Reflection 2

This reflection paper must include comment and content based on weeks 3 (ch 7 and 9 ) and week 4

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After each two-week module, students are required to submit a reflection paper that highlights a topic/subject of choice from the module readings. This could be something new learned, or alternatives to some solutions, or personal experience that relates to any of the course reading materials. Criteria is as follows:

· 1½ to 2 pages in length, typed in double space in Word using 12-point Times New Roman font (coverage page and references page not included).

· Insightful and of academic merit.

· Citing of references is not required unless you provide an exact quote from either your textbook or an assigned reading; however, you must state somewhere in the paper which chapter or assigned reading your topic/subject of choice is located.

1 7 5

L e a r n i n g O b j e c t i v e s

C H A P T E R 7

I M P R O V E M E N T P R O J E C T
T E A M S

After reading this chapter, you will be able to

➤ explain the role of improvement project participants,

➤ discuss the purpose of a team charter,

➤ recognize beneficial and disruptive team behaviors,

➤ apply leadership skills to manage team meetings effectively,

➤ describe the stages of team development, and

➤ identify strategies for preventing improvement project failures.

Spath, Patrice. Introduction to Healthcare Quality Management, Third Edition : Third Edition, Health Administration Press, 2018. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/westernkentucky/detail.action?docID=5517319.
Created from westernkentucky on 2021-02-15 13:06:57.

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I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t1 7 6

➤

Charter

➤

Facilitator

➤

Ground rules

➤

Independents

➤

Inputs

➤

Leadership

➤

Outputs

➤ Problem statement

➤

Process owners

➤

Sponsor

I
f improvement models are the recipe and if improvement tools are the ingredients, where
does the improvement team fit into this analogy? When I bake a cake, I work alone; I
do not need a group of people to help me. I could not work alone, however, if I had to

prepare a banquet for 50 guests. I would need a team of people to help cook the meal. The
more complex the process—whether cooking or improving health services quality—the
greater is the need for teamwork. When improvement opportunities are identified, a group
of people known as an improvement team is assembled. By following an improvement model
and using improvement tools, the team works together to accomplish improvement goals.
This team’s success hinges on effective project management.

A formal team need not be assembled for every improvement opportunity. The case
study at the beginning of chapter 3 describes an initiative to reduce patient wait times at
the Redwood Health Center. The clinic manager did most of the work for this project.
He gathered data on how long patients waited to be seen by a clinician, shared those data
with other people in the clinic, and informally discussed ways of reducing wait times. An
improvement team was not formed for the project. Likewise, for the improvement initia-
tive involving patient identification wristbands at Community Hospital in chapter 4, a
project team was not formed to resolve the problems people were having with the bands.
After collecting information about band defects, the manager fixed the problem on her
own. The case study discussing Sunrise Home Health Agency at the beginning of chapter
5 is yet another example of an informal initiative. The director and clinical staff members
used regular staff meetings to revise the meeting process.

Some performance problems cannot (and should not) be solved individually or
informally and require the attention of a dedicated improvement project team that includes
several people familiar with the systems and processes that need to be changed. A project
team should be created when the improvement goal is more likely to be achieved through the

K e y w o r d S

C h a p t e r 7 : I m p r o v e m e n t P r o j e c t T e a m s 1 7 7

coordinated efforts of people with varying knowledge, skills, and perspectives. The greatest
improvement potential lies in problems that involve different professions and departments.
The team’s role is to analyze and eliminate undesirable, unpredictable, or unworkable per-
formance situations. Once the improvement project is complete, the team is disbanded.

People at all levels in the organization may be part of an improvement project team.
Because projects generally take employees away from their primary work responsibilities,
time spent on an improvement initiative had better produce measurable performance gains.
This chapter describes ways to increase the likelihood that formal improvement projects
will be successful.

pr o j e C t pa rt i C i pa n t S
When the best approach to an improvement opportunity is a formal project, a team of
people is chosen to fill the following roles:

◆ Sponsor

◆ Team leader

◆ Facilitator

◆ Recorder

◆ Timekeeper

◆ Team members

These roles are summarized in exhibit 7.1. Although the roles may vary, at a mini-
mum each project has a sponsor, a team leader, and team members. Involvement of the
other roles depends on the organization’s resources and the scope of the

project.

S p o n S o r

The project sponsor is the individual or group that decides to initiate an

improvement

project. If the improvement project involves more than one department, a leadership rep-
resentative or a quality oversight committee should sponsor the project. (The role of quality
oversight committees is covered in chapter 12.) If the project affects activities in only one
department or unit, the manager of that area usually serves as the sponsor.

The sponsor clearly defines the performance problem that needs to be solved by
writing a problem statement—a description of the situation. The problem statement,
sometimes called the aim statement, influences many aspects of the project, including the
makeup of the team and the improvement expectations. In addition, a clearly communicated

Sponsor

An individual or a

group that supports,

guides, and mentors an

improvement project

team; serves as a link

to the organization’s

leadership; removes

barriers; and acquires

the resources a team

needs to achieve

successful

outcomes.

Leadership

An organization’s

senior leaders or

decision makers.

Problem statement

A description of the

performance problem

that needs to be

solved. Sometimes

called the aim

statement.

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t1 7 8

problem statement establishes project boundaries so that problem-solving activities do not
escalate into larger issues or wander into unrelated topics.

The project goal should include measurable improvement expectations. For instance,
the manager at Community Hospital hoped to achieve an 80 percent reduction in staff
complaints about patient identification bands by making some process changes. The proj-
ect sponsor sets these expectations and defines the time frame for achieving them. An
explicit project goal with clearly stated, measurable expectations and time frames focuses
the improvement efforts.

Once the goal is clear, the sponsor identifies people who need to be included in
the project. If the sponsor already has someone in mind to serve as the team leader, that
person may help the sponsor select these key people. The following questions can guide
their selection:

◆ Where is the problem occurring?

◆ What tasks are involved?

◆ Who carries out these tasks?

Project
Participant Role

Sponsor Charters the improvement team, provides initial improvement
goals, monitors team progress, and supports the team

Team leader Coordinates project assignments and communication with
external parties, removes barriers, and keeps the project on track

Facilitator Helps manage discussions about the process during team
meetings, usually by asking questions (e.g., How do we want to
make this decision? What points can we agree on?)

Recorder Captures ideas, decisions, action items, and assignments on
a flip chart or whiteboard for later transcription into a written
summary of the project

Timekeeper Keeps track of time during project meetings

Team member Participates in discussions, decision-making, and other team
tasks such as gathering data, analyzing information, assisting
with documentation, and sharing results

exhibit 7.1
Roles of

Improvement
Project Participants

C h a p t e r 7 : I m p r o v e m e n t P r o j e c t T e a m s 1 7 9

◆ Who determines how the tasks should be done?

◆ Who provides the inputs to these tasks?

◆ Who uses the outputs of these tasks?

The people chosen for the team should possess detailed knowledge gained through
experience with some part of the performance problem. They also must be willing and able
to attend team meetings and make time for project work that may need to be done between
meetings. Once the project is under way, the team may ask additional members to participate
if critical expertise is needed or a key group is not represented. The team should be capped
at five to ten members. To keep the team from expanding beyond the preferred size, some
individuals may serve as consultants and attend meetings only when their expertise is needed.

In an ideal project initiation, the sponsor creates a written charter incorporating
all the aforementioned elements: the project goal, a description of the system or process to
be improved, the time frame for project completion, deliverables, measures, project scope,
and team members. Exhibit 7.2 is a charter for a project aimed at improving the employee
hiring process in a county-operated emergency medical service (ambulance) company.

When expectations are unclear or too broad, an improvement project can flounder.
At one hospital, for example, staff members voiced concerns about the safety of the process
of ordering, dispensing, and administering chemotherapy medications. An interdisciplinary
team was chartered, which included representatives from the hospital’s inpatient, outpatient,
adult, and pediatric areas (physicians, nurses, pharmacists, and laboratory staff). Over a four-
month period, the team developed a top-down flowchart of the process, which ultimately
was diagrammed as 21 steps, each with multiple substeps. On review, the team realized the
enormity of the project and discovered that each area had its own way of executing tasks.
The charter the team developed at the outset of the project was too broad and was stalling
the project. The team decided it would address only the adult outpatient population and
limited the project to the medication administration phase, where most of the problems
were occurring. Once the project scope and focus were better defined, the improvement
initiative proceeded more

quickly.

Charters keep teams focused and on track during projects. Team members may
want to revisit the charter periodically to remind themselves of the project’s boundaries
and the objectives of the improvement effort. If the team receives new information during
the project or if situations change, it may need to renegotiate its objectives or boundaries.

The sponsor supports the team throughout the project, monitoring progress and
clearing obstacles that may arise. The sponsor acts as a sounding board for improvement
ideas but does not become overly involved in the details of the team’s work. At the end of
the project, the sponsor reviews the team’s improvement actions and ensures the solutions
are effectively implemented.

Inputs

Products, services, or

information flowing

into a process.

Outputs
Products, services, or

information flowing out

of a process.

Charter

A written declaration of

an improvement team’s

purpose. (An example

of an improvement

project charter is found

in exhibit 7.2.)

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t1 8 0

Problem Statement
• During the last fiscal year, 342 applications were received for paramedic

or emergency medical technician (EMT) vacancies. In this same period, 49
applicants—14%—were hired and eventually began employment with Grant County
Emergency Medical Services (EMS).

• The current hiring process for EMTs and paramedics averages 87 days with a range
of 7 to 212 days from time of application.

• As of February, EMS operations are understaffed by 17% (47 vacancies for EMTs and
paramedics).

• Understaffing causes an increase in EMS operational overtime, idle time during
field training, and system and administrative workload.

Goal
A 5% or less vacancy rate for EMTs and paramedics

Project Scope
Individuals who apply for a paramedic or EMT position with Grant County EMS

Out-of-Project Scope
• Existing paramedic or EMT employees who are promoted or return to full-time

status
• Vacancies for other positions

Measures
• Current vacancies
• Current overtime standby utilization
• Hiring process intervals (in days) and

cost

• Applicants (count)
• Applicant status (percentage of overall

applicants)
• Range of application date to start date

Deliverables
Within 6 months:
• Increase the hire rate of qualified applicants from 14% to 30%.
• Reduce annualized cost of EMS overtime and standby time to less than $280,000.
• Reduce cost per new hire (recruiting, advertising, and assessing) to no more than

$300.

Sponsor Robert Jones, Director, Public Safety

Team Leader Larry McNeill, Deputy Chief, EMS Training

Team Members • Jackie Gregory, Administrative Services
• Todd O’Brien, Human Resources
• Michael Fine, EMT
• Gary Young, Paramedic

Team Facilitator Sally Steward, Manager, Information Services

exhibit 7.2
Charter for

Improvement
Project

C h a p t e r 7 : I m p r o v e m e n t P r o j e c t T e a m s 1 8 1

t e a m l e a d e r

The team leader organizes the project, chairs team discussions, keeps the project focused
on the improvement goal, establishes the meeting schedule, and serves as a liaison between
the team and the sponsor. Often, team leaders are process owners—supervisors, manag-
ers, or physicians in the work area most affected by the improvement project. The leader
is considered a member of the team.

The team leader should be familiar with the improvement model to be used during
the project and various improvement tools. She should also be skilled at managing group
interactions and running a project. Some organiza-
tions assign a quality resource advisor to interde-
partmental improvement projects. This person is
familiar with performance

improvement principles

and serves as an internal consultant. The quality
resource advisor helps the team understand the
purpose of the project, the desired results, and
team roles and responsibilities. When there is no
quality advisor assigned to the project, the team
leader takes on these responsibilities.

f a C i l i tat o r

The facilitator supports the team leader. The
facilitator assists with team-building activities,
keeps meeting discussions and the entire project
on track, and ensures deadlines are met. The facili-
tator should be an objective team resource and
detached from the process being improved. As a neutral party, the facilitator is particularly
effective at engaging everyone on the team and helping the group reach consensus on
controversial issues.

The facilitator works with the leader to plan meetings, structure tasks and assign-
ments, and incorporate quality improvement tools into the project. The facilitator knows
what data to gather, how to gather the data, and how to present the results in a meaningful
graphic or tabular form.

In cases where the project is not overly complex, one person may assume the dual
role of team leader and facilitator. Research suggests, however, that multifaceted healthcare
improvement projects involving several departments and professions benefit from having
a facilitator who is not also responsible for leading the project (Agency for Healthcare
Research and Quality 2013).

Process owners

Individuals ultimately

responsible for a

process, including

its performance and

outcomes.
Facilitator

An individual

knowledgeable about

group processes and

team interaction as

well as performance

improvement principles

and techniques.

DID YOU KNOW??

A team leader’s abilities and characteristics influence the out-

come of an improvement initiative. Studies have demonstrated

the importance of the following characteristics of a team leader

(Turner and Müller 2005):

• Problem-solving ability

• Perspective

• Results orientation

• Communication skills

• Energy and initiative

• Negotiation skills

• Self-confidence

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t1 8 2

r e C o r d e r

The recorder, or notetaker, documents activities throughout the project. This position is
usually assigned to one or more team members. During meetings, recorders are responsible
for writing the team’s ideas, decisions, and recommendations on a flip chart or whiteboard.
Recorders also create meeting minutes and distribute them to team members before the
next meeting. The team uses the minutes to recall previous ideas, decisions, the rationales
behind the decisions, actions to be taken, the people responsible for executing those actions,
and the schedule according to which those actions will be carried out.

t i m e K e e p e r

The timekeeper keeps the team on track during meetings. If the time allotted for a discus-
sion point is exceeded, the timekeeper alerts the group. The team then decides whether to
accelerate the discussion, defer the item to another meeting, or end the discussion. In some
cases, the leader functions as the timekeeper, or this role may be assigned to the facilitator
or another team member.

t e a m m e m b e r S

Team members share responsibility for achieving the improvement goal. Members participate
in discussions, decision-making, and other team
tasks such as data collection. Each team mem-
ber should represent a program, department, or
work unit significantly affected by the process to
be improved or the problem to be solved. Ideally,
team members should have a basic understanding
of quality improvement principles, but familiar-
ity with this topic is not a prerequisite for team
membership.

Inclusion of one or two independents—
members with little or no knowledge of the

process—can also be useful. Because independents have no vested interest in the prob-
lem, they may provide a fresh and creative perspective. Some healthcare improvement
projects also benefit from customer input. For example, if a hospital team is working
to improve security in the maternity ward, a woman who recently delivered a baby
in the facility can be included as a team member. The recent patient may be made a
permanent member of the team or serve part time by attending meetings only when
her input is needed.

Independents

Improvement team

members who have

little or no knowledge

of the process under

consideration and have

no vested interest in

the outcome of the

project.

LEARNING POINT
Project Participants*

An improvement project involves several roles. At a minimum,

each project includes a sponsor, a team leader, and team

members.

C h a p t e r 7 : I m p r o v e m e n t P r o j e c t T e a m s 1 8 3

te a m me e t i n g S
At the first meeting, the team leader uses the project charter to introduce and explain the
project goal and scope. He should discuss the charter openly to prevent misunderstandings.
Any confusion or disagreement should be resolved at the first meeting.

The team leader also provides an overview of the project timeline at the first meet-
ing. Exhibit 7.3 is a Gantt chart showing the approximate start and finish times for the
steps of an improvement project.

The first meeting also is a good time to set ground rules for team conduct— directives
stating how team members are expected to communicate in meetings, make decisions,
resolve conflicts, and so forth. Critical concept 7.1 lists examples of

improvement team

ground rules. Teams usually adopt only a few key ground rules; however, project improve-
ment best practices do not limit the number (Barner and Barner 2012).

Ground rules

Established

guidelines for how an

improvement team

wants to operate;

norms for behavior.

(Examples of ground

rules are found in

critical concept 7.1.)

exhibit 7.3
Gantt Chart for
an Improvement
Project

March April May June July August September October

Develop project
charter

Appoint
improvement team

Kick off project—
first team meeting

Analyze current
practices

Gather performance
data

Identify improvement
opportunities—
second meeting

Solicit solution ideas
from colleagues

Finalize solutions—
third meeting

Implement solutions
on a trial basis

Evaluate the
effect of solutions—
fourth meeting

Roll out successful
solutions

Redesign ineffective
solutions—
fifth meeting

Evaluation Criteria

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t1 8 4

CRITICAL CONCEPT 7.1
Improvement Team Ground Rules!

