Hospital Topics

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Strategic Learning in Healthcare Organizations

Michael J. O'sullivan

To cite this article: Michael J. O'sullivan (1999) Strategic Learning in Healthcare Organizations,
Hospital Topics, 77:3, 13-21, DOI: 10.1080/00185869909596526

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Published online: 30 Mar 2010.

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 Strategic Learning in
Healthcare Organizations
MICHAEL J. O'SULLIVAN
Caught between two eternities-the vanished past
and the unknown future-we never cease to seek
our bearings and our sense of direction.
-Daniel J. Boorstin
S
ix years after the defeat of the Clinton
administration's proposal of a national sys-
tem of "managed competition" among
providers, managed care dominates the healthcare
marketplace, having evolved on its own, mainly
because of economic and cost-competitive pres-
sures (Kilborn 1998). Changes in the healthcare
delivery system have been fundamental and far
reaching (Wilson and Porter-O'Grady 1999).
Many healthcare organizations have been forced
to close; others have affiliated or merged to form
vertically and horizontally integrated systems of
care. Some changes have been contradictory. For
example, some physicians have joined hospitals in
physician-hospital organizations to present a uni-
fied approach in negotiating with managed care
organizations; others have formed completely
independent organizations that pit hospitals and
managed care organizations against each other.
Because of the fundamental contradictions and
shifts, there is a need for equally fundamental
change in the way healthcare administrators pro-
vide strategic direction for their organizations.
Dr. Michael J. O'Sullivan reaches and consults in the areas of strategic learning and planning, and is currently working on the
organization of a Comprehensive Community Nahma Coalition for the Greater Lowell area in Massachuserrs,
13
That requires new ways of thinking about strategic
planning and organizational change. With conven-
tional healthcare assumptions turned on their head,
traditional approaches to managing healthcare ser-
vices may not succeed. The changing healthcare
environment demands innovative methods to deal
with new situations (McDaniel 1998).
This article introduces the concept of strategic
learning as part of an approach to the uncertainty
facing hospitals and other healthcare delivery sys-·
terns. Drawing on organizational research and the-
ory, integrated delivery systems, and examples of
strategic learning in hospitals and organizations
outside of healthcare where strategic learning is
more fully embedded, I will suggest practices that
healthcare leaders can implement to create a cli-
mate for continuous strategic learning within their
organizations. Before exploring this approach, how-
ever, it is necessary to review beliefs that still guide
many healthcare planning efforts.
TRADITIONAL MODELS FOR THE PLANNING
OF HEALTHCARE SERVICES
Traditionally, the typical healthcare facility has
assumed that the healthcare landscape is character-
ized by a relatively unimpeded vision of the future
planning horizon. At the start of the traditional
strategic planning effort, administrators scan the
planning horizon and try to forecast all significant
14
environmental changes that may affect the facility,
usually covering a three-to-five-year span. Assum-
ing these forecasts will prove correct, the healthcare
organization then selects points in the future as
fixed objectives against which progress can be
gauged. A detailed road map-the "strategic
plan"-is drawn up with specific routes identified
for clinical and support services; managerial oper-
ations; marketing, finance, and information sys-
tems; and so on, all coordinated to allow the orga-
nization to reach its goal as directly and efficiently
as possible. This is a traditional "command and
control" approach, in which the top of the organi-
zation does the thinking and the rest of the orga-
nization is supposed to comply (Senge 1995). It is
based on the "scientific management" school of
thought and a preoccupa-
tion with organizational
structure and the bureau-
Success stories do cratic control of its devel-
opment (Schein 1969). It
not result from a raises questions such as,
Which departments are
"master plan"
assigned which responsi-
but from a lengthy bilities for pursuing the
goals? and Who should
trial-and-error the nursing department
report to in this new con-
process. figuration? Executives
using this approach design
a plethora of systems, con-
trols, and procedures to
make the plan happen (Collins 1999). The
approach works well when the environment is rel-
atively calm and stable, but it is of little use when
conditions are turbulent and the future uncertain.
