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Strategic Learning in Healthcare OrganizationsMichael J. O'sullivanPublished online: 30 Mar 2010.

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Strategic Learning inHealthcare OrganizationsMICHAEL J. O'SULLIVAN

Caught between two eternities-the vanished pastand the unknown future-we never cease to seekour bearings and our sense of direction.

-Daniel J. Boorstin

Six years after the defeat of the Clintonadministration's proposal of a national sys-tem of "managed competition" among

providers, managed care dominates the healthcaremarketplace, having evolved on its own, mainlybecause of economic and cost-competitive pres-sures (Kilborn 1998). Changes in the healthcaredelivery system have been fundamental and farreaching (Wilson and Porter-O'Grady 1999).Many healthcare organizations have been forcedto close; others have affiliated or merged to formvertically and horizontally integrated systems ofcare. Some changes have been contradictory. Forexample, some physicians have joined hospitals inphysician-hospital organizations to present a uni-fied approach in negotiating with managed careorganizations; others have formed completelyindependent organizations that pit hospitals andmanaged care organizations against each other.

Because of the fundamental contradictions andshifts, there is a need for equally fundamentalchange in the way healthcare administrators pro-vide strategic direction for their organizations.

That requires new ways of thinking about strategicplanning and organizational change. With conven-tional healthcare assumptions turned on their head,traditional approaches to managing healthcare ser-vices may not succeed. The changing healthcareenvironment demands innovative methods to dealwith new situations (McDaniel 1998).

This article introduces the concept of strategiclearning as part of an approach to the uncertaintyfacing hospitals and other healthcare delivery sys-·terns. Drawing on organizational research and the-ory, integrated delivery systems, and examples ofstrategic learning in hospitals and organizationsoutside of healthcare where strategic learning ismore fully embedded, I will suggest practices thathealthcare leaders can implement to create a cli-mate for continuous strategic learning within theirorganizations. Before exploring this approach, how-ever, it is necessary to review beliefs that still guidemany healthcare planning efforts.

TRADITIONAL MODELS FOR THE PLANNINGOF HEALTHCARE SERVICES

Traditionally, the typical healthcare facility hasassumed that the healthcare landscape is character-ized by a relatively unimpeded vision of the futureplanning horizon. At the start of the traditionalstrategic planning effort, administrators scan theplanning horizon and try to forecast all significant

Dr. Michael J. O'Sullivan reaches and consults in the areas of strategic learning and planning, and is currently working on theorganization of a Comprehensive Community Nahma Coalition for the Greater Lowell area in Massachuserrs,

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14 Vol. 77, no. 3 Summer 1999

Success stories do

not result from a

"master plan"

but from a lengthy

trial-and-error

process.

environmental changes that may affect the facility,usually covering a three-to-five-year span. Assum-ing these forecasts will prove correct, the healthcareorganization then selects points in the future asfixed objectives against which progress can begauged. A detailed road map-the "strategicplan"-is drawn up with specific routes identifiedfor clinical and support services; managerial oper-ations; marketing, finance, and information sys-tems; and so on, all coordinated to allow the orga-nization to reach its goal as directly and efficientlyas possible. This is a traditional "command andcontrol" approach, in which the top of the organi-zation does the thinking and the rest of the orga-nization is supposed to comply (Senge 1995). It isbased on the "scientific management" school of

thought and a preoccupa-tion with organizationalstructure and the bureau-cratic control of its devel-opment (Schein 1969). Itraises questions such as,Which departments areassigned which responsi-bilities for pursuing thegoals? and Who shouldthe nursing departmentreport to in this new con-figuration? Executivesusing this approach designa plethora of systems, con-trols, and procedures to

make the plan happen (Collins 1999). Theapproach works well when the environment is rel-atively calm and stable, but it is of little use whenconditions are turbulent and the future uncertain.The problem is that the controls also createbureaucracy, which does not breed innovative staffperformance. "Bureaucracy may deliver results,but they will be mediocre because bureaucracyleads to predictability and conformity. Historyshows us that organizations achieve greatness whenpeople are allowed to do unexpected things-toshow initiative and creativity, to step outside thescripted path. That is when delightful, interestingand amazing results occur" (I 999, 73).

