Organizational Learning In Health Care Essay

Running Head: ORGANIZATIONAL LEARNING AND HEALTHCARE

A Framework for Organizational Learning in Healthcare:
From Individual Learning to the Organizational Learning Systems Model
J. Richard Ray, Jr.
Managing OD Consultant/Adjunct Professor of HRD
Kaiser Permanente of the Mid-Atlantic/George Washington University/
Presented at
Southern Management Association 2002 Conference
Track 2: Health Care Administration/Hospitality Management
Phone: [phone]
Email: [e-mail]
Key Words: Organizational Learning, Learning, Learning Models, Health Care Learning
Revised September 23, 2002 (Reprint October 1, 2006)

Abstract
Many researchers and practitioners have developed models to discuss how organizations learn using concepts of learning, social theory, sensemaking and information transfer. The Organization Learning Systems Model (OLSM) provides a comprehensive framework for discussing how organizations interact with their environments, reflect on information collected, disseminate knowledge to stakeholders and “make sense” with their culture through learning subsystems. After reviewing individual and organizational learning literature, I will reflect on a recent consultation at a major healthcare firm using this frame. This paper suggests that practitioners and
managers can leverage this model to better manage learning, change, effectiveness and strategic planning. A Framework for Organizational Learning in Healthcare:
From Individual Learning to the Organizational Learning Systems Model
In recent years the topic of organizational learning has been discussed in academia and the workplace with great interest. In organizations, these discussions usually begin as the result of some cataclysmic event, strategic planning announcement, market change or dialogue on performance. Some see this subject as the integration or theft of many theories from sociology, psychology, management science and anthropology (Argyris & Schon, 1978; Davis, 2001; Jankowicz, 2000; Schwandt & Marquardt, 2000; Senge, 1990). There are even some who claim that organizational learning can be discussed using “adaptation” language from sciences such as biology, physics and chemistry (Gleick, 1987; Holland, 1996; Marion, 1999; Youngblood, 1997). Regardless of the discipline, how individuals learn and the way this impacts the process by which organizations “learn” will continue to charge academic debates and consume practitioner resources.
Linking theoretical constructs of organizational learning to the “real world” is a difficult challenge. In healthcare, researchers and practitioners have attempted to make this linkage by identifying learning conditions that must exist in order to generate, disseminate and use knowledge. These include: 1) a shared vision of organizational goals and how learning can contribute to success; 2) leaders who ensure that opportunities, resources, incentives and rewards are provided to support learning; and 3) an organic structure with diverse communication channels that efficiently transfers information across organizational boundaries (Barnsley, Lemieux-Charles, & McKinney, 1998). Others also suggest that understanding the environment, information processing functions and cognitive learning frameworks in health care organizations can boost the probability of building and maintaining intellectual capital (Grantham, Nichols, & Schonberner, 1997).
One attempt to connect theory and practice is the Organizational Learning Systems Model (OLSM) (Schwandt & Marquardt, 2000).
This multi-disciplinary model developed at the Center for the Study of Learning at George Washington University is increasingly impacting the practice of organizational learning. This model is founded upon the writings of Talcott Parsons (Schwandt & Marquardt, 2000) and discussions of his organizational prerequisites of adaptation, goal attainment, integration and pattern maintenance functions in organizations. The structure of action provided by Parsons lends a powerful lens by which many organization processes and actions can be viewed (Lackey,
1987).
Schwandt and Marquardt (2000) expand on Parsons General Theory of Action by creating a model that explains organizational learning in the context of four learning subsystems: 1) environmental interface, 2) action/reflection, 3) dissemination and diffusion and 4) meaning and memory. Equally as important, they depict interactions among these subsystems using the interchange media of information, goal reference knowledge, structuring and sensemaking. Many current management theories and models inadequately meet the special needs of the healthcare industry (Grantham et al., 1997); however, the OLSM, can start a new, more comprehensive conversation regarding knowledge creation and organizational learning.
Understanding the theoretical underpinnings of OLSM is the first step to appreciating its practical application in health care organizations. In this paper, theories of adult learning, social interactions and organizational learning are reviewed to provide perspective. I will discuss individual learning and learning in the social context before a discourse on organizational learning. This review will provide the learning foundation that establishes organizational learning as the theoretical basis for the OLSM.
After establishing the theoretical and practical applications of this model, I will use it to analyze an employee opinion survey with one of the nation’s leading healthcare providers. This will provide a bridge from theoretical construct to pragmatic tool. In concluding, I will suggest that other healthcare organizations use this model to frame and facilitate future organizational learning and performance efforts.
Organizational Learning Literature Review
Individual Learning
Learning takes place when individuals and organizations interact with their environments (Hedberg, 1981). Some researchers claim that learning is an on-going process of reflection and action where individuals ask questions, receive feedback, experiment and take action (Davis, 2001; Edmondson, 1999; Goby & Lewis, 2000; Kolb, 1976; Levinthal & March, 1993). Gerber (2001) describes learning as a construct that involves a change in behavior or cognition (or both), relating to perceptions, affect, feelings, attitudes, and values. He continues by stating that learning occurs following, or as the result of experience, direction, thinking, and insight.
Learning through experiences and reflecting on actions has its formal grounding in the works of Dewey, Lewin and Piaget (Miettinen, 1998). Kolb (1976) defines learning as a process whereby knowledge is created through the transformation of experience. Parsons identifies learning as cognitive processes that are required by organisms’ (and organizations) need-fulfillment to complete actions (Lackey, 1987). Most modern theorists share the similar premise that experience plays a significant role in learning (Druskat, 2000; Gerber, 2001; Goby & Lewis, 2000; Kolb, 1976; Miettinen, 1998).
