Can Paramedic Services be Learning Organisations?

Change has always been a challenge in paramedic services. Traditional management paradigms have tended to follow more Newtonian management approaches which are underpinned by a traditional scientific approach which sees change as an event. Kurt Lewin’s Three Phase approach, for example has been widely applied to manage change and is an example of seeing change as a specific and isolated event to be managed.

However, in the modern world, change occurs constantly. One of the challenges for paramedic services is adapting to working conditions which change both over time and location. Environments and communities are unique and have multiple variables which may impact on the provision of health services, including those provided by paramedics. There is inherent risk in operating a service with a static model which is required to operate in an environment of constant change.

A few approaches can be used to look at ways in which service delivery models can adapt to ever changing requirements. Learning Organisations are a model of organisation which is based on the constant sharing of information to allow organisations to adapt to the environment in which they are operating. Garvin (2008) suggests that firstly you need to understand the building blocks of a Learning Organisation which he outlines as:

1)      A supportive learning environment

2)      Concrete learning processes

3)      Leadership that reinforces learning

A supportive learning environment is fundamentally a change in culture to value the collection, creation and dissemination of information. It is through learning about the context in which the organisation operates that information can be collected to allow the organisation to adapt. Garvin suggests four key elements which support this culture of learning.

Psychological safety: People need to be able to express themselves without fear of being sanctioned if they disagree with peers or authority figures and must be able to be comfortable asking questions and expression opinions

Appreciation of differences: When people are aware of opposing ideas or world views, fresh thinking can result.

Openness to new ideas: Learning involves crafting novel approaches as well as responding to and correcting issues. People need to be able to take risks to find innovative solutions.

Time for reflection: Reflection is a critical tool for analysis and learning. When work effort is solely judged by production output or time spent, it lacks thoughtful review which can lead to new lessons being learnt.

For example, a number of hospitals and health systems have improved patient safety by firstly introducing “blameless reporting”. As a result, errors and omissions become available for analysis and innovation solutions to patient safety issues have been developed which translate into real impacts on patient outcomes.

Garvin also argues that concrete learning processes are critical. Knowledge needs to be collected systematically to ensure the quality of the data and experience collected. Likewise it needs to be systematically disseminated to maximise the benefit to the organisation. Systematic reviews and reflection are excellent strategies for creating knowledge and analysing it to determined what lessons can be learned.

An example of these are the After Action Reviews (AARs) developed by the US Army.  These reviews rely on a clear set of guidelines and objectives which allow events to be deconstructed and lessons learnt. AARs can operate both formally resulting in a report or be done informally, often known as “Hotwashes”. The results of AARs are then centrally collected and knowledge managed through the Centre for Army Lessons Learnt allowing organisation wide access to the review outcomes.

Finally organisational leadership needs to support learning. This is more than leaders setting policy but involves leaders listening to followers and questioning them to show that they value the information which they collect and manage. People in authority needs to accept the cultural principals in the first building block and demonstrate them, including accepting new ideas and supporting creativity.

There are a range of advantages in health organisations adopting a Learning Organisation approach. Firstly a collective approach to learning  provides sustainability as individual members of health organisations come and go. Secondly, learning supports innovation and increases the capacity of an organisation to respond to uncertainty, which is a common challenge in health services (Davies & Nutley 2000).

One may argue that an incremental change paradigm may face significant resistance in traditional service delivery models of paramedic services. However, there have been a number of studies outlining the efficacy of Learning Organisation approaches in both the military and in hospital systems. Learning Organisations do not inherently contraindicate hierarchical leadership models as the military experience has shown but in fact empowers lower ranked personnel and shifts the role of officers into becoming stewards of the learning system (DiBella 2010).

Paramedic Services face not only incremental increases in workload combined with geographically disparate workload patterns influenced by factors such as local demographics, local prevalence of chronic disease, availability of health services and a wide range of other variables. The use of a Learning Organisations approach would not only allow paramedics at a local level to respond to incremental changes in their context of practice but also adapt their clinical practice to more effectively reflect skills and knowledge they require.

Combined with related concepts such as Complex Adaptive Systems, a concept borrowed from Environmental Science which allows systems to evolve based on responses to individual stimuli, Learning Organisations can be part of an adaptive to organisational change which does not rely on single episodes of cardinal change but rather an ongoing process of evolution at both the micro and macro levels. One of the key benefits of micro-adaptability in organisations is organisational sustainability in changing service delivery environments (Molnar & Mulville 2003).

For paramedic services, it is accepted that workload variability and growth is a part of the operational environment in which these services exist (Lowithan Et Al 2011). Service delivery will need to be constantly adjusted to meet changing demands and the use of sustainable learning organisation approaches will not only encourage innovation in service delivery but will have a positive impact on organisational sustainability in an scenario where there is both increasing demand and unpredictable workload

More importantly, at the micro, or community level, local providers may have the capacity to adjust local service delivery to maximise impact of paramedic services on health service delivery and health outcomes. Such an approach would support concepts such as demand-driven service design and the emerging area of Community Paramedicine.

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