Enhancing learning, innovation, adaptation, and sustainability in health care organizations: the ELIAS performance management framework.

The Health Care Manager Volume 33, Number 3, pp. 183–204 Copyright # 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Enhancing Learning, Innovation, Adaptation, and Sustainability in Health Care Organizations The ELIAS Performance Management Framework D. David Persaud, PhD The development of sustainable health care organizations that provide high-quality accessible care is a topic of intense interest. This article provides a practical performance management framework that can be utilized to develop sustainable health care organizations. It is a cyclical 5-step process that is premised on accountability, performance management, and learning practices that are the foundation for a continuous process of measurement, disconfirmation, contextualization, implementation, and routinization This results in the enhancement of learning, innovation, adaptation, and sustainability (ELIAS). Important considerations such as recognizing that health care organizations are complex adaptive systems and the presence of a dynamic learning culture are necessary contextual factors that maximize the effectiveness of the proposed framework. Importantly, the ELIAS performance management framework utilizes data that are already being collected by health care organizations for accountability, improvement, evaluation, and strategic purposes. Therefore, the benefit of the framework, when used as outlined, would be to enhance the chances of health care organizations achieving the goals of ongoing adaptation and sustainability, by design, rather than by chance. Key words: accountability, innovation, learning, performance measurement, sustainability

HE ABILITY OF health care organizations to deliver high-quality health care in a sustainable manner is a topic of intense investigation throughout the world.1,2 This is reflected in health care policies in developed countries being directed toward improving the sustainability of health care provision.1 These policies are directed toward a need for accountability for dollars spent in terms of value for money; the utilization of evidence-based practices; the redesign and transformation of health care through

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Author Affiliation: School of Health Administration, Dalhousie University, Halifax, Canada. The author has no conflict of interest. Correspondence: D. David Persaud, PhD, School of Health Administration, Dalhousie University, 5161 George St, Ste 700, PO Box 15000, Halifax, Nova Scotia, B3H 4R2, Canada ([email protected]). DOI: 10.1097/HCM.0000000000000014

learning and innovation; ensuring that health care organizations are adapting to changing environments; the provision of high-quality care; and enabling the provision of health care in a sustainable manner.1-5 These policies are intended to be an impetus for change by encouraging health care organizations to continuously adapt to their dynamic environments as a result of utilizing innovative evidence-based practices. There is also evidence that innovation in health care results from knowledge creation or its acquisition and is driven by organizational learning.6-11 However, the acquisition, utilization, and routinization of innovations and evidence-based research by health care organizations have been slow and haphazard.12-21 In addition, a key finding in the spread of innovation in health care settings has been the importance of local contexts in the successful implementation of innovations and thus must represent an important component in any protocol for successfully implementing evidence-based practices.6,8,9,22-29 183

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THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2014

Therefore, the ELIAS (enhancing learning, innovation, adaptation, and sustainability) performance management framework was designed in response to policies aimed at providing highquality sustainable health care that is responsive to population needs through the acquisition and/or creation of innovative evidence-based practices. The ELIAS performance management framework (hereafter referred to as the ELIAS framework, or the framework) utilizes data that are already being collected for accountability and strategic purposes by health care organizations, thus improving the chances of successful implementation. However, there is the added benefit of reflecting on the data to learn, innovate, adapt, and enhance sustainability. The framework is also aimed at providing solutions for overcoming the poor adoption of innovations and evidence-based research by using research evidence from health care management and health services research while seamlessly integrating the findings from these disciplines into a coherent whole. The article argues that if implemented as outlined, the ELIAS framework is a way forward for health care organizations to deliver innovative, high-quality, sustainable health care. The topics covered in this article are wide ranging in scope; therefore, contributions to the literature were prioritized in terms of reviews of evidence in relevant topic areas, research studies as reported in peer-reviewed publications, and selected prescriptive and/or procedural manuscripts. The databases PubMed, Business Source Complete, Academic Search Premier, CINAHL, and PsycINFO were searched for articles published in the English language since 2000 onward. These databases were searched using combinations of the following keyword concepts ‘‘health care,’’ ‘‘hospital,’’ ‘‘organization,’’ ‘‘system,’’ ‘‘accountability,’’ ‘‘learning,’’ ‘‘sustainability,’’ ‘‘innovation,’’ ‘‘outcome,’’ ‘‘change,’’ ‘‘implement,’’ ‘‘institutionalization,’’ ‘‘routinization,’’ ‘‘knowledge,’’ ‘‘diffusion,’’ ‘‘culture,’’ ‘‘complex adaptive,’’ ‘‘adaptation,’’ ‘‘performance,’’ ‘‘evaluation,’’ ‘‘improvement,’’ and ‘‘measurement.’’ A snowballing strategy was also used by searching the reference sections of reviews, expert commentary, and theoretical papers identified in the search. The topics

utilized included health care sustainability, organizational learning in health care, health care innovation, health care accountability, continuous improvement, diffusion of innovation in health care, health care outcomes, measurement in health care, readiness for change in health care, action learning, organizational learning mechanisms (OLMs), implementation of research evidence into clinical practice, health care quality, innovation in hospitals, clinical microsystems, and health care performance measurement. This article first examines the importance of accountability and its vital position in the development of sustainable health care organizations. This is followed by an explication of health care organizations as complex adaptive systems (CASs) and the necessity of providing mechanisms for continuous learning in order for innovation, adaptation, and sustainability to flourish. The tenets of sustainable health care provision, innovation in health care, and learning in health care organizations will then be outlined. The rationale for the development of a dynamic learning culture that actively promotes and practices organizational learning by utilizing the ELIAS framework will then be proposed as a way of enhancing innovation and sustainability in health care organizations. Lastly, The ELIAS framework will then be delineated, and conclusions regarding the utility and implications of the framework will be outlined.

