Chapter 2Factors influencing the application and diffusion of .docx

Chapter 2
Factors influencing the application and diffusion of CQI in
health care
Contents
Introduction
The dynamic character of CQI
A CQI case study
The current state of CQI in healthcare
CQI and the science of innovation
The business case for CQI
Factors affecting successful CQI application
Introduction
CQI is utilized across health care sectors (including primary and
preventative care) as well as across geographic and economic
boundaries
The need for CQI is increasing
One reason: the safety and quality of care has shown little
improvement over the last decade despite best efforts of
clinicians, managers, researchers, and involvement of public
This lecture will review a number of factors and processes have
been shown to facilitate or impede the implementation of CQI in
health care
The Dynamic Character of CQI
CQI methodology is constantly being refined and tested: it is an

evolutionary quality improvement mechanism
This is because in response to new challenges, CQI applications
develop via continuous, ongoing learning and sharing among
disciplines about ways to use CQI philosophies, processes and
tools in a variety of settings
The Surgical Safety Checklist:
a CQI Success Story
Checklist CQI methodology orginated in aviation
2001 utilised by Pronovost (2006) in Intensive Care Units as a
way of reducing central line infections
Surgical Safety Checklist (SSC) developed by Gawande (2009)
is disseminated by WHO across the world
a CQI Success Story
Development of SSC depended upon:
Effective leadership
Interdisciplinary teamwork
Use of a PDSA improvement cycle to test, learn and improve
Engagement of a broad range of expertise to improve safety on
a global scale
a CQI success story
Results vary but after the introduction of the SSC:
Haynes et al. (2009) demonstrated a reduction in complication
rates from 11.0% at baseline to 7.0% plus, and a reduction in
death rates from 1.5% to 0.8% in eight hospitals in eight cities
The SURPASS group study of six hospitals in the Netherlands,
showed a statistically significant decrease in the proportion of
patients with one or more complications, from 15.4% to 10.6%
(de Vries et al. 2010).

So if Checklists are Successful …
Why aren’t more healthcare providers using CQI tools and
processes?
Why is the gap between knowledge and practice so large?
Why don’t clinical systems incorporate the findings of clinical
science or copy the “best known” practices reliably, quickly,
and even gratefully into their daily work simply as a matter of
course?
Limitations of Checklists
May be too simple a tool and what is required is more complex
system solutions to quality and safety issues (Bosk et al.
2009).
Problems with checklists are indicative of broader CQI and
quality improvement issues in healthcare including:
Process vs. outcome;
Cost vs. benefit vs. value;
Minimum standards required to define evidence for change;
How to balance difference of opinions about findings;
Ways of influencing practitioners to adopt new ideas;
Diffusion of innovation in health care.
Discussion Questions
What is the current state of quality in health care?
What are the problems regarding implementation of CQI in
health care?
Given the widespread application of CQI, what factors that
contribute to the implementation of CQI across industries and
settings?
What are the factors that have influenced the rate of diffusion

and spread of CQI in health care?
The Current State of CQI in Healthcare
• A decade after the Institute of Medicine To Err is Human
(2000) and Crossing the Quality Chasm (2001) and despite best
efforts, improvement in quality and safety remains limited
The ability of the patient safety movement to close the gap in
errors and adverse events was rated as “C+” in 2005, and as a
“B-” in 2009 (Wachter 2009)
A recent review of patient “harms” from 2002 to 2007 in over
2,300 admissions in 10 hospitals in North Carolina showed little
improvement in error rates despite high levels of engagement in
safety efforts (Landrigan et el. 2010)
Discussion Question
Do you agree with the following quotation?
“U.S. health care is broken. Although other industries have
transformed themselves using tools such as standardization of
value-generating processes performance measurement and
transparent reporting of quality, the application of these tools to
health care is controversial, evoking fears of “cookbook
medicine,” loss of professional autonomy, a misinformed focus
on the wrong care or a loss of individual attention and the
personal touch in care delivery…Our current health care system
is essentially a cottage industry of nonintegrated, dedicated
artisans who eschew standardization….Growing evidence
highlights the dangers of continuing to operate in a cottage-
industry mode. Fragmentation of care has led to suboptimal
performance.” (Swenson et al. 2010, p. e12(1))

