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Delivering feedback on learning organization characteristics - Using a Learning Practice Inventory

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Abstract

Learning is recognized to be at the heart of the quality improvement process in the National Health Service (NHS). However, the challenge will be how to ensure that learning becomes embedded within the NHS culture. The aim of this study is to identify a robust feedback process and format in which practices could receive data on their responses to a Learning Practice Inventory (a diagnostic instrument designed to identify a practice's capacity for collective learning and change). Five practices volunteered to test the instrument, and it was distributed to all members of the primary care team. A process was worked through to identify different formats for presenting scores within and between practices. The preferred method of data presentation was sought, and an evaluation gathered information on the preferred form of feedback, the usefulness of the data, the clarity of the questions and the level of interest in receiving further information. Eighty-five staff from five practices completed the questionnaire, and 61 individuals completed the evaluation forms. In most cases, there was a spread of scores by staff within practices and across the scale of 1-10. Medians were clustered at the learning practice end for all five practices. However, despite this skew, there were sometimes quite large differences between practices in their median scores. Our study suggests that a robust feedback process on collective capacity for learning and change can be identified that is useful and feasible. A key implication is that some form of educational support is required, and this work will take place as part of an ongoing programme of research by the authors.

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... Decision-making uses learning organization to describe existing practices [11][12][13] to analyze a situation to guide actions and to change practices within a health service organization. [14][15][16] The learning organization can be a powerful tool to promote learning within the health sector. ...
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... We have opted for a research design already validated by other LO empirical studies [20], involving the cross-sectional administration of a standard questionnaire tool to persons who are familiar with the case under investigation (for applications to health centres or hospitals see, for instance, Kelly et al. [30], Leufvén et al. [27], Mohebbifar et al. [31]). Our own survey tool is inspired from the tool developed by Garvin et al. [28]. ...
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Background: If there is one universal recommendation to countries wanting to make progress towards Universal Health Coverage (UHC), it is to develop the learning capacities that will enable them to 'find their own way' - this is especially true for countries struggling with fragmented health financing systems. This paper explores results from a multi-country study whose main aim was to assess the extent to which UHC systems and processes at country level operate as 'learning systems'. Method: This study is part of a multi-year action-research project implemented by two communities of practice active in Africa. For this specific investigation, we adapted the concept of the learning organisation to so-called 'UHC systems'. Our framework organises the assessment around 92 questions divided into blocks, sub-blocks and levels of learning, with a seven scale score in a standardised questionnaire developed during a protocol and methodology workshop attended by all the research teams. The study was implemented in six francophone African countries by national research teams involving researchers and cadres of the ministries involved in the UHC policy. Across the six countries, the questionnaire was administrated to 239 UHC actors. Data were analysed per country, per blocks and sub-blocks, by levels of learning and per question. Results: The study confirms the feasibility and relevance of adapting the learning organisation framework to UHC systems. All countries scored between 4 and 5 for all the sub-blocks of the learning system. The study and the validation workshops organised in the six countries indicate that the tool is particularly powerful to assess weaknesses within a specific country. However, some remarkable patterns also emerge from the cross-country analysis. Our respondents recognise the leadership developed at governmental level for UHC, but they also report some major weaknesses in the UHC system, especially the absence of a learning agenda and the limited use of data. Conclusion: Countries will not progress towards UHC without strong learning systems. Our tool has allowed us to document the situation in six countries, create some awareness at country level and initiate a participatory action-oriented process.
... In their study, Kelly et al. [22] assessed the 'collective learning capacity for change' by measuring the learning characteristics of a first-line services practice team in Scotland. Their approach was inspired by Senge's definition [1], as well as by other authors [23,24]. ...
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... As such, they were said to help to 'ground' the scale in actual (recognisable and meaningful) behavioural descriptors to add clarity and enhance the validity and acceptability of the instrument. 178,[183][184][185][186] The aim in modifying the BARS questionnaire and in creating the anchors for the questionnaire was, as far as possible, to use the terminology of the respondents and illustrate the choices (dilemmas?) they face in their daily practice as decision-makers trying to use evidence. ...