Not only are outcomes hard to control, forecastscan be faulty. Coile (1998) points out "sure-fire"predictions widely used in healthcare strategicplanning that did not work out. For example, Cal-ifornia's Kaiser staff model of medical organizationwas widely considered the most efficient in U.S.

medicine. It was the standard for determining spe-cialty physician-population ratios. In the early1990s Kaiser invested millions in creating a com-pany-owned network of hospitals and clinics forthe decade ahead. But today, Kaiser is closing hos-pitals and contracting for acute care and physicianservices, abandoning its own model. Despite manypredictions that capitation would dominatehealthcare payment, that reimbursement modelhas taken hold slowly, with discounted fee-for-ser-vice becoming the dominant mode of physicianand hospital payment. California HMOs exten-sively used primary care physicians as gatekeepersto their systems, but attempts to apply the gate-keeper model in other markets have met with stiffresistance from consumers and their political rep-resentatives (Mitchell 1999).

The problem with the traditional approach isnot that it is entirely wrong but that it is incom-plete and static. It makes assumptions about thestability of the environment and the organizationthat do not conform to today's reality. Successfulstrategic change is rarely clear-cut or controllable.First, it is usually impossible to see clearly the finaldestination of a strategic planning process. Insteadof planners standing at the top of a mountain on aclear day and picking out a strategic destination toguide the organization toward, planning is morelike a trip into a fog-shrouded forest where themajor obstacles, let alone the final destination,cannot be clearly discerned. Healthcare organiza-tions confront a murky future in the face of man-aged care, price competition, rising prescriptiondrug costs, and Medicare cuts. Clinical, competi-tive, political, financial, and social developmentsoften cloud our picture of the planning horizon.Moreover, it is only after an organization begins toimplement strategic planning that the next set ofproblems comes into focus and the efforts neededto surmount them can be evaluated. And everystep in the process requires constant reflection andreevaluation.

Successful strategic change usually does notcome about from detailed, bureaucratic plansdeveloped by the senior management. In mostcases, fundamental organizational change arisesfrom setting out in a direction determined by themission, vision, and values of the organization. Asnew insights about the environment are revealedand discoveries made, advancement comesthrough readjusting old maps, revising plans, andtaking new actions. Success stories do not result

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from a "master plan" but from a lengthy trial-and-error process (Kanter 1991). Few organizationsrecognize this fact, and many managers create elab-orate fictional pictures of how changes actuallyoccurred. These managers are revisionist historianswho reconstruct a simplified picture of what reallyhappened to suggest that current successes haveresulted from superb plans developed by idealisticleaders and carried out by skillful managers. Thismay be understandable, as it is difficult to admitthat success has occurred through a messy learningprocess that management did not fully anticipate,comprehend, or control. However, this reality is afar cry from the command and control precepts ofscientific management.

The command and control perspective impliesthat senior management must strictly master theorganization's destiny as part of strategic planning.However, in today's radically changing environ-ment, healthcare organizations must relinquish theillusion of tight control over every functional unit.Rather than seek stability as their goal they mustsee their organization as looser, more fluid andorganic than linear and deterministic (Morgan1997). They must learn to deal with an unfolding,continuously changing environment. The newmodel has been characterized as a "learning orga-nization" by Senge (1990); in healthcare it possess-es many of the attributes of an "agile" organizationas described by Goldman and Graham (1999).

LEARNING TO CHANGE BY CREATING ASTRATEGIC LEARNING ORGANIZATION

According to Senge (1990), the future and theenvironment are so fundamentally unpredictablethat successful change can come about only whenorganizational learning and strategic readinessreplace excessive control in complex organizationssuch as healthcare facilities. Furthermore, the mostimportant learning of an organization comes notfrom what is learned from other organizations-asimportant as benchmarking and looking to otherorganizations for ideas may be-but from innova-tive trial-and-error conducted by the healthcarefacility itself. Healthcare organizations must care-fully reflect on their own experiments in learningand decide whether they will be diffused andimplemented throughout the organization,allowed to operate in just one part of it, or quashedas an important but unsuccessful attempt atchange-a valuable learning experience.

