Conceptualising learning healthcare systems and organisations in the context of rehabilitation: a scoping review protocol

Introduction

With an increasing aging population, changing health needs and growing public expectations for new ambitious health goals, the pressure is on for health systems to produce better health outcomes. However, as highlighted by Kruk et al. (2018) - transformative, system wide actions are needed globally, to meet such goals. An upheaval of this nature to healthcare systems is majorly challenging, and particularly so in current times when healthcare organisations globally are struggling with fragmentation between services and system inefficiencies. Major changes in how health care is designed and delivered will clearly be needed to meet the challenges of ageing populations, chronic diseases and health inequities (Kruk et al., 2018). Integrated care has been identified as a helpful strategy, where health and social services are delivered through comprehensive care pathways organised around patient needs (Robertson, 2011). Within models of integrated care there should be horizontal co-ordination, which spans disciplinary and professional boundaries as well as vertical co-ordination, with a continuum from primary to secondary to tertiary care. In such models, care should not be episodic in nature and an effort should be made to minimise unplanned stays in acute care. The World Health Organization (WHO) has emphasised the value of integrated, person centred care, as building blocks for universal health coverage and higher quality of care (World Health Assembly, 2016). However, questions remain for health systems researchers around the implementation of integrated care. How can we design solutions for healthcare which will best facilitate the major global shift required to meet complex challenges facing healthcare providers today?

A potential transformation to healthcare systems that has gained traction over recent years is the idea that healthcare systems can become "learning" systems/organisations. This aligns well with the WHO definition of integrated care, which emphasises the importance of feedback loops to continuously improve performance as well as multi-disciplinary teams of providers (World Health Assembly, 2016). The literature on this topic includes a diverse range of terminology from across different disciplines (such as implementation science, organisational development, and healthcare management) that we will endeavour to explicate below.

The concept of a learning organisation (LO) originated in the 1990s with the seminal work of Peter Senge and others, who outlined how to build adaptive organisations which learn and lead change. This early work was focused on developing frameworks and tools to operationalise this concept within actual organisations (Garvin, 2000; Marquardt, 1996; Senge, 2006). Much of this work was grounded in exploration and analysis of private companies – with growing recognition of the competitive advantage of investing in knowledge and learning. Over time, the LO concept has also been applied to public organisations. However, researchers have recognised the need for LO frameworks to be sufficiently complex and dynamic to truly accommodate public organisations (Rashman et al., 2009). Frameworks for a LO which are grounded in Senge’s original conception can meet this need. The five pillars of learning organisations as he outlined them were personal mastery, mental models, building a shared vision, team learning and "the fifth discipline" - systems thinking. Systems thinking involves an appreciation of the complexity of interacting components of an organisation. Thus, the fifth discipline also integrates the other four (Iles & Sutherland, 2001) and champions a complexity lens. A complexity approach is particularly essential in the examination of healthcare systems and delivery.

Healthcare systems are characterised by being complex. This complexity emerges from multiple independent agents interconnected in a surrounding environment, with continuous evolution and adaptation – thus healthcare systems qualify as complex adaptive systems (Carroll, 2021; Peters, 2014). Because of this, systems thinking has been identified as an appropriate tool in thinking about complexity in healthcare (Rusoja et al., 2018). Complexity thinking has been increasingly embraced in healthcare with an understanding that more traditional industrial oriented healthcare solutions can be reductionist (Waldman, 2007), and that problems in healthcare should be viewed through a complexity lens with complexity sensitive solutions (Khan et al., 2018; Plsek & Greenhalgh, 2001). Healthcare researchers have noted that this thinking aligns well with popular perspectives and philosophies recently promoted in healthcare – e.g., collectivist leadership, person centredness and interventions in healthcare which require new behaviours from those delivering or receiving the intervention (Carroll, 2021; Khan et al., 2018). Systems thinking can support change within health service delivery (Sarkies et al., 2021), through effective conceptualisation of problems and context in healthcare allowing effective work with stakeholders (Haynes et al., 2020) thus providing insights to improve healthcare quality.

Thus, systems thinking is useful in healthcare innovation as it incorporates a complexity lens and complexity sensitive solutions to problems in healthcare. However, common criticisms of “learning organisations” as a concept are that there are contradictory definitions and vague concepts (Shea & Taylor, 2017). Some scholars refer to this concept as an outcome while others conceptualise it as a process “organisational learning” (Argyris & Schön, 1978; Bateson, 1979). A scoping review of the application of LO to healthcare systems (Akhnif et al., 2017) noted the versatility of the application of the concept – that it has been applied to different levels of healthcare systems, in descriptive, prescriptive, and analytical manners. Alongside diversity in the application of the concept, there was also consensus across papers about the transformative potential of the LO concept for promoting learning and healthcare reformation. This demonstrates another longstanding critique of LO - despite the potential of the concept, there is a lack of empirical evidence on how to effectively apply LO frameworks and support organisational learning in practice (Huber, 1991; Tosey et al., 2012; Visser, 2007). Further research is required to build rigorous evidence on the impact of applying LO frameworks to healthcare organisations. This review will contribute to knowledge of how healthcare organisations can become LOs, while focused on a specific context – that of rehabilitation care and rehabilitation organisations. The focus on this context may eliminate some of the variation and inconsistencies between different applications of the LO concept – as Akhnif et al. noted that researchers needed to adapt existing frameworks for their context.