Two key issues have been associated with the lack of
improvement in the quality and safety of care in the U.S.:
Complexity and cost
These are same key factors in the recent debate about health
reform in the United States
Complexity of U.S. Healthcare
The complexity of the healthcare system is both a challenge and
a source of ideas for how to make improvements (Plsek &
Greenhalgh 2001)
Health care is described as a complex adaptive system (Rouse
2008)
This has implications for how to improve the system of
healthcare:
Health care can only be designed to a certain extent
Cannot be designed around minimizing costs
Requires a focus on maximizing value
There is a need to be proactive - designing the system required,
rather than continuing to let it evolve
Therefore leadership is critical and
There need to be incentives for improvement
Cost of U.S. Healthcare
The U.S. Healthcare system is much more expensive, but not
significantly better than other healthcare systems around the
world (Leonhardt 2009)
The U.S. spends more per capita for health care than any other
country, yet ranks 27th in infant mortality, 27th in life
expectancy, with Americans less satisfied with their care

than the English, Canadians or Germans (Berwick 2003)
CQI and the Science of Innovation
There are no simple answers about how to move CQI
innovations into the mainstream of health care more quickly and
efficiently
A common element to all complex systems is the difficulty
surrounding diffusion of innovation
Diffusion theory provides one way of understanding the barriers
and facilitators of CQI in healthcare
Complexity must be considered in understanding healthcare
innovation
Innovation may not be able to be managed, but organizational
conditions can be designed and controlled in a way that
“enhance the possibility of innovation occurring and spreading”
(Greenhalgh et al. 2005, p.80)
Factors which facilitate these conditions include:
Leadership
The creation of a receptive and even enthusiastic culture (e.g.
the development of quality improvement collaboratives).
The speed and overall adoption of any change is influenced by
the characteristics of the change and how it is perceived by
those responsible for implementation
Characteristics affecting change include:
Relative advantage
Compatibility
Simplicity

Trialability
Observability (Rogers 1995)
In the SSC example, compatibility (how closely do the change
ideas align with the existing culture and environment) and
trialability (the evidence base for whether the change can be
adapted and tested in the new environments in which they are
being spread) were most pertinent.
Berwick (2003) identified 7 rules for dissemination of
innovation in health care:
Find sound innovations
Find and support innovators
Invest in early adopters
Make early adopter activity observable
Trust and enable reinvention
Create slack for change
Lead by example

Fundamental levers of CQI include:
Reinvention
Trust
Leadership
CQI cannot be a top-down mandate
It must be part of the vision of an organization and accepted by
all who must implement CQI - requiring trust at all levels
Trust comes from leadership and teamwork and Deming’s
concept of “constancy of purpose.”
Top leadership must be involved and support and communicate
the vision for innovation and change
The participation, buy-in and support from opinion leaders at all
levels within an organization are critical for successful
implementation, and the process to reinvention.
One size will not fit all. As described by Berwick (2003,
p.1974) “To work, changes must be not only adopted locally,
but also locally adapted.” Berwick asserts that for this to
happen requires reinvention. “Reinvention is a form of learning,
and, in its own way, it is an act of both creativity and courage.
Leaders who want to foster innovation … should showcase and
celebrate individuals who take ideas from elsewhere and adapt
them to make them their own”(Berwick, 2003, p.1974).

Checklist example cited at the beginning of this chapter is a
clear illustration of this process of reinvention and leadership.
adapted from the airline and other industries
Health care is complex and requires diligence to spread the
improvement process.
Equally complex quality improvement strategies are required,
slow adaptation
- Simple PDSA cycles, have enjoyed broad success.
Review of a study by Foy et al. (2002) by Greenhalgh et al
a prospective study of the attributes of 42 clinical practice
recommendations in gynecology.
Examples of progress in specific segments of health care
models that can be considered to increase diffusion of CQI
ideas.
Social marketing
Discussion Question
“Reinvention is a form of learning, and, in its own way, it is an
act of both creativity and courage. Leaders who want to foster
innovation … should showcase and celebrate individuals who
take ideas from elsewhere and adapt them to make them their
own”(Berwick, 2003, p.1974).
Do you agree?
The Business Case for CQI
A business case for a health care improvement intervention
exists if the entity that invests in the intervention realizes a
financial return on its investment in a reasonable time frame,
using a reasonable rate of discounting. This may be realized as

