Supporting Cultural and Learning Enablers for a Learning Health System ( <scp>SCALE</scp> ): A Program Theory Approach

Background: Health systems around the world are investing in learning health system (LHS) infrastructure to strengthen their capacity to adapt, improve, and respond in real time. While prior work has focused on technical infrastructure, less is known about the conditions that enable learning to happen as envisioned. We aimed to address this knowledge gap by developing a multi-level, empirically grounded theory for operationalizing organizational attributes and leadership practices that influence learning in LHS. Methods: We adopted an iterative, theory-informed qualitative approach inspired by realist evaluation principles. Drawing on organizational and LHS literature, we developed an initial program theory hypothesizing key antecedents of organizational learning and conducted semi-structured interviews with formal leaders in a large community hospital using a "teacher-learner cycle" to test and refine the initial program theory. Results: Based on interviews with 12 formal leaders, we developed a mid-range program theory outlining how structural, leadership, and cultural factors interact to create (or impede) the conditions for organizational learning in LHS. Resource investment, organizational governance, shared organizational identity, and leadership approaches emerged as key factors. These factors influence both the relational dynamics and execution dynamics that drive how work is done, determining whether the culture is characterized by learning catalysts or inertial loops. Conclusions: Leadership practices shape the cultural conditions that enable or stall system-level learning in LHS. While structural supports matter, they do not create the conditions for learning without leadership practices that reinforce clarity, connection, and curiosity.