construct and share all are part of the practice" (p. 7).

These processes all involve interpersonal communications that are integral to forging the type of organizational model communities of practice need to sustain themselves over time. Lee and Valderrama (2003) report that efficient interpersonal communications at all levels within the organization are essential to the success of communities of practice: "Although many activities facilitate the evolution and growth of successful CoPs, those that center around the completion of a feedback loop are the most valuable. At every level of the CoP, timely and critical feedback is necessary if the community is to survive and thrive. From the executive level (sponsor, champions, influence leaders) to the community itself (knowledge managers, subject matter experts, other members), an open environment, in which all are willing to accept critical feedback, is essential" (p. 29).

Based on the work of Wallace and Loughran (2003), a number of features determine how rapidly communities of practice will mature, including the following:

1. It is important to develop communities of practice that are marked by fluid boundaries. Participants potentially move across borders—through a constellation of communities—learning from one another, sharing expertise, interests, and experiences. Through these communities, collective learning and cultural practices are shared, negotiated, and often redefined.
2. The emergence of identities in communities of practice allows participants to connect with one another, share a common vision, and experience a sense of belonging.
3. Collaborations need time and flexible infrastructures that will support practitioners in setting and researching their own problems.
4. Communities of practice are most effective when leadership is shared and distributed among its members; embedded within communities of practice, shared leadership provides an opportunity for collective meaning-making and continued professional growth (Wallace & Loughran, 2003, p. 234).

Although they are challenging to establish and sustain over time, the growing body of research clearly suggests that when communities of practice are able to mature, they can model the way for other similarly situated networks. The research to date also clearly indicates that mature communities of practice can facilitate the diffusion of innovative practices and products by healthcare industry organizations more efficiently than less cost-effective marketing approaches. Sophisticated community of practice networks can be established using publicly available resources such as Facebook, where members can communicate with each other easily and share feedback or new information at any time. Similarly, practitioners may use an existing intranet to create a forum for sharing information and discussing current events and trends in their industry, or simply create an email group wherein everyone is sent copies of relevant communications. Whatever approach is used for communicating within communities of practice, the process is influenced by a wide range of variables, some of which may not be readily discernible to outsiders but all of which will undoubtedly be influenced to some extent by the network's identified or otherwise acknowledged leaders (Hemmasi & Csanda, 2009).

In truth, though, a professional community of practice's formal or informal leaders may not always be the best choice for ensuring that a new product or practice receives the attention the marketer is seeking; in some cases, the leaders' close professional associates who serve as confidants may be a better choice, since leaders assign higher priorities to the issues advanced by these individuals compared to those raised by an industry sales representative. These individuals, termed "brokers" by Fincher and Tenenberg, are the main conduit of access to some communities of practice: "Brokers are able to make new connections across communities of practice, enable coordination, and—if they are good brokers—open new possibilities for meaning" (p. 266).

Although there is an expanding network of healthcare-related communities of practice in the UAE, there are a number of other professional business organizations that can serve as ancillary networks to further expand and facilitate the diffusion of innovative practices and products in the country. A current representative list of these professional business organizations is provided in Table 3 below.

Table 3: Current Representative List of Professional Business Organizations in the UAE

International Business Women's Group (ibwgdubai.com): A group of expatriate business women established for exchanging ideas and vital information and supporting other business women. Run by women in business for women in business, the International Business Women's Group in Dubai is a prestigious international organization that offers great networking opportunities and provides consistent professional and efficient support, as well as a strong platform of events through which members share experiences and best practices (About us, 2010).

Dubai Chamber of Commerce and Industries (dubaichamber.ae): Incorporated to carry out a fourfold mission with the vision of becoming one of the best chambers in the world. Mission: Represent, support, and protect the interests of the business community in Dubai. Strategic objectives: (1) Create a favorable business environment; (2) Support the development of business; (3) Promote Dubai as an international business hub (Mission & Objective, 2010).

Dubai Women Business Council: Aims to encourage business and professional women in Dubai to participate in a variety of business segments in order to increase the contribution, productivity, and activity of businesses in the UAE. Objectives include: representing the Council in Arab and international conferences and forums related to business and professional women; cooperating with local and international institutions to increase awareness; negotiating problems that face women at the workplace and finding solutions; and organizing networking opportunities through the Dubai Chambers of Commerce (UAE business associations, 2010).

These professional organizations are characterized by an emphasis on developing improved networking opportunities that can provide their membership with expanded access to the most recent developments in their fields—mirroring in large part the same function performed by communities of practice in other specialty settings. Moreover, these professional organizations likely have communities of practice under development or already in place in varying stages of maturity, even if they do not specifically refer to them as such. These networks can provide yet another avenue by which innovation can be diffused, if access to the gatekeepers is acquired. As Lee and Valderrama (2003) note, "CoPs exist in virtually every organization; however, most do not recognize their presence" (p. 29). Simply acquiring access to a community of practice's gatekeeper, though, is no guarantee of success; the same levels of trust and authenticity that characterize other successful business relationships must also be established.