Organizational learning, even if it works per-

fectly at first, should evolve. New learning experi-ences often produce unintended negative conse-quences that need correction. Administrators needto engage their organizations in learning processesthat allow strategy to emerge as the organizationinteracts with its environment (Kiel 1994;Mintzberg 1994). Learning as things unfold, per-mitting strategy to arise, is the key to confrontingeffectively the problems that emerge from theunknowable future. For example, Ginter, Swayne,and Duncan (1998) described how a hospitalmoved into a full range of cardiac services withoutan explicit strategy to do so. In an effort to attractpatients and enhance its image, the hospital firstbegan offering limited cardiac services. The movewas successful, but soon they found that they werenot performing enough procedures to be "worldclass." They added services, equipment, and facili-ties to help create the required volume and endedup with an emergent strategy to develop compre-hensive cardiac services (27). These managersdevised a preliminary strategy, started down theroad, and, acquiring new information, madechanges based upon the new knowledge.

INDMDUAL LEARNING ANDORGANIZATIONAL LEARNING

There have been many attempts to understandthe elusive process of individual experiential learn-ing. As described by Redding and Catalanello(1994), John Dewey first conceptualized individualexperiential learning as a cyclical process, movingfrom thought to action to reflection, and thenrepeating in a continuous cycle. A slightly modifiedexample of this cycle might be a physician treating apatient with severe clinical depression. In the firststep, the physician conceptualizes a treatment planbased on the patient's presenting symptoms, onwhat the physician learned in medical school, andon successful experiences with similar cases. Thephysician prescribes, for example, medication, anexercise and diet regimen, and a course of "talking"therapy, and meets with the patient's family to gath-er more information. The physician reviews thepublished literature or requests consultations withmedical colleagues experienced with the condition.After devising the preliminary treatment plan, thephysician implements the treatment strategy. Imple-menting the plan is the second phase of the learningprocess. The physician then checks on how thepatient is faring and enters the third phase, revisingthe plan based upon the latest available information.

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THE STRATEGIC ORGANIZATIONALLEARNING CYCLE

care practice, such as gene therapy, or a modifiedpractice, such as genetic counseling for breast can-cer patients, does not guarantee the knowledge willbe used effectively. The healthcare organizationmust change policies and procedures based on thisnew knowledge. Garvin (1993) offers a conceptionof organizational learning as both acquisition ofnew knowledge and new action based upon thatknowledge. "A learning organization is an organi-zation skilled at creating, acquiring, and transfer-ring knowledge, and at modifYing its behavior toreflect new knowledge and insights" (80). Accord-ingly, learning organizations have the capacity tothink and act in fresh ways based on new knowl-edge that comes from their own performance andfrom the environment. This can be accomplishedsystematically by continually cycling through astrategic organizational learning process.

The Strategic Organizational Learning Cycle issimilar to the individual learning cycle, with theaddition of the important concept of organization-al diffusion. The five steps of the organizationallearning cycle are (1) continuous planning, (2)improvised implementation, (3) continual revi-sion, (4) organizational diffusion, all of it heldtogether with (5) intense reflection. These steps arediagrammed in figure 1 and explained below.

Continuous Planning

Traditionally, healthcare organizations haverelied on detailed written programs and proceduresto communicate from the top to the bottom of theorganization what needs to be accomplished. Oftenthe manner in which the plan was developed wasungainly and slow, and when the time for imple-mentation arrived, the plan was out ofdate becauseof changes in both the organization and the envi-ronment between conception and execution. More-over, healthcare organization managers often forgotabout the human side of organizational change.Because the members of the staff responsible forcarrying out the plan frequently were not meaning-fully involved in the plan's development, they werenot committed to its implementation. Asa result ofthese factors, the strategic plans of healthcare orga-nizations, once developed, were often irrelevant. Totranscend these formidable problems, strategicplanning in healthcare organizations has to becomecontinuous and must involve a wide array of people

ment strategy.

