Original Article
Hospitals as Learning Organizations: Fostering Innovation Through Interactive Learning Casimiro Dias, MPH; Ana Escoval, PhD The article aims to provide an analytical understanding of hospitals as “learning organizations.” It further analyzes the development of learning organizations as a way to enhance innovation and performance in the hospital sector. The article pulls together primary data on organizational flexibility, innovation, and performance from 95 administrators from hospital boards in Portugal, collected through a survey, interviews with hospital’s boards, and a nominal group technique with a panel of experts on health systems. Results show that a combination of several organizational traits of the learning organization enhances its capacity for innovation development. The logistic model presented reveals that hospitals classified as “advanced learning organizations” have 5 times more chance of developing innovation than “basic learning organizations.” Empirical findings further pointed out incentives, standards, and measurement requirements as key elements for integration of service delivery systems and expansion of the current capacity for structured and real-time learning in the hospital sector. The major implication arising from this study is that policy needs to combine instruments that promote innovation opportunities and incentives, with instruments stimulating the further development of the core components of learning organizations. Such a combination of policy instruments has the potential to ensure a wide external cooperation through a learning infrastructure. Key words: health services, hospital, innovation, learning organization, performance
H
ospitals in Portugal, as well as across Europe, are currently facing several challenges, including the aging population, the increasing burden of chronic diseases related to risk factors, and the expansion of health care options by new technologies. Moreover, the current economic crisis has resulted in both negative implications on the availability of resources and a positive impact on the demand for health services. These circumstances are increasingly adding pressure to performance improvement of the hospital sector.1 It is widely assumed that these current changes in the economic environment might be described by the concept of “the learning economy.”2 It argues that besides the increasing use of knowledge in the economy, the knowledge itself becomes obsolete at a faster pace. While mechanisms for knowledge creation and diffusion have significantly advanced, the access and application of such knowledge have not kept up the same pace. The result is an important gap between existing evidence and daily practice in the hospital sector. This calls for an increased focus on learning capacities of hospitals to make the best use of knowledge in terms of innovation development.3 In this article, learning refers to the acquisition of new skills and compeAuthor Affiliations: World Health Organization, Regional Office for Europe, Copenhagen, Denmark (Dr Dias); and School of Public Health, University Nova Lisboa, Lisbon, Portugal (Dr Escoval). Correspondence: Casimiro Dias, MPH, Division of Health Systems and Public Health, World Health Organization, Regional Office for Europe, 8, Scherfigsvej, DK-2100 Copenhagen Ø, Denmark ([email protected]). The authors declare no conflicts of interest. Q Manage Health Care Vol. 24, No. 1, pp. 52–59 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
DOI: 10.1097/QMH.0000000000000046
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tencies in order to achieve individual or organizational goals.4,5 As hospitals are facing an increasing turbulent environment, it becomes imperative to support learning conditions within hospitals in order to tackle current and emergent challenges.6 The recognition that knowledge and learning are key drivers of innovation and performance has been a major breakthrough in management thinking. It has opened new perspectives on management toward learning processes across different sectors of the economy. These research traditions, building on the work of sociology and economy, have been summarized by Rogers,7 which have focused on linkages between the innovation developers and adopters. However, the knowledge-based approaches have radically redefined both innovation development and dissemination in terms of knowledge creation and dissemination. The absorptive capacity for new knowledge has been introduced as a nonstructural factor of innovation including “learning organization” values and goals, the organization’s existing knowledge base, and promotion of knowledge dissemination within and outside the organization.8 Such focus on learning as part of enhancing organizational flexibility may be traced back to the theoretical developments by Kanter9 and Rogers.7 The main argument of these authors is the need of organizations to enhance the capacity to transform themselves in a continuous way. Such stream of literature has led to the concept of the learning organization, combining different disciplines such as total quality management and organizational learning.10 The management literature has pointed out the relevance of establishing learning organizations.11 Here, the organizational structure will have a major effect on www.qmhcjournal.com
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the rate of learning that takes place. Other factors include human resources development, new organizational forms, and external collaboration networks.12 Managers in the hospital sector recognized the importance of improving learning in their organizations to achieve quality improvement.13 Therefore, it is necessary not only to clarify the concept of learning organizations but also to clarify to which extent hospitals can be classified as learning organizations. Hospitals have been described as complex adaptive systems.14,15 Taking into account the principles and resources supporting a learning environment, it is possible for hospitals to take full advantage of local knowledge in generating continuous improvements.16 Indeed, recent empirical developments by the Institute of Medicine have redefined the health sector as a learning health care system, which collects data from daily activities and facilitates the use of scientific evidence to improve care in a continuous way.17 The learning health care systems will require the capacity to manage information-intensive work flows, with significant potential to fill major knowledge gaps on health care costs and the benefits and risks of specific drugs and clinical procedures.18-20 The purpose of this study was to explore the concept of learning organization in the hospital sector in Portugal. The article has 3 main objectives: explore the relevance of knowledge and learning; assess the impact of learning organizations in innovation capacity; and identify the major mechanisms that enhance learning organizations in the hospital sector. CONCEPTUAL FRAMEWORK The study builds on the approach by Lundvall21 of a national system of innovation as a social system through a combination of evolutionary and institutional theorizing. Innovation is analyzed as the outcome of cumulative causation in learning through routine activities of production, distribution, and consumption. This approach has been widely used in academic contexts, as well as a framework for innovation policy making.22 Within a sociotechnical perspective, this framework shifts the focus from technological to organizational innovation. The analytical distinction between technical and organizational innovation is particularly important for 2 major reasons. First, the organizational structure of hospitals has a major impact on how innovation happens. Second, such distinction makes it possible to link organizational and technological innovation to organizational performance. Indeed, a series of empirical studies have demonstrated that organizational changes are the key to transform innovation into economic results.23,24 This conceptual model includes the variables of learning organization, innovation, and performance.
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takes place. The basic idea is that the appropriate institutional structures may improve knowledge production in terms of competence building based on daily activities. The move toward learning organizations is reflected in changes both in the firm’s internal organization and in interfirm relationships. The choice of this definition is based upon the DISKO researchers’ concept of society as a learning economy.2 Therefore, this study use the DISKO survey with questions aimed at pointing out some organizational attributes, which are implicitly considered as an organization’s ability to learn and evolve when faced with new challenges.23 The survey measured the incidence of an array of organizational dimensions, which all directly or indirectly refer to contemporary theories dealing with innovation and flexibility in organizations: Cross-occupational work groups, integration of functions, softening demarcations, delegation of responsibility, and self-directed teams are empirical indicators, referring to Kanter’s9 theory of integrative organization6 and Burns and Stalker’s25 organic organizations. “Quality circles” and “proposal collection systems” are indicators of total quality management and knowledge management.26 “Tailored educational system” and “educational planning” indicate human resources development, and cooperation with external actors refer to innovation as an interactive process.23 The surveyed hospitals were classified into 3 groups according to the learning organization index: r Basic learning organizations—Hospitals that introduced 0 to 4 of the dimensions. r Moderate learning organizations—Hospitals with 5 to 8 different new dimensions. r Advanced learning organizations—Hospitals with more than 9 new dimensions. Innovation
The study defines innovation as the implementation of a new or significantly improved product/service or process.27 The study takes a broader understanding of innovative performance and encompasses indicators related to the different stages of these developments from idea creation to the introduction of new products and services. Previous research has formally described, operationalized, and empirically analyzed the different modes of innovation performance in the health sector.28,29 Building on these studies and taking into ´ 30 innovation account the review of Fosfuri and Tribo, performance was measured as the ratio of product, services, and process innovation during a period of 2 years previous to 2007. For robustness purposes, the analysis was also performed with a different measure of innovation performance as a dummy variable that equals 1 if the hospital had introduced a product, service, and process innovation over a 2 years period and zero otherwise.
