title: Sustainability of healthcare improvement: what can we learn from learning theory?
abstract: BACKGROUND
  Changes that improve the quality of health care should be sustained. Falling back to old, unsatisfactory ways of working is a waste of resources and can in the worst case increase resistance to later initiatives to improve care. Quality improvement relies on changing the clinical system yet factors that influence the sustainability of quality improvements are poorly understood. Theoretical frameworks can guide further research on the sustainability of quality improvements. Theories of organizational learning have contributed to a better understanding of organizational change in other contexts. To identify factors contributing to sustainability of improvements, we use learning theory to explore a case that had displayed sustained improvement.
  
  
  METHODS
  Førde Hospital redesigned the pathway for elective surgery and achieved sustained reduction of cancellation rates. We used a qualitative case study design informed by theory to explore factors that contributed to sustain the improvements at Førde Hospital. The model Evidence in the Learning Organization describes how organizational learning contributes to change in healthcare institutions. This model constituted the framework for data collection and analysis. We interviewed a strategic sample of 20 employees. The in-depth interviews covered themes identified through our theoretical framework. Through a process of coding and condensing, we identified common themes that were interpreted in relation to our theoretical framework.
  
  
  RESULTS
  Clinicians and leaders shared information about their everyday work and related this knowledge to how the entire clinical pathway could be improved. In this way they developed a revised and deeper understanding of their clinical system and its interdependencies. They became increasingly aware of how different elements needed to interact to enhance the performance and how their own efforts could contribute.
  
  
  CONCLUSIONS
  The improved understanding of the clinical system represented a change in mental models of employees that influenced how the organization changed its performance. By applying the framework of organizational learning, we learned that changes originating from a new mental model represent double-loop learning. In double-loop learning, deeper system properties are changed, and consequently changes are more likely to be sustained.
authors.affiliation: Institute of Social Science, Sogn og Fjordane University College, Postbox 133, 6851, Sogndal, Norway. einar.hovlid@hisf.no
authors.forename: Einar
authors.initials: E
authors.lastname: Hovlid
authors.forename: Oddbjørn
authors.initials: O
authors.lastname: Bukve
authors.forename: Kjell
authors.initials: K
authors.lastname: Haug
authors.forename: Aslak Bjarne
authors.initials: AB
authors.lastname: Aslaksen
authors.forename: Christian
authors.initials: C
authors.lastname: von Plessen
mesh_terms: D019091:Critical Pathways; D006769:Hospitals, General / Q000458:organization & administration; D006801:Humans; D007858:Learning; D008962:Models, Theoretical; D009664:Norway; D009936:Organizational Innovation; D015397:Program Evaluation; D011785:Quality Assurance, Health Care; D058996:Quality Improvement