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Proponents say shared learning, staff empowerment work wonders
Do you work for a "learning organization"? Given the fact that you’re a health care professional, the odds are pretty good that you don’t. However, a number of quality experts say that if you did, both you and your organization would be performing much more efficiently — and that your personal sense of professional fulfillment would be dramatically increased.
Sound too good to be true? Perhaps, but that’s the picture painted by proponents of organizational learning. [Peter M. Senge’s book, The Fifth Discipline. The Art and Practice of the Learning Organization (Random House; 1990), is considered to be the seminal publication of organizational learning (OL).]
"The key shift I see happening when organizations — including health care organizations — apply OL methods and tools is that they actually integrate learning with work. Specifically, they engage in a collective learning process that often yields extraordinary results," says Jeff Clanon, MS, director of partnership development for the Society of Organizational Learning (SOL), based in Cambridge, MA. The SOL is the successor organization to the Organizational Learning Center, originally established at the Massachusetts Institute of Technology.
"A learning organization is a place where people seek to learn rather than to know; where they admit they need to learn from each other to get a complete picture of their system," explains Sue Nieboer, RN, vice president, patient care services and quality management at Gerber Memorial Health Services in Fremont, MI.
"Health care is under continual pressure to change," she adds. "One of the things a learning organization does is it allows you to turn on a dime. People are so invested in the organization and its processes that if something hits you, like changes in federal government reimbursement, you are able to fully mobilize your resources."
"In health care organizations in particular, the communication between departments and functions could be better," notes Judy Homa-Lowry, RN, MS, CPHQ, director of patient care services at Brighton (MI) Hospital. "There are a lot of breakdowns and delays involved in rework. When you begin to flatten leadership levels and make employees more accountable for systems and processes they own, you really improve the efficiency and effectiveness of the processes in the organization."
Clanon explains that OL is distinguished by a set of core learning competencies.
"What we’ve found, basically, is that this set of core learning competencies seems to be either missing entirely or is vastly underdeveloped in all the organizations we studied or worked with," he asserts. (The SOL has been studying mostly large corporations, but in the last few years, it has turned its attention to governmental agencies such as the Department of Education, the Environmental Protection Agency, the National Security Agency, some nonprofit organizations, and health care organizations.)
According to Clanon, these three core competencies are:
People in the organization are clear on what they want to create in their own lives and in the organization. "What is it that they really want to get done?" Clanon asks. "This is different from management’s vision, which is supposed to mean something to the organization. We talk about having people be really clear about and engaged in clarifying their personal visions and how those personal ones connect on an organizational level."
• Reflective conversation.
A lot of time is spent in organizations talking about tasks, but much of that talk is not truthful, Clanon asserts. "The real meetings happen in the men’s room or women’s room," he says. "There’s not a lot of reflection and assumption testing to understand our thinking — and thinking drives behavior."
• Understanding complexity.
In most organizations, particularly health care organizations, the issues are very complex, Clanon says, yet most people in those organizations don’t have the tools and methods to deal with that complexity.
"To view things from a systemic perspective [systems thinking] — this is the hard piece of this process," he says.
"We have found that when groups develop these three competencies, they are clear on what they want, and they talk things through with each other," Clanon says. "They get the big picture, and they get incredible results."
Nieboer was first exposed to OL in 1994, when representatives of her 73-bed hospital (the system also includes a large home care agency) were asked to participate in a conference on systems thinking.
"We thought it was about our system," she recalls. "We spent three days in the most life-changing experience, and it has altered the course of this organization."
Nieboer and her colleagues spent about a year attending more conferences and learning about how to implement OL. Then, Gerber hired its first organizational facilitator.
"This is a cultural change," she explains. A cultural survey was conducted, and then a "dream team" was pulled together to envision the Gerber of the future. Communication was seen as one of the biggest challenges. "There was no trust," Nieboer recalls, so groups were established to address the problem.
Putting it to the test
The new approach was put to the test in 1998 with the passage of the Balanced Budget Act. "We were looking at a $1.2 million deficit; we knew we had to downsize if we were going to survive," Nieboer says.
"Through systems-thinking tools and the use of our people, we pulled our whole leadership group together and redesigned the leadership structure," she adds.
Within two months, Gerber went from five vice presidents down to two, and leadership shrank from 35 to about half that. "In order not to impact care, we took the hit at the management level," Nieboer explains, noting that staff input helped inform these decisions.
With such a lean structure, there was concern that the voice of the organization would not be heard, so a strategic council was created. The quality management (QM) committee of the medical staff was combined with the strategic planning committee of the board. The new body is chaired by the chair of the staff QM committee. "If you truly want to get to the point where quality drives the organization, it should drive the strategic plan," Nieboer explains.
Three board members, three medical staff, and three administrative staff then were joined by a community member and three frontline staff to form the Organizational Improvement Council.
"We knew we had to build volume," Nieboer says. "It was the only way to survive with less reimbursement. Our first initiative was customer satisfaction and reimbursement — we had to get people in the door and serve them very, very well."
The OL model was driven down to the whole organization. "We even worked closely with the union, and they trusted us — they accepted less of an increase. The following year, we were able to reward them with a larger bonus than the contract called for," she says. "Last year, we will have made 3.6% profit on the bottom line."
Why it works
Organizational learning works, Nieboer says, because it is dramatically different from the traditional approach to health care.