“bankable dollars” (profit), a reduction in losses for a given
program or population, or avoided costs
A business case may also exist if the investing entity believes
that a positive indirect impact on organization function and
sustainability will accrue within a reasonable time frame. (p.
18)
The economic case for an innovation includes the returns to all
the actors, not just the individual investing business unit
The social case involves measuring benefits, but not requiring
positive returns on the investment
The social case has been overriding consideration in the battle
to control medical variation and medical errors (McGlynn et al.
2003)
Economics alone does not provide an argument strongly for or
against the use of CQI, but does add to the complexity of the
wider and more rapid implementation of CQI in health care.
The business case for CQI faces the same negative factors as the
business case for other preventive health care measures:
all or part of the benefits accruing to other business units or
patients, and delayed impacts that get discounted heavily in the
reckoning.(Leatherman et al. 2003)
The regulatory arguments for quality improvement efforts are
usually justified on the basis of social and economic benefits
such as lives saved and overall cost reductions, but are not
necessarily profitable to the investor.
Factors Associated with Successful CQI Applications
Motivational factors
Regulatory agencies and accreditation

Transformational leadership, teamwork and a culture of
excellence
1. Motivational factors
Intrinsic motivation
CQI as job enrichment
Capturing the intellectual capital of the workforce
capitalizing on professional and specialist knowledge of
workers
Reducing managerial overhead
unique implications for healthcare setting
Lateral linkages
interdisciplinary care, interdependence and effective teamwork
2. Regulatory Agencies and Accreditation
Regulatory mechanisms such as accreditation are key factors
that have led to greater diffusion of CQI
The Joint Commission (TJC) and the Centers for Medicare and
Medicaid Services (CMS) have led to the implementation of a
series of initiatives that require hospitals to report on quality
measures
Quality Improvement Organizations (QIOs) report extensive
CQI activities and findings associated with these activities
Joint Commission has noted the use of robust, evidence based
measures, linking process performance and patient outcomes
(Chassin,et al. 2010) in the acute sector, but identified more
work was required in measurements of quality in ambulatory
care
3. Transformational Leadership, Teamwork, and a Culture of
Excellence
Transformational leadership is distinguished by its reliance on
vision

A culture of excellence of excellence in CQI has been defined
as a culture in which “a commitment to safety permeates all
levels of the organization from frontline personnel to executive
management” (AHRQ 2010)
A culture of excellence is one that ensures excellence and high
quality at every customer interface, in which a commitment to
the highest quality and CQI is shared by all in the organization
Figure 2.1:
Factors Influencing Successful CQI Implementation
Leadership
Vision
Constancy
of
Purpose
Culture of Excellence
Statistical Thinking
Empowerment
Teamwork
Motivation
CQI
Communication/Feedback
Systems Thinking
Customer Focus
Excellence
Underlying the creation of a culture of excellence is a need for
systems view which emphasizes the importance of:
adding value

leadership rather than management
influence rather than power and
the alignment of incentives focused on quality not quantity of
services (Rouse 2008).
Excellence
Customer Focus
Emphasizing the importance of both internal and external
customers
Systems Thinking
Optimizing the system as a whole and thereby creating synergy
(Deming 1986; Kelly 2007)
Understanding causes of variation, learning from measurement,
and using data to make decisions (Balestracci 2009)
Excellence
Teamwork
Teams of peers working together to ensure empowerment and
motivation, ensuring alignment of the organization, the team
and the individual around the CQI vision
Communication and Feedback
Open channels of communication and feedback to make
adjustments as needed, including feedback which is fact based
and given with true concern for individuals’ organizational
success (Balestracci 2009).
Leadership and Diffusion
Innovativeness is seen as critically dependent on good
leadership

