Evaluation of Improvement Capability Grants:
 

Lessons from the Field: Part 1
 

Carol VanDeusen Lukas, EdD 

Martin P. Charns, DBA 

Center for Organization, Leadership & Management Research 

(COLMR) 

February 2013 

Center for Organization, Leadership & Management Research 1 
 

 

 

 

Acknowledgement of a large team effort
 

COLMR 

– Lauren Babich Systems Redesign 

– Sally Holmes Michael Davies 

– Emily Lopez Ro Hurley 

– Katelyn Gormley Sharon Kwasny 

Many dedicated staff on David Vass 

the site visit & analysis 

teams 

Center for Organization, Leadership & 

Management Research 2 
 

 

 

 

 

 

Why do we care about improvement capability?
 

•	 USH goal for VHA is continuous improvement 

•	 VHA strives to continue to move to higher 

levels of performance in terms of being 

Veteran-centered, data driven & team-based 

•	 To accomplish this goal, the system needs to 

have the capacity & will to continuously 

change & improve 

Center for Organization, Leadership & Management Research 3 
 

 

 

 

 

 

Priority of capability to continuously improve in 

VHA is reflected, e.g., in
 

•	 FY13 Senior Executive Performance Plan under 

the critical element of Leading People 

– “CE 2b: Culture of Continuous Improvement and 

Learning: The Senior Executive demonstrates 

strong commitment to ongoing, real-time learning 

to ensure the sustainability of quality 

improvement and patient-driven model 

engineering and redesign efforts.” 

Center for Organization, Leadership &
 

Management Research
 4 
 

 

 

 

 

To bring VHA to the next level of performance
 

•	 Systems thinking & improvement knowledge, 

skills & experience are important tools for the 

continuous improvement needed 

•	 Yet in FY2008, few staff in our medical centers 

had this expertise & few medical centers had a 

strong improvement culture 

Center for Organization, Leadership & 

Management Research 5 
 

 

 

Q1. In the past year, have you been involved in a
 

team to improve work processes or outcomes? 

• Yes 

• No 

Center for Organization, Leadership &
 

Management Research
 6 
 

 

 

Q2. In what role were you usually involved ? 

• Not involved in this type of team 

• Team member 

• Team leader 

• Improvement advisor/facilitator/coach 

Center for Organization, Leadership & 

Management Research 7 
 

 

 

 

 

Improvement Capability Grants (ICG) to address
 

the gaps
 . 

•	 VHA Systems Redesign (SR) developed the ICG 

initiative to: 

– Fund innovative, creative, & practical approaches 

to creating improvement capability that engages 

leadership & front line staff together in activities 

that improve day-to-day function of every aspect 

of VA care 

Center for Organization, Leadership & 

Management Research 8 
 

 

 

SR competitively awarded 30 grants 

•	 RFP with broad guidelines to encourage local 

strategies 

•	 Grants awarded to VISNs & medical centers 

–	 10 grants in 2009 to 7 medical centers & 3 VISNs 

–	 20 grants in 2010 to 18 medical centers & 2 VISNs 

•	 Three-year grants with total possible funding of 

$450K-500K/year 

•	 All grants now completed 

Center for Organization, Leadership & 

Management Research 9 
 

 

 

Grantees developed local approaches to building
 

improvement capability
 

• Activities clustered in 4 categories: 

• Training in improvement methods = 9 grants 

• Targeted clinical improvement projects = 9 grants
 

• Combined training & improvement projects = 8 

grants 

• Building infrastructure such as a registry or
 

resource center = 4 grants
 

Center for Organization, Leadership & Management Research 10 
 

 

 

 

COLMR commissioned to evaluate the ICG
 

initiative
 

•	 Did the sites carry out their grant initiatives as 

proposed & meet their short-term objectives? 

•	 Did the sites’ initiatives achieve intended program 

aims & build to the long-term goals of broader 

improvement capabilities & the development of 

learning organizations? 

•	 What factors contributed to success or hindered 

progress in each site? 

Center for Organization, Leadership & 

Management Research 11 
 

 

 

 

Site visits with all grantees 

•	 COLMR two-person teams conducted site 

visits with the 30 grantees at 6 month 

intervals 

•	 Grantees included VISNs & individual facilities 

•	 34 sites reported here 

•	 Currently conducting 

•	 One-year follow-up visits with 2009 sites
 

•	 End of grant visits with 2010 sites 

Center for Organization, Leadership & 

Management Research 12 
 

 

 

 

Majority of sites showed good progress in
 

building improvement capability
 

•	 Based on ratings of 3-4 (mostly/fully) on 0-4 

scale: 

–	 74% met their grant objectives 

– 65% spread grant activities beyond the original 

pilot area or clinical focus 

– 68% planned to sustain grant activities after grant 

funding ends 

Center for Organization, Leadership & 

Management Research 13 
 

 

 

 

Key factors in developing improvement capability
 

that builds a culture of improvement
 

•	 Improvement training linked with application to 

improvement projects 

•	 Data & skills to analyze 

•	 Strong improvement infrastructure 

•	 Front-line staff engagement 

•	 Middle manager engagement 

•	 Senior leadership engagement 

•	 Strategic alignment with organizational priorities 

Center for Organization, Leadership & 

Management Research 14 
 

 

 

Q3. Roughly how many staff in your facility
 

have been trained in systematic
 

improvement methods beyond employee
 

orientation?
 

• More than 100 

• 50-100 

• 10-49 

• 0-10 

• Don’t know 

Center for Organization, Leadership & 

Management Research 15 
 

 

 

 

Q4. Is there an explicit expectation that
 

people trained will participate in
 

improvement projects when they return?
 

• Yes, for all trainees 

• Yes, for some trainees 

• No 

• Don’t know 

Center for Organization, Leadership & 

Management Research 16 
 

 

 

 

 

Improvement training linked with application
 

• Neither training nor conducting projects alone 

is sufficient 

•	 High volume of projects does not build capability 

unless coupled with skill building 

•	 Heavy reliance on improvement experts without 

engaging staff has little sustained impact 

•	 Without opportunity to apply skills learned, 

trained staff do not retain skills 

Center for Organization, Leadership & 

Management Research 17 
 

 

 

 

 

 

Improvement training linked with application
 

ICG sites with combined training & projects 

foci had greater success 

• Trainees work on projects during or immediately 

after training 

• There is ongoing support for use of new skills by 

supervisors and improvement advisors 

• But this isn’t easy 

Center for Organization, Leadership & 

Management Research 18 
 

 

 

 

 

 

 

Data & skills to analyze
 

Information is critical for improvement 

 Systematic data on processes & performance are 

critical in diagnosing problems, identifying potential 

solutions & monitoring progress 

Application of data is particularly important in 

four areas: 

 Selecting & directing projects 

 Tracking progress in meeting goals 

 Sharing & discussing at levels of the organization 

 Monitoring to detect performance changes 

Center for Organization, Leadership & 

Management Research 19 
 

 

 

 

 

Q5. How deep is the improvement expertise in 

your medical center? Select all that apply
 

•	 A few people in an improvement/qualityrelated office 

•	 People across the facility with expertise to 

coach teams 

•	 Don’t know 

Center for Organization, Leadership & 

Management Research 20 
 

 

Strong improvement infrastructure
 

Challenges 

 Insufficient improvement resources 

 Level of expertise 

 Collateral duties 

 Working alone 

 Staff trained without plans for projects or support 

when they return 

Structural & functional depth is needed 

Center for Organization, Leadership & 

Management Research 21 
 

 

 

 

 

Strong improvement infrastructure
 

Capacity is needed in five key areas 

 Staff with the expertise & experience to oversee 

improvement work 

 Sufficient numbers of systems redesign resources
 

A clear plan, defined expectations & ongoing
 

support at all levels
 

 Clear linkages between training & projects for staff 

to apply when return from training 

Orientation for new staff & refresher training for 

existing staff 

Center for Organization, Leadership & 

Management Research 22 
 

 

 

An improvement culture consists of:
 

• Engaged staff with improvement skills 

• Infrastructure of expert skills, structures & 

culture to support improvement 

• Senior leaders engaged in system 

improvement 

Center for Organization, Leadership & 

Management Research 23 
 

Q6. How would you rate the improvement
 

culture in your facility?
 

• Minimal 

• Developing 

• Mature 

• Don’t know 

Center for Organization, Leadership & 

Management Research 24 
 

 

Recap of lessons & preview of Part 2
 

•	 Improvement training linked with application to 

improvement projects 

•	 Data & skills to analyze 

•	 Strong improvement infrastructure 

2/14 

•	 Front-line staff engagement 

•	 Middle manager engagement 

•	 Senior leadership engagement 

•	 Strategic alignment with organizational 

priorities 

Center for Organization, Leadership & 

Management Research 25 
 

July–September • 2010 235

Strengthening organizations to 

implement evidence-based 

clinical practices 

Carol VanDeusen Lukas
 

Ryann L. Engle
 

Sally K. Holmes
 

Victoria A. Parker
 

Robert A. Petzel
 

Marjorie Nealon Seibert
 

Michael Shwartz
 

Jennifer L. Sullivan

Objectives: Despite recognition that implementation of evidence-based clinical practices (EBPs) usually depends

on the structure and processes of the larger health care organizational context, the dynamics of implementation

are not well understood. This project’s aim was to deepen that understanding by implementing and evaluating

an organizational model hypothesized to strengthen the ability of health care organizations to facilitate EBPs.

Conceptual Model: The model posits that implementation of EBPs will be enhanced through the presence of three

interacting components: active leadership commitment to quality, robust clinical process redesign incorporating

EBPs into routine operations, and use of management structures and processes to support and align redesign.

Study Design: In a mixed-methods longitudinal comparative case study design, seven medical centers in one

network in the Department of Veterans Affairs participated in an intervention to implement the organizational

Key words: evidence-based clinical practice, hand hygiene, implementation, innovation, organizational change

Carol VanDeusen Lukas, EdD, is Senior Investigator, Center for Organization, Leadership and Management Research, Department of
 

Veterans Affairs, Boston, MA, and Clinical Associate Professor, Department of Health Policy and Management, Boston University School of
 

Public Health, Boston, MA. E-mail: carol.vandeusenlukas@va.gov.
 

Ryann L. Engle, MPH, is Health Scientist and Project Manager, Center for Organization, Leadership and Management Research, Department
 

of Veterans Affairs, Boston, MA.
 

