Institute of Social Science, Sogn og Fjordane University College, Postbox 133, 6851, Sogndal, Norway.
BMC Health Serv Res. 2012 Aug 3;12:235. doi: 10.1186/1472-6963-12-235.
Changes that improve the quality of health care should be sustained. Falling back to old, unsatisfactory ways of working is a waste of resources and can in the worst case increase resistance to later initiatives to improve care. Quality improvement relies on changing the clinical system yet factors that influence the sustainability of quality improvements are poorly understood. Theoretical frameworks can guide further research on the sustainability of quality improvements. Theories of organizational learning have contributed to a better understanding of organizational change in other contexts. To identify factors contributing to sustainability of improvements, we use learning theory to explore a case that had displayed sustained improvement.
Førde Hospital redesigned the pathway for elective surgery and achieved sustained reduction of cancellation rates. We used a qualitative case study design informed by theory to explore factors that contributed to sustain the improvements at Førde Hospital. The model Evidence in the Learning Organization describes how organizational learning contributes to change in healthcare institutions. This model constituted the framework for data collection and analysis. We interviewed a strategic sample of 20 employees. The in-depth interviews covered themes identified through our theoretical framework. Through a process of coding and condensing, we identified common themes that were interpreted in relation to our theoretical framework.
Clinicians and leaders shared information about their everyday work and related this knowledge to how the entire clinical pathway could be improved. In this way they developed a revised and deeper understanding of their clinical system and its interdependencies. They became increasingly aware of how different elements needed to interact to enhance the performance and how their own efforts could contribute.
The improved understanding of the clinical system represented a change in mental models of employees that influenced how the organization changed its performance. By applying the framework of organizational learning, we learned that changes originating from a new mental model represent double-loop learning. In double-loop learning, deeper system properties are changed, and consequently changes are more likely to be sustained.
提高医疗质量的变革应得以持续。回归到陈旧且不尽人意的工作方式是对资源的浪费，并且在最坏的情况下可能会增加对后续改善护理举措的抵触。质量改进依赖于改变临床系统，但影响质量改进可持续性的因素还未被充分理解。理论框架可以指导对质量改进可持续性的进一步研究。组织学习理论有助于更好地理解其他背景下的组织变革。为了确定有助于改进可持续性的因素，我们使用学习理论来探讨一个持续改进的案例。
弗尔德医院对择期手术的流程进行了重新设计，实现了取消率的持续降低。我们使用了一种由理论驱动的定性案例研究设计，以探讨有助于弗尔德医院改进持续的因素。证据在学习型组织中的模型描述了组织学习如何促进医疗机构的变革。该模型构成了数据收集和分析的框架。我们对 20 名具有战略意义的员工进行了深度访谈。访谈主题涵盖了我们理论框架中确定的主题。通过编码和浓缩的过程，我们确定了与我们的理论框架相关的共同主题，并对其进行了解释。
临床医生和领导者共享了有关其日常工作的信息，并将这些知识与如何改进整个临床路径联系起来。通过这种方式，他们对临床系统及其相互关系有了更深入的了解。他们越来越意识到不同元素需要如何相互作用以提高绩效，以及自己的努力如何能够做出贡献。
对临床系统的理解的提高代表了员工心智模式的变化，这影响了组织如何改变其绩效。通过应用组织学习框架，我们了解到源于新心智模式的变革代表了双环学习。在双环学习中，系统的更深层次属性发生变化，因此变革更有可能持续。
