THE ASSIGNMENT DUE SUNDAY (WILL PAY SEPERATELY)Closely read.docx

THE ASSIGNMENT: DUE SUNDAY (WILL PAY
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3
to make decisions on the basis of their data analy-
sis. Although QI holds promise for improving
quality of care, hospitals that adopt QI often strug-
gle with its implementation (Ferlie and Shortell
2001; Institute of Medicine [IOM] 2001; Meyer
et al. 2004; Shortell, Bennett and Byck 1998). Sev-
eral researchers have examined the structures,
processes, and relationships common to designing,
organizing, and implementing hospital QI efforts
(Barsness, Shortell, and Gillies 1993; Berlowitz et
al. 2003; Blumenthal and Edwards 1995; Gilman
and Lammers 1995; Shortell 1995; Weiner,
Alexander, and Shortell 1996; Weiner, Shortell,
and Alexander 1997; Westphal, Gulati, and Short-
ell 1997). Few, however, have examined the actual
quality impact of hospital QI practices in relation
to their implementation, and none have consid-
ered the conditions under which implementation
would lead to improved quality outcomes.
In the present study, we argue that the effective-
ness of QI depends on the organizational and envi-
ronmental context in which such programs are
implemented. Context is important because hospi-
tals that adopt QI often struggle with its imple-
Abstract. The authors examined how the association between
quality improvement (QI) implementation in hospitals and

hospital clinical quality is moderated by hospital organiza-
tional and environmental context. The authors used Ordinary
Least Squares regression analysis of 1,784 community hospi-
tals to model seven quality indicators as a function of four
measures of QI implementation and a variety of control vari-
ables. They found that forces that are external and internal to
the hospital condition the impact of particular QI activities on
quality indicators: specifically data use, statistical tool use, and
organizational emphasis on Continuous Quality Improve-
ment (CQI). Results supported the proposition that QI
implementation is unlikely to improve quality of care in hos-
pital settings without a commensurate fit with the financial,
strategic, and market imperatives faced by the hospital.
Keywords: hospital quality indicators, implementation,
quality improvement
uality Improvement (QI) is a systemic
approach to planning and implement-
ing continuous improvement in perfor-
mance that is common in healthcare systems. QI
emphasizes continuous examination and improve-
ment of work processes by teams of organizational
members who are trained in basic statistical tech-
niques and problem-solving tools and empowered
Jeffrey A. Alexander, PhD, is the Richard Carl Jelinek
Professor of Health Management and Policy in the School of
Public
Health, University of Michigan. He also holds positions as
professor of organizational behavior and human resources
management,
School of Business, and faculty associate, Survey Research
Center, Institute for Social Research. Bryan J. Weiner, PhD, is
director

of the Program on Health Care Organization at the Cecil G.
Sheps Center for Health Services Research and associate
professor in
the Department of Health Policy and Administration at The
University of North Carolina at Chapel Hill. Stephen M.
Shortell,
PhD, is the dean of the School of Public Health, at the
University of California, Berkeley. Laurence C. Baker, PhD, is
an associate
professor of Health Research and Policy and chief of Health
Services Research at the Stanford University School of
Medicine, fel-
low of the Center for Health Policy at Stanford University, and
research associate of the National Bureau of Economic Research
in
Cambridge, MA. Dr. Baker also holds a courtesy appointment in
the Stanford University Department of Economics.
Copyright © 2007 Heldref Publications
Does Quality Improvement
Implementation Affect Hospital
Quality of Care?
JEFFREY A. ALEXANDER, BRYAN J. WEINER, STEPHEN
M. SHORTELL, and LAURENCE C. BAKER
Q
3-12 Alexander Spr 07 5/8/07 9:55 AM Page 3
mentation (Pollack and Koch 2003; Shortell, Ben-
nett and Byck 1998; Tu et al. 2004). QI imple-
mentation is demanding on individuals and orga-

nizations. It requires sustained leadership,
extensive training and support, robust measure-
ment and data systems, realigned incentives and
human resources practices, and cultural receptivity
to change. Therefore, hospitals need a supportive
context to make QI implementation successful. A
supportive context makes successful implementa-
tion imperative, either because it gives the hospital
a competitive advantage or because external stake-
holders demand it. A supportive context also pro-
vides sufficient resources for successful implemen-
tation. In sum, QI is more likely to be successfully
implemented––and therefore positively affect
quality of care––when hospitals operate in a con-
text that places a high priority on successful imple-
mentation and make the resources needed for
implementation available.
In this study, we assess the relationship between
hospital QI implementation and selected quality
indicators in a national sample of 1,784 commu-
nity hospitals. For the purpose of this analysis, we
investigated how the relationship between QI
implementation and hospital quality indicators
varies as a function of the hospital’s organizational
and market context.
Theory and Hypotheses
Conducive organizational and environmental
contexts are important catalysts for QI implemen-
tation. For example, hospitals located in more com-
petitive markets demonstrate more extensive QI
implementation than hospitals located in less com-
petitive markets (Blumenthal and Edwards 1995;
Weiner, Shortell, and Alexander 1997; Byrne et al.

2004). Because the success of such efforts may have
consequences for hospital market share, financial
performance, or level of reimbursement from man-
aged care payers, such hospitals may also exert
greater effort to ensure that QI activities produce
demonstrable results. By contrast, hospitals located
in less competitive markets may face less pressure to
ensure that a strong link exists between QI imple-
mentation and quality of care. For such hospitals,
simply demonstrating that they are “doing some-
thing” to improve quality may be sufficient to show
compliance with the demands of accrediting orga-
nizations, regulatory agencies, and other external
actors––even if the QI effort is more symbolic than
effective (Westphal, Gulati, and Shortell 1997).
H1: The more competitive a hospital’s market, the
stronger the positive association between QI
implementation and hospital-level indicators
of quality care.
H2: The higher the managed care penetration in a
hospital’s market, the stronger the positive
association between QI implementation and
hospital-level indicators of quality care.
Research shows that the most innovative organi-
zations are those that have the resources and finan-
cial slack to devote to new techniques and strategies
(Aiken, Clarke, and Sloane 2002; Alexander and
Weiner 1998). For QI, we contend that hospitals
must have sufficient resources to invest in informa-
tion systems, training of staff, and oversight to
make these efforts successful. Conversely, hospitals
that are struggling financially will not be able to
afford the sustained effort that is required to make

QI programs successful. They may exhibit the out-
ward structures and processes, but without ade-
quate financial support and in the face of compet-
ing demands for scarce resources, these efforts are
likely to be little more than “window dressing.”
H3: The greater the profitability of the hospital,
the stronger the positive association between
QI implementation and hospital-level indica-
tors of quality of care.
METHODS
Data Sources
We derived data on hospital QI practices from a
1997 national, mailed survey that was sent to the
CEOs of all 6,150 U.S. hospitals by the American
Hospital Association (AHA). Each CEO was asked
to complete the survey and seek the assistance of
the person responsible for the hospital’s QI effort
to ensure the most accurate data or assessment
about the hospital’s QI activities. The 26-page sur-
vey requested information about all hospital efforts
to improve quality and did not assume (or encour-
age respondents to make assumptions about) the
superiority of any specific approach. The survey
provided definitions of terms like “quality
improvement,” “quality assurance,” “continuous
quality improvement,” “total quality manage-
ment,” and “quality improvement project” to
increase the consistency and comparability of
respondents’ answers.
Of the 6,150 hospitals in the sampling frame,
2,350 (or 38%) responded to the survey. Regression
analysis showed no statistically significant differ-

4 Vol. 85, no. 2 Spring 2007
HOSPITAL TOPICS: Research and Perspectives on Healthcare
5
ences between respondents and nonrespondents in
terms of bed size, ownership, community hospital
status, teaching hospital status, metropolitan loca-
tion, or census region. We derived data on hospital
quality indicators from the Medicare Inpatient
Database, which contains the universe of the inpa-
tient discharge abstracts for Medicare patients in all
states, translated into a uniform format to facilitate
multistate and multihospital comparisons. We
obtained data on hospital, market, and other envi-
ronmental characteristics from the 1997 AHA’s
Annual Survey of Hospitals, the 1998 Bureau of
Health Professions’ Area Resource File, and two
proprietary data sets compiled by Solucient
(Evanston, IL). The AHA Annual Survey is admin-
istered annually in the fourth quarterlyer to all AHA
registered and nonregistered facilities. The Area
Resource File supplies county-specific data on an
annual basis for numerous market and demograph-
ic factors comprising the local operating environ-
ments of hospitals. Solucient provides information
on county-level coverage for six types of insurance,
making possible the construction of managed care
penetration measures. Solucient also supplies hospi-
tal financial performance ratios derived from the
1997 and 1998 Medicare Cost Reports.

