Using Concept Map Based Team Knowledge Elicitation To Enhance Effectiveness For A Public Health...

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USING CONCEPT MAP-BASED TEAM KNOWLEDGE ELICITATION TO ENHANCE ORGANIZATIONAL EFFECTIVENESS

FOR A PUBLIC HEALTH AGENCY

Barbara L. Bowen, PhD, Knowledge Architect/Principal Consultant, Sound Knowledge Strategies Jean Baldwin, MPH, Director, Jefferson Public Health

Abstract : This article describes a Concept Map-based team knowledge elicitation initiative for a county public health agency in the United Status. The purpose was to increase organizational effectiveness by fostering knowledge sharing and development of a shared vision of the core concepts and values of public health. The specific goals of the agency director were to enhance a shared focus on core public health knowledge principles throughout the agency and to reduce time and resources needed for new employees to become effective team members. The introduction contains a brief overview of the situation of public health organizations in the United Status, the concept of effectiveness in a knowledge-based organization and a brief overview of literature on previous team knowledge elicitation efforts. The remainder of the paper discusses the situation of the agency, the conduct of the sessions, the knowledge model, and the impact of the project.

1 Introduction

The executives and staff of public health agencies in the United Status typically face work demands that outstrip the agency’s available capacity. In most cases, the work for which the agencies are responsible is mandated by law, which means that reducing the workload by eliminating work usually is not an option. The nature of the work itself - dealing with the public in what can be highly-emotionally charged situations - is stressful and the stress can work against effectiveness. The loss of capacity that results when staff members resign, retire or even when they are absent for vacation creates additional burdens, as does the necessary commitment of staff time and resources required to bring a new person on-board. A common base of shared knowledge, insights and perspective enables more effective prioritization and decision-making, which are essential to enable the agency to fulfill its purpose. Existing methods to address these issues include staff training, monthly meetings of agency staff, and team meetings. While these are essential, they typically address operational and tactical issues, and are not designed to create the kind of clarifying “map of what matters” that a suite of Concept Maps, or visual knowledge model, can provide. The effectiveness of Concept Maps and visual knowledge models created using CmapTools lies in their ability to clarify conceptual hierarchy, key inter-relationships and inter-dependencies and their use as performance support and decision-support tools. The following sections describe relevant literature, characteristics of the public health agency and its staff, the knowledge elicitation sessions, the knowledge model and the impact of the initiative and an assessment of its success in achieving its goals. 2. Relevant Theory and Literature 2.1 The Concept of Effectiveness for Knowledge Workers and Knowledge Organizations In Out of the Crisis, W.E. Deming (2000), father of total quality management, wrote, the aim of an organization needs to be to “make best use of all knowledge and skill in the company to improve its quality, productivity and competitive position…” Peter Drucker (2007) said something similar, “Organization is the specific instrument to make human strengths redound to performance while human weakness is neutralized and largely rendered harmless.” In Drucker’s view, the key function of a knowledge organization, and knowledge workers, is effectiveness. Effectiveness requires contributions to the organization’s goals and purpose (Drucker, 1969). Effectiveness requires everyone in the organization to align their work with the organization’s purpose and to focus it on “what matters.” Effective executives are those who make good use of people’s strengths and provide help and support to address weaknesses or gaps in capacity (Drucker, 2007). A key means for accomplishing this is promoting a shared vision of the goals and purpose of the organization and fostering alignment of the contributions individuals and teams make to help achieve them.