LEARNING INORGANIZATIONS

At the point the physician takes stock of thepatient's condition, he or she has the opportunityfor experiential learning. The doctor intenselyreflects on the actions and interventions taken andjudges which ones seem to have had a beneficialeffect. The physician questions original assump-tions and modifies the original plan in response tothe patient's behavioral signs and symptoms, datafrom laboratory results, and feedback from thepatient. Over the next several cycles of this learningprocess, the treatment plan becomes more refinedas the physician reflects and makes judgments as towhat worked and what did not. The learning con-tinues, and as the physician passes through eachcycle, he or she observes whether the patient isimproving or deteriorating. By passing through the

cycles, the physician exer-cises individual experien-tial learning to determinethe direction of the treat-

Organizations learnfrom experiences in muchthe same way as individu-als. Argyris and Schon(1978) first formed theconcept of organizationallearning as a mechanismto correct mistakes. In a

study that attempted to discover ways to ensure thesurvival of organizations, de Geus (1988) found ituseful to conceptualize strategic planning as aprocess of organizational learning. He studied anumber of organizations that had survived for rel-atively long periods of time (more than 75 years),compared with the average survival of companies(about 40 years). He concluded that the successfulorganizations survived because of management'scapacity to absorb what was going on in the envi-ronment and to act on that information by initiat-ing appropriate responses. In other words, theseorganizations depended on learning, or more accu-rately on organizational learning, to adapt to thechanging conditions.

However, for an organization to survive, organ i-zationallearning cannot be limited to the acquisi-tion of new knowledge; the knowledge must beput to effective use within the organization.Acquiring information about a brand new health-

Healthcare organiza-

tion managers often

forgot about the

human side of organi-

zational change.

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FIGURE 1. The strategic learning cycle

17

from the top to the bottom of the organization.Those individuals must be committed to thechange and must have the clinical and managerialskills necessary to carry out new behaviors (Mac-Cracken 1998), rather than merely comply withtop administrators' directions.

Strategic plans are still essential for significantorganizational change. The managerial and bud-getary details of strategic plans are often valuablereality checks for untested visions and goals. End-ing the process would be a mistake. Hospitals andother healrhcare organizations must analyze theinformation about their environments, chartstrategic directions, and develop measurable objec-tives as well as budgetary targets for the future. Theproblem is not strategic planning itself but theunderlying assumption that administrators canpeer three to five years into the future and makeforecasts with precision and reliability. The prob-lem is the limited, mechanistic, and linear bureau-cratic approach that attempts to create the all-encompassing master plan.

By contrast, in learning organizations strategic

planning is an evolving process, with plans beingquestioned, refined, and continuously modifiedbased upon the most current information aboutthe environment as well as insights gained fromimplementation, reflection, and diffusion efforts.In strategic learning organizations, fixed plans arereplaced by flexible strategic directions that involvethe participation of key people throughout thehospital, including physicians, nurses and othertechnical professionals (the source of most clinicalinnovation), top-level administrators, mid-levelmanagers, and employees from all levels. Patientsare also a source, perhaps one of the most impor-tant ones, for appropriate and timely solutions.Coile (1998) reports that one hospital's qualityteam focused on 300 ideas for speeding up thetime required to discharge patients, without find-ing an effective solution. Finally, a chance remarkby a patient led to an insight by a low-level mem-ber of the team: schedule a ride in advance. Thehospital had always assumed it was the patients'responsibility to arrange for their own transporta-tion upon discharge.

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ImprovisedImplementation

In strategic learning

organizations,

individuals and teams act

in creative, autonomous,

and spontaneous ways to

convert plans into reality.