Organizational leadership is also critical to the development of
a culture that fosters innovation (Greenhalgh et al. 2005).
Discussion Question
“Leaders within organizations are critical firstly in
creating a cultural context that fosters innovation and
secondly, establishing organizational strategy, structure and
systems that facilitate innovation”
(Greenhalgh et al. 2005, p. 69)
Three types of leaders: opinion leaders, champions, and
boundary spanners can contribute to the diffusion of innovation
across an organization
Each of these types of leaders is found in the adoption of
quality improvement initiatives in health care and often these
various types of leaders are found in combination.
Opinion leaders
At all levels of the organization
Influence on the beliefs and actions of their colleagues
Influence can be either positive or negative in regard to
embracing innovation
Opinion leaders
May be experts, respected for formal academic authority in
regard to an innovation
Their support represents a form of evidenced based knowledge
May also be peers, respected for their know-how and
understanding of the realities of clinical practice (Greenhalgh et
al. 2005).

Champions
Persistently support new ideas
May come from the top management of or within organizations,
including technical or business experts
Include team and project leaders and others who have
persistence to fight both resistance and/or indifference to
promote the acceptance of a new idea or to achieve project
goals (Greenhalgh et al. 2005).
Boundary spanners
Are a combination of these various types of leaders of
innovation
Are distinguished by the fact that they have influence across
organizational and other boundaries (Greenhalgh et al. 2005;
Kaluzny 1974)
Play an important role in multi-organizational innovations and
quality improvement initiatives (ie quality improvement
collaboratives)
Teamwork
Teams play a major role in all of health care
Teamwork is one of the most important components of all
successful CQI initiatives
Team building centers on the ability to create teams of
empowered and motivated people who are leaders themselves
and who will take the lead as necessary to foster change,
innovation and improvement
The link between leadership and teamwork is the glue which
holds CQI together – with leadership exhibited as called for at
all levels within a team
“There is no substitute for teamwork and good leaders of

teams to bring consistency of effort along with knowledge”
(Deming 1986, p.19).
Teamwork
Inherent in teamwork involves:
A high level of empowerment of team members which in turn
leads to high levels of motivation
Empowerment implies that levels of authority match levels of
responsibility, and training
Training is critical to the success of leaders, and the training of
future leaders is one of the most important responsibilities of a
leader (Tichy 1997).
Results in all members of the team being able to make
suggestions and interventions can be made to allow
improvements and prevent problems or errors(Berwick, 2010)
Teamwork
Improved motivation is the result of empowerment, and both
will interact to lead to higher quality
But both require a culture of trust
Deming’s point number eight is:
“Drive out fear. No one can put in his best performance unless
he feels secure…Secure means without fear, not afraid to
express ideas, not afraid to ask questions” (Deming 1986, p.59).
Kotter’s change model
Kotter’s work has been used to define a culture of change,
including the role of vision and leadership
Eight-stage change model which describes “how to” rather than
“what is” major organizational change
Provides guidance on traditional errors to avoid
There is a clear overlap between Kotter’s model and the factors

defined in the figure describing the culture of excellence
Common elements include:
Empowerment
Communication
feedback loops to produce more change
the central role of vision and anchoring change in the culture.
Table 2-1:
Kotter’s Eight-Stage Process of Creating Major Change
1. Establishing a Sense of Urgency
2. Creating the Guiding Coalition
3. Developing a Vision and Strategy
4. Communicating the Change Vision
5. Empowering Broad-Based Action
6. Generating Short-Term Wins
7. Consolidating Gains and Producing More Change
Anchoring New Approaches in the Culture
Source: Adapted from John Kotter, Leading Change
Conclusion
The factors that are associated with successful CQI applications
can be clearly identified
These include leadership and team work and their role in
developing a shared vision leading to a culture of excellence
which embraces CQI
CQI leaders are individuals who lead by example, teach others,
and continue to develop and expand both the philosophy and
processes of CQI
Despite the spread of CQI its further adoption in health care
continues to meet challenges, including the lack of substantial
progress in improving quality of health care and most important