In this project, Drucker’s notion of effectiveness was a guiding principle for the work. In the public


health agency discussed in this paper, organizational effectiveness requires staff in both community health and environmental health to use core high-level public health concepts as guiding principles in daily work, as the basis for decision-making and for conducting their daily work. 2.2 Team Knowledge Elicitation and Concept Mapping Novak (1998/ first described the value of team knowledge elicitation as a tool for enhancing the effectiveness of teams in the context of his work with product development teams at a multi-national consumer products company. “...in seminars with research directors at a very large consumer products company we used Concept Maps...to help groups design new products and to pinpoint gaps in knowledge available that needed to be filled through new, targeted research. The manager of the program remarked, ‘You led the team to see better the nature of the new product and research that needs to be done in four hours than usually occurs in four months.’ “ Bowen and Meyer (2008) describe the use of a “skeleton expert map” (Novak, 2004) of essential requirements for effective teacher induction to foster strategic alignment and build capacity within a distributed team of K-12 teachers and administrators involved in state-wide a project to improve teacher induction. Perez and Bowen (2008) describe the use of Concept Maps to facilitate the gathering and effective use of stakeholder feedback on a national environmental monitoring project in Cuba. Fourie (2008) describes the use of Concept Maps of strategic intent, created via knowledge elicitation with CEOS, to assess the degree of strategic alignment at all levels within South African wine cooperatives. Perez (2008) describes the use of Concept Maps to elicit feedback from stakeholders for a national environmental monitoring plan. While Concept Map-based knowledge elicitation process for individual and team knowledge elicitation sessions is guided by the same principles, because team members bring different mental models, assumptions, points of view and even vocabulary, team knowledge elicitation can be both more challenging and more rewarding than knowledge elicitation with an individual expert. Clarifying the concepts themselves, the conceptual hierarchy and conceptual relationships can be a more extensive process for a team than for an individual expert. Sometimes the Concept Map undergoes substantial revision from one session to the next as the participants gain clarity and re-structure their own individual and group mental models. The team knowledge elicitation process itself promotes alignment and effectiveness by fostering the construction of a common mental model, which is represented by the Concept Maps. 3. A Concept Map-based Knowledge Elicitation Project ��for Public Health

The agency director undertook a Concept Map-based team knowledge elicitation initiative as a way to foster expert knowledge sharing and enhance shared vision. In addition, it was intended that the resulting knowledge resource – a customized visual knowledge model, would be useful in orienting new staff and as a resource for current staff. The knowledge elicitation took place on site in the agency’s offices. The staff who were involved are specialists in a broad range of community health and environmental health functions including: maternal and child health, epidemiology, water quality, septic system compliance, watershed health, storm water management and solid waste education. A total of eleven knowledge elicitation sessions were conducted with groups of different sizes. The two key goals of the agency director who sponsored the project were to: 1) foster a common vision, rooted in core public health concepts and values, for both community health and environmental health for the agency’s work to promote and improve the health of the community, and 2) reduce the time and cost of integrating new staff into the agency. The Concept Map-based team knowledge elicitation, and the sharing of the expert knowledge and insights that this process fosters, was the primary means for achieving these goals. 3.1 The Agency The public health agency featured in this article is composed of two divisions - community health and environmental health. Due to the long-standing history of community health in the United States, community