Sample
Given our focus on U.S. community hospitals,
we eliminated federal hospitals, specialty hospitals,
and hospitals located in U.S. territories. We also
eliminated hospitals that responded to the QI sur-
vey but lacked an AHA identification number (of
which there were 50), a Medicare (HCFA) identi-
fication number (96), or any MEDPAR discharges
(43). Our final sample consisted of 1,784 hospi-
tals. Comparisons with the population of U.S.
community hospitals in 1998 indicated that this
sample was proportionately comparable on region-
al location, size, system membership, and rural-
urban location. However, investor-owned hospitals
were slightly underrepresented in the sample.
Measures
Independent Variables. Hospitals vary in the
intensity with which they approach QI implemen-
tation. Intensity refers to the extent or range of
application of QI philosophy and methods and, as
such, indicates the pervasiveness with which QI
practices permeate organizational structures and
routines. We measured QI intensity by four vari-
ables. The first variable indicated the number of
conditions or procedures for which a clinical
guideline, pathway, or protocol existed at the hos-
pital. We examined nine common conditions or
procedures: asthma, diabetes, hypertension, coro-
nary artery bypass graft (CABG) surgery, total hip
replacement, depression, pregnancy, pneumonia,
and stroke. The second variable indicated the per-

centage of conditions or procedures for which
quality data are collected and used by formally
organized QI project teams. We examined 10 con-
ditions and procedures: acute myocardial infarc-
tion (AMI), congestive heart failure (CHF), pneu-
monia, hip replacement, transurethral resection of
the prostate, coronary bypass, Cesarean section,
hysterectomy, asthma, and diabetes. The third
variable indicated the average extent to which a
few, many, or all groups or teams within the hos-
pital used statistical and process-management
tools. We examined 12 tools: cause and effect, fish-
bone diagrams, control charts, run charts, his-
tograms scatter diagrams, process flow charts,
affinity diagrams, nominal group methods, brain-
storming, systems thinking, rapid cycle process
improvement, and Pareto diagrams. Exploratory
factor analysis supported the construction of a sin-
gle scale, which showed good reliability (α = .88).
The fourth variable indicated the extent to which
the hospital’s activities focused on improving
processes and systems of care as opposed to cor-
recting individuals’ mistakes after the fact. Respon-
dents rated five program aspects: (a) the use of
structured problem solving processes that incorpo-
rate statistical methods and measurement to diag-
nose and monitor progress; (b) the philosophy of
continuous improvement of quality through
improvement of organizational processes; (c) the
empowerment of employees to identify quality
problems and improvement opportunities and to
take action on these problems and opportunities;
(d) the explicit focus on customers both internal
and external; and (e) the use of QI teams as the
major mechanism for introducing improvements
in organizational processes, which include employ-

ees from multiple departments and from different
organizational levels Each aspect was measured on
an ordinal scale ranging from 1 (not at all) to 5 (a
very great extent). Exploratory factor analysis sup-
ported the construction of a single scale, which
showed good reliability (α = .84).
With respect to the moderator variables, we
measured hospital competition by using a
Herfindal Index of market concentration, defined
as the sum of the squared market shares of the
hospitals in the county in 1997 (Phibbs and
Robinson 1993). We measured managed care pen-
etration as the percentage of the total insured pop-
ulation in a county enrolled in a private risk,
Medicare risk, or Medicaid risk insurance product
in 1997. Last, we measured profitability as the net
available for debt service (i.e., net patient income,
depreciation, amortization, and interest expense)
divided by the sum of net patient revenue and
total other income. We measured profitability as a
two-year average (1997 and 1998) to smooth
short-term fluctuations.
Dependent Variables. To capture hospital quality,
we selected seven Agency for Healthcare Research
and Quality (AHRQ) Indicators on the basis of
their favorable performance on four empirical tests
of precision and five empirical tests of minimum
bias. The UCSF-Stanford Evidence-Based Practice
Center (EPC), partners in the current investiga-

tion, employed an extensive process for identify-
ing, refining, risk-adjusting, and testing the
AHRQ Quality Indicators (AHRQ 2004). Five
indicators focused on inpatient procedures or con-
ditions in which mortality rates have been shown
to vary substantially across institutions and in
which evidence suggests that high mortality, at
least in part, may be associated with deficiencies in
quality of care. These indicators were inpatient
hospital mortality for CABG, AMI, CHF, stroke,
and pneumonia. In addition, two indicators (bilat-
eral catheterization and laparoscopic cholecystec-
tomy) focused on a procedure whose use varies sig-
nificantly across hospitals, and for which evidence
suggests that a high rate of use represents inappro-
priate care (AHRQ). We constructed each Quality
Indicator as a two-year average (1997 and 1998) to
smooth short-term fluctuations.
Control Variables. We included four categories of
covariates that we expected to relate to QI imple-
mentation, hospital quality indicators, or both:
market characteristics, hospital characteristics,
accreditation and quality standards, and length of
QI experience. In terms of market characteristics,
we included two competition variables: the per-
ceived number of hospital competitors, and the
perceived level of competition intensity for
patients among hospitals in the market. We mea-
sured each on a seven-point scale that ranged from
1 (not at all intense) to 7 (highly intense). We also
included one managed care variable: percentage of
patients covered under private managed care.
We included seven variables that indicated the
hospital’s structural complexity. These included a

binary variable indicating whether the hospital
belonged to the Council of Teaching Hospitals
(COTH); a binary variable whether the hospital was
owned, leased, or sponsored by a healthcare system
or health network; three binary variables indicating
whether a hospital had developed––on its own or
through a health system, health network, or joint
venture with an insurer––a health maintenance
organization (HMO), preferred provider organiza-
tion (PPO), or indemnity product (FFS); and a vari-
able indicating the number of physician arrange-
ments in which the hospital participates, either on
its own or through a health system or health net-
work. We examined eight physician arrangements
(e.g., independent practice association).
Other hospital characteristics included (a) a
measure of hospital volume: the number of inpa-
tient surgeries performed in the past 12 months
divided by 1,000; (b) two binary variables indicat-
ing whether the hospital was public (nonfederal)
or investor-owned; and (c) two measures of hospi-
tal service mix variables: total outpatient visits,
including emergency room visits and outpatient
surgeries, adjusted by hospital bed size and divided
by 1000; and (d) the ratio of the number of out-
patient services offered by the hospital to the num-
ber of inpatient services offered by the hospital.
For the latter of the hospital service mix indicators,
25 services listed in AHA Annual Survey (AHA
1997) were designated outpatient services; 47 were
designated inpatient services.
With respect to accreditation and quality stan-
dards, we included three variables that indicated
the self-reported influence of the Joint Commis-

sion on the Accreditation of Healthcare Organiza-
tions (JCAHO), Foundation for Accountability
(FAACT), and National Committee of Quality
Assurance (NCQA) on the hospital’s QI effort.
We measured these variables on a five-point scale
that ranged from 1 (no influence) to 5 (very great
influence).
Last, we controlled for the number of years since
the hospital first became involved in QI. We
defined involved as the first training of organiza-
tional members in QI principles and methods or
the substantive investment of upper management’s
time in organizing QI. We used a square-root
transformation to correct for positive skew. Table 1
summarizes the descriptive statistics for all study
variables.
6 Vol. 85, no. 2 Spring 2007
7
TABLE 1. Descriptive Statistics for Study Variables
Variable N M SD
Quality improvement (QI) implementation
Number of guidelines developed 1784 2.66 2.3
Intensity of process improvement tool use 1749 1.32 0.55
Use of quality of care data by QI teams 1749 0.72 0.43

Emphasis on quality improvement 1751 3.83 0.74
Moderator variable
Market concentration 1784 0.57 0.36
Managed care penetration 1783 0.22 0.2
Profitability 1773 10.61 14.62
Hospital-level quality indicator
In-hospital mortality–CABG 414 0.05 0.03
In-hospital mortality–AMI 1762 0.18 0.12
In-hospital mortality–CHF 1781 0.05 0.03
In-hospital mortality–Stroke 1776 0.12 0.06
In-hospital mortality–Pneumonia 1784 0.09 0.04
Bilateral catherization 843 0.15 0.17
Laparoscopic cholecysectomy 1683 0.6 0.21
Control variable
Perceived no. of hospital competitors 1749 4.55 4.43
Perceived hospital competition intensity 1749 5 1.52
% patients private managed care 1749 0.32 0.3
Teaching hospital status (binary) 1780 0.25 0.43
System or network affiliated 1784 0.61 0.49
HMO ownership 1784 0.27 0.44
PPO ownership 1784 0.36 0.48
Indemnity ownership 1784 0.12 0.32
No. of physician arrangements 1784 1.22 1.29
No. of inpatient surgeries 1784 2251.31 3536.99
Public, nonfederal ownership 1784 0.27 0.44
For-profit ownership 1784 0.09 0.29
Outpatient visits (adjusted by beds) 1784 605.24 514.22
Outpatient/inpatient ratio 1784 0.49 0.22
Perceived influence of JCAHO 1749 4.01 1.26
Perceived influence of FAACT 1749 1.19 0.54

