Functioning of healthcare entities as learning organisations in Poland on the example of Podlaskie voivodeship

The article aims to present issues regarding learning organisations in the context of the functioning of healthcare entities as examples of such organisations in Poland. A literature review was conducted, and the research problem and two research questions were formulated for veriﬁ cation. The subject of the study is public healthcare entities functioning as learning organisations in Poland, using the example of the Podlaskie voivodeship. In order to gather literature for the article, the desk research method was used, using scientiﬁ c databases: Google Scholar and ScienceDirect. The literature on the subject covers the years 2015–2023. Firstly, the literature was reviewed, deﬁ ning a learning organisation. Next, methods and tools used in organisational learning were listed. Lastly, the validity of medical entities as learning organisations was discussed. The next part of the article presented therapeutic entities from Podlaskie voivodeship as learning organisations in 2016–2022. The general criteria of the “Learning Organization” Competition were presented, followed by a discussion on the awarded therapeutic entities. In the end, the limitations of the article were discussed, and conclusions and practical implications were formulated. It was emphasised that changing and responding to market trends is essential for modern health organisations to sustain themselves in a turbulent market. The ability to constantly improve knowledge and search for it is crucial here. Therefore, in healthcare entities such as learning organisations, constant access to knowledge, not strictly medical, is crucial for medical and administrative staﬀ . Helpful in the pursuit


Introduction
The transformation of Poland's healthcare system has been taking place continuously for more than three decades.From the functioning of budgetary units in healthcare institutions to independent public healthcare institutions and medical entities (Pasowicz, 2012).The current shape of the health sector was also infl uenced by the coronavirus pandemic outbreak in 2020, which signifi cantly accelerated the digital transformation of the entire industry (Marx and Padmanabhan, 2020;Wahab and Saad, 2022).
The hitherto dominant management model for the public sector, including the health sector, is gradually transitioning from traditional to a client/patient approach (Frączkiewicz-Wronka and Dyaczyńska, 2012).The learning organisation, considered the main or even the only factor that gives a company a competitive advantage, is an "organisation of the future" capable of continuous self-improvement (Trzcieliński, 2007).In the literature, a learning organisation is an ideal entity that is an expected image of the organisation from two points of view -management and ordinary employees acting in unison to improve the organisation and its position in the marketplace (Skowron, 2017).This ideal entity of the future as a new type of enterprise is referred to as an "anti-structured" or "structureless" system that is constantly changing and in constant turmoil (Jóźwiakowski, 2016).
This paper aims to synthesise the knowledge about learning organisations and the functioning of healthcare entities as examples of such organisations in Poland by reviewing the literature on the subject.The research problem is to determine whether there are examples of healthcare entities functioning as learning organisations in the Polish healthcare system.In order to verify the research problem, the following research questions were formulated: 1. What elements are emphasised by current health learning organisations in Poland?
2. What methods and tools are used by today's health learning organisations?
The subject of consideration is public healthcare entities functioning as learning organisations in the health market in Poland on the example of Podlaskie voivodeship.

Theoretical framework of the research
A learning organisation is defi ned as an organisation that is self-learning and, at the same time, encourages its employees to participate in the learning process.In such an organisation, the key factors are accessible and open information and its system, encouraging employees to be proactive, opportunities for development, and the spirit of learning (Dobrzinskiene et al., 2022).A learning organisation allows individual and team learning to expand the personnel's knowledge and skills to maximise and optimise organisational performance (Faizal Iylia Mohd Ghazali et al., 2015).Such an organisation is seen in this sense as experimental, fl exible, able to respond quickly to changes in its environment and processes, and impacting the external environment (Örtenblad, 2018).
A learning organisation is based on open communication, risk-taking and knowledge management.The learning process in this type of organisation must move from individual to collective, from organisational to inter-organisational and vice versa, causing changes in behaviour (Vainauskienė and Vaitkienė, 2022).
A learning organisation represents an entity that enables stakeholders to expand their capabilities and achieve common organisational goals (Aggestam, 2006;Githuku et al., 2022;Kaziemierska et al., n.d.;Senge, 2006).One of the main goals of a learning organisation is to build a culture of organisational learning (Gagnon et al., 2015).However, knowledge sharing across work environments and time differs from simply sharing information, as people need support in interpreting each other's perspectives and negotiating a new, shared one (Stefanelli, 2001).
The concept of the learning organisation in healthcare has a solid ethical basis in improving health by understanding optimal care delivery processes and improving long-term outcomes (Friedman and Rigby, 2013).Medical entities are particularly predestined to implement modern knowledge management concepts and organisational learning processes due to their strong dependence on the human factor (Dyaczyńska, 2013).Knowledge management strategy in this entity should focus on the following activities: promoting innovation in management and treatment, shaping organisational culture, developing and transferring best management and treatment practices, and reducing treatment and organisational costs (Karkowski and Korczak, 2016).

