Learning Organisations in Health Care

• Abstract
• Introduction
• Setting the Scene
  • Meeting the Needs of Patients
  • Patient Safety
  • Complex Adaptive Systems
• Introduction to Learning Organisations
  • Overcoming Barriers to Organisational Change
• Embodying Maori Culture in Learning Organisations
• Medical Professionalism in Learning Organisations
• Implications for Leadership and Management Development in Health Care
  • You Can’t Create Leaders in a Classroom
  • Ethnic Cultures
  • Professional Sub-cultures
  • The Individualistic Approach to Learning
• Barriers to Change
  • Fundamental Changes in Mind-set
  • Inappropriate Organisational Forms
  • Other Barriers to Change
• From Theory to Practice
• Conclusion
• References

Abstract

This paper uses the example of health care provision in New Zealand to consider how the application of the principles of learning organisations could assist in the improvement of health care systems.

A body of evidence highlights the apparent failure of the New Zealand health care system to meet patient needs or even to maintain patient safety. Barriers to change include the requirement for a fundamental change in mind-set, inappropriate organisational forms, the lack of financial investment in leadership development in health care, for both clinicians and managers, and the lack of deep relationships between health care organisations and the communities they serve, as a larger health system.

Key questions relate to how is it possible to create health care organisations with the capacity to solve such deep-rooted problems and how much of the failure to address these issues stem from inappropriate models of thinking and organisational design?

A learning organisation operates with three foundations: a culture based on transcendent human values of love, wonder, humility and compassion; a set of practices for generative conversation and co-ordinated action and; a capacity to see and work with the flow of life as a system. Learning organisations are built by communities of "servant-leaders", people who lead because they choose to serve, both to serve one another and to serve a higher purpose. Development of this style of leadership, among both clinicians and managers, is crucial for the improvements we desire in quality, safety and effectiveness of health care.

In addition in New Zealand, there might be the opportunity to evolve a unique form of learning organisation by working alongside our indigenous peoples and understanding and adopting indigenous concepts from Maori cultures such as shared learning, mutual respect and obligation.

Introduction

This paper uses the example of health care provision in New Zealand to consider how the application of the principles of learning organisations could assist in the improvement of health care systems. While the content is drawn strongly from New Zealand experience, the issues and ideas presented equally apply internationally, in particular in Australia, the US, Canada and the UK.

Setting the Scene

Out of simple stories, come profound lessons.

How can health professionals apparently conspire to act with such callous disregard for the needs of a dying patient? It would be easy to blame the nurse and attribute her behaviour to a lack of compassion or professional standards. But there may also be deeper causes of this failure to provide care. A number of issues arise:

• To what degree was the behaviour of the registrar and nurses driven by their own deep-seated fears and feelings of inadequacy about the imminent death of a patient?
• In their workplace, is there a system that supports them to cope with failure to achieve a cure and trains them in interpersonal communication to help them deal with the grieving family?
• What training and support do junior doctors and nurses receive in palliative care? When medical training emphasises the great dangers of morphine overdose and the medico-legal environment punishes mistakes, how likely is it that an inexperienced doctor would chart an adequate dose of morphine for a dying man?
• In this case, why was the patient not admitted to the hospice to receive pain relief, rather than a busy hospital ward? The family never knew that was an option.
• How easy is it for a nurse to call a doctor out of hours? What combination of fatigue, busyness, conflicting duties, personal insecurities and arrogance might sometimes cause a junior doctor to respond angrily to a request for help from a nurse? How easy is it for a junior doctor to ask a consultant for help?
• What system of incentives, rewards and punishments drives behaviour within hospital systems? Does the system overvalue paperwork, compliance with administrative procedures and achievement of volume targets but undervalue caring and compassion and the time to listen?
• What is the nature of the power relationship between a patient, family and caregivers? Is it right that absolute power and control over a patient and family should be given to professionals, when the rights of the patient are commonly overridden?

Meeting the Needs of Patients

The New Zealand Code of Health and Disability Services Consumers’ Rights includes:

• the right to be treated with respect (right 1)
• the right to dignity and independence (right 3)
• the right to services of an appropriate standard (right 4)
• the right to effective communication (right 5)
• the right to be fully informed (right 6)
• the right to make an informed choice and give informed consent (right 7)
• the right to support (right 8)
• the right to complain (right 10)

We might hope that the opening story is an isolated example of bad care but everyday observations show that systems of care consistently fail to respond to the needs of its patients and clients.

