Health Services Management Research 20: 227–237

r 2007 Royal Society of Medicine Press

Learning – the only way to improve

health-care outcomes

J Deane Waldmanyz and Steven A Yourstoney

The Children’s Hospital Heart Center, Health Sciences Center, University of New Mexico;
y
The RO Anderson Schools of Management, University of New Mexico; zADM Healthcare Consulting,
Albuquerque, NM, USA

Attempts to improve health care have generally failed. Systems analysis urges addressing
processes, such as learning, rather than isolated parts of a system. We apply learning
curve theory to health care and then explicate the process of learning. Specific
recommendations involve how we learn (and unlearn), who should learn, and what
should be learned.

Introduction medicine and management, incorporating such

disciplines as organizational behaviour, opera-
A major city thoroughfare called Lomas Street tions, managerial accounting, medical practice,
runs through the University of New Mexico in
strategic management, etc. Our colloquy quickly
Albuquerque. To the west of Lomas is the
led to an understanding of the inter-relatedness
Health Sciences Center and to the east is the
and the interdependence of the components of
main campus including the RO Anderson
the health-care system and perforce, to the
Graduate Schools of Management. The physi-
inability of achieving desired outcomes by
cal distance between the university hospital
attacking any isolated element within that
and the business school is about 200 yards, but
system. Sustained improvements and achieve-
the cultural and cognitive distance can only be
ment of intended consequences require systems
measured in light-years. Several Faculty mem-
thinking with redress of processes. Given that
bers are trying to bridge that chasm (Figure 1), health care is a science and a nascent one at that,
including the authors of this paper.
we chose to focus on learning as a process that
Observing the woes of the USA health-care
cuts across all aspects of any system or
system – cost escalation, adverse impacts, errors organization, from finance to distribution, from
and lawsuits, contracting access, and personnel
the practice of medicine to the design of
shortages – we asked if business knowledge and
effective and efficient health-care delivery sys-
experience might be used to improve health-
tems. Our analysis produced recommendations
care outcomes. A query group (nothing so fancy
for the augmentation of learning in order to
as a think-tank) was formed of experts in
achieve better health-care outcomes.
J Deane Waldman MD MBA, Tenured Professor, RO
Anderson Schools of Management and Children’s Hospital
Heart Center, University of New Mexico Health Sciences
Center, and Principle, ADM Healthcare Consulting; Primary thesis
Steven A Yourstone PhD, Professor, RO Anderson Schools We reason as follows.
of Management, University of New Mexico, Albuquerque,
NM 87106, USA
Correspondence to: J Deane Waldman (1) the observed outcomes from health care
E-mail: info@admhealthcareconsulting.com are generally not those desired;

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Health Services Management Research

High quality, Reduced Error,

Resource Sensitive Healthcare

Medical Center School of Management

Figure 1 Bridging the chasm between medical and management schools. Although commonly part of the same university
and usually in close physical proximity, medical and management schools often function as though the other did not exist.
The creation of a bridge, encouraging easy communication between the schools, could produce the desired outcomes from
our health-care system: high quality, reduced error, resource-sensitive medicine

Table 1 Translation of learning curve theorems to business and to healthcare

Learning curve theorems
1a Unit production time
decreases with each
iteration
2a Unit production time
improvement decreases
over time
3a Unit production time
improvement follows a
predictable pattern
Business application Health-care translation
1b Unit costs decrease with 1c Patient #100 is at less risk
increased production than patient #1
experience
2b Cost decrease that occurs 2c Outcomes in health care
with increased experience can never be perfect
follows an asymptotic
curve
3b Activities have different but 3c Outcomes can be improved
calculable learning rates by structured learning

(2) a positive relationship exists between which increased experience improves out-
volume of experience and desired out- comes in medicine is not precisely delineated.
comes; However, whether measured by mortality,
(3) the mechanism by which volume pro- morbidity, length of hospital stay, or resource
duces better outcomes is learning; utilization, there is a strong positive correlation
(4) learning is a process that has unique between volume of experience and positive,
issues in health care; intended results, presumably mediated by
(5) learning can be structured specifically for learning.4–13
the needs and particular constraints of A learning physician, by definition, moves
health care; and from a state of lesser knowledge to a state of
(6) structured and mediated learning can greater knowledge. However, patients do not
improve the outcomes from our health- want to consider, much less accept, that their
care system. personal physician might have less than
complete and perfect knowledge. No one
wants to be patient #1 on whom the doctor
Learning curve theory and health care learns but some one must be, or there will
People in manufacturing have known for many never be a patient #100, who will receive an
decades that the more you do, the less it costs improved outcome. While outcomes do
and the better quality you produce. Learning is improve with experience, it is disquieting to
the means by which this occurs. Recently, the recognize (cf. Table 1) that the learning curve is
Toyota Production system has been touted as a asymptotic, meaning that perfection is never
solution to the ills of health care.1,2 At its heart, attainable: some person must have an imper-
the Toyota system is a process for continuous fect, possibly adverse, result. The application of
learning. We have taken the three basic learn- structured learning has profound implications
ing curve theorems (Table 1), applied them to for the health-care system, from the individual
the business world and then translated them to medical college to the USA Congress or the
the practice of medicine.3 The mechanism by National Health Service (NHS).