Learning organizations
Performance
The degree of learning organization denotes the way an organization is structured, and the routines followed will have a major effect on the rate of learning that
Finally, the conceptual model includes the variable of hospital performance. While the ultimate goal of hospital care is to provide better health, other
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intermediate administrative and clinical measures of both process and outcome may be considered.31,32 Therefore, hospital performance was measured by a set of 5 indicators covering 3 dimensions, including “service quality” (rate of hospital readmissions within 15 days), “operational efficiency” (proportion of outpatient surgery in the total number of surgical procedures and average length of hospital stay), and “financial efficiency” (hospital net profit, proportion of extraordinary hours in the total staff costs). The set of indicators was weighted to obtain a relative value of organizational performance, which was defined by the National Coordination of Hospital Commissioning.33 These different dimensions of performance are interdependent and should be simultaneously assessed within a multidimensional approach.
METHODS A mixed-methods design was used to explore the relationship between the learning organization and innovation in the hospital sector. The study systematically integrates multiple forms of quantitative and qualitative data. The research takes the approach of connecting data. This integration involved data analysis from a quantitative survey on organizational flexibility and innovation with the existing database on hospital performance. These data were further used to inform the subsequent qualitative data collection, including the content and structure of the interview. It was also used to determine the most appropriate participants with which to explain the mechanism behind the quantitative results. This way it merges quantitative and qualitative data to develop a more complete understanding of a problem to compare, validate, and triangulate results. Quantitative survey
Primary data were collected through a survey to determine the level of organizational flexibility and the innovation rate of hospitals in 2007. It used a revised version of the DISKO survey, which was developed by the Danish Research Unit for Industrial Dynamics (DRUID). This survey is based on the search for “organizational traits” related to organizational capacity to react and evolve when faced with unstable environments. While the DISKO survey has been widely applied in the manufacturing sector, it has not been previously used in the hospital sector. Therefore, specific adjustments were made to the instrument in order to make it applicable to the health sector. The revised survey excluded questions related to external competition due to the fact that it does not apply to the public sector hospitals in Portugal. Further reliability and validity tests were performed on the instrument before the survey was conducted, given that the initial instrument was explicitly altered to consider specificities of the health sector. Following the revision of the survey by 2 experts on health services research, the comprehensibility of the revised survey was tested on 6 hospital administrators who had not
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been included in the study group and their opinions were used to prepare the final version of the survey. The DISKO survey was translated into Portuguese by the researchers and revised by an expert in the English language whose native language is Portuguese. Finally, it was translated back into English for quality assurance by an independent translator who had not seen the original questionnaire. Each questionnaire consisted of 80 questions grouped into 4 sections, including work organization and management, work content and the demand for qualifications, innovation in terms of new product services and processes, and level of external cooperation. The paper survey was submitted by mail to a national sample of 136 hospital boards, listed from the official list of hospitals from Portuguese public sector. A total number of 95 administrators from hospital boards replied to the survey during a period of 3 months, corresponding to a response rate of 70%, which is higher than the rate of response on the first DISKO survey, which was 48%.23 All survey responses were tracked using a unique login, which was linked to the particular hospital in a master list, accessible only to the research team. The data from hospital performance were further collected through the National Coordination of Hospital Commissioning for each respondent hospital.33 The database referred to earlier has wider purposes than those presented in this study. However, this article only uses and presents the questions and data relative to learning organization and innovation in the Portuguese hospital sector.34 The data were submitted for statistical analysis to determine correlations between the level of learning organization and innovation. The bivariate and partial correlations were controlled for possible confounding variables (correlation Pearson R). The partial correlations enable variables that increase, decrease, or eliminate the relationship between the 2 initial variables to be revealed. An analysis of cases through analysis of clusters and analysis of variance (1way analysis of variance) was further performed. The analysis of clusters detected homogeneous groups of data based on quantitative information on variables. Finally, the binary logistic regression was used to test the predictive capacity of the degree of learning organization on innovation. Interaction effects were also tested between innovation, performance, size, and specialization level. No significant differences were identified. In all cases, the level of significance was set at .05. All statistics were calculated with SPSS (version 15.0; SPSS Inc, Chicago, Illinois). Interview study
The qualitative component of the study was aimed to develop a better understanding of the key processes involved in the development of learning organizations toward innovation development. A purposive sampling of the surveyed hospitals was undertaken to include a range of hospitals with different characteristics of learning organizations based on the quantitative data. The
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selected hospitals included 2 advanced learning organizations, 2 moderate learning organizations, and 1 basic learning organization. Semistructured and face-to-face interviews were undertaken with 10 administrators of hospital boards, with the focus on their views of the relationship between learning and innovation, as well as the major drivers of learning organizations. The interviews lasted approximately 2 hours and were recorded and further transcribed. The content analysis of the interviews was performed by using a grid of categories framed within the different themes and context units of learning organizations. Building on the qualitative analysis of the interview content, a statistical analysis was further performed. A comparative assessment of the content based on the frequency analysis of the main events into subcategories was undertaken. The analysis was carried out taking into account the number of analysis units shown in subcategories and its significance. Nominal group technique
The third phase of the research included a qualitative study using the nominal group technique. This technique was performed to consensualize the major findings of the relationship between learning organizations and innovation based on the statistical analysis of data surveys and content analysis of interviews. The group included 15 experts on health system performance assessment, hospital administration, financing, information system, and human resources development. A modified nominal group technique was applied by introducing evidence for discussion in a stepwise manner before voting. The use of votes by the experts was particularly relevant to overcome an unequal representation of different opinions. Through this technique, the group of experts reached consensus on the major mechanisms for the development of learning organizations in the Portuguese hospital sector. Such integration of the 3 research phases, including both qualitative and quantitative data, contributed to a detailed picture of the relationship between innovation and learning organizations in the hospital sector. The database included other variables that are not referred in this article. All data collected refer to 2007. RESULTS
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common latent factors with multiple dimensions. The factorial analysis uncovered 2 latent factors as aims for innovation development, as presented in Table 1. The first factor covers specific aims such as the ability to strengthen and renew knowledge and know-how, innovation development, and adaptation to the external environment. This factor explains 45% of the variation in responses. The second factor corresponds to effectiveness and internal coordination, explaining 33% of the variation in responses. Clusters of learning organizations
The article further examines whether the aims for innovation by hospitals might vary according to specific characteristics. The Figure shows that the aims for innovation development vary according to the hospital size and the level of specialization. While the big and specialized hospitals give more importance to innovation and knowledge, the small and less specialized hospitals are almost exclusively focused on effectiveness. Building on these initial findings, further empirical distribution of observations along the additive index of learning organizations might reveal major characteristics of the relationship between innovation and learning. Therefore, the study questions whether organizational structure and practices complement each other, as well as enhance innovation performance in a cumulative way. Such complementarities might reflect “bundles” of organizational mechanisms supporting each other. By grouping all the organizations according to the index of learning organization development, 27% of total hospitals were situated in the basic category, 44% in the moderate category, and 28% in the advanced category. Table 2 shows the major factors that are relevant in explaining the differences in innovation and performance across the 3 groups. “Advanced learning organizations” show a high rate of innovation, with a mean of 6.95 (SD = 3.42). In fact, this innovation rate is 4 times higher than the cluster of “basic learning organizations,” with a mean of 1.56 (SD = 2.27). Furthermore, the level of performance of the cluster of advanced learning organizations is the highest, with a mean of 9.27 (SD = 5.99). Similarly, this level of Table 1. Factorial Analysis of the Aims of Innovation in the Hospital Sector
Aims of innovation development
Performance improvement is considered as the major aim of innovation development by 60% of the total number of surveyed hospitals. Improving quality and flexibility, as well as external cooperation, is also quoted as an aim of innovation by more than half of the hospitals. Finally, knowledge creation and transfer are seen as important aims by 30% of the hospitals. However, it should also be noted that 25% of the total number of hospitals state that enhancing the knowledge base of the organization is of minor or no importance. Building on these results, a key issue is whether and to what extent the aims of innovation represent
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Components Aims of Innovation
Knowledge Effectiveness − 0.045
0.941
Cooperation and coordination in the organization
0.158
0.898
Ability to adapt to the external environment
0.665
0.164
Ability to develop new services
0.907
− 0.006
Ability to develop knowledge
0.934
− 0.022
Effectiveness of daily work
Variation explained
45%
33%
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Figure. Distribution of the relevance of the aims of innovation by hospital size and specialization level.