A body of research indicates that health practitioners are profoundly inhibited by the systems of inter-professional relationships and norms of workplace culture, from connecting with patients as fellow human beings, from understanding their needs and providing the help and care that is most desired.

A New Zealand based project was undertaken to improve the care of elderly patients with multiple medical problems, by integrating all the information about these patients held by their various health professionals and creating a single care plan for each patient (Mahoney 2001). In 51% of patients, there were dose discrepancies between what the GP had listed and what the patient said they were taking. Each patient wrote a detailed self-assessment of his or her various medical problems and was asked what one thing could be improved that would really make a difference to their health or life. The patient goals were modest and achievable - not "cure my arthritis", but "if you could improve my mobility a bit, I could get into the garden and that would transform my life".

For each patient, the multidisciplinary team met to develop an integrated care plan that would be shared with the patient. However, the outcomes of the research were as unexpected as they were dismal:

• Only 52% of the problems considered most important by patients were discussed at the planning meeting by the health professionals.
• Only 35% of the problems considered most important by patients were included in the planned interventions.
• Only 14% of the problems considered most important by patients were actually addressed in the implementation of the care plan.

Research in the US examining the primary care of elderly patients produced strikingly similar results (Nelson & Wasson 1994). 45% of patients over 70 have severe physical limitation and, of those, 80% said their doctor was aware of the problem, 50% remembered that the doctor had treated it and only 15% indicated they were much better as a result.

The truth is, health professionals rarely allow patients or clients to set the agenda. A study in Canada and the US examined audio recordings of 264 interviews between patients and experienced family physicians (Marvel et al 1999). Physicians solicited patients’ concerns in only 75% of cases. Patients completed their statement of concern in only 28% of the interviews because physicians redirected patients’ opening statements after a mean of 23 seconds. Patients allowed to complete their statement of concern only used 6 seconds more on average than those who were redirected before completion of concerns. Those physicians with "fellowship training", which included counselling and communication skills, solicited a complete list of concerns from the patient more frequently (44% versus 22%).

One would hope that nurses and therapists, who spend many more hours with patients, might be better than doctors at understanding the experience and perspective of patients undergoing care. But even in rehabilitation wards, which aim to guide patients back to independence and autonomy, this awareness may sometimes be sadly lacking. A New Zealand study examined the experiences of seven patients undergoing rehabilitation, by listening and analysing their personal stories (Gooder 2000).

The first area of learning is related to the impact of the altered body on the patient’s sense of self:

Sadly, hospital wards rarely allow patients to create a sense of self in their bed space. The second area of learning focuses on the mood of health professionals working within the ward or therapy departments:

A further finding related to the impact of systems on patients’ sense of dependence. For example, the practice of removing walking frames at night may have a logical basis and may be to enhance the work of the nurses but the impact on patients was so great, that the balance between the good of the patient and the convenience of the nurse needs to be questioned.

Another problem was failure to meet dietary needs and personal preferences, effectively failure to recognise eating patterns and food choices as part of the expression of individuality and cultural norms. Having facilities for self-service of drinks and light snacks would give some autonomy and enable more active patients to move towards the degree of self-sufficiency that will be required when they are discharged.

Patient Safety

To failure of listening, caring and compassion, we can add failure to keep safe. Adverse events were associated with 12.9% of admissions to New Zealand public hospitals. Approximately 35 percent of adverse events were classified as highly preventable. Adverse events increase the average hospital stay by nine days. System errors featured prominently in the analysis of areas for future prevention of recurrence (Davis 2001).

A curious feature of recent major reports on patient safety, such as the Institute of Medicine’s "To Err is Human" (2000), is that patient safety is defined in the reports in purely physical terms. Emotional, psychological, spiritual and cultural safety is not considered in the reports and yet it may be the greater cause of long-lasting harm. Many reports on patient safety emphasise the need to change the culture of organisations, moving away from "name, shame and blame" of health care practitioners and towards increased consideration of their emotional and psychological safety. However, if emotional and psychological safety of patients is not considered valid, there is little hope of changing the culture for health care workers.