• Participate by sharing your own opinions and experiences.

• Contribute but do not dominate.

• Actively listen to and consider the opinions of others.

• Stay focused on the improvement goal.

• Avoid side conversations.

• Respect other people’s time (e.g., arrive on time, do not leave early, return from

breaks promptly).

• Complete assignments to which you have committed.

• Speak one at a time.

• Leave rank at the door; all team members are equal.

• Address conflict by dealing with the issue, not the person.

• Turn off cell phones and other mobile devices.

• Be a participant, not a lurker.

• Have fun, but not at the expense of someone else’s feelings.

• Be physically and mentally present during meetings.

• Listen, listen, listen, and respond.

• Allow for some mistakes; acknowledge them, let go, and move on.

• Accept conflict and its resolution as necessary catalysts for learning.

• Be open-minded to new thoughts and different behaviors.

• Honor confidentiality.

• Accept diversity as a gift.

• Begin and end all meetings on time.

• Share in the responsibilities of the recorder.

• Criticize ideas, not individuals.

C h a p t e r 7 : I m p r o v e m e n t P r o j e c t T e a m s 1 8 5

Some organizations have a core set of ground rules for all improvement projects.
From this set, teams are usually allowed to select the rules they wish to observe. If the
organization has no such set of rules, the leader solicits ideas from the team members by
asking them to describe acceptable team behaviors. When the list is finalized and everyone
understands the ground rules, members individually acknowledge that they agree to abide
by the group behaviors. Posting the rules on a large sheet of paper in the meeting room is
an effective way to remind group members of the rules they agreed to follow.

i m p r o v e m e n t p r o j e C t l e n g t h

The time needed to complete an improvement project varies. Some projects are elephant-
sized, and some are bite-sized. Exhibit 7.4 is a timeline for completing a project involving
hospital signage. At this hospital, patients occasionally have difficulty finding the outpa-
tient testing departments. Although signs are posted to lead the way, patients may not be
able to read the signs or the signs may be unclear. The director of the patient registration
department brought this concern to the attention of the chief operating officer, who then
sponsored a project to resolve the problem.

Not all projects are completed quickly. A project team at the University of Wisconsin
Hospital and Clinics was formed for the purpose of improving the use of intravenous pumps
to deliver patient medications (Tosha et al. 2006). The 22-member team included represen-
tatives from anesthesiology, biomedical engineering central supply, industrial engineering,
internal medicine, nursing, and pharmacy. The team met for 46 hours over four-and-a-half
months to describe the process, identify improvement opportunities, and design solutions,
and then it took additional time to implement the solutions (Tosha et al. 2006).

Whether the project is long or short, the team should meet regularly; otherwise,
enthusiasm for achieving the improvement goal diminishes. The project sponsor must stay
informed of the progress of the initiative and intervene when progress is moving too slowly.

t h e l e a d e r ’ S r e S p o n S i b i l i t i e S

The team leader manages project meetings. This responsibility involves activities that ensure
meetings are well run, including

◆ preparing the meeting agenda and distributing it at least one day in advance,

◆ keeping the meeting focused on the agenda,

◆ encouraging participation by all team members,

◆ fostering an environment in which team members feel safe expressing their
ideas, and

◆ distributing the last meeting’s minutes before the next meeting.

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t1 8 6

Timeline Activities

Week 1 The team meets for two hours to discuss project objectives and set ground
rules. The members brainstorm reasons patients might get lost when trying to
find outpatient testing departments. To determine whether these assumptions
are correct, the members will gather some data over the next seven days.
Some members will evaluate the current signs, and other members will
interview patients and staff in the testing areas to gain their perspective.

Week 2 The team meets for two hours to review the collected data. In three
locations, the signs are not at eye level, making it more difficult for people
to see them. People who are having an electrocardiogram (EKG) may not
recognize that they need to go to the EKG unit. Five of the interviewed
patients have limited English proficiency and cannot read the signs. Several
staff members confirm that lack of English proficiency is a major cause of the
problem. The team comes up with three solutions:

1. Place all signs at eye level.
2. Describe outpatient departments and testing areas in terms that

laypeople can understand.
3. Color code departments/testing areas (lines of the corresponding color

will be painted along the wall to lead patients to the different areas).

The team drafts an implementation plan for each of these solutions.

Weeks 3–7 • Team members identify signs using terminology that laypeople may
not understand. New signs with patient-friendly terminology are
manufactured.

• Maintenance staff move existing signs to eye level and hang all new
signs at eye level.

• Colors are assigned to each testing area. Maintenance staff paint lines
of the corresponding color along the walls leading from the registration
area to the various departments.

The team leader monitors the activities to ensure the solutions are
implemented as expected.

Week 8 The team meets for one hour to discuss the solutions’ effectiveness.
Members agree to gather information to evaluate the success of the
solutions. Some members will evaluate the new signs, and some members
will interview staff in the testing areas to gain their perspective.

Week 9 The team meets for one hour to review data collection results. All signs are
now at eye level. The director of the patient registration department reports
that patients are pleased with the color coding and that no patients are
having difficulty finding the outpatient departments. Staff in the testing
departments report similar findings. The project is deemed a success.

exhibit 7.4
Timeline for an

Improvement
Project
Spath, Patrice. Introduction to Healthcare Quality Management, Third Edition : Third Edition, Health Administration Press, 2018. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/westernkentucky/detail.action?docID=5517319.
Created from westernkentucky on 2021-02-15 13:06:57.
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C h a p t e r 7 : I m p r o v e m e n t P r o j e c t T e a m s 1 8 7

The leader’s responsibilities are not glamorous, but leaders keep meetings running
smoothly and prevent them from becoming sloppy and unproductive. Without a leader’s
guidance and preparation, team members may come to meetings unprepared and fail to
follow up on decisions made at prior meetings. Absent a clear agenda, meetings are likely
to veer off track. When meetings deteriorate, issues are left unresolved and team mem-
bers become frustrated. In their frustration, they may stop showing up for meetings. The
responsibility of keeping meetings focused does
not rest on the team leader alone, however. All
team members must cooperate to ensure successful
meeting outcomes.

To minimize disruptions, meetings should
flow in an orderly manner and include the follow-
ing elements:

◆ A brief overview of the agenda,
including the primary objective of the
meeting

◆ A short update (no longer than five
minutes) on work completed since
the last meeting, including a synopsis
of any major obstacles encountered

◆ A group assessment of overall progress, including a review of the improvement
project timeline

◆ A brief discussion or time for reflection on the team’s functioning as a group

◆ Assignment of action items to be accomplished by the next meeting

If team members talk or have questions about an issue that is not on the agenda, the
leader can write the topic on a big piece of paper marked “Issues Bin” or “Parking Lot.” The
team can discuss these issues later or defer them to the next meeting. To keep the meeting
moving, the leader may need to make arbitrary decisions about parking lot issues. If time
allows, the leader can ask the group whether it wants to park the issue or discuss it.

te a m dy n a m i C S
Tension always arises between people who come together to accomplish a common goal.
For instance, when my relatives plan our annual family reunion, they always disagree on
the date, location, or other details. At least one contrarian in the group wants everything
her way. My uncle interrupts to voice his opinions. My older sister doesn’t say a word until

LEARNING POINT
Effective Meetings*

Strong leadership is essential to a well-functioning improve-

ment project. One of a team leader’s first activities is to help the

group establish ground rules and ensure the team abides by

them. While team meetings are an essential part of the improve-

ment project, meetings that lack focus, drag on, or are unpro-

ductive can be a source of frustration. Not only the leader but all

team members are responsible for keeping meetings on track.

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t1 8 8

everyone is in agreement. When she finally speaks, she complains about the decision. In
the midst of this turmoil, I wonder why we bother to have reunions. In the end, though,
they turn out to be lots of fun and worth the effort.

An improvement team is like a family. Each member of the team brings his values,
beliefs, and personal agendas to the project. Some people show up at the first meeting
thinking they already know what the problem is and how it should be fixed. Some team
members are unwilling to express their opinions when a manager or leader is in the room.

Some members want to be sure the improvement
solutions will not require too much extra work.
These people typically advocate easy-to-implement
solutions even though other improvement actions
might produce better results. The team leader,
assisted by the facilitator, is responsible for man-
aging this diverse group of people.

One of the team leader’s greatest chal-
lenges is moving the improvement team through
the stages of team development. In the 1960s,
psychologist B. W. Tuckman (1965) identified
four stages that all teams go through to become
productive:

1. Forming. The team meets and works together for the first time.

2. Storming. Team members “jockey” for position and struggle for

control.

3. Norming. Team members adjust to one another and feel comfortable working
together.

4. Performing. The team begins to function as a highly effective, problem-solving
group.

Typical team characteristics and the role of the leader at each stage of development
are summarized in exhibit 7.5. As mentioned earlier, if a facilitator has been assigned to the
team, he will help the leader with team-building and project management responsibilities.

The rapidity of a team’s progression through the four stages depends on the com-
position of the team, the capabilities of the team leader and members, and the tasks to be
performed. But no team passes through the storming stage quickly. This stage is uncom-
fortable, but this discomfort and any conflict experienced are all prerequisites to successful
project outcomes. When the leader is not able to help the team work through the storming
phase, members are less likely to voice different perspectives. The success of the improve-
ment project is jeopardized if team members cannot work as a cohesive group.

LEARNING POINT
Team Development*

Improvement teams mature experientially and in stages; des-

ignating a group of individuals to function as a team is only the

first step in team development. Developing a group of people

into a team takes time, commitment, and energy. To achieve

desired outcomes, teams must establish and focus on common

goals ahead of personal needs.

C h a p t e r 7 : I m p r o v e m e n t P r o j e c t T e a m s 1 8 9

Stage Team Characteristics Role of Team Leader

Forming

Members are

concerned with

inclusion and

acceptance.

• Interactions are polite and

superficial; open conflict is rare.

• Groupthink (conformity of

opinion) tends to dominate.

• Members rely on the leader for

direction.

• Project goals are not clear.

The leader’s role is primarily

directive. She introduces the team

members to the project and shares

project goals and the timeline for

completion. The leader helps team

members become acquainted

and allows time for them to get

comfortable with one another while

still moving the project along.

Ground rules are established.

Storming

Members want

to be heard and

begin to assert

control.

• Participation increases; members

want to exercise some influence

on the improvement project.

• Groupthink decreases; open

conflict increases.

• Members look more critically at

the improvement

process and

question how and why decisions

are made.

• Members may challenge the team

leader directly or indirectly.

The leader clarifies the team’s

role in achieving project goals

and addresses conflicts as they

surface. Ground rules are reviewed

and enforced. The purpose of the

improvement project is revisited.

The leader engages the project

sponsor in resolving conflicts that

cannot be effectively handled within

the team structure.

Norming

Members have

a good under-

standing of the

improvement
process and

want to accom-

plish the project

goals.

• Members are friendlier and more

supportive of one another.

• Ground rules that may have been

overlooked in the beginning are

now taken more seriously.

• Subgroups may be formed to

move the project along more

quickly.

• Conflict is handled openly and

constructively.

The leader encourages members to

spend less time on idea generation

and more time on decision-making.

She keeps the team on track toward

improvement goals and provides

time for discussion and feedback.

Performing

Members are

highly effec-

tive problem

solvers.

• All contributions are recognized

and appreciated.

• Members develop a sense of

cohesiveness and team identity.

• Project goals are achieved.

Members may look for additional

improvement opportunities.

The leader takes a less directive and

more supportive role as members

actively take responsibility for

achieving the improvement goals.

exhibit 7.5
Team
Characteristics
and the Role of
the Team Leader
Through the
Four Stages of
Development

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t1 9 0

Improvement teams do not develop as neatly and sequentially as these stages imply.
Teams can cycle from one stage to another relatively easily or become stuck in one stage.
The team leader must identify where the team is along the development path and move
it to the next phase with minimal fuss and resistance. Leaders with good team facilitation
skills are better able to help teams progress through the stages than are leaders with poor
skills in this area.

As healthcare processes become increasingly complex, teams of people working in
various aspects of the delivery system must be personally involved in improving them.
To achieve improvement goals, the environment must foster team interaction and
open communication. Such an environment promotes the generation of new ideas and
continuous improvement.

Effective teams share many characteristics, but respect for other team members is
essential. Cooperation as a team requires trust among its members, focus on—and belief
in—the end goal, less argument, and more exploration.

In the early stages of a team’s existence, members are dependent on the initiative
of the team sponsor and leader. As the team develops, it begins to take responsibility for
the success of the project. It is then that each member should fully participate, suggest
improvements, challenge other members when needed, and support the established
ground rules.

1. Of the ground rules listed in critical concept 7.1, which three are most important for
a team to adopt, and why? When choosing the rules, consider your past experiences
working with a team or a decision-making group.

2. Use the template in exhibit 7.2 to create a charter for an improvement project
involving a healthcare process that you are familiar with. Complete as many sections
of the charter as possible.

3. If you were the team leader of the group described in the following case study, how
would you refocus and remotivate the team toward achieving the improvement goal?

When members were recruited for the improvement project, they were told
that the team’s work would be additional to their regular work responsibili-
ties but that they had to treat team activities as a high priority. They were

C o n C l u S i o n

f o r d i S C u S S i o n

C h a p t e r 7 : I m p r o v e m e n t P r o j e c t T e a m s 1 9 1

expected to complete team assignments on time and were required to attend
meetings. Despite being aware of these clear expectations, by the third
week of the project, team members started arriving late to meetings, mak-
ing excuses for not having completed their assigned tasks, and neglecting
to return the leader’s phone calls.

• Agency for Healthcare Research and Quality. Practice Facilitation Handbook.
www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/
index.html

• Agency for Healthcare Research and Quality Primary Care Practice Facilitation
learning community
www.pcmh.ahrq.gov/page/practice-facilitation

• Health Research & Educational Trust. 2013. Leading Improvement Across the
Continuum: Skills, Tools and Teams for Success. Chicago: Health Research &
Educational Trust.
www.hpoe.org/Reports-HPOE/Improvement_Continuum_October2013

• Health Resources & Services Administration, Improvement Teams
www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/improvementteams

• Institute for Patient- and Family-Centered Care, Partnering with Patients and Families
to Enhance Safety and Quality: A Mini Toolkit
www.ihi.org/education/conferences/APACForum2012/Documents/I1_Toolkit

• National Quality Center Quality Academy: Using Teams to Improve Quality (tutorial)
http://nationalqualitycenter.org/resources/nqc-quality-academy-using-teams-to-
improve-quality/

Agency for Healthcare Research and Quality. 2013. Practice Facilitation Handbook. Pub-

lished June. www.ahrq.gov/professionals/prevention-chronic-care/improve/system/

pfhandbook/index.html.

Barner, R., and C. P. Barner. 2012. Building Better Teams: 70 Tools and Techniques for

Strengthening Performance Within and Across Teams. San Francisco: Pfeiffer.

w e b S i t e S

r e f e r e n C e S

L e a r n i n g O b j e c t i v e s

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t1 9 2

Tosha, B., T. B. Wetterneck, K. A. Skibinski, T. L. Roberts, S. M. Kleppin, M. E. Schroeder, M.

Enloe, S. S. Rough, A. Schoofs Hundt, and P. Carayon. 2006. “Using FMEA to Plan Imple-

mentation of Smart IV Pump Technology.” American Journal of Health-System Pharmacy

63 (16): 1528–38.

Tuckman, B. W. 1965. “Developmental Sequence in Small Groups.” Psychological Bulletin

63: 384–89.

Turner, J. R., and R. Müller. 2005. “The Project Manager’s Leadership Style as a Success Fac-

tor on Projects: A Literature Review.” Project Management Journal 36 (1): 49–61.