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... A recent study of military personnel found that feedback of data and revelation of problematic areas or deficits was more likely to result in the survey being perceived as useful and, in turn, influenced respondents' intentions to complete future surveys [14] . In a 2007 study of processes and formats for feedback of survey results to healthcare practices, researchers identified a useful and feasible feedback mechanism, which involved a feedback session comprising visual presentation of aggregated data in the form of dot plots [15]. From the knowledge-translation literature, evidence on the effectiveness of audit and feedback suggests that feedback of audit data has the potential to be effective in improving the practice of healthcare providers [16]. ...
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Background This project occurred during the course of the Translating Research in Elder Care (TREC) program of research. TREC is a multilevel and longitudinal research program being conducted in the three Canadian Prairie Provinces of Alberta, Saskatchewan, and Manitoba. The main purpose of TREC is to increase understanding about the role of organizational context in influencing knowledge use in residential long-term care settings. The purpose of this study was to evaluate healthcare aides’ (HCAs) perceptions of a one-page poster designed to feed back aggregated data (including demographic information and perceptions about influences on best practice) from the TREC survey they had recently completed. Methods A convenience sample of 7 of the 15 nursing homes participating in the TREC research program in Alberta were invited to participate. Specific facility-level summary data were provided to each facility in the form of a one-page poster report. Two weeks following delivery of the report, a convenience sample of HCAs was surveyed using one-to-one structured interviews. Results One hundred twenty-three HCAs responded to the evaluation survey. Overall, HCAs’ opinions about presentation of the feedback report and the understandability, usability, and usefulness of the content were positive. For each report, analysis of data and production and inspection of the report took up to one hour. Information sessions to introduce and explain the reports averaged 18 minutes. Two feedback reports (minimum) were supplied to each facility at a cost of CAN$2.39 per report, for printing and laminating. Conclusions This study highlights not only the feasibility of producing understandable, usable, and useful feedback reports of survey data but also the value and importance of providing feedback to survey respondents. More broadly, the findings suggest that modest strategies may have a positive and desirable effect in participating sites.
... While the systematic review by Jamtvedt et al. did not provide evidence that audit and feedback combined with other interventions , such as educational meetings or outreach, were more effective than audit and feedback alone [14], our interviews revealed that it was helpful and valuable for the administrators to speak with researchers in order to obtain more in-depth knowledge about included areas. Educational support during feedback to teams has been identified as a key factor to facilitate learning and change [23]. The Decision Innovation Process from Roger's theory is helpful in interpreting findings from this study [8]. ...
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Tables summarising the development and measurement properties of instruments included in Stage 4 of the review (Tables S11–S13).
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Aims first, to develop an instrument for a holistic analysis of learning organizations; and second, to test the validity and reliability of this instrument. The framework developed was mainly influenced by the work of Mike Pedler, Tom Boydell and John Burgoyne, Peter M. Senge as well as Chris Argyris and Donald A. Schön. Analyses eight existing diagnosis tools. The Learning Organization Diamond Tool was based on a concept of a learning organization regarded as a structure of related elements. Data consisting of 691 answers were gathered from 25 Finnish organizations in 1998. After analysis the reliability of the instrument was measured with Cronbach’s alpha. Cronbach’s alphas for the elements of the tool varied between 0.5141 and 0.8617. Validity of the tool was established by presenting the process as a chain of phases from theory to statements. Comparison between the tool developed and other tools presented in this article yields somewhat contradictory findings, because the purposes of the instruments differ. The tool developed here aims to create a holistic picture for further analysis and discussions and to serve as an internal tool for development. More tailored instruments should be developed for more specific purposes. The article is aimed at an audience involved in learning organizations and their development.
Article
Aim To use a learning organisation diagnostic tool to ascertain the organisational culture of general practices. Setting General practice. Subjects Medium and large-sized general practices in the North Tees Primary Care Trust (PCT). Method A questionnaire was developed to gauge staff perceptions of the extent to which their employing practice reflected eight characteristics of a learning organisation. The 40-item, indexed Likert scale questionnaire was completed by the practice-employed staff of 15 participating practices. Results There were high levels of practice (93.8%) and staff (85.5%) participation in the study. The areas identified as least well developed among participating practices were: fostering understanding of others' roles; developing pluripotentiality and interdependence of skills; recognition and reinforcement of positive behaviour; seeking and valuing feedback from staff; development of shared values and goals; releasing the creative potential of staff; and learning from and working through conflict in the team. Conclusion Measurement of organisational culture within general practices is possible and is able to identify priorities for change in practices seeking to develop as learning organisations.