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Learning is a process
Mental models
Every day, every minute, people are exposed
to an infinite number of perceptions, some at
and most below conscious level. Since the
early 20th century, it has been recognized
that we need some method to organize this
constant bombardment of perceptual data.
Whether they are called ‘labels’ (14quoting
Bertalanffy), ‘patterns of vision’,15 Schelling
points,16 ‘psychological archetypes’,17 ‘effective
tags’,18 ‘dispositional representations’,19 or ‘sche-
mata’,20 everyone uses mental models or short-
hands to organize perceptual data from skin
temperature to our vision of ink on paper to the
smell of ambient pheromones. In health care,
such short-hands are usually in the form of the
dreaded TLA (three letter acronym). Without
such mental organizational aids, we could not
function because of information overload.
Rosch and Lloyd21 coined the phrase ‘cogni-
tive economy’ to describe a method by which
we maximize the amount of information while
minimizing cognitive effort. Thus, using a
name such as Elton John or Zacarias Mous-
saoui, we communicate a large body of
information and associations: physical charac-
teristics, past history and behaviours, and even
what we might expect from him as future
behaviour. In medicine, the label is called a
diagnosis.
Using cognitive economy in the cardiac
intensive care unit, a pale, sweaty, weak, dis-
oriented elderly patient with laboured breath-
ing calls to mind the diagnosis congestive heart
failure (CHF). A nurse or physician would
apply this mental model and thereby know
what to do and what to expect. When the
mental model is integrated with repetitive
action, it leads to ‘habituated routines’ that
could lead to a successful resuscitation of a
patient in cardiac arrest or could produce the
famous Mann Gulch disaster,22 where using
the standard, accepted, and practiced proce-
dures resulted in 13 deaths.
Despite the ubiquitous nature of mental
models, they have serious drawbacks. Because
of their very utility, such models are very hard
to modify or to give up. Furthermore, they can
function as blinders: the same patient de-
scribed above, in the neurology ward, would
call to mind stroke with a totally different set of
reactions and expectations. Context is an
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The means to improve health-care outcomes
important influencing factor in our schemata.
When below our conscious level of thinking,
such ‘axes of bias’23 are especially hard to
change. (Note that in Figure 2 mental models
can both promote and constrain learning.)
Mental models can prepare us for problem
solving. When these shortcuts enable us to set
up appropriate expectations, good outcomes
result. When they distort reality, adverse
impacts can occur. If the patient or situation
does not behave as expected, tension is created.
In these circumstances, we tend to alter or
reassess our perceptions rather than reconsider
the model. Perceivers’ expectations have the
power to steer attention away from actual
visual data, enabling perceptual processes to
construct images consistent with expectations.
Italian has a word – scotoma – for seeing what
we expect rather than what is actually before
our eyes. ‘If we see what we expect rather than
what is real, we can make mistakes such as
administering lidocaine instead of heparin
(because a bottle of the expected shape and
colour is in the wrong place). Similarly, well-
learned activities can be carried out without
conscious attention.’24 It is this quality of
automaticity that can lead people to make
mistakes despite the obvious staring them in
the face. Finally, mental models tend to restrict
our imagination, the very attribute necessary
for effective learning and innovation.
Learning requires unlearning
Learning theorists say that the hardest aspect
of learning, particularly for highly educated
and successful individuals such as nurses and
doctors, is unlearning. A person who would
learn (or even better create) something new
must have a mindset willing to doubt what he
or she knows. Only after admitting that what
we know might be inaccurate or incomplete or
non-functional, can we consider alternatives.
Thus, we must unlearn into order to learn.
‘When it becomes necessary to develop a new
perception of thingsythe problem is never to
get new ideas in, the problem is to get the old
ideas out.’25 A necessary requirement for
continuous learning is continuous unlearning.
Otherwise, first learned will be only learned,
status quo will reign and neither people nor
organizations will be able to adapt and to
improve.
Bettis and Prahald26 have delineated why
dominant logic and over-learned behaviours
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EXPERIENCE
X

E
E CE
N
d
E
NRI

E
E R I EE
C
Xq
Innovation
Structured
(or Mediated)
Repetitive
Learning Experience
Processes Qu

ni ic
an

ar ist
An tita

ng
Mental

Le eur
Mediator aly tive
Models Culture

H
sis

Mental Culture Unique Trials Technical Skills Judgement Evidence

Models Constraints Revisions
Sta

Better Better
rt

ga Actions Decisions
A

in
Less than
perfect results Better Outcomes

Conditions
Change

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Time (in years)
Learning
Figure 2 m Volume
! " Outcome. Medical experience is funnelled into a learning process where mental models can
either promote or block learning, where culture can either enable or constrain learning, and where the unique aspects of
medicine apply. As the system is a thinking one, it needs a systems approach to encourage self-adaptation and co-
evolution. The system itself creates and modifies structured learning plans, innovates, revises, and repeats the cycle to
produce experience. Such experience produces evidence and judgement that allow better decision-making and ultimately
better outcomes. Although outcomes are improved, they are never perfect and, therefore, the cycle of structured learning
starts again