performance is 2 times higher than the performance of the cluster of “basic learning organization,” with a mean of 4.80 (SD = 1.92). Examining the relationships between learning organizations and innovation, the organizational flexibility and external cooperation emerge as the 2 major factors. The results point out significant differences in flexibility across the different levels of learning organizations, ranging from a mean of 6.63 (SD = 0.85) to 9.57 (SD = 1.20). Regarding external cooperation, the group of advanced learning organizations has more than double the level of external cooperation, with a mean of 0.73 (SD = 0.22), than the basic learning organizations, with a mean of 0.33 (SD = 0.16). The impact of learning organizations on innovation performance
The categories representing different levels of learning organizations were tested in a logistic model with innovation as a dependent variable and controlling for organization size and level of specialization. As Table 3 reveals, the hospitals in the cluster of advanced learn-
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ing organizations have 5 times more chance of developing innovation than basic learning organizations. Similarly, the innovation development in the cluster of “moderate learning organizations” is 2 times higher than the basic one. The content analysis of the interviews further revealed significant differences in terms of the dynamic of learning processes across the different departments of hospitals. The cluster of basic learning organizations shows a focus on performance, neglecting knowledge creation and dissemination within the hospital. The learning processes are mainly restricted to standard training courses on specific clinical procedures. The cluster of moderate learning organizations recognizes the dissemination of knowledge as a major driver of innovation and performance improvement. Therefore, several mechanisms are in place to promote teamwork and learning across departments. Finally, the advanced learning organizations consider both knowledge creation and dissemination as major goals of the hospital. Besides enhancing learning across different department, they put particular focus on external collaboration with universities. Furthermore, such external collaboration networks go beyond the health sector to include other sectors, particularly biomedical and information technology industries. On the basis of data from the survey and interviews, the expert panel identified the major mechanisms to enhance learning organizations in the hospital sector. Three key mechanisms were particularly highlighted: human resources development aligned with the organizational strategy (26% of responses); solving daily problems in work teams (32% of responses); and cooperation with other organizations (42% of responses). Furthermore, the expert panel pointed out that current efforts to enhance innovation reflect a shift from formal and isolated mechanisms of professional development, as, for example, standard courses, to informal mechanisms based on team work and external cooperation well integrated into daily work. DISCUSSION On the basis of theoretical considerations, empirical results show that innovation and knowledge creation are 2 sides of the same coin. On the one side, it is true that learning organizations are more apt to
Table 2. Main Characteristics of the Categories of “Learning Organizations” Basic Learning Organization
Moderate Learning Organization
Advanced Learning Organization
Mean
SD
Mean
SD
Mean
SD
Flexibility
6.63
0.85
7.97
1.43
9.57
1.20
External cooperation
0.33
0.16
0.52
0.19
0.73
0.22
Innovation
1.56
2.27
3.91
3.71
6.95
3.42
Performance
4.80
1.92
7.60
4.15
9.27
5.99
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Table 3. Logistic Regression of the Different Categories “Learning Organizations” on Innovation (Extraction of Factors by Backward Logistic Regression, Odd Ratios, 95% Confidence Interval, Estimates, and P Values) Effect
Lower
Upper
Estimate
c2
P
Advanced learning organization
5.12
3.620
6.819
0.820
120.03
.002
Moderate learning organization
2.11
1.616
2.650
0.323
35.09
.024
mobilize and apply different sources of knowledge for innovation development. On the other side, it is also true that innovation itself increases the need for an organizational framework able to cope with new problems as they appear during the innovation process. The aim of a learning health care organization is to deliver the best care every time and to learn and improve continuously. Organizational changes could contribute to a learning health care organization that supports continuous learning and knowledge creation as a natural by-product of health care delivery. A fully functional system of this sort would deliver increasing value to the health service user through innovation. According to the response pattern of major aims for innovation, most hospitals are obviously aiming at efficiency and organizational flexibility. The distribution of organizational capacities to innovate and develop new knowledge reveals significant differences between hospitals. Knowledge as a reason for organization innovation is seen by a third of hospitals as high, whereas the others see it as of low (one-third) or moderate (one-third) importance. The distribution of opinions by the hospital’s administration boards reveals 3 different ways of looking at knowledge within the organization. In fact, the relevance attributing different ways of thinking might influence the organization of hospitals toward a learning organization. Therefore, the article further makes a more detailed analysis of the 3 different groups of hospitals based on the degree of learning organization to bring relevant insights into learning dynamics and its contributions for innovation. Clusters of learning organizations
The cluster analysis by organizational changes points out the distinguishing characteristics of learning organizations and their relationship with innovation and performance. It has to be underlined that the number of organizations in each group is dependent upon the chosen criteria. Therefore, the different terms of basic, moderate, and advanced learning organizations have to be understood within the limits defined by its operationalization. The basic learning organizations are marked by managerial hierarchies, with a clear division of functions and tasks. Within this context, health care professionals are performing well-defined functions, which are controlled by several layers of managers. Such control mechanisms rely on highly standardized procedures. This points to a more structured or bureaucratic style of organization, with the lowest level of innovation and performance, with a mean of 1.56 (SD = 2.27) and 4.8 (SD = 1.92), respectively.
The moderate learning organizations have statistically significant higher levels of organizational flexibility. However, learning can be constrained and isolated into one department whereas the rest of the organization remains bureaucratic. The impact of learning mechanisms already in place might explain a significant higher level of innovation and performance than the former cluster, with a mean of 3.91 (SD = 3.71) and 7.6 (SD = 4.15), respectively. The cluster of advanced learning organizations is characterized by high levels of learning and problem solving in work teams. Such a learning environment is widely spread across the different departments. This group, combining several characteristics of learning organizations, tends to show a higher capacity for innovation and performance than the rest, with a mean of 6.95 (SD = 3.42) and 9.27 (SD = 5.99), respectively. The advanced learning organizations might be particularly instructive to other hospitals by revealing the main mechanisms for integrating research and practice, as well as for translating external research findings into practice. Flexibility and external cooperation
The major variables distinguishing the 3 clusters are those indicators capturing conditions for enhancing learning including self-assessment of work quality, quality standards, cross-department collaboration, external cooperation, team work, and work task allocation and rotation. The cluster of advanced learning organizations shows a wider use of organizational changes toward enhancing learning across the hospital than moderate learning organizations. The cluster of basic learning organizations shows a residual use of these organizational changes, reflecting a less conducive environment toward learning. The 3 clusters of hospitals reveal significant differences in terms of organizational structure and processes, management style, and skills development. As the horizontal and vertical divisions of labor evolve, they contribute to the necessary diversity feeding innovation. However, they also create new barriers for communication and interaction within the hospital and with other organizations. This is highly relevant because innovation is the outcome of combining knowledge located at different sites. Organizational flexibility and external cooperation are the 2 major discriminating factors explaining differences in terms of innovation and performance across the 3 clusters of hospitals. The results from this research bring implications for management in the health sector. Management
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needs to enhance a supportive environment for learning, creating room for human resources development, as well as work team and cross-department collaboration. While management cannot force renewal, it can support an environment for radical renewal through wide internal networks across departments and divisions. This is a requisite for continuous learning. It is well documented that different departments within a hospital have difficulties in understanding and communicating with each other. Increasing this internal capability is also a prerequisite for effectively assimilating and applying knowledge from outside. Furthermore, the recent models of innovation particularly emphasize learning as an interactive process in which hospitals interact with other organizations, including suppliers and universities. This is also the background for developing a systemic approach to knowledge creation. A wide external cooperation has the potential to create opportunities to access new knowledge for further development of innovations. Results suggest that the integration of service delivery systems might expand capacity for real-time learning in daily practice. The impact of learning organizations on innovation development
Summing up, the model examined in this article has shown significant effects of the development of the so-called learning organization on innovation. This strongly supports the validity of theoretical considerations regarding the construct of learning organization. It illustrates that hospitals combining quality control, human resources development, and external cooperation are much more prone to innovation. The proposed measures set the way to systematically capture and translate information generated by clinical research and health care delivery by promoting close open-ended learning loops. As noted in the “Results” section, the supply of knowledge currently available to hospitals has several deficiencies. Hospitals often lack reliable evidence on the effectiveness of different treatment options, interventions, and technologies and on how the effectiveness of treatments varies for different patients. Moreover, the quality of care depends not only on the effectiveness of a given treatment but also on the way that treatment is delivered. Thus, it is necessary to build knowledge about different methods of delivering care and provide hospitals with tools to improve care processes. Learning processes must also be tailored to the circumstances and needs of hospitals and other stakeholders in the health system. Each stakeholder has a different role in the generation and dissemination of knowledge, so each will need different tools to support continuous learning and improvement. Furthermore, the learning potential of hospitals and their cooperation partners might be significantly enhanced by the new opportunities provided by information and communication technologies to share information and measure progress.