Complex Adaptive Systems
How can we begin to understand the failure of the New Zealand health care system to address these fundamental issues? Perhaps the very design of our health organisations and the current prevailing theory and practice of management are at the root of the problem. Don Berwick at the Boston-based Institute for Healthcare Improvement (a not-for-profit organisation created to help lead the improvement of health care systems) has defined the "First Law of Improvement" ^{[ 2 ]}:

• Every system is perfectly designed to achieve exactly the results it gets.
• The worst plan is to try harder.

Plsek (2001) explores the application of complexity science to health care.

Plsek questions whether the biggest barrier to implementing these new approaches prompted by complexity thinking might be the leaders of health care systems who have risen within their hierarchies based on command and control methods.

Increasingly, the emphasis is shifting away from "control" toward "enabling" innovation and improvement at the front line. "Only those who provide care can in the end change care" ^{[ 3 ]}.

The fundamental question remains, how is it possible to create health care organisations with the capacity to solve these deep-rooted problems? How much of the failure to address these issues stem from inappropriate models of thinking and organisational design?

Introduction to Learning Organisations

If nothing else, the world-wide failure to address issues of patient safety should be ringing alarm bells for those designing quality improvement systems. Health care organisations have consistently failed to learn from their past mistakes and to resist change even in the face of overwhelming evidence of continuing harm to patients. The top-down, prescriptive approach to clinical governance adopted in the UK may be doomed to failure. (The UK Government has introduced a statutory requirement for all health organisations to seek quality improvement through clinical governance. The final accountability for clinical governance rests with the chief executive of the health organisation. The Commission for Health Improvement (CHI), a statutory body, will publish information on the comparative performance of health providers.) Wallace (2001) examined the implementation of clinical governance in 47 hospital trusts in the West Midland region of the UK:

In the business world, the last decade has seen an explosion of research, knowledge and literature about the discipline of learning organisations, profoundly influenced by Peter Senge, author of the widely acclaimed book, The Fifth Discipline: the Art and Practice of the Learning Organisation (Senge 1990). Senge asks,

Senge believes there are three characteristics of society that may be reflected in the basic dysfunction of large organisations:
1. fragmentation
2. competition
3. reactiveness.

These characteristics are deeply rooted in western attitudes, mental models and instinctive approach to the solution of complex problems. Together they cause a profound learning disability within organisations. The health care reforms of the 1990s in New Zealand, which created competition and fragmentation, have worsened that learning disability.

The defining characteristic of a system, such as health care, is that it cannot be understood as a function of its isolated components. The behaviour of the system does not depend on what each part is doing but on how each part is interacting with the rest. In health care organisations, people are the system. The widely divergent perceptions, beliefs and mental models of health consumers, nurses, doctors and managers are part of the system.

Senge believes that a learning organisation must have three foundations:

1. a culture based on transcendent human values of love, wonder, humility and compassion
2. a set of practices for generative conversation and co-ordinated action
3. a capacity to see and work with the flow of life as a system.

Learning organisations are built by communities of "servant-leaders" - people who lead because they choose to serve, both to serve one another and to serve a higher purpose. Development of this style of leadership, among both clinicians and managers, is crucial for the improvements we desire in quality, safety and effectiveness of healthcare. Health care leaders might ponder the difference between a teaching hospital, full of "esteemed and learn’d colleagues" and a learning hospital.

Overcoming Barriers to Organisational Change

Argyris (1993) shows that effective communication and learning are often inhibited by people’s innately defensive behaviour preventing the real issues from surfacing. Certain difficult and embarrassing issues can be undiscussable. Unconscious habits of argument and debate reinforce existing patterns of communication, in which the conflicting theories and assumptions of participants are never exposed or challenged. This systematised form of self-censorship limits real communication. Instead of telling the truth, people within an institution might express only those views acceptable within the institutional culture. Patterns of interpersonal behaviour create organisational defence mechanisms, which, in turn, reinforce the individual defence mechanisms.

