VHA Systems Rede

A Plan for Organizational Tran

VHA Systems Rede

A Plan for Organizational Tran

Mike Davies, MDNational Director of Systems 

Mike Davies, MDNational Director of Systems 
VHA 

... “Honor America’s Veteran

providing exceptional healththat improves their health abeing...” 

...

“Honor America’s Veteran

providing exceptional healththat improves their health abeing...”
Quality Im

“Unceasing efforts of everyone....to 

changes that will lead to better paoutcomes (health), better system performance (care) and better prodevelopment (learning)... 

“Unceasing efforts of everyone....to 

changes that will lead to better paoutcomes (health), better system performance (care) and better prodevelopment (learning)...

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Download
Central Office Suppor

What

Policy & Program 

Development

How Much

Measurement and Analysis

Im

Patient Care

Services

S

R

Quality &

Safety
Systems Redesign 

Burning

platform

Pockets

of

Success

Linked

Success

Le

O

•Education•Awareness

•Learn•Do

•Connect Success•Engage Value Stream

Engagement of People Re-Designin

Improvements measured in: Years Months Days Hours Min

“Having the spirit to endure the training is the first step on the road to winning.”

-- Taichi Ohno

Slide Adapted from B
National

Systems Redesign

Steering Committee

National

Systems Redesign

Program Office

Leadership/

Management

Inpatient Outpatient Administrative

Deputy Under

Secretary for Health

For Operations & Management

VHA Systems Red

Education Sub-committee
Systems Redesig

Strategic Object

• VHA has a culture of continuous 

and learning

• VHA leadership is competent and 

leading SR 

• VHA organization/leadership has 

knowledge understanding of SR

• VHA is actively engaged in SR to 

“organizational transformation

”
SR Outpatient 

Sub-committee

• Mental Health Access Collabor

– 115 Teams– LS 3

• Access Partnership

– In planning stages

• Specialty Care Improvements

– Committee formed – Survey of support staff and proc
Accomplishments 

Outpatient

• Outpatient:

– Facilitated the organization of the Access Partnership. – This effort connected 29 teams from the lowest performing outpat

29 teams from the best performing facilities

– Access list was reduced from 109,090 patients waiting Oc

patients waiting Sept 15, 2008 (a difference of 59,347 few
Accomplishments co

No Veteran Left Behi

• No Veteran Left Behind: (NVLB)• Collaborated with Primary Care, PCS, to create new No Veteran Left B• NVLB II was launched later in 2008 and includes patient satisfaction w

• 95% of primary care sites at >95% new patients within 30 days by Apri

• Eliminate Primary Care EWL by April 1, 2009 and keep it at zero throug

• New patient satisfaction (“Were you able to get an appointment as soo

by July 1, 2009

NVLB Result s: % New PC Patients Seen < 3 0 Da ys (NVLB began in April 07)

50%55%60%65%70%75%80%85%90%95%

100%

Oc t-04

Dec-04

Fe b-05

A p r-05

J un -05

A ug -05

Oct-05

D ec-05

F eb -06

Ap r-06

Jun-06

Aug-06

Oct-06

Dec-06

Fe b-07

A p r-07

J un -07
Some Outpatient Q

• Ideal measurement of delay• Ideal support staff

– Numbers/roles/tasks– Teamwork/integration

• Strategies to decrease NS’s• New models of care for Chronic • Sustaining access• Best contingency plans
SR Inpatient 

Sub-committee

• Collaboratives (45 hospitals each)

– PFC – Patient Flow Center– TLC – Transitioning Levels of Care– BCC – Bedside Care Collaborative

• Initiatives

– Partner with Office of Q & S on Util– Partner with PCS on Policy Develo
Systems Redesign 

Accomplishments

• Inpatient Flow:

– National improvement 

effort focused on inpatient flow. 