tend to become permanent and prevent un- grooves in anyone; (2) Practice choosing, such
learning. (1) Repeated use produces habitua- as airline pilots do in simulators; and (3)
tion, (2) repetitive behaviours become accepted Practice creating (practicing for the unknown).
as norms of organizational culture, (3) increas- The third is analogous to gaming scenarios
ing complexity leads to confusion and fall-back where one invents a possibility and then seeks
to previous patterns of thinking and behaviour. ways to deal with this new thing, using past
This is particularly true as the stress level rises, experiences, heuristics, structured learning,
such as in life-or-death situations, and (4) whatever resolves the problem that the game-
questioning, doubting, and recognition of master has created. Better improved outcomes
ambiguity or uncertainty are the first steps in in medicine require all three forms of practice.
unlearning. Unfortunately, health-care culture
values the person who is sure, reveres the one
who knows the answer and who makes Innovation
decisions with certitude. Since early in the 20th century, investigators
have been evaluating how innovation – the
creation of new ideas or objects – occurs,
Practice makes perfect diffuses, and is adopted. A necessary precursor
The aphorism practice makes perfect is gen- is the person’s mindset: open, not certain of
erally considered the way to improve. In his/her correctness, willing to consider silly,
common parlance, it translates to repeating obviously wrong, and/or unpopular ideas.
the same action or thought process. Practice Innovation requires creativity, defined as
can be in three modes: (1) Rote practice, such as ‘figuring out how to use what you already
creating muscle memory in athletes or mental know to go beyond what you currently

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think’.27 A second pre-requisite for innovation
is an environment and culture that encourages
new ideas and risk taking. Modern medicine is
the antithesis. Finally, an innovation must be
diffused into the mainstream. In Diffusion of
Innovation,28 the revered and recently deceased
Everett Rogers describes five characteristics
of any new idea that influence its adoption
into the everyday world: relative advantage,
compatibility, complexity, observability, and
testability (what he called ‘Trialability’). In
health care, adoption of an innovation is
problematic. Divergent, often conflicting, stake-
holder priorities make determination of relative
advantage a question of whose ox is being
gored. Observability and testability are parti-
cularly problematic in medicine because of: (a)
biologic variability in humans, (b) ethical
constraints to animal – including human –
testing, and (c) the long timeline between action
and outcome. As the complexity of innovations
increases and the gap between medical inno-
vator and practicing physician widens, success-
ful communication becomes harder. The
expanding gap can reduce the availability of
the newest therapies in the real world.
Learning requires time
Many factors that can effect learning include
the rate of experience acquisition, incentives,
individual versus group learning, and physical
versus mental skill sets.1,29–32 However, all
learning requires time-on-the-job, sustained
saddle time as bicycle racers say. This translated
to job retention, which is not the inverse of
turnover.33 Health-care administrators are well
aware of the problem of workforce turnover,
but often fail to link retention with learning and
ultimately better outcomes.34–46 Current reten-
tion data suggest that the situation is even more
ominous than suspected. In a recent study,47 net
five-year retention rate in a major medical
centre was as low as 15–20%, meaning that
very few workers stayed long enough to
develop and acquire much less pass on learning
curves. Low retention impairs the ability to
learn, leading to less effective and less efficient
job performance and to more errors.
Learning in medicine has unique constraints
Medical science possesses attributes that are
fundamentally different from the natural
sciences and that negatively impact the poten-
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The means to improve health-care outcomes
tial for learning. Consider tubing for a bicycle
frame.
 One can test a piece of tubing to the breaking
point in order to assess tensile strength.
 One can create new tubes out of various
substances and in different dimensions to
determine optimal characteristics for func-
tion.
 Tubes made in an identical manner behave
similarly; in modern manufacturing, varia-
bility is generally minimized seeking to
achieve a six-sigma consistency.48
Each of the asterisked statements above does
not apply to medicine. One cannot manufac-
ture patients to study. Even if this were
possible, one cannot ethically test people with
drugs carrying significant risk unless that risk
is less than the inherent disease risk. Two
patients with the diagnosis of ‘X’ may in fact
have two different diseases that just look like
‘X’ (inaccurate mental model). Even if both
patients have ‘X’, the disease may manifest
differently or on divergent time scales. Finally,
people assume that answers to medical pro-
blems are known and that doctors – like
physicists – can predict precise outcomes in
specific patients. This is not true.
Medicine is much less advanced than the
