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Keywords

clinical algorithms, corporate culture, errors in medicine, outcomes research, regionalization

 

Authors

  1. Waldman, J. Deane
  2. Yourstone, Steven A.
  3. Smith, Howard L.

Abstract

This article explores the uses of learning curve theory in medicine. Though effective application of learning curve theory in health care can result in higher quality and lower cost, it is seldom methodically applied in clinical practice. Fundamental changes are necessary in the corporate culture of medicine in order to capitalize maximally on the benefits of learning.

 

Learning occurs when improvement in an activity results from understanding gained from prior experience. The learning curve, derived initially from manufacturing1 characterizes this relationship in quantitative terms. The more a system produces, the lower the cost. Learning in health care is extremely important given limited resources and high error rates in medicine. Learning is critical for increasing productivity of health care providers as a means for lowering costs. Thus, there is ample motivation to understand how improved learning contributes to better performance of health care organizations. This is especially true for the more expensive aspects of health care delivery involving surgery and sophisticated medical technology.

 

Learning also contributes to improved management processes that lead to enhanced performance at many levels-individual and team, department or division, organization and industry. Evidence-based management has become a catch phrase for this effort at incorporating findings from applied research-learning-into actual management practice as a means of raising performance at different levels.2 Current interest in improving management processes and organizational structures in health care through the application of research findings is a direct result of recent clinical emphasis on evidence-based medicine.3 However, the foundation for applied management research can be traced to organization development models developed more than thirty years ago.4

 

Many principles of learning in manufacturing settings can be transferred to health care. The classic log-linear model states that for each doubling of cumulative volume, constant improvement will occur. While the percentage of improvement varies by process, the prospects for demonstrable gains in lower costs and higher quality are promising, whether considering care delivered by surgeons, primary care physicians, nurses, or technicians. The challenge for clinicians and managers is to capitalize on learning theory in the development and implementation of clinical protocols.

 

Application of evidence-based (viz., learned) medical management is not totally absent from health care, just underutilized. For example spectacular successes in anesthesia and pediatric oncology are a testament to the effectiveness of structured, collaborative learning in clinical practice. On the other hand, the myriad ways to treat obesity, asthma, or bronchopulmonary dysplasia as reported in small personal series of experiences document the rarity of applied learning and speak to the lack of evidence-based medical management. Furthermore, the lack of predictable successful outcomes, of achieving a six sigma standard,5 indeed our appalling national medical error rates,6 all confirm the need for structured learning in health care, just as corporations have turned to intentional learning as a means to improve outcomes.7,8

 

This article reviews the foundations of learning theory, applies these concepts and experiential knowledge to the health care setting, examines the obstacles to developing successful applications in the health care setting, and proposes strategies for adopting manufacturing-based learning models by health care providers. A conceptual model of learning is presented. Constraints and rationales affecting learning in health care are analyzed in order to facilitate application of the model.