– Five collaborative regions 

with 35 hospitals

– ICU: Improvement in Observed Minus 

Expected Length of Stay (OMELOS) of 0.3 days across the system. This translates to about $110,250,000 for ICU ( -0.30 days /patient X 105,000 patients X $3500 / day). Some directly saved from the bottom line – for example patients who are able to be transferred to VA from the community, saving fee basis outlays. Some is savings of direct cost (supplies and personnel). Some of this is mission expansion (ability to accept more patients for VA care who otherwise would go elsewhere).
Accomplishments c

Inpatient Flow

• Medicine and Surgery Wards: 

– Reduction in both operative and non-operative LOS OMELOS 

– Savings of 143,100 Bed Days of Care on 530,000 admissions, wh

$98,000,000 ($684.75/day X 143,100 days). 

– Direct savings from the bottom line – for example patients who ar

VA from the community, saving fee basis outlays. Some of this is 

(supplies and personnel). Some of this is mission expansion (abi

for VA care who otherwise would go elsewhere). 
Accomplishments 

Inpatient Flow

• Discharge Timeliness

– Improved overall through the efforts of the FIX Collaboratives 

– Shift of discharges to earlier in the day

– Contributing to improvements noted above in inpatient flow.
Some In-Pt Questi

• Best hospital/network flow manage

system?

• Optimal contingency plan for each t

supply?

• Nurse care that leads to better outc• Best way to do Multidisciplinary Ro• Shift handovers• Admission and discharge planning• Ward “schedule” or rhythm
SR Administrative 

Sub-committee

• HR Recruitment Collaborative

– 145 Teams– LS 1 and 2 Virtual – Now LS 3 is regional

• Telephone Care Collaborative 

CMO/QMO’s and Primary Care
SR Leadership/Manag

Sub-committee

• New Patient Experience

– Targeting March– Coordinated new patient improve

request through the first visit to V

• ECF Assessment Center
SR Systems Improve

Sub-committee

• Improvement Capability Grants - Enhanc

Improvement Infrastructure and capability

– Fund 10 projects in FY 2009 ($500,000 X 3 Years– Fund 20 additional projects in FY 2010 ($450,0– ROI Analysis– Spread in 2011

• Knowledge Sharing Portal • National Improvement Initiatives (700+)• Evaluation

– Tools (Collaboratives, Performance Measures

Projects)

– Tool Kits (Self-Evaluation Tools)– Improvement Capability Grant Project and Ten 

and ROI)
Veteran Enginee

Resource Centers (

• Request for Initiative had 24 re• 9 invited to submit formal RFP• Selection of 3 VERCs in June, • Competitively funded to work in 

national priorities (projects will research apps)

• VERC’s linked to SR Sub-comm• Partner with engineering Acade

institutions
Other SR Initiativ

• Cancer Care Improvement Collabo

– Building from C4 work– 20 teams selected to improve timeline

of cancer care

• Surgical Tri-VISN Collaboratives

– About 1⁄2 of VISN’s involved– Felt to be quite successful

• IHI Triple Aim• RPIW Training• A 2nd National RPIW Activity
Model C

• Transformational Change - in H

Care Systems: An organization

– Impetus to Improve (Will)– Leadership– Improvement Initiatives– Alignment– Integration

VanDeusen LukaRev 2007, 32(4), 

ReferencTransforin Health An organ
Model C

• Impetus to Improve (Will)

– From unique history– Sense of urgency

• Leadership

– Commitment– Passion– Personal Involvement– Involve all levels of leadership

VanDeusen LuRev 2007, 32(4
Model C

• Improvement Initiatives

– Must re-engineer not just do a pr– Must be important work– Successful initiatives build mome

• Alignment

– All levels with shared understand– Match resources with goals– Meaningful employee goals and 

VanDeusen LuRev 2007, 32(4
Model C

• Integration

– Across patient clinical care need

professions

– Cooperation of all departments

FINALLY: 

MUST HAVE ALL 5 TO TRAN

VanDeusen LuRev 2007, 32(4
• Team

• Aim• Map• Measure• Change• Sustain

• Team• Aim• Map• Measure• Change• Sustain

VHA Improvement 

See Attached W

Paper 

Microsoft Word 

Document
What’s Next 

FY 2010

• FY 2010 Planned Conferences

– Chronic Disease Heart Failure C

(Partnering with OQP, PCS)

– FIX Collaborative (s)– Transforming Flow in Mental Hea– Smoothing Veteran Transitions C

(Partnering with Office of MH) 

– Improvement Forums
Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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.