Perceived influence of NCQA 1749 2 1.11
Years of formal involvement in QI 1568 4.15 2.36
Instrumental variable
CEO participation in QI activities 1749 3.66 1.17
Board monitoring of QI 1784 10.45 3.17
Board activity in QI 1784 1.95 1.61
Total expenses on QI 1749 246637.82 392170.41
Integrated data base 1733 0.21 0.41
Clinical IS capabilities 1751 2.37 0.88
Clinical integration (binary) 1749 0.47 0.5
Perceived barriers to QI 1751 3.23 0.96
Hospital size (beds) 1784 185.6 185.26
Hospital size (beds-squared) 1784 68746.16 161588.04
Note. CABG = coronary artery bypass surgery; AMI = acute
myocardial infarction; CHF = congestive heart failure; HMO =
health mainte-
nance organization; PPO = preferred provider organization;
JCAHO = Joint Commission on the Accreditation of Healthcare
Organiza-
tions; FAACT = Foundation for Accountability; NCQA =
National Committee on Quality Assurance.
Statistical Analysis
We addressed our hypotheses by estimating
regression models that relate the hospital-level
patient quality indicators to the QI implementation
scores and controlling for hospital organizational
and financial characteristics and hospital market

attributes (H1). We interacted the QI implementa-
tion variables with the moderating variables in some
specifications to test the conditional effects of mar-
ket and organizational context on the QI implemen-
tation-quality indicator relationship (H2–H4). In
both cases, we evaluated the marginal contribution
to variance explained by the QI implementation set
over that explained by the control variables alone.
We tested for the significance of these relationships
by using standard F tests and considered results sta-
tistically significant if the p value was less than .05.
RESULTS
Table 2 presents the results of the hypotheses.
8 Vol. 85, no. 2 Spring 2007
TABLE 2. General Linear Model Regression Results: Moderated
Effects of Quality Improvement (QI)
Implementation on Quality Indicators: Market Concentration,
Managed Care Penetration, and Profitability
Mortality
CABG AMI CHF
Quality indicator β SE β SE β SE
Market concentration
No. guidelines developed 0.028 0.029 0.096 0.023*** 0.057
0.014***
No. guidelines squared −0.002 0.003 −0.008 0.002** −0.003
0.002*

Use of quality of care data −0.082 0.180 0.298 0.116* 0.132
0.070+
Use of statistical/process tools −0.032 0.062 −0.099 0.056+
−0.035 0.035
Quality improvement emphasis −0.003 0.041 0.072 0.039+
−0.011 0.025
Guidelines × Concentration −0.032 0.031 −0.034 0.019* −0.019
0.012
Use of Data × Concentration −0.069 0.421 −0.279 0.158+
−0.160 0.095+
Tool Use × Concentration 0.086 0.154 0.283 0.080*** 0.111
0.050*
QI Emphasis × Concentration 0.005 0.108 −0.121 0.056* 0.027
0.036
N 405 1712 1730
Adjusted R2 .19 .42 .39
Managed care penetration
0.011***
No. guidelines squared −0.002 0.003 −0.006 0.002** −0.003
0.001+
Use of quality of care data −0.433 0.229+ 0.013 0.072 −0.026
0.043
Use of statistical/process tools 0.129 0.081* 0.179 0.041***
0.091 0.025***
Quality improvement emphasis 0.047 0.056 −0.031 0.029 0.006
0.018
Guidelines × Managed Care 0.010 0.041 0.007 0.031 0.028
0.020
Use of Data × Managed Care 1.068 0.634 0.678 0.296* 0.335
0.174+

Tool Use × Managed Care −0.420 0.212 −0.560 0.141***
−0.299 0.089***
QI Emphasis × Managed Care −0.153 0.145 0.157 0.100 −0.003
0.063
N 405 1712 1730
Adjusted R2 .21 .42 .39
Profitability
0.011***
No. guidelines squared −0.002 0.003 −0.006 0.002* −0.003
0.001+
Use of quality of care data −0.085 0.180 0.089 0.063 −0.020
0.037
Use of statistical/process tools −0.036 0.091 0.056 0.038 0.036
0.023
Quality improvement emphasis −0.022 0.050 0.061 0.025*
0.036 0.016*
Guidelines × Profitability −0.001 0.001 0.000 0.001 0.000 0.000
Use of Data × Profitability −0.001 0.014 0.003 0.004 0.006
0.002*
Tool Use × Profitability 0.003 0.007 0.001 0.002 −0.001 0.001
QI Emphasis × Profitability 0.002 0.004 −0.006 0.001* −0.003
0.001***
N 405 1712 1730
Adjusted R2 .19 .42 .39
Note. CABG = coronary artery bypass surgery; AMI = acute
myocardial infarction; CHF = congestive heart failure; Cath =
catheterization.
+p < .10. *p < .05. **p < .01. ***p < .001.

9
Because of the size of the models and the number
of quality indicators we examined, control variable
parameter estimates are not shown. However, the
displayed results control for all covariates described
under the Independent Variables and Control
Variables sections above and in Table 1.
The QI implementation variables as a set added
a significant increment to the explained variance of
all models tested. As we expected, the effects of QI
implementation on hospital quality indicators var-
ied as a function of hospital organizational and
environmental context, although the effects were
not always consistent or in the predicted direction.
Hypothesis 1 predicted a stronger positive rela-
tionship between QI implementation and hospi-
tal-quality indicators as competition increased.
This prediction was supported for use of statistical
and process management tools. In four of the
seven models, the product term for extensive tool
use and managed care penetration was statistically
Stroke Pneumonia Bilateral Cath Laproscopy
β SE β SE β SE β SE
0.085 0.021*** 0.134 0.026*** 0.338 0.139* 0.2 0.066**
−0.005 0.002* −0.008 0.003** −0.026 0.014+ −0.013 0.007+

0.215 0.103* 0.288 0.124* 0.187 0.808 0.772 0.332*
−0.039 0.050 −0.069 0.063 0.284 0.331 −0.127 0.159
0.002 0.035 0.048 0.044 −0.196 0.22 0.163 0.111
−0.031 0.017* −0.066 0.021** −0.084 0.13 0.024 0.055
−0.260 0.138* −0.315 0.167+ −0.169 1.466 −1.193 0.46**
0.202 0.072** 0.211 0.09* −0.369 0.652 0.519 0.232*
−0.042 0.051 −0.054 0.064 0.332 0.425 −0.119 0.162
1725 1733 818 1633
.46 .42 .14 .35
0.061 0.016*** 0.072 0.02*** 0.269 0.129* 0.214 0.053***
−0.004 0.002 −0.007 0.003* −0.025 0.014+ −0.012 0.007+
−0.052 0.063 −0.013 0.077 0.453 0.794 −0.341 0.217
0.129 0.037*** 0.149 0.046** −0.108 0.36 0.401 0.121***
−0.031 0.026 −0.009 0.033 0.027 0.251 0.092 0.085
−0.004 0.028 0.598 0.307+ −1.319 2.47 2.191 0.855*
0.612 0.255* 0.073 0.035* 0.092 0.202 −0.063 0.091
−0.243 0.128+ −0.461 0.159** 0.895 1.038 −1.108 0.41**
0.041 0.091 0.128 0.113 −0.325 0.714 0.039 0.291
1725 1733 818 1633
.46 .42 .14 .35
0.058 0.016*** 0.079 0.02*** 0.372 0.127* 0.171 0.053**
−0.003 0.002 −0.005 0.003* −0.184 0.305 −0.013 0.007+
−0.038 0.057 0.036 0.067 0.098 0.599 −0.451 0.198*

0.064 0.035+ 0.059 0.042 −0.023 0.014 0.335 0.12**
0.000 0.023 0.061 0.028* −0.158 0.196 0.266 0.075***
0.000 0.001 0 0.001 −0.008 0.004* 0.003 0.002+
0.011 0.004** 0.006 0.004 0.006 0.031 0.053 0.013***
0.002 0.002 −0.001 0.003 0.029 0.019 −0.015 0.008+
−0.002 0.001* −0.005 0.002** 0.007 0.011 −0.016 0.004***
1725 1733 818 1633
.46 .42 .15 .36
significant and negative. In one additional model
(stroke mortality), the product term was marginal-
ly significant and negative. This finding indicates
that, as managed care penetration increases, exten-
sive tool use is increasingly associated with better
values on hospital-quality indicators (e.g., lower
adjusted mortality). By contrast, in three of the
seven models, we observed the opposite pattern for
use of quality of care data by multiple, formally
organized QI project teams. As managed care pen-
etration increased, use of quality of care data was
increasingly associated with poorer indicator val-
ues for AMI mortality, stroke mortality, and
laparoscopic cholecystectomy. We observed a sim-
ilar pattern for CHF mortality and pneumonia
mortality, although these findings achieved only
marginal statistical significance.
In Hypothesis 2, we predicted that, as managed
care penetration increases, QI implementation
would exhibit an increasingly positive association