Accountability Health care organizations are complex adaptive entities that are accountable to a variety of stakeholders such as patients, employees, and accreditation and government agencies.5 Accountability ‘‘encompasses the procedures and processes by which one party justifies and takes responsibility for its activities such as for achieving organizational goals.’’30(p124) According to Brinkerhoff,31 ‘‘the essence of accountability is answerability; being accountable means having the obligation to answer questions regarding decisions and/or actions.’’31(p372) Accountability aims to ensure that health care organizations through their management and staff demonstrate


The ELIAS Performance Management Framework responsible management of human, physical, and financial resources.3,32 This entails the monitoring of activities and their outcomes and then reporting them to the respective governing bodies in order to inform on not only what was done, but the reasons behind what was done.31 Furthermore, accountability includes being answerable for meeting strategic goals and objectives as well as learning and continuous improvement that leads to adaptation and sustainability.5 Therefore, ‘‘all accountability strategies require the exchange of performancerelated information between parties in a relationship based on mutual expectations.’’5(p73) This means that hospital boards require information from senior management regarding the accomplishment of financial and quality goals, evidence of improved access and appropriateness of care, and the achievement of high levels of quality and safety.5 Governments are using accountability policy mechanisms to drive improvement in health care provision while focusing on the sustainability of health care provision.3,33 Accountability is enhanced by developing a culture of accountability.30 Such a culture includes values that: utilize contemporary information systems to monitor and report on organizational performance; develop systems such as cross-functional teams or networks for sharing of information and knowledge in a way that enhances trust; emphasize continuous quality improvement; explicitly link performance measurement to strategic planning, and utilize performance measurement and management to enhance achievement of strategic goals.6,21,26,32,34-39 Health Care Organizations as Complex Adaptive Systems Health care organizations are complex because of their complicated design and varied stakeholders.40-47 Glouberman and Mintzberg46,47 reinforce this by conceptualizing the health care sector as consisting of the 4 ‘‘worlds’’ of cure, care, control, and community. This characteristic of health care provision affects the success of strategic initiatives, innovation, and performance predictability. The reality of independent and

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interdependent entities interacting in deeply interconnected ways can frequently lead to nonlinear, dynamic, and unpredictable outcomes.26,42,48,49 Therefore, planned, controlled, and orderly approaches to innovation and change may not achieve the outcomes sought and quite often can result in unforeseen and unintended consequences.41,42,49,50 This can cause consternation, frustration, and even disillusionment in managing health care organizations because the traditional ways of solving problems using a reductionist linear perspective no longer lead to the outcomes we expect.40,42,44,51 This has prompted some scholars to propose a different perspective for viewing and understanding health care organizations that is based on complexity science through the lens of CASs.17,40,44,49,52 Specifically, complexity is synonymous with diversity and multiple elements, whereas adaptive implies the capacity to change through learning and experience. Finally, a system comprises connected, interdependent, and embedded elements that are reflected in multiple relationships.44,53 The provision of health care fulfills these criteria, and the utility of the CAS framework can enhance the understanding of organizations charged with health care provision.40,43,45,54-56 Furthermore, because health care complexity makes it possible for individual agents to have the freedom to act in ways that are frequently unpredictable and because of the interconnectedness of actions, an agent’s actions may change the context for other agents and thus lead to surprising outcomes.40,49,50 Characteristics of CASs that can lead to unexpected outcomes include selforganization (the spontaneous emergence of new behaviors to fit the environment as a result of internal feedback loops), emergence (the development of new structures that are not merely the sum of agents acting together but the result of nonlinear dynamics generating both predictable and unforeseen properties), and coevolution or adaptation (organizations and environments influence and are influenced by their ongoing evolution).42 Two forms of complexity are exhibited in the health care sector.41 The first is combinatorial complexity—which involves seeking the best solution from a large permutation of possibilities because of the interconnected


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nature of multiple stakeholders involved in health care provision. The second is dynamic complexity—the operation of feedback loops that can either reinforce activities in a system (reinforcing feedback loops) or balance feedback loops that can counteract or oppose activities within a system.41 Moreover, the existence of dynamic complexity is important for understanding CASs because the same action can have different effects in the short term and the long term and locally and elsewhere in the system.40-42,57 Complex adaptive systems can also have hundreds of interlocking feedback loops; hence, it is cognitively and perceptually challenging to predict the behavior of such systems. Nevertheless, the behavior of CASs can create the potential for innovation if managers utilize OLMs and continuous learning systems that can recognize novel unexpected outcomes then contextualize and utilize them to enhance innovation, adaptation, and coevolution of health care organizations.9,40,41,48,49 Therefore, although complexity theory indicates that future states of CASs are unknowable, the sustainability of health care organizations can be greatly enhanced by having formal networks that not only manage information exchange and knowledge acquisition but also encourage and enable informal social networks that engender practices that utilize reflection and sense making that leads to organizational learning and knowledge generation.42 In this way, learning replaces tight control and enhances adaptation to and coevolution with changing environments.7,9,10,41,48,54-56,58-64 Because organizational learning is important for the coevolution of knowledge within health care organizations and adaptation to the external environment, it also represents a critically important feature for success within CASs.7,9,10,37,41,42,48,52,56,65 Therefore, since health care organizations are CASs, managers are encouraged to utilize practices based on interdisciplinary teams so as to allow input from different perspectives and the emergence of solutions that can be tested; create an awareness and responsiveness to unexpected outcomes; use performance measurement to enhance knowledge acquisition and reflection; develop an awareness of the importance of context in

the implementation of innovations and the assessment of outcomes, and to utilize networks to enhance learning. Sustainability Sustainability as it relates to health care has been described as delivering effective evidenceinformed health care services in the most efficient manner.66 Sustainability must be a strategic imperative in order for health care organizations to succeed.66 It involves managing resources with input from stakeholders inside and outside the health care organization and is specific to the contextual environment within which an organization finds itself.28,55,56,60-62 It is reflective of a continuous process of learning, innovation, and adaptation that enables health care organizations to adapt to and coevolve with its environment despite environmental ambiguity and uncertainty.1,27,48,66 Unfortunately, there has been little research relating to sustainability of health care organizations, and hence health care researchers have had minimal evidence and advice to offer managers.66 A first step in the process of designing sustainable health care organizations is to develop a workable definition for health care contexts. Sustainability has variously been conceptualized as being concerned with change capacity, innovation, fulfilling the needs of the community, continuous adaptation, thriving under ambiguous conditions, providing high-quality services, and the responsible use of resources without limiting the capacity of future generations to fulfill their needs.67-69 Guyatt et al70 indicate that within the context of publicly funded health care systems, sustainability refers to the challenge of maintaining equitable-quality health care that addresses the full range of a citizen’s needs. Mitleton-Kelly48 defines sustainability from a CAS perspective as ‘‘a continuous process of coevolution with a changing environment. It is a dynamic process underpinned by learning; it creates new structures and ways of working to adjust and to continue adjusting to a changing set of conditions.’’48(p45) Given these multiple perceptions of sustainability, a sustainable health care organization can be


The ELIAS Performance Management Framework defined as one that efficiently achieves its strategic goals while providing effective, equitable, evidence-informed, high-quality health services in a manner that allows for continuous adaptation to the environmental and coevolution with it.66,70