natural sciences with respect to basic mechan-
isms. The laws of physics and chemistry are
well established, and for day-to-day practical
applications, they provide predictable, reprodu-
cible results. Adding equal amounts of sodium
hydroxide and hydrochloric acid will always
produce water and table salt. But five milli-
grams of captopril (Capotens) will not pre-
dictably lower blood pressure by same amount
in every patient. Even autopsies, considered the
final word in diagnosis, often leave the care-
givers (and lawyers) with incomplete pictures of
what happened and why.49 This lack of predict-
ability, due to limited understanding of basic
causality in disease processes, creates great
challenges as to what one can and should learn
from clinical experience.
Learning should produce: evidence
and judgement
Evidence in medicine
One of the intermediary products of learning is
analysed data or evidence. The practice of
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medicine involves a balance of established
principles, incompletely understood physiolo-
gic processes, limited sample population, and
biologic variability, in toto resulting in an
inability to predict individual medical out-
comes. Personal experience, particularly one’s
most recent bad outcome, tends to dominate
clinical decision-making. Increasing the num-
ber of inputs and developing structured
approaches to learning will create hard data –
evidence – resulting in improved medical
outcomes and reduced errors/adverse im-
pacts.50–52 Unfortunately, organized medicine’s
‘continued quiet refusal to take [nation-wide,
structured] quality improvement actions,’ what
Millenson calls ‘The Silence’, has reduced the
moral standing of the medical profession.53
Medical practitioners accept their obligation
to use evidence-based decision-making, even if
they do not uniformly behave that way.
Medical managers do not accept a routine duty
to produce evidence of effect before action. The
phrase ‘evidence-based management’ has only
recently entered the management lexicon54,55
and even so, it is not consonant with manage-
ment culture. Lack of evidence before manage-
rial action has two undesirable consequences: it
frequently produces unintended consequences,
and it reduces the credibility of medical
managers in the eyes of medical practitioners.
Learning should produce judgement
A 99% success rate, which sounds quite
encouraging, means that in one out of a 100
cases, the treatment will fail or will generate an
adverse impact. There is no way to know in
advance if a specific patient is in the group of
99 or in the group of one. Probabilities apply
only to statistical populations, not to a single
sample within the population distribution. This
is self-evident to any one who understands
statistics, but apparently is not in the main-
stream of popular consciousness. The public
thinks that doctors predict, that answers are
established, and that the recommended treat-
ment will work as promised in a specific
individual.
Experienced doctors will say that they deal
with ambiguity not truth, that they exercise
judgement and never offer guarantees. People
assume that medical science understands heart
failure the same way that physicists under-
stand metal fatigue. This is simply incorrect.
Learning should foster judgement, not a
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recitation of statistical facts or worse, the idea
of medical certainty. Functionally, judgement is
the ability to make the best choice among
competing alternatives. (An old funny-yet-
serious medical aphorism defines a great
surgeon as one who makes the right decision
at the right time based on clearly inadequate
data.)
Learning has no finish line
To develop judgement takes patients (as well as
patience), experience, mistakes, analysis of
mistakes, revision of accepted wisdom and
procedures, additional experience, more (new)
mistakes, etc. Furthermore, as nothing remains
static, learning must be continuous, to cope
with the ever-changing landscape. Therefore,
what should be learned is not Final Truth, but
how to engage in continuous learning, which
requires the following:
 discretionary energy: to overcome learning
anxiety and cultural disincentives;
 effective ways to learn and unlearn;
 enabling corporate culture;
 necessary substrates and foundation for
testing;
 potential for change; and
 time.
To admit doubt openly, to test, to try, and
then learn – all require discretionary energy:
the ability to go beyond repetition of the same
rote, established tasks. An employee who is
overwhelmed by the system, or worse one who
has been ‘turned-off’,56 has no discretionary
energy. The turn-off gets by doing the mini-
mum required without generating new ideas
and certainly taking no risks. Such a person,
focused on personal survival and utilizing
‘defensive routines’ (described by Argyris in
Senge57), learns little and thus improves mar-
ginally or not at all.
Some agree with Senge57 that people love to
learn. The management guru Edgar Schein
presents a radically opposite view, likening
learning to brain washing. He said, ‘You can’t
talk people out ofylearning anxieties; they’re
the basis for resistance to change.’32 In a
construct reminiscent of Kurt Lewin’s58 coun-
terbalance of restraining versus promoting
forces for change, Dr Schein says that learning
happens only when survival anxiety is greater
than learning anxiety.