Gerber (2001) has posited that learning can be viewed in four categories aligned into two classes. The first class (two categories) is based on the research of Skinner and Pavlov. The Skinnerian model suggests that individuals are subjected to a stimulus that causes a response (traditional S  R). This response and stimulus interaction is called Association Learning. Reinforcement Learning is similar, but the learning is “reinforced” with another stimulus in close proximity (S  R  S).
The second class of learning assumes that a process occurs within the subject that impacts the response produced by the stimulus (Gerber, 2001). This class is represented as S  O  R, where “O” symbolizes the role of the subject in producing the response. In this category, termed Cognitive-Perceptual Learning, learning is a mental process that considers varying perceptual “frames” until one corresponds to a universal structure. Past perceptual “Gestalts” are stored in memory and become data for future decisions. Theorists such as Rogers, Maslow and Lewin are considered the founders of this type of learning. Cognitive-Rational/Linguistic Learning is the second category in this class and builds on the Cognitive-Perceptual Learning. Here, learning is based on experiences that can be coded and remembered through language; it permits higher levels of structuring that can be configured to create new knowledge.
In Cognitive-Rational/Linguistic Learning, the subject is using language (not necessarily words) as a means to collect data, enhance information analysis and communicate it to others. Information precedes thoughts, thought precede actions. Behavior results from cognitive analysis of data and decision-making (Gerber, 2001) based on individual experiences/action. One view of what is happening at “O” is that the subject is using dimensions of learning to “frame” the stimulus (Kolb, 1976) to create understanding. Weick (1993; 2001)) describes the formation of frameworks as important to helping people identify meaning. As will be viewed later, the OLSM provides a framework for this data-information-knowledge-meaning relationship.
As individuals create frameworks, language (not necessarily words) may be used a means to create “schemas” and “narratives” that are used to interpret and catalogue new experiences (Boland et al., 2001; Nonaka, 1994; Weick, 1993). They develop frameworks by reflecting on experiences and through a process called “dialogue.” Dialogue means that assumptions are suspended as individuals “think together” (Senge, 1990). Dialogue in the form of face-to-face communication is a process where one builds on the concepts in collaboration with others. Individuals in groups can enrich knowledge transfer and help to construct and reconstruct collective frameworks. It allows for people 's hypothesis to be tested (Nonaka, 1994). Frameworks, fed by experiences, knowledge and dialogue, are accumulated by individuals and allow for and are developed in a social context (Casey, 1997; Weick, 1993). Schwandt and Marquardt (2000) discuss this framework building as critical to learning. Nonaka (1994) states that groups provide a “shared context” where ideas can be dialogued and reflected upon to impact performance.
Social Context and Learning
At the Rational/Cognitive Learning level, language, through dialogue becomes the facilitator of knowledge creation and new learning in a social setting. Therefore, learning occurs in the social context (Gerber, 2001). Learning is not the same for individuals alone as it is for individuals in groups or teams. Some theorists contend that to isolate learning from the “social context” in which it occurs is counter productive (Gerber, 2001). Individual learning is necessary for survival; however, transference of learning requires “social systems” (Allee, 2000; Gardner & Korth, 1998; Hedberg, 1981; Schwandt & Marquardt, 2000; Sparrowe, Liden, Kraimer, & Wayne, 2001). Senge (1990). Teams, not individuals, are the fundamental learning unit in modern organizations and that if teams cannot learn, organizations will not (Kasl, Marsick, & Dechant, 1997). Learning in teams becomes complex (Gibbons, 1999). When setting the stage for OLSM, Schwandt and Marquardt (2000) stat that learning is an individual process that involves the accumulation of knowledge that accommodates benefit to a larger collection of individuals.
Edmondson (1996) states that this type of learning for collections of individuals is possible, but the collections must be defined as part of a larger organization. Members must have a shared culture, clearly defined membership and shared responsibility for outcomes. This culture along with other factors will affect learning (Hedberg, 1981; Weick, 1993; Wilson & Wilson, 1998). Group learning and performance are more than the some of individual parts (Edmondson, 1996; Sparrowe et al., 2001). “Learning in teams is an attempt to articulate behaviors through which such outcomes as adaptation to change, greater understanding or improved performance can be achieved” (Edmondson, 1999). This is Rational/Cognitive Learning at the group level is the “O” processes required for the group to respond to the environment and learn together.
In healthcare, targeted learning in teams produces benefits for individuals and organizations (Gibbons, 1999; Weick, 1993). Learning in groups has proven useful in problem solving, product development, leadership development, quality implementation and transitioning theory into action (Gibbons, 1999; Schwandt & Marquardt, 2000; Sparrowe et al., 2001; Wilson & Wilson, 1998). To achieve higher performance and to better understand what happens in organizations, individuals form in groups to learn, create knowledge and communicate (Kasl et al., 1997).
Through social learning, knowledge is created and legitimized. Informal communities of social interactions nurture knowledge (Nonaka, 1994). These social networks become “communities of practice” (Allee, 2000) that create knowledge and transform it (Sparrowe et al., 2001). Kleiner and Roth (1997) describe a similar concept of “learning histories” where teams of people create narratives to identify and share organization learning.
The ability to frame, reframe, learn and unlearn can be enabling devices for organizations (Hedberg, 1981; Nonaka, 1994). In healthcare settings, training and education programs are powerful tools that are usually undervalued at the team level, therefore reducing the potential for building collective frames and effective learning integration. To make matters worse, in health care, employees are often segregated into classes of physicians, nurses, administrators and others. Collective frames are then occupational specific. This does not contribute to organizational learning and may lead to conflicting learning and performance goals.
