We begin by discussing our findings with regard to the theoretical framework and proceed to relate our findings to previous studies. We conclude with implications for quality improvement in health care.
A new understanding of the clinical system and double-loop learning
By structuring and analyzing our data according to the four themes of the ELO model, we were able to construct a representation of how the learning process unfolded. Furthermore, our theoretical frameworks helped us identify factors that contributed to sustain the improvements.
Our findings demonstrate that employees at the hospital developed a revised and deeper understanding of their clinical system and its interdependencies during the course of the improvement project. This new understanding had implications for organizational behavior. We consider this a key finding because it indicates a change in clinicians’ mental model of their clinical system that influenced organizational action.
This new understanding emerged from a dynamic process in which clinicians shared information, reflected on it, and related it to their everyday work situation. Consistent with the extended SECI model, including
ba[
26,
30], individual tacit knowledge was made explicit and interpreted in a new shared context. This shared context was provided by the hospital leadership. Specifically this context involved how the various elements of the clinical pathway needed to interact to enhance the performance of the clinical system as a whole. Through this process of sharing and reflection among individuals across professional groups and departments, the employees’ new model of the clinical system was transformed into a mental model that was shared by the organization [
25]. As pointed out by Kim [
25], a changed mental model that is shared at the organizational level can serve as a foundation for double-loop organizational learning if it affects organizational action [
24].
Individuals in a system tend to focus on their immediate surroundings and pay less attention to the functioning of the clinical system as a whole [
43,
44]. We observed the same kind of behavior at Førde Hospital before the project started. During the project clinicians shared and reflected on information with regard to how the performance of the clinical system as a whole could be improved. In line with the CAS framework we observed that clinicians revised their understanding of the clinical system as they acquired a better understanding of its interdependencies [
43]. Clinicians’ improved understanding of the interdependencies in the clinical system affected three important stages of the change process: inquiry about what to change, change of organizational routines, and adaptations of interventions to the context.
As clinicians gradually improved their understanding of the clinical system and its interdependencies, they became able to detect system problems they previously had been unaware of. Failures prone to transitions between clinical entities were revealed as these transitions were evaluated from a new perspective, i.e., the clinical system as a whole. Furthermore, the new understanding led to a deeper and more precise understanding of the underlying causes of the quality problems.
Organizational learning becomes manifest through new or modified organizational routines [
20]. In our case, clinical practice was altered as a consequence of a new understanding of the clinical system and its interdependencies. At the individual and group levels, physicians began cooperating in a new way that benefited the patients. At an organizational level, to offer one example, the hospital improved the scheduling and coordination of surgery by doing this across departments as opposed to department-wise as was done before the project. The new routine contributed to reducing cancellations and increasing the number of operations performed. Furthermore, remarks by the physicians demonstrated that their better understanding of the system of care facilitated the development of new organizational procedures in general.
Frontline employees were engaged in suggesting adaptations and modifications of the interventions. The improved understanding of the system increased the employees’ awareness of the interaction between context and interventions and improved their ability to adapt interventions to specific situations. Moreover, the hospital increased the effectiveness of changes by fitting them to a constantly changing context in a way pointed out by Fixsen et al. [
45].
Consistent with Berwick [
5], improvements in our case were made by changing the clinical system. During this process, clinicians developed a deeper understanding of their clinical system and its interdependencies. This was transformed into a shared mental model at the organizational level. The shared mental model affected organizational action, indicating that double-loop organizational learning occurred [
24]. According to our theoretical framework, organizational change that involves double-loop learning is more likely to be sustained because it alters the deeper, structural, and cultural properties of systems. The fact that the hospital was able to facilitate and induce systemic change through double-loop learning appeared to be important for understanding how improvements were sustained. In our case, important stages in the process of changing the system were based on double-loop learning: inquiry about the need to change, change of clinical practice, and adaptations of interventions.
Our findings in relation to earlier studies
An understanding of an organization as a system is a prerequisite for organizational learning [
29]. The performance of a system is far more dependent on how the elements work together than on how each element performs separately [
46]. According to Batalden and Davidoff [
47], knowledge about
processes and
patterns is a prerequisite for improving the performance of a clinical system (i.e., knowledge about how clinicians interact to deliver the actual care that patients need). However, many health professionals are
process illiterate, partially owing to the challenges of recognizing and understanding causal implications of their actions in a system [
44,
48]. In our case, clinicians improved quality by focusing on interdependencies, i.e., the way clinicians cooperated in their clinical processes to deliver care. By doing so, clinicians’ understanding of the implications of their actions grew, deepening their understanding of the clinical system.