18

Other stakeholders from outside the health careorganization who are often involved include thesuppliers of new technologies, insurers and thepayers of care with new payment and reimburse-ment schemes, and politicians and governmentalregulators with new social policies. All are impor-tant players in the strategic learning organization,and their insights and perspectives can be invalu-able. In one city, clinical researchers from an MRIfirm providing mobile services to several hospitalsand radiologists at the hospital sites were thesources of new MRI applications. Innovation camefrom outside the organization-from supplierswho developed and designed the equipment-andfrom the hospital radiologists who were employingthe equipment.

In a strategic learningorganization, implementa-tion differs greatly fromthat in traditional organiza-tions, which rely on for-mal, detailed proceduresthat spell out how plans areto be implemented. Instrategic learning organiza-tions, individuals andteams act in creative,autonomous, and sponta-neous ways to interpret

strategic direction and convert plans into reality(Beckman 1992). Describing the implementation ofa strategic learning process, Redding and Catalanel-10 (1994) reported that rather than micromanagingthe implementation process-s-developing detailedschedules with tight timelines and strict account-abilities-the company used an improvisationalapproach to implementation, encouraging experi-mentation and directing change in a flexible man-ner. At the early stage, the company supported spon-taneous, grassroots initiatives and established ad hocstructures to support experimentation. As changesdeveloped, the organization's leaders sanctionedthem without taking them over, quietly clearingaway obstacles and facilitating cross-fertilizationamong the staff. After a change began to prove itselfuseful, the company recognized the success, reward-ed the achievement of those responsible, and insti-tutionalized the change with formal conversions ofstructures, rewards, procedures, and policies.

Vol. rr, no. 3 Summer 1999

HealthSystem Minnesota offers a good exampleof a similar type of implementation (Appleby1997). HealthSystem Minnesota grew out of amerger in 1993 between Methodist Hospital andthe 450-doctor Nicollet Clinic, attempting to pro-vide integrated care across all delivery points. Tocement the merger, the system had to undergomajor strategic change, including numerous incre-mental and adaptive changes. The pattern ofchanges that took place at HealrlrSystern Minneso-ta is indicative of the strategic learning that occursat all levels of an organization. A major clinicaleffort called Care 2000 was developed to integratecare in all settings within the expanded system.The strategic direction included producing arough outline showing how the system providedcare for patients, envisioning the ideal process ofcare through discovering the gaps in the currentprocesses, and, finally, determining how informa-tion technology and open communication tech-niques among staff could help make the newly dis-covered ideal of care a reality throughout theorganization.

The implementation of new practices across com-plex healthcare delivery systems is a major challengecomposed of predisposing, enabling, and reinforc-ing activities such as shared vision, facilitative lead-ership, and open channels of communication withreciprocal information flows (Barnsley, Lemieux-Charles, and Kinney 1998). Personnel who areexpected to acquire the knowledge and skills to

implement a new clinical or administrative practicemust be convinced that it will work in their areas ofresponsibility. Furthermore, they must have theresources, such as funding, personnel, and informa-tion, to make the change (Shapeman and Backer1995). And staff members must have the time andresources to acquire the new knowledge and skills.When they feel their performance will be assessedwith little or no time for learning or skill develop-ment, they are likely to adopt defensive behaviorsthat support their own survival rather than the mis-sion of the healthcare facility.

Leadership plays a major role in establishing theinfrastructure for organizational learning (Kotter1990). Overcoming the barriers that prevent orga-nizational learning involves defining a vision anddirection, including employees in the wholeprocess, and putting information into their hands(Beckman 1992). The commitment of the organi-zation's leaders to learning and innovation can beassessed by the extent to which they create struc-

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Organizational Diffusion

Learning that occurs

within a healthcare

organization has to be

more than just a local

affair.

HOSPITAL TOPICS: Research and Perspectives on Healthcare

tures to support the transfer and assimilation ofknowledge.