To have an impact, organizations must first begin the conversation of how they organize learning, how they evaluate and monitor learning and how they share learning and key messages among stakeholders. Framing and re-framing will need to take place if teams are to learn and be effective as they network and connect (Gibbons, 1999; Miettinen, 1998; Weick, 1993). Healthcare leaders must develop opportunities for learning to be connected and networked to other parts of the organization and to the environment (Kouzes & Posner, 1995).
Organizational Learning
Individual learning, particularly Cognitive/Rational-Linguistic learning, and collective learning comprise the foundation of organizational learning. Organizational learning, as a discipline, is formed by concepts from psychology, sociology, education, anthropology and management science (Argyris & Schon, 1978; Davis, 2001; Jankowicz, 2000; Schwandt & Marquardt, 2000; Senge, 1990). Such an interdisciplinary construct allows application to organizational actions that include organizational behavior, team development, knowledge management, leadership development and others.
The interaction between the collective and the individual (Argyris & Schon, 1978; Nonaka, 1991; Sparrowe et al., 2001), application of learning theories (Gerber, 2001; Kolb, 1976; Zemke, 1999) and the understanding of a “whole systems” approach (Dannemiller & Jacobs, 1992; Katz & Kahn, 1966; Senge, 1990) are key to how knowledge is shared throughout organizations. Schwandt and Marquardt (2000, pg 22) refer to organizational learning as “an intricate and complex relationship among people, actions, symbols and processes.”
Practicing Organizational Learning
For good reasons, practitioners in organizations are investing in ways to harness this new discipline (Argyris & Schon, 1978; Boland et al., 2001; Duffy, 2000; Marquardt, 1996; Sigler, 1999; Stewart, 2000; Warhurst, 2001). Some have suggested that the future of many organizations is directly related to how well they transition individual learning and experiences into collective knowledge. Others support this by positing that contentiously managing effective learning, knowledge sharing and change implementations will be major competitive factors (Allee, 2000; Davis, 2001; Jankowicz, 2000; Marquardt, 1996; Schwandt & Marquardt, 2000; Senge, 1990).
To be more effective, learning in organizations must maximize the interactions among individuals so that knowledge creation is continuous, fostered by the leadership (Kasl et al., 1997; Nonaka, 1991) and structured in a way that permits flexibility. Opportunities to create knowledge structures, maps and frameworks must be planned so that the knowledge created can be applied to linear and nonlinear learning environments (Jankowicz, 2000; Nonaka, 1994; Schwandt & Marquardt, 2000; Weick, 2001). Practitioners need a model based on compelling research, theory and practice that considers the pragmatic needs of organizations to maximize learning. The Organizational Learning Systems Model provides these elements necessary to fully consider what is occurring in organizations as they learn.
Organizational Learning Systems Model (OLSM)
Introduction to Organizational Learning Systems Model
Many components, subsystems and “disciplines” of organizational learning have been identified so that theorists and practitioners can discuss learning environments and systems (Marquardt, 1996; Nonaka, 1994; Schwandt & Marquardt, 2000; Senge, 1990; Sigler, 1999; Stewart, 2000). The OLSM describes four subsystems of learning, based on Parsons General Theory of Action and functional prerequisites. Parsons identified organizations as relationships among adaptation, goal attainment, integration and pattern maintenance functions (Schwandt & Marquardt, 2000) moderated by exchanges between influence, power, culture and resource allocation . This provides a basis to describe learning in terms of concrete organizational actions related to four learning subsystems.
Schwandt and Marquardt (2000) discuss four subsystems that impacts organizations’ environments, actions, processes and cultures. Based on Parsons model, they posit that relationships between organizations and their environments will control interactions between internal and external factors as they collect energy (information). The OLSM seems complex at first (See Figure 2) and it may be difficult to determine exactly what is occurring and how. In breaking the model down into four separate sections and explaining how interchange media interacts with the separate subsystems, I will attempt to make the model less complex and easier for the first-time viewer to interpret.
The Environmental Interface subsystem represents Parson’s adaptation function and describes how information enters the learning system. This subsystem requires “imported energy and information to survive” (Schwandt and Marquardt, pgs 88, 115). The Action/Reflection subsystem represents the goal attainment function and describes the learning needs of the system. In this subsystem, mechanisms are engaged to transfer information to knowledge (Schwandt and Marquardt, pgs 88, 152). The Dissemination and Diffusion subsystem represents the integration function and describes coordination within the learning system. This subsystem (Schwandt and Marquardt, pg 63) refers to the procedures that allow the organization to coordinate elements of the learning system such as communication, leadership and internal modifications. Finally, Schwandt and Marquardt (2000) develop the Meaning and Memory subsystem to represent the pattern maintenance function. They describe the maintenance of a learning system’s pattern of action. This may also be interpreted as the culture subsystem where organizations enact the sensemaking process to maintain “the way we do it here.” Each of these subsystems is required to fully understand how organizational learning occurs and each will be discussed in more detail.
Environmental Interface
In learning systems, new information is the “energy” required for survival. New information becomes the interchange media that relates the Environmental Interface subsystem with the other subsystems in the organization. The way that organizations interact with their environments can have power over how they learn and use information (Daft & Weick, 1984; Nonaka, 1994). Other authors have supported this view (Allee, 2000; Boland et al., 2001; Gardner & Korth, 1998; Schenke, 2001; Senge, 1990; Warhurst, 2001). Schwandt and Marquardt (2000) describe the Environmental Interface (See Figure 3) subsystem as the portal for new information. As information is introduced into health care organizations, it must be transformed through processes that lead to new knowledge (Lemieux-Charles, McGuire, & Blidner, 2002) and action.