reducing harm to patients (Landrigan et al. 2010; Wachter
2009)
Factors that influence the adoption of CQI include complexity,
which can inhibit further adoption and the slowing down of
progress after the impact of early adopters has waned
Conclusion
Chapter 2
Factors influencing the application and diffusion of CQI in
health care
Contents
Introduction
The dynamic character of CQI
A CQI case study
The current state of CQI in healthcare
CQI and the science of innovation
The business case for CQI
Factors affecting successful CQI application
Introduction
CQI is utilized across health care sectors (including primary and
preventative care) as well as across geographic and economic
boundaries
The need for CQI is increasing
One reason: the safety and quality of care has shown little

improvement over the last decade despite best efforts of
clinicians, managers, researchers, and involvement of public
This lecture will review a number of factors and processes have
been shown to facilitate or impede the implementation of CQI in
health care
The Dynamic Character of CQI
CQI methodology is constantly being refined and tested: it is an
evolutionary quality improvement mechanism
This is because in response to new challenges, CQI applications
develop via continuous, ongoing learning and sharing among
disciplines about ways to use CQI philosophies, processes and
tools in a variety of settings
a CQI Success Story
Checklist CQI methodology orginated in aviation
2001 utilised by Pronovost (2006) in Intensive Care Units as a
way of reducing central line infections
Surgical Safety Checklist (SSC) developed by Gawande (2009)
is disseminated by WHO across the world
a CQI Success Story
Development of SSC depended upon:
Effective leadership
Interdisciplinary teamwork
Use of a PDSA improvement cycle to test, learn and improve
Engagement of a broad range of expertise to improve safety on
a global scale

a CQI success story
Results vary but after the introduction of the SSC:
Haynes et al. (2009) demonstrated a reduction in complication
rates from 11.0% at baseline to 7.0% plus, and a reduction in
death rates from 1.5% to 0.8% in eight hospitals in eight cities
The SURPASS group study of six hospitals in the Netherlands,
showed a statistically significant decrease in the proportion of
patients with one or more complications, from 15.4% to 10.6%
(de Vries et al. 2010).
So if Checklists are Successful …
Why aren’t more healthcare providers using CQI tools and
processes?
Why is the gap between knowledge and practice so large?
Why don’t clinical systems incorporate the findings of clinical
science or copy the “best known” practices reliably, quickly,
and even gratefully into their daily work simply as a matter of
course?
Limitations of Checklists
May be too simple a tool and what is required is more complex
system solutions to quality and safety issues (Bosk et al.
2009).
Problems with checklists are indicative of broader CQI and
quality improvement issues in healthcare including:
Process vs. outcome;
Cost vs. benefit vs. value;
Minimum standards required to define evidence for change;
How to balance difference of opinions about findings;
Ways of influencing practitioners to adopt new ideas;
Diffusion of innovation in health care.

Discussion Questions
What is the current state of quality in health care?
What are the problems regarding implementation of CQI in
health care?
Given the widespread application of CQI, what factors that
contribute to the implementation of CQI across industries and
settings?
What are the factors that have influenced the rate of diffusion
and spread of CQI in health care?
• A decade after the Institute of Medicine To Err is Human
(2000) and Crossing the Quality Chasm (2001) and despite best
efforts, improvement in quality and safety remains limited
The ability of the patient safety movement to close the gap in
errors and adverse events was rated as “C+” in 2005, and as a
“B-” in 2009 (Wachter 2009)
A recent review of patient “harms” from 2002 to 2007 in over
2,300 admissions in 10 hospitals in North Carolina showed little
improvement in error rates despite high levels of engagement in
safety efforts (Landrigan et el. 2010)
Discussion Question
Do you agree with the following quotation?
“U.S. health care is broken. Although other industries have
transformed themselves using tools such as standardization of
value-generating processes performance measurement and
transparent reporting of quality, the application of these tools to
health care is controversial, evoking fears of “cookbook
medicine,” loss of professional autonomy, a misinformed focus
on the wrong care or a loss of individual attention and the

