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The Challenges of Achieving Sustained System Change

How can health care systems transform to provide consistently safe, high-quality care for patients as envisioned by the 2001 Institute of Medicine's (IOM) report, Crossing the Quality Chasm? From our research in both VA and non-VA health care organizations, we have identified five critical drivers of change that distinguish organizations that have reached sustained system change-- meaning higher levels of reliability in their care processes and greater changes in their systems and cultures. These five critical elements are illustrated in the Figure below.

Organizational Transformation Model

1) Impetus to transform often came from outside the organization in response to external pressures for change, but also came from within the organization, often stimulated by multiple factors. In successful transformations, organizations sustained impetus for change over time.

2) Leadership commitment to quality and change -- beginning at the top of the organization but including all levels -- proved a critical element for organizational transformation. Senior leaders drove change in two ways. First, they steered change through the organization's structures and processes to maintain urgency, set a consistent direction, and provided resources and accountability to support change. Second, to create momentum for dramatic improvement in patient care, leaders demonstrated authentic commitment to quality, by expending significant personal capital to motivate staff, often leading by example through personal involvement in improvement efforts.

3) Improvement initiatives that actively engaged staff in meaningful problem solving were central to change. Improvement initiatives contributed to transformation in at least three ways. First, initiatives such as clinical redesign improved operations. Second, initiatives actively engaged staff in problem solving around meaningful, urgent problems across disciplines and hierarchical levels. Third, successful initiatives built momentum for further improvement and contributed to culture change.

4) Alignment from top to bottom to achieve consistency of organizationwide goals with resource allocation and actions ensured that improvement efforts contributed to larger system change. Accountability was a key aspect of alignment, ensuring that behaviors, operations, and processes in practice supported organization-wide goals.

5) Integration to bridge traditional intraorganizational boundaries between individual components occurred at a later stage of transformation. Integration is a multi-faceted concept that applies to all organizational levels and is both an end state for a high-performing system and a strategy for transformation. Integration often began with multidisciplinary improvement teams that encouraged communication and problem solving across work units. However, by themselves, improvement teams ran up against the limits of traditional organizational boundaries. To move beyond those limits, organizations needed integration at the systems or organizational level in the form of structures and processes that involved managers with decision-making authority and responsibilities spanning the organization. Integrating structures and processes also facilitated the spread of improved clinical practices and values for improvement across the organization.

These elements affected transformation by driving change in complex and dynamic health care organizations. As illustrated inside the dotted circle in the Figure, we define the organization, or network of organizations comprising the system, in terms of four basic components:

  1. mission, vision, and strategies that set direction and priorities;
  2. culture that reflects values and norms;
  3. operational functions and processes that embody the work that is done in patient care; and
  4. infrastructure, such as information technology and human resources, that support delivery of patient care.

Transformation of health care systems is a complex and difficult undertaking that is achieved over a period of time. Each model element offers direct practice implications for managers seeking to change their systems to improve patient care. However, no single element is sufficient to achieve organizational transformation. Managers should recognize that all model elements are important, and that the challenge is to maximize the likelihood that the elements will interact with one another in complementary ways to maintain urgency to change and to move the organization forward. Full transformation may be attained only when multiple improvements are spread across the system and sustained over time.

Finally, successful transformation takes time. Transformation most likely unfolds over a decade or more. Although many of the systems we studied demonstrated considerable progress, they too described transformation as a continuing journey with no fixed endpoint. Persistence and constancy of purpose is required for this journey.

  1. Institute of Medicine; Committee on Quality of Health Care in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington D. C.: National Academy Press.
  2. Lukas CV, et al. An Organizational Model of Transformational Change in Health Care Systems. Health Care Management Review, 2007; 32(4): 309-20.

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