Learning requires both effective mechan-
isms, including structured approaches, as
well as an enabling culture.59 Unfortunately,
medical culture is constraining, risk-averse,
innovation-unfriendly, covered with layers of
protection, a ‘Name, blame and shame’ cul-
ture.20 On the organizational level, it is ‘Teams,
not individuals, [that] are the fundamental
learning units of modern organizations’.57 Such
team learning calls for ways to approach
problems and even discourse that are new
and, therefore, threatening to the established
corporate culture of most organizations, espe-
cially in health care.
After learning what works and what does
not, one can make evidence-based recommen-
dations for change and develop implementa-
tion plans that achieve better outcomes.
Resistance to change can be encountered on
individual, group/organizational, and system-
wide (‘policy resistance’ according to Ster-
man60) levels. Such resistance must be expected
and countered, which is a specific purview of
systems thinking. Finally, learning takes time.
Given biologic variability and the long lag
between cause and effect in health care, the
time frame for learning is in decades, not in
days or months.
Learning can be planned
Humans can structure their own learning. This
unique ability allows them to create focused
testing and learning processes intended to
accomplish pre-defined goals like curing child-
hood cancer or winning the Tour de France.
However, health-care institutions have the first
or more immediate demand to deliver care.
These potentially conflicting needs: to get the
work done and to study as well as learn is a
delicate balancing act. A significant challenge
to health-care administrators is the implemen-
tation of current standards of care while
simultaneously encouraging the questioning
of those standards. When Young et al61 com-
pared high- and low-performing hospitals
(measured by risk-adjusted mortality and
morbidity) within the Veterans Administration
system, they found the key lesson for leaders,
planners, and administrators was the essential
role of coordination of work combined with
continuous learning.
Learning is more likely to achieve success
(acquisition of the desired outcomes) when the
learning process is structured, hypothesis
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The means to improve health-care outcomes
driven, mediated, and uses proper scientific
methodologies. As defined by Fickeisen, a
mediated learning experience ‘occurs when-
ever an individual deliberately places him or
herself between external or internal stimuli and
the learner, and transmits the stimuli in a
particular way to that learner’ (italics per
author).62 The mediator always has an inten-
tion, a desired effect on the learner, part of
which includes imparting meaning.
People enter the health-care field seeking
self-worth in their work life. Any activity that
assists in creating meaning for them increases
satisfaction, retention, and job performance.
Making sense within context, called transcen-
dence, is the particular purview of mediated
learning. The addition of mediation to the
learning process helps the learner – nurse,
doctor, therapist, technician, manager – under-
stand not just what works and how to do it but
why: what his or her actions mean.
In one sense, learning requires the death of
the old way of thinking. It is of interest that the
stages of ‘learning as transformation’63 are
reminiscent of the stages of grief suggested
by Kubler-Ross64: Shock/anger, Denial, Mem-
ories, Open space, Imagination, and finally
Vision. Hock25 too likens unlearning to the
death of outdated ideas. Those planning a
learning process should include mediation as a
means to deal with the rejection by health-care
culture of death in any form, even when it is
the demise of the old, outdated, no longer
effective ways of providing care.
Fickeisen62 and others such as Reuven
Feuerstein at the Center for the Development
of Human Potential in Jerusalem promote
mediated learning as a way to achieve trans-
cendence – the creation of connections between
the specific and the general. Transcendence
is particularly relevant to medical learning
where a good doctor or nurse must be able to
apply or, when necessary, discard a mental
model.
Application of business expertise to
learning in health care
In the recent years, there has been recognition
of the potential applicability of management
knowledge and experience to medical practice.
This generally has taken the form of direct
transfer of business concepts or fads to the
practice of medicine without adjustment or
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consideration of fundamental differences. Suc-
cess has been limited and isolated, but great
potential exists for improved medical pro-
cesses.65
Toyota has neither an academic mission nor
a primary purpose to do social good. None-
theless, the company has developed a culture
and process whereby it continuously improves
the production of motors by a structured
approach to learning.1 Toyota production sys-
tem concepts that are being successfully
applied in health care include: (1) smooth and
direct flows of people, equipment, and finished
work, (2) immediate root cause analysis of
errors, (3) value stream mapping to identify
process steps that do not create value for
people, and (4) Kaizen, which loosely trans-
lates to continuous improvement.2,66
Berta and Baker52 suggest four factors that
influence the successful transfer of business
experience and expertise to health care: (1) the
external environmental, (2) hospital and unit
characteristics, (3) the knowledge targeted for
transfer, and (4) the processes by which the
knowledge is transferred. Numerous manage-
ment concepts, approaches, and tools can and
should be translated to health care. One,
however, stands out as a requirement: systems
thinking, a discipline that emphasizes the inter-
relatedness of parts of a system,14,60,67–74
whether the system is a kidney cell, the heart,
a person, the hospital, or an entire nation.
Many of the adverse impacts and other unin-
tended consequences experienced in health
care can be traced to silo or linear thinking.
Plans for structured learning in health care
should include systems thinking, both as an aid
to the development of the curriculum and as a
topic for study within the curriculum.
A word of caution is required. While the
successes of Toyota,1 VISA,25 General Electric,75
Southwest Airlines,76 and Baptist Health
System77 all have lessons that can be useful
to health-care administrators and planners,
unmodified adoption of business concepts or
experience generally will fail. There are unique
aspects to health care, both the system and the
culture, that require major modification of any
management method or approach before it can
be successfully applied to the people-proces-
sing world of health care. Furthermore, all
systems must allow for the exception, the
atypical patient. Including an out-clause or
escape hatch3 recognizes that healthcare cannot
function under the assumption of uniformity of
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patient and/or provider characteristics and
problems.
Conclusion
Health care is a holistic, interdependent system
that must be approached with systems rather
than silo thinking. Sustained improvement in
health-care outcomes requires working on the
system, not on its parts separately. We suggest
that enhancing a structured process of learning
can achieve system-wide improvements:
error and cost reductions, higher quality, and
improved access as well as service. Changes in
the approach to learning will demand new
ways of thinking, changes in culture, and in the
external environment. Process planning should
start with four simple but powerful questions:
(1) Who should learn? (2) What should they
learn? (3) How will they learn? (4) How will we
know that they learned?
Specific recommendations
Each of the stakeholder groups in health care –
planners and medical leaders, providers of
care, managers of care delivery, regulators and
legislators, and the general public – must
become both student and teacher. In some
ways, the highly educated and demonstrably
successful leaders of medicine have the hardest
jobs. They need to rethink and redesign the
learning process without recourse to tradition
or to their own success ladders. For example,
what role within the process of health care
should the doctor play? And how will the next
generation of physicians be socialized to that
model? Mental models need to be reconsid-
ered, recognizing that they simultaneously
help medical care and hinder medical innova-
tion. Planners and leaders need to access the
management literature and translate that
experience to the exigencies of health care. They
must specify the outcomes desired (tracking
those, not their opposites as surrogates) and
still recognize that health-care outcomes cannot
be precisely predicted or controlled. Designers
of a learning process must accept that health
care is a system composed of humans, as both
patients and providers and that humans
always learn. It is their nature. A successful
learning process will engage these willful parts
of the health-care system in the planning and
implementation of any structured learning
process.