In one hospital's mental health service thismeant hiring a hospitalwide contracts officer(based in administrative services) to keep track ofall negotiations the hospital had with managedcare organizations and monitor their differentrequirements for reports, payment schedules, andbenefit packages-information essential in prepar-ing contract proposals for provision of services totheir members. The contracts officer's effortswould help the mental health service and otherdepartments position themselves to respond pro-grammatically to the complicated and changingrequirements. The challenge for the manager ofthis mental health service was to develop a compli-cated set of relationships both within and outsidethe organization, forming networks of informa-tion-driven connections to create order from a dis-ordered world (Senge 1990). The administrativemanager took the lead and scheduled regular meet-ings with the contracts officer, the marketingdirector, administrators, and clinicians from themental health service to discuss, and envision ful-filling, the demands of the managed care organiza-tions. Her goal, in responding to the requirementsof the external world, was to find ways in whichstaff members, each with their limited perspective,could contribute to the development and emer-gence of the hospital's managed care strategy.

In this instance, the manager of the mentalhealth service was rewarded with a raise and high-er status for her innovative steps involving the con-tracts officer and securing additional contracts. Toencourage this type of innovation and creativity,administrators need to reward risk taking thatcould result in failure, thus ensuring that the dis-tribution of incentives and rewards reflects thehigh value placed on learning.

Continual Revision

Revising a plan based on the latest informationfrom the environment, and from changes broughtabout by the plan's implementation within theorganization, is a continual process in the strategiclearning cycle. Open structures involving variablejob responsibilities and extensive lateral and verti-cal communication enable and reinforce theseorganizationwide revisions. Some of the methodsused for the continual revision of strategic plan-ning are the total quality management (TQM) andcontinuous quality improvement (CQI) processes

(Leebov and Ersoz 1991), the organization ofpatient care around clinical service lines, and inte-grating mechanisms such as systemwide newslet-ters, regular meetings of hospital executives, con-tinuing-education programs, learning forums withspecific learning goals, and clinical and manage-ment rotation programs.

Learning that occurs within a healthcare organi-zation has to be more than a local affair to be effec-tive. Transferring the new knowledge to other sec-tors of the hospital or healthcare system, where itcan be applied, is essential. As pointed out by Kan-ter (I 991), who studied change in successful orga-nizations, most successfulchange efforts startthrough the proliferationof a large number of mod-est experiments and inno-vations, and the most suc-cessful are promotedthroughout the organiza-tion. The actual nature ofa strategic change is onlygradually revealed, as peo-ple throughout the organi-zation act to make thechange. Through this dif-fusion process, people dis-cover for themselves overtime that change is in their best interest and thatthe benefits outweigh risks such as the potentialloss of power, status, security, and expected careeradvances. And over time, successes and accom-plishments can be reinforced and institutionalized.Again in the diffusion stage, development of com-munication channels within an open structure isessential so that various parts of the system canlearn about the new innovations and adopt thosethat work.

As in any effective strategic learning process, theprocedures of Care 2000, HealthSystem Minneso-ta's strategic effort, initially were not adopted orga-nizationwide but were tested in one location. Thecancer center was selected for initial implementa-tion because it spanned a wide range of care set-tings, with significant inpatient, outpatient, andhome care components. The cancer programincluded a special care floor in the hospital with150 staff members, a home care agency that sup-ported inpatient treatment and provided hospice

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care, a multi-doctor outpatient clinic, two outpa-tient IV chemotherapy sites, a solo medical prac-tice, and pastoral care and music therapy pro-grams. The center's staff already participated inpatient care teams, but the challenge was to geteverybody pulling in the same direction, and toreflect on how well the teams did their jobs. Thismix demonstrates that many healthcare teamsneed to learn and communicate what they learnedwith each other to be an effective team of care-givers. By providing the time and resources for thestaff to learn and apply new communication tech-niques, managers demonstrated the value of newknowledge and the importance they placed onbuilding new clinical skills.