personal touch in care delivery…Our current health care system
is essentially a cottage industry of nonintegrated, dedicated
artisans who eschew standardization….Growing evidence
highlights the dangers of continuing to operate in a cottage-
industry mode. Fragmentation of care has led to suboptimal
performance.” (Swenson et al. 2010, p. e12(1))
Two key issues have been associated with the lack of
improvement in the quality and safety of care in the U.S.:
Complexity and cost
These are same key factors in the recent debate about health
reform in the United States
Complexity of U.S. Healthcare
The complexity of the healthcare system is both a challenge and
a source of ideas for how to make improvements (Plsek &
Greenhalgh 2001)
Health care is described as a complex adaptive system (Rouse
2008)
This has implications for how to improve the system of
healthcare:
Health care can only be designed to a certain extent
Cannot be designed around minimizing costs
Requires a focus on maximizing value
There is a need to be proactive - designing the system required,
rather than continuing to let it evolve
Therefore leadership is critical and
There need to be incentives for improvement

Cost of U.S. Healthcare
The U.S. Healthcare system is much more expensive, but not
significantly better than other healthcare systems around the
world (Leonhardt 2009)
The U.S. spends more per capita for health care than any other
country, yet ranks 27th in infant mortality, 27th in life
expectancy, with Americans less satisfied with their care
than the English, Canadians or Germans (Berwick 2003)
There are no simple answers about how to move CQI
innovations into the mainstream of health care more quickly and
efficiently
A common element to all complex systems is the difficulty
surrounding diffusion of innovation
Diffusion theory provides one way of understanding the barriers
and facilitators of CQI in healthcare
Complexity must be considered in understanding healthcare
innovation
Innovation may not be able to be managed, but organizational
conditions can be designed and controlled in a way that
“enhance the possibility of innovation occurring and spreading”
(Greenhalgh et al. 2005, p.80)
Factors which facilitate these conditions include:
Leadership
The creation of a receptive and even enthusiastic culture (e.g.
the development of quality improvement collaboratives).

The speed and overall adoption of any change is influenced by
the characteristics of the change and how it is perceived by
those responsible for implementation
Characteristics affecting change include:
Relative advantage
Compatibility
Simplicity
Trialability
Observability (Rogers 1995)
In the SSC example, compatibility (how closely do the change
ideas align with the existing culture and environment) and
trialability (the evidence base for whether the change can be
adapted and tested in the new environments in which they are
being spread) were most pertinent.
Berwick (2003) identified 7 rules for dissemination of
innovation in health care:
Find sound innovations
Find and support innovators
Invest in early adopters
Make early adopter activity observable

Trust and enable reinvention
Create slack for change
Lead by example
Fundamental levers of CQI include:
Reinvention
Trust
Leadership
CQI cannot be a top-down mandate
It must be part of the vision of an organization and accepted by
all who must implement CQI - requiring trust at all levels
Trust comes from leadership and teamwork and Deming’s
concept of “constancy of purpose.”
Top leadership must be involved and support and communicate
the vision for innovation and change
The participation, buy-in and support from opinion leaders at all
levels within an organization are critical for successful
implementation, and the process to reinvention.

One size will not fit all. As described by Berwick (2003,
p.1974) “To work, changes must be not only adopted locally,
but also locally adapted.” Berwick asserts that for this to
happen requires reinvention. “Reinvention is a form of learning,
and, in its own way, it is an act of both creativity and courage.
Leaders who want to foster innovation … should showcase and
celebrate individuals who take ideas from elsewhere and adapt
them to make them their own”(Berwick, 2003, p.1974).
Checklist example cited at the beginning of this chapter is a
clear illustration of this process of reinvention and leadership.
adapted from the airline and other industries
Health care is complex and requires diligence to spread the
improvement process.
Equally complex quality improvement strategies are required,
slow adaptation
- Simple PDSA cycles, have enjoyed broad success.
Review of a study by Foy et al. (2002) by Greenhalgh et al
a prospective study of the attributes of 42 clinical practice
recommendations in gynecology.
Examples of progress in specific segments of health care
models that can be considered to increase diffusion of CQI
ideas.
Social marketing
Discussion Question
“Reinvention is a form of learning, and, in its own way, it is an
act of both creativity and courage. Leaders who want to foster
innovation … should showcase and celebrate individuals who
take ideas from elsewhere and adapt them to make them their
own”(Berwick, 2003, p.1974).

