DB2-43

The assigned reading for this week, “Building Organizational Supports for Change,” had a lot of good information about managing change in healthcare. The authors specifically identified six (6) challenges that must be addressed when redesigning health care organizations.

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For this discussion you will:

· Rank these six challenges in order of importance, in your opinion, with 1 being the most important and six (6) being the least important.

· After ranking, tell us why you chose this order.

· Support your ranking decision with information provided in the article, your own research, personal experiences, observations, etc.

To receive full credit, you will finish by thoughtfully responding/commenting on the post of at least two (2) classmates.

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SUGGESTED CITATION

http://nap.edu/10027

Crossing the Quality Chasm: A New Health System for the 21st
Century (2001)

360 pages | 6 x 9 | HARDBACK
ISBN 978-0-309-07280-9 | DOI 10.17226/10027

Committee on Quality of Health Care in America; Institute of Medicine

Institute of Medicine 2001. Crossing the Quality Chasm: A New Health System for
the 21st Century. Washington, DC: The National Academies Press.
https://doi.org/10.17226/10027.

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

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

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5

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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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Emma Logsdon

The six challenges for resigning health care organizations are each very crucial for the success of healthcare delivery. In my opinion, I believe that the six challenges rank by importance as follows: (1) redesigned care processes, (2) incorporating performance and outcome measurements for improvement and accountability, (3) managing clinical knowledge and skills, (4) making effective use of information technologies, (5) coordinating care across patient conditions, services, and settings over time, and (6) developing effective teams. Redesigning healthcare processes is the most important, in my opinion, because all the other challenges intertwine or rely on this in some way. This challenge focuses on simplifying, standardizing, reducing waste, and implementing continuous flow methods, which has a positive impact on every other challenge. This challenge also focuses on redesigning the process to meet the needs of evolving healthcare needs, which is significantly essential to ensure organizations care up-to-date and well equipped to meet the population’s needs. Incorporating performance and outcome measurements is next, in my opinion, because it shows the leadership what works or does not work for an organization. This step assists in developing the basis of every other challenge. Managing clinical knowledge and skills follows this because healthcare professionals must be knowledgeable of current healthcare practices. As well, this step incorporates change within an organization, which falls onto the remaining challenges. Making effective use of information technologies is equally as important in my opinion as to the previous challenges. By implementing better use of IT, communication is done more efficiently, errors and the harm from mistakes can be reduced, and data can be narrowed down for more accessible use. Coordinating care across patient conditions is next on my list since many of the previous steps include work to implement this step. This challenge focuses on making sure different teams working on the same patient are all on the same page to increase efficiency. This step is done more easily with the implementation of IT. The last on my ranking is developing effective teams. Even though this step is significant, I believe that if all other challenges are met, this step will reap the benefits, and success will be found here. Many members of different backgrounds are required to fulfill team needs. If all these challenges are met, the success of a healthcare organization is endless. I believe that these qualities are necessary for a productive and effective healthcare organization.

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Lydia Terry

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4

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5

After reading “Building Organizational Supports for Change”, and after much careful thought, I had a difficult time ranking these challenges in order of importance. There is no doubt that each challenge is vital in terms of redesigning our health care system. However, drawing upon my personal experience and observations, I have ranked the challenges in the order that I believe most pertinently affect patients in our health care system.

1. Redesigning care processes based on best practices – I ranked this challenge as most important because it has the most time-sensitive impact on quality of care for patients, which is our number one priority as healthcare providers. We must evaluate the best way to treat our patients and immediately put these processes into practice. I truly believe that ranking any other challenge above this does a disservice to our communities and the patients that need us in the here and now.

2. Coordinating care across patient conditions, services and settings over time, AND

3. Developing effective teams – I have coordination of care and developing effective teams tied for #2/#3 because I feel that they go hand in hand. As a pharmacist, I have had the opportunity to work closely with healthcare professionals from other areas, such as MDs, nurses, social workers and physical therapists to make sure that patients receive well-rounded, totally encompassing healthcare solutions. As we discussed in the last module, chronic conditions is one of the biggest healthcare problems in the US, and most people that have one chronic condition also have more than one. Knowing this, we must use an interdisciplinary approach to treat these patients. This may mean different healthcare professionals in different settings such as inpatient, outpatient, home health, therapy, and follow up visits.

4. Making effective use of information technologies to improve access to clinical information and support clinical decision-making – As we all know, information technology is more important than ever in 2021. If we can implement better use of IT, we can reduce communication errors and access information that is significant to patient care in a more timely and organized manner.

5. Incorporating performance and outcome measurements for improvement and accountability – Evaluation of staff and processes and accountability for failures and shortcomings is an important part of redesigning our healthcare system. Having a streamlined system for improvement based upon inadequacies is vital for providing the best care for patients and running a successful healthcare institution.

6. Managing clinical knowledge and skills – I have ranked this last not because it isn’t important, but because I truly believe in the clinical knowledge and skills that are already possessed by the healthcare professionals in the US. The most common source of medical errors in the United States is not from lack of knowledge, but from lack of communication. If we can resolve this issue through other improvements as mentioned above, we can reduce medical errors and provide better care to our patients.

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Areas of Expertise

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

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