Sally K. Holmes, MBA, is Investigator, Center for Organization, Leadership and Management Research, Department of Veterans Affairs,
 

Boston, MA, and Senior Research Fellow, Boston University Health Policy Institute, Boston, MA.
 

Victoria A. Parker, DBA, is Investigator, Center for Organization, Leadership and Management Research, Department of Veterans Affairs,
 

Boston, MA, and Assistant Professor, Department of Health Policy and Management, Boston University School of Public Health, Boston, MA.
 

Robert A. Petzel, MD, is Under Secretary for Health, Department of Veterans Affairs, Washington, DC.
 

Marjorie Nealon Seibert, MBA, is Management Analyst, Center for Organization, Leadership and Management Research, Department of
 

Veterans Affairs, Boston, MA.
 

Michael Shwartz, PhD, is Investigator, Center for Organization, Leadership and Management Research, Department of Veterans Affairs,
 

Boston, MA, and Richard D. Cohen Professor of Management, Department of Operations and Technology Management, Boston University
 

School of Management, Boston, MA.
 

Jennifer L. Sullivan, PhD, is Investigator, Center for Organization, Leadership and Management Research, Department of Veterans Affairs,
 

Boston, MA.
 

Health Care Manage Rev, 2010, 35(3), 235-245 

Copyright A 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 
 

236 Health Care Management Review July–September • 2010 

model over 3 years. The network was selected randomly from three interested in using the model. The target EBP

was hand-hygiene compliance. Measures included ratings of implementation fidelity, observed hand-hygiene

compliance, and factors affecting model implementation drawn from interviews.

Findings: Analyses support the hypothesis that greater fidelity to the organizational model was associated with

higher compliance with hand-hygiene guidelines. High-fidelity sites showed larger effect sizes for improvement in

hand-hygiene compliance than lower-fidelity sites. Adherence to the organizational model was in turn affected by

factors in three categories: urgency to improve, organizational environment, and improvement climate.

Implications: Implementation of EBPs, particularly those that cut across multiple processes of care, is a complex

process with many possibilities for failure. The results provide the basis for a refined understanding of relationships

among components of the organizational model and factors in the organizational context affecting them. This

understanding suggests practical lessons for future implementation efforts and contributes to theoretical

understanding of the dynamics of the implementation of EBPs.

ne of the pressing issues in health care today is 

that promising research findings about best clinical practices are often not widely used, despite 

extensive efforts to influence their use. Early, providerfocused efforts to introduce evidence-based clinical practices (EBPs) were not consistently successful. Most efforts 

focused on unidirectional translation of evidence delivered to individual providers in the practice setting (Grol & 

Grimshaw, 2003; Wensing, Wollersheim, & Grol, 2006), 

but targeting diffusion efforts only to individuals generally 

fails because providers do not act in isolation. Although 

there is now recognition that implementation or uptake 

of EBPs is complex, the organizational processes and dynamics of successful implementation are not well understood (Feldstein & Glasgow, 2008; Greenhalgh, Robert, 

Macfarlane, Bate, & Kyriakidou, 2004; Nembhard, 

Alexander, Hoff, & Ramanujam, 2009). To improve the 

implementation of new practices, we need to learn to build 

organizations with structures, processes, and cultures that 

can accommodate the complexity of implementing EBPs in 

daily operations. The growing number of frameworks that 

lay out the range of theoretical perspectives and complex 

array of dimensions to be considered in implementing new 

practices (Damschroder et al., 2009; Feldstein & Glasgow, 

2008; Greenhalgh et al., 2004; Grol, Bosch, Hulscher, 

Eccles, & Wensing, 2007; Nembhard et al., 2009) provide 

important steps forward. However, further work is needed 

to deepen our knowledge of how those dimensions and 

factors interact in different contexts. 

The aim of this study was to contribute to that knowledge by implementing and evaluating an organizational 

model that we expected to strengthen the ability of 

health care organizations to implement EBPs. In a mixedmethods longitudinal comparative case study design, seven 

medical centers in one network in the Department of 

Veterans Affairs (VA) participated in an intervention to 

implement the organizational model. The network, or 

the Veterans Integrated Services Network, was selected 

randomly from three interested in using the model. The 

O network directors recommended hand-hygiene compliance as the target EBP for the study. 

Conceptual Framework

The organizational model being tested is grounded in the 

organizational transformation model (OTM) developed 

in the evaluation of the Robert Wood Johnson Foundation’s Pursuing Perfection (P2) initiative (Lukas et al., 

2007). According to Lukas et al. (2007), OTM was 

based theoretically in research on complex organizational 

change (Greenhalgh et al., 2004; Grol et al., 2007; Poole & 

Van de Ven, 2004), microsystem effectiveness (Donaldson 

& Mohr, 2001; Nelson et al., 2002), and organizational 

diffusion of innovation (Rogers, 1995). It was based empirically in the experiences of the P2 health care organizations. The key drivers of change identified in OTM 

are those that emerged as most important as the P2 organizations worked to transform their systems to provide 

perfect patient care (Lukas et al., 2007). 

Our aim was to build from, although not precisely 

replicate, OTM in two ways. First, we applied it to EBPs. 

Our expectation was that the organizational elements 

that drive organizational transformation would facilitate 

the change required to implement EBPs. Second, we 

applied it in an intervention. Because OTM was based 

on an observational study, we wanted to test its usefulness as an implementation strategy by intentionally 

introducing it to organizations. 

The organizational model used in the study is a consolidated version of OTM that posits that the implementation of EBPs will be enhanced through the presence of 

three critical organizational components that are interactive and synergistic. Figure 1 presents these elements in 

highly simplified form. We recognize that organizations 

are dynamic and that change is complex and iterative with 

multiple feedback connections and is influenced by many 

factors not shown. We chose a simplified figure to focus on 

the model elements that we expect are key drivers and 

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 
 

Strengthening Organizations to Implement EBPs 237

Figure 1

Organizational model for implementing evidence-based clinical practices

which medical center leaders can influence and control. 

The complexity of the larger context is depicted as a box in 

the background to represent the array of other organizational factors that act on and are influenced by the model 

components. Not only were the three model components 

identified as critical in OTM, but each separately is supported in the literature. Therefore, in describing each component, we cite examples of other prior research. 

The three components are as follows: 

Active top leadership commitment. Organizational 

change is more likely when senior leaders promote change 

and foster a learning environment (Beer, Eisenstat, & 

Spector, 1990; Lukas et al., 2007; Sirio et al., 2003). Senior 

leaders orchestrate transformation by promoting conditions for change, by specifying the direction in which the 

organization should move, and then by spreading the lessons of both successes and failure (Beer et al., 1990). By 

spending their own time on activities that directly support 

continuous improvement and quality of care, senior leaders 

demonstrate the personal commitment and investment 

needed for sustained improvement (Sirio et al., 2003). 

Clinical process redesign. The success and the speed 

of adoption of EBP are related to (among other things) 

an infrastructure dedicated to process redesign (Bradley, 

Webster, et al., 2004). Clinical redesign serves several 

functions. First, it provides a vehicle for building EBPs reliably into routine work rather than layering them on top 

of existing work as added demands (Bradley, Holmboe, 

et al., 2004). Second, it facilitates change by engaging 

front-line staff, including physicians, in high-priority 

problem solving around a concrete, meaningful issue (Beer 

et al., 1990; Sirio et al., 2003). Third, successful redesign 

builds momentum for further change and improvement. 

Short-term experiences working in teams and seeing success motivate staff to go further with improvement. 

Links to senior management structures and processes. By itself, the redesign process runs the risk of 

becoming a quality improvement project that, like many 

before, is not sustained or spread. To counter this threat, 

the organization’s structures and processes must reinforce the need for change and enhance staff motivation 

to strive for improvement. More specifically, in organizations with successful change efforts, improvement initiatives are aligned with system strategies and priorities, 

and staff are held accountable and rewarded for alignment with goals and starting change processes (Beer et al., 

1990). Senior management provides the needed infrastructure resources of staff time, equipment, and data systems 

(Lukas et al., 2008) and addresses integration across organizational boundaries (Greenhalgh et al., 2004). Finally, 

senior management creates opportunities to communicate improvement successes and failures so that redesign 

efforts build a culture of a learning organization (Bradley, 

Webster, et al., 2004; Tucker & Edmondson, 2003). 

Methods

The study is a mixed-methods longitudinal comparative 

case study based on a 3-year intervention in which one VA 

network implemented the organizational model in support of redesign efforts to improve hand-hygiene practices, 

the designated EBP. The mixed-methods data collection 

strategy was judged to be an appropriate methodological 

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 
 

238 Health Care Management Review July–September • 2010 

fit given the intermediate level of theory development: 

There was prior work related to the research question, but 

the theory on which the project was based was not mature 

(Edmondson & McManus, 2007). 

Research Objectives

The study addressed three questions: 

1) Is the organizational model implemented with high

fidelity to the model design? For this study, fidelity is 

defined as elements of the organization model were in 

place and being used as intended. We assessed the extent of fidelity for two reasons. First, it serves as an independent variable in evaluating the effectiveness of the 

organizational model in improving hand-hygiene compliance: Medical centers may not have fully implemented the model and thus reduced its effectiveness. 

Second, it serves as the dependent variable in assessing 

factors that affect the success of implementation. 

2) Are medical centers that implement the model with

high fidelitymore successful in improving performance

of a targeted EBP? The study tested the hypothesis that 

medical centers that implement the organizational 

model more fully would show stronger improvement 

and performance in hand-hygiene compliance in comparison with their own performance before model implementation and with medical centers only using a 

few elements of the organizational model. 

3) Why is the organizational model implemented more

fully in some sites than others? Anticipating that the 

model might be implemented with greater fidelity 

in some contexts than others, the study was designed 

to examine the factors affecting implementation and 

thus increase our understanding of the dynamics of 

implementation. 

The Intervention

The intervention consisted of both research team activities to introduce and support the organizational model 

and the local implementation of the organizational model. 

Study sites. The participating medical centers were 

varied, ranging from large urban highly-affiliated tertiary 

facilities to small medical centers in rural areas; six were 

acute inpatient facilities and one was primarily a long-term 

care facility. All medical centers were part of the same 

network, an important structural and reporting feature of 

the VA health care system. 

Operational elements ofthe organizational model.

Organizational interventions are most likely to be successful when they can be tailored by local staff to local 

conditions (Berwick, 2003). Therefore, for each of the 

three model components, we identified key elements drawn 

from OTM and other literature, as outlined in Table 1. 