with hospital-level quality indicators. As with
Hypothesis 1, this prediction was supported for
extensive use of statistical and process management
tools. In five of the seven models (the exceptions
being CABG mortality and bilateral catheratiza-
tion), the product term for extensive tool use and
market concentration was statistically significant
and positive. This means that, as market concen-
tration increases (and as competition decreases),
extensive tool use is increasingly associated with
inferior values on hospital-quality indicators (e.g.,
lower adjusted mortality). Stated conversely, as
market competition increases (and market concen-
tration decreases), extensive tool use is associated
with better values on quality indicators.
The results offer suggestive evidence that, con-
trary to Hypothesis 1, use of data by multiple, for-
mally organized project teams is increasingly asso-
ciated with better values on hospital-level quality
indicators as concentration increases (and compe-
tition decreases). The product term for use of data
and market concentration was statistically signifi-
cant and negative for stroke mortality and laparo-
scopic cholecystectomy. It was also negative for
three other hospital-level quality indicators; how-
ever, these associations achieved only marginal sta-
tistical significance (p < .10).
In Hypothesis 3, we predicted that, as hospital
profitability increases, QI implementation would
exhibit an increasingly positive association with
hospital-level quality indicators. This prediction
was supported most consistently for the QI imple-
10 Vol. 85, no. 2 Spring 2007

mentation measure of organizational focus on
improving systems and processes. In five of the
seven models, the product term for organizational
focus and hospital profitability was statistically sig-
nificant and negative. As profitability increases, the
association between hospital focus on improving
system processes and better quality indicators
strengthens. In three of the models, we observed
the opposite pattern for use of quality of care data
by multiple, formally organized project teams.
That is, contrary to expectations, as hospital prof-
itability increases, use of data is increasingly associ-
ated with poorer indicator values on CHF mortal-
ity, stroke mortality, and laparoscopic
cholecystectomy.
Discussion
Our findings suggest that the impact of specific
QI implementation dimensions on quality indica-
tors depends on the economic and market contexts
in which the hospital actually delivers care. Most
notably, we observed that a hospital’s relative focus
on improving systems and processes of care led to
better quality indicators as the financial position
(i.e., profitability) of the hospital improved. This
finding suggests that a strategic commitment to
quality improvement (vs. simply quality assurance)
must be accompanied by enough organizational
slack to make such a commitment meaningful.
Having the resources to devote to QI efforts is like-
ly an important condition to ensuring the success
of such efforts. Alternatively, hospitals that adopt a
strategy of continuous improvement without suffi-
cient financial cushion may be creating superflu-

ous structures with no real substance behind them.
This may actually serve to negatively impact qual-
ity of care, as scarce resources and staff time are
diverted from established care routines.
We observed similar moderating effects for both
competition (market concentration) and managed
care penetration. In both cases, these market char-
acteristics raised the effectiveness of increased use
of statistical and process improvement tools. It
may be the case that market forces emanating from
other providers or insurers pressure hospitals to
more seriously adopt and use QI tools to maintain
market share or satisfy the requirements of man-
aged care payers. Without such pressures, the
impetus for their use may be lacking or, as noted in
the main effects results, even counterproductive.
However, it should be noted that the moderat-
ing effects of market and organizational context do
11
not always operate in the expected direction. For
example, the increased use of quality of care data in
support of QI efforts was associated with lower
quality at the hospital level when managed care
penetration, competition and, to a lesser extent,
profitability increased. Although these results are
not as consistent as the results for the moderated
effects of the other QI dimensions, they do suggest

that quality improvement data fare better under
less rigorous market or payer pressures, possibly
because data capabilities are used more for cost-
control or cost-reduction purposes. This may
weaken any attempt to add quality to the data sys-
tem and force the hospital into trying to meet two
somewhat separate goals. Alternatively, if market
pressures are weaker, hospitals may be able to pur-
sue quality-related data systems without having to
contend with conflicting pressures to reduce costs.
This, in turn, may foster improved quality of care
at the hospital level.
From these analyses, we conclude that forces
external and internal to the hospital condition the
impact of particular QI activities on quality indi-
cators: specifically data use, tool use and organiza-
tional emphasis on CQI. The moderating effects
are both positive and negative, meaning that there
are conditions that both strengthen the relation-
ship between QI implementation and better qual-
ity outcomes (e.g., competition and QI tool use),
and enhance the relationship between QI imple-
mentation and poorer quality outcomes (e.g.,
managed care penetration and QI data use). Inter-
nal and external organizational forces only mini-
mally moderate the effects of other QI dimensions,
such as guidelines.
Our results reinforce the findings of the recent
Institute of Medicine (IOM) report Crossing the
Quality Chasm (2001). The report posited that the
relevant systems of healthcare delivery are nested
or hierarchically arrayed, with each successive level
affecting the one(s) below it. In this study, two lev-
els are particularly relevant: the organizational sup-

port system level and the environment, which can
be considered to operate as organizational charac-
teristics of the hospital and its immediate operat-
ing environment. The IOM report specifically
mentioned six aspects of organizational support
necessary for clinical teams at the microsystem
level to be effective: (a) attention to care processes
through QI and CQI, (b) effective use of informa-
tion technologies, (c) knowledge and skills man-
agement; (d) effective teams, (e) coordination of
care, and (f ) performance measurement and
enhancement. The report strongly suggested that
the effectiveness of these support systems is influ-
enced (either reinforced or attenuated) by the sys-
tem of payment and market conditions faced by
organizations. Our results indicate that QI imple-
mentation operates differently on quality indica-
tors as a function of these contextual conditions.
Therefore, it is unlikely that QI will improve qual-
ity of care in hospital settings without a commen-
surate fit with financial, strategic, and market
imperatives faced by the hospital. In designing
approaches to QI, managers and physicians need
to be cognizant of both the internal and external
environment to ensure that they are supporting
effective QI.
Study Limitations
Two important study limitations should be
noted. First, because our analysis required the
merger of several existing databases, we cannot
assure that our sample is representative of the pop-
ulation of United States community hospitals.
Although our sample appears to be formally repre-

sentative of the population with respect to several
organizational and environmental characteristics,
it is not a probability-based, random sample and
thus, we cannot fully discount the possibility that
nonresponders are systematically different than
responders on some important, unmeasured char-
acteristics. This limitation indicates that caution
should be exercised in generalizing our study find-
ings to a specific hospital population. Nonetheless,
we believe that the breadth and depth of our hos-
pital QI data, coupled with reliable, validated
quality indicators, represent an advance over previ-
ous small-sample studies of hospital QI and pro-
vide a solid basis for subsequent research.
Second, our use of cross-sectional survey data
raises concerns about the potentially endogenous
relationship between hospital QI practices and
hospital quality indicators. For example, poorly
performing hospitals may be motivated to correct
performance problems by adopting more focused
initiatives aimed at improving quality of care. Or,
some hospitals may have unobserved attributes
that predispose them to higher quality of care and
that also increase the likelihood that they will
invest in QI activities. To address this concern, we
re-estimated our models using a two-stage instru-
mental variables approach (results available from
the authors). We identified 10 instruments
through a careful review of the research literature
on QI adoption and implementation. The instru-

ments included three measures of leadership for
QI, four measures of hospital infrastructure for
QI, and three measures of resources for QI. All 10
exhibited satisfactory predictive power. The two-
stage instrumental variables estimation approach
generated results comparable with those produced
by the simpler one-stage models presented earlier.
Although our theoretical logic and statistical tests
suggest that our instrumental variables were valid,
additional work using other instruments or study
designs that approach endogeneity in other ways
(e.g., analysis of changes over time when hospitals
adopt QI) could help better understand these
issues.
CONCLUSION
Multiple stakeholders––from community mem-
bers and patients to employers and
purchasers––are demanding data and evidence
from providers regarding the effectiveness of their
care. Despite a shift in attention toward clinical
outcomes, there has not been a commensurate
shift in efforts to examine why variations in clini-
cal outcomes exist and, perhaps more importantly,
what organizational practices and procedures are
associated with improved quality indicators at an
institutional level. The present study provides mul-
tiple stakeholders with information about the rela-
tionships of one aspect of hospital QI activity to
hospital-level quality indicators.
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12 Vol. 85, no. 2 Spring 2007
Australian Society for Simulation in Healthcare

QUALITY MANAGEMENT PLAN
Table of Contents
1 BACKGROUND
...............................................................................................
............................ 4
1.1
OBLIGATION.........................................................................
.................................................. 4
1.2 DEFINITIONS
...............................................................................................
........................... 4
1.3 OBJECTIVES
...............................................................................................
............................ 4
2 PROJECT QUALITY PLANS
...............................................................................................
..... 5
2.1 PLANNING
QUALITY...............................................................................
................................ 5