Do you agree?
A business case for a health care improvement intervention
exists if the entity that invests in the intervention realizes a
financial return on its investment in a reasonable time frame,
using a reasonable rate of discounting. This may be realized as
“bankable dollars” (profit), a reduction in losses for a given
program or population, or avoided costs
A business case may also exist if the investing entity believes
that a positive indirect impact on organization function and
sustainability will accrue within a reasonable time frame. (p.
18)
The economic case for an innovation includes the returns to all
the actors, not just the individual investing business unit
The social case involves measuring benefits, but not requiring
positive returns on the investment
The social case has been overriding consideration in the battle
to control medical variation and medical errors (McGlynn et al.
2003)
Economics alone does not provide an argument strongly for or
against the use of CQI, but does add to the complexity of the
wider and more rapid implementation of CQI in health care.
The business case for CQI faces the same negative factors as the
business case for other preventive health care measures:
all or part of the benefits accruing to other business units or
patients, and delayed impacts that get discounted heavily in the
reckoning.(Leatherman et al. 2003)

The regulatory arguments for quality improvement efforts are
usually justified on the basis of social and economic benefits
such as lives saved and overall cost reductions, but are not
necessarily profitable to the investor.
Factors Associated with Successful CQI Applications
Motivational factors
Regulatory agencies and accreditation
Transformational leadership, teamwork and a culture of
excellence
1. Motivational factors
Intrinsic motivation
CQI as job enrichment
Capturing the intellectual capital of the workforce
capitalizing on professional and specialist knowledge of
workers
Reducing managerial overhead
unique implications for healthcare setting
Lateral linkages
interdisciplinary care, interdependence and effective teamwork
2. Regulatory Agencies and Accreditation
Regulatory mechanisms such as accreditation are key factors
that have led to greater diffusion of CQI
The Joint Commission (TJC) and the Centers for Medicare and
Medicaid Services (CMS) have led to the implementation of a
series of initiatives that require hospitals to report on quality
measures
Quality Improvement Organizations (QIOs) report extensive
CQI activities and findings associated with these activities
Joint Commission has noted the use of robust, evidence based
measures, linking process performance and patient outcomes

(Chassin,et al. 2010) in the acute sector, but identified more
work was required in measurements of quality in ambulatory
care
Excellence
Transformational leadership is distinguished by its reliance on
vision
A culture of excellence of excellence in CQI has been defined
as a culture in which “a commitment to safety permeates all
levels of the organization from frontline personnel to executive
management” (AHRQ 2010)
A culture of excellence is one that ensures excellence and high
quality at every customer interface, in which a commitment to
the highest quality and CQI is shared by all in the organization
Figure 2.1:
Factors Influencing Successful CQI Implementation
Leadership
Vision
Constancy
of
Purpose
Culture of Excellence
Empowerment
Teamwork
Motivation
CQI
Communication/Feedback

Systems Thinking
Customer Focus
Excellence
Underlying the creation of a culture of excellence is a need for
systems view which emphasizes the importance of:
adding value
leadership rather than management
influence rather than power and
the alignment of incentives focused on quality not quantity of
services (Rouse 2008).
Excellence
Customer Focus
Emphasizing the importance of both internal and external
customers
Systems Thinking
Optimizing the system as a whole and thereby creating synergy
(Deming 1986; Kelly 2007)
Understanding causes of variation, learning from measurement,
and using data to make decisions (Balestracci 2009)
Excellence
Teamwork
Teams of peers working together to ensure empowerment and
motivation, ensuring alignment of the organization, the team
and the individual around the CQI vision
Communication and Feedback
Open channels of communication and feedback to make

adjustments as needed, including feedback which is fact based
and given with true concern for individuals’ organizational
success (Balestracci 2009).
Innovativeness is seen as critically dependent on good
leadership
Organizational leadership is also critical to the development of
a culture that fosters innovation (Greenhalgh et al. 2005).
Discussion Question
“Leaders within organizations are critical firstly in
creating a cultural context that fosters innovation and
secondly, establishing organizational strategy, structure and
systems that facilitate innovation”
(Greenhalgh et al. 2005, p. 69)
Three types of leaders: opinion leaders, champions, and
boundary spanners can contribute to the diffusion of innovation
across an organization
Each of these types of leaders is found in the adoption of
quality improvement initiatives in health care and often these
various types of leaders are found in combination.
Opinion leaders
At all levels of the organization
Influence on the beliefs and actions of their colleagues
Influence can be either positive or negative in regard to
embracing innovation
Opinion leaders