health nurses share a common grounding in community health principles and concepts, e.g., prevention and the value of building and maintaining relationships with clients and with colleagues. Because the background and training of environmental health staff are more varied, these principles and values do not typically occupy the same core status within their daily work life. The current culture of the public health agency is rich with knowledge sharing via sharing stories and experiences both in staff meetings and “on-the-fly” in the course of daily work. While this sharing has enormous value, it is informal and does not result in the creation of permanent organizational resources that increase capacity and effectiveness. Increasing the performance and effectiveness of staff typically takes the form of formal training session that address the content or process of the work, and team or management meetings. 3.2 Attributes of the Participating Team The participants in the Concept Map-based knowledge elicitation were five community health staff, three environmental health staff, the chief medical officer, the agency director and the finance manager. The participants were selected and invited by the agency director and included both those community health staff with long-standing experience and deep knowledge of community health, as well as key environmental health staff who could benefit from enhanced awareness and knowledge of community health. The average length of employment in the agency was 12 years for the community health nurses and 6 years for environmental health staff. The agency director is a very experienced public health professional who has held her position for 10 years. 3.3 The Concept Map-based Knowledge Elicitation Sessions �� The focus question identified by the director was: “What are the core knowledge and capabilities needed for a public health organization to protect and improve public health.” The Concept Map-based knowledge elicitation followed the process developed by Prof. Joseph D. Novak (Novak 1984) at Cornell University and the Institute for Human and Machine Cognition (IHMC). �� Both the knowledge elicitation and the Concept Mapping were done by the consultant, in contrast to the “tag team approach” used by Hoffman and Coffey (Crandall 2006) at the Institute for Human and Machine Cognition (IHMC). A total of eleven Concept Map-based knowledge elicitation sessions were conducted with the director and staff of the agency. Four of these sessions were with groups of 7-13, four were with a small groups of 3-4 staff involved in developing a key sub-Concept Map, and three were with the director to review and format the emerging Concept Maps. The sessions with the larger groups were 4 hours in length, the small group sessions were 2 hours and the sessions with the director were typically an hour or less. The group was diverse and management has cultivated an environment of respect for the knowledge, thinking and experience of each staff member. As a result, in some sessions the focus shifted as different staff contributed their knowledge and perspective. Following each knowledge elicitation session, the consultant formatted the draft maps, generated clarifying questions, e.g. about concept hierarchy, linking phrases and knowledge gaps, and sent jpeg files of the Concept Maps to the project participants with a request for feedback. The agency director was the primary, and often the sole, source of feedback, though on one occasion the finance manager had important insights about the organization of a key sub-Concept Map that resulted in re-organizing the map in a way that left it much improved as a performance support tool.

During knowledge elicitation, the first core capability brought to the fore by experienced community health nurses was a “value for relationships” and the “capacity to build and maintain relationships” – a capability that these nurses regard as a key source of support “to do this hard work.” The role of this capability, and its inter-relationship with other is shown in Fig. 1 After this session, a key member of the environmental health team commented to the agency director, “It’s the same for


environmental health, but we haven’t put it in these terms.” The expression of this insight provided the agency director with evidence that the knowledge elicitation and sharing between community health and environmental health staff was serving its intended purpose – to foster a shared values and knowledge of core public health concepts, and in turn, a shared vision of not only of the agency’s goal, but how its staff members do their work. In the course of the second large group session, one of the community health nurses remarked: “What we do is make tough decisions.” When asked for an example of a tough decision, the “decision to file a child protective services report” was offered. Several public health nurses and one environmental health staff contributed to the creation of this sub-Concept Map (Figure 1). A major insight shared in the course of creating this Concept Map was the importance of the concept of “breaking the cycle of intergenerational violence,” (i.e., prevention) as a guiding principle for the work of community health nurses. Filing a child protective services report means taking on a difficult situation in terms of relationships with the family involved, especially the parents. Navigating this challenge successfully requires outstanding capabilities in “valuing and maintaining relationships.” The most experienced community health nurses were unanimous in agreeing that their ability to keep the long-term goal of prevention in focus was a key driver for building and maintaining relationships – because it is through the relationships that the goal can be achieved. The sub-Concept Map of “Scientific Knowledge” was created over the course of several sessions, and a one-on-one knowledge elicitation with the agency director. The third large group knowledge elicitation session was diffuse and the focus shifted often. Several staff questioned the purpose of the project. The differences between the perspective and work of public health and environmental health came to the fore. One senior environmental health staff said she did not “think this way.” After considerable exploration of diverse foci, the environmental health staff present agreed that a Concept Map that could be used as a decision-support tool for prioritizing response to citizen complaints would be useful to them. They explained that at the current time, environmental health staff have different ways of prioritizing responses and there is no shared set of principles or guidelines for decision-making. As a result, it is difficult for staff to respond to questions from citizens about how or why another staff member made a decision, or why their complaint has not been addressed. The remaining knowledge elicitation sessions were devoted to the development the Concept Map: “Environmental Health Complaint Response Prioritization Process”. Core participants were two environmental health staff, the agency director and the finance manager – a long-time employee of the agency who is very familiar with its work. Typically, only the agency director provided feedback to the Concept Maps aubmitted by the lead author for comment. The finance manager was one of the key exceptions. She made a major contribution to re-organizing the top part of the Concept Map in a way that made the inter-relationships much clearer. �� The final session was with a larger group to review the whole knowledge model. 4. The knowledge model The knowledge model created during this project consists of twenty (20) Concept Maps: • One top map: Figure 1: Core Knowledge and Capabilities Needed to Protect and Improve Public Health. • Four (4) first-level sub-Concept Maps: Scientific Knowledge Value for Relationships/Capability to Build and Maintain Relationships

