In 1990 Peter Senge published his best-selling book, The Fifth Discipline, where he ushered in a new wave of organizational thinking focused on creating a learning organization. He identified four elements that were necessary to create a learning organization: personal mastery, mental models, shared vision, and team learning. His point was to call out the need for organizations to adopt the mindset and practice of continuous learning, and how this particular mindset was essential for survival in an ever-increasingly complex environment (Senge 1990).
At the time, it became quite common to hear leaders declare that their organization was a learning organization, or that it needed to become a learning organization. For those listening to the message, it made good sense and we would all nod our heads in agreement, for truly this was the wave of the future. The problem was in how to actually make it happen. In fact, Senge himself fretted that the idea of the learning organization could simply become a passing fad, the concept du jour, as it were (Senge 1990). Interestingly, it was his ideas around systems thinking that eventually took on more prominence, likely because it was comprised of “archetypes” that were much more concrete, and thus seen as easier to implement.
Today, we continue to hear executive leaders in health care proclaim to large audiences: “We are a learning organization, and we are well-positioned to succeed in the future.” While the idea of being a learning organization is still attractive, it has continued to remain abstract at best. How does one actually create a learning organization? Furthermore, what does it actually mean to be a learning organization?
In hindsight, this makes sense. The genius of Senge’s work, from our perspective, is that he was calling out the complex nature of our environment and that a new metaphor was needed for our organizations, one that shifted us from the notion that organizations are machines, to one that recognized organizations as biological entities that live, change shapes, and sometimes die. The field of complexity science (which itself was active during this time period, but little known) has consistently built on this over the past two decades, and is now generating more deliberate and actionable models (Decuyper, Dochy, and Van den Bossche 2010).
Table 2.1 Comparison of learning organization approaches (Edmondson 2012; Senge 1990)
Edmondson |
|
Personal mastery Mental models Shared vision Team learning |
Teaming Organizing to learn Execution as learning |
In 2013 Amy Edmondson published Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy, where she sought to make the idea of a learning organization less abstract and more practical. Her model focuses on creating a learning organization through the act of “teaming.” Once teaming behaviors are well established, an organization must then structure and organize itself to learn. Lastly, the organization must then focus on execution as learning, which acknowledges the fact that the learning must be continuous and never cease (Edmondson 2012). Edmondson makes deliberate connections to complexity science and discusses how complex adaptive systems are able to self-organize and adapt in response to a rapidly changing environment. This is not possible without bringing an explicit and deliberate focus to the practice of learning. Our focus here is on the learning capability of teams. While we believe in the notion of the learning organization, it is much easier to conceptualize—and implement—a learning mindset at the individual and team level. (See Table 2.1 for a comparison of Edmondson’s and Senge’s perspectives on learning organizations.)
So what does it truly mean to learn? And more importantly, what does it mean to learn collectively? While Senge and Edmondson certainly offer useful frameworks, we would like to expand on their thinking by further exploring the following areas as they relate to teams creating a culture of learning:
• Mindset
• Adaptability
• Positive deviance (PD)
• Treating mistakes as learning opportunities
• Debriefing
Mindset
Having a learning focus begins with establishing a mindset to learn. On the surface, this may sound like a relatively simple thing to do—or at least proclaim. After all, learning is something that has been a focus for us since we began our educational “careers” as preschoolers and kindergartners, eventually culminating (for many, but not all) with a college degree. This focus continues in many of our organizations where training and development programs provide opportunities for employees to gain new skills and abilities to make them more productive or efficient. In fact, one could say that the attainment of education is a goal espoused the world over, and many invest significant resources to help make this achievement possible (“Education | Global Partnership for Education”).
Yet, when we look more deeply into our health care organizations we can find innovation lacking, and situations where staying with the tried and true becomes the norm—not because it necessarily works best, but because it is simply easier (Berwick 2003). Or worse, we have become complacent. It therefore becomes clear that education and learning are not necessarily synonymous. And what we need today in our health care organizations is more learning.
By having a learning culture, we are talking about a culture where exploration of new ideas is valued and considered the norm, where people are encouraged to speak up and collaborate, and where communicating openly across divisions, boundaries, and functions is a regular occurrence (Edmondson 2012).
Having such a mindset requires a fundamental belief that this type of learning is not just valuable, but is also critical to the future success of patient care and quality. Bruce Avolio, with the University of Washington’s Foster School of Business, and executive director of the Center for Leadership and Strategic Thinking (CLST), believes leaders need to assess their “readiness and motivation to learn” and one way to do this is to understand our own preclusion toward having a learning goal orientation or performance goal orientation (See Table 2.2 for a comparison of learning goal and performance goal orientations.) (Avolio and Hannah 2008).