Innovation It has become increasingly obvious that organizations whose strategic directions emphasize sustainability and develop organizational structures, policies, and cultural values congruent with the tenets of sustainability are also organizations where learning, innovation, and adaptation can flourish.48,68,69 Moreover, there is empirical evidence and consensus opinion that the innovation that results from practicing the tenets of a learning organization will result in adaptive, sustainable health care organizations.1,67,71 In addition, Prada72 has stated that regarding the health care system, ‘‘innovation is the key to the system’s sustainability.’’72(p4) Calatone et al73 describe innovation as ‘‘the generation, acceptance, and implementation of new ideas, processes, products, or services,’’73(p515) whereas Cain and Mittman74 define innovation as ‘‘an idea, practice, or object that is perceived as new by an individual or some other unit of adoption.’’74(p2) Innovation is therefore a multistage process of adapting to change by transforming ideas into new products or services and involves risk and requires collaboration by organizational members.23,26,27,41,75-77 Innovations in health care can include new services (diabetic clinic), new business models (organizational restructuring), new processes and practices (eg, new or altered treatment protocols), or new technologies (electronic patient record).26,29,41,77-79 Innovation can be continuous (nondisruptive, incremental) or discontinuous (disruptive, radical).41,78 The former builds on current competencies and cognitive mindsets, whereas the latter challenge current mental models and are a result of fundamentally different new knowledge.11,35,41,74,80-83 Continuous improvement over time can result in innovation, but because of its incremental

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nature, the overall change may not be as obvious unless viewed from a large enough time frame. This may be advantageous because beliefs and values are slow to change, and continuous improvement may be easier on organizational members in terms of learning and adaptation.35 Nevertheless, there are occasions where discontinuous change occurs because of new products, which not only radically alter work processes but also improve care and productivity dramatically.84 This was the case with the adoption of laparoscopic surgery.84 Specifically, the benefits in terms of patient satisfaction, effectiveness, and efficiency were obvious, and the innovation spread rapidly. There is empirical evidence from health care and other disciplines that a culture that supports learning is key to an organization developing, acquiring, and using innovations.9,23,35,75,76,85-89 Smith and Kaluzny90 have proposed a 4-stage process for the implementation of innovations within health care organizations. The 4 stages are awareness (determining there is a gap between expected performance and actual performance), identification (developing a solution[s] to close the gap between expected and actual performance), implementation (putting in place the solution[s] to improve performance), and institutionalization (making the solution[s] a normal aspect of work through policies and procedures). In addition, there are key characteristics that an innovation has been shown to possess in order to be accepted.21,29,84,91 These include relative advantage—the perception that the innovation is better than current practice,84 compatibility—the fit between the innovation and current culture,16,21,84,91-95 complexity— the perception of the ease of adoption of the innovation,96-98 trialability—the chance to test the innovation locally to observe its benefits,91,96,97 and observability—the degree to which the benefits of an innovation are visible to intended adopters.41,91,92,99 Greenhalgh et al29 have also observed that other factors that are important for diffusion of innovations in health care organizations include the utilization of the influence of true opinion leaders and the support of both formal and informal organizational networks for the adoption of the proposed innovation.


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Organizational learning, learning organizations, action learning, and organizational learning mechanisms Organizational learning is an important driver of innovation and adaptation in organizations.9,24,37,41,59,100-103 Furthermore, organizational learning is essential for building sustainable organizations and is fundamental for the sustainability of CASs such as health care organizations.7,9,11,27,48,56,69,83 Learning is premised on the reality that we evaluate organizational structures, processes, and their outcomes then reflect on how the structures and processes can be modified to generate the outcomes we desire.10,69,96,104-107 Argyris and Scho¨n108 proposed that organizational learning occurs when discoveries, inventions, and evaluations of individual members become embedded into the organization’s theory-in-use and reflected in operating procedures and routines. Not surprisingly, Calatone et al73 have demonstrated that the higher the level of learning orientation, the greater the degree of organizational innovativeness and therefore, by extension, organizational sustainability. Similarly, a meta-analysis by Goh et al59 has demonstrated a strong positive correlation between learning capability and innovation capacity. Revans109 believed that learning must be greater than or equal to environmental change (L EC) in order for an organization to be sustainable. Marsick and Watkins110 define a learning organization as ‘‘one that learns continuously and transforms itself.’’110(p142) Garvin111 describes a learning organization as ‘‘an organization skilled at creating, acquiring, and transferring knowledge and at modifying its behavior to reflect new knowledge and insights.’’111(p80) Garvin et al101 define the building blocks of a learning organization as having a supportive learning environment (psychological safety, appreciation of difference, openness to new ideas, and time for reflection) and fundamental learning processes (these include experimentation, ongoing skill development, and feedback from and assessment of work outcomes). Yet, others have outlined the defining characteristics of a learning organization in health care as challenging assumptions, information

sharing, and collaboration; action learning; the utilization of specific structural OLMs; and constant readiness for change.9-11,37,56,71,75,79,83,112 The concept of action learning refers to group learning that enables the development of people and organizations and leads to innovation and adaptation.10,86,89,109,113 Action learning is a cyclical learning process of action and reflection on processes and outcomes.6,7,10,37 If results are below predetermined benchmarks, then new actions are implemented by focusing on changing the previous activities and patterns of behaviors by utilizing structured questioning and developing implementable solutions that are cognizant of context.6,44,86,100,104,114,115 This is then followed by a new round of action and reflection. This form of action, reflection, and change builds innovation capacity because it engenders continuous adaptation to changing external and internal environments. In order to maximize the benefits of action, reflection, and change, there needs to be conditions for experimentation and learning from experience.6,7,9,11,27,36,65,83,116 Reflection done in a social context (eg, a team) enhances the reflection process because it allows for input from multiple perspectives.7,83,96,99,117 Reflective questions help to determine how participants view the problem (reflectivity), thereby creating a clearer deeper articulation of its complexities (discovery).10,37,89,116 Therefore, action learning involves reevaluation, acceptance or rejection, and unlearning of ideas that are not resulting in expected outcomes.6,35,58,116 If the unlearning is more a result of reflectivity than discovery, then it is really not unlearning but merely the modification of actions within the same belief systems and is akin to single-loop learning.108 If unlearning is a result of both reflectivity and discovery, it can lead to new mental models and can be considered double-loop learning.107 However, several iterations of single-loop learning can lead to double-loop learning if the sum of each single modification leads to substantial modification over time.116 An example of the institutionalization of action learning is through OLMs.10 Organizational learning mechanisms are congruent with the concept of concrete learning processes and practices.101,118,119