2 2 5

L e a r n i n g O b j e c t i v e s

C H A P T E R 9

A C H I E V I N G R E L I A B L E
Q U A L I T Y A N D S A F E T Y

After reading this chapter, you will be able to

➤ explain the role of reliability science in the improvement of healthcare services,

➤ recognize how process reliability is measured and managed,

➤ identify strategies to increase the reliability of healthcare processes by improving

the effectiveness of people and the systems in which they work, and

➤ discuss how to measure the effectiveness of improvement actions and sustain

the gains.

➤ Catastrophic

processes

➤

Human factors

➤ Noncatastrophic processes

➤

Reliability science

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I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 2 6

E
very year, healthcare organizations throughout the United States conduct hundreds
of improvement projects following the models and using the tools you studied in the
preceding chapters. With all of this activity, you might think the quality of healthcare

services is exemplary, with few inefficiencies and mistakes. Yet studies of healthcare perfor-
mance continue to report high rates of error, overuse of services, and costly wastefulness
(Agency for Healthcare Research and Quality 2016).

Why are many of the expected improvements not materializing? Does the fault lie
with the improvement project models or tools? Do we need to conduct twice as many proj-
ects and involve more frontline workers? Although a lack of significant progress is caused by
many factors, one element that greatly contributes to quality problems is the design of work
systems. As noted by Paul Batalden, MD, director of healthcare improvement leadership
development at Dartmouth Medical School in Hanover, New Hampshire, “every system is
perfectly designed to get the results it gets” (McInnis 2006, 32). If we want fundamentally
different results in healthcare, we must use fundamentally different improvement strategies.

Regardless of which improvement model is used for a project, at some point actions
or risk reduction strategies are designed. Often these interventions focus on creating new
procedures and training people to do their job correctly. Too little attention is given to the
work systems that give rise to inefficiencies and human errors. Bohmer (2010) proposes
that the only realistic hope for substantially improving healthcare delivery is for the core
processes to be revamped.

In this chapter, we introduce the systems approach to achieving safe and reliable
healthcare. These techniques are based on reliability science, sometimes called human
factors engineering, which originated in the US military during World War II (Wickens et
al. 2012). The concepts are commonplace in other industries and should be applied when
healthcare improvement teams reach the action planning phase of a project. By thinking
differently about the changes needed to improve performance, project teams can have a
significant and sustainable positive impact.

re l i a b l e pe r f o r m a n C e
Performance reliability can be measured in various ways. The simplest way is to measure
process output or outcomes. The number of actions that achieve the intended results are
divided by the total number of actions taken. For instance, when you see your doctor, you
expect her to have access to the results of your recently completed laboratory tests. The
reliability of that process can be measured by gathering data on the occurrences of missing
lab test results. If a clinic finds that 15 percent of outpatient appointments are affected
by missing lab information, the process is said to have a failure rate of 15 percent and a
reliability rate of 85 percent.

Reliability science

A discipline that

applies scientific

know-how to a process,

procedure, or health

service activity so

that it will perform its

intended function for

the required time under

commonly occurring

conditions.

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 2 7

You may not clearly understand the concept of reliability; however, when your
automobile will not start, you clearly understand the concept of failure. You also learn the
cost of failure when you have to pay a mechanic to restore your automobile to a reliable
condition.

Human factors scientists and engineers have studied the interactions of people,
technology, and policy across multiple industries for years. Knowledge gained from these
studies allows us to predict the rate of failures based on the reliability rating of the process.
For instance, if the clinic’s process of reporting lab results has an 85 percent reliability
rating, the clinic physicians should expect miss-
ing results for one or two of every ten patients
who underwent recent laboratory tests. Exhibit
9.1 shows the expected failure rates for each level
of reliability (Resar 2006).

The reliability of healthcare processes var-
ies. Studies suggest that most US healthcare orga-
nizations currently perform at the 90 percent level
of reliability, meaning they have a failure rate of 1
in 10 (Nolan et al. 2004). Some hospital processes
(e.g., hand hygiene, hand-off communications) fail
40 to 60 percent of the time (Bodenheimer 2008;
Erasmus et al. 2010). One of the most reliable
healthcare processes is giving patients compatible
blood for a transfusion. Failures of this process
are rare, with the reliability rate estimated to be
99.999 percent (Amalberti et al. 2005).

Human factors

“The environmental,

organizational and job

factors, and individual

characteristics which

influence behavior at

work” (Clinical Human

Factors Group 2016).

Reliability Level (%) Expected Failure Rate

Less than 80 Unpredictable, chaotic performance

80–90 1–2 failures out of 10 opportunities

95 Up to 5 failures per 100 opportunities

99.5 Up to 5 failures per 1,000 opportunities

99.99 Up to 5 failures per 10,000 opportunities

99.999 Up to 5 failures per 100,000 opportunities

99.9999 Up to 5 failures per 1,000,000 opportunities

exhibit 9.1
Process Reliability
Levels and
Expected Failure
Rates

DID YOU KNOW??

• You have a 1 to 2 percent chance of dying accidentally for

every 10 mountains you climb in the Himalayas. The reliabil-

ity rating for this high-risk activity is 80 to 90 percent. Bun-

gee jumping has a similar risk of death.

• Automobile travel is fairly safe, with a reliability rating of

99.99 percent. The risk of a fatal accident is low—up to 5 for

every 10,000 times you ride in a car.

• The reliability of commercial aviation is better than 99.9999

percent, with an extremely low risk of a complete engine fail-

ure leading to loss of aircraft.

Source: Amalberti et al. (2005).

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 2 8

i m p r o v i n g Q u a l i t y

Reliability ratings are important for healthcare quality improvement purposes. Reliability
science has demonstrated that certain process improvements are more likely to create
consistent quality. When improvement actions rely mostly on people’s vigilance and hard
work to get things done correctly, the best level of reliability that can be achieved is 80 to
90 percent (Luria et al. 2006). On occasion, higher levels of reliability can be achieved,
but they are not possible to sustain over time.

People often work in complex healthcare environments without carefully designed
mistake-proofing infrastructures. For instance, hospital nurses are constantly interrupted
as they carry out important patient care duties. In a review of several studies of nurse
activities, the reported interruptions per hour ranged from 0.3 to 13.9 (Hopkinson and
Jennings 2013). Healthcare professionals are able to cope with these situations and, most
often, performance is not affected. However, people cannot be vigilant 100 percent of the
time, and mistakes happen.

Exhibit 9.2 summarizes the types of actions necessary to achieve sustained reliable
quality at different percentages (Amalberti et al. 2005). These actions, based on human
factors and reliability science principles, should be considered in the design of actions
intended to improve quality.

Not every healthcare process can be made highly reliable. Resources are insufficient,
and not every process requires a high (99.5 percent or greater) level of reliability. For
noncatastrophic processes, good outcomes depend on having at least 95 percent process
reliability. For catastrophic processes, good outcomes depend on having 99.5 percent or
better reliability. Improvement project teams should agree on the desired level of reliability
and then implement actions that will achieve this level. For some healthcare processes, 80 to
90 percent reliability may be sufficient. Organizations might achieve better patient outcomes
by bringing several chaotic processes to 90 percent reliability rather than concentrating on
improving the reliability of just a few to 99.5 percent. This thinking coincides with the risk
management concept of ALARP, which stands for “as low as reasonably practicable.” Deter-
mining the extent to which workplace risks are controlled “involves weighing a risk against
the trouble, time and money needed to control it” (Health and Safety Executive 2014).

The US Department of Veterans Affairs (VA) National Center for Patient Safety
(2016) created an action categorization system on the basis of human factors science. These
action categories are used by teams involved in root cause analyses and other patient safety
improvement projects. Rather than divide improvement actions into levels of reliability,
the actions are labeled as weak, intermediate, and strong. Studies at the VA have shown
that when a strong action is developed and implemented, it is 2.5 times more likely to
be effective at improving performance than are weak or intermediate actions (DeRosier,
Taylor, and Bagian 2007). The types of actions that fall into the weak, intermediate, and
strong categories are listed in exhibit 9.3.

Noncatastrophic

processes

Processes that do

not generally lead

to patient death or

severe injury within

hours of a failure

(e.g., hand hygiene,

administration of low-

risk medications).

Catastrophic processes

Processes with a high

likelihood of patient

death or severe injury

immediately or within

hours of a failure

(e.g., identification of

correct surgery site,

administration of

compatible blood for a

transfusion).

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 2 9

Reliability Level (%) Actions

Less than 80 Primarily rely on qualified people doing what they believe is the
right thing

80–90 Implement basic failure prevention strategies, such as the
following:
• Standard protocols/procedures/order sheets
• Personal checklists
• Common equipment
• Feedback on compliance
• Awareness and training

95 Implement sophisticated failure prevention and basic failure
identification and mitigation strategies, such as the following:
• Build decision aids and reminders into the system.
• Set the desired action as the default (based on scientific

evidence).
• Account for and take advantage of habits and patterns in the

process design.
• Specify process risks, and articulate actions for reducing risks.
• Take advantage of scheduling.
• Use redundant processes.
• Operate independent backups.
• Measure and provide feedback on compliance with process

specifications.

99.5 Gather information to understand which failures are occurring,
how often they occur, and why they occur. Then redesign the
system to reduce these failures using sophisticated failure
prevention, identification, and mitigation strategies:
• Design the system to prevent the failure, making sure the

steps in the process act independently of each other so
failures can be identified and corrected.

• Design procedures and relationships to make failures visible
when they do occur so they may be intercepted before
causing harm.

• Design procedures and build capabilities for fixing failures
when they are identified or mitigating the harm caused by
failures when they are not detected and intercepted.

Better than 99.5 Moving beyond 99.5% requires technology and advanced
system design that require significant resource investments.

Source: Adapted from Nolan et al. (2004).

exhibit 9.2
Actions Necessary
to Achieve
Reliability Levels

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 3 0

Improvement teams frequently favor weak interventions over higher-level actions
because weak actions are lower risk and easier to create and implement. Staff training and
distribution of memos telling everyone to follow procedures can be accomplished fairly
easily. Unfortunately, such actions by themselves rarely have a lasting impact (Williams and
Bagian 2014). Training can be made stronger by combining it with periodic competency
assessments involving random observation by management. People newly trained in a
procedure are more likely to follow it if they know they will be occasionally and randomly
observed (Bernstein et al. 2016).

ap p ly i n g re l i a b i l i t y pr i n C i p l e S
When actions based on reliability principles are not incorporated into the design of health-
care improvement initiatives, the project goals are less likely to be achieved. Consider

Strength of
Improvement Action Example of Action

Weak • Double-checks
• Warnings and labels
• New procedure/policy
• Memos
• Training
• Additional study/analysis

Intermediate • Checklist/cognitive aid
• Increase in staffing/decrease in workload
• Redundancy
• Enhanced communication (e.g., read back)
• Software enhancements/modifications
• Elimination of look-alikes and sound-alikes
• Elimination/reduction of distractions (e.g., sterile

medical environment)

Strong • Architectural/physical plant changes
• Tangible involvement and action by leadership in

support of patient safety
• Simplified process, with unnecessary steps removed
• Standardized equipment, process, or care map
• New-device usability testing before purchasing
• Engineering control or interlock (forcing functions)

Source: Reprinted from National Center for Patient Safety, US Department of Veterans Affairs, “Root Cause
Analysis.” Retrieved from www.patientsafety.va.gov/professionals/onthejob/rca.asp. Copyright © 2016.

exhibit 9.3
Strength of Various

Improvement
Actions

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 3 1

what happened in the following case study. An improvement team met for several weeks
to design and implement actions aimed at reducing the incidence of heel pressure ulcers
(skin breakdowns) among hospitalized patients.

C a S e S t u d y

Many patients in the hospital were developing heel ulcerations. More than 13 percent of
patients aged 18 or older developed a heel ulcer within four days of admission. This rate was
higher than the national average, so an improvement team was formed with representatives
from nursing, physical therapy, and wound care services to reduce the incidence of heel
ulcers by 50 percent within one year. The team evaluated current practices and implemented
the following stepwise actions to improve the process:

1. Nurses were trained to use an assessment scoring system to identify patients at
risk of heel ulcerations. A poster board showing assessment instructions was
made available for five days in each nursing unit.

2. After reviewing the training material, nurses took a test to determine their
proficiency in assessing a patient’s heel ulcer risk. A score of 90 percent was
required to pass the test.

3. Once all nurses had taken and passed the test, a new protocol was
implemented that required use of the risk-assessment scoring system at the
time of a patient’s admission, 48 hours after admission, and whenever a
significant change was seen in a patient’s condition.

4. The hospital’s computerized health record system was modified so nurses
could add the patient’s ulcer risk score into the patient’s record at the required
intervals.

5. Patients at moderate or high risk of a heel ulcer were started on a protocol of
ulcer prevention that included application of a thin dressing or heel protectors
on reddened areas and elevation of the patient’s heels with pillows.

One year after the actions were completed, the incidence of hospital-acquired heel
pressure ulcers had not significantly changed. An analysis of current practices found that
staff nurses were not consistently completing the periodic risk assessments and that heel
ulcer prevention interventions were not always employed. A lot of work had been done by
the improvement team, the people who had created the training and post-training exam,
and the people who had modified the computerized record system, yet no significant
improvements occurred.

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 3 2

Everyone involved in improvement projects wants performance to improve. But good
intentions are not enough to ensure good outcomes. To achieve better performance that
is reliable, human factors science must be taken into consideration when making changes.

C o n S i d e r t h e h u m a n f a C t o r S

Often, improvement initiatives fail because we expect people to perfectly execute their job
responsibilities. Competence is important to an individual’s ability to do her job—you
wouldn’t expect someone untrained in automobile repair to fix your car. But humans are
not perfect, and there are no guarantees that mistakes will not be made. Interventions to
improve performance are most successful when they address both the individuals doing the
work and the way in which work gets done. For instance, the automobile mechanic must
be adequately trained, have the right tools, and be provided a tolerable work environment.
When healthcare improvement teams reach the action-planning phase, they must consider
the human aspects that cause inconsistent performance and design systems that promote
reliable quality.

Strong and effective systems make people more effective than they might be without
such systems. Changes in procedures, rules, workflow, and automation; the introduction of
new technology and equipment; and other system changes help to make people effective. In
addition, strong and effective people make systems more effective. Rather than blaming and
shaming people for not doing their job, seek to develop and enhance the competencies and
skills of people in the system and ensure their needs are met. When introducing workflow
changes, automation, new roles, and other interventions designed to improve performance,
consider the needs of the people involved and how they will be affected. Organizations
often fail in this regard by making the following mistakes (Spath 2015):

◆ Creating additional work for fewer people

◆ Removing people from roles in which they were comfortable

◆ Placing people in unfamiliar new roles as if they were interchangeable parts

◆ Not involving or consulting with the people affected by decisions but instead
making assumptions about what is “good for them”

When working in complex and sometimes fast-moving healthcare environments,
people can become overwhelmed with tasks, potentially causing cognitive overload—a situ-
ation in which the demands of the job exceed the individual’s ability to mentally process
all the information encountered regarding a situation (Ternov 2011). To ensure people are
as effective as possible in their job, cognitive overload must be minimized. Critical concept
9.1 shows how to do this.

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 3 3

t e S t r e d e S i g n e d p r o C e S S e S

Changes to processes are often implemented without a clear understanding of how the
change affects other parts of the system—the people, other processes, and services. Testing
the impact of redesigned processes on performance is a crucial step in all the improvement
models described in chapter 5. One way to assess improvements is to test process changes,
before they are implemented, on a small subset of activities or patients (usually five to ten
individuals). If the changes achieve the intended goals, they can be applied to all activities
or patients. Quantitative and qualitative data should be collected during the pilot phase
of a process change. This information helps the project team see the impact changes will

CRITICAL CONCEPT 9.1
Steps to Reduce Cognitive Overload on People!

• Limit or discourage people from working when they are physically ill or under psy-

chological duress.

• Be sure people are physically and psychologically fit for the tasks that need to be

completed.

• Provide people with adequate breaks away from their job; breaks should not be op-

tional.

• Add technologies that reduce reliance on memory, and insist that the technology

be used as designed (e.g., barcoded patient identification systems, monitoring

systems).

• Rotate tasks in a department when possible; when people do the same task all the

time, they can become complacent and experience the effects of mental underload.

• Monitor people for excessive fatigue; a lack of adequate rest reduces productivity

and efficiency.