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CONCLUSIONS The primary result is the distinction of different types of learning organizations in the Portuguese hospital sector, which has not before been covered in this manner. Furthermore, the article reveals the mutually reinforcing interrelationship between innovation and learning processes. The study concludes that hospitals pursuing strategies of innovation realize the relevance of enhancing a learning organization. Such an approach suggests the key role of hospitals for the creation, transfer, and application of knowledge for innovation development. Indeed, a mismatch between the hospital’s knowledge and innovation domains might favor external collaboration to get the right match of knowledge. Therefore, the analytical framework of learning organizations goes beyond the hospital to include the external cooperation network, as well as the way they exchange knowledge between each other. In conclusion, the article proposes a wider perspective to innovation development in hospitals in order to focus on the knowledge infrastructure. Such infrastructure would include both individual and organizational learning toward enhancing innovation. Because of the complexity of the Portuguese National Health Service, it cannot, as a whole system, become a learning organization. However, it is possible that hospitals may achieve this status to varying degrees. In fact, as more hospitals become exposed to the need to engage on innovation development, there is an increasing potential for learning dimensions to be reflected in organizational strategies and public policies. Such a trend would bring higher priority to policies aiming at human resources development, developing new forms of organizations, and creating external cooperation networks. The major implication arising from this study is that policy needs to combine instruments that promote innovation opportunities and incentives, with instruments stimulating the further development and diffusion of the core components of learning organizations. Such a combination of policy instruments has the potential to ensure a wide external cooperation and bring together different organizations through a learning infrastructure. The article also reflects a shift from a static to a more dynamic model of learning organizations in terms of innovation policies. It recognizes the nonlinear and interactive nature of learning through the development of innovations adapted to local health needs and assets. In this context, hospital services would go from “silo” to “systems” thinking, enhancing the delivery of health services based on updated evidence and wide communication among the main stakeholders. Drawing from current results, the study proposes several policy solutions: First, support a culture renewal that encourages problem solving in new ways across the whole organization; second, emphasize the links between elements of the hospital care and administrative processes. Both measures are crucial for effective health care models and new
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communication systems to provide the accurate, timely transfer of information throughout the health care continuum. Third, continuous learning and health care improvement require transparency in processes and outcomes, as well as the capacity to capture feedback and make adjustments. Finally, there is also the need to align rewards on the key elements of continuous learning and improvement of health care performance across the different stakeholders. In fact, incentives, standards, and measurement requirements can serve as powerful change agents and are key elements of the policy framework for innovation development in the hospital sector. REFERENCES 1. Morgan D, Astolfi R. Health Spending Growth at Zero: Which Countries, Which Sectors Are Most Affected?. Paris, France: OECD Publishing; 2013. ¨ Johnson B. The learning economy. J Ind Stud. 2. Lundvall B-A, 1994;1(2):23-42. 3. Nembhard IM, Tucker AL. Deliberate learning to improve performance in dynamic service settings: evidence from hospital intensive care units. Org Sci. 2011;22:907-922. 4. OECD. Working Out Change: Systemic Innovation in Vocational Education and Training. Paris, France: OECD Publishing; 2011. 5. Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Q. 2001;79(2):281-315. 6. Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care. 2004;13(2): 3-9. 7. Rogers E. Diffusion of Innovations. New York, NY: Free Press; 1995. 8. Argorte L. Organizational learning: past, present and future. Manage Learn. 2011;42(4):439-446. 9. Kanter RM. The Change Masters. New York, NY: Simon & Schuster; 1983. 10. Mulgan G, Albury D. Innovation in the public sector. Strategy Unit, Cabinet Office, 2003. 11. Senge P. The Fifth Discipline. New York, NY: Doubleday; 1990. 12. Fleuren M, Wiefferink K, Paulussen T. Determinants of innovation within health care organizations. Int J Qual Health Care. 2004;16:107-123. 13. Dean B. Learning from prescribing errors. Qual Saf Health Care. 2002;11 (3):258-260. 14. Plsek P, Greenhalgh T. Complexity science: the challenge of complexity in health care. BMJ. 2001;323:625-628 15. Anderson RA, McDaniel RR Jr. Managing health care organizations: where professionalism meets complexity science. Health Care Manage Rev. 2000;25(1):83-92.
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16. Best A, Greenhalgh T, Lewis S, Saul JE, Carroll S, Bitz J. Largesystem transformation in health care: a realist review. Milbank Q. 2012;90(3):421-456. 17. Institute of Medicine. Learning Health Care System. Washington, DC: Institute of Medicine; 2011. 18. Greene SM, Reid RJ, Larson EB. Implementing the learning health system: from concept to action. Ann Intern Med. 2012;157(3): 207-210. 19. Davies HT, Nutley SM, Mannion R. Organisational culture and quality of health care. Qual Health Care. 2000;9(2):111-119. 20. Crites GE, McNamara MC, Akl EA, Richardson WS, Umscheid CA, Nishikawa J. Evidence in the learning organization. Health Res Policy Syst. 2009;7:4. ˚ National Systems of Innovation. Towards a Theory 21. Lundvall B-A. of Innovation and Interactive Learning. London, England: Pinter Publishers; 1992 22. Greenhalgh T, Robert G, McFarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82:581-629. 23. Gjerding AN. Technical Innovation and Organisational Change. The Innovation Design Dilemma Revisited. Aalborg, Denmark: Aalborg University Press; 1996. 24. Leonard-Barton D. Implementation as mutual adaptation of technology and organization. Res Policy. 1988;17:251-267. 25. Burns T, Stalker GM. The Management of Innovation. Oxford, England: Oxford University press; 1994. 26. Nonaka I, Takeuchi H. The Knowledge Creating Company. Oxford, England: Oxford University Press; 1995. 27. OECD; EUROSTAT. The Measurement of Scientific and Technological Activities: Oslo Manual Guidelines for Collecting and Interpreting Innovation Data. Paris, France: OECD Publishing; 2005. 28. Kimberly JR, Evanisko M. Organisational innovation: the influence of individual organisational and contextual factors on hospital adoption of technological and administrative innovations. Acad Manage J. 1981;24(4): 689-713. 29. Salge TO, Vera A. Hospital innovativeness and organizational performance: evidence from English public acute care. Health Care Manage Rev. 2009;34(1):54-67. 30. Fosfuri A, Tribo´ JA Exploring the antecedents of potential absorptive capacity and its impact on innovative performance. Omega. 2008;36:173-187. 31. Freeman T. Using performance indicators to improve health care quality in the public sector: a review of the literature. Health Serv Manage Res. 2002;15:126-137. 32. Veillard J, Champagne F, Klazinga N, Kazandjian V, Arah OA, Guisset AL. A performance assessment framework for hospitals: the WHO regional office for Europe PATH project. Int J Qual Health Care. 2005;17(6):487-496. 33. National Coordination of Hospital Commissioning. Indicators of Hospital Performance. Lisbon, Portugal: Ministry of Health; 2008. 34. Dias C, Escoval A. The open nature of innovation in the hospital sector: the role of external collaboration networks. Health Policy Technol. 2012;1(4):181-186.