Article
A procedure was tested for the construction of evaluative rating scales anchored by examples of expected behavior. Expectations, based on having observed similar behavior, were used to permit rating in a variety of situations without sacrifice of specificity. Examples, submitted by head nurses as illustrations of nurses' behavior related to a given dimension were retained only if reallocated to that dimension by other head nurses, and then scaled as to desirability. Agreement for a number of examples was high, and scale reliabilities ranged above .97. Similar content validity should be obtained in other rating situations. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Rationale, aims and objectives: This paper is the third of three related papers exploring the ways in which the principles of Learning Organizations (LOs) could be applied in Primary Care settings at the point of service delivery. Methods: Here we provide a systematic literature review of contextual factors that either play a key role in providing a facilitative context for a Learning Practice or manifest themselves as barriers to any Practice's attempts to develop a learning culture. Results and conclusion: Core contextual conditions are identified as, first, the requirement for strong and visionary leadership. Leaders who support and develop others, ask challenging questions, are willing to be learners themselves, see possibilities and make things happen, facilitate learning environments. The second core condition is the involvement and empowerment of staff where changes grow from the willing participation of all concerned. The third prerequisite is the setting-aside of times and places for learning and reflection. This paper contributes to the wider quality improvement debate in three main ways. First, by highlighting the local contextual issues that are most likely to impact on the success or failure of a Practice's attempts to work towards a learning culture. Second, by demonstrating that the very same factors can either help or hinder depending on how they are manifest and played out in context. Third, it adds to the evidence available to support the case for LOs in health care settings.
Article
Rationale, aims and objectives This paper is the second of three related papers exploring the ways in which the principles of Learning Organizations (LOs) could be applied in Primary Care settings at the point of service delivery. Methods Based on a theoretical and empirical review of available evidence, here we introduce the process by which a Practice can start to become a Learning Practice (LP). Results and conclusions Steps taken to enhance both individual and organizational learning begin the process of moving towards a learning culture. Attention is given to the routines that can be established within the practice to make learning systematically an integral part of what the practice does. This involves focusing on all three of single-, double- and triple-loop learning. Within the paper, a distinction is made between individual, collective and organizational learning. We argue that individual and collective learning may be easier to achieve than organizational learning as processes and systems already exist within the Health Service to facilitate personal learning and development with some opportunities for collective and integrated learning and working. However, although organizational learning needs to spread beyond the LP to the wider Health Service to inform future training courses, policy and decision-making, there currently seem to be few processes by which this might be achieved. This paper contributes to the wider quality improvement debate in three main ways. First, by reviewing existing theoretical and empirical material on LOs in health care settings it provides both an informed vision and a set of practical guidelines on the ways in which a Practice could start to effect its own regime of learning, innovation and change. Second, it highlights the paucity of opportunities individual general practitioner practices have to share their learning more widely. Thirdly, it adds to the evidence base on how to apply LO theory and activate learning cultures in health care settings.
Article
Rationale, aims and objectives: This paper is the first of three related papers exploring the ways in which the principles of Learning Organizations (LOs) could be applied in Primary Care settings at the point of service delivery. Here we introduce the notion of the Learning Practice (LP) and outline the characteristics and nature of an LP, exploring cultural and structural factors in detail. Methods: Drawing upon both theoretical concepts and empirical research into LOs in health care settings, the format, focus and feasibility of an LP is explored. Results and conclusions: Characteristics of LPs include flatter team-based structures that prioritize learning and empowered change, involve staff and are open to suggestions and innovation. Potential benefits include: timely changes in service provision that are realistic, acceptable, sustainable, and owned at practitioner level; smoother interprofessional working; and fast flowing informal communication backed up by records of key decisions to facilitate permanent learning. Critical comment on potential pitfalls and practical difficulties highlights features of the present system that hinder development: tightly defined roles; political behaviours and individual-oriented support systems; plus the ongoing difficulties involved in tolerating errors (whilst people learn). This paper contributes to the wider quality improvement debate in the area in three main ways. First, by locating Government's desires to create health systems capable of learning within the theoretical and empirical evidence on LOs. Second, it suggests what an LP could be like and how its culture and structures might benefit both staff and patients in addition to meeting externally driven reforms and health priorities. Third, it extends the application of LO concepts to the health care sector locating the principles in bottom-up change.
