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Improving hospital care: Are learning organizations the answer?

Article  in  Journal of Health Organisation and Management · November 2014

DOI: 10.1108/JHOM-10-2013-0229

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JHOM
28,6
830
Received 21 October 2013
Revised 2 April 2014
Accepted 14 April 2014
Journal of Health Organization and
Management
Vol. 28 No. 6, 2014
pp. 830-838
© Emerald Group Publishing Limited
1477-7266
DOI 10.1108/JHOM-10-2013-0229
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1477-7266.htm
Improving hospital care:
are learning organizations
the answer?
Sophie Soklaridis
Innovation and Education Scholarship (RISE), Division of Psychotherapies,
Humanities and Education Scholarship (PHES),
Centre for Addiction and Mental Health, Toronto, Canada
Abstract
Purpose – Hospital leaders are being challenged to become more consumer-oriented, more
interprofessional in their approach to care and more focused on outcome measures and continuous
quality improvement. The concept of the learning organization could provide the conceptual
framework necessary for understanding and addressing these various challenges in a systematic way.
The paper aims to discuss these issues.
Design/methodology/approach – A scan of the literature reveals that this concept has been applied
to hospitals and other health care institutions, but it is not known to what extent this concept has been
linked to hospitals and with what outcomes. To bridge this gap, the question of whether learning
organizations are the answer to improving hospital care needs to be considered. Hospitals are
knowledge-intensive organizations in that there is a need for constant updating of the best available
evidence and the latest medical techniques. It is widely acknowledged that learning may become the
only sustainable competitive advantage for organizations, including hospitals.
Findings – With the increased demand for accountability for quality care, fiscal responsibility and
positive patient outcomes, exploring hospitals as learning organizations is timely and highly relevant
to senior hospital administrators responsible for integrating best practices, interprofessional care and
quality improvement as a primary means of achieving these outcomes.
Originality/value – To date, there is a dearth of research on hospitals as learning organizations
as it relates to improving hospital care.
Keywords Hospitals, Leadership, Organizational theory, Medical professions, Methodology,
Management theory
Paper type Viewpoint
Introduction
Hospitals are subject to reform and ongoing change as funding and government bodies
seek better value from health funds, and as consumer expectations rise ( Joiner et al.,
2011). Hospital leaders are being challenged to become more consumer-oriented, more
interprofessional in their approach to care and more focused on outcome measures and
continuous quality improvement.
The concept of the learning organization could provide hospitals with an
opportunity to understanding and addressing these various challenges in a systematic
way. Business organizations such as Corning, General Electric, Honda and Xerox have
applied the concept of the learning organization to gain a competitive advantage in a
rapidly changing business environment (Nonaka and Takeuchi, 1995; Prokesch, 1997).
Hospitals are similar to business organizations because their “competitive advantage”
relates to the successful implementation of both the most current and evidence-based
research and technology into clinical practice for improved patient care. Although
business and healthcare are quite different in relation to context and institutional
frameworks, hospitals have had to make changes in the way they approach the
business of healthcare. Hospitals are knowledge-intensive organizations in that there is Improving
a need for constant updating of the best available evidence and the latest medical
techniques. These innovations have lead to a significant increase in the cost of
hospital care
providing care. For hospitals to succeed in being innovative in patient care for both
procedures and treatments and remain cognizant of the need for cost containment
efforts, they will have to be run more like businesses than community services
(McDonald and Srinivasan, 2004; Kim et al., 2006). 831
From a medical educational learning perspective, an example of a cost-effective
strategy is to ensure that innovation and scholarship in hospitals is informed by a
sound review of literature and/or based on a theoretical framework. Scholarship and
innovations that lacks these elements are an impediment to knowledge creation (Albert,
2004) and diminish the overall quality and efficacy of patient care. It is widely
acknowledged that learning may become the only sustainable competitive advantage
for all organizations (Vassalou, 2001), including hospitals. Hospitals have been
anecdotally described as learning organizations. However, to date, no review of the
literature of any kind has been performed on hospitals as learning organizations.
If business organizations have demonstrated that implementing learning organization
concepts has kept them ahead of change, then hospitals can benefit from a similar process.
This paper considers whether the concept of the learning organization can be used
to improve hospital care. It provides a brief overview of the literature on learning
organizations and provides case study examples to illustrate how this concept has been
adapted into practice in two different hospital settings.