Previous studies indicated that organizational learning in health care is fragmented (i.e., consisting of many learning cycles that are not interconnected) [
21,
49,
50]. Contrary to our findings, Tucker and Edmondson [
51] found that single-loop learning was dominant when nurses learned from mistakes. They suggested that this type of learning may mask the underlying structural problems of the system that could have been detected and corrected by double-loop learning. In our case, the hospital leaders were able to address underlying systemic problems through the dynamic process of inquiry, information sharing, and reflection, thereby facilitating double-loop learning.
Consistent with earlier studies [
6,
52], we found that multidisciplinary teams of professionals, combined with knowledge about improvement, was an important success factor in our case study. The staff that supported the project groups helped to structure an arena for reflection and sharing information. Furthermore, their guidance and assistance in mapping and visualizing the clinical system, along with their role in keeping track of decisions, were important for maintaining a system perspective during the inquiry process.
Perseverance from middle managers, who led the implementation process through their clinical work, was a key driver in overcoming resistance and implementing change. Consistent with previous findings, middle managers built and demonstrated knowledge about the clinical system through their work and leadership, thereby facilitating the spread of the new mental model [
53,
54]. By doing so, they maintained double-loop learning at the organizational level.
Implications for quality improvement in health care
We report here that clinicians revised their understanding of their clinical system and developed a new mental model. The mental model was then shared by the organization and influenced the inquiry process, clinical practice, and the way interventions were adapted. These steps are illustrated in Figure
1. The improvement strategy triggered clinicians to inquire about their system and opened an arena for information sharing and for relating these activities to the context of the whole clinical system. These combined activities improved clinicians’ understanding of their clinical system. The process was circular as the new understanding influenced the actions that had induced it.
Our case demonstrates that clinicians’ understanding of their clinical system can be improved, partially depending on how a project is planned and conducted. The hospital’s general strategy for improvement influenced how this new understanding emerged. A fundamental part of the strategy was to provide an arena and structured approach for sharing information and involving frontline professionals in the inquiry about systemic problems by equally addressing patient, professional, and administrative quality [
55]. By providing clinicians with an arena for sharing information and a context for reflecting on the shared information, the leadership facilitated the process that led to a revised understanding of the clinical system. We therefore suggest that it may be possible to influence clinicians’ understanding of their clinical system by paying close attention to how improvement work is planned and conducted. Table
2 summarizes and suggests implications of our findings for quality improvement work in health care.
Table 2
Implications for quality improvement in health care
Create a multidisciplinary arena for sharing information Provide a system context for interpreting shared information Provide guidance to clinicians about improvement knowledge | Revised and deeper understanding of the clinical system that is shared by the organization |
Design and implement new organizational routines based on the new understanding of the clinical system | Change the system based on double-loop organizational learning |
Facilitate continuous information sharing and reflection | Spread the new mental model in the organization |
Modify and adapt interventions based on the new understanding of the clinical system | Sustained improvement |
Limitations, relevance, and further research
The retrospective study design has inherent limitations such as information bias and confounding; thus, we cannot prove causality between interventions and outcomes. However, combining a retrospective design with a theory-driven analysis allowed us to learn from a successful case by exploring how and why the improvement efforts worked and were sustained [
9,
10,
56]. Retrospective interview data may be influenced by what respondents remember and how they emphasize various parts of their experiences. In our case, the respondents independently described how the improvement process changed their understanding of the clinical system and their own roles in this system. This finding was consistent across professional groups, regardless of the degree of involvement in the improvement work, thus increasing the credibility and trustworthiness of our analyses [
37]. The rigor of our analyses was also enhanced by our use of complementary theoretical perspectives [
57].
Our study is based on a single case that cannot be directly generalized. However, lack of sustainability of healthcare interventions is a substantial and ubiquitous problem [
58,
59]. The literature suggests that an incomplete understanding of the clinical system in not unique to our case; our findings are consistent with the literature and previous empirical findings [
47,
50]. In line with recommendations in the literature, we used theoretical perspectives to generate a middle-range theory, or context-dependent theory, which describes how clinicians’ increased understanding of their clinical system contributes to sustainability [
9,
10,
60]. Despite the inherent limitations of a retrospective case study, we suggest that our theory may help hospitals to increase the sustainability of improvements.
Our study may also open a new line of research into sustainability of improvements. Future studies should address factors that improve individuals’ understanding of clinical systems, changes of mental models, sharing of mental models, and how these models affect organizational behavior [
61]. A better understanding of these factors might eventually increase the sustainability of healthcare improvements.