The ELIAS Performance Management Framework Organizational learning mechanisms ensure performance management not just measurement and enhance the institutionalization of learning.6,9,120 When fully implemented, OLMs are institutionalized structural and procedural arrangements that allow interdisciplinary teams within organizations to learn by utilizing organizational data to review, change, and eventually institutionalize organizational routines with the specific aim of improving organizational performance and sustainability.10,11,89,100 Organizational learning mechanisms are context specific and specifically designed for learning in different circumstances. Therefore, OLMs can be designed for either learning during performance, learning immediately following performance, or learning after performance through timely feedback on a weekly, monthly, or quarterly basis.6,10,89,100 The Imperative of a Dynamic Learning Culture That Emphasizes Accountability, Learning, Innovation, Adaptation, and Sustainability The dynamism of health care environments means that health care organizations can improve their chances of success when they possess a culture that matches their environments.38,121 This means that health care organizations should

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possess a dynamic learning culture that reinforces accountability, action learning, and performance management so as to improve their chances of developing innovative practices that enhance adaptation and sustainability.1,6,9,11,56,57,89,92,121 The Table outlines factors that can encourage the development of such a culture. It is proposed that the presence within a health care organization of a dynamic learning culture and the utilization of the ELIAS framework will enhance the success of continuous improvement initiatives, the development of innovative practices, and the continuous adaptation to the external environment, thereby enhancing sustainability.9,29, 35,38,39,57,59,67-69,73,77,79,86,89,101,118,121-123

The ELIAS Performance Management Framework The ELIAS framework represents an integration of the health care management literature and other management literature relevant to its components of the ELIAS framework. The literature utilized includes accountability5,32,33; organizational strategy124,125; performance management and measurement3,119,126-129; quality improvement6,130-133; change management22,93, 134-139 ; health care innovation27,29,35,41,76,79, 91,96 ; knowledge management28,97,140,141; adaptation9,48,118; sustainability1,48,67,68,70,96;

Table. Factors for Creating a Dynamic Learning Culture A focus on being accountable individually and as an organization The explicit linkage of performance measurement to strategic planning An emphasis on the utilization of continuous quality improvement and performance management A recognition of the implications of health care organizations being complex adaptive systems Policies that encourage the participation of stakeholders who affect performance measures in the design and implementation of these measures The utilization of contemporary information systems to monitor and report on performance Upper management support for the utilization of interdisciplinary teams and collaborative processes when developing solutions to performance problems An emphasis on action learning that uses organizational learning mechanisms to assess feedback from performance measures to initiate reflection and redesign An obligation to the utilization of the best research evidence in decision making The utilization of knowledge management strategies (creation, acquisition, and testing of knowledge to improve outcomes; dissemination of best practices; formal and informal networks for enhancing knowledge exchange) The development of the capacity for continuous low-risk experimentation The presence of a psychologically safe environment that avoids blame The utilization of facilitated learning techniques (collective reflection, simulations, case discussions, and e-learning methods) with the aim of learning for performance The provision of opportunities for individual and team learning before, during, and after performance with the goal of enhancing the entity’s capacity to generate, acquire, transfer, utilize, and institutionalize knowledge


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organizational culture22,38,110,121,142; goal setting143,144; self-efficacy97,135,145; CASs40,46-48, 63,146 ; system cybernetics6,64,147; organizational learning, learning mechanisms, experiential learning, and action learning9,27,41,58,89,103,108, 116,148 ; clinical microsystems6,36,114,149; and the PARIHS framework.150,151 The ELIAS framework represents an integration of these topics, and it can be used for improving current processes, practices, or treatment protocols; the implementation of evidence-based practices or new practices reflective of technical changes such as innovative surgical methods; new programs such as a diabetic clinic; or new business models such as restructuring. Moreover, it can be used to improve or replace standard practices in order to ensure adaption to changing health care environments. The framework is premised on continuous improvement that heightens the processes of organizational learning, innovation, adaptation, and sustainability in health care organizations

(Figure). The concepts of organizational strategy, accountability, cybernetics (feedback and modification), CASs, action learning, knowledge management, performance measurement and management, along with the structures and values of a dynamic learning culture, form the core of the framework.3,5,6,9,22,33,36,77,119,143, 149,152 Accountability, strategy, and culture are at the center of the framework because accountability is the driver of performance measurement and management; whereas strategy signals how the health care organization proposes to achieve its goals, and culture must be aligned with strategy for organizational success.3,5,23,32,33,38,121,124,142 Evaluation is important for assessing the achievement of strategic outcomes, for signaling stage progression through the ELIAS framework, and for evaluating the ongoing impact of innovations— intended and unintended.9,76,79,115,131,153,154 The cyclical aspect of the ELIAS framework begins with measurement. Measurement is

Figure. Enhancing learning, innovation, adaptation, and sustainability (ELIAS) in health care organizations.


The ELIAS Performance Management Framework central to goal setting, outcome assessment, CASs, improvement, and learning in health care.34,60,92,96,119,131,144,146,149,153,155,156 Learning occurs as a result of using the feedback from measurement and the deliberate act of reflection on the information being communicated with the aim of developing evidencebased solutions.6,36,37,61,94,107,108,111 The search for solutions and their utility lead to innovation when modification of current practices or completely new practices yield the outcomes being sought.7,9,11,37,48,59,76 Innovation is a reflection of coevolution of the knowledge of organizational members and can lead to external environmental coevolution and adaptation to changing health care environments.42,48 Not surprisingly, when a health care organization adapts to its environments, this enhances its sustainability.48,57,67,68,74,96 Therefore, the critical aspect of measurement in the ELIAS framework is its utility for signaling the need for change and the search for solutions that result in learning and innovation. Measurement as shown in the Figure can be as a result of the performance measurement aspect of accountability mechanisms, or assessment of the achievement of strategic objectives, or quality assurance and continuous improvement programs, or an aspect of benchmarking initiatives—hereafter altogether referred to as performance measurement or performance measurement systems. Moreover, performance measurement has become ubiquitous in health care as a result of accountability and quality improvement imperatives.5,30,33,132 However, its utility as the initiator of performance management is being poorly utilized, thus leaving this latter purpose largely unfulfilled.34,39,119,131,155,157-159 In addition, because health care organizations are CASs, performance measurement is imperative because outcomes may not be as expected as a result of multiple agents and their independent but interconnected actions, sometimes resulting in the phenomena of self-organization and emergence.40,49,60,146 Furthermore, Berwick155 explicitly stated that measurement is a critical and necessary component for enhancing learning in health care organizations while helping to clarify cause-and-effect relationships and determining whether innovations should be kept,