The concept of a learning organization

Although some have argued that the learning organization is not a new concept and to
describe it as such does not appropriately recognized the learning that occurred in
organizations in the 1800-1950s (Gronhaug and Stone, 2012), the learning organization,
as a phenomenon, was popularized by Senge (1990, 1991, 1996).
The concept of the learning organization (Garrat, 1987) became a focus of research in
the 1990s when Senge’s work described a new type of organization that intentionally
develops strategies to promote learning. This concept was presumed to become
important to organizations due to an increase in competition, advances in technology
and shifts towards customer preferences (Garvin, 2008). To stay competitive in this
environment, it was believed that employees needed to become more skilled at creating,
acquiring and transferring knowledge. According to Senge (1990) a company that
becomes a learning organization has a greater ability to adapt to the unpredictable,
which gives that company a competitive advantage over their competitors.
A learning organization promotes learning through two interacting forces:
individual learning and a contextual environment of learning (Hodgkinson, 2000).
For example, when individuals increase their capacity to learn, they can collectively
enhance the overall capacity of the organization to learn, as long as the organization
has a culture and climate that is receptive to their efforts and puts in place appropriate
mechanisms to enable, support and reward the use of what is learned (Marsick and
Watkins, 2003).
Although learning organizations may have different characteristics depending on
the contextual setting, there are common threads that are shared by all learning
organizations and that demonstrate their potential to enable innovations in hospitals.
A learning organization has a strong focus on individuals; concern for all stakeholders;
learning as one of its core values; an openness to experimentation and an attitude of
JHOM responsible risk taking; a readiness to recognize, accept and learn from errors; open
communication; knowledge sharing; and a willingness to unlearn and relearn (Ahmed
28,6 et al., 1999; Hill, 2006; Rebelo and Gomes, 2008; Senge, 2006). In addition, there is an
increased awareness among scholars who study learning organizations that most
learning on the job happens informally, in groups or through conversations (Marsick,
2006; Yedema et al., 2007). Learning organizations can range from corporations to higher
832 education institutes, hospitals or even a family unit (Dowd, 2000). Identification as a
learning organization is seen as a desirable status symbol (Tosey and Mathison, 2008).
The recent business management literature provides examples of how the concept
of the learning organization has been applied successfully in various organizations to
removing restraints to learning, aligning structure and culture for group learning, and
harnessing staff commitment and motivation for personal and service improvement
(Garvin, 2008; Gronhaug and Stone, 2012; Mishra and Bhaskar, 2011; Margherita and
Secundo, 2011; Samli, 2011).

The hospital as a learning organization

A scan of the literature reveals that the concept of the learning organization has been
applied to hospitals and other health care institutions (Bell et al., 2013; Birleson, 1998,
1999; Rowley, 2006). However, it is not known to what extent this concept has been
linked to hospitals and with what outcomes. Consolidating, mapping and synthesizing
the literature on hospitals as learning organizations could be used to develop a
preliminary conceptual framework. This exercise would assist in extracting common
themes from the findings into three key areas of particular importance to hospitals:
implementation of best practices, improving interprofessional care and continuous
quality improvement that could serve as potential benchmark indicators for measuring
continuous quality improvement.
Various theoretical perspectives on learning organizations exist and are
communicated separately in journals that only a portion of the population
(depending on sector) reads. For example, there is a literature on hospital learning
organizations in business management journals that health care providers might not
access, since the topic is only indirectly related to their field of education, research and/
or practice. Intentional linkages among the “siloed” perspectives would provide the
opportunity to bring together theories from these various sectors of research.
The findings would highlight the similarities between, differences between and
intersections of these theories and how the concept of the learning organization,
vis-à-vis these theories, has been utilized by hospitals and health care institutions.
An analysis that identifies the interplay and intersections among the identified theories
would provide a more holistic representation of hospitals as learning organizations.
Thus, an answer to the question, “Are learning organizations the answer to improving
hospital care?” could provide essential information to hospital administrators who are
responsible for ensuring that their hospital operates efficiently and provides appropriate
health care to patients.