2.2 WHAT NEEDS TO BE CHECKED?
..............................................................................................
5
2.3 WHAT IS THE MOST APPROPRIATE WAY TO CHECK?
............................................................... 5
2.4 WHEN SHOULD IT BE CARRIED OUT?
...................................................................................... 5
2.5 WHO SHOULD BE INVOLVED?
........................................................................................... ....
.. 5
3 QUALITY PLANNING FRAMEWORK
................................................................................... 6
3.1 QUALITY MATERIALS
...............................................................................................
............. 6
3.2 QUALITY
EVENTS.................................................................................
.................................. 7
3.3 QUALITY METRICS
.............................................................................................. .
.................. 8
4 EXAMPLE PROJECT QUALITY
PLAN.................................................................................. 9
5 CONTINUOUS IMPROVEMENT
...........................................................................................
10
5.1 STEP-BY-STEP IMPROVEMENT
..............................................................................................
10
5.2 CONTINUOUS IMPROVEMENT FRAMEWORK
......................................................................... 10

Document information
Criteria Details
Document title: Quality Management Plan
Document owner: Chair, Australian Society for Simulation in
Healthcare
Document author: Anthony Rowley, Lange Consulting &
Software
Version: 2 Revision: 2
Issue date: 11 July 2008
Version control
Version Date Description
1 1 May 2008 Draft (based on SIAA template)
2 11 July 2008 Released
3
4
5
6

Document approval
This document requires the following approval:
Name Title Organisation
Dr Leonie Watterson Chair Australian Society for Simulation in
Healthcare
1 BACKGROUND
1.1 Obligation
1.1.1 Every project should have a Project Quality Plan to ensure
whatever is
delivered is within the quality expectations of the organisation.
1.1.2 This Quality Management Plan establishes a framework
for developing
Project Quality Plans.
1.1.3 This Quality Management Plan defines how and when
"Quality Events" and
"Quality Materials" are applied to a project.
1.2 Definitions
1.2.1 In this Quality Management Plan the following definitions
are applied:

Term Definition
Quality Materials The artefacts used within an organisation to
assist a Project
Manager improve quality in the project e.g. Templates,
Standards, Checklists. These materials are used in "Quality
Events"
Quality Events How the "Quality Materials" are applied to a
project. They are
the activities undertaken using "Quality Materials" to validate
the quality of the project.
Quality Control The implementation of the "Quality Events" in
the "Quality
Plan"
Quality Assurance The processes used to verify that
deliverables are of
acceptable quality and that they meet the completeness and
correctness criteria established.
Quality Metrics Statistics captured during the various activities
undertaken as
part of "Quality Assurance". Metrics are captured to identify
areas where quality improvements can be made. They can also
be used measure the effectiveness of Continuous
Improvement.
Continuous
Improvement
Use of captured metrics, and lessons learnt to continually
improve quality. They are the main reason for capturing
statistics around quality.

Well Engineered Well Engineered means the construction is
sound and reliable.
It does not necessarily mean it is correct.
Correct Correct means the end results are an accurate reflection
of the
requirements. It does not necessarily mean it is Well
Engineered.
Work Break-down
Structure
The defined hierarchy of Milestones, Deliverables and Tasks
associated with a project.
1.3 Objectives
1.3.1 The objective of this Quality Management Plan is to
ensure Project Quality
Plans are developed for projects. Plans should establish a
balance between
“the quality of the project” and “the quality of deliverables”.
2 PROJECT QUALITY PLANS
2.1 Planning Quality
2.1.1 A quality plan needs to cover a number of elements:
a) What needs to go through a quality check?
b) What is the most appropriate way to check the quality?
c) When should it be carried out?

d) Who should be involved?
e) What "Quality Materials" should be used?
2.2 What needs to be checked?
2.2.1 Typically what needs to be checked are the deliverables.
Any significant
deliverable from a project should have some form of quality
check carried
out.
2.2.2 Deliverables need to be prioritised in the context of
carrying out quality
checks, for instance:
a) a requirements document can be considered significant,
whereas
b) a memo or weekly report may not be significant.
2.2.3 For the project itself, it may be appropriate to have the
project management
practices reviewed for quality once the project is initially
established. This
may be useful to give a Project Board confidence in the team.
2.2.4 When considering what needs to be checked, you also
need to differentiate
between Correct and Well Engineered.
A Well Engineered bridge may never fall down.
If it is doesn't cross the river at the right place, it is not Correct.
2.2.5 Quality checking may be for either Correct or Well
Engineered, or it may be
for both.

2.3 What is the most appropriate way to check?
2.3.1 To answer this question requires thinking backwards. If
the end result is that
a particular deliverable should meet a standard, then part of the
quality
checking should focus on compliance with the standard. This
would indicate
a Standard Audit could be the best approach.
2.4 When should it be carried out?
2.4.1 Most Quality Events are held just prior to the completion
of the delivery.
2.4.2 If there are long development lead times for a deliverable,
it might be
sensible to hold earlier Quality Events.
2.5 Who should be involved?
2.5.1 The person(s) who produced the deliverable should be
involved.
2.5.2 It is also useful to have some representation from the
recipients of the
deliverable in order to ensure you are meeting their needs.
3 QUALITY PLANNING FRAMEWORK
3.1 Quality Materials

3.1.1 The following Quality Materials might be used in a
quality plan:
Quality Materials Description
Standards Standards are instruction documents that detail how a
particular aspect of the project must be undertaken.
There can be no deviation from "Standards" unless a
formal variation process is undertaken, and approval
granted.
Guidelines Guidelines are intended to guide a project rather
than
dictate how it must be undertaken. Variations do not
require formal approval.
Checklists Checklists are lists that can be used as a prompt
when
undertaking a particular activity. They tend to be
accumulated wisdom from many projects.
Templates Templates are blank documents to be used in
particular
stages of a project. They will usually contain some
examples and instructions.
Procedures Procedures outline the steps that should be
undertaken in
a particular area of a project such as managing risks, or
managing time.
Process A Process is a description of how something works. It
is
different to a Procedure in that a Procedure is a list of
steps; i.e. what and when. A Process contains

explanations of why and how.
User Guides User Guides provide the theory, principles and
detailed
instructions as to how to apply the procedures to the
project. They contain such information as definitions,
reasons for undertaking the steps in the procedure, and
roles and responsibilities. They also have example
templates.
Example Documents These are examples from prior projects
that are good
indicators of the type of information, and level of detail
that is required in the completed document.
Methodology A Methodology is a collection of processes,
procedures,
templates and tools to guide a team through the project
in a manner suitable for the organisation.
3.2 Quality Events
3.2.1 The following Quality Events are typically used to review
the quality of
deliverables. They tend to have a different mix of reviewing the
structure
and reviewing the content.
Quality Events Description

Expert Review Review of a deliverable by a person who is
considered
an expert in the area. The person may not currently hold
a position but has expert knowledge in the area. This
type of review is good when the focus is on accuracy of
content (Correct) rather than of structure (Well
Engineered).
Peer Review Review of deliverables by one's peers. Peer
reviews are
better suited where the emphasis is on structure rather
than content. A peer review will focus on ensuring the
deliverable is well engineered. Neither an "Expert
Review" nor a "Peer Review" is exclusively focused on
content or structure. They each however, have a different
emphasis.
Multi person Review A review carried out independently by
several people is
likely to pick up more points however it does bring the
difficulty of trying to reconcile different viewpoints. It is
best undertaken when the purpose is to gain agreement
between different stakeholders. Time should be allowed
to reach agreement of conflicting opinions. This may
entail a meeting or workshop to resolve differences.
Walk-through A walk-through is a useful technique to validate
both the
content and structure of a deliverable. Material should be
circulated in advance. If particular participants have not
done their homework, they should be excluded from the
walk-through.
Formal Inspection A formal inspection is a review of a
deliverable by an

inspector who would typically be external to the Project
Team. The inspector captures statistics on suspected
defects. It is a useful technique for use with
documentation.
Standard Audit A Standard Audit is carried out be a person who
is only
focused on ensuring the deliverable meets a particular
standard(s).
Process Review Where Process is reviewed to ensure all
necessary
actions are being undertaken, information recorded, and
procedures followed. A Process Review is useful to
validate the existing processes in an organisation; for
example, modification to an existing system may be
based on the assumption an existing business process is
being followed. If the business process is either not
being followed or is different, the modification to the
system may have unexpected results.
3.3 Quality Metrics
3.3.1 Adding Quality Metrics to a Project Quality Plan removes
subjective
assessment during Quality Assurance.
3.3.2 A metric is a verifiable measure stated in either
quantitative or qualitative
terms; for example,

a) “95 percent accuracy”
b) “as evaluated by our clients, we are providing above-average
service”
c) “delivered within 7 days of authorisation”
3.3.3 Metrics must have the following characteristics:
Characteristic Description
Clarity of Definition Because the metric is intended to convey a
particular
piece of information regarding an aspect of business
performance in a summarized manner, it is critical that
its underlying definition be stated in a way that clearly
explains what is being measured.
Each metric should be subject to an assessment process
in which the key project stakeholders participate in its
definition and agree to the definition's final wording.
Measurability Any metric must be measurable and should be
quantifiable within a discrete range.
Controllability Any measurable characteristic of information
that is
suitable as a metric should reflect some controllable
aspect of the project.
Reportability Each metric's definition should provide enough
information that can be summarized as a line item in a
report.