The ability of leaders and employees to adapt through rapid information processing can speed or slow learning. Levinthal and March’s (1993) discussion of adaptation among multiple actors offers an explanation for how organizations have a tendency to look into their own network for answers as opposed to relying on new provided data. While acknowledging and reflecting upon internal information is important, failure to accurately “scan” the environment for new information will limit knowledge creation (Daft & Weick, 1984; Weick, 1993). By not considering external systems and engaging stakeholders, organizations will not learn effectively. Without relevant environmental information, the ability to link knowledge to action (in the Action/Reflection subsystem) will be seriously degraded. Thus learning, and indeed action, will be compromised. Employees and leaders must scan the environment constantly to determine what information is “out there” and the potential impact it may have on their networks.
In planning for the interface between the environment and other learning subsystems, organizations must take into consideration how they identify new information, employ mechanisms to engage the environment and determine how to control the interaction with the environment. Again, information is the energy. It is collected from the environment and shared with the Action/Reflection subsystems where attempts to formulate actions and goals are made. The actions and goals processed must be shared throughout organizational networks via the Diffusion and Dissemination subsystem. The information is then sifted through the Meaning and Memory subsystem to determine how the culture will respond, and patterns maintained or modified.
Action/Reflection
Once data is collected through the scanning process, interpretation is used to give meaning to the data (Daft & Weick, 1984). The OLSM considers interpretation as key when organizations reflect on new information in processing new goals and actions. Through action learning, collective learning and training, organizations transform data into information; information into knowledge. Daft and Weick (1984) support this need for organizations and individuals to interpret information entering the system before producing action. Knowledge creation and action are the result.
The Action/Reflection subsystem of the OLSM represents the actions that occur as organizations attempt to satisfy learning goals. Here, organizations experiment, test, and simulate with the information provided from the Environmental Interface. In this subsystem (See Figure 4), organizations examine those mechanisms and actions that enable them to assign meaning to new information, thus creating goal reference knowledge. Weick (1993) and Nonaka (1994) support the OLSM proposition that frameworks are developed that allow this subsystem to interpret and share goal reference knowledge. Organizations may consider training, new technologies, processes and systems to assist in the action/reflection process and to prepare knowledge for dissemination throughout the organization. They may ignore precedent, rules, and enact traditional expectations depending on interactions with the other subsystems, especially Meaning and Memory (Schwandt & Marquardt, 2000). Without mechanisms to collect, analyze and compare new information and establish learning goals, health care organizations will experience dysfunction in their learning systems (Barnsley et al., 1998; Lemieux-Charles et al., 2002).
Dissemination and Diffusion
The Dissemination and Diffusion subsystem is concerned with coordinating elements of subsystems and “communicating.” It deals with how organizations move knowledge and integrate it. Dissemination and Diffusion is the primary subsystem for moving, transferring, retrieving, and sharing information and knowledge (Schwandt & Marquardt, 2000). This subsystem produces structuring activities such as leading, communicating and other mechanisms that shift information and knowledge throughout the system. This includes acts of networking, managing, coordination, and implementing roles and norms that facilitate movement of information and knowledge.
Providing treatment to patients offers an analogy for information dissemination. The healthcare provider receives symptoms (information) from the patient (environment) which may dictate which prescription (action) is most appropriate. Informal networking may be the prescription for certain types of dissemination, while a memo from management might serve as the best “medicine” to diffuse other types of knowledge. Like medical treatment, dissemination will vary among practitioners and result varying degrees of success. As in healthcare, some dissemination may be more preventative, some may require emergency application.
Dissemination and Diffusion (See Figure 5) of knowledge is a key leadership role and may determine how successful organizations are at integrating learning. More importantly, it may determine the success by communicating key messages. The output produced from this subsystem is dynamic structuring that integrates organizational structure, roles, norms, processes, and objects. Giddens (1979) describes “structuration as the production and reproduction of social systems through the application of generative rules and resources”.
Structuration incorporates interactions within the system. By structuring knowledge and information, organizations can communicate and prepare networks to operate more effectively. Processes, development activities and equipment such as computers may aid organization in storing, retrieving and facilitating knowledge. This dynamic interaction enables the Dissemination and Diffusion subsystem to integrate the other three subsystems.
Memory and Meaning
The final subsystem mentioned in the OLSM involves how organizations construct meaning and store artifacts and “memories.” The essence of the learning system is its Meaning and Memory subsystem. It is from this learning subsystem that other subsystems draw guidance and control (Schwandt & Marquardt, 2000). Referring to our previous patient treatment example, the symptoms (information) may suggest the provider offer specific protocol or medicine (action). The protocol requires a shot, followed by a prescription regimen and change in diet. If a new protocol (new information from the environment) is announced, the healthcare provider will attempt to make sense out of it in relationship to the patient being treated. Based on the influence of the Memory and Meaning subsystem, he/she may select to do treat the patient the way “we have always done it” instead of using the new protocol.
This subsystem is composed of interpretative assumptions that are intrinsically linked to the organizations’ culture. It maintains the culture of organizations through language, symbols, norms and these assumptions (Schein, 1992; Schwandt & Marquardt, 2000). It defines the ability of organizations to make sense of what is happening to them and remembers the knowledge that is critical to its survival. The Meaning and Memory function attempts to maintain organizations’ basic assumptions through sensemaking and the creation of learning controls. It creates barriers that maintain certain assumptions and patterns. This is the genesis of “resistance to change.” This subsystem serves other subsystems through sensemaking.