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Hospitals as Learning Organizations: Fostering Innovation Through Interactive Learning Casimiro Dias, MPH; Ana Escoval, PhD The article aims to provide an analytical understanding of hospitals as “learning organizations.” It further analyzes the development of learning organizations as a way to enhance innovation and performance in the hospital sector. The article pulls together primary data on organizational flexibility, innovation, and performance from 95 administrators from hospital boards in Portugal, collected through a survey, interviews with hospital’s boards, and a nominal group technique with a panel of experts on health systems. Results show that a combination of several organizational traits of the learning organization enhances its capacity for innovation development. The logistic model presented reveals that hospitals classified as “advanced learning organizations” have 5 times more chance of developing innovation than “basic learning organizations.” Empirical findings further pointed out incentives, standards, and measurement requirements as key elements for integration of service delivery systems and expansion of the current capacity for structured and real-time learning in the hospital sector. The major implication arising from this study is that policy needs to combine instruments that promote innovation opportunities and incentives, with instruments stimulating the further development of the core components of learning organizations. Such a combination of policy instruments has the potential to ensure a wide external cooperation through a learning infrastructure. Key words: health services, hospital, innovation, learning organization, performance
H
ospitals in Portugal, as well as across Europe, are currently facing several challenges, including the aging population, the increasing burden of chronic diseases related to risk factors, and the expansion of health care options by new technologies. Moreover, the current economic crisis has resulted in both negative implications on the availability of resources and a positive impact on the demand for health services. These circumstances are increasingly adding pressure to performance improvement of the hospital sector.1 It is widely assumed that these current changes in the economic environment might be described by the concept of “the learning economy.”2 It argues that besides the increasing use of knowledge in the economy, the knowledge itself becomes obsolete at a faster pace. While mechanisms for knowledge creation and diffusion have significantly advanced, the access and application of such knowledge have not kept up the same pace. The result is an important gap between existing evidence and daily practice in the hospital sector. This calls for an increased focus on learning capacities of hospitals to make the best use of knowledge in terms of innovation development.3 In this article, learning refers to the acquisition of new skills and compeAuthor Affiliations: World Health Organization, Regional Office for Europe, Copenhagen, Denmark (Dr Dias); and School of Public Health, University Nova Lisboa, Lisbon, Portugal (Dr Escoval). Correspondence: Casimiro Dias, MPH, Division of Health Systems and Public Health, World Health Organization, Regional Office for Europe, 8, Scherfigsvej, DK-2100 Copenhagen Ø, Denmark ([email protected]). The authors declare no conflicts of interest. Q Manage Health Care Vol. 24, No. 1, pp. 52–59 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
DOI: 10.1097/QMH.0000000000000046
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tencies in order to achieve individual or organizational goals.4,5 As hospitals are facing an increasing turbulent environment, it becomes imperative to support learning conditions within hospitals in order to tackle current and emergent challenges.6 The recognition that knowledge and learning are key drivers of innovation and performance has been a major breakthrough in management thinking. It has opened new perspectives on management toward learning processes across different sectors of the economy. These research traditions, building on the work of sociology and economy, have been summarized by Rogers,7 which have focused on linkages between the innovation developers and adopters. However, the knowledge-based approaches have radically redefined both innovation development and dissemination in terms of knowledge creation and dissemination. The absorptive capacity for new knowledge has been introduced as a nonstructural factor of innovation including “learning organization” values and goals, the organization’s existing knowledge base, and promotion of knowledge dissemination within and outside the organization.8 Such focus on learning as part of enhancing organizational flexibility may be traced back to the theoretical developments by Kanter9 and Rogers.7 The main argument of these authors is the need of organizations to enhance the capacity to transform themselves in a continuous way. Such stream of literature has led to the concept of the learning organization, combining different disciplines such as total quality management and organizational learning.10 The management literature has pointed out the relevance of establishing learning organizations.11 Here, the organizational structure will have a major effect on www.qmhcjournal.com
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the rate of learning that takes place. Other factors include human resources development, new organizational forms, and external collaboration networks.12 Managers in the hospital sector recognized the importance of improving learning in their organizations to achieve quality improvement.13 Therefore, it is necessary not only to clarify the concept of learning organizations but also to clarify to which extent hospitals can be classified as learning organizations. Hospitals have been described as complex adaptive systems.14,15 Taking into account the principles and resources supporting a learning environment, it is possible for hospitals to take full advantage of local knowledge in generating continuous improvements.16 Indeed, recent empirical developments by the Institute of Medicine have redefined the health sector as a learning health care system, which collects data from daily activities and facilitates the use of scientific evidence to improve care in a continuous way.17 The learning health care systems will require the capacity to manage information-intensive work flows, with significant potential to fill major knowledge gaps on health care costs and the benefits and risks of specific drugs and clinical procedures.18-20 The purpose of this study was to explore the concept of learning organization in the hospital sector in Portugal. The article has 3 main objectives: explore the relevance of knowledge and learning; assess the impact of learning organizations in innovation capacity; and identify the major mechanisms that enhance learning organizations in the hospital sector. CONCEPTUAL FRAMEWORK The study builds on the approach by Lundvall21 of a national system of innovation as a social system through a combination of evolutionary and institutional theorizing. Innovation is analyzed as the outcome of cumulative causation in learning through routine activities of production, distribution, and consumption. This approach has been widely used in academic contexts, as well as a framework for innovation policy making.22 Within a sociotechnical perspective, this framework shifts the focus from technological to organizational innovation. The analytical distinction between technical and organizational innovation is particularly important for 2 major reasons. First, the organizational structure of hospitals has a major impact on how innovation happens. Second, such distinction makes it possible to link organizational and technological innovation to organizational performance. Indeed, a series of empirical studies have demonstrated that organizational changes are the key to transform innovation into economic results.23,24 This conceptual model includes the variables of learning organization, innovation, and performance.
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takes place. The basic idea is that the appropriate institutional structures may improve knowledge production in terms of competence building based on daily activities. The move toward learning organizations is reflected in changes both in the firm’s internal organization and in interfirm relationships. The choice of this definition is based upon the DISKO researchers’ concept of society as a learning economy.2 Therefore, this study use the DISKO survey with questions aimed at pointing out some organizational attributes, which are implicitly considered as an organization’s ability to learn and evolve when faced with new challenges.23 The survey measured the incidence of an array of organizational dimensions, which all directly or indirectly refer to contemporary theories dealing with innovation and flexibility in organizations: Cross-occupational work groups, integration of functions, softening demarcations, delegation of responsibility, and self-directed teams are empirical indicators, referring to Kanter’s9 theory of integrative organization6 and Burns and Stalker’s25 organic organizations. “Quality circles” and “proposal collection systems” are indicators of total quality management and knowledge management.26 “Tailored educational system” and “educational planning” indicate human resources development, and cooperation with external actors refer to innovation as an interactive process.23 The surveyed hospitals were classified into 3 groups according to the learning organization index: r Basic learning organizations—Hospitals that introduced 0 to 4 of the dimensions. r Moderate learning organizations—Hospitals with 5 to 8 different new dimensions. r Advanced learning organizations—Hospitals with more than 9 new dimensions. Innovation
The study defines innovation as the implementation of a new or significantly improved product/service or process.27 The study takes a broader understanding of innovative performance and encompasses indicators related to the different stages of these developments from idea creation to the introduction of new products and services. Previous research has formally described, operationalized, and empirically analyzed the different modes of innovation performance in the health sector.28,29 Building on these studies and taking into ´ 30 innovation account the review of Fosfuri and Tribo, performance was measured as the ratio of product, services, and process innovation during a period of 2 years previous to 2007. For robustness purposes, the analysis was also performed with a different measure of innovation performance as a dummy variable that equals 1 if the hospital had introduced a product, service, and process innovation over a 2 years period and zero otherwise.