October–December  2007 309

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

Copyright A 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

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.

Key words: alignment, health system change, integration, organizational change, transformation
Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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

310 Health Care Management REVIEW October–December  2007
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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 evaluation design, we conducted comparative case studies in 12 health care

systems over 3.5 years.

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.

Transformational Change in Health Care Systems 311
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Table 1

Description of study systems and data collection

P2 Systems Site Description

Number of

Site Visits

Interview

Sessions/Site

Visit

Cambridge Health

Alliance

Academically affiliated public health care system

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

7 7–18

Cincinnati Children’s

Hospital Medical Center

Pediatric academic medical center in Cincinnati,

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

6 11–16

Hackensack University

Medical Center

Academically affiliated hospital subsidiary of

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

7 8–16

HealthPartners Nonprofit integrated care delivery and financing

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.

7 8–13

McLeod Regional

Medical Center

Nonprofit, academically affiliated multifacility

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

7 8–13

Tallahassee Memorial

Hospital

Flagship hospital of a nonprofit integrated health care

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

7 7–13

Whatcom County/

Peace Health

County-wide collaboration of health care providers,

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

7 9–12

(continues)

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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

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

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

5 8–12

I Religiously affiliated medical system of approximately

20 hospitals and 2 nursing homes in 4 Midwestern

states with approximately 5,000 affiliated physicians

and 24,000 employees

2 15–21

J Hospital that is part of a nonprofit, academically

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

3 10–16

K Academically affiliated health system including

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

3 13–18

L Academically affiliated nonprofit health care

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

1 5

Note. P2 = Pursuing Perfection.

Expanded-Study Systems

Transformational Change in Health Care Systems 313
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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

Figure 1

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

314 Health Care Management REVIEW October–December  2007
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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.

Transformational Change in Health Care Systems 315
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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

316 Health Care Management REVIEW October–December  2007
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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 also was needed at the

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

Transformational Change in Health Care Systems 317
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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 of the organization’s QI 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

318 Health Care Management REVIEW October–December  2007
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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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320 Health Care Management REVIEW October–December  2007
Systems Redesign Framework for Improvement 

(TAMMCS) 

There are many successful “ways” to approach or frame the improvement journey. 

Depending on the philosophical approach to improvement that people have experienced 

in the past, staff may have different comfort levels with the approach and language used. 

In order to keep VA improvement communities speaking the same language, at this point 

in history VA Systems Redesign will use a straightforward non-branded framework that 

identifies the basis steps and tasks in a logical order. This improvement framework is 

(the almost unpronounceable) “TAMMCS” which means Team-Aim-Map-MeasureChange-Sustain. It could be referred to as the Improvement Framework. This document 

will explain each of these components. 

Prework/planning 

Before using this framework, please remember this improvement framework approach 

assumes that there is an improvement topic already chosen. The process of identifying, 

prioritizing and choosing these topics are beyond the scope of this paper. In addition, 

any improvement approach can be utilized more-or-less formally by a larger-or-smaller 

group, and in a short-or-longer timeframe. For example, a chartered collaborative may 

use this same framework and occur over 6 to 18 months of time, while a Rapid Process 

Improvement Workgroup (RPIW) could play out within one week or a “deep dive” could 

occur in a single day. TAMMCS is a touchstone, or organizing framework that can be 

useful in all improvement approaches. 

Also beyond the scope of this paper, but a crucial step in embarking on improvement is 

leadership support and sponsorship. The sponsor’s role is to select, prioritize, authorize, 

participate, and facilitate the success of each improvement effort. There are some 

changes that require executive leader action. The role of the executive leader cannot be 

overstated. 