• Place limitations on employee overtime, and provide adequate off-work intervals

between shifts.

• Provide team training, including the use of simulation methods.

Source: Adapted from Kochar and Connelly (2013); Patel and Buchman (2016); Vincent and Amalberti (2016).

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 3 4

have on the people doing the work as well as on related activities and systems. It also can
convince others of the value of adopting the changes organization-wide.

Testing does not end at the pilot phase. After changes have been implemented for
a short time, the team must determine how well they are working.

a C h i e v e 80 t o 90 p e r C e n t r e l i a b i l i t y

To consistently reach 80 to 90 percent work system reliability, the improvement team must
create a specific process and use staff education and vigilance to achieve standardization. The
attempt at reducing heel pressure ulcers described in the case study earlier in this chapter
lacked an important component: vigilance. Specific processes were designed to assess a
patient’s risk of a heel ulcer and to prevent one from developing, and staff was educated in
these processes. But management exercised no ongoing oversight to determine if nurses were
following the processes, and no actions were taken for noncompliance. Without vigilance,
compliance slid, and the failure rate often exceeded 20 percent.

Standardization and vigilance are necessary to reach sustained 80 to 90 percent
reliability. These contributors to quality can be instituted by creating defined protocols,
requiring the use of common equipment or supplies, creating checklists that remind people
what needs to be done, and following other methods for reducing process variation. Many
of these techniques are the same strategies used during a Lean project to eliminate waste
and improve process efficiencies (Zidel 2012).

Process standardization also improves patient safety. According to Bagian and
colleagues (2011), local patient safety managers in VA facilities rated process standard-
ization as one of the best interventions for achieving good results. Other actions rated as
leading to much better results included those that improve the communication process
between clinicians and those that enhance the computerized medical record through
software upgrades.

If an improvement team has determined that 80 to 90 percent reliability is suffi-
cient, it need not take further action other than periodic monitoring to ensure the failure
rate does not increase. Exhibit 9.4 describes the steps that a rehabilitation facility took to
reach 80 to 90 percent sustained compliance with hand-hygiene requirements. This level
of reliability was the goal, so no further interventions were needed.

Additional improvement actions are necessary if a higher level of reliability is desired.
They should not be taken, however, until a sustained level of 80 to 90 percent reliability has
been achieved for at least six months (Baker, Crowe, and Lewis 2009). Adding improve-
ment actions when a process is still unstable could further degrade reliability. The adverse
effect of tampering was discussed in chapter 4.

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 3 5

a C h i e v e 95 p e r C e n t r e l i a b i l i t y

Moving a work system from 80 to 90 percent reliability to 95 percent requires stronger
interventions than have been adopted thus far. Some actions, such as building decision aids
into the system, may be as straightforward as creating paper checklist reminders for people
to use. Decision aids can also take the form of more sophisticated computerized feedback
that alerts people to unusual clinical situations requiring attention.

Intermediate and strong actions needed to improve the reliability of a process to 95
percent are listed in exhibits 9.2 and 9.3. Often, a number of advanced failure prevention
and failure identification and mitigation strategies are needed. For instance, the inpatient
psychiatric unit at Sinai Hospital of Baltimore (2017) reduced the incidence of patient
elopements (unauthorized absence without permission) from four attempted and actual
elopements in 2013 to none in 2016. To achieve this improvement, the unit implemented
several interventions throughout 2015 and 2016:

◆ Provide staff education to improve awareness and increase staff vigilance

◆ Add more security cameras in the unit

Improvement Action Measurement Results

1. Mandatory hand-hygiene and infection-control training
for all patient care staff

40% compliance

2. “Clean Your Hands” posters displayed in units; weekly
observation reviews by infection control team, with
immediate feedback for noncompliance

Up to 60% compliance

3. Hand-hygiene process standardized using “Five Key
Moments for Hand Hygiene” and staff educated in
process; data gathered to better understand the causes
of noncompliance so that process can be changed to
prevent these failures

Up to 70% compliance

4. “Five Key Moments” posters displayed in units and
patient rooms; hand-hygiene reminders included
in shift change discussions and during patient bed
rounds; ongoing weekly observation reviews by hand-
hygiene champions, with nonconfrontational feedback
for noncompliance; continued evaluation of causes of
noncompliance and changes made to prevent failures

Sustained 80–90%
compliance

exhibit 9.4
Rehabilitation
Facility Hand-
Hygiene
Improvement
Project

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 3 6

◆ Keep patients in hospital garments for 24 hours after arrival in the unit

◆ Limit the number of outside staff with access to the locked unit

◆ Escort ancillary hospital staff pushing carts (food and linen) to the unit exit
door

◆ Dress patients at risk for elopement in green gowns and green socks

◆ Place black-out tape over the five-second flashing green light on the exit door
badge scanner

◆ Install safety signs to direct patients to the day area and away from high-risk
elopement areas

◆ Add a “panic button” to the staff communication devices to allow for
immediate and simultaneous elopement alerts

Exhibit 9.5 shows intermediate and strong actions taken by a hospital to improve
the reliability of the intravenous (IV) medication and solution administration process.
These actions resulted in sustained 95 percent reliability for many of the process steps. Of
course, the interventions differ in their power to effect changes. Some, such as automated
functions that prevent IV pumps from being incorrectly programmed, are very strong in
preventing failures. Other interventions, such as labels on the IV bags, are less likely to
reduce failures. An important step in any improvement project is to closely monitor the
effectiveness and impact of action plans and make adjustments as needed.

a C h i e v e 99.5 p e r C e n t o r b e t t e r r e l i a b i l i t y

Some healthcare processes should function at 99.5 percent reliability or better because failures
within them are likely catastrophic for patients. To achieve 99.5 percent performance or
greater requires identifying failures, determining how often they occur, and understanding
why they occur.

Specifically, getting to 99.5 percent reliability requires three essential steps. First,
process failures must be closely monitored. Second, targeted interventions must be designed
and tested until the desired level of reliability is achieved and maintained. For example, a
large ambulatory health center in the South implemented several process changes to ensure
patients with diabetes have regular body mass index (BMI) measurements (Baker, Crowe,
and Lewis 2009). In addition to educating staff on the importance of obtaining a BMI at
every patient visit, BMI was made a data element on the clinic’s standardized flow sheet
that serves as the front page of the record. A care manager reviews patient records the day
before a visit to determine if BMI is entered into the electronic record, and job descriptions
for all patient care staff were updated to include the task of ensuring BMI documentation

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 3 7

Type of Action Intervention

Standardization is
pervasive

• Reduce the variety of IV solutions available as floor stock to
those most frequently used

• Use only standard concentrations of IV solutions
• Make only one kind of IV medication pump in each class

available in the hospital
• Develop and implement standard IV physician orders

Decision aids and
reminders are built
into the system

• Label all IV solutions that do not come from the pharmacy
with a tag displaying the nurse’s name, date, name of
solution, and rate of administration

• Place on each IV bag a drug-specific label containing flow
rate calculations

• Program standard IV orders into the computerized order
entry system

The desired action is
the default

• Use IV pumps with forcing functions to prevent
programming errors

Habits and patterns
are studied and used
in the design

• Change the arrangement of the medication access control
device so only one injection is available per drawer

Process risks are
specified, and
actions for reducing
risks are articulated

• Include discussion of risks and interventions in the annual
staff competency assessment process to reduce these risks

Scheduling is used
to advantage

• At change of shift, double-check all potentially hazardous
IVs (medications, pump settings, and IV tubing) for failure

Redundant processes
are in place

• Place on each IV bag a drug-specific label containing flow
rate calculations

Independent backup
is in place

• Have two nurses independently double-check all IV
medications, pump settings, and IV tubing before
administration and before patient transfer to another
location

Compliance is
measured and
results are shared

• Gather data on compliance with the new process and
the number of incidents involving IV medication and
IV solutions; regularly evaluate results and share with
everyone involved in the process

exhibit 9.5
Examples of
Interventions
That Improved
Reliability of
Administration of
IV Medications and
Solutions

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 3 8

at every visit. After experiencing negative reactions from some patients when asked to be
weighed, the clinic revised its diabetic education materials with input from patients. The
percentage of patients with diabetes with a completed BMI improved from less than 20
percent to 100 percent.

Third, once sustained reliability (99.5 percent or better) is achieved, performance
must be regularly reviewed and feedback provided to the people doing the work. Every

failure should be examined, and the information
obtained should be used to redesign the process
or create ways for staff to better identify and cor-
rect failures quickly or to lessen the effects of the
failures.

In some situations, the healthcare organiza-
tion may seek to improve reliability to 99.9 percent
or better. Achieving such a high level of reliability
requires more than human labor. Technology and
possibly architectural changes are needed. Anesthe-
sia administration, once thought to cause 1 to 2
deaths in every 10,000 patients receiving anesthe-
sia, is now considered to be one of the most reliable
processes occurring in healthcare delivery (Stoelt-
ing 2017). A host of changes to anesthesia admin-
istration, based on an understanding of human
factors principles, were initiated throughout the
United States in the 1970s. Reaching the current
high level of reliability required the adoption of

important safety technology (pulse oximetry, capnography, audible physiologic alarms,
electronic health records) as well as improvements in the culture of safety. Overall, the
combined effect of all the initiatives has been a 10- to 20-fold reduction in mortality and
catastrophic morbidity for healthy patients undergoing routine anesthesia (Stoelting 2017).

mo n i t o r i n g pe r f o r m a n C e
Designing process changes on the basis of reliability science is the starting point to achieving
consistently high quality. The next step is to make the changes. Once the improvement team
has developed action plans, leadership oversight will ensure the actions are implemented
as intended. Researchers studying the implementation of corrective measures following
root cause analyses found that healthcare organizations never fully implemented up to 55
percent of the proposed actions (Peerally et al. 2016).

The organization’s progress in implementing action plans must be tracked and leaders
kept informed of outstanding and completed action items. Exhibit 9.6 is an excerpt from a
monthly report on the status of improvement actions provided to hospital leaders. When

LEARNING POINT
Reaching 95 Percent or Better Process Reliability*

Reaching 95 percent or better process reliability involves four

main steps:

1. Agree on a measure for assessing reliability.

2. Measure how often accuracy is achieved according to the

agreed-on measure, thereby establishing a baseline against

which to compare results of the initiative.

3. Establish reliability goals for the measure.

4. Make stepwise improvements and measure success.

Source: Dlugacz and Spath (2011).

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 3 9

delays are unacceptable, senior leaders often need to intervene to clear away implementa-
tion barriers. In chapter 12, we discuss the leadership structure necessary to support quality
management activities, including the role of the organization’s governing board and quality
oversight groups in monitoring performance.

m e a S u r e e f f e C t i v e n e S S

Improvement goals are set at the start of an improvement project. Clearly documented goals
help frame the improvement initiative. The project goals guide decisions about what needs
to be changed in the process and how best to accomplish the changes. Once action plans

Date of Report: ____________________________________________

Current
Status Project Description Actions Responsible Party Actions to Date

Needs
attention

Reduce delays in
start times for
interventional
radiology
procedures

1. Revise the patient
scheduling
procedure

2. Publish an article
about new policy
in medical staff
newsletter

3. Revise the
scheduling
software to
accommodate
new policy

4. Conduct
monitoring
by radiology
department for
compliance with
new policy

1. Imaging director

2. Medical staff
services office

3. Imaging director
and software
vendor

4. Imaging director

1. Done

2. Done

3. Vendor has
repeatedly
canceled on-site
visit for software
upgrade

4. Radiology
department unable
to start new
procedure due to
software upgrade
delay

In progress Improve timeliness
of electrocardiogram
(EKG) interpretations

1. Standardize the
EKG interpretation
process

2. Modify
transmission
process at off-site
locations

3. Obtain software
upgrade to enable
results tracking

1. Vice president of
medical affairs

2. Diagnostic center
managers

3. Managers of
noninvasive
cardiology and
information
technology
departments

1. Done

2. Done

3. Funds for software
in next year’s
capital budget

exhibit 9.6
Improvement
Action Tracking
Log

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 4 0

have been implemented, evaluate whether goals
have been achieved. Regardless of what improve-
ment model is used to execute the project, it will
include a step in which the effectiveness of action
plans is measured.

Action plan effectiveness can be determined
using process or outcome measures. Recall from
chapter 3 that process measures are data describing
how services are delivered, and outcome measures
are data describing the results of healthcare ser-
vices. Exhibit 9.7 is a description of an improve-
ment project undertaken in a multiclinic primary
care organization to improve the use of preventive
care screenings. Several actions were taken, and
three measures were used to evaluate the success
of the actions.

Chapter 3 discusses data collection sys-
tems for gathering performance measurement
information. Similar data collection systems
must be enacted to measure the effectiveness of
action plans. Useful and accurate performance
information is needed to judge the success of
action plans.

A question that often arises during discus-
sions of how to measure the success of improve-
ment actions is, How long must we continue to
gather and report measurement data? Ideally, all
of the following criteria should be met to con-

clude that successful corrective action plan implementation has been achieved (Minnesota
Department of Health 2015):

◆ Data for the process measure were monitored over time.

◆ The goal was attained (process and outcome).

◆ You are confident that the change is permanent.

◆ The event is not repeated (if improvements were made to prevent another
adverse event).

LEARNING POINT
Measuring Action Plan Effectiveness*

Consider the following questions when developing measures to

evaluate the success of improvement actions:

1. How will you know the action has been effective in improving

performance?

2. What will you evaluate to determine if the process is more

reliable?

3. Do you have any data that can be used for before-and-after

comparisons?

4. How often will you measure performance (by shift, daily,

weekly, biweekly, monthly, other)?

5. How will data be gathered, and by

whom?

6. How long will you continue to measure performance?

7. How often will performance results be reported, and to

whom?

8. Once measurement data substantiate that performance

goals are met, how often will you measure to ensure im-

proved performance is sustained?

Source: Adapted from Bagian et al. (2011).

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 4 1

re a l i z i n g Su S ta i n e d im p r o v e m e n t S
Once the desired level of reliable quality has been reached, the problems affecting undesir-
able performance must stay fixed. “I thought we solved that problem already” is an utter-
ance often heard in healthcare organizations. Financial and human resources are constantly
expended on improvement projects and system redesign, yet familiar problems may creep
back in to disrupt the performance of key processes. Managers trying to improve perfor-
mance sometimes make mistakes that could have been avoided with forethought.

Improvement Project Goal: Increase rates of preventive care screening services
Improvement Actions:
1. Telephone patients to remind them to come to the clinic for needed preventive care

screening.
2. Design a preventive care services summary in patient electronic records to

document needed preventive screening, date of patient contact, and date of
completion.

3. Educate staff in preventive service requirements and how to use the summary in
patient records.

4. Change the workflow to include having medical assistants or nurses prepare
paperwork for preventive screenings before a patient’s visit and give to the provider
at the time of the visit.

How Effectiveness of Actions Will Be Measured:

Measure Data Collection Method Goal

Percentage of patients
needing preventive
screenings who are
contacted by phone

Quarterly query of
database of patients
needing screenings to
determine if patient was
contacted

Sustained 95 percent

Percentage of patients
needing preventive
screenings who receive
them as required

Quarterly query of
preventive care services
summary database

Sustained 95 percent

Number of patients
who refuse preventive
screenings after discussion
with provider

Quarterly query of
preventive care services
summary database

No more than 5 percent
per quarter

exhibit 9.7
Improvement
Project Measures
of Action Plan
Effectiveness

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 4 2

C h a n g e b e h av i o r S

When process improvements come undone, the cause often can be traced back to the
attitudes or behaviors of the people doing the work—behaviors that should have been
modified but were not. Process improvement efforts tend to focus on standardizing and
error-proofing work steps and sometimes overlook the human part of the process. For
instance, nurses in a hospital that implemented a barcoded patient identification system to
reduce medication errors found the process too cumbersome and began to take shortcuts
(Koppel et al. 2008). The nurses made duplicate copies of patient wristbands so they could
check the barcodes at the nursing station rather than in patient rooms. This shortcut sig-
nificantly raised the potential for medication errors. Understanding what causes shortcuts
is at the heart of knowing how to modify attitudes and behaviors. This is just as important
as creating a more efficient process. Otherwise, people will lapse into the old way of doing
things, and the new process will have no chance of becoming a habit.