"It’s very customer-service focused. We have very high morale, a lot of trust in the organization, very few recruitment/retention problems, very high customer satisfaction, and high patient safety," she says.
Sounds like nirvana, but there are practical reasons why it works, she explains.
"Take the nursing shortage," Nieboer posits. "A quick-fix approach is to offer a $5,000 bonus to get RNs in the door. Once they’re in, they start working in an organization where nurses are not empowered and not viewed as an important piece of the organization.
"They have mandated overtime, they’re given a larger patient load than they can handle safely, they’re never asked their opinion, and their talent is not used to the fullest in terms of improving systems," she says. "A year later, [the new RN] has a bonus and leaves, so the hospital has to start over with another $5,000 bonus."
In a learning organization, Nieboer says, the nurse is valued. "We work intensely on trust and communication and on learning what’s wrong, how to do things better.
"We don’t mandate overtime because we respect the fact that the nurse also has a family. It’s about the person, too," Nieboer observes. "We establish committees that include nurses, and we empower them to make changes."
"Gerber has actually been able to retain nurses," notes Homa-Lowry, who has worked with Nieboer. "And the CEO says that as a result of the move to this approach, not only has quality of patient care improved, but they’ve seen quite an increase in revenue for the hospital."
Her mention of the CEO is significant, for as Nieboer notes, management involvement is a key element in the OL approach. "Management has to always be true to its word."
"They must give out a lot of information and keep few secrets. In a learning organization, everyone knows where they stand, what the financial condition of the organization is, what the strategic goals are — in short, what we want to accomplish." Nieboer explains.
At Gerber, new employees "get it when they come in the door, during new employee orientation," she adds.
An ongoing process
The OL approach recognizes an ongoing process, as opposed to a finite beginning and conclusion, Nieboer explains.
"You don’t ever become a learning organization, because you are always becoming one; you can always go to another level," she says. "That’s the other beauty of it. It helps you keep evolving. It eliminates the sense of Here we are; we don’t have to do any more.’"
As part of that ongoing process, Gerber does a lot of benchmarking with culture and customer satisfaction. "We benchmark internally and externally," she explains. "We have a balanced scorecard that reports to the board and the organization the results of those surveys."
Every quarter, a scorecard is posted for the employees. "Information is the key," Nieboer says. "If people don’t know, how can they help you get better?"
"Now we’ve developed a structure," she adds. "There are communication officers in each department who are responsible for getting the information out. In systems thinking, there is a concept called circles of influence — you need to spread information out through those circles, which we mostly do through e-mail."
In another ongoing process, Clanon spent three years working at the Maine Medical Center in Portland. He began with a group of radiologists, and the project’s scope has since been expanded.
"I was brought in to help them clarify their vision and introduced them to some tools," he recalls. "The radiologists were able to look at the situation systemically and realized they would need to involved administration, staff, and even clerical people involved in records."
What has resulted today are 18 or 19 quality teams that still are functioning. "A number of them were able to get clear on the processes they wanted to approve," Clanon notes.
So what are the prospects for OL in health care? "My sense is that it is not that widespread yet, but in order for health care organizations to survive and do a good job, we need to look again at how our resources are allocated," Homa-Lowry says. "We really need to take a closer look at patient care and the processes and all of the people in the organization, and whether they really contribute to patient care," she says.
In a lot of organizations, there are functions that don’t relate to patient care or improve the core business, Homa-Lowry points out.
"In a learning organization, you focus on what can help you become more efficient, not on rework or a lot of administrative overhead, so you save money. You become streamlined down to a few people who are all on the same page," she says.
The result? A safer environment
If health care organizations became learning organizations, "They’d be much safer places," Nieboer says. "Physicians would listen to nurses, nurses to dietary people. You take away the hierarchy and focus on patient satisfaction and safety because every one of us contributes to achieving those goals."
As for Clanon, he says the movement is growing. "SOL now has a worldwide network with almost 30 fractals,’ including initiatives in India and China; it’s taking hold," he says. "The stuff works, and I think that people in the health care arena who are really interested in going beyond quick fixes are embracing it."
"I’ve always wanted to integrate quality into the culture," Nieboer adds, "and I’d like to think I’ve achieved some of that."Need More Information?
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Are you ready for EMTALA? Audio conference clarifies final regulations
At press time, the final version of the recently proposed changes to the Emergency Treatment and Labor Act (EMTALA) was expected to become effective soon. Issues in the final regulations could include changes to physician on-call requirements, "comes to the emergency department" definitions, later-developed emergencies, nonhospital entities, and prior authorization. With all the confusion surrounding the proposals during the past year, make sure you know what it takes to comply with the final regulations.
To keep you on track, American Health Consultants offers the EMTALA: Complying with the Final Regulations audio conference, scheduled for Tuesday, Nov. 12, 2002, 2:30 to 3:30 p.m. ET. The conference will be presented by Charlotte S. Yeh, MD, FACEP, and Nancy J. Brent, RN, MS, JD. Yeh is medical director for Medicare policy at National Heritage Insurance Co. in Hingham, MA. Brent is a Chicago-based attorney with extensive experience as a speaker on EMTALA and related health care issues. In June of this year, both speakers presented EMTALA Update 2002, one of AHC’s most successful audio conferences.
Each participant can earn FREE CE or CME for one low facility fee. Invite as many participants as you wish to listen to the audio conference for $299, and each participant will have the opportunity to earn 1 nursing contact hour or 1 AMA Category 1 CME credit.
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