4 EXAMPLE PROJECT QUALITY PLAN
4.1.1 A typical Project Quality Plan may look something like
this:
Deliverable Quality Event Quality Materials Quality Metrics
Purpose
Preliminary
Business Case
Expert Review • Business Case
template
• All elements of the Template
have been completed
Ensure the information is accurate
and well constructed prior to
submission to Project Board.
Final Business
Case
Formal Inspection
by Sponsor
• Requirements
• Business Case
template
• Approval by the Project Board Ensure the Business Case is in
a fit

state to be submitted to the Finance
Review Committee.
Project
Management Plan
Walk-through of
early draft
• Project Management
Plan template
have been completed
Review early draft for completeness.
Peer Review of final
draft
• Project Management
Plan template
have been completed
• Project Schedule achieves
contracted timelines
Review final draft for completeness
and construction
Programme
Design
Expert Review of

Programme Design
• Programme Guidelines
• Programme Objectives
• Previous Programme
Design Examples
• Design is meets all
Programme Guidelines
• Design achieves Programme
objectives
Compliance with guidelines,
requirements and general accuracy.
Formal Inspection
by Sponsor
• Programme Guidelines
• Programme Objectives
• Design was delivered in
accordance with the Project
Schedule
• Design meets all Programme
Guidelines
• Design achieves Programme
objectives
Compliance with contract terms.
4.1.2 Quality should be specified for all project deliverables

associated with a project Work Break-down Structure.
5 CONTINUOUS IMPROVEMENT
5.1 Step-by-step improvement
5.1.1 What goes wrong in one project is likely to go wrong in
other projects unless
the cause is identified and fixed.
5.1.2 Continuous improvement is defined as the progressive
step-by-step
improvement of all aspects of the organisation and its resources.
Steps may
often be small; however, they can achieve significant impact by
the sheer
weight of accumulation.
5.1.3 Practical examples of Continuous Improvement include:
a) If a template is missing a heading, don't just fix the project
document, fix
the template.
b) If projects continually fail to meet a standard, either change
the standard
or fix the cause.
c) If there are no generally accepted availability criteria for
business
applications, don't just add some to your requirements. Get them

published as corporate criteria.
5.2 Continuous Improvement Framework
5.2.1 The framework for Continuous Improvement is:
Cycle Stage Description
Plan Identify an opportunity and plan for change.
Do Implement the change on a small scale.
Check Use data to analyse the results of the change and
determine whether it made a difference.
Act If the change was successful, implement it on a wider
scale and continuously assess your results. If the change
did not work, begin the cycle again.
liealtlicare
By Mary Hayes Finch and Maurice Rellins
Abraham Lincoln once said thedogmas ofthe quiet past are inad-
equate to the stormy present. The occa-
sion is piled high with dijficulty, and we
must rise with the occasion. The over-
all challenges facing the health and
human service agencies in our country

are certainly piled high with difficulty.
Faced with constant change, decreas-
ing resources, increasing demand, and
human need, we are in the midst of
perhaps one of the most transitional
times experienced. Health and human
service agencies across the board are
operational and legal environment.
Whether it is within Medicaid, public
welfare, state nutritional assistance
programs, or TANF, today's public
health and human service organiza-
tions are operating in arguably one of
the most complex economic and politi-
cal environments of its history. While
technology advancements have offered
tremendous opportunities for automa-
tion and efficiency, technology alone
is not enough to transform the current
operations of America's HHS agen-
cies. Technology is a tool for improve-
system worldwide. Why? Evidence-
based results that are irrefutable.
The goal ofthe Six Sigma program
is to achieve a level of quality that is as
close to perfection as possible. Sigma
is actually a statistical term used to
gauge how far a process deviates from
perfection. The Six Sigma and Lean
program institutes innovative methods
of affecting cost savings while striving
for perfection. In the health and human
service sector, it does so by improving

efficiency and boosting the quality of
service. Providing high-quality service
is profitable and the long-term
Getting More Done with Less: How :Zt!ZZ:::.^Ly
Lean Six Sigma Enhances Performance Î L T t l ' r a î r Î
being asked—required, even, to retool
operational policy and procedures in
a manner predicated on transparency,
technical integration, the adage of
doing more with less. In light of these
challenges, public health and human
service agencies remain anchored by
the overall philosophy that individual
health, Wellness and safety are ulti-
mately what will strengthen our com-
munities, states and country, and the
quality of life enjoyed by our citizenry.
More with less—cut out the waste.
These phrases are often bantered about
when resources are low and need is
high. The current economic and politi-
cal environments are no different. What
is different is the growing expectation
that public health and human ser-
vice agencies operate in an efficient,
fully integrated and interoperable,
consumer-centered, and user friendly
environment. While this philosophy
is shared by most agencies, they have
historically been plagued with a con-
stant dilemma—-how to respond with
the continued increase in need for ser-

vices with declining state and federal
resources in an ever-more complex
ment and efficiency. However, more
fundamental than technology, is the
underpinning of any system—opera-
tional policies, procedures, and orga-
nizational culture. What is required to
reaffirm the foundation of health and
human services in this country at a time
when demand is high and resources
continue to dwindle is a rethinking
and redesign of traditional operational
policies, procedures and relationships
to identify opportunities for contin-
ued improvement and system wide
integration.
Jack Welch, former chairman and
chief executive officer of General
Electric, once said, "Once you under-
stand the simple maxim "variation is
evil," you're 60 percent ofthe way to
becoming a Six Sigma expert yourself.
The other 40 percent is getting the evil
out." The evil he was speaking about
could well be ignoring the value of
eliminating waste and not implemting
a performance-based system in the day-
to-day operation ofa business.
Since its inception in 1986 with
Motorola, Six Sigma has become the
most popular business performance
" ^ ' ^ ' " ' Every year 200,000 incorrect

prescriptions are made. Five
thousand incorrect surgical procedures
are made each week.
Eliminating errors, redundancies
and waste will help the health care
industry maintain its profit margins
while complying with the new law and
increasing customer satisfaction. The
Six Sigma Lean strategy has been suc-
cessful with such corporate giants as
General Electric, Toyota and Merrill
Lynch. Six Sigma was instituted at G.E.
in 1996. In the following two years,
the company increased revenue by 11
percent, profits went up 13 percent, and
operating margins grew 17 percent.
Lessons learned about organization,
mistakes and efficiency from automo-
bile giants like G.E. don't lead to the
dehumanization of medical patients.
In fact the Lean method creates more
doctor patient interaction. Cutting out
middle-men increases the number of
patients one physician can see in a day.
Efficiency at hospitals can be increased
by applying common sense strategies
like listening to employees, cutting
redundancies and becoming more user-
friendly for patients.
2 4 Policv&Practice June 2010

liealtlicdrev
Lean Six Sigma is a practice that
considers the outlay of resources for
any goal Lean creates more value with
less work. Like it or not, health care is
a business and hospitals and doctors
are seeking ways to increase their prof-̂
its. Systemic change in the health care
industry will bring higher quality and
cost savings for patients and hospitals
alike.
Lean's successes in the health care
industry have been well documented.
In 2005. Virginia Mason Medical
Center in Seattle had remarkable
results with Six Sigma. For example,
in the chemotherapy unit, the center
cut preparation time by two-thirds,
enabling doctors to treat an additional
50 patients weekly. Furthermore, the
hospital was able to free 13,000 square
feet of space, cut tbe cost of inventory
by $360,000, and save $6 million in
capital investments.
The Alabama Primary Health Care
Association adopted Lean practices
and the result has been better moti-
vated and empowered employees, flex-
ible and cross-trained staff, and again,
shorter patient wait times.
Lean Six Sigma teaches hospitals
innovative methods to optimize efforts,

use less space, cut down on capital
investment, decrease material use,
save time, and most important, reduce
errors.
Continuous efforts to improve effi-
ciency and care are necessary. Lean Six
Sigma is not only based on incremental
improvements, but also offers a guide
on how to make long-term changes.
Managers should view changes from a
patients prospective rather than one of
simple functionality.
Lean was designed for customer
satisfaction. Anything that doesn't
achieve that goal should be eliminated.
Outdated or superfluous equipment
takes up space that could be used
for something useful and should be
removed. Sigma gives a step-by-step
guide of how to eliminate inefficiencies
and improve care.
The five disciplines of Six Sigma;
sort, set in order, shine, standardize
and sustain have revolutionized care at
hospitals that have embraced them.
• Sorting is the process of removing
items that are superfluous to opera-
tions, leaving only what is absolutely
needed. Extra gear equals wasted
space and a cluttered and confusing
workplace.