At the heart of the learning difficulty is the difference between what Argyris calls "theories espoused" and "theories in use". Consider what can happen when a group sits around a table to discuss a difficult organisational issue, such as the conflict between the quality of health care and financial restraints. The group members may even overtly say, "Let’s be as open and honest about this one as we can be". This is the "theory espoused". However, the real culture of the organisation can make certain statements dangerous, leading to self-censorship - the "theory in use" - that is at variance from the theory espoused. As a result, group members often say one thing while believing another.

Real learning takes place, according to Argyris, not simply when an organisation refines work practice in response to external stimuli, which he calls "single-loop learning", but when it refines its theories and assumptions about the way the world works, engaging in "double loop learning". Argyris describes practical strategies for learning to "craft conversations" in ways which overcomes unconscious defensive behaviours. For instance, rather than advocating a position, which allows no challenge to the underlying unspoken assumptions and beliefs, participants can learn to craft statements in ways that expose those assumptions. A "learning" stance, rather than a "knowing" stance, will lead to real dialogue and learning.

Embodying Maori Culture in Learning Organisations

In Aotearoa New Zealand, we might have the opportunity to evolve a unique form of learning organisation by working alongside our indigenous peoples and understanding and adopting concepts from Maori culture. The Maori term "whakawhitiwhitikorero", for instance, which means shared conversations, a form of research that implies a collective journey of learning and discovery. In Western tradition, health care research often involves outside experts observing and measuring behaviour and then taking the resulting information away for retrospective study.

The principles of respect, mutual obligation, reciprocity and shared conversations, strongly espoused in Maori custom, provide a strong foundation for learning relationships (Durie 2001).

Maori cultural concepts promote a holistic approach to health and well-being and emphasise the influence of the whanau (family).

Thus, in Aotearoa New Zealand, we have a unique opportunity to develop within our health care organisations a holistic approach to health and well-being within learning organisations that embody indigenous Maori concepts of shared learning, mutual respect and obligation.

Medical Professionalism in Learning Organisations

Following an editorial in the New Zealand Medical Journal on the subject of medical professionalism (Bagshaw 2001), a vigorous debate ensued in the journal’s correspondence columns. The editorial alleged that evidence-based practice, credentialing of medical practitioners and clinical governance were overt attempts by "management" to undermine the basis of medical professionalism. CLANZ (The Clinical Leaders Association of New Zealand) took an opposing view. If professionalism is understood to be that which is embodied in the values and behaviours that individual physicians demonstrate in their daily interactions with patients, families, other physicians and other professional colleagues, it is hard to see how any external influence could threaten professionalism.

With advances in medical technology and increasing monetary rewards for "procedural" medicine rather than thoughtful caring, the professions have become more closely connected to the application of expert knowledge and less closely linked to functions central to the good of the public they serve. Thus we have seen the emergence of expert professionalism rather than social trustee professionalism. At no time has there been a greater need within the medical profession for broad thinking, courageous and selfless leaders to demonstrate a "learning" rather than a "knowing" stance, to understand the needs of New Zealand communities and to commit to fundamental change within the profession.

Sir John Scott made the point in his valedictory address (1998):

Implications for Leadership and Management Development in Health Care

Leadership is a practice requiring the development of interpersonal skills, knowledge, attitudes and beliefs. Leadership must be demonstrated at every level of an organisation and is not the sole preserve of senior executives. Leadership has many different forms, and effective teams circulate leadership among the team members, according to complementary knowledge, skills and roles.

You Can’t Create Leaders in a Classroom

Eminent management theorists, such as Mintzberg, question whether leadership and management practice can be taught in a classroom. Mintzberg has created an alternative management programme to the traditional MBA, in which management practice and leadership skills are developed within the context of real-life problems (International Masters Program in Practising Management Mintzberg 2001).

Students, who are working managers, complete five modules that deliberately expose them to different ethnic cultures in order to broaden their approaches to problem-solving and managing change. They work on "ventures", which are programme-long projects aimed at creating real change in the students’ work environments. The five modules are related to managing:

• self, the reflective mind-set;
• relationships, the collaborative mind-set;
• organisations, the analytic mind-set;
• context, the worldly mind-set; and
• change, the action mind-set.