Why don’t people adopt desired process changes? Five main factors that affect per-
formance are listed in exhibit 9.8.

Performance Factor Possible Interventions

Expectations
Do people know what they are
supposed to do?

• Provide clear performance standards and job
descriptions.

• Create channels to communicate job
responsibilities.

Feedback
Do people know how well
they are doing?

• Offer timely information about people’s
performance.

• Use mistakes as learning opportunities.

Physical environment
Does the work environment
help or hinder performance?

• Make sure people are able to see, hear, touch, and
feel what is necessary to do the job.

• Correct problems causing environment, supply, or
equipment complaints.

Motivation
Do people have a reason to
perform as they are asked to
perform? Does anyone notice?

• Frequently provide reinforcement to people while
they are learning new tasks.

• Apply consequences (positive or negative) to
change behaviors toward the desired direction.

Required skills and
knowledge
Do people know how to do the
task?

• Ensure people have the skills needed to perform
the work.

• Provide access to learning opportunities.

exhibit 9.8
Performance
Factors and

Possible
Interventions

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 4 3

Interventions to achieve compliance with process changes vary according to the
performance issue, but the cause of failures must be understood before action is taken to
correct them.

d o n ’ t o v e r l o o K e d u C at i o n

Knowledge, diligence, effort, focus, resources, and effective leadership are all essential
to the achievement of performance improvement goals. Leaders would be unwise to
announce improvement priorities and then expect the improvements to automatically
materialize. This approach does not work. Just as cheerleading does not improve a football
team’s chances of winning, announcements from leadership alone do not create reliable
quality. Project teams need encouragement from leaders, but everyone involved in process
improvement also must be able to use basic quality tools and techniques such as those
covered in this text.

Only recently has more attention been given to securing reliable healthcare quality
through the application of human factors principles and reliability science. Rather than
tinker with work systems and hope for the best, some healthcare organizations are
applying improvement strategies that have been used successfully for years in other
industries. High-reliability industries, such as aviation, air traffic control, and nuclear
power, have long recognized that relying on human perfection to prevent accidents is a
fallacy. These industries conduct training, enforce rules, and expect their high standards
to be met, but they do not rely on people being perfect to prevent accidents. They look to
their systems, as should healthcare organizations (Ghaferi et al. 2016).

Human factors and reliability design concepts should be required for all
healthcare improvement projects. To reach higher levels of reliable performance, systems
and processes must be designed to be more resistant to failure. Situations or factors
likely to give rise to human error must be identified and process changes made to reduce
the occurrence of failure or to minimize the impact of any errors on health outcomes.
Efforts to catch human errors before they occur or to block them from causing harm are
ultimately more fruitful than those seeking to somehow create flawless people.

The application of human factors principles and reliability science is long overdue
in healthcare. As noted by Deming (1986), one of the founders of the contemporary
quality movement, “It is not enough to do your best; you must know what to do, and then
do your best.”

C o n C l u S i o n

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 4 4

1. What does reliability mean to you? In your experience, what healthcare process have
you found to be reliable? What process have you found to be unreliable? Explain
what is different about the reliable process versus the unreliable process.

2. Consider the failed improvement project in this chapter’s case study when answering
the following questions:

a. What process changes could be implemented to achieve 80 to 90 percent
reliability in preventing and managing heel ulcerations?

b. What process changes could be implemented to reach 95 percent reliability in
preventing and managing heel ulcerations?

c. If process changes are made to achieve 80 to 90 percent reliability, how would
you measure the effectiveness of these changes?

d. If process changes are made to achieve 95 percent reliability, how would you
measure the effectiveness of these changes?

• Agency for Healthcare Research and Quality (AHRQ) Innovations Exchange
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• AHRQ, Becoming a High Reliability Organization: Operational Advice for Hospital
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• AHRQ Comprehensive Unit-Based Safety Programs (CUSP)
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• AHRQ Patient Safety Network: High Reliability
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• American Hospital Association, Hospitals in Pursuit of Excellence
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• Clinical Human Factors Group

chfg

• The Dartmouth Institute Microsystem Academy
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Crossing the Quality Chasm: A New Health System for the 21st
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Crossing the Quality Chasm: A New Health System for the 21st Century

111

Building Organizational
Supports for Change

Between front-line clinical care teams and the health care environment lies
an array of health care organizations, including hospitals, managed care organi-
zations, medical groups, multispeciality clinics, integrated delivery systems, and
others. Leaders of today’s health care organizations face a daunting challenge in
redesigning the organization and delivery of care to meet the aims set forth in this
report. They face pressures from employees and medical staff, as well as from
the local community, including residents, business and service organizations,
regulators, and other agencies. It is difficult enough to balance the needs of those
many constituencies under ordinary circumstances. It is especially difficult when
one is trying to change routine processes and procedures to alter how people
conduct their everyday work, individually and collectively.

This chapter describes a general process of organizational development and
then offers a set of tools and techniques, drawing heavily from engineering con-
cepts, as a starting point for identifying how organizations might redesign care.
Chapter 3 offered a set of rules that would redesign the nature of interactions
between a clinician and a patient to improve the quality of care. This chapter
describes how organizations can redesign care to systematically improve the
quality of care for patients. This is not an exhaustive list of possible approaches,
but a sampling of techniques used in other fields that might have applicability in
health care. The broad areas discussed in this chapter apply to all health care
organizations; the specific tools and techniques used would need to be adapted to
an organization’s local environment and patients.

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Copyright National Academy of Sciences. All rights reserved.

112 CROSSING THE QUALITY CHASM

Recommendation 7: The Agency for Healthcare Research and Qual-
ity and private foundations should convene a series of workshops
involving representatives from health care and other industries and
the research community to identify, adapt, and implement state-of-
the-art approaches to addressing the following challenges:

• Redesign of care processes based on best practices
• Use of information technologies to improve access to clinical

information and support clinical decision making
• Knowledge and skills management
• Development of effective teams
• Coordination of care across patient conditions, services, and

settings over time
• Incorporation of performance and outcome measurements for

improvement and accountability

To achieve the six aims identified in Chapter 2, board members, chief execu-
tive officers, chief information officers, chief financial officers, and clinical man-
agers of all types of health care organizations will need to take steps to redesign
care processes. The recommended series of workshops is intended to serve
multiple purposes: (1) to help communicate the recommendations and findings
of this report and engage leaders and managers of health care organizations in the
pursuit of the aims, (2) to provide knowledge and tools that will be helpful to
these individuals, and (3) to encourage the development of formal and informal
networks of individuals involved in innovation and improvement.

STAGES OF ORGANIZATIONAL DEVELOPMENT

The design of health care organizations can be conceptualized as progressing
through three stages of development to a final stage that embodies the committee’s
vision for the 21st-century health care system, as represented by the six aims set
forth in Chapter 2 (see Table 5-1). Although settings and practices vary, the
committee believes much of the health sector has been working at Stages 2 and 3
over the last decade or more. As knowledge and technologies continue to ad-
vance and the complexity of care delivery grows, the evolution to Stage 4 will
require that Stage 3 organizations accelerate efforts to redesign their approaches
to interacting with patients, organizing services, providing training, and utilizing
the health care workforce.

Stage 1

Stage 1 is characterized by a highly fragmented delivery system, with physi-
cians, hospitals, and other health care organizations functioning autonomously.

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 113

The scope of practice for many physicians is very broad. Patients rely on physi-
cian training, experience, and good intentions for guidance. Individual clinicians
do their best to stay abreast of the literature and rely on their own practice
experience to make the best decisions for their patients. Journals, conferences,
and informal consultation with peers are the usual means of staying current.
Information technology tools are almost entirely absent. Norman (1988) has
characterized this approach to work as based on “knowledge in the head,” with
heavy dependence on learning and memory. The patient’s role tends to be pas-
sive, with care being organized for the benefit of the professional and/or institu-
tion.

Stage 2

Stage 2 is characterized by the formation of well-defined referral networks,
greater use of informal mechanisms to increase patient involvement in clinical
decision making, and the formation of loosely structured multidisciplinary teams.
For the most part, health care is organized around areas of physician specializa-
tion and institutional settings. Patients have more access to health information
through print, video, and Internet-based materials than in Stage 1, and more
formal mechanisms exist for patient input. However, these tend to be generic
mechanisms, such as consent forms and satisfaction surveys. Patients have infor-
mal mechanisms for input on their care.

Most health data are paper based. Little patient information is shared among
settings or practices; the result is often gaps, redundancy of data gathering, and a
lack of relevant information. In this stage, institutions and specialty groups, for
example, try to help practitioners apply science to practice by developing tools
for knowledge management, such as practice guidelines.

Stage 3

In Stage 3, care is still organized in a way that is oriented to the interests of
professionals and institutions, but there is some movement toward a patient-
centered system and recognition that individual patients differ in their prefer-
ences and needs. Team practice is common, but changes in roles are often slowed
or stymied by institutional, labor, and financial structures, as well as by law and
custom. Some training for team practice occurs, but that training is typically
fragmented and isolated by health discipline, such as medicine, nursing, or physi-
cal therapy.

Clinicians and managers recognize the increasing complexity of health care
and the opportunities presented by information technology. Some real-time deci-
sion support tools are available, but information technology capability is modest,
and stand-alone applications are the rule. Computer-based applications for labo-
ratory data, ordering of medications, and records of patient encounters typically

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Crossing the Quality Chasm: A New Health System for the 21st Century
Copyright National Academy of Sciences. All rights reserved.

114

T
A

B
L

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5

-1
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).

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Crossing the Quality Chasm: A New Health System for the 21st Century
Copyright National Academy of Sciences. All rights reserved.

115
3

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116 CROSSING THE QUALITY CHASM

cannot exchange data at all or are not based on common definitions. Practice
groups—particularly those that are community based—typically lack informa-
tion systems to make such decision support tools available at the point of patient
care, or to integrate guidelines with information about specific patients. Clinical
leaders recognize the need for what has been called “knowledge in the world”
(Norman, 1988)—information that is retrievable when needed, replaces the need
for detailed memory recall, and is continuously updated on the basis of new
information. More organized groups rely on best practices, guidelines, and dis-
ease management pathways for clinicians and patients, but these are not inte-
grated with workflow.

Stage 4

Stage 4 is the health care system of the 21st century envisioned by the
committee. This system supports continued improvement in the six aims of
safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
Health care organizations in this stage have the characteristics of other high-
performing organizations. They draw on the experiences of other sectors and
adapt tools to the unique characteristics of the health care field.

Patients have the opportunity to exercise as much or as little control over
treatment decisions as they choose (as long as their preferences fall within the
boundaries of evidence-based practice). Services are coordinated across prac-
tices, settings, and patient conditions over time using increasingly sophisticated
information systems.

Whatever their form, health care organizations can be characterized as “learn-
ing organizations” (Senge, 1990) that explicitly measure their performance along
a variety of dimensions, including outcomes of care, and use that information to
change or redesign and continually improve their work using advanced engineer-
ing principles. They make efficient and flexible use of the health workforce to
implement change, matching and enhancing skill levels to enable less expensive
professionals and patients to do progressively more sophisticated tasks (Christen-
sen et al., 2000).

The committee does not advocate any particular organizational forms for the
21st-century health care system. The forms that emerge might comprise corpo-
rate management and ownership structures, strategic alliances, and other contrac-
tual arrangements (“virtual” organizations) (COR Healthcare Resources, 2000;
Robinson and Casalino, 1996; Shortell et al., 2000a). New information and
delivery structures might be located in a particular city or region or might be the
basis for collaborative networks or consortia (COR Health LLC, 2000). What-
ever the organizational arrangement, it should promote innovation and quality
improvement. Every organization should be held accountable to its patients, the
populations it serves, and the public for its clinical and financial performance.

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 117

In some respects, such as economies of scale, workforce training and deploy-
ment, and access to capital, larger organizations will have a comparative advan-
tage. In other cases, small systems will evolve to take on functions now per-
formed by larger organizations. The use of intranet- or Internet-based applications
and information systems may enable the development of an infrastructure to
accomplish certain functions. New forms might include, for example, Web-
based knowledge servers or broker-mediated, consumer-directed health care pur-
chasing programs.

KEY CHALLENGES FOR THE REDESIGN OF
HEALTH CARE ORGANIZATIONS

Health care services need to be organized and financed in ways that make
sense to patients and clinicians and that foster coordination of care and collabora-
tive work. They should be based on sound design principles and make use of
information technologies that can integrate data for multiple uses (Kibbe and
Bard, 1997a; Rosenstein, 1997). Whatever their form, organizations will need to
meet six challenges, see Figure 5-1, that cut across different health conditions,
types of care (such as preventive, acute, or chronic), and care settings:

• redesigning care processes;
• making effective use of information technologies;
• managing clinical knowledge and skills;
• developing effective teams;
• coordinating care across patient conditions, services, and settings over

time; and
• incorporating performance and outcome measurements for improvement

and accountability.

The following discussion of these six challenges includes excerpts from
interviews with clinical leaders conducted as a part of an IOM study aimed at
identifying exemplary practices (Donaldson and Mohr, 2000).

Redesigning Care Processes

I try to help people understand that we can “work smarter.” You can feel
rotten about how you are practicing. I tell them, “You are right—and it’s going
to get worse.” But change is possible. We don’t need a billion-dollar solution.

We need a billion $1 solutions. You have to create the will to change. There’s
the will to change, then execution.—Hospital-based endoscopy unit

Like any complex system, health care organizations require sophisticated tools
and building blocks that allow them to function with purpose, direction, and high

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118 CROSSING THE QUALITY CHASM

reliability. Effective and reliable care processes—whether registering patients
who come to the emergency room, ensuring complete immunizations for chil-
dren, managing medication administration, ensuring that accurate laboratory tests
are completed and returned to the requesting clinician, or ensuring that discharge
from hospital to home after a disabling injury is safe and well coordinated—can
be created only by using well-understood engineering principles. Not only must
care processes be reliable, but they must also be focused on creating a relation-
ship with a caregiver that meets the expectations of both the patient and the
family. Redesign can transform the use of capital and human resources to achieve
these ends.

Redesign may well challenge existing practices, data structures, roles, and
management practices, and it results in continuing change. It involves conceptu-

FIGURE 5-1 Making change possible.

CARE SYSTEM

Supportive
payment and
regulatory
environment

Organizations
that facilitate
the work of
patient-
centered teams

High performing
patient-centered
teams

Outcomes
• Safe
• Effective
• Efficient
• Personalized
• Timely
• Equitable

REDESIGN IMPERATIVES: SIX
CHALLENGES

• Redesigned care processes
• Effective use of information technologies
• Knowledge and skills management
• Development of effective teams
• Coordination of care across patient conditions, services,

and settings over time
• Use of performance and outcome measurement for

continuous quality improvement and accountability

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 119

alizing, mapping, testing, refining, and continuing to improve the many processes
of health care. Redesign aimed at increasing an organization’s agility in respond-
ing to changing demand may be accomplished through a variety of approaches,
such as simplifying, standardizing, reducing waste, and implementing methods of
continuous flow (Bennis and Mische, 1995; Goldsmith, 1998).

Students of organizational theory have learned a great deal through careful
examination of the work of organizations that use very complex and often haz-
ardous technologies. The committee’s earlier report, To Err Is Human, outlines
the achievements of several manufacturing companies and the U.S. Navy’s air-
craft carriers in using replicable strategies to achieve great consistency and reli-
ability (Institute of Medicine, 2000). Other world-class businesses, notably those
that have received the prestigious Malcolm Baldrige National Quality Award,
have embraced many of the tenets of quality improvement described by Deming,
Juran, and others (Anderson et al., 1994), which include the need to improve
constantly the system of production and services. Yet few health care organiza-
tions have developed successful models of production that reliably deliver basic
effective services, much less today’s increasingly advanced and complex tech-
nologies. Nor have most been able to continually assess and meet changing
patient requirements and expectations.

