The objective of this paper is to enhance the tool for francophone countries for better use of the potential of the learning organization concept and tools. Indeed, to trigger the change in health organizations for a better achievement of the UHC objective, health organizations have to develop their abilities to use the knowledge to improve their performance but also to guide transformations. Indeed, it’s difficult for health organizations like hospitals to copy and past other hospitals transformational strategies, a contextualization is highly needed. The learning organization framework and tools appear to be good to trigger the change by creating a collective learning dynamic around the action and the use of knowledge. The learning organization culture is also strong in providing possibilities to create collaborative processes. With this paper we simplified the use of the concept for francophone countries so they can introduce change guided by each of the attributes presented in Garvin Framework.
Garvin’s survey translated into French can be considered a satisfactory instrument for the evaluation of health learning organizations, as showed high internal consistency, Cronbach's alpha was above 0.961 for the 55 questions. Although some of the dimensions individually remained at 0.6, the different blocks had satisfactory results with > 0.85, which could also be explained by some specificities of the context in which the adaptation is conducted
Despite the urgent need for innovation, adaptation, and change in health care, few tools enable researchers or practitioners to assess the extent to which health care facilities perform as learning organizations or the effects of initiatives that require learning.
Many difficulties regarding the assessment of organizational culture lie in the fact that there are an abundance of instruments for assessing and measuring them, applied to a large number of settings, each instrument with their own theoretical background. Moreover, these instruments have mainly been developed for, and tested in, enterprises and high-income settings, resulting in a lack of well established and/or validated instruments for health organizations in low- and middle-income settings .
Garvin’s et al. revealed three broad factors that are essential for organizational learning and adaptability: a supportive learning environment, concrete learning processes and practices, and leadership behavior that provides reinforcement. And they refer to these as the building blocks of a learning organization. By assessing performance on each building block, you pinpoint areas needing improvement, moving your company that much closer to the learning organization ideal. To know that, they created a diagnostic tool: the Learning Organization Survey, which determines how well your team, department, or entire company is performing with each building block, so after that you identify areas for improvement .
In addition to the fact that according to the extensive review of Aknif et al on the subject they concluded that most of the models are based on Garvin, we decided to adapted it to our specific context and objectives . The adaptation we conducted has also a strategic objective to prepare health organizations for a change towards learning organizations. The change can not happen without a deep understanding of the concept, its use and main importantly to facilitate the transition from simple auditing of the organization to a course of action. indeed, each of the questions of the tool can lead to a type of action that could be put forward to achieve à LO objective. We know also that if the objective of all health systems is to achieve UHC, paths and ways of concretizing it are not clearly known. The only way to ensure that health organizations are capable of developing efficient strategies for UHC is to invest in learning and collaborative culture.
After adaptation, we can say that health professionals are familiar with the terminology used in the questionnaire and that facilitates the understanding of its content. This assimilation is a sign of the success of the adaptation process.
The application of the instrument could be retained to allow comparisons between services or organizations and also be considered in other groups of workers, (today excluded for lack of full understanding of the French language) with an interview through, rather than self-application.
Although the tool proved to be discriminative and reliable in its entirety, some of the independent dimensions showed no significant difference as the dimensions respect to psychological safety, the appreciation of differences and experimentation. Instead, dimensions such as openness to new ideas and time for reflection showed much discriminative difference.