1. Team. This element asks us to think through the question: Does everyone who 

touches this process have a say in the process changes? This question highlights 

the realization that the people who DO the work on a day-to-day basis must 

transform the work. Outside experts “telling” front line staff what to do may not 

have lasting impact. Teams work best when they have clear sponsorship or 

authority from executive leaders, consist of front-line staff who have integrity, 

are passionate around improvement, and possess a facilitator or improvement 

professional who has deep knowledge and skill doing improvement work. 

Training (if needed) can be done “just in time.” Small teams can often move 

faster, yet must remember to include all stakeholders. Large teams can include all 

stakeholders, but must not get bogged down in process steps. While not 

traditionally done, including a patient on a team will bring a mindfulness of 

mission and a perspective of customer that sometimes was missing in the past. 

Sponsors and teams must recognize that not all improvement work can be done in 
the course of a normal job. The time invested in focusing on the problems at 

hand, meeting, and testing changes are directly related to the success. Teams 

must meet and work a-pace to make progress. Sponsors must be very involved in 

leading and supporting the work of improvement teams. It is recommended that 

weekly or bi-weekly contact with the sponsor be considered. Here is a checklist 

of things to consider when identifying team members: 

• Is the team leader willing and able to do the job? 

• Does the team leader understand and agree with the reason for the team, 

the resources, and timeframe? 

• Does the team have a skilled facilitator who organizes, arranges, teaches, 

helps, and communicates whatever is needed to achieve the aim? 

• Are the appropriate disciplines included? 

• Is there a patient on the team? If not, how is their viewpoint represented? 

• Is the team “the right size” for the task at hand? 

• Will the team commit to accomplishing the aim? 

2. Aim. What is your aim or goal? If the team cannot describe the aim in one or 

two crisp sentences, they may be unclear about their task. Teams who lose focus 

of their aim get lost and are ineffective. It is not uncommon for teams to invest a 

few hours, days or even weeks in clarifying and achieving buy-in around the real 

aim. For this reason, time is well spent to write a clear, measurable aim statement 

in a sentence or two that describes the WHAT and BY WHEN. Aim statement are 

best when they focused on the patient experience (in clinical services) or the 

support of patient experiences (in administrative services) – even if they are 

removed a step or two (i.e., the patient is always the ultimate customer for 

anything we do). Teams will sometimes set more than one aim. In addition to 

clarifying the improvement work at hand, well written aim statements help 

identify the end of the work. The following are some additional guidelines to 

consider when establishing aim statements: 

• State the aim clearly 

Achieving agreement on the aim of a project is critical for maintaining 

progress, but agreement is not easily achieved unless the aim is very 

clearly stated. Teams make better progress when they are very specific 

about their aims. Be brief; a single sentence is best. 

• Base your aim on data Examine data that your department has on the 

particular process under study. Remember the best aims address either 

timeliness or reliability goals. Focus on issues that matter to your patients 

and you.

• Include numerical goals 

For example; setting an aim such as “Reduce delays in patients moving 

from 3N Medicine to the Skilled Nursing Facility” is not as effective as 

“Reduce the delay from decision to discharge from 3N Medicine to 

placement in the SNF from 7 days to 1 day by July 1st, 2009.” Numerical 
goals clarify the aim, direct the measures of improvement, and focus 

initial changes. 

• Set stretch goals 

Setting stretch goals—for example, “assure superior satisfaction for > 95% 

of patients”—immediately tells people that the status quo is not an option. 

The role of leadership is to make it clear that the goal cannot be met by 

simply tweaking the existing system. (A key to setting effective stretch 

goals is to make them ambitious enough that they are indeed a “stretch” 

but not so ambitious that teams assume they are impossible to meet and 

quickly lose interest.) Once this is clear, people begin to see how barriers 

to achieving the stretch goals can be overcome. 

