Organizational learning: Key to improved quality?

Shared learning can 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 (OL). (The seminal publication on Organizational Learning, Peter M. Senge’s The Fifth Discipline: The Art and Practice of the Learning Organization, was published in 1990 by Random House.)

"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 Organizational Learning is distinguished by a set of core learning competencies. According to Clanon, these three core competencies are:

  • Aspiration. This involves people in the organization being really 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 really complex, says Clanon, 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," says Clanon. "They get the big picture, and they get incredible results."

"This a cultural change," Nieboer explains. To implement this change at Gerber Memorial, a cultural survey was conducted, and then a dream team was pulled together to envision the Gerber of the future.

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," says Nieboer. "Through systems thinking tools and the use of our people, we pulled our whole leadership group together and redesigned the leadership structure."

Within two months Gerber went from five vice presidents down to two, and leadership shrank from 35 to about half that.

With such a lean structure, there was concern that the voice of the organization would not be heard, so the Organizational Improvement Council was created. Three board members, three medical staff, and three administrative staff then were joined by a community member and three front-line staff to form the new body.

"We knew we had to build volume," says Nieboer. "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," says Nieboer. "Last year, we will have made 3.6% profit on the bottom line."

Organizational learning works, says Nieboer, 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," she suggests. "A quick-fix approach is to offer a $5,000 bonus to get an RN 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. A year later, she has her 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."

The Organizational Learning 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," says Nieboer. "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 a lot of organizations, she says, there are functions that don’t relate to patient care or improve the core business. "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."

If health care organizations became Learning Organizations, "They’d be much safer places," says Nieboer. "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."

Need More Information?

  • The Society for Organizational Learning, 955 Massachusetts Ave., Suite 201, Cambridge, MA 02139. Telephone: (617) 300-9500. Fax: (617) 354-2093. E-mail: Web site:
  • Judy Homa-Lowry, RN, MS, CPHQ, Director of Patient Care Services, Brighton (MI) Hospital. Telephone: (734) 459-9333.
  • Sue Nieboer, RN, Vice President, Patient Care Services and Quality Management, Gerber Memorial Health Services, Fremont, MI. Telephone: (231) 924-3300.