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modified, or rejected.6,149,156 This is why measurement explicitly represents the pivotal stage that initiates and completes the ELIAS framework. It is the information provided in the measurement stage of this cybernetic system that signals whether there is a need for modification or replacement of organizational routines in order for continuous adaptation to the health care environment to occur. Measurement not only triggers the other stages in the ELIAS cycle, but it also gives feedback on the continuing success of implemented and institutionalized processes— the essential aspect of cybernetic systems.6,119,147 In addition, the awareness of problems in goal achievement, with the concomitant inability to achieve strategic objectives effectively and efficiently, is made clear to all stakeholders through performance measurement and evaluation. The next stages in the ELIAS framework are disconfirmation of the assumptions regarding the processes and procedures in place for goal achievement because of the existence of a gap between expected and actual performance107,108; this is followed by contextualization—the development and evaluation of solutions to specifically fit the organization’s context,15,28,92, 96,115,136,160 their implementation,97,135,137 and finally the routinization of the solutions once they are evaluated to be within predetermined expected ranges and are accepted by organizational members (Figure).17,18,91,93,140 The overall process is depicted as cyclical because moving from one stage to the next may not be linear because continuous evaluation may cause a shift to a previous stage because of unanticipated factors such as inadequate resources, changes in strategic direction, or poor performance of proposed solutions.154 Nevertheless, through the utilization of this cycle and continuous evaluation, learning occurs that leads to either modification of previous practices or the introduction of new practices. Either way, these improved practices are reflective of knowledge acquisition, learning, and innovation, the implementation of which enhances adaptation and sustainability.39,66,72,92,96 Measurement Performance measurement informs on whether a health care organization is achieving its strategic and improvement goals.161 The management


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of the information resulting from measurement, reflection, and change is critical to improvement.119,126,131,149,155,162,163 Therefore, when an organization properly manages what it measures, learning, innovation, adaptation, and sustainability are the natural outcomes of this process.9,39,66,78,81,140,149,156,161 A good set of health care performance measures indicates how efficiently a service is delivered and its effectiveness on its intended recipients and the community in general.126 Ideally, measurement results from the utilization of goal setting to evaluate success in fulfilling an organization’s strategy.3,144 Health care performance measures should help managers diagnose and improve poor performance.3,126,129,131,140,143,162 Behn164 indicated that performance measurement is meant ‘‘to evaluate, control, budget, motivate, promote, celebrate, learn, and improve.’’164(p588) Bouckaert165 suggests that the design of performance measures must utilize a bottom-up and top-down process, and the involvement of middle management and frontline staff in the creation of measures increases the probability of commitment to them and increases the chances of action and reflection on the results of measurement, thereby enhancing learning and innovation while finally fulfilling an important aspect of the remit of performance measurement.119,126,131,140,157,162,166 Organizational level measures inform on strategic goal accomplishment and is used for governance purposes, whereas operational level measures report on services and operations at the unit level and are used for improvement and learning.3 Generally, the operational-level indicators (eg, rate of unit hip fractures from falls) are rolled up to the organizational level (rate of in-hospital hip fractures from falls), and organizational-level indicators aggregated to form system-level indicators (rate of adverse events). However, although organizational-level indicators can indicate a lack of strategic goal achievement, it is operational-level indicators that demonstrate gaps in effectiveness and efficiency that can be addressed more easily because they reflect the outcomes of activities (cause-and-effect relationships) that can be tested and acted upon locally to improve quality.119,126,131,140,158

Conceptualization of Performance Measurement Several conceptual factors must be considered when designing performance measures. First, scope is important and refers to the key processes provided by a program or service to be examined, and these can cross vertical or horizontal levels within the organization. Second, it is important to determine who will be using the measures.28,130,131,143,161,167 Generally, stakeholders such as government agencies will utilize more system-level-type measures; governing boards and senior management will look more at organizational measures; and managers will review operational measures. Third, the domains of performance must be considered. Domains (measurement groups) are reflective of the strategic direction of the organization and can relate to constructs such as quality, access, and sustainability.3,126,127,152,162,168 Fourth, health care organizational quality measures refer to aspects of structure, process, or outcomes.130 Structure pertains to having the necessary resources to provide adequate health care; process refers to the activities and procedures used to deliver care and indicate if things were done right; and outcomes refer to the results of the processes used to deliver care and signal successful achievement of goals and are key to assessing organizational activities aimed at achieving the organization’s strategy.130,131,162,167 Fifth, the framework of measurement is important. Most performance measurement frameworks provide a list of indicators representing the domains being assessed. However, because health care organizations are CASs, a balanced set of measures representing several domains is the most informative because attempting to improve one measure within a domain may compromise another measure within another domain.6,28,146,156 For example, reducing the length of stay for a surgical procedure may result in more readmissions due to wound infections (effectiveness), which then results in higher overall cost (efficiency) as well as patient dissatisfaction and reduced quality of life (patient-centeredness). Finally, the reporting format for performance and quality measures must be determined. The


The ELIAS Performance Management Framework important point here is to produce reports that management is likely to act on. For example, when assessing treatment processes for a clinical condition such as myocardial infarction, outcome information can be presented in a balanced scorecard format with measures related to clinical status, functional status, patient satisfaction, and costs.6,156,169 In addition, process measures related to aspects of proper enactment of accepted organizational procedures and protocols can be reported.131 In this way, process and outcome measures that are actionable are presented with the specific intent of improving care. It is at this level that learning and innovation are most likely to occur, thereby enhancing adaptation and sustainability. In addition, dashboards with measures related to the program or service of interest can be presented in a temporal fashion to indicate changes in measured processes and outcomes over time.6,39,130 Guidelines for Designing Performance Measures In order to achieve the goal of enabling learning and innovation, performance measures must possess certain characteristics.73,126,130,131,143,170 They must be actionable with evidence-based causal links between specific processes and measured outcomes so that changes to these processes will result in different outcomes.128, 131,155,159,171 Measures must be aligned with the strategic direction of the health care organization and be amenable to risk adjustment while being cost-effective to use.3,36,126,161 Measures must also be valid in terms of being technically sound and relevant to managers while being reliable in terms of accuracy over time.131,152,162,170 Paradoxically, there should also be measures that are harder to conceptualize but important to evaluate. These measures should reflect aspects of learning and behavior change at the individual and organizational level and inform on the organization’s progress to being a learning organization.115,169 Finally, measures must reflect functionality in terms of their utility to contribute to the maintenance, development, adaptation, and sustainability of the health care organization.31,126,131,149,166