The problem is that the controls also create
bureaucracy, which does not breed innovative staff
performance. "Bureaucracy may deliver results,
but they will be mediocre because bureaucracy
leads to predictability and conformity. History
shows us that organizations achieve greatness when
people are allowed to do unexpected things-to
show initiative and creativity, to step outside the
scripted path. That is when delightful, interesting
and amazing results occur" (I 999, 73).
Not only are outcomes hard to control, forecasts
can be faulty. Coile (1998) points out "sure-fire"
predictions widely used in healthcare strategic
planning that did not work out. For example, Cal-
ifornia's Kaiser staff model of medical organization
was widely considered the most efficient in U.S.
Vol. 77, no. 3 Summer 1999
medicine. It was the standard for determining spe-
cialty physician-population ratios. In the early
1990s Kaiser invested millions in creating a com-
pany-owned network of hospitals and clinics for
the decade ahead. But today, Kaiser is closing hos-
pitals and contracting for acute care and physician
services, abandoning its own model. Despite many
predictions that capitation would dominate
healthcare payment, that reimbursement model
has taken hold slowly, with discounted fee-for-ser-
vice becoming the dominant mode of physician
and hospital payment. California HMOs exten-
sively used primary care physicians as gatekeepers
to their systems, but attempts to apply the gate-
keeper model in other markets have met with stiff
resistance from consumers and their political rep-
resentatives (Mitchell 1999).
The problem with the traditional approach is
not that it is entirely wrong but that it is incom-
plete and static. It makes assumptions about the
stability of the environment and the organization
that do not conform to today's reality. Successful
strategic change is rarely clear-cut or controllable.
First, it is usually impossible to see clearly the final
destination of a strategic planning process. Instead
of planners standing at the top of a mountain on a
clear day and picking out a strategic destination to
guide the organization toward, planning is more
like a trip into a fog-shrouded forest where the
major obstacles, let alone the final destination,
cannot be clearly discerned. Healthcare organiza-
tions confront a murky future in the face of man-
aged care, price competition, rising prescription
drug costs, and Medicare cuts. Clinical, competi-
tive, political, financial, and social developments
often cloud our picture of the planning horizon.
Moreover, it is only after an organization begins to
implement strategic planning that the next set of
problems comes into focus and the efforts needed
to surmount them can be evaluated. And every
step in the process requires constant reflection and
reevaluation.
Successful strategic change usually does not
come about from detailed, bureaucratic plans
developed by the senior management. In most
cases, fundamental organizational change arises
from setting out in a direction determined by the
mission, vision, and values of the organization. As
new insights about the environment are revealed
and discoveries made, advancement comes
through readjusting old maps, revising plans, and
taking new actions. Success stories do not result
HOSPITAL TOPICS: Research and Perspectives on Healthcare
from a "master plan" but from a lengthy trial-and-
error process (Kanter 1991). Few organizations
recognize this fact, and many managers create elab-
orate fictional pictures of how changes actually
occurred. These managers are revisionist historians
who reconstruct a simplified picture of what really
happened to suggest that current successes have
resulted from superb plans developed by idealistic
leaders and carried out by skillful managers. This
may be understandable, as it is difficult to admit
that success has occurred through a messy learning
process that management did not fully anticipate,
comprehend, or control. However, this reality is a
far cry from the command and control precepts of
scientific management.
The command and control perspective implies
that senior management must strictly master the
organization's destiny as part of strategic planning.
However, in today's radically changing environ-
ment, healthcare organizations must relinquish the
illusion of tight control over every functional unit.
Rather than seek stability as their goal they must
see their organization as looser, more fluid and
organic than linear and deterministic (Morgan
1997). They must learn to deal with an unfolding,
continuously changing environment. The new
model has been characterized as a "learning orga-
nization" by Senge (1990); in healthcare it possess-
es many of the attributes of an "agile" organization
as described by Goldman and Graham (1999).