Some health care organizations have dedicated considerable energy and re-
sources to changing the way they deliver care. Although these organizations
have recognized the need for leadership to provide the necessary commitment to
and investment in change, they have also recognized that change needs to come
from the bottom up as front-line health care teams recognize opportunities for
redesigning care processes and acquire the skill to implement those new ap-
proaches successfully (National Committee for Quality Health Care, 1999; Wash-
ington Business Group on Health, 1998). Many other organizations have taken
steps toward redesigning processes, but have found replication and deployment
difficult or short-lived (Blumenthal and Kilo, 1998; Shortell et al., 1998). The
committee recognizes these efforts and the difficulties that stem from, among
other things, restructuring and economic pressure, misaligned incentives, profes-
sional entrenchment, competing priorities, organizational inertia, and lack of
adequate information systems (Shortell et al., 1998).

A growing body of literature in health care indicates that well-designed care
processes result in better quality (Desai et al., 1997; Griffin and Kinmouth, 1998).
Some have argued that health care is not amenable to quality improvement ap-
proaches derived from other industries because inputs (patients) are so variable;
outputs, such as health-related outcomes, so ill-defined; and the need for expert
judgment and improvisation so demanding. Similar arguments have been made,
but not substantiated, in other service industries and by those in the specialized
departments (e.g., legal) of manufacturing industries that have subsequently ex-
perienced success in embracing principles of quality improvement (Galvin, 1998).

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120 CROSSING THE QUALITY CHASM

Fortunately, useful redesign principles that are now used widely in other indus-
tries can be (and in some cases have been) adapted to health care.

Engineering principles have been widely applied by other industries and in
some health care organizations to design processes that improve quality and
safety (Collins and Porras, 1997; Donaldson and Mohr, 2000; Hodgetts, 1998;
Kegan, 1994; Peters and Waterman, 1982). The following subsections describe
five such principles and their use by health care professionals to improve pa-
tients’ experiences and safety, the flow of care processes, and coordination and
communication among health professionals and with patients (Langley et al.,
1996).

System Design Using the 80/20 Principle

The nurse assesses the patient demographics, risk factors, support available,
medication, lifestyle, and barriers to making changes. The first visit is usually
45 minutes to an hour long. Preventive screening visits are done yearly—assess
vital signs, behavior, willingness to make changes. We take retinal photos,
which are sent directly to the ophthalmologist, instead of sending the patient
there. We learned that we need to risk stratify and fit the level of services to the
level of risk. Services are less or more intense based on risk. We use protocols
to identify risk level: primary—those with diabetes, secondary—those with
diabetes and any other risk factors, tertiary—those who have already had a
stroke, myocardial infarction, or renal failure.—Diabetic management group

This engineering principle can be restated: Design for the usual, but recog-
nize and plan for the unusual. Process design should be explicit for the usual
case—for 80 percent of the work. For the remaining 20 percent, contingency
plans should be assembled as needed. This concept is useful both for designing
systems of care and as an approach to acculturating new trainees. Also referred
to as the Pareto Principle, the 80/20 principle is based on the recognition that a
small number of causes (20 percent) is responsible for a large percentage (80
percent) of an effect (Juran, 1989; Transit Cooperative Research Program, 1995).
In health care, for example, 20 percent of patients in a defined population may
account for 80 percent of the work and incur 80 percent of costs. Similarly, 20
percent (or fewer) of common diagnoses may account for 80 percent of patients’
health problems.

A fundamental approach in health care has been to build care systems to
accommodate all possible occurrences. This approach is cumbersome and often
the source of delays when, for example, laboratory tests are done in case a rare
disease is present, or certain procedures must be followed in case an unusual
event should happen. System design based on the 80/20 approach exploits the
existence of routine work, often a large proportion of the total work load, that is
involved in an assortment of patient problems. One determines what work is

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 121

routine and designs a simple, standard, and low-cost process for performing this
work efficiently and reliably. This leaves the more complex work to be per-
formed employing processes that appropriately use higher-skilled personnel or
more advanced technologies.

In accordance with this principle, approaches to planning care are designed
to reflect the different sorts of clinical problems encountered in practice. Level 1
represents the most predictable needs. In a pediatric practice, well-child health
supervision, immunization, and middle-ear infections represent a large portion of
the work and very predictable needs. In an obstetrics–gynecology practice, pre-
natal care and contraceptive counseling are examples of Level 1. In adult pri-
mary care, examples include management of hypertension, acute sprains, low
back pain, and sinusitis. For newly diagnosed patients with asthma, instruction in
the use of an inhaler is an example of predictable work. The more predictable the
work, the more it makes sense to standardize care so that it can be performed by
a variety of workers in a consistent fashion.

When needs are predictable, standardization encompasses the key dimen-
sions of work that should be performed the same way each time using a defined
process and is a key element of the principle of mass customization discussed
later in this section. For example, variation in the care of patients with commu-
nity-acquired pneumonia can be reduced by identifying and standardizing the key
dimensions of care. Standardization may involve very complex or very simple
technologies and processes. An example of the latter is a nursing assistant stamp-
ing on a patient’s chart, “Immunization up to date?” and circling “Yes” or “No”
for a clinician to see as he or she enters the exam room. Focused standardization
often entails simplifying processes. For example, instead of each clinician on
staff having a different protocol, clinicians might agree to use a single chemo-
therapy protocol for most patients, or a single dose, route, or frequency for a
commonly administered medication. Although it might be permissible to use
other protocols, clinicians would have to agree to evaluate the outcomes for
patients under both the standard and nonstandard protocols to determine which
was best (Institute of Medicine, 2000). In another example, Duke University’s
pediatric emergency department uses a color-coded tape to measure a child’s
length and an approximate weight range. Color-coded supplies (e.g., IV tubing,
airway masks, syringes) correspond to the four weight ranges. Standardizing
equipment for each color zone ensures that dosages and equipment are appropri-
ate and safe for children in that range (Glymph, 2000).

Level 2 represents health care needs of medium predictability. At this level,
it is important for practice settings to triage patients accurately to determine their
needs. Examples are patients with chronic illnesses, such as asthma or diabetes,
whose condition is not under control and who need special services to help them.
Some patients might best be served by group visits with a diabetic counselor,
others might need individual support, and others might need hospitalization.
Appropriate triage based on needs could include working out a care plan with

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122 CROSSING THE QUALITY CHASM

patients in terms of exercise, weight loss, and insulin control and providing them
with materials and resources to help them meet their objectives.

Level 3 represents patients with rare or complex health care health condi-
tions for which special resources must be assembled. In such cases, applying
excellent listening skills, assembling resources, and managing the clinician–
patient relationship are especially important. Examples are a patient with an
infectious disease that is rare and difficult to identify, or the need to assemble a
multidisciplinary team for health supervision of children with special needs, such
as those with cystic fibrosis, meningomyelocele, or craniofacial syndromes
(Carey, 1992).

The assembling of these resources can sometimes be accomplished within a
single office practice. In other cases, a relationship with another system—an-
other critical care unit or an individual such as a subspecialist, for example—may
be required. Recent evidence indicates that for ambulatory care, nurses and nurse
practitioners can manage a substantial proportion of the work (Mundinger et al.,
2000; Shum et al., 2000). The remaining 20 percent of the work would corre-
spond to the third level, which requires the most highly trained practitioners.

Design for Safety

When lab results are returned by e-mail, they come back by provider, and I can
attach them to the patient’s chart. When I open the patient record, the “desk-
top” flags alert me to abnormal results.—Primary care practice

The doctor–patient relationship is important, but perhaps more important is
how much [doctors] can rely on the system not to let [the patient] slip through
the cracks. —Primary care practice

The prevention, detection, and mitigation of harm occur in learning environ-
ments, not in environments of blame and reprisal. Designing systems for safety
requires specific, clear, and consistent efforts to develop a work culture that
encourages reporting of errors and hazardous conditions, as well as communica-
tion among staff about safety concerns. Such learning also requires attention to
effective knowledge transfer, including the systematic acquisition, dissemina-
tion, and incorporation of ideas, methods, and evidence that may have been
developed elsewhere (Institute of Medicine, 2000). As described in detail in the
committee’s earlier report, To Err Is Human (Institute of Medicine, 2000), de-
signing health care processes for safety involves a three-part strategy: (1) design-
ing systems to prevent errors, (2) designing procedures to make errors visible
when they do occur, and (3) designing procedures that can mitigate the harm to
patients from errors that are not detected or intercepted (Nolan, 2000).

Designing systems to prevent errors includes designing jobs for safety, avoid-
ing reliance on memory and vigilance, and simplifying and standardizing key
processes (such as using checklists and protocols). Designing jobs for safety

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 123

means attending to the effects of work hours, workloads, staffing ratios, appropri-
ate training, sources of distraction and their relationship to fatigue and reduced
alertness, and sleep deprivation, as well as providing appropriate training. Avoid-
ing reliance on memory and vigilance can be accomplished in simple ways, such
as instituting reminder systems and color coding, eliminating look-alike and
sound-alike products, wisely using checklists and protocols, and employing more
complex automated systems that may prevent many errors (though they may also
introduce new sources of error). Simplification and standardization are key
principles not only in delivering effective services, but also in making them safer.
For example, standardization of data displays so that all are expressed in the same
units, of equipment so that on–off switches are in consistent locations, of the
location of supplies and equipment, of order forms, and of prescribing conven-
tions can prevent many errors (Institute of Medicine, 2000).

Designing procedures to make errors visible can also improve safety. Al-
though human beings will always make errors, procedures can be designed so
that many errors are identified before they result in harm to patients. For ex-
ample, pharmaceutical software can alert the prescriber to an incorrect dose or
potential interaction with another medication (Institute of Medicine, 2000).

Designing procedures that can mitigate harm from errors is a third means of
improving patient safety. Examples of this strategy are having antidotes and up-
to-date information available to clinicians; having equipment that is designed to
default to the least harmful mode; and ensuring that teams are trained in effective
recovery from crises, such as unexpected complications during operative proce-
dures (Institute of Medicine, 2000).

Mass Customization

Mass customization involves combining the uniqueness of customized prod-
ucts and services with the efficiencies of mass production. In manufacturing, this
strategy has been developed as a way to give customers exactly what they want in
a way that is feasible from a business standpoint—that is, quickly, at an accept-
able cost, and without added complexity (Pine et al., 1995).

With reference to the three levels of predictability discussed earlier, mass
customization is the design approach to Level 2 (patients with moderate levels of
predictability of needs). Patients can often be grouped according to their need for
a common set of services. For example, many medical conditions are defined in
terms of their grade or degree of severity (e.g., cancer staging), degree of control
achieved (e.g., controlled or uncontrolled hypertension), or level of risk (e.g.,
high- or low-risk pregnancy and the Glasgow trauma scale). With good informa-
tion about the past needs and preferences of patients, it is often possible to
standardize processes of care within a given stratum. It is possible to predict
fairly accurately, for example, what proportion of patients will choose a variety
of options, such as a group versus individual visit for management of a condition.

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124 CROSSING THE QUALITY CHASM

In a non-health care example, hotels such as the Ritz Carlton keep track of their
customers’ preferences so they can be offered appropriate services (Gilmore and
Pine, 1997).

Yet patients thus grouped are not identical, and the health system should be
responsive to differences in their preferences and special needs. Mass customi-
zation involves attempting to standardize the common set of services needed by
many patients while customizing or tailoring other aspects of those services to
respond to individual preferences and needs. In the computer world, Internet
sites can cater to “segments of one” by efficiently providing each customer with
products that match his or her preferences (Leibovich, 2000). Likewise, the use
of independent modules means that computer products can be assembled into
different forms quickly and inexpensively (Feitzinger and Lee, 1997). Gateway
is an example of a retail computer company that uses modules (such as varying
amounts of memory or hard drive capacity) in mass customizing its products for
the consumer. This use of modules for mass customization can be applied to the
health care arena, for example to patients with congestive heart failure who need
acute care. Modules for admission to a hospital or nursing home, for family
education, and for rehabilitation can be drawn on and combined for individual
patients. Another example is the steps in patient care, which can be thought of as
a series of modules, such as (1) prescribing a medication, (2) assessing and
encouraging adherence to therapy, and (3) monitoring patient outcomes. In these
examples, the 80/20 approach also applies; that is, for each module, the set of
options should be appropriate for 80 percent of patients.

In applying the principle of mass customization, differentiation is the last
step—in industry, an example is manufacturing all products in the same way up
to the addition of the product color. A health care example is having standardized
instructions for patients with a given health problem, but writing in further infor-
mation for those with additional health conditions.

Continuous Flow

When a patient calls to make an appointment, our philosophy is: If your doctor
is here today, you will see your doctor.—Primary care practice

We have bedside registration in the emergency department. Each room re-
ceives a portable computer rolled in on a cart. Computer orders for lab and
pharmacy are entered from the bedside.—Emergency department

Each morning we make rounds on all 34 intensive care patients. The discussion
includes pointed, patient-oriented reports, social as well as medical needs. All
such issues can be dealt with and work begun at once.—Intensive care unit

If a patient calls in with a breast lump, she is usually seen within a day or so.
First she sees her primary care provider, then she is sent to us for a mammo-
gram—usually an ultrasound as well. We can do what we think should be done

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 125

right then—a biopsy and surgery if needed. Usually everything is done within
1 or 2 days.—Breast care center

Volume has dramatically increased here. We have had to change the way we
work. Although most ERs have 12-hour shifts, we shortened the shifts to 9
hours. We have a system where there is “virtual on-call.” Physicians have
agreed in advance that if our tracking system shows that the cycle time from the
arrival of a patient to being seen by a doctor is past a specific threshold, they
will stay longer, even if more help is there or on its way.—Emergency depart-
ment

Continuous flow, sometimes referred to as “a batch size of one,” is an impor-
tant design concept in which the system is designed to match demand so there is
no aggregation of persons or units during processing. It represents the theoretical
optimum for any production or service delivery system. In health care, application
of this principle involves examining current assumptions about patient demand
and redesigning the care process to better correspond to the characteristics of the
demand curve (Murray and Tantau, 1998; Nolan et al., 1996).

If clinicians and managers assume that patient demand is insatiable, health
care systems and individual practitioners must find ways to manage this demand.
Management of demand generally entails using barriers, such as waiting, to dis-
suade some people from seeking services or reducing the need to use resources
that could be used elsewhere, or both. Alternatively, if the assumption is that
patient demand is steady, predictable, and reasonable, then continuous flow is a
more appropriate and effective solution. Some of the most advanced examples of
continuous flow have been pioneered by office practices that use “open-access”
scheduling (Grandinetti, 2000; Murray, 2000; Terry, 2000). Most scheduling
systems rely on distinguishing between urgent and nonurgent requests for ap-
pointments; the result is often waits of 2 weeks for a nonurgent appointment and
several months for a physical examination. As a result, many patients do not
keep their appointments (Bowman et al., 1996; Festinger et al., 1995). In an
open-access system, office staff do not triage patients who call for an appoint-
ment on the basis of whether they believe those patients need to be seen that day.
Patients can schedule an appointment and be seen the same day, if they wish, by
their doctor (or nurse practitioner) if that individual is in. Continuous flow does
not, however, mean that patients must be fit into a lock-step process. If they
prefer to wait or schedule an appointment for the future, they are always free to
do so.

To implement such a program and match demand with resources requires
that a practice first deal with its backlog of future appointments. Once it has
implemented an open-access process, the practice will have only one scheduling
system for all patients. Practices that have implemented open access report that
they are able to see as many or more patients as before; that they finish the day on
time and with personnel less exhausted; and that they are providing more appro-

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126 CROSSING THE QUALITY CHASM

priate—effective, patient-centered, timely, and probably safer—care (Institute
for Healthcare Improvement, 2000).

Under a system of continuous flow, as opposed to batch flow, practitioners
dictate notes, take care of other tasks after a patient’s visit, and respond to tele-
phone messages as they occur or as patients are seen, rather than “batching” such
tasks to be addressed at the end of the day. In the case of telephone messages, for
example, batching often results in repeated calls by patients who are not certain
their message has been received, repeated calls to patients who may be on their
way home from work by the time the message is returned, delays in managing
medications or in providing information about laboratory tests and instructions
for self-care, and sometimes greater anxiety and suffering.