Results indicate that the respondents obtained the lowest score in the dimension of information transfer (9), with an overall score of 3 out of 7, indicating a potential area for improvement. For Garvin [11,20], transfer information is part of the concrete steps for learning processes and practices. Without information transfer, knowledge cannot be shared. It is not less than in group 3 and group 2 this gap is bigger. It can only be speculated on what the reasons for this could be, such as academic level or to a centralized hierarchical structure [21,22]. The predominant organizational structure for hospitals is, by tradition, mostly bureaucratic, with rigid rules and standard procedures and processes, which leave a narrow margin for the transfer of information . Employees of lower academic level in particular, have little or no influence on decision making so that the information does not reach them more than as specific guidelines . Although this traditional structure is increasingly challenged, there are still many hospitals and organizations in general, in developing countries such as Morocco, which continue with that traditional management structure. But the concrete thing is that noticing this helps to find solutions like open up boundaries and stimulate the exchange of ideas. Boundaries inhibit the flow of information; they keep individuals and groups isolated and reinforce preconceptions. Opening up boundaries, with conferences, meetings, and project teams, which either cross-organizational levels or link the services, patients and suppliers, ensures a fresh flow of ideas and the chance to consider other perspectives.
The two dimensions that obtained the highest score, in general, were those related to psychological safety (6) and openings to new ideas (3) with 5 of 7. As Garvin said “to learn, employees cannot fear being belittled or marginalized when they disagree with peers or authority figures, ask naive questions, own up to mistakes, or present a minority viewpoint. Instead, they must be comfortable expressing their thoughts about the work at hand”, against that, “they must be encouraged to take risks and explore the untested and unknown” 9. Finding these two dimensions with high relevance in the population, although it can be further developed, gives hope that the actions that must be made to be LO will have a favorable ground of contention and listening.
Another result that can be considered relevant, but not surprising is that group 1 highlighted an organization with a high level in education and training, 4.94, far from the other two groups. This can be considered in part expected, since it is the Medical staff, whether professors, residents or students, who are still bound in permanent training. But in contrast to that, are the nurses the group that declared less formation [8,18].
The short time of reflection was marked in the three groups. Garvin remarks that the first step is to foster an environment that is conducive to learning. There must be time for reflection and analysis. Learning is difficult when employees are harried or rushed; it tends to be driven out by the pressures of the moment [11,16,25]. Therefore, when applying the first measures of change this should be a priority.
Finally, with respect to dimension 10 or Block 3 independently, the three groups marked a lack of leadership that reinforces knowledge. Management must be the first to change their behaviors. Since when people in power demonstrated through their own behavior; the willingness to entertain alternative points of view, openness to dialogue and debate, and the importance of using time to identify problems, transfer information, and reflections post-audits; people in the institution will be more encouraged to learn and offer new ideas and options [20,26],.
We can refer to the strengths of the study as being the first translation, back-translation of the Garvin tool for French-speaking countries in health organizations. As well and not least important the cultural adaptation for user compression and ensure a reliable answer to the question: is yours an LO?
The representativeness of the sample was another strong point, diverse with different health professionals. The results of this exploratory study provide some evidence of how perceptions vary across organizational levels at the INO concerning the learning organization.
Also, the fact of having added to the study descriptive background data of the population allows a more exhaustive and accurate analysis and define what are the points to cover to become an LO.
The weaknesses of the study were mainly that the survey was not conducted by the total number of INO employees, those who were absent or on vacation did not complete it. In addition to the support staff (security and cleaning due to frequent rotation), their participation should also be considered for future evaluation, since although they are in the institution for a short period of time, they are also an important part of the organization's activities. For a future study, the possibility of including as many people as possible should be evaluated.
Further limitations include biases regarding the people to whom the survey was delivered and who potentially could have answered the questionnaire but did not, which, of course, also adds a level of uncertainty regarding the results.
We could also name the prominent hierarchical structure that can produce a culture of "willingness to please" in the organization that leads the respondents not to score according to their actual perception, but with what they believe the researcher and/or the administration wants them to answer. This could be exaggerated if respondents have confidentiality concerns and fear retribution if they do not score accordingly. This would challenge the credibility of the results, as well as the test itself, and might render the suggested findings invalid. A point to evaluate for future analysis is a preliminary interview with the respondent.
Perspectives: This will allow its later use as a concrete analysis tool that will delimit actions to move towards a learning organization, facing the challenges of a dynamic environment, such it is the Moroccan health system.