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DISCONFIRMATION Performance gap The second stage of the ELIAS cycle is disconfirmation (Figure). This is a process of determining which domains of organizational activity should be the focus of performance scrutiny and has been called agenda setting.91 Agenda setting is based on the health care organization’s strategic direction, and the domains of performance reflective of this are indicative of priorities in areas such as quality, access, and sustainability. The process of disconfirmation is initiated by an awareness of a gap in performance that is signaled by a process of evaluation based on comparisons with benchmarks and agreedupon performance goals. Awareness can come from several sources: reviews of incident reports, surgical errors, or other adverse events; assessment of trends obtained from monitoring specific clinical, financial, or functional outcomes; or assessment of performance data such as length of stay for various types of surgery; readmission rates; or percentage of postoperative complications.6,126 Awareness can also be the result of assessment during or after performance. For example, during the performance of surgical procedures or after the completion of a surgical procedure or both.7,10,89,120,148 In addition, disconfirmation can be signaled during evaluation of the implementation of evidencebased practices.12,61,150,151,160 Evaluation process The process of assessing performance gaps is based on action learning through the use of OLMs.7,8,10,100 Essentially, an interdisciplinary team that is responsible for assessing performance information reflected in a balanced set of measures (scorecard, dashboard) determines from assessment of the information provided whether structures and/or processes should be modified, changed, or replaced in order to close the gap in performance. The coach (leader) of the team guides the conversation in terms of gaining agreement that a problem exists and needs attention, or the achievement of organizational goals could be compromised in the area reflected by the performance measure(s).


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For example, monitoring may indicate that the postsurgery in-hospital length of stay for a specific high-cost, high-volume surgical procedure is on average consistently greater than acceptable goals or benchmarks after risk adjusting for patient comorbidities. An important aspect of implementing change relates to a general acceptance that a problem or discrepancy exists and is signaled by a difference between actual and expected performance.97,108,119,135-138 However, the awareness of a performance gap is not enough to cause disconfirmation.15,20,83,105,172 The cycle may be stalled if awareness does not lead to disconfirmation. This lack of movement can be due to reasons such as perceived loss of power, lack of efficacy, absence of a dynamic learning culture, and the persistence of ingrained mental models.9,83,112,145,147,159,172 Therefore, evaluation of relevant performance measures and senior management support coupled with a dynamic learning culture are factors that can enhance agreement that current practices must be modified or replaced. This removes the first hurdle to readiness for change, thereby improving the capacity to initiate change, while initiating the process of closing the knowingdoing gap.22,27,35,96,135,139,172

CONTEXTUALIZATION Developing Solutions That Fit The process of identification of a solution(s) is the second aspect of the action learning framework that is integral to OLMs and is guided by a rational decision-making process.106,155,173,174 This systematic process is data driven and involves defining the problem that was identified. It requires the establishment of decision criteria for the assessment of solution alternatives (eg, consistency with program and organizational strategic goals, compatibility with prevailing cultural values, and testability); the generation of alternatives; the assessment of proposed alternatives and choosing which alternative(s) to implement; implementation of the alternative(s); and evaluating the alternative(s) through monitoring and feedback.6,92,119,149,155,174 In keeping with the tenets of CASs and the presence of multiple agents and interconnectedness,

the development of solutions should not be the purview of a few but should involve stakeholders at all organizational levels affected by and who affect the performance measures. 6,17,22,49,60,116,146,150,151,175 This is why it is best done within an action learning framework utilizing OLMs that ensure the generation and utilization of performance feedback, experimentation and experiential learning; local contextual research evidence; the utilization of social networks; top-down and bottom-up participation in the generation of decision criteria; assessment of alternatives based on these criteria; and choosing the solution.6,10,22,36,55,61,64,86,96,176 Solution identification reflects a matching phenomenon between the solution’s characteristics, the criteria set out by the team, the congruence with the shared values and beliefs of organizational members, the involvement of key stakeholders, and the health care organization’s strategic direction.14,17,28,48,60,91,99,176 Getting to the root of the problem The nature of OLMs will vary depending on the context within which action, reflection, and evaluation occur. As outlined earlier, they can be deployed for learning during performance, learning immediately following performance, or learning after performance through timely feedback on a weekly, monthly, or quarterly basis.7,10,58,61,89,148 Nevertheless, teams utilizing OLMs can choose among specific established methods to best identify where problems may be occurring and then initiate the search for solutions. These methods can include logic models as well as tools subsumed under the topic of causal mapping such as process mapping, systematic outcome mapping, failure mode effects analysis, root-cause analysis, and lean thinking.39,115,119,122,132,149,167,173,177 It is imperative that the methods utilized for solution identification involve those who will implement the solutions at the frontline, thereby encouraging frontline ownership and a better chance of success.22,96 The search for solutions can be influenced by expediency and urgency; thus, organizational members may choose to modify existing structures and processes


The ELIAS Performance Management Framework (single-loop learning) or to completely reassess the thinking that went into developing the structures and process(es) (double-loop learning).9,83,107 Either way, these solutions are perceived as more acceptable by organizational members and enhance the processes of implementation and routinization when they are based on local research evidence or previously institutionalized organizational routines.12,14,17,18,28,29,55,60,63,91,123,151,160 Plan-Do-Study-Act The chosen solution(s) must be subjected to local research testing in order to assess their viability within the organizational context where it will be implemented.14,28,37,60,123,150,178,179 This is best accomplished within the plan-dostudy-act (PDSA) cycle.63,149,155 The PDSA cycle is premised on testing or adapting a change idea with the intent of spreading it to a larger area or organization-wide.6,36,60,132,178 The purpose for using this framework is to minimize resistance upon full-scale implementation by determining whether proposed changes will result in improvement in the organizations strategic initiatives, the level of improvement over previous practices, and the training necessary to implement the change.17,167,178 During the planning phase, measures are developed by multiple stakeholders with the aim of assessing goal achievement.167 The doing aspect of the framework involves carrying out the plan and collecting performance measurement data. This is the action component of the action-reflection perspective of learning. The study phase of the cycle involves comparing performance measures to what was expected while reflecting on what was learned in the action phase. It is also a necessary practice for working with CASs.40,48,58,60-62,64,104 Finally, this is followed by the act phase of the cycle and involves modifications or changes to the program or process in order to improve the chances of achieving the agreed-upon goals. This phase may also involve another round of decisionmaking assessments and the utilization of causal mapping techniques with the aim of developing research informed solutions. The PDSA cycle is repeated until the outcomes of testing demonstrate goal achievement.