We asked the participating medical centers to identify 

the details of the structures and processes they would use 

to put each element into place. This operationalization 

of the model allowed us to distinguish between local tailoring that was consistent with the key elements and therefore reflected high fidelity and variation that reflected 

only partial implementation of the model. 

Clinical focus on hand-hygiene compliance. In collaboration with participating network leaders, we selected 

hand-hygiene compliance as the clinical focus across all 

sites. Basic hand hygiene is one of the most fundamental, 

widely publicized and effective processes shown to reduce 

hospital-associated infections (Lautenbach, 2001; Newell, 

Edelman, Scarbrough, Swan, & Bresnen, 2003). However, 

research indicates that compliance with hand-hygiene 

guidelines is highly variable and often lower than expected. 

Although hand-hygiene compliance may seem to be a 

simple individual practice, in fact, it requires complex 

system changes to improve across an organization. Because 

hand hygiene is important in all aspects of hospital functioning, it offered many opportunities for redesign that 

would engage staff. 

Activities to introduce and support the organizational model. In a 3-day visit to each site, a twoperson research team conducted a preimplementation assessment, introduced the organizational model, and began 

working with local project leads to develop a detailed 

implementation plan. Over the remaining 2ˇ1

/2 years of the 

project, the team used site visits at 4- to 6-month intervals 

to monitor model implementation and to address issues 

that arose. In addition, at the request of the local redesign 

leads, it conducted periodic informal telephone calls and, 

after the first year, quarterly calls with medical center 

leadership. Two network-wide activities complemented 

these local efforts: a shared learning group convened via 

telephone for members of all clinical redesign teams and an 

in-person quarterly consortium for medical center directors 

convened by the network senior leaders to stimulate 

opportunities for information exchange, dialogue, and 

shared problem solving. These activities were consistent 

across the seven sites. 

Data Sources

The comparative case study drew on three data sources: 

Organizational model implementation fidelity ratings. At the end of each site visit, the two-person team, 

which remained consistent visit to visit when possible, 

rated implementation fidelity in terms of the extent to 

which the elements of the organizational model were in 

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 
 

Strengthening Organizations to Implement EBPs 239

Table 1

Organizational model for implementing evidence-based clinical practices:

components and elements

1. Active top leadership commitment

Leadership vision and direction, constancy of purpose, use of own time

• Set high local expectations of improvement in measures in target clinical area

• Set local expectations for becoming a learning organization

• Convey quality as a high priority by the way leaders use their own time, for example, participating in an

improvement team or on a quality oversight committee

2. Links to senior management structures and processes

Alignment and accountability

• Appoint strong clinician and administrator to lead local improvement efforts in the target area, with charge

that they will establish a multidisciplinary redesign team; appoint an improvement advisor to support the

redesign team (see below)

• Create incentive and reward structures to encourage use of evidence-based practices and, where needed,

fundamental redesign of clinic processes

• Establish structures to link the improvement efforts to senior management such that senior management

gives the initiative high priority and holds the design team accountable

• Reporting relationship to senior leadership team

• Member of senior management and chief or comparable service line leader in the targeted area

designated as formal champions to advocate for redesign and help the design team solve problems
 

Integration and resource support
 

• Link improvement efforts to senior management such that senior management facilitates cooperation

across organizational boundaries and provides other resources to design team, for example, protected time

to work on initiative; staff, equipment, and space as needed; IT support as needed

Communication

• Celebrate and broadcast successes and share failures to learn from them

• Use lessons from this redesign to spread processes, redesign skills and values to other parts of the organization

3. Clinical process redesign

• Create a collaboratively functioning redesign team that is multidisciplinary and crosses organizational lines

to include all owners of processes that touch the target clinical area

• Provide training/refresher in QI techniques as needed to team members

• Analyze performance and processes and identify areas for improvement

• Review performance data to identify areas for improvement

• Aim for system redesign that builds evidence-based practices into daily work not just add them on; take

away old actions

• Set goals and measures and map processes and activities expected to improve measures to reach the goals

• Identify new parts of organization that need to be involved—add team members as needed

• Monitor, analyze, and modify or extend improvement processes (ongoing)

• Report progress, including problems, to senior leadership regularly

• Spread successful improvement efforts to other parts of the organization

• Monitor successful areas to ensure that improvements are sustained

place and used as intended. Using a structured tool, each 

team member independently rated the presence of each 

element, both assigning a quantitative score of 0 (no

evidence of the element present) to 4 (element in place and

consistently being used as intended) and providing narrative 

evidence to support each score. After the independent ratings, the site-visit team members compared ratings and 

developed a consensus score for each element. By measuring implementation after each round of interviews, we 

were able to track changes over time. 

Observations of hand-hygiene compliance. Observations of adherence to national hand-hygiene guidelines 

were conducted by the sites using local data collection 

instruments and practices. Core data elements were constant across sites, but observers varied. This approach was 

consistent with the study intent of building on local 

processes that would be sustained after the research project. To some extent, this compromised cross-site comparisons of raw rates of adherence. However, our main focus 

was on within-site changes over time. With one exception, 

there were no major changes in data collection approach 

over the study period. In most sites, observation data 

were collected monthly between the last quarter of 2006 

and the third quarter of 2008. 

Semi-structured interviews during site visits. The 

site visits were designed to collect data on the course of 

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 
 

240 Health Care Management Review July–September • 2010 

the intervention and to provide feedback to the medical 

centers. Semi-structured interviews were conducted by 

the two-person teams, with the medical center leadership 

including the director, the chief of staff, the nurse 

executive, and the associate director; the clinical redesign 

team members, leaders, and project improvement advisor; 

and selected front-line staff. Questions were designed to 

evaluate the use and dynamics of organizational model 

elements and site-specific tailoring. Interview protocols 

were reviewed after each wave of site visits and refined 

to capture emerging issues. Each site was visited five or 

six times with an average total of 37 interview sessions 

conducted over the study, many with multiple informants. 

Detailed interview notes were written up and circulated 

within the site-visit team for review and clarification. 

Using Nvivo 2.0 (QSR International 2006, Melbourne, 

Australia), the qualitative coding team reviewed and 

independently coded transcripts for sites they did not 

personally visit. The initial coding list was developed on 

the basis of the broad concept areas of the organizational 

model followed by more specific codes as they evolved. 

After each round of site visits, the codes were reassessed 

and refined for continued content validity. Initial reliability of the coding protocol was assessed by an interrater coding comparison, resulting in 70% agreement. To 

maintain a high level of coding reliability, the coding 

team held quarterly meetings to review the codes and compare coding. 

Measures and Analyses

To answer three study questions, we developed and 

analyzed three sets of measures: 

Ratings of implementation fidelity. We used the 

fidelity ratings to analyze the extent of organizational 

model implementation from two perspectives. First, we 

used the quantitative ratings as summary indicators of the 

extent to which the key elements of the organizational 

model were in place and to track changes over time. To 

create summary fidelity scores for each site visit, we 

aggregated the scores on each element to the level of the 

three model components and calculated an unweighted 

mean for each on the 0 to 4 scale. Means of component 

scores were used rather than individual elements to weight 

each component equally. The overall fidelity rating is an 

unweighted average of the three component scores. For 

the analyses reported here, we focused on ratings of fidelity 

at the final site visit and overall change between first and 

last visit. Second, we used the narrative evidence given to 

support each rating to capture qualitatively an operational 

picture of what the ratings meant. 

Hand-hygiene compliance scores. For each observation period, we calculated the percent of hand-hygiene 

compliance at the site level. The effect size of improvement 

in compliance was calculated by comparing the baseline 3­

and 6-month periods to the last 3- and 6-month periods of 

the study. To evaluate the statistical significance of changes 

in proportion adherence over time, we ran a weighted least 

squares regression model with time (i.e., month) as the 

independent variable and adherence proportion as the 

dependent variable. The sample size in each data collection 

period was used as the weight. Our interest is in the 

statistical significance of the coefficient associated with 

time. To evaluate the practical significance of the change 

preintervention and postintervention, we examined the 

effect size associated with the change in proportion 

adherence in the first 3-month period of data collection 

(denoted by p1) and the last 3-month period (p2). Effect 

size was calculated as follows: 2 X arcsin(sqr(p2)) - 2 X

arcsin(sqr(p1)). Using Cohen’s criteria, an effect size of 

.2 is interpreted as small, .5 as medium, and .8 as large 

(Cohen, 1977). 

Factors affecting model implementation. Factors 

affecting the extent of implementation of the organizational model were identified qualitatively through 

interviews. The analysis was designed to understand 

the impact of the organizational context on model 

implementation in each site and to examine patterns of 

similarity and difference across sites, especially between 

high-fidelity and lower-fidelity groups. Following the 

procedures described by Miles and Huberman (1994), 

we conducted thematic analyses of the interview notes, 

identifying both within-site patterns and across-site 

differences. We used an explanation-building strategy, 

focusing on understanding each case first before conducting cross-site comparisons and then cycling back 

and forth between the individual site cases and the 

cross-site comparisons. Cross-site matrices were used to 

compare and to contrast evidence of activities, processes, and structures across sites. 

Findings

Is the Organizational Model Implemented

With High Fidelity to the Model Design?

Overall fidelity ratings ranged from 1.42 to 3.95 at the 

end of the study, indicating considerable variability in 

fidelity to the model design. As shown in Table 2, sites 

clustered in two groups by implementation ratings, both 

overall and by the individual components: Sites were 

grouped into high implementation fidelity (four sites) and 

lower implementation fidelity (three sites). In the lowerfidelity group, implementation scores were 2.50 or less 

across dimensions, indicating that elements were partially present (2 = partially present). In the high-fidelity 

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 
 

Strengthening Organizations to Implement EBPs 241

Table 2

Ratings of fidelity to the organizational model

Facility

Fidelity:

leadership

Fidelity:

management links

Fidelity:

redesign efforts

Fidelity:

overall

Fidelity:

overall change

from baseline

Fidelity

rank order

A 4.00 4.00 3.85 3.95 2.82 1

B 4.00 3.20 2.95 3.38 2.11 2

C 3.75 2.60 3.35 3.23 1.99 3

D 3.00 3.00 3.50 3.17 1.84 4

E 2.00 2.20 2.25 2.15 1.21 5

F 2.50 1.80 1.65 1.98 0.41 6

G 2.50 1.25 0.50 1.42 -0.05 7

Note. Bold font indicates data for high implementation fidelity sites (facilities A–D).

group, scores were above 3.0 on the overall ratings, indicating that the elements were mostly or fully present (3 = 

mostly present,4= element in place and consistently used as

intended). Sites with the highest final ratings were also those 

with the largest changes in implementation scores over the 

project, as shown in Table 2. At baseline, implementation 

scores were closely clustered between 1.13 and 1.57, indicating that the differences in final scores were not simply a 

reflection of preexisting differences among sites. 