Intense Reflection

At the center of the Strategic OrganizationLearning Cycle, and integral to all aspects of it, isintense reflection. In strategic learning organiza-tions, learning is not something that just happens,it is made to happen by constant reflection on thesuccess or failure of the experimentation. Learningbegins when those involved in an activity stop andexamine how things are being done and whatkinds ofeffects are being produced. Strategic learn-ing organizations attempt to provide continuous,ongoing opportunities for reflective learning,rather than wait for problems to arise beforeundertaking evaluation. Reflection becomes partof the organizational culture-"way things aredone"-and is built into the process of strategicchange. Through reflection, strategic learningorganizations question basic beliefs and search forsystemic solutions to problems, rather than merelyreact to symptoms (Redding and Catalanello1994). In contrast, traditional strategic planningprovides limited opportunities for reflection. Iknow of healthcare organizations in which there isbut one designated iteration of the planning cycleper year. Many organizations stop and examineimplementation activities only when obviousobstacles appear, rather than continually reflectingon the success or failure of innovation. As a result,strategic responses may take years to occur andmay be the proverbial "too little, too late."

Information systems are necessary for seriousand continuous reflection. Computerized systemsfor selecting methods of care and for managementdecision-making can be important learning tools;they develop a communal memory that partici-pants throughout the organization can tap into

Vol. 77, no. 3 Summer 1999

and use (Menduno 1998). Although such auto-mated computer systems can be very helpful, theyare not essential. What is essential for success is afree flow of information up and down the organi-zation as well as across traditional departmentalboundaries.

Strategic learning organizations continuouslytake action, reflect upon that action, and modifyplans based on insights gained through this learn-ing process. The aim is to maximize the speed andeffectiveness of strategic change by incorporatingintense reflection into all change efforts, not wait-ing for the next annual planning cycle or crisis todemand reevaluation. Each iteration of the learn-ing process consists of drawing back, if just for aninstant, and asking, How far have we come inaccomplishing not just what we set out to do, butwhat we need to accomplish, given what we knowtoday about our healthcare facility and our envi-ronment? It is essential to question originalassumptions continually and develop deep, sys-tematic solutions to newly discovered problems.Insights gained through this process are then usedto modify the original plans. The process of reflec-tion allows emergent strategies to bubble to thesurface and become apparent.

SUMMARY

There is no definitive blueprint for the health-care organization involved in strategic learning.However, what distinguishes strategic learninginstitutions is their acknowledgment that theymust discover their own paths and solutions ratherthan blindly follow a detailed strategic mandatefrom administration. Answers to their most criticalimplementation and adaptive questions will notflow down ready-made from above, but will be tai-lored to meet the requirements of their own par-ticular situation. Strategic learning organizationshave certain attributes in common in developingtheir own answers:

• They continuously experiment rather than seekfinal solutions.

• They favor improvisation over forecasts.• They formulate new actions rather than defend

past ones.• They nurture change rather than permanence.• They encourage creative conflict rather than

tranquillity.• They encourage questioning rather than compli-

ance.

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• They expose contradictions rather than hidethem (Weick 1977).

Most importantly, strategic learning organizationsrealize that successful strategic change is bestundertaken as a process of learning (O'Sullivan1999).

Healthcare organizations can no longer affordthe illusion of traditional strategic planning, withits emphasis on bureaucratic controls from the topto the bottom. They must embrace the fundamen-tal truth that most change occurs through process-es of learning that occur in many locations simul-taneously throughout the organization. The initialstep in discovering ways to improve the capabilityof healthcare organizations is to adapt continuous-ly while fulfilling their mission. Healthcare leadersmust create a shared vision of where an institutionis heading rather than what the final destinationwill be, nurture a spirit of experimentation anddiscovery rather than close supervision andunbending control, and recognize that plans haveto be continuously changed and adjusted.

To learn means to face the unknown: to recog-nize that we do not possess all the answers; to con-cede that we do not always know what to do; to

admit that past actions and solutions may nolonger be appropriate, in fact may have been theincubators of today's problems; to question basicassumptions long held about running the institu-tion; and to make ourselves vulnerable to the polit-ical dynamics prevalent in all organizations. Hos-pitals and other healthcare organizations must seekto develop and maintain a continuing state ofreadiness in which everyone in the organization,from front-line clinician to senior management, ispoised to act in anticipation of and in response to

unforeseen changes in the environment and tolearn from their own experiences in confrontingthe future.

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