Article
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Article
Continuous improvement programs are proliferating as corporations seek to better themselves and gain an edge. Unfortunately, however, failed programs far outnumber successes, and improvement rates remain low. That's because most companies have failed to grasp a basic truth. Before people and companies can improve, they first must learn. And to do this, they need to look beyond rhetoric and high philosophy and focus on the fundamentals. Three critical issues must be addressed before a company can truly become a learning organization, writes HBS Professor David Garvin. First is the question of meaning: a well-grounded, easy-to-apply definition of a learning organization. Second comes management: clearer operational guidelines for practice. Finally, better tools for measurement can assess an organization's rate and level of learning. Using these "three Ms" as a framework, Garvin defines learning organizations as skilled at five main activities: systematic problem solving, experimentation with new approaches, learning from past experience, learning from the best practices of others, and transferring knowledge quickly and efficiently throughout the organization. And since you can't manage something if you can't measure it, a complete learning audit is a must. That includes measuring cognitive and behavioral changes as well as tangible improvements in results. No learning organization is built overnight. Success comes from carefully cultivated attitudes, commitments, and management processes that accrue slowly and steadily. The first step is to foster an environment conducive to learning. Analog Devices, Chaparral Steel, Xerox, GE, and other companies provide enlightened examples.
Article
In recent business literature, the model of the learning organisation has been proposed as a solution to the problem of continually changing environments and increasing consumer expectations of maximum quality and value for money. The model seems highly appropriate for health services, which are staffed by educated professional staff who must become more adaptive and concerned with improving consumer outcomes. This case study describes how the principles of learning organisations have been applied to the design of a new structure and the creation of a learning culture within a mental health service for children and adolescents.
Article
To determine whether physicians who received feedback from six peers, six referring/referral physicians, six co-workers, and 25 patients about 55 aspects of their medical practices (e.g., able to reach doctor by phone after office hours) would make changes to their practices based on that feedback. In an earlier study, 308 physicians were given feedback about 106 aspects of their practices in the form of mean Likert-scale ratings that (1) the peers made on 26 aspects; (2) the referring/referral physicians made on 23 aspects; (3) the co-workers made on 17 aspects; and (4) the patients made on 40 aspects. Three months later 255 of these physicians responded when asked to indicate whether they had contemplated or initiated changes, or whether no change had been necessary, regarding 31 practice aspects, each of which was a summary of one or more of 55 of the original 106 aspects on which they had received ratings. These 55 were considered the aspects most amenable to change over a short period. The physicians were also asked about the educational interventions that they felt would help them make changes. Multivariate analysis of variance was used to see whether the types of changes reported for the specific aspects of practice were associated with the feedback ratings received for those aspects. An examination of the responses showed that 83% of the 255 physicians reported having contemplated a change, and 66% reported having initiated a change for at least one aspect of practice. Changes were contemplated most frequently for aspects of practice associated with clinical skills and resource use. Changes were initiated most frequently for aspects of practice associated with communication with patients and support of patients. Physicians who contemplated or initiated changes had lower (i.e., more negative) mean ratings than did physicians who reported that no change was necessary, which suggests that the physicians did use their feedback ratings to decide about changes, although their qualitative comments indicated other sources as well. Printed material was chosen most often as a method of receiving continuing medical education related to making changes in the practice areas examined.
Article
Learning has been identified as a central concern for a modernized NHS. Continuing professional development has an important role to play in improving learning but there is also a need to pay more attention to collective (organizational) learning. Such learning is concerned with the way organizations build and organize knowledge. Recent emphasis within the NHS has been on the codification of individual and collective knowledge - for example, guidelines and National Service Frameworks. This needs to be balanced by more personalized knowledge management strategies, especially when dealing with innovative services that rely on tacit knowledge to solve problems. Having robust systems for storing and communicating knowledge is only one part of the challenge. It is also important to consider how such knowledge gets used, and how routines become established within organizations that structure the way in which knowledge is deployed. In many organizations these routines favour the adaptive use of knowledge, which helps organizations to achieve incremental improvements to existing practices. However, the development of organizational learning in the NHS needs to move beyond adaptive (single loop) learning, to foster skills in generative (double loop) learning and meta-learning. Such learning leads to a redefinition of the organization's goals, norms, policies, procedures or even structures. This paper argues that moving the NHS in this direction will require attention to the cultural values and structural mechanisms that facilitate organizational learning.
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