Sensemaking is the primary interchange medium with the other subsystems and is represented by language, symbols, assumptions and values. It is the output that interprets interactions with the other subsystems (Sigler, 1999; Weick, 1993). Weick (2001) describes sensemaking as the process of assigning meaning to organizational actions. Weick (1993) indicates that sensemaking is necessary in organizations and without it, collapses in structure will occur. To affect sensemaking throughout the organization, a series of planned synchronized actions must be used. Education, communication and new technology can be useful. These dissemination and diffusion actions can produce change in the Memory and Meaning subsystem while maintaining certain useful patterns and structural integrity of the system.
Healthcare and OLSM: Employee Opinion Survey Example
Kaiser Permanente People Pulse
Kaiser Permanente of the Mid-Atlantic States (KPMAS) is a 6,000-employee health maintenance organization that serves more than 500,000 healthcare clients. It has a unique not-for-profit structure that combines characteristics of an insurance company with a practicing physician group to provide a unique health care delivery model. Every year KPMAS conducts an employee opinion survey to measure satisfaction among employees. The leadership refers to this attempt to “take the pulse of the employees” as People Pulse. This thirty-two questions survey is categorized into eight dimensions including Work Unit, Leader Communications, Quality, Labor Relations, etc. It is a typical opinion survey
In previous years, the leadership distributed surveys, analyzed the results and created reports that summarized the data. These reports were then provided to managers and supervisors to communicate the results of the survey throughout the organization. In some cases, work unit managers, distributed the reports to their work units and some even established “People Pulse” committees to discuss the results. However, as in many firms, the reports were mentioned briefly at the end of staff meetings and then filed away. Some managers sent the reports directly to the filing cabinets without sharing the information. There was no systemic follow-up activities or support offered.
Some attempted to impact employee satisfaction by engaging in a variety of actions. The number of managers taking this approach seemed insignificant for organizational change. In fact, there is evidence that the majority of the managers actually did nothing with the results. Like many companies, the employee opinion survey seemed to be conducted in order to satisfy a commitment to “hear what the employees have to say,” but also like many companies, the organization did little to sponsor organization-wide discussions of the results or employee involvement.
The information provided from the survey was never appropriately transitioned from data to knowledge. It was not clearly disseminated into the organization and not effectively incorporated into the culture. From the employees’ and managers’ perspective, People Pulse was just another project that the senior leadership had initiated. Lessons-learned from other projects and years past were not shared. Organization-wide did not seem to occur. KPMAS was basically experiencing what the majority of healthcare companies that conduct these types of surveys experiences – nothing.
A Different Approach
The leadership of KPMAS desired a different outcome that would permit more employee involvement in 2001. They decided to develop a process that would improve employee participation in completing the survey. The results would be analyzed, processed and via “action planning.” Managers, employees, labor representatives and physicians would be involved. The belief was that if employees were involved in collecting, analyzing, disseminating and developing actions from the data, that employees would take greater responsibility for general satisfaction in the workplace. They determined that a successful effort would be more employee driven and less manager directed. They also tasked the human resources vice president with facilitating a process that would be simple, would not require organization restructure and would consume minimal resources. The vice president delegated the project to the workforce and organization development department to integrate this into other OD projects. KPMAS was in the middle of a very tough year financially, and the market more competitive. Growth projections had not been met, competitors were looming, retention and recruiting efforts were not stellar and satisfaction of members needed improvement. In others words, KPMAS was experiencing what most other firms in healthcare was experiencing. KPMAS leadership had also been considering lessons learned from other organizations regarding the link between employee satisfaction, customer satisfaction and business performance (Kam & Brooks, 1998; Koys, 2001; Rucci, Kirn, & Quinn, 1998; Schenke, 2001). People Pulse was positioned to provide information about employee satisfaction and other measures were employed to measure customer satisfaction and business performance. The real difference for 2001 was that the leadership was committed to change in employee satisfaction. The workforce and organization development department designed a process for interpreting data, creating ownership in the process, helping managers involve employees in decision-making and disseminating data from the external consulting firm throughout the organization. The organization employed an external consulting firm to distribute and collect surveys, perform initial analysis and format data into standardized reports. These reports were the result of some simple descriptive statistical tests and designed for users with virtually no statistics training. The external consultants did an excellent job binding the reports and identifying key stratifications of the data for managers to compare “work units.” The external consultants provided these reports to the KPMAS leadership and internal workforce and organization development (WOD) consultants. Using the mantra of “simple actions, small steps and employee involvement,” a process was developed anchored by a seven-hour workshop. The design of this workshop permitted work unit representatives including physicians, nurses, technicians and labor partners to work together to “make sense” of the data, determine key messages, create a presentation for their work units and begin the process of developing action to positively impact employee satisfaction. Even though the intent was to keep things simple, simplicity gave way to complexity and chaos when the culture of the organization resisted.
Many leaders and employees immediately challenged the data collected. Phone calls and emails were received claiming that the data collected could not be accurate (even before seeing the data in some cases). Once realization set in that the surveys depicted an accurate view of employee opinion, those resisting then determined that project itself was designed faulty. Some “field” managers resisted because they saw People Pulse as a way for the regional staff to become more involved in field operations. Finally, when no traction for these arguments could be made, the subordinate leaders and employees decided to redefine “what was really meant” by the data and the process supported by KPMAS leadership. They “made stuff up.” The resistance continued as managers registered for the workshops. The workshop was presented as job aids to assist teams in accomplishing the leadership’s expectations. The workshop presented information about reading reports, working in teams, organizational learning, employee involvement and action planning.