LEARNING TO CHANGE BY CREATING A
STRATEGIC LEARNING ORGANIZATION
According to Senge (1990), the future and the
environment are so fundamentally unpredictable
that successful change can come about only when
organizational learning and strategic readiness
replace excessive control in complex organizations
such as healthcare facilities. Furthermore, the most
important learning of an organization comes not
from what is learned from other organizations-as
important as benchmarking and looking to other
organizations for ideas may be-but from innova-
tive trial-and-error conducted by the healthcare
facility itself. Healthcare organizations must care-
fully reflect on their own experiments in learning
and decide whether they will be diffused and
implemented throughout the organization,
allowed to operate in just one part of it, or quashed
as an important but unsuccessful attempt at
change-a valuable learning experience.
Organizational learning, even if it works per-
15
fectly at first, should evolve. New learning experi-
ences often produce unintended negative conse-
quences that need correction. Administrators need
to engage their organizations in learning processes
that allow strategy to emerge as the organization
interacts with its environment (Kiel 1994;
Mintzberg 1994). Learning as things unfold, per-
mitting strategy to arise, is the key to confronting
effectively the problems that emerge from the
unknowable future. For example, Ginter, Swayne,
and Duncan (1998) described how a hospital
moved into a full range of cardiac services without
an explicit strategy to do so. In an effort to attract
patients and enhance its image, the hospital first
began offering limited cardiac services. The move
was successful, but soon they found that they were
not performing enough procedures to be "world
class." They added services, equipment, and facili-
ties to help create the required volume and ended
up with an emergent strategy to develop compre-
hensive cardiac services (27). These managers
devised a preliminary strategy, started down the
road, and, acquiring new information, made
changes based upon the new knowledge.
INDMDUAL LEARNING AND
ORGANIZATIONAL LEARNING
There have been many attempts to understand
the elusive process of individual experiential learn-
ing. As described by Redding and Catalanello
(1994), John Dewey first conceptualized individual
experiential learning as a cyclical process, moving
from thought to action to reflection, and then
repeating in a continuous cycle. A slightly modified
example of this cycle might be a physician treating a
patient with severe clinical depression. In the first
step, the physician conceptualizes a treatment plan
based on the patient's presenting symptoms, on
what the physician learned in medical school, and
on successful experiences with similar cases. The
physician prescribes, for example, medication, an
exercise and diet regimen, and a course of "talking"
therapy, and meets with the patient's family to gath-
er more information. The physician reviews the
published literature or requests consultations with
medical colleagues experienced with the condition.
After devising the preliminary treatment plan, the
physician implements the treatment strategy. Imple-
menting the plan is the second phase of the learning
process. The physician then checks on how the
patient is faring and enters the third phase, revising
the plan based upon the latest available information.
16
At the point the physician takes stock of the
patient's condition, he or she has the opportunity
for experiential learning. The doctor intensely
reflects on the actions and interventions taken and
judges which ones seem to have had a beneficial
effect. The physician questions original assump-
tions and modifies the original plan in response to
the patient's behavioral signs and symptoms, data
from laboratory results, and feedback from the
patient. Over the next several cycles of this learning
process, the treatment plan becomes more refined
as the physician reflects and makes judgments as to
what worked and what did not. The learning con-
tinues, and as the physician passes through each
cycle, he or she observes whether the patient is
improving or deteriorating. By passing through the
cycles, the physician exer-
cises individual experien-
tial learning to determine
the direction of the treat-
Healthcare organiza- ment strategy.
tion managers often LEARNING IN
ORGANIZATIONS
forgot about the
Organizations learn
human side of organi- from experiences in much
the same way as individu-
zational change. als. Argyris and Schon
(1978) first formed the
concept of organizational
learning as a mechanism
to correct mistakes. In a
study that attempted to discover ways to ensure the
survival of organizations, de Geus (1988) found it
useful to conceptualize strategic planning as a
process of organizational learning. He studied a
number of organizations that had survived for rel-
atively long periods of time (more than 75 years),
compared with the average survival of companies
(about 40 years). He concluded that the successful
organizations survived because of management's
capacity to absorb what was going on in the envi-
ronment and to act on that information by initiat-
ing appropriate responses. In other words, these
organizations depended on learning, or more accu-
rately on organizational learning, to adapt to the
changing conditions.
However, for an organization to survive, organ i-
zationallearning cannot be limited to the acquisi-
tion of new knowledge; the knowledge must be
put to effective use within the organization.
