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The Critical Role of Leadership in Creating a Culture of Improvement

As VHA strives toward higher levels of Veteran-centered, data-driven, and team-based care, VA medical centers need to engage in continuous change and improvement. Recognizing that most medical centers have not yet fully developed a culture of improvement, the Office of Systems Redesign (OSR) initiated a program of Improvement Capability Grants (ICG) in 2009. OSR awarded grants to support local approaches to building improvement capability in five VISNs and 25 VA medical centers in FY2009 and FY2010. OSR commissioned the Center for Organization, Leadership, and Management Research (COLMR) to evaluate the experiences of the grantees over the course of the program.

One of the key findings that emerged from the evaluation is that strong senior executive support and engagement play critical roles in building a culture of improvement, consistent with the literature on the importance of senior leadership in organizational change (e.g., Beer, Eisenstat, & Spector, 1990; Lukas et al., 2007). While leadership at all levels is important, the drive for a sustained improvement culture must come from the top—in VA medical centers, leadership begins with the medical center director and the other members of the quadrad or pentad.

The experiences of the ICG sites offer lessons in four areas to build strong improvement capability, lessons that can help senior executives foster needed change.

Vision and alignment. Senior executives develop, communicate, and translate a vision for continuous improvement that supports the medical center's strategic and operational priorities. Senior executives create a motivating vision for improving the organization by focusing on the organization's long-term goals. They see a clear direction for the organization's future and have identified the path that will enable them to fulfill their vision. Senior executives align and integrate their vision with organizational priorities, structures, processes, and local context. In addition, they clearly communicate their vision for performance improvement to middle managers and staff. Leaders also acknowledge and reinforce positive behaviors that support their goals and encourage staff to take initiative in improving their work.

Personal expertise. Senior executives have deep knowledge about performance improvement principles and incorporate them in their management behavior. Senior executives are well-trained in advanced improvement methods so they can lead in a strong improvement culture and guide other staff in improvement management approaches. They serve as executive sponsors or coaches of improvement initiatives, and facilitate change by addressing barriers encountered in the improvement process. Senior executives actively participate in setting the performance improvement agenda by contributing to the identification, prioritization, adoption, implementation, and monitoring of improvement initiatives. They ensure that these initiatives support the facility's overall strategic and operational priorities. Importantly, senior executives apply systems redesign tools and principles to respond to crises rather than using them only when time allows.

Infrastructure. Senior executives understand what is required in order for performance improvement projects and training to succeed, and they develop systems, processes, and structures to support success. To develop a sustained culture of improvement, medical centers need both key staff with improvement expertise (i.e., system redesign coordinators and quality managers) and a larger group of trained staff versed in supporting improvement teams and helping spread improvement efforts on a daily basis across the medical center. Senior executives provide staff with the time and other resources required to engage in performance improvement and succeed in their work. They also hold staff accountable for applying their training, hold managers accountable for facilitating improvement, and implement reward systems to spur change efforts. Senior executives play a key role in supporting the development of data systems that track measures and monitor improvement progress. Finally, they develop structures and processes to elicit information about successful projects in order to acknowledge and promote accomplishments—and share lessons about factors that contributed to success; they also elicit information to learn from projects that failed.

Staff engagement. Senior executives foster active collaboration and engagement in performance improvement efforts by establishing a psychologically safe environment. Senior executives show respect for their staff and recognize their considerable technical skills, tacit knowledge, and practical experience. They teach, coach, and monitor improvement work on the frontlines of care delivery. They manage by asking questions that stimulate staff to develop their own solutions. They encourage innovation by fostering an environment in which staff feel secure in taking risks and by accepting that failures may occur. Senior executives are also careful to demonstrate their support for improvement without dominating, thereby encouraging others to lead improvement efforts.

Active engagement of senior executives is critical to implementing strategies that build solid knowledge, skills, and commitment to systems redesign among senior leaders and middle managers; establish an infrastructure of improvement expertise; align improvement efforts with organizational priorities; and engage staff across the organization in routinely improving their work. Leadership at all levels of the organization is important, but the drive for a sustained improvement culture must come from the top.

  1. Beer, M., Eisenstat, R. A., and Spector, B. "Why Change Programs Don't Produce Change," Harvard Business Review 1990; 68(6):158-66.
  2. Lukas, C.V. et al. "Transformational Change in Health Care Systems: An Organizational Model," Health Care Management Review 2007; 32(4):309-20.