Abstract
Learning Health Systems (LHS) emphasize continuous improvement through cycles of evidence generation, implementation, and evaluation, yet relatively little attention has been paid to the educational processes through which clinicians and organizations learn during implementation. This study examined how implementation of a frostbite treatment protocol functioned as a process of transformative learning within a LHS. We conducted a realist case study of implementation of a frostbite treatment protocol across four tertiary-care hospitals within a Canadian health system. Semi-structured realist interviews were conducted with nine interest holders representing six professional groups and analyzed alongside implementation documents, including clinical protocols, electronic health record order sets, and educational materials. Data were analyzed iteratively using Context-Mechanism-Outcome Configurations (CMOCs), which were synthesized into program theories explaining how implementation generated learning and organizational change. Eighty-five CMOCs were synthesized into five program theories describing an iterative learning process through which interest holders: (1) recognized deficiencies in existing frostbite care, (2) overcame organizational barriers, (3) mobilized collective action, (4) institutionalized new clinical practice, and (5) reinforced and sustained transformation through improved patient outcomes. A chance clinical encounter functioned as a disorienting dilemma, challenging assumptions about appropriate frostbite care and motivating change. Trust, professional credibility, multidisciplinary collaboration, and distributed leadership enabled interest holders to reinterpret uncertainty, navigate organizational barriers, and develop new clinical pathways. Rather than occurring before implementation, transformative learning emerged through participation in implementation itself. Improved patient outcomes subsequently reinforced confidence, facilitated dissemination, and stimulated continued organizational learning. This study begins to extend transformative learning beyond formal educational settings by demonstrating how implementation can function as a collective learning process within healthcare organizations. By integrating realist inquiry, transformative learning theory, and LHS, we propose implementation as a mechanism through which clinicians and organizations collectively question assumptions, reinterpret evidence, and sustain system transformation.