Table 2.2 Comparison of performance goal and learning goal orientations
Learning goal orientation |
|
Focus is on completing tasks May avoid risk Feedback equals fixing something |
Thrives on new challenges Failure equals learning opportunity Seeks feedback; feedback equals learning |
Leaders with a learning goal orientation are curious and frequently seek new ways of understanding the issues and situations that confront them. They want to move beyond existing practices, and have a true desire to understand the deeper workings behind the problems they are facing. In their book, Managing the Unexpected, Karl Wieck and Kathleen Sutcliffe call out the key traits of High Reliability Organizations (HROs) of preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise (Weick and Sutcliffe 2011). Leaders of HROs engage others in this questioning to help get more hearts and minds involved in examining the issues at hand.
Leaders with a performance goal orientation are more concerned with meeting daily tasks and operational goals. The accomplishment of the project or task becomes paramount for them, and there may not be as much energy devoted to the learning process behind the task or project (Avolio and Hannah 2008; Dweck and Leggett 1988; Edmondson 2012).
While both orientations are needed (and beneficial) the leadership research clearly shows that leaders who adopt a learning goal orientation generally achieve better results (Avolio and Hannah 2008).
Yet another argument that supports the idea of having a learning mindset is Daniel Pink’s enlightening book on motivation, Drive. Pink called out mastery as one of the three elements having the most significant impact on our intrinsic motivation. He describes mastery in very simple terms: “the desire to get better and better at something that matters” (Pink 2009). He discovered that an important factor in getting “better and better at something that matters” requires putting in the time to get better. In other words, practice and effort. Putting in this practice, and engaging in this effort, requires a mindset that the hard work will pay off in the end. In health care we must ask ourselves: how do we make it possible for our teams to gain mastery?
To get better at what matters most to us, which is providing the highest quality and safest care in a way that respectfully engages the patient, we must not just support our teams, but we must take it to a higher level by engendering a learning mindset, one that gives them control over diagnosing and solving problems, and encourages their continual development in an effort of working toward mastery.
Questions to help you understand if you are engendering a learning mindset:
• Do you regularly ask your team members for their ideas on how to address problems (either recurring or acute)?
• When team members come to you, as the leader, and ask you to solve their problem, how do you respond? Do you take on their problem as your own, or do you ask them questions and encourage them to keep at it?
• To what extent do you question your own biases and assumptions? (also see Chapter 4)
Adaptability
We all recognize that our environment is constantly changing and the days of finding stability in our work places are largely a thing of the past. In the 1980s Shell Oil tackled this reality by revolutionizing the practice of scenario planning (De Geus 2002; Schwartz 1996). Its objective was to collect as much information as possible about the environment, and it used many different sources for this, looking well beyond the energy and petroleum sectors (e.g., political, social, technological, and so on). With the information in hand, teams would create various scenarios that could potentially come true. Eventually they would settle on three to five scenarios and would then ask: “How will we respond if this potential future happens?” It proved to be a powerful way to anticipate change and allowed them ultimately to be more adaptive and flexible as the environment continued to shift.
Consider our current health care environment for a moment: we are seeing unprecedented levels of change (e.g., accountable care, pay for performance, meaningful use, big data, health care grades, telemedicine, and other technological innovations). In speaking with leaders at all levels one consistent theme we continue to hear is the challenge and difficulty leaders are having in responding to these massive and continuous changes. Leaders report feeling overwhelmed, stressed, anxious, and worried that they may have missed something because they can’t possibly keep up with everything coming at them.
We assert that our response should be one of getting more comfortable being uncomfortable. We need to become more adaptive, more flexible. While this is a simple statement, and it sounds like the right thing to do, it really is more of an abstraction—“Sure, I’ll just come in tomorrow and I will be more adaptive!” Yet there are in fact some concrete skills we can employ to assist us with becoming more adaptive.
• Conduct regular environmental scans, and include your entire team (see Chapter 4 for more detailed information on conducting an environmental scan)—regularly engaging the team in the process of scanning the environment helps the team create a shared mental model of not only what they are seeing, but how they actually experience the environment around them. Since we all view the world through different lenses, giving the team the chance to periodically get explicit about what they are viewing helps reduce the instances of working at cross-purposes, and also provides clarity about new goals and improvement opportunities.