As mentioned above, unlearning is the
first and generally hardest step to take. Often,
we must start with unlearning our presump-
tions. Most planning sessions start with what
is possible and what the budget will allow.
This must change. For example, better and
cheaper are NOT necessarily mutually
exclusive.78,79
Medical culture needs revision, particularly
the values, interactions, and incentive struc-
tures. Innovation and risk-taking, improvisa-
tion, and bricolage22 should be encouraged not
suppressed. Creating a learning culture will
require drastic changes in the external environ-
ment, viz., tort reform as well as public
expectations. As long as there is a ‘blame and
shame’ culture,20 no one will take the risks
necessary to innovate.
While standing firm on our recommendation
for cultural change, we recognize the difficulty,
indeed the danger, of trying to tamper with
how people think. Almost five centuries ago,
Niccolo Machiavelli gave warning: ‘There is
nothing more difficult to take in hand, more
perilous to conduct, or more uncertain in its
success, than to take the lead in the introduc-
tion of a new order of things, because the
innovator has for enemies all those who have
done well under the old conditions and the
lukewarm defender in those who may do well
under the new’.80 To change how people
visualize the world, themselves and what they
value will require great and committed leader-
ship. Nonetheless, without changing how we
think about learning in health care, we will
persist in applying band-aids, unintended con-
sequences will continue unabated and the
Bristol Affair will recur.81
If medicine is to be evidence-based, then
structured learning must be an integral part of
the entire process. This obligation applies not
only to medical providers but also to medical
managers and (upstream) to regulators and
legislators. A credible manager does not
espouse evidence-based decision-making and
then announce a change based on reasoning
without proof. We mean well and therefore we
do well is insufficient justification for passage
of health-care legislation. All too often, logic is
the sole due diligence before system-wide
actions and all too often, logic provides a way
to err with confidence. Unintended conse-
quences abound when we depend on logic
and we do not test, produce evidence, analyse,
and learn.
Downloaded from hsm.sagepub.com at University of Manitoba Libraries on June 4, 2015
The means to improve health-care outcomes
To achieve evidence-based management re-
quires a commitment to a formal learning
process. Managers, regulators, and legisla-
tors need to think in terms of statistically
valid sample populations, testable hypotheses,
research protocols. They need a culture that
encourages innovation and risk taking. The
system should be focused on acquiring the
requisite data before decisions are made,
whether for a single patient, a hospital, or the
entire country. This leads to care pathways,
management research, multi-centre protocols,82
precise quantification,83 regionalization,84 and
regulatory reform.
As indicated above, the learning process
should proceed in multiple directions at the
same time. Managers need to be students of the
care providers regarding technical medical
matters and at the same time managers need
to teach the providers about management
techniques and approaches.
The changes necessary will require active
participation of the public. It cannot be foisted
on them with any chance of success. We urge
the engagement of our populace in a new
learning process – as both student and as
teacher – that will require a national dialogue
and ultimately a plebiscite to decide funda-
mental questions about our health-care system.
References
1 Spear S, Bowen HK. Decoding the DNA of the Toyota
Production system. Harvard Business Rev 1999;77:97–106
2 Spear SJ. Fixing Healthcare from the inside, today.
Harvard Business Rev 2005;81:2–16
3 Waldman JD, Yourstone SA, Smith HL. Learning curves
in healthcare. Health Care Manage Rev 2003;28:43–56
4 Jollis JG, Peterson ED, DeLong ER et al. The relation
between the volume of coronary angioplasty
procedures at hospitals treating medicare beneficiaries
and short-term mortality. N Engl J Med 1994;331:
1625–9
5 Phibbs CS, Bronstein JM, Buxton E, Phibbs RH. The
effects of patient volume and level of care at the hospital
of birth on neonatal mortality. J Am Med Assoc
1996;276:1054–9
6 Clark RE. Outcome as a function of annual coronary
artery bypass graft volume. Ann Thorac Surg 1996;6:
21–6
7 Ellis SG, Weintraub W, Holmes D et al. Relation of
operator volume and experience to procedural outcome
of percutaneous coronary revascularization at hospitals
with high interventional volumes. Circulation
1997;95:2479–84
8 Klein LW, Schaer GL, Calvin JE et al. Does low
individual operator coronary interventional procedural
volume correlate with worse institutional procedural
outcome? J Am Coll Cardiol 1997;30:870–7
235
Health Services Management Research
9 Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact
of hospital volume on operative mortality for cancer
surgery. J Am Med Assoc 1998;280:1747–51
10 McGrath PD, Wennberg DE, Malenka DJ. Operator
volume and outcome in 12,998 percutaneous coronary
interventions. J Am Coll Cardiol 1998;31:570–6
11 Hannan EL, Racz M, Kavey R-E et al. Pediatric cardiac
surgery: the effect of hospital and surgeon volume on
in-hospital mortality. Pediatrics 1998;101:963–9
12 Simunovic M, To T, Theriault M et al. Pediatric cardiac
surgery: the effect of hospital and surgeon volume on
in-hospital mortality. Pediatrics 1998;101:963–9
13 Birkmeyer JD, Stukel TA, Siewers AE et al. Surgeon
