Learning: Contemplating the unexamined core of Learning Health Systems.

INTRODUCTION: The current Learning Health Systems literature affords insufficient attention to the process of learning. In response, Billings Clinic focused on how to advance its learning capabilities and subsequently to contribute new insights into the process of learning to the LHS literature. METHODS: An environmental scan was conducted, including the grey literature (eg, technical reports and white papers) and peer-reviewed research publications. Semistructured interviews were also conducted with Clinic staff members to determine the motivation of their engagement in meaningful quality improvement, or learning, initiatives. RESULTS: Six learning principles emerged from the literature review and staff interviews: (1) draw on wisdom of groups and value connections; (2) embrace sensemaking over decision making in dealing with the unexpected; (3) bring diverse perspectives to complex challenges; (4) animate people, provide direction, update regularly, and interact respectfully; (5) appreciate the power and ubiquity of emergent change and the limitations of planned change; and (6) concentrate on small wins and characterize challenges as mere problems. Examples of how these principles are beginning to influence how learning and improvement are understood and approached at Billings Clinic are described and serve as illustrations of the principles in action. CONCLUSION: Becoming adept in learning is essential to realizing the vision of Learning Health Systems-to harness science, clinical research, and information generated by digital technology to inform and accelerate improvement in quality health care. This article seeks to contribute to greater understanding of this process by sharing a set of principles that are proving useful at one health care organization and to a more comprehensive conceptualization of Learning Health Systems.

Making sense: duty hours, work flow, and waste in graduate medical education.

Parsimony, and not industry, is the immediate cause of the increase of capital. Industry, indeed, provides the subject which parsimony accumulates. But whatever industry might acquire, if parsimony did not save and store up, the capital would never be the greater.Adam Smith, The Wealth of Nations, book 2, chapter 31In 2003, the Accreditation Council for Graduate Medical Education implemented resident duty hour limits that included a weekly limit and limits on continuous hours. Recent recommendations for added reductions in resident duty hours have produced concern about concomitant reductions in future graduates' preparedness for independent practice. The current debate about resident hours largely does not consider whether all hours residents spend in the educational and clinical-care environment contribute meaningfully either to residents' learning or to effective patient care. This may distract the community from waste in the current clinical-education model. We propose that use of "lean production" and quality improvement methods may assist teaching institutions in attaining a deeper understanding of work flow and waste. These methods can be used to assign value to patient- and learner-centered activities and outputs and to optimize the competing and synergistic aspects of all desired outcomes to produce the care the Institute of Medicine recommends: safe, effective, efficient, patient-centered, timely, and equitable. Finally, engagement of senior clinical faculty in determining the culture of the care and education system will contribute to an advanced social-learning and care network.