Core Public Health Knowledge & Capabilities That Guide the Decision to File a Child Protective Services Report: Figure 2

Process to Prioritize Citizen Complaints to Environmental Health: Figure 3 • Fifteen (15) second and third-level Concept Maps that clarify the concepts in first-level sub-Concept Maps.


Figure 1. Top Concept Map: Core Knowledge and Capabilities Needed to Protect and Improve Public Health

Figure 2. Core Public Health Knowledge & Capabilities That Guide the Decision to File a Child Protective Services Report


Figure 3. Process for Prioritizing Environmental Health Citizen Complaint Investigations

5. Preliminary Results/Impact

5.1 Goal of the Initiative Was Achieved: Director’s Evaluation The director reported that her goal of enhancing a shared vision for community health and environmental health was achieved: [The] processes of tacit knowledge elicitation and creation of Concept Maps of our collective knowledge and insights leave us with training procedures and tools for prioritization and planning. Everyone finally has a common language that helps us orient ourselves in the context of core principles of community and public health. (Baldwin 2009, email to author). She also reports that the Concept Maps have been used with new staff to provide an overview of the knowledge, capabilities and values that guide the agency’s work, although few new staff have been hired due to the financial crisis and ensuing budget constraints.


5.2 Goal of Initiative Achieved: Staff Evaluation The consistency of staff comments on a questionnaire about the impact of the Concept Map-based knowledge elicitation sessions support the view that the initiative made important contributions to the goals of enhancing shared vision, promoting expert knowledge sharing and creating a knowledge resource that can be used to help orient new staff to the agency’s purpose and the knowledge and values its staff use to achieve them.

• Goal: fostering strategic alignment with the organization’s purpose and goals (the “big picture”) “It’s not that often that we get a chance to look at the bigger picture of public health, even at the local level. Sharing practice wisdom with a varied group of individuals whom I hold in great respect is a privilege. The process helps strengthen my resolve to continue in the work.” “Team-wise, the Little Quilcene [River] example [of septic violation] was very instructional as it illustrated how important it is to ask the right questions and identify preferred outcomes early in the compliance process.”

“As I deal with projects though, I will refer back to the mapping exercises to envision how my work interfaces with the larger [agency] and department goals.”

• Goal: fostering the sharing of expert knowledge and insights

“ [I have] A clearer understanding of what my colleagues face day to day in their jobs and how they frame important questions about how [agency] serves the needs of the public and environment.”

• Goal: promoting a shared vision and shared values to guide the agency’s work in both departments

“I had anticipated parallels between caring for the community and for our piece of the planet, but the mapping clearly demonstrated how we are dealing with two sides of the same coin. I’d like to see the language and approaches to human and environmental health become increasingly consistent over time.”

5.3 New Performance Support Tool for Environmental Health The Concept Map, “Environmental Health Process for Prioritizing Citizen Complaint Investigations” has been adopted as a decision and performance support tool to enhance consistency and quality with the environmental health team. The finance manager, who provided critical input to the development of the Concept Map, is serving as the operations manager for the environmental health staff. 5. 2 Suggestions for improvement Several staff suggested that it would have been valuable to include even more staff in the knowledge elicitation sessions. In addition to her role as virtual operations manager with the Environmental Health team, the finance manager also has responsibility for administering the CmapTools software. There have been some difficulties accessing the server and using the software. A half-day training session was provided in use of CmapTools software, but additional support would have been helpful. Staff is already overloaded and there is no time available for training sessions. The consultant has provided occasional support when needs were communicated, but the use of the software and access to the server and Cmaps has proved to be a challenge.