Within healthcare literature, a similar (though potentially separate) concept to the LO has emerged and greatly grown in popularity – that is the "learning healthcare system" (LHS). As with the LO concept, the core idea is for health systems and organisations to continuously learn and adapt. However, definitions of LHS revolve around a data driven approach to healthcare, in which data routinely collected as a part of care are used in healthcare improvement. For example: “We define a LHS as a system in which routine health practice data, from service delivery and patient care, can lead to iterative cycles of knowledge generation and healthcare improvement" (Enticott et al., 2021, p. 2). Commonly cited definitions have arisen from the Institute of Medicine in the US - “science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience” (Institute of Medicine, 2011; Institute of Medicine, 2014). Similar problems persist as those from the field of organisational learning with varying definitions and inconsistent use of terminology (as evident in our table of search terms, see Table 1.). However, commonalities and core features of the concept have been identified. Defining features include cyclical data driven approaches, embedded researchers and academic partnerships and an emphasis on being service led and community led (Enticott et al., 2021; Johnson et al., 2021). Co-design with knowledge stakeholders has been highlighted as a key part of successful implementation of any "learning" model of healthcare (Johnson et al., 2021).

Barriers to the successful implementation of these models largely relate to financial obstacles and infrastructural impediments. Researchers have noted difficulties in obtaining external funding as agencies which support clinical research have historically valued randomised controlled trials over robust observational study designs best suited to LHS research (Bindman et al., 2018; Forrest et al., 2018). With data driven approaches that have gained popularity, particularly in the US, the success is dependent on the existence of electronic health records and infrastructure. Gaps in the academic literature continue despite the recent popularity of the concept, with a significant gap around how to create and sustain a LHS (Budrionis & Bellika, 2016). Previous evidence syntheses have been conducted on this topic (Budrionis & Bellika, 2016; Enticott et al., 2021; McLachlan et al., 2018; Platt et al., 2020; Pomare et al., 2022). However, there has been no review published focused on learning health systems within the specific context of rehabilitation. LHS is a concept which has been used in a wide variety of settings including oncology, surgery, cardiology, primary care and paediatrics (Platt et al., 2020), but far more rarely in rehabilitation setting.

The concepts of LHS and LO have great potential utility for rehabilitation organisations. As healthcare organisations and systems move towards electronic health records, generating data from existing practices, creating knowledge, and feeding this knowledge back into practice could be highly beneficial to rehabilitation practice. A recent systematic review reported benefits across settings and countries which included benefits to patients such as self-management opportunities and evidence-based care, benefits to system level performance such as identification of patients for follow up, specialised care and longitudinal tracking and benefits to research through enablement of real-world research and evaluation (Enticott et al., 2021). Furthermore, many of Senge's pillars of a learning organisation are highly relevant to rehabilitation such as team learning and building a shared vision. This is evident from definitions of rehabilitation for example:

(National Policy/Strategy for the Provision of Rehabilitation Services, 2009, p. 3) - based on the definition by the British Society of Rehabilitation Medicine (Turner-Stokes & Wade, 2004)

Such definitions illustrate the multi-dimensional, multi-disciplinary nature of rehabilitation care which evidently requires an expert, skilled interdisciplinary team who work towards patient-centred goals over time and across settings as the patient changes (Wade, 2015). Thus, we propose that the concepts relevant to becoming a learning organisation or healthcare system have the potential to offer useful frameworks for rehabilitation that align with the priorities of integrated services and person-centred care. With the shift to electronic health records, now is the time to explore and test such possibilities. The first step in this regard must be in clarifying terminology, solidifying a clear conceptualisation of what is meant by "learning" organisations and healthcare systems. This work should be explored and applied to different healthcare settings - including rehabilitation and other non-acute settings.

This review will offer a unique contribution to healthcare improvement literature, as the first evidence synthesis of the concept of a "learning" healthcare system or organisation in the context of rehabilitation care. A scoping review has been identified as the appropriate method of evidence synthesis for this topic. The Joanna Briggs Institute evidence synthesis manual defines scoping reviews as a type of evidence synthesis which allows researchers to systematically map the breadth of evidence available on a topic, identify key features of a concept and clarify definitions of a concept (Munn et al., 2022). In this case, a scoping review will allow insight into a) the volume of papers on these topics of LO and LHS within rehabilitation literature b) the varying definitions and terminology, which has previously been identified as a problem with these concepts c) the similarities and differences between the two concepts and d) the key features of these concepts as they apply to rehabilitation.

Methods

Public and patient involvement

This review is part of a larger co-research project. This review team includes healthcare professionals working in rehabilitation as co-researchers and a former rehabilitation patient. Their involvement goes beyond stakeholder consultation, as the co-researchers are contributing not only clinical expertise and knowledge alone but are actively involved in each stage of the review process. All co-researchers have been involved in reviewing the development of this protocol and the conceptual elements of the review question and search.

The involvement of patients and healthcare professionals as knowledge stakeholders has been ensured within this first step of the project. There is evidence that involving patients not only brings lived-experience perspective into research but increases its quality and the relevance (Brett et al., 2014; Nierse et al., 2012).

The aim is to ensure a democratic co-operation between researchers and involved patients and healthcare professionals. This will include involving them in the design of research and encouraging their uptake of research findings.

Dissemination

This review will guide a larger research project on teamwork in rehabilitation. The results of the scoping review will be published in a peer reviewed journal and presented at both national and international conferences (see Table 4 for review timeline). All data will be stored in line with best General Data Protection Regulation Practice.

Timeline for review