President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Building the Capacity to Improve Quality

Chapter Twelve
Adapting Organizations for Change

Because the science of health care is changing so fast, health care organizations -- health plans; hospitals, nursing homes, and other health care facilities; and health care practitioners -- need to match that pace of change. While quality health care depends heavily on the building of strong relationships between patients and those who care for them, the systems of care that surround those relationships are becoming increasingly complex and difficult to manage. Health care organizations must be willing to learn from other industries that have demonstrated success in making complex systems function better in order to improve quality. While numerous health care organizations already have begun to tackle this task and provide good role models for others, much remains to be done. Implementing the recommendations below will require significant cultural change in the leadership, professional participation, and daily work of most of today's health care organizations.


Quality Improvement Requires Leadership

The literature on quality improvement, both inside and outside of health care, is unanimous in highlighting the important role of leadership in improving quality. Only strong leadership can build an organizational culture supportive of change, establish aims for improvement, and mobilize resources to meet those aims.

Focusing on Consumers

The capability of health care systems to measure their own achievements, a precondition to improvement, requires the ability to see care through the eyes of the patient. At a more technical level, research suggests that the measurement of functional status, pain, emotional well-being, social and role functioning, and target symptom status is best done by asking patients themselves (Greenfield et al., 1985).

One example of a renewed focus on customer satisfaction in health care is increasing attention to waiting times as a key area for improvement. Long waits for appointments and tests frustrate patients and can lead to quality problems if patients are unable to see a physician or must endure long waits for test results. In 1996, the Institute for Healthcare Improvement in Boston assembled 27 health care organizations in a "Waits and Delays" project. The group met three times over 12 months to learn classic quality management principles and industrial design concepts. Participants also stayed in touch between meetings to swap ideas. The group's work has led to a dramatic turnaround in some cases. In just 3 months, a Catholic hospital in Illinois cut triage time in the emergency room from 45 minutes to no more than 15 (Nordhaus-Bike, 1997).

Customer focus is also leading health care organizations to redesign patient satisfaction surveys so that they can provide real guidance for improvement efforts. In 1991, the Henry Ford Health System began surveying internal and external customers regarding the barriers they experienced in accessing care. These data were used to guide the work of process improvement teams, which tried to address the identified barriers. One team, for example, focused on the availability of telephone triage and nursing-advice services and recommended upgrading phone systems and developing consistent advice guidelines (Antcil and Winters, 1996).

Quality Improvement Requires Learning

A health care organization dedicated to continuous improvement must become, almost by definition, a learning organization. A learning organization is an organization "skilled at creating, acquiring, and transferring knowledge and at modifying its behavior to reflect new knowledge and insights" (Garvin, 1993). While a great deal of learning already goes on in health care organizations, much of this learning is aimed at improving individuals -- physicians learning to become better physicians, nurses learning to become better nurses -- rather than learning how the system as a whole can improve.

Quality Improvement Requires Organizational Change

Not all change is improvement, but all improvement requires change. Once aims have been established and information has been gathered and evaluated, organizations must take action. They must commit to continually improving their processes of care, reducing error, and eliminating waste. They must be willing to overcome barriers between disciplines, departments, and organizations. And they must empower their own employees to make change.


Ackoff, Russell L., Creating the Corporate Future (New York: John Wiley and Sons, 1981).

American Medical Association, The National Patient Safety Foundation at the AMA (Chicago: 1997).

Antcil, Beth, and Maggie Winters, "Linking Customer Judgements With Process Measures to Improve Access to Ambulatory Care," Journal on Quality Improvement 22(5):345-347, May 1996.

Belkin, Lisa, "How Can We Save the Next Victim," New York Times Magazine p. 25, June 15, 1997.

Berwick, Donald M., "Continuous Improvement as an Ideal in Health Care," New England Journal of Medicine 320(1):53-56, January 5, 1989.

Berwick, Donald M., A. Blanton Godfrey, and Jane Roessner, Curing Health Care: New Strategies for Quality Improvement (San Francisco: Jossey-Bass, 1990).

Berwick, Donald M. "Improvement as Science," in David Blumenthal and Ann C. Scheck, eds., Improving Clinical Practice (San Francisco: Jossey-Bass, 1995).

Berwick, Donald M., "A Primer on Leading the Improvement of Systems," speech to the First Annual European Forum on Quality Improvement in Health Care, London, March 9, 1996.