Learning organizations
Performance
The degree of learning organization denotes the way an organization is structured, and the routines followed will have a major effect on the rate of learning that
Finally, the conceptual model includes the variable of hospital performance. While the ultimate goal of hospital care is to provide better health, other
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intermediate administrative and clinical measures of both process and outcome may be considered.31,32 Therefore, hospital performance was measured by a set of 5 indicators covering 3 dimensions, including “service quality” (rate of hospital readmissions within 15 days), “operational efficiency” (proportion of outpatient surgery in the total number of surgical procedures and average length of hospital stay), and “financial efficiency” (hospital net profit, proportion of extraordinary hours in the total staff costs). The set of indicators was weighted to obtain a relative value of organizational performance, which was defined by the National Coordination of Hospital Commissioning.33 These different dimensions of performance are interdependent and should be simultaneously assessed within a multidimensional approach.
METHODS A mixed-methods design was used to explore the relationship between the learning organization and innovation in the hospital sector. The study systematically integrates multiple forms of quantitative and qualitative data. The research takes the approach of connecting data. This integration involved data analysis from a quantitative survey on organizational flexibility and innovation with the existing database on hospital performance. These data were further used to inform the subsequent qualitative data collection, including the content and structure of the interview. It was also used to determine the most appropriate participants with which to explain the mechanism behind the quantitative results. This way it merges quantitative and qualitative data to develop a more complete understanding of a problem to compare, validate, and triangulate results. Quantitative survey
Primary data were collected through a survey to determine the level of organizational flexibility and the innovation rate of hospitals in 2007. It used a revised version of the DISKO survey, which was developed by the Danish Research Unit for Industrial Dynamics (DRUID). This survey is based on the search for “organizational traits” related to organizational capacity to react and evolve when faced with unstable environments. While the DISKO survey has been widely applied in the manufacturing sector, it has not been previously used in the hospital sector. Therefore, specific adjustments were made to the instrument in order to make it applicable to the health sector. The revised survey excluded questions related to external competition due to the fact that it does not apply to the public sector hospitals in Portugal. Further reliability and validity tests were performed on the instrument before the survey was conducted, given that the initial instrument was explicitly altered to consider specificities of the health sector. Following the revision of the survey by 2 experts on health services research, the comprehensibility of the revised survey was tested on 6 hospital administrators who had not
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been included in the study group and their opinions were used to prepare the final version of the survey. The DISKO survey was translated into Portuguese by the researchers and revised by an expert in the English language whose native language is Portuguese. Finally, it was translated back into English for quality assurance by an independent translator who had not seen the original questionnaire. Each questionnaire consisted of 80 questions grouped into 4 sections, including work organization and management, work content and the demand for qualifications, innovation in terms of new product services and processes, and level of external cooperation. The paper survey was submitted by mail to a national sample of 136 hospital boards, listed from the official list of hospitals from Portuguese public sector. A total number of 95 administrators from hospital boards replied to the survey during a period of 3 months, corresponding to a response rate of 70%, which is higher than the rate of response on the first DISKO survey, which was 48%.23 All survey responses were tracked using a unique login, which was linked to the particular hospital in a master list, accessible only to the research team. The data from hospital performance were further collected through the National Coordination of Hospital Commissioning for each respondent hospital.33 The database referred to earlier has wider purposes than those presented in this study. However, this article only uses and presents the questions and data relative to learning organization and innovation in the Portuguese hospital sector.34 The data were submitted for statistical analysis to determine correlations between the level of learning organization and innovation. The bivariate and partial correlations were controlled for possible confounding variables (correlation Pearson R). The partial correlations enable variables that increase, decrease, or eliminate the relationship between the 2 initial variables to be revealed. An analysis of cases through analysis of clusters and analysis of variance (1way analysis of variance) was further performed. The analysis of clusters detected homogeneous groups of data based on quantitative information on variables. Finally, the binary logistic regression was used to test the predictive capacity of the degree of learning organization on innovation. Interaction effects were also tested between innovation, performance, size, and specialization level. No significant differences were identified. In all cases, the level of significance was set at .05. All statistics were calculated with SPSS (version 15.0; SPSS Inc, Chicago, Illinois). Interview study
The qualitative component of the study was aimed to develop a better understanding of the key processes involved in the development of learning organizations toward innovation development. A purposive sampling of the surveyed hospitals was undertaken to include a range of hospitals with different characteristics of learning organizations based on the quantitative data. The
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selected hospitals included 2 advanced learning organizations, 2 moderate learning organizations, and 1 basic learning organization. Semistructured and face-to-face interviews were undertaken with 10 administrators of hospital boards, with the focus on their views of the relationship between learning and innovation, as well as the major drivers of learning organizations. The interviews lasted approximately 2 hours and were recorded and further transcribed. The content analysis of the interviews was performed by using a grid of categories framed within the different themes and context units of learning organizations. Building on the qualitative analysis of the interview content, a statistical analysis was further performed. A comparative assessment of the content based on the frequency analysis of the main events into subcategories was undertaken. The analysis was carried out taking into account the number of analysis units shown in subcategories and its significance. Nominal group technique
The third phase of the research included a qualitative study using the nominal group technique. This technique was performed to consensualize the major findings of the relationship between learning organizations and innovation based on the statistical analysis of data surveys and content analysis of interviews. The group included 15 experts on health system performance assessment, hospital administration, financing, information system, and human resources development. A modified nominal group technique was applied by introducing evidence for discussion in a stepwise manner before voting. The use of votes by the experts was particularly relevant to overcome an unequal representation of different opinions. Through this technique, the group of experts reached consensus on the major mechanisms for the development of learning organizations in the Portuguese hospital sector. Such integration of the 3 research phases, including both qualitative and quantitative data, contributed to a detailed picture of the relationship between innovation and learning organizations in the hospital sector. The database included other variables that are not referred in this article. All data collected refer to 2007. RESULTS
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common latent factors with multiple dimensions. The factorial analysis uncovered 2 latent factors as aims for innovation development, as presented in Table 1. The first factor covers specific aims such as the ability to strengthen and renew knowledge and know-how, innovation development, and adaptation to the external environment. This factor explains 45% of the variation in responses. The second factor corresponds to effectiveness and internal coordination, explaining 33% of the variation in responses. Clusters of learning organizations
The article further examines whether the aims for innovation by hospitals might vary according to specific characteristics. The Figure shows that the aims for innovation development vary according to the hospital size and the level of specialization. While the big and specialized hospitals give more importance to innovation and knowledge, the small and less specialized hospitals are almost exclusively focused on effectiveness. Building on these initial findings, further empirical distribution of observations along the additive index of learning organizations might reveal major characteristics of the relationship between innovation and learning. Therefore, the study questions whether organizational structure and practices complement each other, as well as enhance innovation performance in a cumulative way. Such complementarities might reflect “bundles” of organizational mechanisms supporting each other. By grouping all the organizations according to the index of learning organization development, 27% of total hospitals were situated in the basic category, 44% in the moderate category, and 28% in the advanced category. Table 2 shows the major factors that are relevant in explaining the differences in innovation and performance across the 3 groups. “Advanced learning organizations” show a high rate of innovation, with a mean of 6.95 (SD = 3.42). In fact, this innovation rate is 4 times higher than the cluster of “basic learning organizations,” with a mean of 1.56 (SD = 2.27). Furthermore, the level of performance of the cluster of advanced learning organizations is the highest, with a mean of 9.27 (SD = 5.99). Similarly, this level of Table 1. Factorial Analysis of the Aims of Innovation in the Hospital Sector
Aims of innovation development
Performance improvement is considered as the major aim of innovation development by 60% of the total number of surveyed hospitals. Improving quality and flexibility, as well as external cooperation, is also quoted as an aim of innovation by more than half of the hospitals. Finally, knowledge creation and transfer are seen as important aims by 30% of the hospitals. However, it should also be noted that 25% of the total number of hospitals state that enhancing the knowledge base of the organization is of minor or no importance. Building on these results, a key issue is whether and to what extent the aims of innovation represent
55
Components Aims of Innovation
Knowledge Effectiveness − 0.045
0.941
Cooperation and coordination in the organization
0.158
0.898
Ability to adapt to the external environment
0.665
0.164
Ability to develop new services
0.907
− 0.006
Ability to develop knowledge
0.934
− 0.022
Effectiveness of daily work
Variation explained
45%
33%
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Figure. Distribution of the relevance of the aims of innovation by hospital size and specialization level.