May be experts, respected for formal academic authority in
regard to an innovation
Their support represents a form of evidenced based knowledge
May also be peers, respected for their know-how and
understanding of the realities of clinical practice (Greenhalgh et
al. 2005).
Champions
Persistently support new ideas
May come from the top management of or within organizations,
including technical or business experts
Include team and project leaders and others who have
persistence to fight both resistance and/or indifference to
promote the acceptance of a new idea or to achieve project
goals (Greenhalgh et al. 2005).
Boundary spanners
Are a combination of these various types of leaders of
innovation
Are distinguished by the fact that they have influence across
organizational and other boundaries (Greenhalgh et al. 2005;
Kaluzny 1974)
Play an important role in multi-organizational innovations and
quality improvement initiatives (ie quality improvement
collaboratives)
Teamwork
Teams play a major role in all of health care
Teamwork is one of the most important components of all

successful CQI initiatives
Team building centers on the ability to create teams of
empowered and motivated people who are leaders themselves
and who will take the lead as necessary to foster change,
innovation and improvement
The link between leadership and teamwork is the glue which
holds CQI together – with leadership exhibited as called for at
all levels within a team
“There is no substitute for teamwork and good leaders of
teams to bring consistency of effort along with knowledge”
(Deming 1986, p.19).
Teamwork
Inherent in teamwork involves:
A high level of empowerment of team members which in turn
leads to high levels of motivation
Empowerment implies that levels of authority match levels of
responsibility, and training
Training is critical to the success of leaders, and the training of
future leaders is one of the most important responsibilities of a
leader (Tichy 1997).
Results in all members of the team being able to make
suggestions and interventions can be made to allow
improvements and prevent problems or errors(Berwick, 2010)
Teamwork
Improved motivation is the result of empowerment, and both
will interact to lead to higher quality
But both require a culture of trust
Deming’s point number eight is:
“Drive out fear. No one can put in his best performance unless
he feels secure…Secure means without fear, not afraid to
express ideas, not afraid to ask questions” (Deming 1986, p.59).

Kotter’s change model
Kotter’s work has been used to define a culture of change,
including the role of vision and leadership
Eight-stage change model which describes “how to” rather than
“what is” major organizational change
Provides guidance on traditional errors to avoid
There is a clear overlap between Kotter’s model and the factors
defined in the figure describing the culture of excellence
Common elements include:
Empowerment
Communication
feedback loops to produce more change
the central role of vision and anchoring change in the culture.
Table 2-1:
Kotter’s Eight-Stage Process of Creating Major Change
1. Establishing a Sense of Urgency
2. Creating the Guiding Coalition
3. Developing a Vision and Strategy
4. Communicating the Change Vision
5. Empowering Broad-Based Action
6. Generating Short-Term Wins
7. Consolidating Gains and Producing More Change
Anchoring New Approaches in the Culture
Source: Adapted from John Kotter, Leading Change
Conclusion
The factors that are associated with successful CQI applications
can be clearly identified
These include leadership and team work and their role in
developing a shared vision leading to a culture of excellence

which embraces CQI
CQI leaders are individuals who lead by example, teach others,
and continue to develop and expand both the philosophy and
processes of CQI
Despite the spread of CQI its further adoption in health care
continues to meet challenges, including the lack of substantial
progress in improving quality of health care and most important
reducing harm to patients (Landrigan et al. 2010; Wachter
2009)
Factors that influence the adoption of CQI include complexity,
which can inhibit further adoption and the slowing down of
progress after the impact of early adopters has waned
Conclusion

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