Berwick, Donald M., "The Total Customer Relationship in Health Care: Broadening the Bandwith," Journal on Quality Improvement 23(5):245-250, May 1997.

Blumenthal, David, written statement to the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, July 21, 1997.

Blumenthal, David, and Jennifer N. Edwards, "Involving Physicians in Total Quality Management," in David Blumenthal and Ann C. Scheck, eds., Improving Clinical Practice (San Francisco: Jossey-Bass, 1995).

Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services, Community-Based Quality Improvement Education for the Health Professions: Program Description (Washington, DC: 1997).

Carman, James M., Stephen M. Shortell, Richard W. Foster, et al., "Keys for Successful Implementation of Total Quality Management in Hospitals," Health Care Management Review 21(1):48-60, Winter 1996.

Chassin, Mark R., "Assessing Strategies for Quality Improvement," Health Affairs 16(3):151-161, May/June 1997.

Deming, W. Edwards, Out of the Crisis (Cambridge, MA: Massachusetts Institute of Technology Center for Advanced Engineering Study, 1986).

Employer Health Care Alliance Cooperative, The Alliance Strategic Framework (Madison, WI: 1997).

Evans, R. Scott, Stanley L. Pestotnik, David C. Classen, et al., "Prevention of Adverse Drug Events Through Computerized Surveillance," Proceedings of the Annual Symposium of Computer Applications in Medical Care, 1992.

Felch, William C., and Donald M. Scanlon, "Bridging the Gap Between Research and Practice: The Role of Continuing Medical Education," Journal of the American Medical Association 277(2):155-156, January 8, 1997.

Garvin, David A., "Building a Learning Organization," Harvard Business Review July/August 1993.

Greenfield, Sheldon, Sherrie H. Kaplan, and John E. Ware Jr., "Expanding Patient Involvement in Care: Effects on Patient Outcomes," Annals of Internal Medicine 102:520-528, 1985.

Group Health Cooperative of Puget Sound, Supplier Quality Certification Program (Seattle: 1995).

Home Care Associates Training Institute, written statement to the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, Subcommittee on a Quality Improvement Environment, September 9, 1997.

James, Brent, Executive Director, Institute for Health Care Delivery Research, Intermountain Health Care, interview with Advisory Commission staff, January 9, 1998.

Laffel, Glenn, and David Blumenthal, "The Case for Using Industrial Quality Management Science in Health Care Organizations," Journal of the American Medical Association 262(20):2869-2873, November 24, 1989.

Leape, Lucian L., "Error in Medicine," Journal of the American Medical Association 272(33): 1851-1857, December 21, 1994.

Leape, Lucian L., written statement to the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, November 19, 1997.

Nordhaus-Bike, Anne M., "No Room for Waiting," Hospitals and Health Networks August 5, 1997, p. 64.

Shewart, Walter, Economic Control of Quality of Manufactured Product (Milwaukee: ASOC Quality Press, 1980).

Shortell, Stephen M., James L. O'Brien, James M. Carman, et al., "Assessing the Impact of Continuous Quality Improvement/Total Quality Management: Concept Versus Implementa-tion," Health Services Research 30(2):377-401, June 1995.

Stahlhut, Richard, and Joan Gosbee, "Systems Best Weapon Against Human Error in Medicine," American Medical News August 12, 1996.

Udvarhelyi, Steven, et al., "Comparison of the Quality of Ambulatory Care for Fee-for-Service and Prepaid Patients," Annals of Internal Medicine 115(5):394-400, 1991.

Van de Ven, Andrew H., "Managing the Process of Organizational Innovation," in George P. Huber and William H. Glick, eds., Organizational Change and Redesign: Ideas and Insights for Improving Performance (New York: Oxford University Press, 1993).

Weiner, Brian J., Stephen M. Shortell, and Jeffery Alexander, "Promoting Clinical Involvement in Hospital Quality Improvement Efforts: The Effects of Top Management, Board, and Physician Leadership," Health Services Research 32(4):491-510, October 1997.

Womack, James P., and Daniel T. Jones, Lean Thinking: Banish Waste and Create Wealth in Your Corporation (New York: Simon and Schuster, 1996).

U.S. eagle seal
[ About the Commission | Charter | Commission Membership | Press Releases | Meetings ]

Last Revised: Sunday, July 19, 1998