Acquiring information about a brand new health-
Vol. 77, no. 3 Summer 1999
care practice, such as gene therapy, or a modified
practice, such as genetic counseling for breast can-
cer patients, does not guarantee the knowledge will
be used effectively. The healthcare organization
must change policies and procedures based on this
new knowledge. Garvin (1993) offers a conception
of organizational learning as both acquisition of
new knowledge and new action based upon that
knowledge. "A learning organization is an organi-
zation skilled at creating, acquiring, and transfer-
ring knowledge, and at modifYing its behavior to
reflect new knowledge and insights" (80). Accord-
ingly, learning organizations have the capacity to
think and act in fresh ways based on new knowl-
edge that comes from their own performance and
from the environment. This can be accomplished
systematically by continually cycling through a
strategic organizational learning process.
THE STRATEGIC ORGANIZATIONAL
LEARNING CYCLE
The Strategic Organizational Learning Cycle is
similar to the individual learning cycle, with the
addition of the important concept of organization-
al diffusion. The five steps of the organizational
learning cycle are (1) continuous planning, (2)
improvised implementation, (3) continual revi-
sion, (4) organizational diffusion, all of it held
together with (5) intense reflection. These steps are
diagrammed in figure 1 and explained below.
Continuous Planning
Traditionally, healthcare organizations have
relied on detailed written programs and procedures
to communicate from the top to the bottom of the
organization what needs to be accomplished. Often
the manner in which the plan was developed was
ungainly and slow, and when the time for imple-
mentation arrived, the plan was out of date because
of changes in both the organization and the envi-
ronment between conception and execution. More-
over, healthcare organization managers often forgot
about the human side of organizational change.
Because the members of the staff responsible for
carrying out the plan frequently were not meaning-
fully involved in the plan's development, they were
not committed to its implementation. As a result of
these factors, the strategic plans of healthcare orga-
nizations, once developed, were often irrelevant. To
transcend these formidable problems, strategic
planning in healthcare organizations has to become
continuous and must involve a wide array of people
HOSPITAL TOPICS: Research and Perspectives on Healthcare
FIGURE 1. The strategic learning cycle
from the top to the bottom of the organization.
Those individuals must be committed to the
change and must have the clinical and managerial
skills necessary to carry out new behaviors (Mac-
Cracken 1998), rather than merely comply with
top administrators' directions.
Strategic plans are still essential for significant
organizational change. The managerial and bud-
getary details of strategic plans are often valuable
reality checks for untested visions and goals. End-
ing the process would be a mistake. Hospitals and
other healrhcare organizations must analyze the
information about their environments, chart
strategic directions, and develop measurable objec-
tives as well as budgetary targets for the future. The
problem is not strategic planning itself but the
underlying assumption that administrators can
peer three to five years into the future and make
forecasts with precision and reliability. The prob-
lem is the limited, mechanistic, and linear bureau-
cratic approach that attempts to create the all-
encompassing master plan.
By contrast, in learning organizations strategic
17
planning is an evolving process, with plans being
questioned, refined, and continuously modified
based upon the most current information about
the environment as well as insights gained from
implementation, reflection, and diffusion efforts.
In strategic learning organizations, fixed plans are
replaced by flexible strategic directions that involve
the participation of key people throughout the
hospital, including physicians, nurses and other
technical professionals (the source of most clinical
innovation), top-level administrators, mid-level
managers, and employees from all levels. Patients
are also a source, perhaps one of the most impor-
tant ones, for appropriate and timely solutions.
Coile (1998) reports that one hospital's quality
team focused on 300 ideas for speeding up the
time required to discharge patients, without find-
ing an effective solution. Finally, a chance remark
by a patient led to an insight by a low-level mem-
ber of the team: schedule a ride in advance. The
hospital had always assumed it was the patients'
responsibility to arrange for their own transporta-
tion upon discharge.
18
Other stakeholders from outside the health care
organization who are often involved include the
suppliers of new technologies, insurers and the
payers of care with new payment and reimburse-
ment schemes, and politicians and governmental
regulators with new social policies. All are impor-
tant players in the strategic learning organization,
and their insights and perspectives can be invalu-
able. In one city, clinical researchers from an MRI
firm providing mobile services to several hospitals
and radiologists at the hospital sites were the
sources of new MRI applications. Innovation came
from outside the organization-from suppliers
who developed and designed the equipment-and
from the hospital radiologists who were employing
the equipment.