Production Planning

We reorganized into teams 2 years ago. An MD, RN, and Medical Assistant
form a team. We have six or seven teams; each team sees a panel of 1200
patients. Each team sees patients for a 4 1/2-hour block of time per day. The
morning starts with a 30-minute meeting to review appointments that are sched-
uled for the day. Then the compressed clinic day. Then time for charting each
afternoon. We have practice management time that is scheduled every week.
Patients are not scheduled for that time. That time is for reviewing data, col-
lecting data. It’s funny, but you can see almost the same number of patients
during a compressed clinical day as during a full day. The teams are staggered
throughout the day so that we can be open from 8 a.m. to 8 p.m. The number of
teams is scheduled to match times when patient demand is the greatest.—Pri-
mary care practice

Production planning has been used in other industries to find the best way to
allocate staff, equipment, and other resources to meet the needs of customers, as
well as to reduce costs. Application of the principle depends on a detailed
understanding of work processes, specifically, the identification of repetitive
patterns of work.

Although the needs of patients and the work required to meet those needs
will vary from day to day, all clinical practices have a natural rhythm defined by
a period—for example, a week—after which the nature of the work repeats. One
method of production planning involves the use of a repetitive master schedule to
make the best use of resources in meeting patient needs. Creating such a sched-
ule necessitates defining the work to be done, assembling a team suited to per-
form the work, understanding the time period within which the work repeats, and
making work assignments based on the standard time period. If a master sched-
ule can be built for a typical week, it can be used with minor adjustments for any
week. The repetitive master schedule serves a variety of purposes. Its primary
purpose is to match resources to the needs of patients, but it also provides a

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 127

method for understanding complex systems and designing better production pro-
cesses.

Summary

The reengineering principles described in this section—system design using
the 80/20 approach, design for safety, mass customization, continuous flow, and
production planning—are used by other industries, and, as indicated in the ac-
companying quotations, by teams across a range of health care settings that
include ambulatory office practices, hospital units, emergency departments, and
hospices. Such engineering principles illustrate what is meant by focusing at a
system level. They enable health care teams to organize their resources effec-
tively to better meet patient needs, and make medical practice more satisfying
without driving up costs. Such deliberate crafting of systems of care results not
in impersonal, one-size-fits-all care processes. Rather, it makes care safer, en-
ables standardization where appropriate, and at the same time results in situations
that meet the unique needs of each patient.

Making Effective Use of Information Technologies

Spending 1 hour each day online, I send 800–900 e-mails each month. In my
former visit-based model, I would see 400–500 patients each month. Now I see
200 patients each month, in unhurried and more time intensive visits, but I
communicate with over 1,000 patients each month. I feel less stressed and my
patients receive better care.—Primary care practice

Chapter 7 examines in detail the potential role of information technology in
improving quality. Information technology can reduce errors and harm from
errors (Bates et al., 1998; Raschke et al., 1998), make up-to-date evidence and
decision support systems available at the point of patient care (Berner et al.,
1999; Classen, 1998; Evans et al., 1998; Hunt et al., 1998), support research
(Blumenthal, 1997), help make quality measurement timely and accurate
(Schneider et al., 1999), improve coordination among clinicians, and increase
accountability for performance (Blumenthal, 1997; National Committee for Qual-
ity Assurance, 2000).

Increasingly, secure Internet and intranet applications are making it possible
for clinicians and patients to communicate with one another more easily, for up-
to-date evidence about what works to become increasingly accessible, and for
clinical data to be shared in a timely fashion (Cushman and Detmer, 1998; Sci-
ence Panel on Interactive Communication and Health, 1999). Some organiza-
tions have begun to implement Internet applications for their patients for such
purposes as obtaining health information, communicating with one another, read-
ing information about physicians and staff, and viewing schedules for health
education classes (Kaiser Permanente Online, 2000).

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128 CROSSING THE QUALITY CHASM

Information technology can provide laboratory results and other findings, as
well as tools that help clinicians apply the health literature when making diag-
noses and deciding among therapeutic approaches. The validity of the informa-
tion used for such decision making is obviously critical. Also important is a user
interface that matches clinical workflow, cognitive style, and the time constraints
of clinical practice (Kibbe and Bard, 1997b), a need that can be addressed by
vendors, experts in medical informatics, and usability experts. The widespread
adoption of Web-based browsers to interface with data systems has influenced
medical informatics, increasing the likelihood of its acceptance and use in health
care settings.

Systems that can access and combine data from many sources should be able
to evolve with the uses to which they are put, the changing demands of the health
care environment, and advances in technology. Such systems should be able to
access all patient data wherever clinical decisions are made. They should be able
to access the evidence base and decision supports, such as clinical practice guide-
lines. They should provide efficient means of entering orders and retrieving
results. They should help practitioners coordinate activities whether they occur
in the inpatient, outpatient, home, or other settings.

A handful of health care organizations have made impressive gains in auto-
mating clinical information—for example, the health systems of the Department
of Veterans Affairs and Intermountain Health Care (in Salt Lake City, Utah)—
but overall progress has been slow. Barriers to moving forward include the many
policy (e.g., privacy concerns), technical (e.g., data standards), financial (e.g.,
capital requirements), and human factors (e.g., clinician acceptance) consider-
ations discussed in Chapter 7.

Managing Clinical Knowledge and Skills

We have an intranet throughout the system that enables physicians to see the
latest guidelines and recommendations about screening and to find out where
each of their patients is in this care process.—Health plan–based breast care
center

Our protocols for brain edema were going well. However, new literature
emerged. One of the neurosurgeons recommended that we revamp the proto-
cols to incorporate the new findings. He gathered the evidence, and the first
protocol was designed by a team headed by a unit nurse. The protocol was soon
standardized, and ownership was created at the physician and nurse level.—
Intensive care unit

All surgeons who join the staff, regardless of seniority, start by assisting, then
being assisted in 150 cases before being left on their own. If we are not com-
pletely confident they have mastered the technique, supervision is extended to
another 100 cases. The secret of success is in everyone using the same tech-
nique. It decreases complications and is more cost-effective.—Small hospital
specializing in two procedures

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 129

If the Respiratory Therapist notes an abnormal lab value, he or she is comfort-
able not just taking a blood sample and reporting it, but managing it. The
technicians are caregivers. Expectations have changed. They [adjust] therapy
to within physiological parameters. They are cross-trained so that they can take
on nursing tasks, for example, starting IVs when needed. When fully trained
and confident, they may tell an admitting doc that a patient is not ready to have
a ventilator tube removed.—Intensive care unit

A key challenge for organizations, requiring a range of competencies, is
translating the evidence base into practice. The competencies involved include
tracking and disseminating new information, managing the clinical change that
helps incorporate new information into practice, and ensuring that health care
professionals have the skills they need to make use of new knowledge. All such
competencies are interrelated. New information and technologies may require
new skills. And new technologies, such as simulation, may enhance skills, such
as those involved in performing surgical procedures or managing crises.

As described in greater detail in Chapter 6, the flood of new information that
is relevant to practice can no longer be managed adequately by individual clini-
cians trying to keep up with the literature and attending conferences or lectures
(Davis et al., 1999; Weed, 1999). One new approach to timely management of
information involves including clinical librarians as a part of clinical care teams,
for example, on morning rounds or on call, to note questions and search the
literature for the best and most relevant information (Davidoff and Florance,
2000). Another response is to create easily accessible systematic reviews of the
literature, using well-understood criteria for determining the strength of evidence
and the generalizability of findings. Such systematic reviews, though important,
are only the first stage, however, in disseminating the flow of new knowledge and
translating it for use with individual patients. First, clinicians need evidence-
based guidelines that make clear which steps are well founded and which are
based on expert consensus (Institute of Medicine, 1992). These efforts may
occur within practices or larger institutions, or may be developed by external
entities such as specialty groups, independent organizations established for the
purpose, or governmental groups. Whatever the source of such guidelines, any
group that uses them needs to understand their validity and ensure that they are
kept up to date.

Ensuring that new knowledge is incorporated into practice also requires a
thorough understanding of how change is managed most effectively in health
care, including the barriers to and facilitators of change. Knowledge about why
guidelines are or are not used is accumulating, and experts now better understand
the circumstances in which such strategies as education, administrative changes,
incentives, penalties, feedback, and social marketing are likely to be effective
(Greco and Eisenberg, 1993; Grol, 1997; Oxman et al., 1995; Solberg et al., 2000;
Wensing et al., 1998) and why the translation of research findings to date has
been characterized as “slow and haphazard” (Grol and Grimshaw, 1999).

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130 CROSSING THE QUALITY CHASM

One strategy for successfully managing change is to design guidelines and
implementation processes so that it is easier to apply the best evidence than not to
do so. This strategy begins with a systematic review of the evidence, but attends
to the creation of clinical guidelines or protocols that match the logic and flow of
care. Implementing this strategy also requires agreement on the part of clinicians
that they will use the new guidelines and protocols, as well as the resources
needed to redesign care processes (despite such resources often being scarce) so
that the guidelines and protocols will become an integral and efficiently designed
element of the care process.

Health care requires complex, sophisticated judgments and psychomotor
skills, perhaps at a level unmatched in any other field. Other industries test
judgment and psychomotor skills. In aviation, for example, simulations are used
to assess competence and to help pilots improve their judgment and skills. Medi-
cine has traditionally relied on cognitive testing of knowledge, not of judgment or
skills. The field also relies on privileges granted by hospitals using various levels
of rigor to assess professionals’ skills, but such mechanisms do not include test-
ing to ensure that those skills are current and have not deteriorated.

Making use of new knowledge may require that health professionals develop
new skills or that their roles change. New skills might include basic technical
proficiency, for example, in executing a procedure, using equipment, and inter-
preting data from new tests and devices. Managing new knowledge may also
require the use of new psychosocial skills to elicit behavior change in patients
and colleagues. Other new skills might include designing data collection efforts
and managing and interpreting quality-of-care information. Finally, incorporat-
ing new knowledge requires skilled leadership to engage the participation of
health professionals in collaborative teams. Leaders need to devote explicit
attention to ensuring that the most appropriate individuals are trained in, maintain
competence in, and are supported in their new tasks.

Developing Effective Teams

There has been a radical change since we introduced teams. You can see it
even where they hang out. Before the docs were together, the nurses together,
etc. But now the team hangs out with the team. At the morning meetings, you
may see the medical assistants providing the leadership. The medical director
calls it the “fast break”—three people on the floor and anybody can finish the
play.—Primary care practice

[The doctors] are worried about managing clinical conditions. They work un-
der pressure and stress and try to find a way to control it. They all claim that
“my patients are sicker.” I reply, “Give me your sickest patients—those with
congestive heart failure, the ones on coumadin, patients with diabetes, hyper-
tension, the old, sick people, anyone who seems to require more than the aver-
age resources and time.” When they ask why I would say this, I reply, “Be-

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 131

cause I will enlist help, resources—clinical pathways, care managers.” We
provide these resources to the practice and should never charge [or penalize] the
doctors for this help. Doctors have not learned yet how to enhance the team
with other kinds of providers—health education, behavioral medicine, physical
therapy, pharmacy.—Primary care practice

Organized work groups, or multidisciplinary teams, have become a common
way to organize health care, and considerable attention has been focused on their
value and functioning. Such teams are found in primary care practice, in the
focused care of patients with chronic conditions, in critical acute care (the inten-
sive care unit, trauma units, operating rooms), and in geriatrics and care at the end
of life. In such settings, smooth team functioning is needed because of the
increasing complexity of care, the demands of new technology, and the need to
coordinate multiple patient needs (Fried et al., 2000). Nonphysician team mem-
bers may increase efficiency (e.g., drawing blood, giving immunizations); substi-
tute for physicians (e.g., care for patients with simple, well-defined problems);
and complement physicians (Starfield, 1992) by filling roles that physicians may
not perform well or may be reluctant to undertake, such as counseling about
behavior change or performing highly technical diagnostic tests. Such distribu-
tions of roles and tasks change dramatically over time. Many tasks, such as
monitoring and adjusting equipment for an ill newborn after hospital discharge,
have been taken over by family members and patients themselves (Hart, 1995;
Lorig et al., 1993, 1999; Von Korff et al., 1997).

An IOM study of small work teams at the front lines of patient care (Donald-
son and Mohr, 2000) included asking practitioners and staff who worked together
on a daily basis about that experience. Respondents cited the importance of
collaborative work both for clinical care and for improvement efforts. They
emphasized the need to base quality improvement work within the team and to
recognize the contributions that all members of the group could make, with
various individuals taking leadership roles for specific improvement activities.
They also described new or expanded roles and the need for coaching and train-
ing new members of the team in their work relationships.

Effective working teams must be created and maintained. Yet members of
teams are typically trained in separate disciplines and educational programs,
leaving them unprepared to enter practice in complex collaborative settings. They
may not appreciate each other’s strengths or recognize weaknesses except in
crises, and they may not have been trained together to use established or new
technologies (Institute of Medicine, 2000). An enormous amount of knowledge
has been accumulated about team creation and management, including effective
communication among team members (Fried et al., 2000). In commercial avia-
tion, for example, emphasis is placed on crew resource management because of
its importance to airline safety, and communication among flight personnel has
become a special focus of proficiency checks by certified examiners (e.g., during
simulated emergencies).

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132 CROSSING THE QUALITY CHASM

Considerable research has gone into identifying the characteristics of effec-
tive teams (Fried et al., 2000). These characteristics include (1) team makeup,
such as having the appropriate size and composition and the ability to reduce
negative effects of status differences between, for example, physicians and nurses;
(2) team processes, such as communication structures, conflict management, and
leadership that emphasizes excellence and conveys clear goals and expectations;
(3) the nature of the team’s tasks, such as matching roles and training to the level
of complexity and promoting cohesiveness when work is highly interdependent;
and (4) the environmental context, such as obtaining needed resources and estab-
lishing appropriate rewards. Effective teams have a culture that fosters openness,
collaboration, teamwork, and learning from mistakes. Shortell et al. (1994) have
demonstrated a significant relationship between better interaction among team
members in intensive care units and decreased risk-adjusted length of stay. Such
interaction includes the dimensions of culture, leadership, communication, coor-
dination, problem solving, and conflict management.

Research on team interactions has also demonstrated that teams often fall
short of the expectations of their clinical leaders, members, and administrative
managers (Pearson and Jones, 1994). One reason is that medical education
emphasizes hierarchy and the importance of assuming individual responsibility
for decision making. An emphasis on personal accountability comes at the price
of losing the contribution of others who may bring added insight and relevant
information, whatever their formal credentials. Acculturation to medical roles
makes it difficult for members of a team to point out or admit to safety problems
and thereby prevent harm. Indeed, challenges to those in positions of power and
authority by nurses, physicians in training, and others is notoriously difficult and
discouraged (Helmreich, 2000; Institute of Medicine, 2000). Avoiding overt
hostility over a slip or lapse and acknowledging shared knowledge and profi-
ciency when recovering from unexpected patient events (Helmreich, 2000) are
examples of how strong collaborative working relationships can improve patient
safety.

In health care environments characterized by uncertainty, instability, and
variability (such as operating rooms and intensive care units), high levels of
stress are common (Mark and Hagenmueller, 1994; Perrow, 1967). Other envi-
ronments do not have the level of instability and uncertainty associated with
critical care units and operating suites, yet the complexity of patients’ needs still
necessitates highly effective coordination of resources across a spectrum of set-
tings, disciplines, and the community. An example is the care of frail elderly
patients, in which the ability to coordinate care and assemble effectively func-
tioning health care teams is paramount, and flexibility in role functioning may be
key.

In Chapter 3, new rule 10 emphasizes the importance of collaboration for
effective team functioning. What is sometimes thought to be collaboration, how-
ever, may in fact be uncoordinated or sequential action rather than collaborative

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 133

work. That is, the work of each individual may be efficient from the perspective
of his or her own tasks, but overall the efforts are suboptimal and do not serve the
needs of patients. An example of suboptimization may occur when an elderly
woman breaks her hip and comes to the emergency department. She may spend
several hours receiving x-rays and being stabilized and will certainly need to be
admitted. At the end of this time, someone may call to notify the nursing staff
that the patient is being admitted, and several hours more may elapse while
admission orders are written and the patient’s room is made available. When
emergency department and floor staff collaborate, notification is given immedi-
ately after the patient arrives in the emergency department so that the admission
process can begin, and the patient can go from the emergency department directly
to her hospital room, where she will be much more comfortable. In such cases
and in many others, running parallel processes reduces delays and improves
outcomes (Nugent et al., 1999).