• Further develop the emotional intelligence competency, flexibility—at an individual level; flexibility involves stepping back from a situation and viewing it with fresh eyes, acknowledging that we may not hold all of the answers and that we need to turn to others (or other resources) to see the situation more clearly. At the team level, individual members can feed off of each other by openly exploring different approaches,
or asking questions to better understand why something may not be working the way they thought it would (the question listed in the next bullet is yet another way to encourage more flexibility).
• Deliberately ask the question, “If this were to happen, what would be the impact on us? How would we respond?” Leading the team through this mental exercise, which takes a page from the process of scenario planning, helps reduce the potential for “group think,” and also forces members of the team to get outside of their own heads, as it were. By role modeling this behavior, the leader can set the expectation of always thinking beyond the current situation—literally expanding the thinking capacity of the team.
Positive Deviance
Finding what is already working really well, despite challenges, learning about it, and figuring out how to replicate it, is the essence of PD. The reality in our health care organizations is that our teams are conditioned to focus on problems and what is not working. We are also constantly confronting what is known as the “normalization of deviance.” This condition arises when we get so comfortable with the current processes and ways of doing our work that we get complacent in continuing to pay attention to important details. Consider the example of learning to drive a car for the first time. Think back to that moment and reflect on the actions you took when you climbed behind the wheel—seat adjusted, seat belt fastened, mirrors adjusted, radio off (to limit distractions)—the list goes on. Now consider the actions you took when getting in your car to get to work, or the grocery store, or the kids soccer game—latte in hand, iPod plugged in, checking text messages—clearly, it is a different level of preparation and our safety is compromised; yet we continue to engage in this unsafe behavior day in and day out.
Examples of PD with health care teams certainly exist in our organizations—we just need to do a better job of seeking them out and learning from them. So this relates back to having a learning mindset. A wonderful example of applying PD is provided by Jerry Sternin, who traveled to Vietnam in 1990 to assist the government with addressing its child malnutrition. At that time, 65 percent of children under the age of three were malnourished. Sternin and his small team visited four villages and discovered that, even among these very poor families, a small number of children were actually not malnourished, and were in fact quite healthy.
He discovered that the parents of these children practiced a different habit of feeding their children. Rather than feeding their children twice a day (as was the normal practice in most households) these parents fed their children four to five times a day with smaller portions. Additionally, they added protein, in the form of shrimp and crab, and also added small amounts of sweet potato greens. His team, working with the various members of the villages, had discovered a reliable solution to the problem. They continued to work with the villagers to develop a process for helping other parents create this habit, and after several weeks 40 percent of children who had participated in this test were no longer malnourished, and an additional 20 percent had transitioned from being severely malnourished to moderately malnourished (Heath and Heath 2010; Marsh, Schroeder, Dearden, Sternin, and Sternin 2004).
Keith McCandless and Henri Lipmanowicz, and their work with Liberating Structures, make use of the concept of PD with their microstructure appreciative interviewing (Liberating Structures 2016). For example, in an effort to reduce hospital-acquired infections, Dr. Michael Gardam and his research team interviewed health care providers and teams to elicit successful examples of how they were working to prevent infections. After collecting these stories, they were able to share the practices with other providers, reinforcing the ability of frontline staff to make a difference in care (Liberating Structures 2016).
Therefore, leaders should seriously consider routinely identifying other teams in their organization (or outside the organization, if appropriate) that are getting outstanding results, are finding innovative solutions, and have adopted a learning mentality.
Treat Mistakes as Learning Opportunities
If we are to create a culture of learning, we must overcome our habit of punishing mistakes. Our society thrives on focusing on problems, identifying what went wrong, and then handing out blame. This is certainly the case in our political circles, our communities, and our health care organizations. These practices do not aid in creating a learning environment, and in fact actually work against it.
Amy Edmondson identifies a key leader behavior as framing situations as learning opportunities (Edmondson 2012). If our natural default state is to critique, criticize, or blame when a mistake occurs, the result will likely be one of self-preservation by the parties involved. Leaders, therefore, need to take the deliberate step of telling their teams that while the goal may still be to be error free, when errors or mistakes do occur, they will seek to understand the cause of the mistake so that appropriate changes can be made in order to prevent the same mistake from occurring in the future (Note: in cases where protocols or policies were deliberately ignored, or where specific intent existed to cause an error or harm, this approach does not apply, and the organization should take action to address the behavior).
Bringing the team together after an event, and openly exploring the reasons behind the mistake, creates shared ownership by the entire team. Once this level of diagnosis has occurred, the team can begin to look for ways to address the mistake, whether that be making changes to existing practices or policies, or developing new, innovative approaches to deal with the problem at hand.
