Andrej Robida, MD, PhD, FACC
Andrej Robida MD, PhD, FACC

Accreditation of healthcare organizations using generic healthcare standards and more recently  diving deeper  into the delivery of services  is considered  by many  as an initial  way towards excellence.  However, without a systemic and systematic approach  to organizational learning,  many opportunities can be lost and  necessary changes slowed down. Not so long ago I  read a story of people shouting for help when a wild river was draining them downstream.  Three rescuers happened to be nearby. The first one, a stout and courageous man, jumped into the river and helped  a drowning person. Comparing this to healthcare  it looked  like an urgent case needing immediate attention. The second rescuer thought that there were too many people in the water and that it would be more effective to have a boat thus  attending to more  people at once. The third one jumped into the water starting to swim upstream. “What are you doing? Why won’t you help us”? the second rescuer shouted at her.  “I am trying to find out what is happening upstream and  why these people are falling into the water.”

It  seems that both a downstream and an upstream approaches are the right things to do, at least at the present state of affairs in healthcare. Healthcare organizations are viewed as a complex systems, as a live organism necessitating constant change to survive and deliver high quality and safe care. Without a robust and integrated information-communication system, it is almost impossible to improve on a whole scale.  Improvement efforts are often short lived  and therefore strong leadership is needed with engagement of physicians, nurses and all other staff.

If you are an “upstreamist”  than the idea of organizational learning is not foreign to you. Organizational learning may be defined as  a process of increasing knowledge and innovation  of work routines with action and reflection going beyond individual focused training  (Carroll and Edmondson , 2002). Organizational learning involves  continuous quality improvement (CQI) teams, improvement collaboration, and healthcare reengineering works.   Organizational learning may have different names, nevertheless the process is generic.

In the UK the term used is “Clinical Governance” The aim of organizational learning is to promote a culture of CQI  made of clinical performance, internal and external clinical audit, clinical risk management, complaints, health needs assessment, practice based on evidence, continuous education, leadership, culture of excellence and distinct  accountability.

Everyone working in healthcare has been  through specific training for his/her future profession. For quality improvement and patient safety it is sometimes thought that no training and no competences are necessary as this is already  imprinted  in the human genome.  The third prerequisite for CQI are leadership skills to promote integration of competences and stimulate working together.


Carroll JS and Edmondson AC. Leading organizational learning in health care. Qual Saf Health Care 2002;11:51-6.