Learning organizations in practice

The development of a conceptual framework could include the characteristics of
hospitals as learning organizations; the key elements of success, including the culture
of success; how the term “learning organization” is used, by whom and for what
purpose; and case examples of hospitals as learning organizations. For example,
Birleson (1998) describes how the Maroondah Child and Adolescent Mental Health Improving
Services took steps to becoming a learning organization. Becoming a learning
organization was deemed as a solution to the problem of continual change and
hospital care
increasing consumer expectations. Through the use of a case study methodology, the
author described how the principles of learning organizations have been applied within
their hospital. An action research approach to change was used to support the process
of aligning the structure and culture of the hospital with the concept of the learning 833
organization. Although the findings are still preliminary, several positive outcomes
emerged as a result of implementing learning organization principles, such as: newly
implemented workload benchmarks have increased output, a patient satisfaction
study has established a baseline for quality improvement, healthcare providers
receive monthly feedback about workload activities, student placements are evaluated,
external research grant funding increased, and team meetings have been altered to
increase dialogue and sharing among team members. The author concludes that the
concept of the learning organization seems to be appropriate for improving their mental
health service.
Framing hospitals as learning organizations could help hospital administrators
address the need for a working balance that promotes a safety and patient care culture.
The current prevailing “culture of blame” in health care has been suggested as a major
source of an unacceptably high number of medical errors (Khatri et al., 2009). Hospitals
can moved away from a “culture of blame” by using change management principles
aligned with the concept of the learning organization. For example, Children’s Hospital
and Clinics in Minnesota instituted a new policy of “blameless reporting” as one
strategy for building a supportive learning environment (Garvin, 2008). Hospital
administrators identified a problem- when something went wrong with patient care, the
last person who was involved in that care was blamed. They used a patient safety
approach that re-focused medical errors on the breakdown of systems rather than
mistakes made by staff. The policy replaced threatening terms with less emotionally
laden terms. For example, the term “incident report” was replaced by “safety learning
report”. These reports encourage staff to tell the story of what happened and to suggest
improvements. The reports were confidential and could be submitted by staff on paper,
by phone or online. Their preliminary findings showed that healthcare providers began
identifying and reporting risks without fear of blame and the number of preventable
deaths and illness decreased. They concluded that as a result of these changes, their
hospital has become a safer place to both work and receive care.
The experiences of these hospitals could serve as a model to develop a learning
organization framework in other hospitals and healthcare organizations. These
examples illustrate how organizational culture plays a critical role in the health care
services and delivery process. Developing concrete measures for applying the concept
of the learning organization to advance the implementation of best practices,
interprofessional care and quality improvement in hospital settings will improve
patient care and healthcare provider satisfaction (see Figure 1). As illustrated by
the examples above, hospital administrators adapted core values of a learning
organization, such as knowledge sharing, risk taking, learning as a core value, the
need to learn and unlearn, and learning from errors into their organizations. The core
values, in both cases, were applied for the purposes of quality improvement and
interprofessional care. Both studies revealed outcomes that indicate increased dialogue
among interprofessional healthcare teams, improved patient satisfaction, and decrease
the number of preventable illness and deaths thereby increasing safety for both
JHOM The Hospital as a Learning Organization

28,6 CORE CHARACTERISTICS

Knowledge Attitude Learning as Learning and Learning

sharing of risk taking a core value unlearning from errors

834 PROCESS

Applying the core characteristics

OUTCOMES
Improving Implementation Continuous
interprofessional care of best practices quality improvement

Examples of outcomes:
* Implementing workload benchmarks
* Establishing a baseline for quality improvement
Figure 1. * Monthly feedback for HCP
Overview of hospital as * Evaluation of student placement
learning organization * Altering team meetings to increase dialogue
* Moving away from a “culture of blame”

patients and providers. These hospital administrators were able to implement

the concept of learning organizations to generate measurable data to show
improved hospital care.

