Roadmaps for building a better system.

BOTH SISTER MARY JEAN Ryan and Glen Barton offer impressive portraits of leading organizations that understand and are committed to making quality in healthcare a reality, and I suspect that the headway they report on in the preceding articles is largely owed to their leadership, energy, and vision. It is important to remember that they are the exception, not the rule. We can hope that other organizations will follow their lead, but experience suggests that not many will, at least not without some aggressive nudging in the right direction. This begs the question, how exactly might we go about making average healthcare systems or average healthcare purchasers act more like extraordinary ones? To be sure, this is no easy task, but neither is it a hopeless pursuit. We can learn much from the examples at hand. SSM Health Care's (SSMHC) unwavering commitment to quality, even in the absence of a "business case," makes it exceptional at the outset. Winning the Baldrige prize also puts them in very elite company. Reading Ryan's account of the challenges encountered along the way makes it all the more impressive that the effort did not derail en route. Remember that SSMHC undertook this transformation because of its commitment to mission and because of a deep conviction that its quality could be improved, not because of any outside regulatory or market pressure. There are other examples of hospitals and healthcare systems with a similar zeal for excellence, but, unfortunately, they are all too few and exceptional in their own ways. SSM Health Care is not such an anomaly, however, that it does not provide a valuable lesson: organizational culture is key to change, and it is key to improvement. In recognizing SSMHC's achievement, the Baldridge award and other such accolades or objective report cards will help reinforce that culture and, one hopes, help it take root elsewhere. Even in the most bottom-line minded of industries or organizations, culture dictates how they act and what they can achieve. We must seek systematic ways to reward and reinforce the idea that in healthcare, quality comes first. Caterpillar, as a purchaser of healthcare, is exceptional in its own way. First, Caterpillar is number 98 on the list of Fortune 500 companies. second, there is a large concentration of Caterpillar employees in Peoria, Illinois, making it a force to be reckoned with for all providers in that market. Third, it is a global firm that competes on quality in its own right, and its leadership deeply understands the close relationship between quality and efficiency in its own operations. Caterpillar has made Six Sigma central to its own strategy, and its leaders understand in a profound way that variability is a sign that processes are not working well. For Caterpillar, the variability in healthcare is a large red flag-of processes not even defined, let alone brought to optimal levels of performance. Caterpillar has chosen to use its market power and sophistication to drive a value agenda for its own employees. Not every large employer has had the energy, vision, and concentrated market power to behave in the same way. For smaller employers, this kind of activated purchasing is generally not even an option. While there are (once again, exceptional) examples of employers forming business coalitions to generate the clout necessary to negotiate better value for their healthcare dollar, their collective purchasing power in most markets remains very limited. Encouraging their growth through regulation and legislation would help grow their clout and enable them to act more like a Caterpillar, leveraging their buying power to drive improvement and to promote quality. A comprehensive strategy for improving healthcare would borrow other lessons from SSMHC and Caterpillar as well. STEPS TO CREATING A QUALITY STRATEGY First, we need transparency of performance for hospitals, doctors, and other medical institutions. …