Debrief
Related to the previous issue of getting comfortable with making mistakes, there is one practice we would like to call out as being particularly effective in creating a learning culture—the debrief.
The U.S. Army regularly conducts after action reviews (AARs) after operations; while leaders generally initiate these, the entire team participates and everyone is expected to offer their observations, the sole purpose being that they can learn what worked and didn’t work so they can make changes in the future.
While working with a group of surgical residents on identifying and practicing certain emotional intelligence skills, one of their attending physicians related a story from his days as a resident. During a surgical procedure, his attending physician instructed him to clamp and cut a duct. Believing he was getting ready to cut the ureter, he brought this to the attending physician’s attention. The response he received was pointed: “Cut it, and do it now!” Of course it did in fact turn out to be the ureter, which now had to be repaired. He took the appropriate action of speaking up, but the attending physician’s single-minded focus resulted in a preventable medical error.
Mistakes like these, unfortunately, still occur far too often in medicine. From our standpoint, the issue isn’t so much about the mistake (which certainly should not have occurred), but rather with the process. After this event, a debrief (or AAR) was never held, so there was no opportunity for the surgical team to turn the event into a learning opportunity, hopefully preventing the same mistake from ever happening again.
The team training program TeamSTEPPS advocates for the regular practice of debriefing. Leaders play a critical role by modeling the debrief where three questions are asked of the team:
1. What went well?
2. What didn’t go as planned?
3. What can we do differently next time?
It is critical to always begin by addressing what worked well. Health care providers are so accustomed to focusing on what is not working (with the good intentions of fixing things and making improvements) that they often forget to identify and call out what they are doing well. Then the team can move on to discussing the other two questions and identifying what they can do better next time. This is really about creating a habit, being extremely rigorous conducting debriefs (also referred to as reflection, AARs); if this process is not hardwired by teams, continuous learning is not possible.
Summary
If our health care teams are to become more effective in this ever-changing, complex environment, adopting a learning orientation can be a key strategy. Focusing on the areas of creating a learning mindset, being deliberately adaptive, researching the positive outcomes of other teams (PD), treating mistakes as learning opportunities, and conducting regular debriefs to learn what has worked and hasn’t worked could be useful to teams striving to take their performance to the next level. Shifting from a focus of problem solving to one of learning can help teams respond more productively to a changing environment, while also providing more support and satisfaction for team members.
End of Chapter Reflective Questions
• Assess your own orientation to learning—how would you describe your own learning mindset? What more could you do to foster a learning environment within your team?
• How can you deliberately seek out examples of efforts in your organization, or within your team, that are working well? How can you learn from their example?
• How do you handle mistakes when they occur? What is an example of a recent mistake that has occurred with your team? How did you handle it? How could you frame it as a learning opportunity?
References
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Berwick, D.M. 2003. “Disseminating Innovations in Health Care.” Jama 289, no. 15, pp. 1969–75.
De Geus, A. 2002. The Living Company: Habits for Survival in a Turbulent Business. Boston, MA: Harvard Business Review Press.
Decuyper, S., F. Dochy, and P. Van den Bossche. 2010. “Grasping the Dynamic Complexity of Team Learning: An Integrative Model for Effective Team Learning in Organisations.” Educational Research Review 5, no. 2, pp. 111–33.
Dweck, C.S., and E.L. Leggett. 1988. “A Social-Cognitive Approach to Motivation and Personality.” Psychological review 95, no. 2, p. 256.
Edmondson, A.C. 2012. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. John Wiley & Sons.
Education | Global Partnership for Education. Retrieved from http://globalpartnership.org/education
Heath, C., and D. Heath. 2010. Switch: How to Change When Change is Hard. New York: Broadway Books.
Liberating Structures 2016. Retrieved from http://liberatingstructures.com/
Marsh, D.R., D.G. Schroeder, K.A. Dearden, J. Sternin, and M. Sternin. 2004. “The Power of Positive Deviance.” BMJ: British Medical Journal 329, no. 7475, p. 1177.
Pink, D.H. 2009. Drive: The Surprising Truth about What Motivates Us, 138, 240. New York: Penguin Group, Inc.
Schwartz, P. 1996. The Art of the Long View: Paths to Strategic Insight for Yourself and Your Company. Crown Business.
Senge, P. 1990. The Fifth Discipline: The Art and Science of the Learning Organization. New York: Currency Doubleday.
Weick, K.E., and K.M. Sutcliffe. 2011. Managing the Unexpected: Resilient Performance in an Age of Uncertainty, 8. John Wiley & Sons.