Improvised
Implementation
In strategic learning In a strategic learning
organization, implementa-
organizations, tion differs greatly from
that in traditional organiza-
individuals and teams act tions, which rely on for-
in creative, autonomous, mal, detailed procedures
that spell out how plans are
and spontaneous ways to to be implemented. In
strategic learning organiza-
convert plans into reality. tions, individuals and
teams act in creative,
autonomous, and sponta-
neous ways to interpret
strategic direction and convert plans into reality
(Beckman 1992). Describing the implementation of
a strategic learning process, Redding and Catalanel-
10 (1994) reported that rather than micromanaging
the implementation process-s-developing detailed
schedules with tight timelines and strict account-
abilities-the company used an improvisational
approach to implementation, encouraging experi-
mentation and directing change in a flexible man-
ner. At the early stage, the company supported spon-
taneous, grassroots initiatives and established ad hoc
structures to support experimentation. As changes
developed, the organization's leaders sanctioned
them without taking them over, quietly clearing
away obstacles and facilitating cross-fertilization
among the staff. After a change began to prove itself
useful, the company recognized the success, reward-
ed the achievement of those responsible, and insti-
tutionalized the change with formal conversions of
structures, rewards, procedures, and policies.
Vol. rr, no. 3 Summer 1999
HealthSystem Minnesota offers a good example
of a similar type of implementation (Appleby
1997). HealthSystem Minnesota grew out of a
merger in 1993 between Methodist Hospital and
the 450-doctor Nicollet Clinic, attempting to pro-
vide integrated care across all delivery points. To
cement the merger, the system had to undergo
major strategic change, including numerous incre-
mental and adaptive changes. The pattern of
changes that took place at HealrlrSystern Minneso-
ta is indicative of the strategic learning that occurs
at all levels of an organization. A major clinical
effort called Care 2000 was developed to integrate
care in all settings within the expanded system.
The strategic direction included producing a
rough outline showing how the system provided
care for patients, envisioning the ideal process of
care through discovering the gaps in the current
processes, and, finally, determining how informa-
tion technology and open communication tech-
niques among staff could help make the newly dis-
covered ideal of care a reality throughout the
organization.
The implementation of new practices across com-
plex healthcare delivery systems is a major challenge
composed of predisposing, enabling, and reinforc-
ing activities such as shared vision, facilitative lead-
ership, and open channels of communication with
reciprocal information flows (Barnsley, Lemieux-
Charles, and Kinney 1998). Personnel who are
expected to acquire the knowledge and skills to
implement a new clinical or administrative practice
must be convinced that it will work in their areas of
responsibility. Furthermore, they must have the
resources, such as funding, personnel, and informa-
tion, to make the change (Shapeman and Backer
1995). And staff members must have the time and
resources to acquire the new knowledge and skills.
When they feel their performance will be assessed
with little or no time for learning or skill develop-
ment, they are likely to adopt defensive behaviors
that support their own survival rather than the mis-
sion of the healthcare facility.
Leadership plays a major role in establishing the
infrastructure for organizational learning (Kotter
1990). Overcoming the barriers that prevent orga-
nizational learning involves defining a vision and
direction, including employees in the whole
process, and putting information into their hands
(Beckman 1992). The commitment of the organi-
zation's leaders to learning and innovation can be
assessed by the extent to which they create struc-
HOSPITAL TOPICS: Research and Perspectives on Healthcare
tures to support the transfer and assimilation of
knowledge.
