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The importance of culture is often emphasized for continuous learning and quality improvement within health care organizations. Limited empirical evidence for cultivating a culture that supports continuous learning and quality improvement in health care settings is currently available.

The purpose of this report is to characterize the evolution of a large division of physical therapists and occupational therapists in a pediatric hospital setting from 2005 to 2018 to identify key facilitators and barriers for cultivating a culture empowered to engage in continuous learning and improvement.

An ethnographic methodology was used including participant observation, document review, and stakeholder interviews to acquire a deep understanding and develop a theoretical model to depict insights gained from the investigation.

A variety of individual, social, and structural enablers and motivators emerged as key influences toward a culture empowered to support continuous learning and improvement. Features of the system that helped create sustainable, positive momentum (e.g., systems thinking, leaders with grit, and mindful design) and factors that hindered momentum (e.g., system uncertainty, staff turnover, slow barrier resolution, and competing priorities) were also identified.

Individual-level, social-level, and structural-level elements all influenced the culture that emerged over a 12-year period. Several cultural catalysts and deterrents emerged as factors that supported and hindered progress and sustainability of the emergent culture.

Cultivating a culture of continuous learning and improvement is possible. Purposeful consideration of the proposed model and identified factors from this report may yield important insights to advance understanding of how to cultivate a culture that facilitates continuous learning and improvement within a health care setting.

In 2016, New Zealand's Ministry of Health introduced the System Level Measures Framework which marked a departure from health targets and pay-for-performance incentives towards an approach based on local, collaborative approaches to health system improvement. This exemplifies an attempt to “overwrite” New Public Management (NPM) institutional practices with New Public Governance (NPG). We aim to trace this process of overwriting so as to understand how attempts to change institutional practices were facilitated, blocked, translated and edited.

We develop a conceptual framework for understanding and tracing institutional change towards NPG which emphasises the importance of discursive strategies in policy attempts to overwrite NPM with NPG. To analyse the New Zealand case, we drew on policy documents and interviews conducted in 2017–18 with twelve national key informants and fifty interviewees closely involved in local development and/or implementation of the SLMF.

Policy sponsors of collaborative approaches to health system improvement first attempted formal institutional change, arguing that adopting collaborative, quality improvement (NPG) approaches would supplement existing performance management (NPM) practices, to create a superior synthesis. When this formal approach was blocked, they adopted an approach based on informal persuasion of local organisational actors that quality improvement should supplant performance improvement. This approach was edited and translated by local actors, and the success of local implementation varied considerably.

This article offers a novel conceptualisation of public management institutional change, which can help explain why it is difficult to completely erase NPM practices in health.

This paper explores the rhetorical practices that are used in the introduction of a New Public Governance policy framework.

Much work about health reform and systems improvement in healthcare looks at shortcomings and universal problems facing health systems, but rarely are accomplishments dissected and analyzed internationally. The purpose of this paper is to address this knowledge gap by examining the lessons learned from health system reform and improvement efforts in 60 countries.

In total, 60 low-, middle- and high-income countries provided a case study of successful health reform, which was gathered into a compendium as a recently published book. Here, the extensive source material was re-examined through inductive content analysis to derive broad themes of systems change internationally.

Nine themes were identified: improving policy, coverage and governance; enhancing the quality of care; keeping patients safe; regulating standards and accreditation; organizing care at the macro-level; organizing care at the meso- and micro-level; developing workforces and resources; harnessing technology and IT; and making collaboratives and partnerships work.

These themes provide a model of what constitutes successful systems change across a wide sample of health systems, offering a store of knowledge about how reformers and improvement initiators achieve their goals.

Few comparative international studies of health systems include a sufficiently wide selection of low-, middle- and high-income countries in their analysis. This paper provides a more balanced approach to consider where achievements are being made across healthcare, and what we can do to replicate and spread successful examples of systems change internationally.

The purpose of this paper is to present a co‐authored reflection on the health improvement leadership development programme and the key evaluation messages derived from piloting in an English National Health Service region. It highlights the specific attributes of this approach to health improvement leadership development and clarifies health improvement development issues.

Appreciative inquiry and soft systems methodology are combined in an evaluation approach designed to capture individual as well as organisation learning and how it impacts on leadership in specific contexts.

The evaluation exposes the health improvement leadership needs of a multi‐organisation cohort, offers some explanations for successful achievement of learning needs while also exposing of the challenges and paradoxes faced in this endeavour.

There are limited reported templates of how to develop leadership for health improvement. This paper details a whole systems approach, acknowledging the impact of context on leadership and an approach to evaluating such complex initiatives.

The purpose of this paper is to describe how clinical registers were designed and used to serve multiple purposes in three health systems, in order to contribute practical experience for building learning healthcare systems.

Case description and comparison of the development and use of clinical registries, drawing on participants’ experience and published and unpublished research.