Work unit managers and leaders were informed of the workshop dates and intent in mid November and informed to register by January 15. The workshops were scheduled to take place between January 15 and February 28, 2002. In an effort to model employee involvement in decision-making, KPMAS leadership did not assign dates specifically for each work unit. Instead each work unit was asked to form a team, select dates and register on their own. No work units signed up for workshops until January 30, and of the 50 teams trained, 30 signed up for workshops from February 19 to 28. Fifteen teams attended in the last two days offered. One team called on February 26 and asked when the “real deadline” was. Three teams did not register at all and when questioned reported that they “were different” and did not know that the process applied to them.
The training was conducted and a process of follow-up has been initiated. The results of the workshops and project are still pending, but there are some early indicators of success. Groups of people that had not normally worked together are working side-by-side, now. Managers are now involving employees in decision-making more than before the training. There are early indications that employees, for the most part, feel more involved and are more satisfied. An organization that was using a compliance model of information transfer (“just do it because I say so”) is practicing a commitment model (“how can we do it and be more dedicated”). Without a lot of effort, major reallocation of budgeted resources or restructuring of the organization, KPMAS involved more than 250 employees directly (thousands indirectly), introduced some new language and disseminated the results of their employee opinion survey to more than 6,000 employees in a matter of months.
KP Analysis using OLSM
As reviewed earlier, the Organizational Learning Systems Model offers a framework by which we can discuss Kaiser Permanente’s organizational learning and knowledge creation. The responses of employees to the People Pulse project, the sensemaking of the data provided and actions taken by the planning teams provide a robust example for discussing organizational learning and how it occurs on teams of healthcare professionals and administrators.
Learning was impaired by actions that normally impact organizations. Employees had “coded” past experiences relating to the People Pulse survey and to KPMAS leadership interaction. Some had positive experiences and some had less-than positive ones. When employees heard words such as “initiative” and “action-planning,” and received memos “from the top” describing the project and announcing company-wide training, they remembered these past experiences. Language, artifacts and memories from past experiences had prepared a frame from which people operated. This example of Cognitive-Rational/Linguistic Learning (Gerber, 2001) on an individual level helps us to begin explaining organizational actions through the lens of OLSM and its subsystems.
Environmental Interface
Levinthal and March (1993) discuss “adaptation among multiple actors” as explanation for how organizations have tendency to look into their own network for answers as opposed to relying on new data provided. These actors attempt to exploit what hey know instead of exploring the environment for new information. In short without considering external systems and engaging stakeholders, organizations will not learn effectively. If they don’t scan the environment for new energy, in the form of information, they will miss a key link to knowledge creation.
Employees were collecting information and interacting with the environment as People Pulse proceeded. They were then attempting to adapt, make decisions, set goals, structure, and make sense based on their past experiences and new information. They were beginning to “frame” the data-information-knowledge-meaning conversation. Without relevant environmental information, the ability to link knowledge to action in subsystem is seriously degraded, thus learning will be compromised, and data will not be transformed into knowledge.
To understand learning in health care organizations, it is useful to understand the means and processes by which they acquire information/energy from the outside world and share with other learning subsystems. In the employee opinion survey at KPMAS, key leaders were supplied information about the results of the survey and the process by which the new information would be shared. New information if the form of reports, employee reactions, membership responses and regulatory guidance constantly flow at KPMAS. The OLSM provides a framework to revw these inter-related actions. Employees and leaders must scan the environment constantly to determine what information is out there and the potential impact it may have. Successful scanning to form organizational actions will determine how new information is transformed into knowledge.
Action/Reflection
At KPMAS, as with most health care organizations, there is a tendency to act immediately without fully reflecting on the information collected. If organizations don’t reflect on information from the environment and previous lessons-learned, they are destined to solve the same problems again and again. In most organizations, this leads to faulty interpretations and results in organizations falling into the “flavor-of-the-month” trap. Due to this misinterpretation, other subsystems react to goal reference knowledge that is inaccurate. The process of attending the seven-hour workshops, analyzing the data collectively and forming action plans was a mechanism and “frame-former” developed so that KPMAS employees could thoughtfully consider survey data, reflect and make small actionable steps to achieve goals. In the workshops, they created common frameworks and a language for planning and implementation.
Due to the reactionary nature of providing health care, it is important for hospitals, clinics and health care systems to identify and monitor how they structure goal and action development – reflection before action. Before emergencies happen, the staff has already practiced protocols and actions to prepare. It is common and necessary that prior to emergency situations, teams of doctors, nurses, technicians and administrators respond quickly to situations to “save” lives. The training they have received, past experiences and protocols implemented ensure that quick decisions made about the information from the environment are rigorously reflected upon. Why shouldn 't organizations attempt to “save” themselves by creating protocols for learning and decision-making that are equally as rigorous? By framing learning with the OLSM, health care organizations can begin the process of establishing flexible protocols that facilitate data to information transformation and transferce to other learning subsystems.
Diffusion and Dissemination
For KPMAS, its lack of information networks and the existence of loosely coupled structuration that prevent accurate information transference, common actions and consistency from location to location. For instance, information about the survey results was shared with three key leaders in different areas. Each communicated and coordinated with their subordinates differently with only one leader obtaining the desired results. This leader’s area received the information in concise messages with clear expectations – her area was active in the action planning and follow up. The other two leaders provided minimal information about People Pulse to their areas and were more vague about expected outcomes and their actions were not as positive as the first leader. In another case, similar information was shared with thirty-eight leaders (subordinate to the before mentioned three). Information they disseminated traveled more quickly and accurately throughout the organization with much better results.