Conclusion
Hospitals are structured to provide opportunities for clinical care and education for
patients, along with clinical education and training of future and current health care
providers (Aston et al., 2012) within an environment in which research and innovation
are core activities. Hospital administrators are expected to encourage and support
knowledge translation and exchange activities, such as translating new knowledge into
cost-effective best practices, developing new frameworks for delivering optimal care
and innovating interventions and medications to improve treatments and health
outcomes (Oborn et al., 2013; Sox, 2011). This viewpoint paper considered whether the
concept of learning organizations can provide a framework for measuring these
activities to improve hospital care.
A brief overview of the concept of learning organizations and how it can be
applied to improve services was described and explained. Two case studies of hospitals
that have implemented core characteristics of a learning organization to their settings
were provided. The outcomes of both case studies suggest that applying learning
organization principles into practice improves hospital care.
Inevitably, there are many tensions within the working environment of a hospital.
With regard to consumers, given that even a very small error could have irreversible
effects on patients’ morbidity and mortality, as well as on the hospital and the
community, it can be argued that a quality orientation is more important in health care
than in any other sector (Carman, 2000). Although attempts have been made to account
for and measure the quality of services in hospitals (e.g. public scorecards), there is no
general agreement on how this should be measured (Mahmood and Mohammadreza, Improving
2011). With regard to interprofessional care, the entrenched hierarchical structure
of hospitals often poses challenges for health care providers and learners alike to
hospital care
communicate across professional boundaries and collaborate for learning (Baker et al.,
2011; Valentine et al., 2011). Unfortunately, this disinclination to communicate
and collaborate can adversely affect patient care and outcomes. It is known that
counterproductive hierarchical communication patterns derived from status 835
differences are partly responsible for many medical errors (Pian-Smith et al., 2009;
Ricci et al., 2012; Wu, 2000). While team functioning is pivotal to the quality of patient
care, there is limited guidance on how to identify and evaluate the dimensions and
behavioural aspects of team functioning that characterize high-performing
interprofessional health care teams (Sutton et al., 2011; Upenieks et al., 2010; West
and Lyubovnikova, 2013).
With regard to continuous quality improvement, health care providers and
administrators do not necessarily have easily accessible information on optimal care
provision, improved health outcomes and the identification of patient safety issues and
their solutions. Despite the volumes of research evidence available that may support
quality improvement, relatively little is disseminated and applied in clinical settings
(Cabana et al., 1999; Grol and Grimshaw, 1999; Lavis, 2009; Lemire et al., 2013; Tetzlaff
et al., 2009; Wallace et al., 2012).
Hospital care related to patient safety, interprofessional care and continuous quality
improvement were some of the challenges raised by hospital administrators. Medical
education informed by a sound review of literature and/or based on a theoretical
framework has been proposed as a means of meeting these challenges. The learning
organization has contributed to something new to our understanding of hospital care
by providing a mechanism for recognizing and appropriately managing medical errors,
facilitating teamwork among healthcare providers and designing measures to improve
the quality of patient care are long-term investments.
With the increased demand for accountability for quality care, fiscal responsibility and
positive patient outcomes, exploring hospitals as learning organizations is timely and
highly relevant to senior hospital administrators responsible for integrating best practices,
interprofessional care and quality improvement as a primary means of achieving these
outcomes. Applying the characteristics of a learning organization to hospitals could serve
as a first and necessary step in assisting hospital administrators to improve hospital care.

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Further reading
Conner, M.L. and Clawson, J.G. (2004), Creating a Learning Culture: Strategy, Technology, and
Practice, Cambridge University Press, Cambridge.
Senge, P., Kleiner, A., Roberts, C., Ross, R., Roth, G. and Smith, B. (1999), The Dance of Change:
The Challenges of Sustaining the Learning Organization, Doubleday, New York, NY.

Corresponding author
Dr Sophie Soklaridis can be contacted at: sophie.soklaridis@camh.ca

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