Clinical registers and new software systems enable fact-based decisions by patients, clinicians, and managers about better care, as well as new and more economical research. Designing systems to present the data for users’ daily work appears to be the key to effective use of the potential afforded by digital data.

The case descriptions draw on the experience of the authors who were involved in the development of the registers, as well as on published and unpublished research. There is limited data about outcomes for patients or cost-effectiveness.

The cases show the significant investments which are needed to make effective use of clinical register data. There are limited skills to design and apply the digital systems to make the best use of the systems and to reduce their disadvantages. More use can be made of digital data for quality improvement, patient empowerment and support, and for research.

Patients can use their data combined with other data to self-manage their chronic conditions. There are challenges in designing and using systems so that those with lower health and computer literacy and incomes also benefit from these systems, otherwise the digital revolution may increase health inequalities.

The paper shows three real examples of clinical registers which have been developed as part of their host health systems’ strategies to develop learning healthcare systems. The paper gives a simple non-technical introduction and overview for clinicians, managers, policy-advisors and improvers of what is possible and the challenges, and highlights the need to shape the design and implementation of digital infrastructures in healthcare services to serve users.

The purpose of this paper is to discuss improvement of the business of health care delivery through the application of systematic problem solving. This was strengthened by recurrence prevention through standardization at every level transforming into culture.

The methodology utilized is set derived from the true fiber and fabric of Toyota, the Toyota Business Practice (TBP) or eight-step problem solving and its translation into health care thinking by aligning to the process of clinical diagnosis of patients. The methodology that gives energy and direction to TBP is Hoshin Kanri, a Japanese approach to strategic planning. When you combine focus and purpose through strategic direction alongside a culture of systematic problem solving you get results.

The application of the Toyota mindset resulted in a cultural shift which built on the strength of the current organizational culture. This approach had a broad impact on the program impacting leadership and management roles, improved employee engagement, complete visibility of organizational priorities, improved system performance, visibility and awareness of the vision and defined measures that drive the health care system. This has also resulted in cost diversions of approximately five million dollars CDN.

A grass roots application of real-time problem solving through strategic alignment.

The purpose of this paper is to show how the Turning Point Initiative to improve the health of populations by improving the USA public health system has many lessons on collaboration for governance systems.

The article synthesizes published literature outlining the results of a Robert Wood Johnson Foundation/W.K. Kellogg Foundation grant program to 21 USA states and 43 communities and relationships to administrative practice.

Turning Point's creation of a formalized network of public health partners across the USA has led to innovations in collaboration, increased system capacity, and alternative structures for improving health.

Turning Point's efficacy in community health system improvement can be mirrored in clinical governance. A major potential for improvement in clinical delivery systems is available by re‐thinking key partners, organizational structures, and system administrative capacity.

Evidence suggests that healthcare system performance may be improved with policy emphasis on primary care, quality improvement, and information technology. The authors therefore sought to investigate the extent to which policy makers in seven countries are emphasizing these areas.

Policies in these three areas in seven high-income countries were compared. A comparative descriptive approach was taken in which each of the country-specialist authors supplied information on key policies and developments pertaining to primary care, quality improvement and information technology, supplemented with routine data.

Each of the seven countries faces similar challenges with healthcare system performance, yet differs in emphasis on the three key policy areas; efforts in each are, at best, patchy. The authors conclude that there is substantial scope for policy makers to further emphasize primary care, quality improvement and information technology if aiming for high-performing healthcare systems.

This is the first study to investigate policy-makers' commitment to key areas known to improve health system performance. The comparative method illustrates the different emphases that countries have placed on primary care, quality improvement and information technology development.

The purpose of this paper is to examine how the design and implementation of learning models for performance management can foster continuous learning and quality improvement within a publicly funded, multi-site community hospital organization.

Niagara Health’s patient flow performance management system, a learning model, was studied over a 20-month period. A descriptive case study design guided the analysis of qualitative observational data and its synthesis with organizational learning theory literature. Emerging from this analysis were four propositions to inform the implementation of learning models and future research.

This performance management system was observed to enable: ongoing performance-related knowledge exchange by creating opportunities for routine social interaction; collective recognition and understanding of practice and performance patterns; relationship building, learning for improvement, and “higher order” learning through dialogue facilitated using humble inquiry; and, alignment of quality improvement efforts to organizational strategic objectives through a multi-level feedback/feed-forward communication structure.

The single organization and descriptive study design may limit the generalizability of the findings and introduce confirmation bias. Future research should more comprehensively evaluate the impact of learning models on organizational learning processes and performance outcomes.

This study offers novel insight which may inform the design and implementation of learning models for performance management within and beyond the study site.

Few studies have examined the mechanics of performance management systems in relation to organizational learning theory and research. Broader adoption of learning models may be key to the development of continuously learning and improving health systems.