Qualitative analyses supported the quantitative differences between the two groups. Although the high-fidelity 

sites did not fully implement every element of the organizational model and the lower-fidelity sites were strong on 

some elements, the overall patterns of behavior and activities in the three model components are clearly different 

in the high and lower groups: 

Active top leadership commitment. In the highfidelity group, senior medical center leaders were supportive of and involved in hand-hygiene improvement efforts. 

Perhaps most important, senior leadership involvement 

and support was consistent across settings and over time. 

Senior leaders set clear expectations about target levels of 

compliance and sent the message that current practices 

were deficient. They received regular briefings about compliance levels and improvement progress. They served 

as role models and champions for hand-hygiene compliance. They also created opportunities for communication 

to emphasize awareness. In the lower-fidelity group, senior 

leaders either did not see hand hygiene as a high priority 

or expressed support but were not consistent in their involvement. In some cases, they modeled good hand hygiene and, for example, addressed it if it came up on patient 

safety and environment of care rounds, but they generated 

little sense of urgency for improvement. 

Clinical process redesign. In the high-fidelity group, 

clinical redesign was characterized by energetic, visible, multidisciplinary improvement teams. Sites with solid 

quality improvement approaches tended to involve staff 

affected by redesign efforts across disciplines and divisions 

on their teams. High-functioning teams had strong team 

leaders with excellent project management skills and often 

had experienced quality improvement experts serving as 

team members or dedicated to the team. Team leaders in 

some sites were paired with clinical leads who used their 

professional collateral to help move the project forward. 

Finally, all teams in the high-fidelity group went beyond 

basic process redesign methods to explore higher reliability 

interventions as compliance improved or plateaued. In the 

lower-fidelity group, clinical process redesign was often 

more ad hoc. Teams, if appointed at the beginning of the 

project, never really got off the ground or fell away to just 

the skeleton of a team because team members could not 

find time to meet or were not released from clinical duties 

to participate. Teams collected data but did not use it to 

help understand possible sources of noncompliance or 

the impacts of their intervention activities. Often lowerfidelity sites felt their teams lacked the leadership, the 

authority, or the infrastructure to accomplish their goals. 

Links to senior management structures and processes. In the high-fidelity group, there were explicit 

strategies to link improvement efforts to senior management. A member of the leadership team was explicitly identified as an executive champion or coach 

to work actively with the hand-hygiene redesign team 

as a liaison and a mentor. Sometimes the executive 

champion served as members of the redesign team but 

if not was connected as part of his or her ongoing 

management responsibilities. In addition to the designated executive champion, the whole leadership team 

remained aware of most of the improvement efforts by, 

among other things, regularly reviewing the handhygiene compliance data. As part of the data review, 

there were clear lines of accountability for performance 

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 
 

242 Health Care Management Review July–September • 2010 

that did not meet the target, although there was variation among sites in their consistency in dealing with 

weak performance. Across high-fidelity sites, data and redesign progress were generally discussed by senior leaders 

in a forum where issues and problems could be assigned 

to appropriate managers to solve. Medical center managers provided resources, such as time and staff, for 

the hand-hygiene improvement efforts as well as for incentives and rewards. Attention to hand hygiene was 

regularly rewarded and hand-hygiene success generally 

celebrated. In the lower-fidelity group, executive champions were less consistently identified and involved or, in 

some cases, served as champions in name only. In addition, reporting hand-hygiene data tended to be reviewed 

by standing performance improvement or patient safety 

committees buried several layers below leadership, which 

diluted the ability of the team to get sufficient leadership attention. Sometimes hand-hygiene performance 

data were reported to leadership, but there was no constructive follow-up action when performance was low. The 

result of such disconnection was that project teams felt 

they did not get consistent direction, cross-department 

issues went unresolved, and hard-won successes were 

not recognized. 

Are Medical Centers That Implement

the Model With High Fidelity More

Successful in Improving Performance

of a Targeted EBP?

Analyses support the hypothesis that greater fidelity to the 

model is associated with higher adherence to handhygiene guidelines, as shown in Table 3 where the sites 

are divided between high and low fidelity in the same way 

they were in Table 2. In the four high-fidelity sites, 

the effect sizes were much larger (.48 to .92) than that in 

the lower-fidelity sites (-.22 to .14). This is true even in 

Table 3

Hand-hygiene compliance ordered by fidelity ranking

Facility

Adherence

preperiod

Adherence

postperiod

Effect size:

3 months

before

and after

Effect size:

6 months

before

and after

Regression

model: time

coefficient

Regression model:

time coefficient

p value

Regression

model: r 2

facility C when a 6-month preperiod and postperiod are 

used (thus reducing the effect of the extremely low adherence rate in the 3-month preperiod). For the most part, 

effect sizes suggest a moderate effect. For the four highfidelity sites, the monthly increase in the percent adhering was statistically significant. In the three lower-fidelity 

sites, the monthly change was not statistically significant. 

Why Is the Organizational Model

Implemented More Fully in Some Sites

Than Others?

As expected, the extent of implementation fidelity was 

affected by the context in which the organizational model 

was implemented in each medical center. Organizational 

factors were identified inductively from the accounts of 

implementation experiences provided in the medical 

center staff interviews. They were analyzed as force fields 

with some factors exerting positive influence and others 

negative influence. We grouped the emergent factors in 

three categories: urgency to improve hand-hygiene compliance, organizational environment, and improvement 

climate. Where there are systematic differences between 

high-fidelity and lower-fidelity groups, they are noted. 

Although we present the factors separately, in practice, 

they are overlapping and interrelated. 

Urgency to improve hand-hygiene compliance.

Organizational change is difficult, and without a strong impetus to move from the status quo, it is not likely to happen. 

As described above, not all the medical center leaders in the 

study accorded hand hygiene high priority for improvement. 

Four factors were most salient in determining whether they 

felt an urgency to improve hand-hygiene compliance. 

1) Infection control problems. An important impetus 

for change is a serious clinical problem or a performance gap—in the case of hand hygiene, an infection 

A 67.6 92.9 .67 .69 1.29 .00 .72

B 74.2 91.5 .48 .40 0.98 .00 .57

C 37.4 80.9 .92 .22 1.41 .01 .36

D 81.7 96.8 .52 .53 0.97 .00 .53

E 69.1 75.2 .14 .07 0.20 .11 .62

F 61.5 68.3 .14 -.27 -0.40 .47 .03

G 80.1 70.8 -.22 -.29 -0.47 .17 .08

Note. Bold font indicates data for high implementation fidelity sites (facilities A–D).

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 
 

Strengthening Organizations to Implement EBPs 243

outbreak. However, in the absence of an immediate or 

recent infection control problem, hand hygiene was not 

a natural top priority for many sites. 

2) External pressures for hand-hygiene compliance. External pressures are commonly cited as an impetus for 

change, particularly in the absence of a strong internal 

reason for change. In this case, The Joint Commission 

(TJC) was a motivator in several sites because they had 

upcoming surveys, and TJC gave considerable attention to hand hygiene in the latest survey round. New 

attention to Methicillin-resistant Staphylococcus aureus (MRSA) outbreaks in the health care environment 

also served as a pressure to change. Partway through 

the project, VA central office issued a directive requiring attention to MRSA. Several sites combined their 

hand-hygiene and MRSA initiatives, which gave added 

attention to hand hygiene. 

3) Source of the intervention. The source of the intervention in all sites was the network office. The network 

director and the chief medical officer—the leaders up 

the corporate ladder—sponsored this project. However, 

the responses to that source differed. For leaders in some 

medical centers, this gave the project legitimacy and, as 

a result, they pursued the project consistently and 

thoroughly. For others, the network sponsorship compromised the project because it did not emerge from 

local priorities or local identification of a problem. 

4) Competing priorities. Perhaps even more than that in 

the private sector, VA medical center leaders, who work 

in a national health care system, are bombarded with 

competing priorities from the network, the VA central 

office, and the Congress. Although all study sites faced 

this dynamic, they varied in the ways in which they 

responded to the myriad of demands. High-fidelity sites 

were able to focus despite the noise. They set priorities 

among competing pressures and had structures in place 

to enable them to delegate responsibilities but at the 

same time, by monitoring them, not let go of priorities. 

In two lower-fidelity sites, attention swung from one 

priority to another, and staff seemed overwhelmed by 

competing forces. A third lower-fidelity site faced particular problems with performance measures. 

Organizational environment. In addition to factors 

that affect the urgency to change, aspects of the broader 

organizational environment may influence model implementation. In some study sites, two factors were important: 

changes in leadership with the result that priorities were 

recast away from hand-hygiene improvement and budgetary pressures that made the resource requests for handhygiene efforts, although low, a barrier to improvement. 

Improvement climate. An organization’s experience 

with quality improvement and the values of improvement 

in the organization affected implementation through both 

their receptivity to the organizational model and the skills 

they brought to the initiative. Three improvement climate 

factors influenced implementation: 

1) Staff skills in and experience with quality improvement. 

Fidelity to the clinical redesign component of the organizational model was facilitated by staff capability with 

systematic quality improvement methods and projects. 

High-fidelity sites had a track record of having done improvement work before, with staff seeing the benefits 

of their work and getting recognition for their efforts, 

thus creating high staff morale around improvement. 

Lower-fidelity sites had neither the skills nor such a track 

record. As a result, improvement efforts were inconsistent and not given enough attention, often leading to 

poor results and low morale. Clinical redesign efforts 

were seen as extra work or unwelcome assignments. 

2) Organizational values for improvement. Beyond specific 

team skills and experience, an improvement climate 

reflects the values of an organization in fostering a 

culture that aims to embed quality and performance 

improvement in the way work is done. Medical centers 

varied in the extent to which quality improvement was 

core to their organizational values, with high-fidelity 

sites being more likely to have organizational values for 

improvement. In contrast, in other sites, systematic 

continuous improvement efforts were not built into 

their way of doing things. 

3) Psychological safety. Closely tied to organizational 

values, the concept of psychological safety is the extent 

to which staff feels safe speaking out and taking the risks 

associated with improvement, including both the initiative to try new ways of doing things and the chance 

of failing. High-fidelity sites were more likely to exhibit 

characteristics of psychological safety. 