performance is 2 times higher than the performance of the cluster of “basic learning organization,” with a mean of 4.80 (SD = 1.92). Examining the relationships between learning organizations and innovation, the organizational flexibility and external cooperation emerge as the 2 major factors. The results point out significant differences in flexibility across the different levels of learning organizations, ranging from a mean of 6.63 (SD = 0.85) to 9.57 (SD = 1.20). Regarding external cooperation, the group of advanced learning organizations has more than double the level of external cooperation, with a mean of 0.73 (SD = 0.22), than the basic learning organizations, with a mean of 0.33 (SD = 0.16). The impact of learning organizations on innovation performance
The categories representing different levels of learning organizations were tested in a logistic model with innovation as a dependent variable and controlling for organization size and level of specialization. As Table 3 reveals, the hospitals in the cluster of advanced learn-
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ing organizations have 5 times more chance of developing innovation than basic learning organizations. Similarly, the innovation development in the cluster of “moderate learning organizations” is 2 times higher than the basic one. The content analysis of the interviews further revealed significant differences in terms of the dynamic of learning processes across the different departments of hospitals. The cluster of basic learning organizations shows a focus on performance, neglecting knowledge creation and dissemination within the hospital. The learning processes are mainly restricted to standard training courses on specific clinical procedures. The cluster of moderate learning organizations recognizes the dissemination of knowledge as a major driver of innovation and performance improvement. Therefore, several mechanisms are in place to promote teamwork and learning across departments. Finally, the advanced learning organizations consider both knowledge creation and dissemination as major goals of the hospital. Besides enhancing learning across different department, they put particular focus on external collaboration with universities. Furthermore, such external collaboration networks go beyond the health sector to include other sectors, particularly biomedical and information technology industries. On the basis of data from the survey and interviews, the expert panel identified the major mechanisms to enhance learning organizations in the hospital sector. Three key mechanisms were particularly highlighted: human resources development aligned with the organizational strategy (26% of responses); solving daily problems in work teams (32% of responses); and cooperation with other organizations (42% of responses). Furthermore, the expert panel pointed out that current efforts to enhance innovation reflect a shift from formal and isolated mechanisms of professional development, as, for example, standard courses, to informal mechanisms based on team work and external cooperation well integrated into daily work. DISCUSSION On the basis of theoretical considerations, empirical results show that innovation and knowledge creation are 2 sides of the same coin. On the one side, it is true that learning organizations are more apt to
Table 2. Main Characteristics of the Categories of “Learning Organizations” Basic Learning Organization
Moderate Learning Organization
Advanced Learning Organization
Mean
SD
Mean
SD
Mean
SD
Flexibility
6.63
0.85
7.97
1.43
9.57
1.20
External cooperation
0.33
0.16
0.52
0.19
0.73
0.22
Innovation
1.56
2.27
3.91
3.71
6.95
3.42
Performance
4.80
1.92
7.60
4.15
9.27
5.99
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Table 3. Logistic Regression of the Different Categories “Learning Organizations” on Innovation (Extraction of Factors by Backward Logistic Regression, Odd Ratios, 95% Confidence Interval, Estimates, and P Values) Effect
Lower
Upper
Estimate
c2
P
Advanced learning organization
5.12
3.620
6.819
0.820
120.03
.002
Moderate learning organization
2.11
1.616
2.650
0.323
35.09
.024
mobilize and apply different sources of knowledge for innovation development. On the other side, it is also true that innovation itself increases the need for an organizational framework able to cope with new problems as they appear during the innovation process. The aim of a learning health care organization is to deliver the best care every time and to learn and improve continuously. Organizational changes could contribute to a learning health care organization that supports continuous learning and knowledge creation as a natural by-product of health care delivery. A fully functional system of this sort would deliver increasing value to the health service user through innovation. According to the response pattern of major aims for innovation, most hospitals are obviously aiming at efficiency and organizational flexibility. The distribution of organizational capacities to innovate and develop new knowledge reveals significant differences between hospitals. Knowledge as a reason for organization innovation is seen by a third of hospitals as high, whereas the others see it as of low (one-third) or moderate (one-third) importance. The distribution of opinions by the hospital’s administration boards reveals 3 different ways of looking at knowledge within the organization. In fact, the relevance attributing different ways of thinking might influence the organization of hospitals toward a learning organization. Therefore, the article further makes a more detailed analysis of the 3 different groups of hospitals based on the degree of learning organization to bring relevant insights into learning dynamics and its contributions for innovation. Clusters of learning organizations
The cluster analysis by organizational changes points out the distinguishing characteristics of learning organizations and their relationship with innovation and performance. It has to be underlined that the number of organizations in each group is dependent upon the chosen criteria. Therefore, the different terms of basic, moderate, and advanced learning organizations have to be understood within the limits defined by its operationalization. The basic learning organizations are marked by managerial hierarchies, with a clear division of functions and tasks. Within this context, health care professionals are performing well-defined functions, which are controlled by several layers of managers. Such control mechanisms rely on highly standardized procedures. This points to a more structured or bureaucratic style of organization, with the lowest level of innovation and performance, with a mean of 1.56 (SD = 2.27) and 4.8 (SD = 1.92), respectively.
The moderate learning organizations have statistically significant higher levels of organizational flexibility. However, learning can be constrained and isolated into one department whereas the rest of the organization remains bureaucratic. The impact of learning mechanisms already in place might explain a significant higher level of innovation and performance than the former cluster, with a mean of 3.91 (SD = 3.71) and 7.6 (SD = 4.15), respectively. The cluster of advanced learning organizations is characterized by high levels of learning and problem solving in work teams. Such a learning environment is widely spread across the different departments. This group, combining several characteristics of learning organizations, tends to show a higher capacity for innovation and performance than the rest, with a mean of 6.95 (SD = 3.42) and 9.27 (SD = 5.99), respectively. The advanced learning organizations might be particularly instructive to other hospitals by revealing the main mechanisms for integrating research and practice, as well as for translating external research findings into practice. Flexibility and external cooperation
The major variables distinguishing the 3 clusters are those indicators capturing conditions for enhancing learning including self-assessment of work quality, quality standards, cross-department collaboration, external cooperation, team work, and work task allocation and rotation. The cluster of advanced learning organizations shows a wider use of organizational changes toward enhancing learning across the hospital than moderate learning organizations. The cluster of basic learning organizations shows a residual use of these organizational changes, reflecting a less conducive environment toward learning. The 3 clusters of hospitals reveal significant differences in terms of organizational structure and processes, management style, and skills development. As the horizontal and vertical divisions of labor evolve, they contribute to the necessary diversity feeding innovation. However, they also create new barriers for communication and interaction within the hospital and with other organizations. This is highly relevant because innovation is the outcome of combining knowledge located at different sites. Organizational flexibility and external cooperation are the 2 major discriminating factors explaining differences in terms of innovation and performance across the 3 clusters of hospitals. The results from this research bring implications for management in the health sector. Management
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needs to enhance a supportive environment for learning, creating room for human resources development, as well as work team and cross-department collaboration. While management cannot force renewal, it can support an environment for radical renewal through wide internal networks across departments and divisions. This is a requisite for continuous learning. It is well documented that different departments within a hospital have difficulties in understanding and communicating with each other. Increasing this internal capability is also a prerequisite for effectively assimilating and applying knowledge from outside. Furthermore, the recent models of innovation particularly emphasize learning as an interactive process in which hospitals interact with other organizations, including suppliers and universities. This is also the background for developing a systemic approach to knowledge creation. A wide external cooperation has the potential to create opportunities to access new knowledge for further development of innovations. Results suggest that the integration of service delivery systems might expand capacity for real-time learning in daily practice. The impact of learning organizations on innovation development
Summing up, the model examined in this article has shown significant effects of the development of the so-called learning organization on innovation. This strongly supports the validity of theoretical considerations regarding the construct of learning organization. It illustrates that hospitals combining quality control, human resources development, and external cooperation are much more prone to innovation. The proposed measures set the way to systematically capture and translate information generated by clinical research and health care delivery by promoting close open-ended learning loops. As noted in the “Results” section, the supply of knowledge currently available to hospitals has several deficiencies. Hospitals often lack reliable evidence on the effectiveness of different treatment options, interventions, and technologies and on how the effectiveness of treatments varies for different patients. Moreover, the quality of care depends not only on the effectiveness of a given treatment but also on the way that treatment is delivered. Thus, it is necessary to build knowledge about different methods of delivering care and provide hospitals with tools to improve care processes. Learning processes must also be tailored to the circumstances and needs of hospitals and other stakeholders in the health system. Each stakeholder has a different role in the generation and dissemination of knowledge, so each will need different tools to support continuous learning and improvement. Furthermore, the learning potential of hospitals and their cooperation partners might be significantly enhanced by the new opportunities provided by information and communication technologies to share information and measure progress.