• Examples Aim statements are typically have either a timeliness or 

reliability focus. These are examples of good aim statements: 

i. “Our aim is to offer patients appointments today for any problem, 

urgent or routine, by July 1st.” This is a timeliness aim statement 

that tells what (offer patients appointments today), is measurable 

by a clearly understood measurement (e.g., offering “today” is 

commonly measured by using the “third next available” measure), 

and by when (July 1st). 

ii. “Our aim is to reduce the time from selection of a new employee to 

the first day of work from 60 days to 7 days by December 1st.” 

This is a timeliness aim also that explains the what (reducing delay 

for new employee “Entry on Duty” date and by when is December 

1st. This process is measurable. 

iii. “Our aim is to increase the use of all elements of the central line 

bundles to 100% by December 1st.” This is a reliability aim 

statement that explains what (use all elements of the bundle) and 

by when (December 1st) and is measureable. 

3. Map. Have you drawn a picture of the process? While it is tempting to skip the 

flow-mapping or flow charting process because teams can feel unfamiliar with the 

tools or assume they know the process, experience has shown this is a mistake. 

Flow-mapping is not particularly difficult but, in order to be effective it requires 

sustained discipline from every team member. In flow-mapping, nothing should 

be taken for granted and every team member should be in agreement that the final 

map accurately represents the process as it really exists. 

Flow mapping serves to identify a process clearly by clarifying the start, end, and 

key decision points. It allows the teams to agree on what IS the current process. 

In addition, the experience of flow mapping itself leads to realizations about how 

complex many processes are, how non-standard and unreliable they can be, and 

how much re-work is involved. Flow mapping can also lead to ideas for 

measurement and improvement of the process in question. 
Flow mapping can occur at a very high level, or at a much more detailed level. 

For example, at a high level, the hiring process could involve 3 steps: 

recruitment, selection, and orientation. That same process flow-mapped at many 

facilities resulted in as many as 145 steps. The facilitator and team must choose 

the appropriate level of detail. An appropriate level of detail allows identification 

of mistakes, rework, and non-value added steps. Flow maps often use circles to 

represent the start and end of a process, rectangles to represent steps, and 

diamonds to represent decision points. It really is not complex. 

Further details of flow mapping are beyond the scope of this paper. However, it 

is worth noting that the goal is to use pictures to start to understand and 

communicate the current process while discovering improvement opportunities as 

the team uses the “current state” map to create a map of an ideal process. 

4. Measure. How do you know a change is an improvement? In order to know if 

changes teams make are really an improvement and fulfill our obligation to 

manage by fact not feeling, we are obligated to measure. Measurement in the 

improvement world is intended to be measurement that is “good enough” to 

support the team meeting its aim, not necessarily “perfect” measurement as, for 

instance, would be required for a research study. This means teams should not 

spend all of their time on measurement, but use measurement to both “diagnose” 

the current state including the constraints, and to “see” the general direction of 

change. Measurement done well contributes immensely to team learning and 

minimizes individual lobbying for any one point of view. 

A decision as to how much measurement to do is important. A few guidelines are 

helpful. 

• Data Sources: Since VA has a culture of measurement, many data sources 

may be available to inform a process. Remember that before relying on 

any measurement, a clear understanding of data definitions, data sources, 

and process are needed. Notwithstanding this, teams often find it’s 

necessary and useful to collect data locally on a given process. 

• Timeliness: For timeliness aims, it is crucial to have some measure of 

timeliness or delay. In addition, since the underlying dynamics of 

demand, supply, and activity are responsible for the overall timeliness of 

any process, teams will find those elements helpful. Teams will also be 

interested in balancing measures such as no-shows (rework) continuity, 

and panel size or case load in clinical care. Satisfaction tends to be an 

outcome measure that improves as the underlying process improves so 

therefore is often not a good day-to-day improvement measure. 

• Reliability: For teams that choose reliability aims, it might be useful to 

look at the performance measures and monitor databases to establish 

current performance. The burden of measurement tends to be less when 

picking a reliability aim as one or two measures can show progress toward 

an aim. 
• Data display: Compelling display of data can serve to quickly 

communicate multiple complex measures AND engender action. The best 

tool to accomplish this is generally a run chart showing the measure of 

interest on the Y axis and time on the X axis. Adding a reference line 

representing the goal is helpful. Advanced measurement tools can put 

data into Statistical Process Control charts and do deeper analysis; 

however for most improvement work, simple run charts suffice. 

