Open Access Highly Accessed Research article

Sustainability of healthcare improvement: what can we learn from learning theory?

Einar Hovlid12*, Oddbjørn Bukve1, Kjell Haug2, Aslak Bjarne Aslaksen34 and Christian von Plessen567

Author Affiliations

1 Institute of Social Science, Sogn og Fjordane University College, Postbox 133, 6851, Sogndal, Norway

2 Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway

3 Department of Radiology, Haukeland University Hospital, Bergen, Norway

4 Institute of Surgical sciences, University of Bergen, Bergen, Norway

5 Department of Thoracic Medicine & Infectious Disease, Hillerød Hospital, Hillerød, Denmark

6 Institute of Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway

7 Department of Health Studies, Faculty of Social Sciences, University of Stavanger, Stavanger, Norway

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BMC Health Services Research 2012, 12:235  doi:10.1186/1472-6963-12-235

Published: 3 August 2012



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.


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.


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.


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.

Quality improvement; Organizational learning; Learning theory; Sustainability