volume and operative mortality in the United States.
N Engl J Med 2003;349:2117–27
14 Davidson M. Uncommon Sense – The Life and Thought of
Ludwig von Bertalanffy (1901–1972), Father of General
Systems Theory. Los Angeles: Tarcher, Inc., 1983
15 Neumann E. The Great Mother: An Analysis of Archetype.
Princeton, NJ: Princeton University Press, 1955
16 Schelling TC. The Strategy of Conflict. Cambridge:
Harvard University Press, 1960
17 Jung CG. Four Archetypes: Mother/Rebirth/Spirit/Trickster.
Princeton, NJ: Princeton University Press, 1973
18 Ashmos DP, Duchon D, McDaniel RR. Participation in
strategic decision-making: the role of organizational
predisposition and issue interpretation. Decis Sci
1998;29:25–51
19 Damasio AR. Descartes’ Error: Emotion, Reason and the
Human Brain. Avon Books: New York, 1994
20 Leape LL. Error in medicine. JAMA 1994;272:1851–7
21 Rosch E, Lloyd BB , eds. Cognition and Categorization.
Hillsdale, NJ: Lawrence Erlbaum, 1978
22 Weick KE. The collapse of sensemaking in organiza-
tions: the Mann Gulch Disaster. Admin Sci Quart
1993;38:628–52
23 Jones WT. The Romantic Syndrome: Toward a New Method
in Cultural Anthropology and the History of Ideas. The
Hague: Martinus Wijhaff, 1961
24 Edmondson AC. Learning from mistakes is easier said
that done: group and organizational influences on the
detection and correction of human error. J Appl Behav Sci
1996;32:5–28
25 Hock D. Birth of the Chaordic Age. San Francisco: Berrett-
Koehler, 1999
26 Bettis RW, Prahalad CK. The dominant logic: retro-
spective and extension. Strategic Manage J 1995;16:237–52
27 Bruner J. In Search of Mind. New York: Harper, 1983
28 Rogers EM. Diffusions of Innovations 3rd edn. New York:
New York Free Press, 1983
29 Baloff N. Extension of the learning curve – some
empirical results. Operat Res Quart 1971;22:329–40
30 Yelle LE. The learning curve – historical review and
comprehensive survey. Decis Sci 1979;10:302–28
31 Argote L, Epple D. Learning curves in manufacturing.
Sci 1990;247:920–4
32 Coutu DL. The anxiety of learning [interview with
Edgar Schein]. Harvard Business Rev 2002;80:100–6
33 Waldman JD, Arora S. Retention rather than turnover—
a better and complementary HR method. Hum Resour
Planning 2004;27:6–9
34 Aiken LH, Clarke SP, Sloane DM et al. Hospital nurse
staffing and patient mortality, nurse burnout, and job
dissatisfaction. J Am Med Assoc 2002;286:1987–93
35 Borda RG, Norman IJ. Factors influencing turnover and
absence of nurses: a research review. Int J Nurs Stud
1997;34:385–94
236
Downloaded from hsm.sagepub.com at University of Manitoba Libraries on June 4, 2015
36 Buckbinder SB, Wilson M, Melick CF, Powe NR.
Primary care physician job satisfaction and turnover.
Am J Managed Care 2001;7:701–13
37 Galloro V. Staffing outlook grim-high turnover expected
to continue in skilled nursing, assisted living. Mod
Healthcare 2001;31:64
38 Goodman EA, Boss RW. Burnout dimensions and
voluntary and involuntary turnover in a health care
setting. J Health Hum Services Admin Spring 1999;21:462–71
39 Irvine DM, Evans MG. Job satisfaction and turnover
among nurses: integrating research findings across
studies. Nursing Res 1995;44:246–53
40 Johnson Rep. Nancy. Congressional outlook: nursing
shortages. Hosp Outlook 2001;4:7
41 Kinard J, Little B. Are hospitals facing a critical shortage
of skilled workers? Health Care Superv 1999;17:54–62
42 Mott DA. Pharmacist job turnover, length of service,
and reasons for leaving, 1983–1997. Am J Health-System
Pharmacy 2000;57:975–84
43 Prescott PA. Vacancy, stability, and turnover of regis-
tered nurses in hospitals. Res Nurs Health 1986;9:51–60
44 Shanahan MM. A comparative analysis of recruitment
and retention of health care professionals. Health Care
Manage Rev 1993;18:41–51
45 Stoller JK, Orens DK, Kester L. The impact of turnover
among respiratory care practitioners in a health care
system: frequency and associated costs. Resp Care
2001;46:238–42
46 Tai TWC, Bame SI, Robinson CD. Review of nursing
turnover research, 1977–1996. Soc Sci Med
1998;47:1905–24
47 Waldman JD, Smith HL, Kelly F, Arora S. The Shocking
Cost of Turnover in Healthcare. Health Care Manage Rev
2004;29:2–7
48 Chassin MR. Is health care ready for six sigma quality?
Millbank Quart 1998;76:565
49 Waldman JD, Spector RA. Malpractice claims analysis
yields widely applicable principles. Pediatr Cardiol
2003;24:109–17
50 Berwick DM. Continuous Improvement as an ideal in
health care. N Engl J Med 1989;320:53–6
51 Allen SW, Gauvreau K, Bloom BT, Jenkins KJ. Evidence-
based referral results in significantly reduced mortality
after congenital heart surgery. Pediatrics 2003;112:24–8
52 Berta WB, Baker R. Factors that impact the transfer and
retention of best practices for reducing error in hospital.
Health Care Manage Rev 2004;29:90–7
53 Millenson M. The Silence. Health Affairs 2003;22:103–12
54 Axelsson R. Toward an evidence-based health care
management. Int J Health Planning Manage
1998;13:307–17
55 Walshe K, Rundall TG. Evidence-based management:
from theory to practice in healthcare. Milbank Quart
2001;79:429–36
56 Flowers VS, Hughes CL. Why employees stay. Harvard
Business Rev 1973:49–60 (DOI:10.1225/73406)
57 Senge PM. The Fifth Discipline – The Art and Practice of the
Learning Organization. New York: Currency Doubleday,
1990
58 Lewin K. Frontiers in group dynamics. Hum Relat
1947;1:5–41
59 Deal TE, Kennedy AA. Corporate Culture: Rites and
Rituals of Corporate Life. Cambridge, MA: Perseus
Publishing, 1982
60 Sterman JD. Systems dynamics modeling: tools for
learning in a complex world. IEEEE Eng Manage Rev
First Quart 2002;1:42–52