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These iterative tests of change inform on the viability of each round of change. Because health care organizations are CASs, context is very important, and empirical studies of the adoption of clinical practice guidelines and health care innovations have strongly indicated this.8,13-15,23,24,93,115,178 Therefore, the achievement of predetermined benchmarks during PDSA cycles makes it easier for previous practices to be discontinued and innovation(s) to be accepted, implemented, and spread throughout the health care organization.35,63,123,155,167,176 This is an aspect of social proof or practice-based evidence that is critical for successful implementation of change.22,25 Furthermore, the process of solution identification, testing, reflection, modification, and retesting enhances learning and innovation.59,118 Successful innovation signals a health care organization’s adaptation to its changing external environments and enhances its sustainability.48,67,72 IMPLEMENTATION The successful implementation of change programs or innovations in health care and other settings has been shown to be dependent on several factors.20,21,29,77,79,93,96,97,135,137,138,150 These factors include attention to change recipients beliefs regarding a discrepancy in actual versus expected performance, the perceived appropriateness of solutions, management (principal) support, personal valence, efficacy regarding the change, and the presence of purposeful facilitation.136,137,139,151,180 Furthermore, not only should performance be monitored during implementation, but each of the factors outlined in this part of the ELIAS framework must be evaluated to ensure successful implementation. Discrepancy Employees must believe that there is a legitimate and rational reason for change. If they feel that current practices are achieving strategic goals, then organizational members will not be inclined to participate fully in the implementation of change programs. The need for change is best demonstrated by assessing performance measures.3,36,126,131,140,149,164 The fact that


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performance measures are important for signaling a need for change reinforces the need for stakeholder participation in measurement design because they are more likely to acknowledge a problem exists when measures they were involved in developing demonstrate that benchmarks or predefined goals are not being achieved.3,17,34,165 This performance gap signals the need for change and legitimizes the search for and identification of solutions.97,119,135 Appropriateness It is incumbent on management to show that the solution that has been devised to close the performance gap is feasible and will work. As outlined in the Contextualization section, this is enhanced by choosing solutions compatible with the cultural values and beliefs of organizational members as well as the health care organization’s strategic direction.14,32,34,84,92,93,97,124,135,181 Furthermore, the research evidence that supports the solution(s) is also important for its acceptance.22,29,97,151,178 The ELIAS framework fulfills these criteria and goes even further by testing the solution(s) using the PDSA framework to determine an optimal solution. There are important benefits to this. Most notably, testing is done within the context where the innovation will ultimately be implemented, and this helps to overcome resistance by organizational members.14,23-25,28,29,37,115,123,179 This practice-based evidence serves as social proof to organizational members that the solution works within the organization’s context and is an important step toward closing the knowing doing gap.22,25,172 Management (principal) support This is a key aspect of any change program. Unless there is support from all levels of management for the initiative, it will not succeed.17,28,79,93,96,97,135–137,175,182 This support must be clearly communicated to those who will affect and are affected by the change in actions such as listening and acting on the feedback provided by those affected by the change; a commitment to changing policies and procedures to reflect the change; the provision

of specific financial and technical resources to properly implement the change; and the prerequisite of continuous training to those whose jobs will be affected by the change.97,119,135,139 If organizational members perceive a lack of tangible support for the proposed change from formal and informal leaders, change agents, managers, and opinion leaders designated to champion the change, then the chance of the change initiative being embraced will be diminished.97,136,139,182,183 Implementation must be guided by the words and especially concrete actions of management and others leading the change program—there must be congruence between espoused theory and theory in use.107 The implementation of innovations also has a better chance of success if agents at different levels of the organization are charged with championing the change during various stages aspects of shared and distributed leadership.175,182 As implementation progresses, different agents can act to motivate their coworkers and sphere of influence to continue the momentum of change.119,175,182 Personal valence This relates to the perception that the eventual outcomes of a change will benefit us in a way that we perceive as important. These can be intrinsic or extrinsic.136,174,184 Extrinsic benefits can be as obvious as the survival of the health care organization, keeping our job, increased recognition, receiving a promotion or a raise, increased interaction and learning from others, and improvements in patient care.41,184 Intrinsic aspects of valence include increased job satisfaction through the benefits of learning new tasks or combinations of new tasks that increase task significance and make the job more intrinsically rewarding and personally significant, thereby leading to higher levels of self-actualization.139,184 Therefore, it is incumbent on change agents and organizational leadership to clearly outline the benefits of the proposed change to all affected stakeholders with the aim of enhancing their motivation and commitment to learning and performing their new tasks related to the proposed change.135,139


The ELIAS Performance Management Framework Efficacy Efficacy as it relates to organizational change refers to one’s perceived capability to perform tasks expected of them in order for the innovation to be implemented successfully. It has been demonstrated that people are more motivated to perform a task that they think they can execute successfully.145 Therefore, it is incumbent on management to provide the training and resources necessary for affected organizational members to feel efficacious at performing the new behaviors expected of them.27,35,55,58,64,65,75,86,116,178 Management can provide the training and support to help those affected by the change by having personnel available to answer questions and reinforce successful acquisition of new behaviors. This facilitates the acquisition of the skills to perform the required tasks necessary for successful implementation of the change program.139,180 The PDSA cycle that is used to test innovations encompasses aspects of training, experiential learning, and trialability, which serves to develop efficacy in the performance of the new skills.28,29,37,61,91,148,155 Purposeful facilitation Those charged with championing the change and implementing it must demonstrate the necessary skills to enhance the implementation of the innovation.14,23,137,151,183 Change agents and champions are an important aspect of the implementation of innovative practices because they possess referent power and can confer legitimacy to the change program.22,24,97,139,150,160 They must also be empathetic and consistent in their commitment and support of the change and utilize all available communication channels such as one-on-one conversations, information sessions, formal and informal networks, and audit and feedback on a regular basis to promote acceptance of the change.15,139 It is also important that policies and procedures reflect the new processes being implemented.34,60 In addition, formal and informal networks (social, clinical, or technological) are important aspects of innovation adoption because they result in increased interconnectivity that enhances positive relationship building and sharing if ideas.22,26,29,35