Research methodology
The author used the desk research method to gather information about the functioning of healthcare entities as learning organisations.The following combinations of keywords and Boolean operators were used in the literature search: ("healthcare entity" OR "medical entity" OR "medical facility" OR "treatment facility) AND "learning organisation".The author used the following professional databases to gather relevant scientifi c literature: Google Scholar and ScienceDirect.During the analysis, the author studied scientifi c articles, industry literature, and electronic sources from 2000-2023, with a preponderance in 2015-2023.Complementing the collected literature was searched in the databases above for the following keywords, each time in combination: "given keyword" AND "learning organisation": CRM, Customer Relationship Management, SCRM, Social Customer Relationship Management, TQM, Total Quality Management, EBM, Evidence-Based Medicine, coaching, mentorship, Kaizen, strategic alliance, benchmarking, outsourcing, reengineering, workfl ow system, strategic scorecard, MRP, Material Requirements Planning.The author used the above databases to collect the literature for the purpose of this article and the research problem.

Healthcare entities as learning organisations in 2016-2022 -the example of Podlaskie voivodeship
Since 2015, the Voivodeship Labor Offi ce in Białystok and the Bialystok University of Technology have awarded prizes to the best employers applying the principles of "organisational learning" in the "Learning Organization" Competition.The purpose of the competition is to promote employers from the Podlaskie voivodeship who are distinguished by the following characteristics and activities: investing in the development of employee competencies; orientation towards knowledge and competency management of employees; fl exible organisational structure; implementation of personnel strategy; an organisational culture that stimulates pro-development behaviour; implementation of activities aimed at the development of their employees, increasing the effi ciency of their organisation while stimulating learning of business partners.The competition is aimed at companies from the SME sector, large companies, and the public sector employers (Wojewódzki Urząd Pracy w Białymstoku, 2022).The competition covers only entities operating in the Podlaskie voivodeship.Hence, it is not nationwide, making it impossible to compare such entities with other voivodeships.
The general criteria for evaluating employers within the competition framework include fi ve areas of functioning of a learning organisation: information about the organisation, personnel policy, continuing education of employees, good practices in knowledge transfer within the organisation, and orientation to organisational learning.Winners of the competition in each category, in addition to a diploma, receive the right to use the title "Learning Organization" for one year from the date of presentation of awards (Wojewódzki Urząd Pracy w Białymstoku, 2022).
Table 1 summarises healthcare entities from the Podlaskie voivodeship that won awards and prizes in 2016-2022 in the "Public Sector" category of the "Learning Organization" competition.In 2015, no healthcare entity was recognized as a learning organisation., 2017, 2018, 2019, 2020, 2021, 2022.