Ethnic Cultures

Effective management and leadership in the New Zealand health and disability sector require practitioners to understand its different ethnic cultures. Mainstream services respond poorly to the needs of Maori and closing the gaps in health status requires that leaders in mainstream services are conversant with Maori culture and values. Other ethnic groups, such as Pacific people, also suffer poor health status. Some understanding of cultural differences is required to understand the barriers that deny them access to the help and care that they need.

Professional Sub-cultures
Research in New Zealand and elsewhere (Degeling 1999) has demonstrated the existence of very distinct professional sub-cultures within hospital organisations. Doctors, nurses and managers as groups have profoundly different beliefs about the nature of accountability and whether inappropriate variations in practice reflect individual or organisational failings. Degeling argues that health service reform in New Zealand, the UK and Australia will fail unless common understandings between these different professional sub-cultures are developed and acted upon.

Simpson (2001) explores the potential of Personal Construct Psychology as a way of creating dialogue and bridging cultural differences between health professionals and managers. Healthcare Review - Online. August 2001; 5:4.

Health education and professional acculturation instill characteristic thinking styles, which are barriers to learning. Edward de Bono (1985) separates thinking into six distinct modes, identified with six coloured "thinking hats", which can be used to shed light on the issues in health care. Black hat thinking is associated with critical and negative thoughts. Many physicians habitually use only black hat thinking, stifling positive constructive thoughts, creativity and new ideas about work organisation.

Physicians also tend to have a low tolerance of ambiguity. One consequence is that physicians tend to construct an unresolvable conflict between the duty of care to an individual patient and a broader stewardship of health resources and general population health gain. Leaders learn to live with such ambiguity and to pursue parallel objectives.

The Individualistic Approach to Learning

The political and economic reforms of the 1990s in New Zealand emphasised individualistic values, competition and learning as the basis for increasing wealth and well-being. This individualistic approach is reflected in education, including postgraduate education and research degrees. However, more current theories about learning organisations and communities highlight the need for shared learning. New Zealand’s tertiary educational institutions, as presently constructed on 1990s ideals, may in fact be powerfully inhibiting learning in this country.

Educational institutions must move away from individual learning and qualifications and find innovative ways to support and recognise organisational learning. We need health professional training programmes that explicitly involve diverse cultures and perspectives, including the consumer viewpoint, and which develop skills and knowledge in the context of solving real-life, complex problems in health care. Clinical leaders of all professional disciplines and health care managers must be given opportunities for shared learning and leadership development.

Barriers to Change

The pace of health care reform in New Zealand over the last decade has inhibited organisation learning. Repeated restructuring and continuing turnover of management executives, for instance, the reappointment of every single CEO in the newly formed District Health Boards (DHBs) has caused the loss of health institutional memory and torn apart effective health care partnerships. (DHBs are responsible for providing or buying Government-funded health care services for the population of a specific geographical area in New Zealand.)

Fundamental Changes in Mind-set

Government health policy, which emphasises population health gain and local community involvement in health care, requires a profound mind-shift from that presently dominating the system. Gauthier (1995) has written one of the few reviews of the application of learning organisations to health care. He identifies the major changes affecting institutional thinking and the forces for change:

• The changing payment basis for health care, from fee-for-service and price-volume contracts to contracted care and capitation.
• The impact of advancing technology on the setting of care, shifting away from inpatient hospital-based care to ambulatory and community care.
• The relative importance and status of specialists versus primary care physicians.
• Shifting health care providers from a product orientation to a customer-focused service orientation.
• The shift from an "illness" to a "wellness paradigm" and health care organisations taking the lead in building healthier communities in partnership with health officials, local government agencies, employers, schools and churches.
• A greater recognition of the effectiveness of alternative medicines, traditional therapies and the self-healing capability of the individual.
• Creating health care organisations as healthy places for the providers of care, giving up stress, burnout and addictive behaviours such as blaming and workaholism.

Inappropriate Organisational Forms
The last several decades have seen thinking about organisations stuck on a bipolar axis, which has government ownership and control at one end and the corporate/competitive model at the other end. In this paradigm, you are either a subordinate within a control-and-command hierarchy, or a customer (internal and external):

Organisations are either owned by the state or by shareholders. Mintzberg (2001) questions whether we should consider a "third way" in which "non-owned" organisations build capacity for learning and the aligned action of individuals within them as members of a community, rather than as subordinates or customers.


