Organizational learning for improvement of fragmented healthcare systems

Doctoral thesis, 2025

Healthcare systems face increasing demands for adaptability, integration, and continuous improvement, driven by challenges such as aging populations, staff shortages, and budget constraints. However, efforts to support organizational learning in healthcare systems can be hindered by fragmentation, complexity, and structural constraints. Consequently, a persistent gap remains between the ambition to become learning healthcare organizations and the ability to fulfil this ambition.

The purpose of this thesis is to contribute new knowledge on strategies, learning actions, and leadership factors that support organizational learning in fragmented healthcare systems. The research addresses four questions:

(1) What strategies can support organizational learning across fragmented healthcare systems?

(2) What learning actions can support organizational learning across fragmented healthcare systems?

(3) What factors can influence learning-oriented leadership in fragmented healthcare systems? and

(4) What are the key elements for supporting organizational learning in fragmented healthcare systems?

 

A participatory action research approach was applied, using a qualitative-dominant mixed-methods design. The research is based on three studies and five papers, combining case studies, interviews, focus groups, document analyses, and a cross-sectional survey. Inductive, deductive and abductive analysis are applied. The design enabled both in-depth analysis and broader validation of findings across settings and roles.

This thesis suggests that organizational learning in fragmented healthcare systems is supported by concrete, participatory actions, including cross-site feedback on shared tools, joint reviews of patient records, structured group sessions to surface conflicting logics, and rapid co-creation and prototyping across involved actors. These actions appeared to be effective insofar as they were embedded within broader strategies of iterative refinement, participatory approaches, purpose-built organizational network architectures, and collaborative leadership. Learning-oriented leadership was found to be shaped by contextual factors like multiple external drivers for change, broad ranges of diverse actors, siloed structures, environments of emergent and unpredictable change, restricted availability of organizational resources and restricted individual leadership autonomy. Despite such constraints, healthcare leaders sustained learning through leadership behaviors of providing support, building climates for learning, and facilitating knowledge dissemination. Taken together, the findings point to a four-part model in which context, organizational architecture, learning-oriented leadership, and collaborative learning could operate interdependently; it is the alignment of these elements that seems to sustain organizational learning across silos.

This thesis contributes novel insights by identifying concrete, participatory learning actions embedded in coordinated strategies for organizational learning across fragmented healthcare systems. It proposes a context-sensitive refinement to the theory expansive learning by incorporating collaborative leadership as an additional element. It also propose extensions to the current framework of learning-oriented leadership to better reflect the complexity of fragmented healthcare systems. Finally, it offers a system-level model that integrates context, organizational architecture, collaborative leadership, and collaborative learning, providing support for practitioners and researchers seeking to bridge the gap between the ambition to build organizational learning in healthcare and the realities of doing so.