Practice Implications and Discussion

This project offers multiple lessons for practitioners. First, 

improvement of the targeted evidence-based practice, handhygiene compliance, is enhanced by the presence of three 

components in the organization that leaders and managers 

can affect: active leadership commitment to improving the 

targeted practices, robust clinical process redesign to engage 

staff and to incorporate EBPs in routine operations, and links 

to management structures and processes to support, to align, 

and to integrate redesign. Medical centers with high fidelity 

to these components had consistently higher hand-hygiene 

scores at the end of the project and greater before and after 

improvement than medical centers with lower-fidelity. The 

premise underlying the study is that the presence of these 

components will facilitate the implementation of other 

evidenced-based practices also. 

Second, the three components interact to create synergies that contribute to improved performance. Links to 

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 
 

244 Health Care Management Review July–September • 2010 

management structures and processes are critical to turn 

personal leadership support into management actions, to 

align the redesign teams with organizational priorities, to 

hold the team accountable, and to provide practical support. 

Third, implementing the OTM components is not always easy. Fidelity of implementation to the organizational 

model varied despite an intervention strategy that was 

consistent across sites, indicating that existing features 

and resources must be taken into account to successfully 

change an organization. Although each medical center 

had its own array of factors that affected fidelity, some 

factors were common across sites. Sites that were best able 

to achieve implementation of the organizational model— 

and through that implementation to improve performance 

in hand hygiene—were those that shared the urgency to 

improve compliance with hand hygiene, had a positive 

improvement climate including staff experience and skills 

with quality improvement and organizational values for 

improvement, and to a lesser extent had no major aspects 

of the organizational environment that interfered with 

implementation, such as leadership changes or severe 

budget constraints. These factors suggest dimensions that a 

medical center might assess to determine the features on 

which it should build and those which must be overcome 

to implement the model components successfully. 

In addition to having implications for practice, the 

study also contributes to research on organizational change 

and implementation science. First, it provided an opportunity to test under new conditions an abbreviated version 

of the OTM that was developed observationally from the 

Robert Wood Johnson Foundation’s P2 initiative (Lukas 

et al., 2007). Our findings provide further validation for 

OTM: Although our model was not identical, the underlying concepts are the same. Second, the organizational 

model presented here complements other organization 

theories of implementation effectiveness. For example, 

Helfrich, Weiner, McKinney, and Minasian (2007) and 

Weiner, Lewis, and Linnan (2009) posit that implementation effectiveness begins with organizational readiness 

for change, which influences implementation policies 

and procedures that in turn influence implementation 

climate that leads to implementation effectiveness. The 

organizational model presented here offers additional understanding of and strategies for creating strong implementation policies and procedures and implementation 

climate through, for example, its emphasis on links to 

management structures and processes. The model is also 

consistent with the conclusions that implementation policies and procedures need to be highly contextual to successfully affect implementation climate (Helfrich et al., 

2007) and that antecedent conditions in an organization— 

its existing features and resources—must be taken into 

account in successful transformation (Harrison & Kimani, 

2008). Going further, it offers strategies for addressing the 

context, both through the elements of the organizational 

model and by offering an approach for understanding factors contributing to implementation success. 

As in most research projects, this study was not without 

limitations. An early design decision to build the project 

structure on local site capabilities presented research challenges, notably from the decision to rely on site staff rather 

than researchers to collect data on hand-hygiene compliance. Our aim was to work with sites on a data collection 

processes that would continue after the research project, 

an aim consistent with TJC requirements for handhygiene monitoring and with our broader intent to build 

lasting structures and processes into the site’s infrastructure. Because of this decision, there was a common core of 

data collected, but it varied in terms of the observer and in 

the number and frequency of observations. 

As we have highlighted, the study was conducted in the 

Department of Veterans Affairs. Although VA has some 

unique characteristics, it also shares many features with 

private-sector hospitals and health care systems. In this 

instance, the commonalities of organizational structures 

and clinical operations across medical centers offer a firm 

basis for generalizing study results to other health care 

settings, especially because the model studied was originally developed from experiences in private-sector systems. From this understanding, we can both draw practical 

lessons for future implementation efforts and contribute to 

the theoretical understanding of the dynamics of the 

implementation of EBPs. 

Acknowledgments

This study was funded by the Health Services Research 

and Development Service of the Office of Research and 

Development in the Department of Veterans Affairs (IMV 

04-055) and approved by the institutional review board 

of the VA Boston Healthcare System. Additional financial support was provided by the participating Veterans 

Integrated Services Networks. The authors acknowledge the contributions of the other members of the study 

team: the Veterans Integrated Services Network leaders, 

Jeannette Chirico Post, MD, Clyde Parkis, Michael Miller, 

MD, PhD, Barry Graham, MD, and Sheila Gelman, MD, 

MS; colleagues at the VA HSR&D Center for Organization, Leadership and Management Research, R. Zoe Le 

Van MacLaren, MSc, Jennifer Nguyen, MPH, Jason 

Silver, MPH, and Preet Ghuman; and Rita Kowalski, 

MS, and Robin Graff-Reed, PhD, at the VA National 

Center for Organization Development. The authors also 

acknowledge and appreciate the participation of leaders 

and staff in the VA medical centers in the study. 

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October–December � 2007 309

Transformational change

in health care systems:

An organizational model

Carol VanDeusen Lukas
 

Sally K. Holmes
 

Alan B. Cohen
 

Joseph Restuccia
 

Irene E. Cramer
 

Michael Shwartz
 

Martin P. Charns

Background: The Institute of Medicine’s 2001 report Crossing the Quality Chasm argued for fundamental

redesign of the U.S. health care system. Six years later, many health care organizations have embraced the

report’s goals, but few have succeeded in making the substantial transformations needed to achieve those aims.

Purposes: This article offers a model for moving organizations from short-term, isolated performance

improvements to sustained, reliable, organization-wide, and evidence-based improvements in patient care.

Methodology: Longitudinal comparative case studies were conducted in 12 health care systems using a

mixed-methods evaluation design based on semistructured interviews and document review. Participating health

care systems included seven systems funded through the Robert Wood Johnson Foundation’s Pursuing Perfection

Program and five systems with long-standing commitments to improvement and high-quality care.

Key words: alignment, health system change, integration, organizational change, transformation

Carol VanDeusen Lukas, EdD, is Senior Investigator, Center for Organization, Leadership and Management Research, Department of
 

Veterans Affairs, and Research Assistant Professor, Boston University School of Public Health, Massachusetts. E-mail: carol.vandeusenlukas@
 

va.gov.
 

Sally K. Holmes, MBA, is Project Coordinator, Boston University School of Public Health, and Investigator, Center for Organization,
 

Leadership and Management Research, Department of Veterans Affairs, Massachusetts.
 

Alan B. Cohen, ScD, is Professor and Executive Director, Boston University Health Policy Institute, and Investigator, Center for Organization,
 

Leadership and Management Research, Department of Veterans Affairs, Massachusetts.
 

Joseph Restuccia, DrPH, is Professor, Boston University School of Management, and Investigator, Center for Organization, Leadership and
 

Management Research, Department of Veterans Affairs, Massachusetts.
 

Irene E. Cramer, PhD, MSSA, is Project Manager and Investigator, Center for Organization, Leadership and Management Research,
 

Department of Veterans Affairs, and Research Assistant Professor, Boston University School of Public Health, Massachusetts.
 

Michael Shwartz, PhD, is Investigator, Center for Organization, Leadership and Management Research, Department of Veterans Affairs, and
 

Professor of Management, Boston University School of Management, Massachusetts.
 

Martin P. Charns, DBA, is Director, Center for Organization, Leadership and Management Research, Department of Veterans Affairs, and
 

Professor, Boston University School of Public Health, Massachusetts.
 

The project was funded by the Robert Wood Johnson Foundation through its evaluation of the Pursuing Perfection Program. It was approved by the
 

Institutional Review Boards at Boston University and the VA Boston Healthcare System.
 

Health Care Manage Rev, 2007, 32(4), 309-320

Copyright A 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 
310 Health Care Management REVIEW October–December � 2007

Findings: Five interactive elements appear critical to successful transformation of patient care: (1) Impetus to

transform; (2) Leadership commitment to quality; (3) Improvement initiatives that actively engage staff in

meaningful problem solving; (4) Alignment to achieve consistency of organization goals with resource allocation

and actions at all levels of the organization; and (5) Integration to bridge traditional intra-organizational

boundaries among individual components. These elements drive change by affecting the components of the

complex health care organization in which they operate: (1) Mission, vision, and strategies that set its direction

and priorities; (2) Culture that reflects its informal values and norms; (3) Operational functions and processes that

embody the work done in patient care; and (4) Infrastructure such as information technology and human

resources that support the delivery of patient care. Transformation occurs over time with iterative changes being

sustained and spread across the organization.

Practice Implications: The conceptual model holds promise for guiding health care organizations in their efforts

to pursue the Institute of Medicine aims of fundamental system redesign to achieve dramatically improved

patient care.

I

n 2001, the Institute of Medicine (IOM) released

the report Crossing the Quality Chasm: A New Health 

System for the 21st Century. Highly critical of the

U.S. health care system, the IOM argued that current

systems of care fail to provide Americans with the highquality health care system they need, want, and deserve.

To achieve safer, high-quality care, intensive efforts are

needed at all organizational levels to fundamentally

redesign systems of care (IOM, 2001). Today in 2007,

many health care systems are striving to respond to the

challenges of the Quality Chasm. Few, however, have

succeeded in making substantial transformations to

achieve the IOM aims. Using traditional quality improvement (QI) techniques, many have attained shortterm improvements in targeted areas through hard work

and focused attention. However, few QI efforts have

yielded sustained system change because they were not

supported by the culture and structure of the larger

organization (Repenning & Sterman, 2001; Rondeau &

Wagar, 2002). Transformational change, by contrast, is

pervasive and involves not only structures and processes

but also the inherent culture and values of the health

care organization (NHS Institute for Innovation and

Improvement, 2006).

The question, then, is how can health care systems

transform to provide consistently safe, high-quality care

for patients? We address this question by identifying

factors critical to successful system redesign, or transformation, from the experiences of 12 health care systems striving to provide superior—and in some cases,

perfect—patient care. Our work stems from the national

evaluation of the Pursuing Perfection (P2) Program, a

major initiative of the Robert Wood Johnson Foundation (RWJF) created in 2001 in response to the Quality 

Chasm. P2 health care organizations sought to achieve

dramatic improvements in patient outcomes by pursuing

perfection in all major care processes, with technical

assistance from the Institute for Healthcare Improvement (IHI), the national program office for P2.