Discussion
Table 1 shows that healthcare entities representing the Podlaskie voivodeship are slowly beginning to function as learning organisations.At the beginning of the competition, this type of institution was missing from the group of distinguished entities.However, since 2016 and every subsequent year (except 2020), public healthcare units already appear on the list.This situation shows a growing awareness of the functioning of learning organisations that can also successfully be medical entities.Hospitals dominate, and one of them -is the Dr. Ludwik Rydygier Regional Hospital in Suwałki, which is a featured entity in the annual competition.
The featured facility (Nursing Home in Mścichy) in 2021 should be no surprise due to the coronavirus pandemic, but it lacks a hospital as the fi rst point of contact for the infected.This situation may be due to the overload of the hospital system during this challenging period and the facility's inability and unwillingness to compete.Noteworthy is that as many as three treatment entities were recognised as learning organisations in 2022.Among them, a psychiatric hospital appeared, which may indicate the search for specialised help during the pandemic and the competition jury's appreciation of eff orts in this direction.
In addition to the hospital and nursing home, the table lists an emergency unit.Other medical entities are missing.This situation may be related to the COVID-19 pandemic, as these entities performed and continue to perform critical functions in helping the infected.Secondly, according to the Voivodeship Labor Offi ce in Białystok (Polish: Wojewódzki Urząd Pracy w Białymstoku), as many as 37 medical entities were deleted from the register kept by the Podlaskie voivodeship in 2022, 18 entities in 2021, 20 entities in 2020, 22 entities in 2019, 39 entities in 2018, 21 entities in 2017, 20 entities in 2016, 16 entities in 2015, 17 entities in 2014, 29 entities in 2013 and 52 entities in 2012 (Podlaski Urząd Wojewódzki w Białymstoku, n.d.).Two hundred ninety-one medical entities in Podlaskie voivodeship were deleted in 2012-2022.Among the deleted entities, the predominant ones were non-public ZOZs, clinics and dental clinics, family doctor clinics, clinics and specialised clinics, psychotherapy centres, rehabilitation clinics, medical centres, and nursing services.There were no hospitals, nursing homes or emergency units among the deleted entities.
The article's author noted that the two types of medical entities in the tabulated list, namely hospitals and nursing homes, are considered total institutions.This situation is because this type of organisation creates for the people associated with it -employees and patients -a separate world, governed by its laws and separated from the rest of society by more or less tight barriers.Such total institutions are characterised by isolation from the outside world (expressed through symbols); imposed external control, group-based nature of activities, strictly scheduled time for individual tasks/procedures/treatments, lack of separation of work, sleep and rest areas; the constant presence of other people; two-part management; control of resources, information and mobility (Domaradzki, 2018).In doing so, it should be noted that the concept of a total institution and describing a psychiatric hospital with this category, for example, refers to how it operates, its staff and patients, not the forms of treatment or mental illness itself (Żółtowski, n.d.).Nursing homes as total institutions have been highlighted by various researchers (Borowski, 2013;Kosiorek, 2012;Zbyrad, 2012Zbyrad, , 2014)).It would be appropriate to ask whether an entire organisation can be a learning organisation simultaneously.An analysis of Table 1 shows that it most certainly can.In addition, examples of such organisations are known in the literature, for example, a school (Fura, 2007;Gajda and Gaudy, 2012;Jurczak, 2017;Rabiej, 2013;Raszewska-Skałecka, 2021), police (Łuczak, 2013;Rzeczkowska, 2018), care and educational facilities (Przywojska, 2014;Wolan, 2004).
The following management systems implemented by the assessed healthcare entities should be indicated as part of the "management by quality" tool.Firstly, (Samodzielny Szpital Miejski im.PCK w Białymstoku, 2022) and Dr. Ludwik Rydygier Regional Hospital in Suwałki has standardised management systems by ISO standards: ISO 9001:2015 Quality Management System, ISO 27001:2017 Information Security Management System, and Hospital Accreditation Programme.These hospitals meet quality and information security requirements and comply with accreditation standards.In addition, the Primary Health Care of the Dr Ludwik Rydygier Regional Hospital in Suwałki was awarded an accreditation certifi cate by the Minister of Health on June 13th 2023, thus confi rming compliance with the accreditation standards for primary care.These standards relate to critical areas of the services provided, including patient safety, comprehensiveness of care, health education, and the quality of medical records.Such an accreditation certifi cate is held by approximately 2% of POZ facilities across Poland (Szpital Wojewódzki im.dr.Ludwika Rydygiera w Suwałkach, 2023).Secondly, Specialist Psychiatric SP ZOZ in Suwałki has received ISO 9001:2015 certifi cation, which confi rms that the hospital applies a management system that complies with the requirements of the international standard (Okoniewska, 2018).Thirdly, (Samodzielny Publiczny Zakład Opieki Zdrowotnej Wojewódzka Stacja Pogotowia Ratunkowego w Białymstoku, 2022) and (Wojewódzka Stacja Pogotowia Ratunkowego w Suwałkach, 2022) have ISO 9001:2015 as part of their quality policy.
In conclusion, using the example of the Podlaskie region, it can be deduced that public medical entities are slowly beginning to function as learning organisations.On the one hand, the coronavirus pandemic disrupted medical institutions' organisational learning process.On the other hand, it highlighted the characteristics necessary for the functioning of such entities in the face of the global health crisis, which was recognised in the "Learning Organization" Competition.