Other Barriers to Change

• The lack of financial investment in leadership development in health care, for both clinicians and managers.
• The lack of deep relationships between healthcare organisation and the communities they serve, as a larger health system.
• The level of fear among senior managers and board members; who may be unable to meet political demands for budgetary control in the face of ever increasing demand for health care. Economic survival may become the main motivator for some providers, thus preventing them from learning from creative experimentation and from their mistakes.

From Theory to Practice

There are ongoing efforts to develop a learning organisation within the Waitemata District Health Board, which services the health care needs of people living in north and west Auckland in New Zealand. An action research programme is using both qualitative and quantitative methods to document organisational learning and cultural change.

Lessons learned in practice over the last year include:

• A shared vision, agreed values and clear principles allow us to resolve conflicting demands and make clear and consistent decisions, for instance in the design of the new Waitakere Hospital, intended to meet the future needs of the population of West Auckland.
• A small group of people, who are committed to a core set of values and shared objectives, and who have the courage to model these values and learning behaviours in their everyday actions, can have a far-reaching influence on the wider organisation.
• Many of our previously held assumptions and models were ineffective in terms of the goals they wished to achieve.
• The most "difficult" people in the organisation have demonstrated much more positive attitudes and interpersonal behaviour when exposed to a learning environment in which there is openness, integrity, the ability to listen and reflect and a set of shared goals. All of us have been guilty of the fundamental attribution error, in which we attributed the behaviour of these "difficult" people to defects in personality, rather than influences of the organisational environment. We are much more optimistic about our ability to create effective relationships with traditional "opponents".
• The timing is right to introduce fundamental change within NZ as a whole.
• We took risks and were fearful of failure. As our confidence grows, we are less afraid and take more risks.
• The speed of change in the organisation has surprised us. Open reflection on organisation dysfunction and interpersonal behaviour, which would have been undiscussable a year ago, is now a common feature of executive meetings.
• Traditional management structures and processes profoundly inhibit the capacity to change. For instance, traditional project management techniques assume that the desired end-state or answer is known in advance. We now have begun to commit to complex change programmes as a learning journey in which we do not know the solution but we are all aligned on a set of shared values and goals.
• Building leadership capacity is crucial. You can’t create leaders in the classroom but only in the context of shared attempts to solve real-life complex problems. We have started to use real-time leadership coaching, observation and feedback of interpersonal behaviour, socio-drama and role-play in developing leadership skills. The price of our learning is anxiety, confusion, embarrassment, self-doubt and intellectual struggle. The joy of working in a learning environment is huge energy, passion, enthusiasm, fun, laughs and deep satisfaction.
• We have learned to create open forums with no pre-set agendas, only deep questions.
• We have learned that true consultation is hard to achieve. We have gained insights into how all the traditional methods of consultation subtly control the agenda and don’t allow the real issues to surface. We have now begun to experiment with methodologies such as "Open Space Technology" to enable effective consultation and dialogue.
• All of these experiences and learning have given us insight into the failure of mainstream services to respond to the needs of Maori. Our new approaches have opened the door for true partnership and collaboration.

Conclusion

Gauthier (1995) talks about the challenge of stewardship, acting in the service of organisations and their broader community. His key concluding lessons are:

• Leaders at all levels, in spite of short-term pressures, must allocate time and resources to a transformational process which doesn’t yield immediate results; they must demonstrate their courage and determination by "staying the course" over several years; they must proactively address the stewardship challenge by investing significantly in both personal and organisational development.
• These leaders must also be willing to experiment with new approaches and tools which help challenge prevailing mental models and habitual behaviours.
• Learning collaboratively with other institutions can accelerate an organisation’s progress toward meaningful change.
• Stewards recognise the need to transcend the boundaries of their organisation and to include other stakeholders in creating a learning community. They gain a sense of what needs to emerge for the greater good, realising that not all visions are created equal.

References

Footnote

1. Clip from video recordings of patients’ stories "Working Together" produced by Clinical Leaders’ Association of New Zealand (CLANZ), in partnership with Nga Ngaru Hauora O Aotearoa
2. Don Berwick, Institute for Healthcare Improvement.
3. Don Berwick, Institute for Healthcare Improvement