The evaluation, which was aimed toward understanding the factors that contributed to (or impeded)

the health care systems’ abilities to achieve their

goals, drew upon theoretical constructs and disciplinary

perspectives regarding complex organizational change

(Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou,

2004; Grol, Bosch, Hulscher, Eccles, & Wensing, 2007;

Poole & Van de Ven, 2004). The initial conceptual

framework was based on research on microsystem

effectiveness—including concepts of communication,

coordination, organizational culture, and management

support and involvement (Donaldson & Mohr, 2001;

Nelson et al., 2002)—and on organizational diffusion of

innovation (Rogers, 1995). This framework reflected

IHI’s intervention strategy to focus first on achieving

perfect patient care in two clinical areas, then expand to

five areas, and finally expand to all areas. We also used

the IOM’s Quality Chasm aims (IOM, 2001) and the

Malcolm’s Baldrige National Quality Program guidelines

(2005) as frames of reference because many study

systems used them. The data collection strategy,

however, was designed to capture key system experiences, dynamics, and learnings that were not necessarily

emphasized in the original frameworks. The factors

reported here are those that emerged from the data as

most important in the systems that we studied.

This article offers a conceptual model for understanding how organizations move from short-term

performance improvements to sustained, organizationwide patient care improvements. The elements identified as critical to successful transformation have been

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Transformational Change in Health Care Systems 311

studied before. Our contribution lies in bringing them

together and sometimes extending their conceptual

basis, to show how they behave and interact in health

care systems striving for perfection.

Methods

Using a mixed-methods

ducted comparative case

systems over 3.5 years.

evaluation

studies in

design,

12 he

we

alth

concare

Study Sites

Participating health care systems included seven systems

that received RWJF funding (P2 systems) and five

systems that were selected initially to provide a basis

for distinguishing the effects of P2 participation from

other improvement efforts in the health care environment (expanded-study systems). The 12 systems are

described in Table 1. The P2 systems were selected

competitively by RWJF, with each receiving $2.4

million in funding over 4 years in addition to ongoing

technical support from IHI. The P2 systems are named in

Table 1 because their identities have been widely

publicized. However, they are identified as Sites A–G

throughout the article to protect the confidentiality of

their interviews. The expanded-study systems were

selected to exemplify organizations of different size and

complexity with long-standing commitments to QI, as

recognized through public ratings and professional

networks. Two systems received small P2 planning

grants but were not selected for implementation funding.

Expanded-study systems are identified throughout the

article as Sites H–L.

Data Sources

We used semi-structured interviews to conduct more than

750 sessions in the 12 systems over the 3.5-year study

period (2002–2005). We visited each system up to seven

times, conducting 5 to 21 interview sessions each time,

as shown in Table 1. Interviewees were selected to

obtain perspectives from across the organization and

included the following: the CEO; clinical executive

staff; senior QI manager(s) and staff; members of interdisciplinary QI project teams (e.g., middle managers, improvement staff, physicians, nurses, and other

frontline staff); representative frontline physicians and

nurses affected by improvement initiatives; and managers responsible for information technology, human

resources, customer service, and other business functions. Many interview sessions involved multiple participants. Except for the interdisciplinary team interviews,

individuals generally were interviewed with their peers.

Although we recognized the drawbacks of group interviews, we opted to talk with more people than would

have been possible with only individual interviews

because of the project’s broad scope. Two- or threeperson teams conducted interviews of 1 to 2 hr in length.

Altogether seven team members participated in interviews, rotating their assignments to visit as many

systems as possible while also ensuring that at least

one team member was present at consecutive visits for

each system. Detailed interview notes were taken

and subsequently transcribed. Materials provided by

the systems also were reviewed, including strategic

plans, improvement team workplans, team and

organizational performance measures, and communication materials.

Analytic Approach

We conducted longitudinal comparative case studies,

using an explanation-building analytic strategy applied

to build, test, and refine our conceptual model. After the

first three waves of interviews, we coded and sorted the

interview transcripts into descriptive meta-matrices

organized by domains specified in the earliest conceptual

model and by new themes that emerged from the site

visits. Consistent with Miles and Huberman’s (1994)

guidelines for comparative case studies, we first created

individual site matrices and analyzed them separately

before seeking cross-site explanations and then cycled

back and forth between analytic strategies to understand both case dynamics and the effects of key

variables. For each emerging domain, we added

questions to the interview guides for subsequent

rounds to enable further definition and refinement

of domains. This iterative process followed Denzin’s

interpretive synthesis approach of collecting multiple

instances and inspecting them for essential elements

(Miles & Huberman, 1994). As we gained deeper

understanding of each system’s approach to improvement and transformation over time, we were able to

validate domains and interactions between elements.

We further refined the model by presenting it iteratively to the study systems for feedback, validation,

and revision.

Finally, as the basis for a summary rating of model

presence in each system, each team member independently rated the system on each model element on a 1 to 5

scale (1 = no or negligible evidence of that dimension present,

5 = fully present). Cross-member ratings were reasonably

consistent, with consistency defined as all ratings being

within one or two adjacent points on the scale. We

aggregated scores across elements and averaged them

across raters to create a summary score of the extent of

model presence in each site.

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312 Health Care Management REVIEW	 October–December � 2007

Table 1

Description of study systems and data collection

P2 Systems Site Description

Number of

Site Visits

Interview

Sessions/Site

Visit

Cambridge Health	 Academically affiliated public health care system 7 7–18

Alliance	 in Cambridge, MA, area with 3 community hospitals,
 

20 primary care sites, and a city public health
 

department; 200–300 hospital beds and
 

approximately 3,500 employees; ethnically
 

diverse patient population with approximately
 

60% uninsured
 

Cincinnati Children’s	 Pediatric academic medical center in Cincinnati, 6 11–16

Hospital Medical Center	 OH, serving approximately 30 regional counties;
 

300–400 beds and approximately 6,000
 

employees; diverse racial and socioeconomic
 

patient population with 40% of children
 

below the federal poverty level
 

Hackensack University	 Academically affiliated hospital subsidiary of 7 8–16

Medical Center	 a health system, which includes 6 other satellite
 

locations serving patients in the greater
 

metropolitan New Jersey and New York area;
 

600–700 beds with approximately 7,000
 

employees and approximately 1,500 affiliated
 

physicians; approximately 5% of the county
 

population is below the U.S. poverty line,
 

4% receive Medicaid, and 6% receive
 

uncompensated care; approximately 25%
 

of the population is from ethnic minority groups
 

HealthPartners	 Nonprofit integrated care delivery and financing 7 8–13

system headquartered in the Minneapolis/St. Paul,

MN, area with 2 hospitals and approximately

50 clinics and practice locations; 1000 beds, 9,000

employees, and over 10,000 contracted providers

for approximately 700,000 members and 100,000

fee-for-service patients including recent immigrants

from Africa and Asia; approximately 20% of

patients are insured through Medicare/Medicaid.

McLeod Regional	 Nonprofit, academically affiliated multifacility 7 8–13

Medical Center	 health care provider in Florence, SC, serving rural
 

Pee Dee county with 500–600 beds, approximately
 

400 medical staff and 4,000 employees, approximately
 

25% of the population is below the poverty line,
 

and almost half are from ethnically diverse backgrounds
 

Tallahassee Memorial	 Flagship hospital of a nonprofit integrated health care 7 7–13

Hospital	 system including the hospital, a home health agency,
 

and more than 10 primary care clinics serving the
 

metropolitan Tallahassee, FL, area and surrounding
 

rural counties; around 800 beds and almost 4,000
 

employees; mixed demographic patient population
 

with approximately 25% below the poverty line
 

Whatcom County/	 County-wide collaboration of health care providers, 7 9–12

Peace Health	 including St. Joseph Hospital, part of the academic and
 

religiously affiliated Peace Health system, a number of
 

community health centers and physician group
 

practices and a nonprofit insurer in rural Washington
 

state; the hospital has 200–300 hospital beds and
 

approximately 1,700 employees including 300 medical
 

(continues) 

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Expanded-Study Systems

Transformational Change in Health Care Systems 313

Table 1

Continued

Site Description

Number of

Site Visits

Interview

Sessions/Site

Visit

staff; the patient population is overwhelmingly

Caucasian, and more than 60% are insured through

government health care programs

Expanded-Study Systems

H Physician-led integrated health care system in a relatively 5 8–12

rural part of a midwestern state, part of a larger

academically affiliated medical system; hospital has

300–400 beds and almost 200 physicians serving

patients with a median household income of

approximately $30,000 and little ethnic diversity

I Religiously affiliated medical system of approximately 2 15–21

20 hospitals and 2 nursing homes in 4 Midwestern

states with approximately 5,000 affiliated physicians

and 24,000 employees

J Hospital that is part of a nonprofit, academically 3 10–16

affiliated regional health care system in a rural area

of a midwestern state; the hospital serves patients

from 32 counties with approximately 400 beds and

400 affiliated physicians

K Academically affiliated health system including 3 13–18

multispecialty group practices, approximately

30 ambulatory care facilities, and a major hospital

with 900–1,000 beds and a staff of approximately

4,000 (including 1,000 physicians) located in a

midwestern urban area serving a patient population

consisting of approximately 90% African Americans

L Academically affiliated nonprofit health care 1 5

system consisting of approximately 20 hospitals,

2,000–2,500 beds, approximately 2,500 employees

serving patients in 1 urban area and several

rural areas in a western state

Note. P2 = Pursuing Perfection.

Model Overview: Framework for

Organizational Transformation

In the P2 program, RWJF and IHI translated the Quality 

Chasm’s aims into a standard of perfect patient care,

emphasizing patient-centered care driven by the needs

and preferences of patients rather than by professional or

organizational judgments. Although none of the 12

study systems achieved perfect care for all patients

during the 4-year grant period, most made substantial

progress in improving clinical performance in targeted

areas, and some made notable strides in redesigning

systems to support broader organizational changes.

From our analyses of all 12 site experiences, we

identified five elements, or key drivers, that appear

critical to a health care organization’s success in moving

to sustained, highly reliable, evidence-based improvements that ultimately lead to patient care transformation across the organization. Through the comparative

case study analysis, we recognized experiences of the

expanded-study systems that fit the same model as

those of the P2 systems. Although some factors played

out differently in the expanded-study sites, the same

factors appeared critical to transformation. Therefore,

we present findings from all 12 systems together rather

than contrasting them as would be done with a usual

comparison group.