Dissemination that occurs in a non-standardized fashion prevents sharing some learnings. Therefore, it was difficult for project leaders to disseminate a singular message and difficult to monitor progress. When the feedback from the employees made it back to the leadership, this same loose coupling prevented clear communication. Attempts to change the environment must be synchronously coordinated and communicated to the internal and external environment. Without this coordination many health care leaders will continue to collect data and develop plans, but not successfully communicate them. These are important lessons for rapidly changing health care environment.
Meaning/Memory
There were several challenges faced leadership team related to Memory and Meaning subsystems. This learning subsystem is key to understanding the Kaiser Permanente employee opinion project. It is in this subsystem that culture, organizational memory, sensemaking and knowledge retrieval are impacted. New information (the survey results) and communications will be sifted through the sensemaking processes and will be compared to past experiences, beliefs and values. Much of the organization 's resistance resulted from an inability of senior leaders to manage the cultural responses generated by the Meaning and Memory subsystem.
The culture at KPMAS is so resistant to change, it is difficult to introduce new processes and behaviors without executive support. This is so with most firms. Many times, WOD consultants were faced with “that’s not the way we do it here.” Other times, the way people made sense of project objectives was to “frame” it in schemas of past events. For instance, the adherence to timeliness and creating or modifying instructions were directly related to the need to make sense out of the new information using old frames. Their old frames influenced employees to interpret that it was “okay” ignore guidelines provided by KPMAS leadership.
The resistance created by the Memory and Meaning subsystem was observed again, when work unit managers and teams disregarded instructions to “keep it simple.” They were asked to respond back to the leadership with a simple one-page format that was provided. Many managers submitted fifteen and twenty page documents and some delivered Power Point presentations. When asked by the senior project consultant why they returned so much more than requested, the response was that “ we know you ‘really’ want more.” Again, employees and managers were “making sense” of the new information based on the experience, culture and past meaning. Many health care organizations attempt to “maintain patterns” that exist to the degree that they never are able to covert new information to actions, actions to learning.
Conclusion
The diffusion of evidence and information in complex organizations, such as health care systems is a social process. The type of interactions that occur among stakeholders addresses the extent to which new knowledge is processed and created (Lemieux-Charles et al., 2002). While no model is perfect and can be applied to every project, the Organizational Learning Systems Model offers a comprehensive view that some other models do not. It is built upon key concepts of learning, education, psychology, sociology and other sciences. It provides a structure to discuss culture, knowledge creation/transfer, the environment, leadership, communication and other organizational actions in a way that offers a unique perspective.
The literature review of organizational learning supports this need and reality of the interdisciplinary foundation. The understanding of individual learning establishes the basis for cognitive processing that occurs when culture, experience and new information collide. Social leaning theory and research provides an appreciation for the impact that collective social interactions and environmental factors have on learning. The continuing evolution of organizational learning theory that has dominated research and practice will no doubt consume more consulting and instruction time. The literature seems to provide the underpinnings necessary to build practical applications from theory using the OLSM.
The four subsystems of the Organizational Learning Systems Model are fundamental to any learning. The Environmental Interface subsystem allows us to interact with “what is out there.” The Action/Reflection subsystem permits interpretation and goal setting based on this new information. The Dissemination and Diffusion subsystem helps to understand how the organizing actions of communication and leadership are critical for success. Finally, the Memory and Meaning subsystem allows organizations to make sense of what is presented or communicated. It sets the context for learning. Through sensemaking, structuring, information attainment and goal reference knowledge, subsystems coordinate with each other to collect, analyze, direct and store learning. What should be clear is that if any one of the subsystems or their interchange media are not considered, learning in organizations will not be comprehensive.
The employee opinion project presented gives context for transition from theory to model to practice. While there were both challenges and success in this project, the fact is that learning took place. The OLSM provides a framework for the data-information-knowledge-meaning relationship. For KPMAS, there has not been a clear framework. As new projects are developed and initiatives implemented, the Organization Learning Systems Model provides KPMAS and other health care organizations with a framing device to make sense out of actions and reactions. Healthcare organizations will continue to be influenced by internal and external factors which will produce new information. How well they transform this new information to knowledge, actions and goals and disseminate it thought the organizations will impact their survival. The OLSM model offers a language to discuss this organizational learning. References Allee, V. (2000). Knowledge networks and communities of practice. Organizational Development Practitioner, 32(4), 4-13. Argyris, C., & Schon, D. A. (1978). Organizational Learning. Reading, MA: Addison-Wesley. Barnsley, J., Lemieux-Charles, L., & McKinney, M. M. (1998). Integrating