6. Summary


This article describes an initiative to use team knowledge elicitation and Concept Mapping with the community health and environmental health staff of a public health agency to enhance organizational effectiveness. The notion of effectiveness used in the project is drawn from the work of Peter Drucker who defines effectiveness as “doing the right things” in alignment with the organization’s goals and purpose. The team knowledge elicitation process enhanced the shared vision and clarity about the core public health knowledge, capabilities and values that needed for the agency and its staff to be effective. The essential role of a focus on the core public health goal of “prevention” to guide “tough decisions” was elucidated by a senior community health nurse and represented in a Concept Map. Feedback from the agency’s staff and director confirmed the usefulness of clarifying and mapping “the big picture” as well as sharing the use of core public health knowledge and principles in making the tough decisions that form the core of the agency’s work. One of the values of team knowledge elicitation is that it is often the source of important insights from unexpected sources. In this initiative, insights of the agency’s finance manager were essential contributions to the re-structuring of the Concept Map, Environmental Health Process for Prioritizing Citizen Complaint Response. The environmental health team now uses the concept map in Figure 3 as a decision-support tool. The finance manager serves as the ad hoc operations manager for the team in this decision support and quality control function. Due to the financial crisis, few new staff has been hired, the top level Concept Map has been used by the director to help new staff gain an overview of the agency’s goals and the core knowledge and capabilities needed to achieve them.

7 Acknowledgements The authors thank Prof. Joseph D. Novak for his essential contributions to fostering meaningful learning and human intelligence, and for his continued guidance, generosity and kindness over the course of forty years of association. Thanks to the director, and the staff of the public health agency that undertook this initiative for their dedicated and intelligent work in behalf of community and environmental health. Thanks to Wendy Schultz, Director of the Talamanca Language Academy, Sabalito, Costa Rica, for her translation of the original document from English into a Spanish version. 8 References Bowen, B. & Meyer, M. 2008. Applying Novak’s New Model of Education to Facilitate Organizational

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Crandall, B., Klein, G., Hoffman, R. R. 2006. Working Minds: A Practitioner’s Guide to Cognitive Task Analysis. MIT Press. Cambridge, MA. Chap. 4.

Deming, W. E. 2000. Out of the Crisis. Cambridge, MA: MIT Press. 473. Drucker, P. F., 2007. The Essential Drucker: Revised Edition. Oxford, UK. Butterworth-Heinerman:

Elsevier, Ltd. 70. Fourie, L.C.H. 2008.The Value and Use of Concept Maps in the Alignment of Strategic Intent. Proceedings

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Novak, J. D. 1998. Learning, creating, and using knowledge: Concept Maps as Facilitative Tools in Schools and Corporations. Mahweh, NJ: Lawrence Erlbaum Associates. 97.

Novak, J. D., & Cañas, A. J. 2004. Building on constructivist ideas and CmapTools to create a new model for education. In A. J. Cañas, J. D. Novak & F. M. González (Eds.), Concept Maps: Theory,


methodology, technology, proceedings of the 1st international conference on Concept Mapping. Pamplona, Spain: Universidad Pública de Navarra.

Novak, J. D., & Gowin, D. B. 1984. Learning how to learn. New York: Cambridge University Press. Perez, R. & Bowen, B. 2008. Cmaps: A Useful Tool for Improving a National Environment Monitoring

System Design. Proceedings of the Third International Conference on Concept Mapping. Canas, Reiska, Ahlberg, and Novak (Eds.) Tallinn, Estonia & Helsinki, Finland.

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Using Concept Map Based Team Knowledge Elicitation To Enhance Effectiveness For A Public Health...

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