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CONCLUSIONS The primary result is the distinction of different types of learning organizations in the Portuguese hospital sector, which has not before been covered in this manner. Furthermore, the article reveals the mutually reinforcing interrelationship between innovation and learning processes. The study concludes that hospitals pursuing strategies of innovation realize the relevance of enhancing a learning organization. Such an approach suggests the key role of hospitals for the creation, transfer, and application of knowledge for innovation development. Indeed, a mismatch between the hospital’s knowledge and innovation domains might favor external collaboration to get the right match of knowledge. Therefore, the analytical framework of learning organizations goes beyond the hospital to include the external cooperation network, as well as the way they exchange knowledge between each other. In conclusion, the article proposes a wider perspective to innovation development in hospitals in order to focus on the knowledge infrastructure. Such infrastructure would include both individual and organizational learning toward enhancing innovation. Because of the complexity of the Portuguese National Health Service, it cannot, as a whole system, become a learning organization. However, it is possible that hospitals may achieve this status to varying degrees. In fact, as more hospitals become exposed to the need to engage on innovation development, there is an increasing potential for learning dimensions to be reflected in organizational strategies and public policies. Such a trend would bring higher priority to policies aiming at human resources development, developing new forms of organizations, and creating external cooperation networks. The major implication arising from this study is that policy needs to combine instruments that promote innovation opportunities and incentives, with instruments stimulating the further development and diffusion of the core components of learning organizations. Such a combination of policy instruments has the potential to ensure a wide external cooperation and bring together different organizations through a learning infrastructure. The article also reflects a shift from a static to a more dynamic model of learning organizations in terms of innovation policies. It recognizes the nonlinear and interactive nature of learning through the development of innovations adapted to local health needs and assets. In this context, hospital services would go from “silo” to “systems” thinking, enhancing the delivery of health services based on updated evidence and wide communication among the main stakeholders. Drawing from current results, the study proposes several policy solutions: First, support a culture renewal that encourages problem solving in new ways across the whole organization; second, emphasize the links between elements of the hospital care and administrative processes. Both measures are crucial for effective health care models and new
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communication systems to provide the accurate, timely transfer of information throughout the health care continuum. Third, continuous learning and health care improvement require transparency in processes and outcomes, as well as the capacity to capture feedback and make adjustments. Finally, there is also the need to align rewards on the key elements of continuous learning and improvement of health care performance across the different stakeholders. In fact, incentives, standards, and measurement requirements can serve as powerful change agents and are key elements of the policy framework for innovation development in the hospital sector. REFERENCES 1. Morgan D, Astolfi R. Health Spending Growth at Zero: Which Countries, Which Sectors Are Most Affected?. Paris, France: OECD Publishing; 2013. ¨ Johnson B. The learning economy. J Ind Stud. 2. Lundvall B-A, 1994;1(2):23-42. 3. Nembhard IM, Tucker AL. Deliberate learning to improve performance in dynamic service settings: evidence from hospital intensive care units. Org Sci. 2011;22:907-922. 4. OECD. Working Out Change: Systemic Innovation in Vocational Education and Training. Paris, France: OECD Publishing; 2011. 5. Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Q. 2001;79(2):281-315. 6. Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care. 2004;13(2): 3-9. 7. Rogers E. Diffusion of Innovations. New York, NY: Free Press; 1995. 8. Argorte L. Organizational learning: past, present and future. Manage Learn. 2011;42(4):439-446. 9. Kanter RM. The Change Masters. New York, NY: Simon & Schuster; 1983. 10. Mulgan G, Albury D. Innovation in the public sector. Strategy Unit, Cabinet Office, 2003. 11. Senge P. The Fifth Discipline. New York, NY: Doubleday; 1990. 12. Fleuren M, Wiefferink K, Paulussen T. Determinants of innovation within health care organizations. Int J Qual Health Care. 2004;16:107-123. 13. Dean B. Learning from prescribing errors. Qual Saf Health Care. 2002;11 (3):258-260. 14. Plsek P, Greenhalgh T. Complexity science: the challenge of complexity in health care. BMJ. 2001;323:625-628 15. Anderson RA, McDaniel RR Jr. Managing health care organizations: where professionalism meets complexity science. Health Care Manage Rev. 2000;25(1):83-92.
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16. Best A, Greenhalgh T, Lewis S, Saul JE, Carroll S, Bitz J. Largesystem transformation in health care: a realist review. Milbank Q. 2012;90(3):421-456. 17. Institute of Medicine. Learning Health Care System. Washington, DC: Institute of Medicine; 2011. 18. Greene SM, Reid RJ, Larson EB. Implementing the learning health system: from concept to action. Ann Intern Med. 2012;157(3): 207-210. 19. Davies HT, Nutley SM, Mannion R. Organisational culture and quality of health care. Qual Health Care. 2000;9(2):111-119. 20. Crites GE, McNamara MC, Akl EA, Richardson WS, Umscheid CA, Nishikawa J. Evidence in the learning organization. Health Res Policy Syst. 2009;7:4. ˚ National Systems of Innovation. Towards a Theory 21. Lundvall B-A. of Innovation and Interactive Learning. London, England: Pinter Publishers; 1992 22. Greenhalgh T, Robert G, McFarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82:581-629. 23. Gjerding AN. Technical Innovation and Organisational Change. The Innovation Design Dilemma Revisited. Aalborg, Denmark: Aalborg University Press; 1996. 24. Leonard-Barton D. Implementation as mutual adaptation of technology and organization. Res Policy. 1988;17:251-267. 25. Burns T, Stalker GM. The Management of Innovation. Oxford, England: Oxford University press; 1994. 26. Nonaka I, Takeuchi H. The Knowledge Creating Company. Oxford, England: Oxford University Press; 1995. 27. OECD; EUROSTAT. The Measurement of Scientific and Technological Activities: Oslo Manual Guidelines for Collecting and Interpreting Innovation Data. Paris, France: OECD Publishing; 2005. 28. Kimberly JR, Evanisko M. Organisational innovation: the influence of individual organisational and contextual factors on hospital adoption of technological and administrative innovations. Acad Manage J. 1981;24(4): 689-713. 29. Salge TO, Vera A. Hospital innovativeness and organizational performance: evidence from English public acute care. Health Care Manage Rev. 2009;34(1):54-67. 30. Fosfuri A, Tribo´ JA Exploring the antecedents of potential absorptive capacity and its impact on innovative performance. Omega. 2008;36:173-187. 31. Freeman T. Using performance indicators to improve health care quality in the public sector: a review of the literature. Health Serv Manage Res. 2002;15:126-137. 32. Veillard J, Champagne F, Klazinga N, Kazandjian V, Arah OA, Guisset AL. A performance assessment framework for hospitals: the WHO regional office for Europe PATH project. Int J Qual Health Care. 2005;17(6):487-496. 33. National Coordination of Hospital Commissioning. Indicators of Hospital Performance. Lisbon, Portugal: Ministry of Health; 2008. 34. Dias C, Escoval A. The open nature of innovation in the hospital sector: the role of external collaboration networks. Health Policy Technol. 2012;1(4):181-186.
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