• Setting the items in order is the pro-
cess of organizing tools so that they
are easy to find and use. Use of visual
aids like color coding and outlining
on work areas improves productivity
and cuts down on errors.
• Step three or shine refers to continu-
ous cleaning and upkeep of the physi-
cal workspace. Six Sigma illustrates
how the use of charts and mainte-
nance schedules improves working
conditions and perpetuates quality.
• Standardization is the method devel-
oped to ensure that the first three dis-
ciplines are maintained.
• Sustain refers to the perpetual pro-
cess of top down evaluation to ensure
and maintain a high level of quality.
A simple example of how efficiency
helps both the patients and the corpo-
rate bottom line is wait times. Reducing
wait times increases the number of
patients you can see. Another example
is increasing the amount of in house
services offered. This can decrease
administrative and transportation
costs.
New strategies can be scary to
employees but one of tbe many great
aspects of Lean is that their opinions

are not only requested but are crucial
to making improvements. Just as the
old saying goes "no man is an island,"
no department or area of a hospital
operates entirely independently. Six
Sigma seeks to make stronger connec-
tions and improve lines of communica-
tion. Interaction between the staff and
management implementing the Sigma
strategy is crucial. Communication is
vital to improve performance and ease
any fears that employees may have con-
cerning their jobs under the business
model.
It is important to look beyond who
can provide a service at the lowest rate
and instead look strategically at what
can be provided efficiently in the long
term. Mangers should act more like
small business owners rather than man-
agement and not be afraid to delegate
responsibility.
Lean Six Sigma provides a continu-
ously improving culture based on the
importance of internal value where
your team is passionate about provid-
ing service. The Lean way makes more
room for doctors to develop long-term
relationships with patients. Better busi-
ness skills can lead to better medicine.
As we embrace the current environ-
ment and expectations, public health

and human service agencies have the
opportunity to do so in a way that
changes and enhances the lives of the
individuals we serve. While we are
clearly in the business of providing
critical health and human services, we
are in professions positioned to influ-
ence the lives of millions of Americans.
In the midst of the fast-paced demands
and challenges of our transformation,
we can continue to be anchored by the
human connection of our respective
agencies—the opportunities we have
every day beyond our operational areas
of expertise—the opportunity to touch
lives in a very real, meaningful way. Ifl
Mary Hayes Finch is the chief execu-
tive officer at the Alabama Primary
Health Care Association. Maurice Rollins
is quality improvement manager at
APHCA.
June 2010 Policy&Practice 2 5
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The Short Story:
Setting and Character
“A writer tries to create believable people in credible,
moving situations in the most moving way he can.”
—William Faulkner, Nobel Prize–winning American fiction
writer
5
© VideoBlocks
Learning Objectives
After reading this chapter, you should be able to do the
following:
• Define setting and analyze its use in a short story.
• Compare and contrast the various types of characters that
appear in short stories.

• Discuss the various ways characters shape the action in a
short story.
• Analyze the use of setting and character in this chapter's
literary selections.
Character Chapter 5
5.1 Setting
Setting identifies conditions, including time and place, of the
action in a story. The time may be
in the past, present, or future; the location may be real or
imaginary. Also, setting is an element
that establishes the atmosphere in which the characters live and
stimulates the reader’s imagi-
nation. Sometimes, it has a cultural aspect as well, which might
include local customs, dress,
speech, or patterns of thought. To more fully portray people and
life in a particular region, writ-
ers use local color—consisting of unique images, realistic
dialogue, and true-to-life descriptions.
Usually, the author describes the setting as the story begins,
often presenting necessary factual
information succinctly. And, typically, the setting includes a
key element—perhaps a time of day,
a season, or a political or religious climate—around which the
plot will unfold.
In “The Gift of the Magi,” discussed in Chapter 4, the basic
time and place questions about the
setting are immediately answered: We are told that it’s
Christmas Eve and that Della is in the
modest flat, with its broken mailbox and broken doorbell, that
she and her husband share. She’s
sobbing on a “shabby little couch,” anxious about not having

enough money to buy an adequate
Christmas gift for her husband—”something fine and rare and
sterling.” Further, we are told that
Della and Jim, though they are being financially squeezed at the
moment, have genuine affection
for each other, which enables them to accept their situation.
Nevertheless, as Della moves to the
window, she is struck by the dullness of her life, reflected by “a
gray cat walking a gray fence in a
gray backyard.”
In particular, these details allow the reader to connect to the
physical place imaginatively.
Additionally, they provide essential information about the
couple’s relationship and reveal Della’s
present emotional outlook. With the setting sufficiently
established, action in the story begins—
urgently driven by Della’s feelings and the fact that it’s
Christmas Eve and time is running out for
gift buying.
5.2 Character
A character, of course, is a fictional person in a story.
Characters carry out the action of the plot
and in doing so they come alive as individuals. Through their
appearance, responses, thoughts,
relationships, and actions, the reader comes to understand them.
Sometimes, in fact, the reader
senses changes in a character’s motivations and values even
before they are revealed in the story.
In other words, characters give a story its life. They are
representations of real people who change
and develop. As such, literary characters fall into several types:
• Round characters are characters whose behavior is
dynamic. They change and develop

over the course of the story, revealing multiple aspects of their
personalities and natures.
Like real people, round characters are complex, most often
exhibiting both positive and
negative personality traits. They attract audience attention more
than flat characters do;
they change as their insights develop and deepen; their vitality
connects with real life at
multiple points. Thebedi in “Country Lovers,” discussed in
Chapter 3, is an example of a
round character: Her motives, fears, strengths, and weaknesses
are all revealed, making
her a dynamic and knowable character—an idealist who learns
about personal and social
acquiescence.
• Flat characters are static rather than dynamic; they are one
dimensional and predictable
in their behavior. E. M. Forster (1955) observes that flat
characters in their purest form “are
constructed around a single idea or quality: when there is more
than one factor in them,
Character Chapter 5
we get the beginning of a curve toward the round” (135–136).
Thebedi’s husband, Njabulo,
is an example. He simply accepts life as it comes, marries
Thebedi, quietly receives a child
who is not his, and continues his routine pattern of work in
bricklaying and odd jobs in
construction. However, flat characters often add vitality and
have a memorable role in a
story. Young William Collins, the pompous, imprudent estate

heir whose marriage pro-
posal Elizabeth turns down in Pride and Prejudice, is such a
character. He is described
as “not a sensible man,” and notably at various points in the
story his behavior reveals the
accuracy of that singular characterization. He does not change.
• Stock characters, also referred to as stereotypical
figures, are characters who traditionally
appear in literature and are readily recognized for exhibiting
“role behavior,” such as that of
the mad scientist, the damsel in distress, the cruel stepmother,
or the boy next door. They
are minor characters often used to create humor or provide
sharp contrast with main
characters in a story.
In many stories, the conflict between the main character (the
protagonist) and an opposing char-
acter (the antagonist) shapes the action.
• The protagonist is the main character in a story. He or she
is the most developed figure,
upon whom the plot is centered and its outcome depends.
Normally, the audience identifies
with and applauds the protagonist’s heroic actions in defeating
whomever or whatever the
opposition is—or, at the very least, emerging successfully from
chaotic, challenging cir-
cumstances. Typically, the protagonist is likable and often
admirable, but this is not always
the case. A classic example is Dorian Gray in Oscar Wilde’s
novel The Picture of Dorian
Gray. He gives himself over to corrupting ideas that
continuously drive him to commit acts
of human cruelty. He recklessly ignores the consequences of his

actions, which eventually
cause several deaths. As this ignoble behavioral pattern unfolds,
his portrait reflects the
deteriorating state of his soul, exhibiting new shades of ugliness
until the portrait becomes
that of a monster.
• The antagonist is the individual or force opposing the
protagonist, setting up the clas-
sic struggle between a hero and a villain. An antagonist must be
seen as a credible rival,
capable of successfully creating difficulties for the protagonist.
The “A & P” store manager,
Lengel, fits this role in Updike’s story, discussed in Chapter 2.
His actions are few, but they
are solid and precise—and completely opposite of the actions
Sammy would take. What
he tells the girls in bathing suits is enough to make Sammy quit
his job and walk out of
the store, overcoming any hold that Lengel has on him. In this
sense, Sammy wins. But
underlying Sammy’s words and actions is a deeper struggle:
Sammy perceives his personal
worldview to be superior to Lengel’s—and totally different.
Sammy sees Lengel’s whole
way of life as an antagonistic presence, and he’s content to
sever himself from it entirely.
Protagonists commonly struggle against threatening ideas,
impending chaos, or even
nature itself, as the veteran fisherman, Santiago, does so nobly
in Hemingway’s novel The
Old Man and the Sea.
• A foil is a minor character in a story or drama whose
nature and observable actions are
distinctly different from those of the main character. This

sharply contrasting behav-
ior allows the reader to better understand the protagonist’s
strengths and weaknesses.
Similarly, sometimes the behavior of a foil can be a source of
inspiration for the protago-
nist, stimulating new motivation to change, which, of course,
alters the plot or outcome of
the story. We are first introduced to the role of foils in stories
we hear or read as children.
In the Cinderella fairy tale, for example, the stepmother is
Cinderella’s antagonist; her two
An Annotated Story Illustrating Elements of Setting and
Character Chapter 5
ugly stepsisters are foils, providing a striking contrast to
Cinderella’s remarkable natural
beauty. This contrast intensifies our identification with
Cinderella.
Most often, characters, like people in everyday life, are not
static: They change. That’s part of
what makes reading fiction exciting and satisfying. Your
impressions about particular characters
at the beginning of a story and the insights you gain about them
by the end of the action can be
dramatically different. Huck Finn, for example, is rather
indifferent to matters of right and wrong
when we first meet him. He is unappreciative of his elders’
efforts to penetrate his indifference
through teaching and training. But by the end of the novel, he is
capable of acting with purposeful
honesty and integrity as he faces the issue of slavery and his
friend Jim’s freedom.