Limitations
The article contains several limitations.First, only articles indexed in databases were used in the analysis: Google Scholar and ScienceDirect, which may have resulted in the omission of valuable items on the issues under consideration.Second, the literature search in the databases above used specifi c word combinations using Boolean operators, which could have distorted or narrowed the search for relevant items.Electronic sources were used for the issues covered to supplement the literature analysis.Third, the focus was exclusively on public healthcare entities and, in addition, representing only the Podlaskie voivodeship -due to the scope of the competition and the availability of information on the functioning of these entities as learning organisations.

Conclusions and practical implications
In today's reality, everything changes quickly, whether it is in economic, social, or business areas.The guarantor of an organisation's survival in a turbulent market is the ability to change and adapt to current trends.People employed in organisations need to keep up with the knowledge necessary to perform their tasks, because few skills can be acquired "forever".In addition, the coronavirus pandemic has highlighted transformative competencies as a guarantor of staying, regardless of age, in the job market.These competencies can help manage professional, social, economic, or fi nancial uncertainty.The above conclusions also apply to medical professionals employed by healthcare entities.Hence, these types of facilities also need to be ready for change and respond quickly to emerging opportunities or chances coming from the environment.
The article's purpose, which was to synthesise the knowledge about learning organisations and the functioning of medical entities as this type of organization in Poland, has been achieved.As part of verifying the research problem, it was established that medical entities function as learning organisations in the Polish healthcare system.Due to the narrowing down to the Podlaskie voivodeship, the accumulated knowledge on this subject does not allow broader coverage of this issue.It suggests a research gap exists in this area.Concerning the research questions posed, the current health learning organisations in Poland, i.e. the healthcare entities from the Podlaskie voivodeship awarded in the "Learning Organization" Competition, emphasise management and leadership, development of employees and their competencies, and organisational culture and structure.Modern learning organisations in the healthcare sector use various methods and tools in their operations, including CRM/SCRM, or (social) customer relationship management; management by quality; evidence-based medicine; coaching and mentorship; Kaizen; benchmarking; outsourcing; reengineering; workfl ow system; strategic scorecard, as well as material requirements planning.
In modern organisations' changing environment and organisational culture, the ability to continuously deepen and search for knowledge is paramount.Therefore, in healthcare entities as learning organisations, continuous access to knowledge, not strictly medical, is extremely important for medical and non-medical staff .Various methods and tools to support the learning and experience process help seek and explore this knowledge.However, about public healthcare providers, additional consideration must be given to the legal regulations regarding the required competencies necessary for the provision of services by medical personnel.In the case of paramedics, these are compulsory periodic training in cardio-pulmonary resuscitation at the ALS level by the guidelines of the Polish Resuscitation Council; in the case of nurses and midwives, these are specialist, qualifi cation and specialisation courses by the framework programmes of the Centre for Postgraduate Training of Nurses and Midwives.In addition, it should be noted that the public healthcare entities indicated in the article are, in most cases, not the organisers of the training but only receive support from external entities.
Several practical implications have been developed based on a review of articles, industry positions and electronic sources.First, to benchmark good practices as learning organisations among healthcare entities in Poland, it would be appropriate to expand the scope of the "Learning Organization" competition to other voivodeships.Secondly, knowledge of the said Competition is impossible without marketing; hence, it would be necessary to inform and encourage companies and employers in the public sector to participate in a nationwide promotional campaign.Thirdly, among healthcare entities, it would be necessary to build awareness of a learning organisation from the ground up -to start a series of training courses for medical and administrative staff , with particular attention to the benefi ts/values for all stakeholders in the process.Finally, since the biggest challenge in knowledge management is to share knowledge, it would be necessary to motivate employees and create a suitable "climate" and atmosphere for sharing acquired information among colleagues.