learning into integrated delivery systems. Health Care Management Review, 23(1), 18-28. Boland, R. J., Singh, J., Salipante, P., Aram, J. D., Fay, S. Y., & Kanawattanachai, P. (2001). Knowledge representations and knowledge transfer. Academy of Management Journal, 44(2), 393-417. Casey, A. (1997). Collective memory in organizations. Advances in Strategic Management, 14, 111-146. Daft, R., & Weick, K. E. (1984). Toward a model of organizations as interpretation systems. Academy of Management Review, 9(2), 284-295. Dannemiller, K., & Jacobs, K. (1992). Changing the way we change: A revolution of common sense. Journal of Applied Behavioral Science, 28(4), 480-498. Davis, N. J. (2001). Organization development and knowledge management: A systemic Merger. Organizational Development Practitioner, 33(1), 36-41. Druskat, V. U. (2000). Learning versus performance in short term project teams. Small Groups Research, 31(3), 328-354. Duffy, J. (2000). Knowledge management: To be or not to be? Information Management Journal, 34(1), 64-67. Edmondson, A. (1996). Learning from mistakes is easier said than done: Group and organizational influence on the detection and correction of human error. Journal of Applied Behavioral Science, 32(1), 5-28. Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(1999), 350-383. Gardner, B. S., & Korth, S. J. (1998). A framework for learning to work in teams. Journal of Education for Business, 74(1), 28-34. Gerber, S. (2001). Where has our theory gone? Learning theory and intentional intervention. Journal of Counseling and Development, 79, 282-291. Gibbons, S. (1999). Learning teams: Action learning for leaders. The Journal for Quality and Participation(July/August 1999), 26-29. Gleick, J. (1987). Chaos: Making a new science. New York: Penguin Books. Goby, V. P., & Lewis, J. H. (2000). Using experiential learning theory and the Myers-Briggs Type Indicator in teaching business communication. Business Communication Quarterly, 63(3), 39-48. Grantham, C. E., Nichols, L. D., & Schonberner, M. (1997). A framework for the management of intellectual capital in the health care industry. Journal of Healthcare Finance, 23(3), 1-19. Hedberg, B. (1981). How organizations learn and unlearn. In W. Starbuck (Ed.), Handbook of Organizational Design (Vol. 1). New York: Oxford University Press. Holland, J. H. (1996). Hidden order: How adaptation builds complexity. Cambridge, MA: Helix Books. Jankowicz, D. (2000). From learning organization to adaptive organization. Management Learning, 31(4), 471-490. Kam, S. M., & Brooks, S. M. (1998). Touching the customer by understanding employees: Preliminary linkage research findings from four regions of Kaiser Permanente. The Permanente Journal, 2(2), 47-54. Kasl, E., Marsick, V. J., & Dechant, K. (1997). Teams as learners: A research-based model of team learning. Journal of Applied Behavioral Science, 33(2), 227-246. Katz, D., & Kahn, R. (1966). Organizations and system concepts, In The social psychology of organizations (pp. 14-29). New York: John Wiley and Sons. Kleiner, A., & Roth, G. (1997). How to make experience you company 's best teacher. Harvard Business Review. Kolb, D. A. (1976). Management and the learning process. California Management Review, 18(3). Kouzes, J. M., & Posner, B. Z. (1995). The leadership challenge: how to keep getting extraordinary things done in organizations (Second ed.). San Francisco: Jossey-Bass. Koys, D. J. (2001). The effects of employee satisfaction, organizational citizenship behavior and turnover on organizational effectiveness: A unit-level, longitudinal study. Personnel Psychology, 54(1), 101-115. Lackey, P. N. (1987). Invitation to Talcott Parsons ' theory. Houston, Tx: Cap and Gown Press, Inc. Lemieux-Charles, L., McGuire, W., & Blidner, I. (2002). Building Interorganizational knowledge for evidence-based health system change. Health Care Management Review, 27(3), 48-59. Levinthal, D. A., & March, J. G. (1993). The myopia of learning. Strategic Management Journal, 14, 95-112. Marion, R. (1999). The edge of organization: Chaos and complexity theories of formal social systems. Thousand Oaks: Sage Publications. Marquardt, M. J. (1996). Building the learning organization. New York: McGraw-Hill. Miettinen, R. (1998). About the legacy of Experiential Learning. Lifelong Learning in Europe, 3, 165-171. Nonaka, I. (1991). The knowledge creating company. Nonaka, I. (1994). A dynamic theory of organizational knowledge creation. Organizational Science, 5(1), 14-37. Rucci, A., Kirn, S. P., & Quinn, R. T. (1998). The employee-customer-profit chain at Sears. Harvard Business Review, 76(1), 82-98. Schein, E. H. (1992). Defining organizational culture, In Organizational culture and leadership, 2nd Edition (pp. 3-23). New York: McGraw-Hill. Schenke, R. (2001). Key assets that create value in health care. Physician Executive, 27(1), 6-11. Schwandt, D. R., & Marquardt, M. J. (2000). Organizational learning: From world-class theories to global best practices. Boca Raton, FL: St. Lucie Press. Senge, P. M. (1990). The fifth discipline: the art and practice of the learning organization (1st ed.). New York: Doubleday/Currency. Sigler, J. (1999). Best practices and guiding principles: A training guide to successful development of a learning organization. Futurics. Sparrowe, R. T., Liden, R. C., Kraimer, M. L., & Wayne, S. J. (2001). Social networks and the performance of individuals and groups. Academy of Management Journal, 44(2), 316-325. Stewart, T. A. (2000). The house that knowledge built. Fortune Magazine, 142(7), 278-280. Warhurst, C. (2001). Knowing in firms: Understanding, managing and measuring knowledge. Management Learning, 32(1), 148. Weick, K. E. (1993). The collapse of sense-making in organizations: The Mann Gulch Disaster. Administrative Science Quarterly, 38(1993), 628-652. Weick, K. E. (2001). Making sense of the organization. Oxford, UK: Blackwell Publishers. Wilson, L., & Wilson, H. (1998). Play to Win: Choosing Growth over Fear in Work and Life. Austin, TX: Bard Press, Inc. Youngblood, M. D. (1997). Life at the edge of chaos: Creating the quantum organization. Dallas, TX: Perceval Publishing. Zemke, R. (1999). Why organizations still aren 't learning. Training, September 1999.