In one hospital's mental health service this
meant hiring a hospitalwide contracts officer
(based in administrative services) to keep track of
all negotiations the hospital had with managed
care organizations and monitor their different
requirements for reports, payment schedules, and
benefit packages-information essential in prepar-
ing contract proposals for provision of services to
their members. The contracts officer's efforts
would help the mental health service and other
departments position themselves to respond pro-
grammatically to the complicated and changing
requirements. The challenge for the manager of
this mental health service was to develop a compli-
cated set of relationships both within and outside
the organization, forming networks of informa-
tion-driven connections to create order from a dis-
ordered world (Senge 1990). The administrative
manager took the lead and scheduled regular meet-
ings with the contracts officer, the marketing
director, administrators, and clinicians from the
mental health service to discuss, and envision ful-
filling, the demands of the managed care organiza-
tions. Her goal, in responding to the requirements
of the external world, was to find ways in which
staff members, each with their limited perspective,
could contribute to the development and emer-
gence of the hospital's managed care strategy.
In this instance, the manager of the mental
health service was rewarded with a raise and high-
er status for her innovative steps involving the con-
tracts officer and securing additional contracts. To
encourage this type of innovation and creativity,
administrators need to reward risk taking that
could result in failure, thus ensuring that the dis-
tribution of incentives and rewards reflects the
high value placed on learning.
Continual Revision
Revising a plan based on the latest information
from the environment, and from changes brought
about by the plan's implementation within the
organization, is a continual process in the strategic
learning cycle. Open structures involving variable
job responsibilities and extensive lateral and verti-
cal communication enable and reinforce these
organizationwide revisions. Some of the methods
used for the continual revision of strategic plan-
ning are the total quality management (TQM) and
continuous quality improvement (CQI) processes
19
(Leebov and Ersoz 1991), the organization of
patient care around clinical service lines, and inte-
grating mechanisms such as systemwide newslet-
ters, regular meetings of hospital executives, con-
tinuing-education programs, learning forums with
specific learning goals, and clinical and manage-
ment rotation programs.
Organizational Diffusion
Learning that occurs within a healthcare organi-
zation has to be more than a local affair to be effec-
tive. Transferring the new knowledge to other sec-
tors of the hospital or healthcare system, where it
can be applied, is essential. As pointed out by Kan-
ter (I 991), who studied change in successful orga-
nizations, most successful
change efforts start
through the proliferation
of a large number of mod- Learning that occurs
est experiments and inno-
vations, and the most suc- within a healthcare
cessful are promoted
throughout the organiza- organization has to be
tion. The actual nature of
a strategic change is only more than just a local
gradually revealed, as peo-
affair.
ple throughout the organi-
zation act to make the
change. Through this dif-
fusion process, people dis-
cover for themselves over
time that change is in their best interest and that
the benefits outweigh risks such as the potential
loss of power, status, security, and expected career
advances. And over time, successes and accom-
plishments can be reinforced and institutionalized.
Again in the diffusion stage, development of com-
munication channels within an open structure is
essential so that various parts of the system can
learn about the new innovations and adopt those
that work.
As in any effective strategic learning process, the
procedures of Care 2000, HealthSystem Minneso-
ta's strategic effort, initially were not adopted orga-
nizationwide but were tested in one location. The
cancer center was selected for initial implementa-
tion because it spanned a wide range of care set-
tings, with significant inpatient, outpatient, and
home care components. The cancer program
included a special care floor in the hospital with
150 staff members, a home care agency that sup-
ported inpatient treatment and provided hospice
20
care, a multi-doctor outpatient clinic, two outpa-
tient IV chemotherapy sites, a solo medical prac-
tice, and pastoral care and music therapy pro-
grams. The center's staff already participated in
patient care teams, but the challenge was to get
everybody pulling in the same direction, and to
reflect on how well the teams did their jobs. This
mix demonstrates that many healthcare teams
need to learn and communicate what they learned
with each other to be an effective team of care-
givers. By providing the time and resources for the
staff to learn and apply new communication tech-
niques, managers demonstrated the value of new
knowledge and the importance they placed on
building new clinical skills.