Coordinating Care Across Patient Conditions, Services,
and Settings Over Time

That is fundamental to what is important to me—that the focus be on the indi-
vidual—a complex person—and you try to do the best you can for them. It
seems odd to say, but that is what is fun. We did focus groups with families and
learned key things that are important: (1) the organization and delivery of care,
(2) shared medical decision making, (3) treating each person as an individual,
and (4) attending to those who care for and love the dying person. The building
blocks to accomplish this are information and education of the patient and
family, coordination, and continuity.—Hospice

Another key challenge for organizations is coordination (or clinical integra-
tion) of work across services that are complementary, such as emergency re-
sponse units, emergency departments, and operating suites, or across primary
care practices, specialty practices, and laboratories to which patients are referred.
Clinical integration can be defined as “the extent to which patient care services
are coordinated across people, functions, activities, and sites over time so as to
maximize the value of services delivered to patients” (Shortell et al., 2000a). In
particular, coordination encompasses a set of practitioner behaviors and informa-
tion systems intended to bring together health services, patient needs, and streams
of information to facilitate the aims of care set forth in Chapter 2. For example,
coordination may involve ensuring that treating physicians are informed about
diagnostic results, therapies attempted during an earlier hospital admission, and
the effectiveness of those efforts. Coordination may involve nurse case managers
transmitting information to both primary and specialty care practitioners about a
patient’s unmet needs. Such coordination may be facilitated as well by proce-
dures for engaging community resources (such as social and public health ser-

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134 CROSSING THE QUALITY CHASM

vices) and other sites of care (such as hospice or home care) when and as
appropriate.

Coordination of care across clinicians and settings has been shown to result
in greater efficiency and better clinical outcomes (Aiken et al., 1997; Gittell et al.,
2000; Knaus et al., 1986; Shortell et al., 1994, 2000a, 2000b). Optimizing care
for a patient with a complex chronic condition is challenging enough, but opti-
mizing care for patients with several chronic conditions and acute episodes, as
well as meeting health maintenance needs, represents an extraordinary challenge
for today’s health care systems (MacLean et al., 2000; Shortell et al., 2000a).
The challenges arise at many organizational levels and across the full range of
tasks, including the design, dissemination, implementation, and modification of
care processes and the payment for these tasks. What is important to patients and
their families is that effective systems for transferring patient-related information
be in place so that the information is accurate and available when needed. Patients
and their families need to know who is responsible for decisions and can answer
questions, and to be assured that gaps in responsibility will not occur.

Some problems—such as substance abuse, AIDS, and domestic violence—
are so interrelated that they appear to require a comprehensive rather than prob-
lem-by-problem approach (Shortell et al., 2000a). Other problems require as-
sembling and making the best use of an array of resources, such as the numerous
federal programs that might be involved in obtaining and paying for a wheelchair
for a child with special needs. In any case, if care is to move beyond single
solutions crafted by individual clinicians (as in the Stage 1 delivery of care
described earlier in this chapter), it will require an accurate understanding of
patient needs so that standard processes can be provided and individual solutions
crafted as appropriate. Newly developed infrastructures, information technolo-
gies, and well-thought-out and -implemented modes of communication can re-
duce the need to craft laborious, case-by-case strategies for coordinating patient
care. A variety of other mechanisms can improve coordination, such as involving
a combination of individuals (e.g., clinicians, members of multidisciplinary teams,
care managers), along with patients and their families.

Some patients and their families become so expert in their condition that they
choose to coordinate care for themselves or a family member. Those who do so
are likely to need new skills in accessing information and new technologies for
structuring and conveying information to others who are involved in their care.
For example, patients can contribute to flow sheets, respond to questions about
changes in health status, or upload data from micromonitoring devices worn on
the body or from home monitoring devices. Not all patients or their families (or
perhaps even most) will choose or be able to become central actors in coordinat-
ing their own care, however. In such cases, appropriate mechanisms within the
delivery system must be available to meet this responsibility.

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 135

One means of improving coordination is based on what are sometimes called
clinical pathways. These blueprints for care set forth a set of services needed for
patients with a given health problem and the sequence in which they should take
place. For some conditions, a set of clearly identified processes should occur. In
complex adaptive systems such as health care, however, few patient care pro-
cesses are linear (such as the transition from hospital to nursing home). Rather,
most organizational processes are reciprocal and interdependent (Thompson,
1967), and coordination requires the design of procedures that are responsive
both to variations among individual patients and to unexpected occurrences.

Incorporating Performance and Outcome Measurements for
Improvement and Accountability

We have a Clinical Roadmap team for breast cancer screening. The team has
formulated four criteria for success that include process and outcome measures.
They are (1) the proportion of women in our population who have received care
in the last 2 years; (2) the number of women who came to the screening pro-
gram when invited; (3) the number of women in the program who develop a late
stage disease; and (4) survey responses during the time of enrollment in the
program. These criteria give us specific as well as broad measures of suc-
cess.—Breast care center

We have a clinical “instrument panel.” We measure cycle time, patient satis-
faction, phone calls (incoming and outgoing), proportion reaching treatment
goals for hypertension, operating costs per visit, proportion of patients seeing
their provider of choice, available appointments, team morale, practice size, and
proportion of pap smears in eligible women.—Primary care practice

The main outcome measure is risk adjusted mortality. We compare ourselves
quarterly to similar institutions for observed versus predicted mortality on one
axis and resource consumption on the other. Using 50 percent random sam-
pling, we track mortality, admission and discharge rates, length of stay, number
of patients readmitted to the ICU, and reintubation rates. This helps us know if
changes that affect efficiency are affecting quality of care. Although our ad-
missions are up, length of stay is down significantly, and our reintubation rate is
very low.—Critical care unit

Although we generally think of individuals as learning and enhancing their
capabilities, it is also possible to think of an organization as learning—increasing
its competence and responsiveness and improving its work (Davies and Nutley,
2000). The committee believes moving toward the health system of the 21st
century will require that health care organizations successfully address the chal-
lenge of becoming learning organizations. A decade ago, Senge and others
(Argyris and Schön, 1978; Senge, 1990) described such organizations as those
that can learn quickly and accurately about their environment and translate this
learning to the work they do. This idea has been incorporated in the work of

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136 CROSSING THE QUALITY CHASM

many companies, most outside of health care—such as 3M, Boeing, the Cadillac
Division of General Motors, Fedex, Motorola, and Xerox—whose drive to re-
duce defects and improve quality and customer service has been recognized by
the Malcolm Baldrige National Quality Award (National Institute of Standards
and Technology, 2000b).

In Senge’s terminology, “single-loop” learning results in incremental im-
provements in existing practice. In health care it might involve efforts to de-
crease waiting time for follow-up appointments for patients who have an abnor-
mal laboratory test result. Another feature of learning organizations is their
reexamination of mental models or assumptions on which they base their work,
giving rise to “double-loop” learning. An example of double-loop learning is
rethinking and reorganizing all ancillary and specialty medical services for women
in a breast care center to eliminate any waiting between reporting of abnormal
mammographic findings, definitive diagnosis, and therapy.

A critical feature of learning organizations is the ability to be aware of their
own “behavior.” In organizational terms, this means having data that allow the
organization to track what has happened and what needs to happen—in other
words, to assess its performance and use that information to improve. The
committee is convinced that a major tool for accomplishing this critical function
is the investment in and use of an effective information infrastructure to develop
a balanced set of measures on, for example, clinical and financial performance,
patient health outcomes, and satisfaction with care (Nelson et al., 1996). It is
important that such measures be balanced—that they include a variety of mea-
sures so that when changes are made in processes, such as to increase efficiency,
other outcomes, such as patient health, are not adversely affected.

Clinical practices that participated in the IOM study of exemplary practices
(Donaldson and Mohr, 2000) described how routine measurement has become
part of their production process. Ideally, such measures can be aggregated for
external reporting, whether to support contract discussions or to help patients
make choices about where and from whom to seek care. Building measurement
into the production process can counter the perception on the part of many health
care leaders that reporting is a burden. Such a perception results when organiza-
tions must respond to numerous demands from external groups for quality mea-
sures, especially if those measures lack specificity or relevance to the clinical
teams that must generate them.

Measures need not involve expensive, large-scale, long-term evaluation
projects to be useful. New methods that use sampling and small-scale rapid-cycle
testing, modification, and retesting are proving useful in dynamic settings such as
patient care units (Berwick, 1996; Langley et al., 1996). As other world-class
businesses have learned, including American industry giants (Walton and Dem-
ing, 1986), attention to improving quality includes continuous monitoring, often
based on small samples of events, that can provide organizations with timely data
at the front lines to manage the processes of concern (James, 1989; Rainey et al.,

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 137

1998; Scholtes, 1988). In the IOM study of exemplary practices, several health
care teams described their use of such methods to manage their care processes
(Donaldson and Mohr, 2000).

It’s an incredible relief to try small changes on a small scale. It’s so simple it’s
brilliant. We had been managing indigent diabetic patients for years and didn’t
think we could do any better. The providers believed that these people are so
hard. But the patients responded to the changes we made. You have to craft
something that is doable. You have to look for the simplicity in complex
things.—Diabetic management group for underserved minorities

We have embraced the concept of “real-time tracking.” We have developed a
“radar screen” that has 8 simultaneous processes continuously monitored. We
get information on the census in the ER, the status of the patients, the x-ray
cycle, etc. We know where in the process not only the patient is, but where the
system is. Each process measured is summarized on the screen by graphs. All
we have to do to obtain data is touch the screen. The graphs are equipped with
goal lines that are based on customer satisfaction, for example waiting time.—
Community based emergency department

The key word to describe a micro-system is homeostasis. A micro-system is
always changing and adapting, just like the human body. We have identified
the “pathophysiology” of a micro-system. It is powerful, yet very predictable.
Think about two downstream processes, x-ray cycle time and getting patients to
the floor. If the downstream [processes] get out of control, there are predictable
changes in the system. Occupancy in the ER goes up, the number of new
patients seen in the ER goes down, the number of free beds in the ER goes
down, and the cycle time between a patient’s arrival to a bed goes up. Eventu-
ally, every measurement goes up. When we obtain three consecutive 15-minute
intervals going the wrong way, we realize that something needs to be done.—
Community based Emergency Department.

LEADERSHIP FOR MANAGING CHANGE

The role of leaders is to define and communicate the purpose of the organi-
zation clearly and establish the work of practice teams as being of highest strate-
gic importance. Leaders must be responsible for creating and articulating the
organization’s vision and goals, listening to the needs and aspirations of those
working on the front lines, providing direction, creating incentives for change,
aligning and integrating improvement efforts, and creating a supportive environ-
ment and a culture of continuous improvement that encourage and enable suc-
cess.

Learning organizations need leadership at many levels that can provide clear
strategic and sustained direction and a coherent set of values and incentives to
guide group and individual actions. The first criterion of performance excellence
for health care organizations listed by the Baldrige National Quality Program is

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138 CROSSING THE QUALITY CHASM

the provision of “a patient focus, clear and visible values, and high expectations”
by the organization’s senior leaders (National Institute of Standards and Technol-
ogy, 2000a). Indeed, strong management leadership in hospitals is positively
associated with greater clinical involvement in quality improvement (Weiner et
al., 1996, 1997).

Leaders of health care organizations may need to provide an environment for
innovation that allows for new and more flexible roles and responsibilities for
health care workers; and supports the accomplishments of innovators despite
regulatory, legal, financial, and sometimes interprofessional conflict (Donaldson
and Mohr, 2000). Leaders need to provide such an environment because the
learning, adaptation, and incorporation of best practices needed to effect engi-
neering changes requires energy that is scarce in a demanding and rapidly chang-
ing environment.

At the level of front-line teams, leaders should encourage the members of the
team to engage in deliberate inquiry—using their own observations and ideas to
improve safety and quality. The individual who serves as leader may not be
constant over time or across innovative efforts, or be associated with a particular
discipline, such as medicine. What is important is for the leader to understand
how units relate to each other—a form of systems thinking—and to facilitate the
transfer of learning across units and practices.

Leaders of health care organizations must fill a number of specific roles.
First, they must identify and prioritize community health needs and support the
organization’s ability to meet these needs. Addressing community needs might
involve collaboration with other community or health care organizations and the
creation of new services. Examples include providing CPR training for a major
employer and identifying and alerting the community to patterns of injury, such
as the number of children with head injuries from bicycle accidents, or a newly
appearing occupational illness. Other examples include addressing the more
complex needs for coordinated local social and health services presented by low-
income ill elderly individuals or the need for more accessible substance abuse
treatment facilities. Leaders of organizations can support accountability to indi-
vidual patients while also assuming responsibility for accountability to public
bodies and the community at large for the populations they serve.

Second, leaders can help obtain resources and respond to changes in the
health care environment, which have been rapid and unrelenting. Leaders must
ensure that their organization has the ability to change. Yet many leaders now
view their role as shielding and protecting the organization from environmental
pressures that may require them to change. Leadership should support innova-
tion and provide a forum so that individuals can continuously learn from each
other. Organizations must invest in innovation and redesign.

Third, and perhaps the most difficult leadership role, is to optimize the
performance of teams that provide various services in pursuit of a shared set of

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BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE 139

aims. In any complex organization, there is danger in supporting some clinical
services (perhaps those that are most profitable) to the detriment of the whole
system. Leaders must strive to align the strategic priorities of their organization,
its resources (financial and human), and support mechanisms (e.g., information
systems). Balancing these elements can be extremely difficult and requires lead-
ers to have a performance measurement capability that includes measures of
safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

Fourth, leaders can support reward and recognition systems that are consis-
tent with and supportive of the new rules set forth in Chapter 3 and that facilitate
coordination of work across sets of services as necessary. Organizations should
support an environment in which incentives to provide effective care are not
distorted before they reach caregivers. An example of distortion is a payment
system based solely on the numbers of home care visits made by a visiting nurse
per day. This sort of productivity measure prevents nurses from focusing on
patient needs. A system based on effectively caring for a given number of
patients recognizes that a predictable mix of needs will occur over a period of
time, and can encourage small teams to organize themselves to meet those needs.
Such decision making can be very difficult, especially in the current economic
environment and payment system (see Chapter 8).

Fifth, leaders need to invest in their workforce to help them achieve their full
potential, both individually and as a team, in serving their patients. The resulting
interpersonal and technical competence can produce the synergies and improved
outcomes that emerge from collaborative work.

Although the leadership roles described are not novel, the orientation toward
facilitating the work of health care teams represents a fundamental shift in per-
spective. The new rules set forth in Chapter 3 and the engineering principles
described in this chapter will require strong and visible leadership with corre-
sponding reward structures. All organizations must overcome their inherent
resistance to change. It is role of leaders to surmount these barriers by visibly
promoting the need for improvement, becoming role models for the required new
behaviors, providing the necessary resources, and aligning recognition and re-
ward systems in support of improvement goals. Leadership’s role in promoting
innovation, gathering feedback, and recognizing progress is essential to success-
ful and sustained improvement.

Finally, leaders must recognize the interdependence of changes at all levels
of the organization—individual, group or team, organizational, and interorganiza-
tional—in addressing the six challenges discussed in this chapter. For example,
providing additional training in error correction or technical skill development to
individuals without recognizing that they work as part of a team will have little
impact. Similarly, working to develop more effective teams without recognizing
that they are part of a complex organization with frequently misaligned incen-
tives will have little effect on improving quality. Likewise, trying to redesign
organizational structures and incentives and revise organizational cultures with-

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140 CROSSING THE QUALITY CHASM

out taking into account the specific needs of teams and individuals is likely to be
an exercise in frustration. And attempting to make changes at any of these levels
without recognizing the larger interorganizational networks that include other
providers, payers, and legal and regulatory bodies (as discussed in subsequent
chapters) is likely to result in the waste of well-intended plans and energy.

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