The five critical elements, shown in Figure 1, include

the following: (1) Impetus to transform; (2) Leadership 

commitment to quality; (3) Improvement initiatives that

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314 Health Care Management REVIEW October–December � 2007

Figure 1

Key elements of organizational transformation to deliver high-quality patient care

actively engage staff in meaningful problem solving; (4)

Alignment to achieve consistency of organization-wide

goals with resource allocation and actions at all levels of

the organization; and (5) Integration to bridge traditional

intra-organizational boundaries between individual

components.

In highlighting these factors, we run the risk of

presenting them as isolated and static. In reality, these

elements effect the transformation by driving change in

complex and dynamic health care organizations. As

illustrated inside the dotted circle in Figure 1, we define

the organization—or network of organizations comprising the system—in terms of four basic components: (1)

Mission, vision, and strategies that set its direction and

priorities; (2) Culture that reflects its 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, human resources, fiscal services, and facilities management that support the

delivery of patient care. Changes in these four components reflect the transforming health care system.

Transformation occurs over time, as illustrated by the

shadow boxes and diagonal line, leading to changes that

spread across the organization and are sustained.

We expand here on the five model elements and

their interactions, providing examples to illustrate each

element in practice and how it interacts with other parts

of the organization.

Key Drivers: Elements of the Model

Impetus to Transform

Each study system had a strong impetus to change. In

Figure 1, impetus appears outside the organization to

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Transformational Change in Health Care Systems 315

emphasize external pressures for change that often were

strongest. However, in some cases, impetus for change

came from within the organization and often was

stimulated by multiple factors.

Among P2 systems, each reported that its P2 grant

was a major driving force behind its improvement

efforts. Although most systems had well-defined improvement programs in place by the time that P2 began,

the program brought renewed focus. For systems with

serious financial challenges, P2 funding contributed

importantly to their improvement efforts. For all P2

systems, however, the prestige and visibility engendered

by P2 seemed more important than the financial gain.

As one senior manager in Site F said,

Pursuing Perfection gives legitimacy to the [clinical improvement] efforts... by building a coalition of people... and hopefully having a lasting

impact. It provides a focus and gives a framework

for changing culture in different parts of the

organization... P2 challenges us to think about the

next level. We are better thinkers than before...

Among the expanded-study systems, the impetus for

change varied. For example, in Site I, the impetus was

the recognition by system leaders that organizational

performance had plateaued and that the Baldrige

Award criteria provided a framework for linking clinical

improvement efforts with the organization’s business

strategy. The Baldrige application process, with its deadlines and feedback opportunities, also created a powerful urgency to change. In contrast, in Site J, medical

errors created urgency. The institution was stunned

when one of its own physicians suffered a medication

error while undergoing treatment. This sentinel event

spurred the leadership to action.

Regardless of its source or nature, the impetus had to

be sustained within the organization to motivate and

engage staff in ongoing change efforts. Senior leaders

shaped their system’s response to the impetus by setting organizational priorities and choosing the best

strategy around which to rally the entire staff. They

also engaged staff in change efforts by communicating

about performance gaps, by holding staff accountable

for improvement goals, and by actively participating

in change-oriented activities.

Leadership

Leadership commitment to quality and change—

beginning at the top of the organization but including

all levels—was a critical element for organizational

transformation. In Figure 1, leadership is shown in the

upper left corner to reflect the importance of senior

leadership promoting change down through the

organization.

In our study systems, senior leadership drove change in

two ways. First, senior leaders steered change through the

organization’s structures and processes to maintain

urgency, set a consistent direction, reinforced expectations, and provided resources and accountability to

support change. They set the path for other model

elements and for the interactions among those elements in the larger organization. Second, to create the

climate and momentum for dramatic improvement

in patient care, leaders needed to demonstrate authentic passion for and commitment to quality. Many

expended significant personal capital to inspire and

motivate staff, often leading by example through personal

involvement in QI efforts. At Site D, for instance, the

CEO spoke of engendering an ‘‘edgy, impatient culture’’

around patient care quality. Although QI operations

were led by a highly effective physician leader, the

CEO remained personally involved, both as a champion

for a clinical improvement team (despite not being a

clinician) and as a member of the quality integrating

committee. The CEO also worked actively behind the

scenes to clarify expectations and to resolve problems.

Leadership involved more than the CEO. Engagement of the larger senior leadership team provided

important linkages and facilitated cultural change

throughout the organization. At Site F, the full senior

leadership team (including the CEO) began each day

with patient rounding in which team members asked

patients and frontline staff specific questions about their

experiences and then engaged in a debriefing session to

resolve identified issues. Senior leaders also were required to serve as champions for improvement projects,

with responsibility for linking the team to other senior managers who could help to resolve barriers.

Although leadership strategies began at the top of

the organization, improvement was greater when middle

and frontline managers were also committed to quality,

being actively involved in supporting process redesign,

and wholly aligned around the importance of QI. One

strategy used in several systems was to include in improvement teams process owners who had operational

responsibility for redesigned work processes. Their

participation in the change process allowed them to

successfully implement new work methods developed

by the teams.

Improvement Initiatives

Targeted microsystem improvements were central to

IHI’s strategy in P2. Expanded-study sites also were

committed to a strategy involving improvement initiatives, which are shown in the center of Figure 1 to

signal their importance to transformation. Improvement initiatives contributed to transformation in at

least three ways.

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316 Health Care Management REVIEW October–December � 2007

First, these initiatives, such as clinical redesign,

improved operations. Those with sustained impact

progressed beyond short-term improvement to build into

routine work new practices that were visible, easier to

perform, more reliable, and more efficient than old

practices. Leaders in Site F, for example, found that

improvement changes did not stick once special project

resources were removed unless the system itself changed.

In a surgical infection project, the site initially improved

prophylactic antibiotic use through the use of guidelinebased reminders and education but changed its approach

after performance plateaued. To reach a zero-defect level,

the site reengineered its practices to provide patients with

antibiotics at a specific moment in the preoperative

process signaled by explicit physical cues. As a result, the

site attained consistently high performance without

additional resources.

Second, improvement initiatives actively engaged

staff across disciplines and hierarchical levels in problem

solving around a concrete, meaningful, urgent problem.

In the study systems, such engagement resulted in skill

development, a newly honed sense of inquiry and problem solving, and more rigorous use of data. Equally

important, engagement in problem solving generated

a palpable sense of enthusiasm and accomplishment.

As on person in Site F said,

It was very rewarding to see how excited staff and

physicians were about making these changes. It

became a competition; it was fun and we celebrated

successes, in part by posting the successes... It is part

of the ‘pull.’ Doctors, respiratory therapists, etc. travel

to all units and communicate ‘what’s doing’ to other

units. If it is good, people say ‘why can’t we have that?’

Third, successful initiatives built momentum for

further change and improvement. They contributed to

culture change when the clinical focus for improvement was aligned with the organizational mission and

strategic direction, was an area needing improved

performance, and had scientifically valid evidence on

which to base redesigned practices. Projects included

improving clinical care for patients with acute conditions, such as heart attack or stroke, and with chronic

conditions, such as asthma. Such projects engaged clinical staff because of their unmistakable clinical importance and because of the momentum built by

incremental, short-term gains.

Alignment

Alignment, as defined in the Baldrige framework

(Baldrige National Quality Program, 2005), refers to

consistency of plans, processes, information, resource

decisions, actions, results, and analysis to support key

organization-wide goals. An important factor in

successful organizational change, alignment is represented in Figure 1 as a vertical line to signify its role

in moving work at all levels of the organization in a

consistent direction.

The study systems used different methods to convey

their messages to ensure consistent visions and purposes

across the organization. The leadership at Site D, for

example, identified 18 corporate strategies that defined

the organization’s direction and priorities. Staff members throughout the organization became familiar with

these strategies and their meaning.

Effective alignment required not only shared understanding of purposes and goals but also deployment

of resources to reinforce the behaviors, operations, and

processes that supported organizational goals Study

systems varied in how they accomplished this deployment, with several actively employing the Baldrige

framework to create highly aligned priorities. In most

systems, though, organizational priorities were translated

into department goals for which managers were held

accountable. Some systems carried alignment down

to the front line of the organization. Site I, for instance,

cascaded its organizational objectives to the front

line through individual employee goals, with each

employee expected to maintain a document containing

position-specific goals that were measurable, timedependent, and aligned with department and organizational goals. To illustrate, a nurse on a patient unit

might have an individual goal of responding to patient call requests within y minutes to support the

unit goal of improving patient satisfaction scores by

xpercent to support the organization’s overall patient

satisfaction goal.

Aligning goals down to the level of individual employees was challenging for most organizations. As one

manager in Site F expressed it,

We need to do a better job of connecting our frontline supervisors to our plan, connecting the dots.

We are creating a web or a map so we can easily

update each other on where we are relative to our

30-40 [quality and other strategic] initiatives.

Accountability was a key aspect of alignment,

ensuring that behaviors, operations, and processes

were, in fact, aligned to support organization-wide

goals. All study systems used performance measures in

some form to encourage alignment. In some cases,

managers’ performance evaluations and bonuses were

tied to their performance on strategic quality

measures and, in a few systems, these measures were

a component of physician compensation.

Even so, most systems admitted that effective alignment

and accountability were difficult to achieve. Site E managers acknowledged that a high-level goal not met in a fiscal

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Transformational Change in Health Care Systems 317

year was not likely to incur penalty or corrective action;

instead, the goal simply was moved to the next year.

Integration

Integration across traditional organizational boundaries

occurred at a later stage of transformation in our study

systems. Consistent with the Baldrige framework, integration was needed to break down and bridge boundaries between individual components so that a system

operated as a fully interconnected unit to support

organization-wide goals (Baldrige National Quality

Program, 2005). In Figure 1, integration is represented

as a horizontal line to signify the importance of working

across intra-organizational boundaries. In our model,

integration is a multifaceted concept that applies to all

organizational levels and is both an end state for a highperforming system and a strategy for transformation. As

a strategy, integrating structures and processes can

facilitate the spread of improved clinical practices across

the organization.

All study systems worked to integrate clinical care to

improve coordination and continuity of care. At the front

line, extensive work on patient flow, case management,

and electronic support systems (e.g., clinical reminders

and registries) was aimed toward improving care for individual patients or populations. Several study systems developed comprehensive planned care models to integrate

patient care processes across workgroups, microsystems,

or the entire organization. Some systems used service

lines to integrate providers and support staff to improve

coordination of patient care. However, some service line

structures also created new silos, integrating care within

the lines but impeding integration across them.