• Sampling vs. continuous measurement: A decision must be made about 

how much data is needed. If a team over-measures, then all the energy is 

focused on the measurement and not the results. If a team undermeasures, then they may not understand the process dynamics nor know if 

there is progress toward an aim. Don’t be afraid to sample. A good rule 

of thumb is this: If the data you are collecting requires a lot of effort, or is 

causing frustration among your team members, this is a good sign that you 

should re-think what data you need and/or how it is collected. 

• Level of detail. A good guideline is to measure everything at the frontline or team level where the process can be impacted. This allows each 

employee/team to know the impact of their process execution. Individual 

or team data can then be rolled up into sections, departments, services, or 

facilities as desired. 

5. Change. What changes are you making to improve? Hard won experience has 

taught us that the practice of simply telling people what to do doesn’t work. This 

results in resistance. Underlying this resistance is often the belief that “we’re 

different” or “that won’t work here” or “it’s not ours.” For this reason there are 

two critical issues to understand in this area of change: first, focus on 

considering change principles, not necessarily “best practices” or strategies and 

secondly, use “small tests of change” as embodied in PDSA or an equivalent 

approach, before attempting large, system-wide change. 

Principles: Principles are “universal truths” in system design. They are like 

chapters in books that are common to all understanding while the details can be 

different. These underlying details or strategies are change ideas consistent with 

a principle that can be adopted or adapted by the team. Teams find some change 

principles work better/worse for a given situation and they should feel free to 

adopt, modify or create change strategies that work best for them, consistent with 

the principles. These principles are well worked out and exist for many common 

timeliness topics such as “Advanced Clinic Access” (ACA) and In-patient flow. 

They include Balancing Demand and Supply, Decreasing Backlog, Decreasing 

Queues, etc. Reliability principles include (5 “S,” visual controls, fail-safe 

design, etc). While further discussion of these principles is beyond the scope of 

this paper, remember that these may be topics for just-in-time training, research, 

or idea-mining. 

Testing: This testing and adoption process is best done through PDSA. PDSA is 

Plan-Do-Study-Act (also known as Plan-Do-Check-Act) and is intended to 
communicate the imperative to do very small tests of change. It is a method that 

has stood the test of time and is incorporated into practically every improvement 

approach. The power of PDSA is the cumulative effect of small changes and the 

ability to try ideas on a small scale, fine tune them, build consensus and then 

generalize the change on a larger scale. The image of PDSA may be better stated 

to simply “follow your hunches”. PDSA could be thought of as trying out a new 

idea. Remember that small tests of change are paradoxically powerful and 

therefore the desired state for all improvement activities. 

6. Sustain. If everyone on your team retires, how do you know these change 

strategies will continue to be used? It seems many teams do not celebrate 

enough. Before sustaining anything, don’t miss the opportunity to meaningfully 

celebrate successes both along the way and at the end. Then, the “sustain” 

strategies require us to think about what changes were successful first. Then think 

about the process and task changes that resulted in the success. Now we must 

“memorialize” those changes. This typically involves assignment of 

responsibility, changing of job descriptions, evaluations, reward systems, revising 

policies and new employee orientation/training. In addition, ongoing 

measurement of the key process is crucial to sustain. Past improvement efforts 

have often failed because the appropriate system changes and safeguards were not 

been put in place to assure the new processes are supported. 

Summary 

Historically, many improvement efforts have failed because of one or more of the basic 

elements noted above are absent. Experience has shown that choosing and using a 

consistent improvement framework to organize the improvement effort serves to clarify 

and facilitate the ongoing work. While no framework is perfect, the suggested 

TAMMCS approach is generally understandable and does work. 

Please address questions or comments to the VHA Office of Systems Redesign or Mike 

Davies by e-mail to Michael.Davies@VA.gov or 605 347 7416.