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ROUTINIZATION This refers to the integration of the innovation into the activities and fabric of the health care organization (Figure).91 The successful implementation of innovations serves to enhance their institutionalization.91 Specifically, the routinization phase overlaps with its implementation counterpart in the ELIAS framework and is a natural extension of it. Certainly, if organizational members believe the change is necessary; the solution is justified through research evidence coupled with local knowledge and testing and has organizational support that is reflected in the provision of financial and technical resources; there are opportunities for training that engender positive perceptions of efficacy in implementing the change; and facilitators are respected, credible, and helpful, then the chance of the innovation being implemented and routinized is very good.14,135,138,181,182 Virani et al141 indicate that several knowledge reservoirs must be utilized in order to institutionalize innovations. These include adequately training the people who will perform the work required of the innovation(s), legitimizing the new practices in policies and procedures, and making them part of standard operating procedures. Williams35 believes that information systems and networks must be developed in order to transfer and disseminate best practices so as to speed their acceptance and adoption. Similarly, Zimmerman et al22 have observed the need for increased interconnectivity of organizational members through social networking in order to solve complex problems. Interconnectivity provides for a richer source of observations and insights that can ultimately result in better solutions that can be implemented and institutionalized CONCLUSION Health policy makers and administrators are looking for ways to ensure the sustainability of health care organizations.1,48,70 It is clear that innovation is key to achieving this goal, and a health care organization’s learning capability is vital for innovation.2,23,26,35,41,48,59,72,185 In addition, when health care organizations innovate


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successfully, they are essentially coevolving and adapting with their complex environments, thereby enhancing their sustainability.1,48 However, the level of successful acquisition, implementation, utilization, and routinization of evidence-based practices and innovations has been disappointing.12,14,15,21 Therefore, it is against this backdrop and health care policies directed at improving efficiency, effectiveness, and sustainability that the ELIAS performance management framework was developed. The components of the framework (measurement, disconfirmation, contextualization, implementation, and routinization) work within the context of a health care organization’s strategy, culture, and accountability mechanisms to improve the successful adoption, implementation, and institutionalization of innovative evidencebased practices in a way that will enhance its adaptation and sustainability (Figure). The measurement component is premised on utilizing a balanced set of actionable measures that inform on the extent of goal achievement. The measures are designed by those who affect them and are affected by them, thereby improving their chances of being acted upon.22,28,49,131,143,146,170 This process is driven by OLMs that assess the performance measures to determine whether processes linked to them must be redesigned or replaced so as to improve goal achievement.10,119 Solution identification incorporates the organization’s context because it has been identified as a major barrier to the implementation of evidence-based practices.14,17,28,60,92,96,115,150,151 Practice-based evidence and social proof are reinforced by using the PDSA cycle to test evidence-based practices and innovations. The PDSA cycle demonstrates to organizational members that the solution(s) is appropriate given the organization’s contextual realities and addresses concerns related to complexity, observability, compatibility, trialability, and training.22,28,29,37,61,167,176 It is incumbent on senior management to demonstrate support for the initiative, enhance the self-efficacy of those affected by the innovation, provide adequate facilitation, and heighten the feeling of ownership for the innovation by those who will be charged with implementing and using it at the frontlines.12,22,23 Routinization

is improved with the use of information systems and networks that encourage the integration of the innovation into the organization’s standard operating procedures.22,35,91,141 Health care organizations are CASs, and the effect of multiple agents and their interconnectedness is a necessary and important consideration when implementing change.22,40,44,48,60,178 In addition, senior management must also nurture a dynamic learning culture that creates a dynamic learning environment in order for the potential of the ELIAS framework to be achieved,9,38,121

IMPLICATIONS OF THE ELIAS FRAMEWORK The ELIAS framework is specifically designed for improving the sustainability of health care organizations and can be seamlessly integrated into existing performance measurement systems. The framework is premised on action learning while assessing the achievement of organizational goals and evaluating the efficacy of organizational routines and evidence-based practices. Therefore, health care managers will find the framework a useful and cost-effective method for developing and testing evidence-based practices, which can then be directly utilized within their organization because they have been proven effective within the organization’s context. An important attribute of the ELIAS framework is the proposition that performance-related measures that are provided by health care organizations for accountability and strategic assessment purposes can be simultaneously integrated within the framework to drive organizational learning, innovation, adaptation, and sustainability. This means that there are minimal costs for implementing the framework and is therefore an appealing consideration in terms of the costs and benefits of implementation. The ELIAS framework maps onto the strategy, goals, context, and history of the organization and is supported by a dynamic learning culture (Table) that is nurtured by senior management. The framework is designed to go beyond merely gaining buy-in from those affected by proposed changes.186 It is designed specifically to engender a sense of ownership at every stage of the framework by


The ELIAS Performance Management Framework those affected by changes, thereby leading to improved commitment and engagement.22 As outlined previously, the acquisition, utilization, and routinization of innovations and evidence-based research by health care organizations have been slow and haphazard.12 The reasons for this include failing to take into account the organization’s contextual realities such as culture and history, as well as not paying enough attention to concerns associated with complexity, observability, compatibility, trialability, and training.22-25 However, as described throughout the article and especially in the Contextualization domain, the ELIAS

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framework addresses these factors. Specifically, it provides a template for testing institutionalized routines as well as evidence-based practices and innovations within the health care organization’s context. This therefore moves beyond researchbased evidence to practice-based evidence while providing social proof of efficacy and closes the gap between research and practice. Therefore, the ELIAS framework represents a powerful tool that can be used by managers to assess, develop, and implement evidence-based practices and innovations within health care organizations, which also has the important added benefit of enhancing the organization’s ongoing sustainability.

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Development of a culture of sustainability in health care organizations.

Physician adaptation to health maintenance organizations and implications for management.

Hospitals as learning organizations: fostering innovation through interactive learning.

Learning for sustainability among faith-based organizations in Kenya.

Revisiting Balint's innovation: enhancing capacity in collaborative mental health care.

The health care innovation bubble.

Do organizations spend wisely on employees? Effects of training and development investments on learning and innovation in organizations.

Exploring the state of health and safety management system performance measurement in mining organizations.

Action errors, error management, and learning in organizations.

Insourcing health care innovation.

Future developments in health care performance management.

Health care financing and the sustainability of health systems.

The risks of innovation in health care.

Accountable Care Organizations in the U.S. Health Care System.

Accountable Care Organizations and Oral Health Accountability.

Enhancing the Relevance of Incident Management Systems in Public Health Emergency Preparedness: A Novel Conceptual Framework.

Dimensions of Learning Organizations Questionnaire (DLOQ) in a low-resource health care setting in Nepal.

Measuring technical efficiency in health care organizations.

Managing change in health care organizations.

Geriatric care approaches in health maintenance organizations.

Can health care organizations improve health behavior and treatment adherence?

From strategy to action: how top managers' support increases middle managers' commitment to innovation implementation in health care organizations.

Merging Problem-Based Learning with Simulation-Based Learning in the Medical Undergraduate Curriculum: The PAIRED Framework for Enhancing Lifelong Learning.

Early Performance of Accountable Care Organizations in Medicare.