Also at the front line, all systems facilitated care

integration through multidisciplinary improvement

teams that encouraged communication and problem

solving across work units. However, by themselves,

improvement teams ran up against the limits of

traditional intra-organizational boundaries. Often teams

could not obtain the commitment of resources or the

cooperation from other departments needed to effect

change. Without such collaboration, improvement efforts could not fully make the changes necessary to

address sources of problems and to build improvement

into the organization such that lasting change occurs.

For example, some study systems working on

medication errors were unable to acquire resources

to implement new technologies, such as bar coding,

which resulted in less than fully effective workarounds.

To move beyond the limits of a team’s or service line’s

authority and resources, integration alsowas needed atthe

systems or organizational level in the form of structures

and processes that involved managers with decisionmaking authority and responsibilities spanning the organization. However, integration at these high levels in

our study sites appeared to be more difficult to achieve. As

one manager in Site G expressed it,

Getting people to talk to each other, breaking down

silos, and getting people to work across units [is

frustrating]....Hospitals really do have silos and

they are there for good reasons. What would be

ideal is a tunnel that goes all the way across that

would allow us to share each other’s goals. You need

a dynamism that takes people out of the structure

and creates a new way of doing things.

A deliberate focus on integration often occurred after

an organization had learned to do redesign work and to

address alignment. Many study systems used quality

management steering committees to address crossorganizational issues in high-priority QI efforts, but

only a few moved beyond integration around improvement projects to build integration into the way they

worked by using standard or newly invented management structures. Site D, for instance, redesigned its

horizontal management structures to create multidisciplinary groups responsible for care processes defined by

patients’ experiences (e.g., inpatient, outpatient, and

emergency care teams). In addition, an integration

committee staffed by senior leaders, including the CEO,

addressed redundancy, conflicts, and the spread of best

practices across groups. Site D saw these structures as

transitional, recognizing inconsistencies with other

structures in the medical center.

A Dynamic Model: Interaction
 and Iteration
 

The five critical elements of the model did not operate

in isolation. Rather, they occurred in and through

the context of complex and dynamic health care

organizations. Substantial systemic change required

interaction of the key elements with one another and

with the rest of the organization, as illustrated in

Figure 1. Our model shows the interconnections among

elements that support transformational change, as called

for in the Quality Chasm (IOM, 2001).

To illustrate the importance of these interactions, we

found that improvement initiatives were unlikely to be

sustained or spread across the organization if they were

not linked to the organization’s management structure

and work processes. Structures and processes to create

alignment and integration were critical to establishing

those links. When an improvement initiative was

aligned with the organization’s priorities and strategic

direction, senior managers were more likely to provide

the needed infrastructure resources (e.g., staff time,

funds, and data systems) and to hold staff accountable for

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318 Health Care Management REVIEW October–December � 2007

making necessary changes. Alignment also increased the

likelihood that specific redesign would build momentum

for further change as staff understood how their roles

in achieving project objectives contributed to larger

organizational goals. Integration facilitated redesign efforts by ensuring that all parts of the organization affected by redesign engaged in the redesign process, by

fostering implementation through shared lines of communication and authority, and by resolving conflicting

priorities and needs when multiple improvement projects

affected common systems. This fundamentally changed

how work was done throughout the organization, an

important building block of sustainability.

Alignment and integration also interacted with each

other. For example, Site D integrated its horizontal

management structures around care processes and defined

key priorities that cut across the horizontal management

groups. To create alignment, each horizontal group was

expected to address for each key priority how the group

would contribute to meeting organizational goals and

would collaborate with other groups. In our view, study

systems that addressed alignment and integration at this

level of the organization had a more advanced understanding of the need for consistency and interconnectedness throughout the organization. Even so, these

organizations had not perfected an integrative approach.

Although Site D had been developing its approach for

almost 2 years, it still believed that it was a work in

progress. The evolving integration structures sometimes

conflicted or were redundant with traditional structures

that remained in place. Patient safety, for instance, was a

priority addressed by the horizontal integrating groups,

but there was tension with the Patient Safety Committee’s plans.

To achieve transformation, the five elements not

only interacted with each other but also drove change

through the organization’s mission, culture, infrastructure, and operations. For example, some improvement

initiatives interacted with the organizational infrastructure, such as information technology. Thus, infrastructure development ensured that organizational resources

were in place to support improvement initiatives, but

improvement projects also led to infrastructure enhancements. For example, in Site B, the medication reconciliation project stimulated the development of an

online, interactive tool for patient use, and in Site G,

work on patient flow triggered the design of an

automated bed availability board to facilitate patient

movement from the emergency department (ED) to

the floor.

Improvement initiatives also interacted with other

care processes, stimulating the spread of change across the

organization and its incorporation into regular practices.

Site F’s first project involved work with county ambulance staff to improve triage of acute myocardial

infarction (AMI) patients entering the hospital ED.

These changes stimulated the broader redesign of ED

processes for acute myocardial infarction patients, which

led, in turn, to redesigned processes for patients coming

to the ED with other conditions.

In addition to being interactive, organizational transformation was iterative. Individual improvements fed

into one another and occurred over time. Making one

system improvement often set the stage for others

or uncovered new problems or opportunities requiring attention.

Conclusions

Based on interviews and discussions with 12 health care

systems actively working to transform their organizations,

we identified five elements that appear to be critical to

successful organizational change to improve patient care.

Other factors, such as effective communication, contribute to and are necessary for successful change, but the five

identified elements were most prominent in driving the

study systems toward transformation.

Progress toward transformation was consistent with

the model in all study systems, although the model was

more evident in some systems than in others and no

system had fully implemented all elements. The model

fits across different types of health care organizations.

Although the P2 initiative accelerated transformation

efforts, the factors affecting the transformation in P2

systems were not systematically different from those in

the expanded-study systems.

Our conclusion that the model reflects key factors

associated with successful transformation is supported by

preliminary findings from a survey of staff in eight study

systems (seven P2 systems and one expanded-study

system), to be reported in a separate article. The analyses

show that systems with stronger presence of model

elements also scored higher on survey items reflecting

progress to transformation, including ratings of patient

care quality in the organization and judgments regarding

the impact ofthe organization’sQI efforts on productivity/

efficiency, patient outcomes, medical errors, and staff

involvement in QI efforts.

Each of the five model elements is supported by a substantial literature. The principal contribution of this

article is the finding that all five elements are needed

for organizational transformation that substantially improves patient care. Transformation occurs when the five

factors interact with each other over time and drive

change through the larger organization. The article

adds to the growing literature on multilevel theories

of change and innovation (e.g., Poole & Van de Ven,

2004). For example, it extends the multilevel framework

of Nelson et al. (2002), which focuses on clinical

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Transformational Change in Health Care Systems 319

microsystems as an essential building block of system

transformation, by elaborating on the nature of the links

between the microsystem and the larger organization.

As another example, it extends the multilevel system

redesign framework of Wang, Hyun, Harrison, Shortell,

and Fraser (2006) by adding integration and alignment as

important elements to direct and coordinate work across

the multiple levels of the system.

One limitation of the study is the lack of a common

set of clinical performance measures across systems that

might serve as indicators of success in improving patient

care. All P2 systems began with specific objectives, but

the project content, goals, and metrics were site-specific

and often changed over the life of P2. The evaluation

would have benefited from shared clinical measures, but

any such measures would not have equally reflected the

priorities of participating systems and thus would not

have evaluated them on a level playing field.

Another study limitation from some perspectives is

that it focused on 12 leading systems that were committed

to making major changes to improve patient care. By

design, our evaluation tracked attempts at transformation under the most favorable conditions. However, we

recognize that many health care systems are not at the

same stage of organizational readiness for change. We

did not study the processes by which an organization and

its leadership decide to engage in transformation. Further research is needed in this regard to understand

the motivation behind major system redesign and the

capabilities necessary for the transformation journey.

Practice Implications

Transformation of health care systems is a complex and

difficult undertaking. The P2 systems had the advantage

of sharing ideas and working with IHI, but no system

had a roadmap for achieving perfect care, and each

learned as it went along. Their experiences, however,

provide important lessons that can facilitate the process

in other systems.

First, each model element as described earlier in the

article offers direct practice implications for system

managers seeking to change their systems to improve

patient care.

Second, however, no single element is sufficient to

achieve organizational transformation. For example,

successful improvement projects can contribute importantly to improved quality, but improvement projects

alone do not ensure sustainability of the improvements,

including the spread of core values and expectations, the

engagement of staff in delivering near-perfect care, and

the skills and methods for achieving it. Managers should

recognize that all model elements need to be part of

organizational transformation and that the challenge is

to maximize the likelihood that the elements and the

organization will interact 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.

Third, successful transformation takes time. All study

systems acknowledged that transformation (and the

attainment of near-perfect care) most likely unfolds

over a decade or more. No study system became fully

transformed in the sense that values and expectations

for near-perfect care were completely shared or that

organizational functions operated to achieve near-perfect

care in all major care processes. Although many systems

demonstrated considerable progress, they described

transformation as a continuing journey with no fixed

end point. They argued that changes and adaptations

always are needed to stay abreast of the volatile health

care environment and the discovery of new areas for

improvement. Clearly, organizations embarking on this

journey require persistence and constancy of purpose.

Although based on 4 years’ experience in only 12

health care systems, the conceptual model nonetheless

holds promise for guiding other organizations in their

efforts to pursue fundamental system redesign for

dramatically improving patient care. In the meantime,

we continue to test and refine the model through further

research, including a Veterans Affairs-funded project

that assesses the implementation of model elements to

support the use of evidence-based practices and a second

RWJF-funded project to validate the model in other

health care systems.

Acknowledgments

The project was funded through a grant to the Boston

University School of Public Health from the Robert

Wood Johnson Foundation. An earlier version of the

paper was presented at the 8th Health Care Organizations Conference in Los Angeles in June 2006. The

authors gratefully acknowledge the cooperation and

insights of the 12 participating systems and the P2

Program Office at IHI, the guidance and support of

Linda Bilheimer and Lori Melichar at RWJF, and the

comments of colleagues and two anonymous reviewers.

They also thank Laney Bruner-Canhoto, Barbara

Lerner, Ledia Tabor, Spenser Weppler, and Maureen

Festa for their research assistance.

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