61 Young GJ, Charns MP, Daley J et al. Best practices for
managing surgical services: the role of coordination.
Health Care Manage Rev 1997;22:72–81
62 Fickeisen DH (1991). Learning how to learn, An inter-
view with Kathy Greenberg. The Learning Revolution
(IC#27) by the Context Institute. www.context.org/
ICLIB/IC27/Greenbrg.htm Accessed December 2004
63 Owen H (1991). Learning as transformation. The
Learning Revolution. (IC#27) by the Context Institute.
www.context.org/ICLIB/IC27/Greenbrg.htm. Accessed
December 2004
64 Kubler-Ross E. On Death and Dying. New York:
Touchstone, 1969
65 Arndt M, Bigelow B. The transfer of business practices
into hospitals: history and implications. Adv Health Care
Manage 2000;1:339–68
66 Wysocki B. To fix health care, hospitals take tips from
factory floor. Wall Street J A6, 9 April 2004
67 Ackoff RL. Ackoff’s Best-His Classic Writings on Manage-
ment. New York: Wiley & Sons, 1999
68 Ackoff RL, Rovin S. Redesigning Society. Stanford, CA:
Stanford Business Books, 2003
69 Aronson D. Overview of systems thinking. www.
thinking.net. Accessed February 2004, 1996–98
70 Beinhocker ED. Strategy at the edge of chaos. McKinsey
Quart 1997;1:24–40
71 Bertalanffy L. Perspectives on General systems Theory:
Scientific-Philosophical Studies. New York: Braziller, 1975
72 Kauffman SA. At Home in the Universe. New York:
Oxford University Press, 1995
73 Lazlo E. The Systems View of the World. New York:
George Braziller, 1972
Downloaded from hsm.sagepub.com at University of Manitoba Libraries on June 4, 2015
The means to improve health-care outcomes
74 McDaniel RR, Driebe DJ. Complexity science and health
care management. Adv Health Care Manage 2001;2:11–36
75 Collins JC, Porras JI. Built to Last. New York: HarperBu-
siness, 1997
76 Freiberg K, Freiberg J. Nuts! Southwest Airlines’ Crazy
Recipe for Business and Personal Success. New York:
Broadway Books, 1996
77 Stubblefield A. The Baptist Healthcare Journey to Excel-
lence. Hoboken, NJ: Wiley & Sons, 2005
78 Waldman JD, Young TS, Pappelbaum SJ et al. Pediatric
cardiac catheterization with ‘same-day’ discharge. Am J
Cardiol 1982;50:800–4
79 Waldman JD, Pappelbaum SJ, George L et al. Cost-
containment strategies in congenital heart disease.
Western J Med 1984;141:123–6
80 Machiavelli N. The Prince. England: Wordsworth
Editions, Hertfordshire, 1993, 1513
81 The Bristol Royal Infirmary Inquiry Final Report, July
2001; Accessed 15 March 2006 at: www.bristol-inquir-
y.org.uk/final_report/index.htm
82 Mahony L, Sleeper LA, Anderson PAW et al. The
pediatric heart network: a primer for the conduct of
multicenter studies in children with congenital and
acquired heart disease. Pediatr Cardiol 2006;27:191–8
83 Lacour-Gayet F, Clarke D, Jacobs J et al. The Aristotle
Score: a complexity-adjusted method to evaluate
surgical results. Eur J Cardio-Thorac Surg 2004;25:
911–24
84 Luft HS, Bunker JP, Enthoven AC. Should operations
be regionalized? The empirical relation between
surgical volume and mortality. N Engl J Med 1979;301:
1364–9
237