Intense Reflection
At the center of the Strategic Organization
Learning Cycle, and integral to all aspects of it, is
intense reflection. In strategic learning organiza-
tions, learning is not something that just happens,
it is made to happen by constant reflection on the
success or failure of the experimentation. Learning
begins when those involved in an activity stop and
examine how things are being done and what
kinds of effects are being produced. Strategic learn-
ing organizations attempt to provide continuous,
ongoing opportunities for reflective learning,
rather than wait for problems to arise before
undertaking evaluation. Reflection becomes part
of the organizational culture-"way things are
done"-and is built into the process of strategic
change. Through reflection, strategic learning
organizations question basic beliefs and search for
systemic solutions to problems, rather than merely
react to symptoms (Redding and Catalanello
1994). In contrast, traditional strategic planning
provides limited opportunities for reflection. I
know of healthcare organizations in which there is
but one designated iteration of the planning cycle
per year. Many organizations stop and examine
implementation activities only when obvious
obstacles appear, rather than continually reflecting
on the success or failure of innovation. As a result,
strategic responses may take years to occur and
may be the proverbial "too little, too late."
Information systems are necessary for serious
and continuous reflection. Computerized systems
for selecting methods of care and for management
decision-making can be important learning tools;
they develop a communal memory that partici-
pants throughout the organization can tap into
Vol. 77, no. 3 Summer 1999
and use (Menduno 1998). Although such auto-
mated computer systems can be very helpful, they
are not essential. What is essential for success is a
free flow of information up and down the organi-
zation as well as across traditional departmental
boundaries.
Strategic learning organizations continuously
take action, reflect upon that action, and modify
plans based on insights gained through this learn-
ing process. The aim is to maximize the speed and
effectiveness of strategic change by incorporating
intense reflection into all change efforts, not wait-
ing for the next annual planning cycle or crisis to
demand reevaluation. Each iteration of the learn-
ing process consists of drawing back, if just for an
instant, and asking, How far have we come in
accomplishing not just what we set out to do, but
what we need to accomplish, given what we know
today about our healthcare facility and our envi-
ronment? It is essential to question original
assumptions continually and develop deep, sys-
tematic solutions to newly discovered problems.
Insights gained through this process are then used
to modify the original plans. The process of reflec-
tion allows emergent strategies to bubble to the
surface and become apparent.
SUMMARY
There is no definitive blueprint for the health-
care organization involved in strategic learning.
However, what distinguishes strategic learning
institutions is their acknowledgment that they
must discover their own paths and solutions rather
than blindly follow a detailed strategic mandate
from administration. Answers to their most critical
implementation and adaptive questions will not
flow down ready-made from above, but will be tai-
lored to meet the requirements of their own par-
ticular situation. Strategic learning organizations
have certain attributes in common in developing
their own answers:
• They continuously experiment rather than seek
final solutions.
• They favor improvisation over forecasts.
• They formulate new actions rather than defend
past ones.
• They nurture change rather than permanence.
• They encourage creative conflict rather than
tranquillity.
• They encourage questioning rather than compli-
ance.
HOSPITAL TOPICS: Research and Perspectives an Healthcare
• They expose contradictions rather than hide
them (Weick 1977).
Most importantly, strategic learning organizations
realize that successful strategic change is best
undertaken as a process of learning (O'Sullivan
1999).
Healthcare organizations can no longer afford
the illusion of traditional strategic planning, with
its emphasis on bureaucratic controls from the top
to the bottom. They must embrace the fundamen-
tal truth that most change occurs through process-
es of learning that occur in many locations simul-
taneously throughout the organization. The initial
step in discovering ways to improve the capability
of healthcare organizations is to adapt continuous-
ly while fulfilling their mission. Healthcare leaders
must create a shared vision of where an institution
is heading rather than what the final destination
will be, nurture a spirit of experimentation and
discovery rather than close supervision and
unbending control, and recognize that plans have
to be continuously changed and adjusted.
To learn means to face the unknown: to recog-
nize that we do not possess all the answers; to con-
cede that we do not always know what to do; to
admit that past actions and solutions may no
longer be appropriate, in fact may have been the
incubators of today's problems; to question basic
assumptions long held about running the institu-
tion; and to make ourselves vulnerable to the polit-
ical dynamics prevalent in all organizations. Hos-
pitals and other healthcare organizations must seek
to develop and maintain a continuing state of
readiness in which everyone in the organization,
from front-line clinician to senior management, is
poised to act in anticipation of and in response to
unforeseen changes in the environment and to
learn from their own experiences in confronting
the future.
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