Characterization is the term for the methods writers use to
reveal a character. Besides describ-
ing what characters do, writers make sure the reader knows
what characters look like, how they
think and interact with others, and what they feel and believe. If
a character changes over the
course of the story, the writer must allow that change to develop
naturally if it is to be credible.
In her reflection “On Writing Short Stories,” Flannery
O’Connor observed, “In most good stories
it is the character’s personality that creates the action of the
story. . . . If you start with a real per-
sonality, a real character, then something is bound to happen.”
5.3 An Annotated Story Illustrating Elements of
Setting and Character
In “A Worn Path,” Eudora Welty swiftly and effectively
establishes the time of year (December)
and the geographic location of the story (the South); she
identifies the main character, an old
African-American woman (Phoenix Jackson); and she describes
the old woman’s appearance and
thoughts as the woman begins to move along the path in the
pinewoods. Through her use of
evocative details, Welty creates a sense of determined struggle
in Phoenix. In just a few words,
the author sets the external environment and internal conditions
that will contribute to the
action and the outcome of the story.
Eudora Welty (1909–2001)
Eudora Welty’s parents moved from Ohio to Jackson,
Mississippi, where

Welty was born. After earning a bachelor’s degree from the
University of
Wisconsin, Welty entered graduate studies at Columbia
University in adver-
tising (her father doubted she would be able to support herself
as a writer).
She returned to Jackson, where she spent her life writing short
stories and
novels. Welty enjoyed photography, lecturing, and teaching. In
her fiction,
she was a keen observer of Mississippi life, identifying its
hardships and
struggles, but also offering a vision of hope and change based
on family
and love relationships. She won a Pulitzer Prize for her novel
The Optimist’s
Daughter in 1973 and was awarded the Presidential Medal of
Freedom
in 1980.
© Bettmann/CORBIS
Character Chapter 5
A Worn Path
Eudora Welty (1941)
It was December—a bright frozen day in the early morning. Far
out in the country there was an old Negro woman with her head
tied in a red rag, coming along a path through the pinewoods.
Her
name was Phoenix Jackson. She was very old and small and she
walked slowly in the dark pine shadows, moving a little from

side
to side in her steps, with the balanced heaviness and lightness
of
a pendulum in a grandfather clock. She carried a thin, small
cane
made from an umbrella, and with this she kept tapping the
frozen
earth in front of her. This made a grave and persistent noise in
the still air that seemed meditative, like the chirping of a
solitary
little bird.
She wore a dark striped dress reaching down to her shoe tops,
and
an equally long apron of bleached sugar sacks, with a full
pocket:
all neat and tidy, but every time she took a step she might have
fallen over her shoelaces, which dragged from her unlaced
shoes.
She looked straight ahead. Her eyes were blue with age. Her
skin
had a pattern all its own of numberless branching wrinkles and
as
though a whole little tree stood in the middle of her forehead,
but
a golden color ran underneath, and the two knobs of her cheeks
were illumined by a yellow burning under the dark. Under the
red
rag her hair came down on her neck in the frailest of ringlets,
still
black, and with an odor like copper.
Now and then there was a quivering in the thicket. Old Phoenix
said, “Out of my way, all you foxes, owls, beetles, jack rabbits,
coons and wild animals! . . . Keep out from under these feet,
little

bob-whites . . . Keep the big wild hogs out of my path. Don’t let
none of those come running my direction. I got a long way.”
Under
her small black-freckled hand her cane, limber as a buggy whip,
would switch at the brush as if to rouse up any hiding things.
On she went. The woods were deep and still. The sun made the
pine needles almost too bright to look at, up where the wind
rocked. The cones dropped as light as feathers. Down in the hol-
low was the mourning dove—it was not too late for him.
The path ran up a hill. “Seem like there is chains about my feet,
time I get this far,” she said, in the voice of argument old
people
keep to use with themselves. “Something always take a hold of
me
on this hill—pleads I should stay.”
After she got to the top she turned and gave a full, severe look
behind her where she had come. “Up through pines,” she said at
length. “Now down through oaks.” Her eyes opened their
widest,
and she started down gently. But before she got to the bottom of
the hill a bush caught her dress.
Her fingers were busy and intent, but her skirts were full and
long,
so that before she could pull them free in one place they were
caught in another. It was not possible to allow the dress to tear.
“I
in the thorny bush,” she said. “Thorns, you doing your
appointed
work. Never want to let folks pass, no sir. Old eyes thought you
Exposition—The first five
paragraphs offer factual,

descriptive information
about the main character
and the setting:
• The setting is rural, a
cold, early morning in
December in the South.
• An “old Negro woman” is
on a solitary journey.
• Notice the amount of
detail about her slow pace,
her clothes, her untied
shoes, her skin, her hair.
• We learn her name,
Phoenix—which is also the
mythical creature that rises
from its own ashes.
• The information about
how she uses her cane to
scatter the small animals
from her path clarifies our
picture of her and reveals
her character, particularly
her determination.

Enough detail has been
given about the woman
to suggest that the story
will involve her struggle
against aging: a struggle
within herself and with an
external reality. When her
path turns uphill and she
admits, “Something always
take a hold of me on this
hill—pleads I should stay,”
this struggle is identified as
a central part of the story.
5
Will she still have strength
to deal with the bushes?
Character Chapter 5
was a pretty little green bush.” Finally, trembling all over, she
stood free, and after a moment dared to stoop for her cane.
“Sun so high!” she cried, leaning back and looking, while the
thick
tears went over her eyes. “The time getting all gone here.”

At the foot of this hill was a place where a log was laid across
the
creek.
“Now comes the trial,” said Phoenix.
Putting her right foot out, she mounted the log and shut her
eyes.
Lifting her skirt, leveling her cane fiercely before her, like a
fes-
tival figure in some parade, she began to march across. Then
she
opened her eyes and she was safe on the other side.
“I wasn’t as old as I thought,” she said.
But she sat down to rest. She spread her skirts on the bank
around
her and folded her hands over her knees. Up above her was a
tree
in a pearly cloud of mistletoe.
She did not dare to close her eyes, and when a little boy brought
her a plate with a slice of marble-cake on it she spoke to him.
“That would be acceptable,” she said. But when she went to
take
it there was just her own hand in the air.
So she left that tree, and had to go through a barbed-wire fence.
There she had to creep and crawl, spreading her knees and
stretch-
ing her fingers like a baby trying to climb the steps. But she
talked
loudly to herself: she could not let her dress be torn now, so late
in the day, and she could not pay for having her arm or her leg
sawed off if she got caught fast where she was.

At last she was safe through the fence and risen up out in the
clearing. Big dead trees, like black men with one arm, were
stand-
ing in the purple stalks of the withered cotton field. There sat a
buzzard.
“Who you watching?”
In the furrow she made her way along.
“Glad this not the season for bulls,” she said, looking sideways,
“and the good Lord made his snakes to curl up and sleep in the
winter. A pleasure I don’t see no two-headed snake coming
around that tree, where it come once. It took a while to get by
him, back in the summer.”
She passed through the old cotton and went into a field of dead
corn. It whispered and shook and was taller than her head.
“Through the maze now,” she said, for there was no path.
Then there was something tall, black, and skinny there, moving
before her.
At first she took it for a man. It could have been a man dancing
in the field. But she stood still and listened, and it did not make
a
sound. It was as silent as a ghost.
10
Is her self-assessment of
strength realistic?
Is her thinking still clear? 15

Irony is used to show the
intensity of her struggle.
Just when she gets “in the
clearing” and feels “safe,”
she sees a buzzard, a
reminder of death.
20
Character Chapter 5
“Ghost,” she said sharply, “who be you the ghost of? For I have
heard of nary death close by.”
But there was no answer—only the ragged dancing in the wind.
She shut her eyes, reached out her hand, and touched a sleeve.
She found a coat and inside that an emptiness, cold as ice.
“You scarecrow,” she said. Her face lighted. “I ought to be shut
up
for good,” she said with laughter. “My senses is gone. I too old.
I the oldest people I ever know. Dance, old scarecrow,” she
said,
“while I dancing with you.”
She kicked her foot over the furrow, and with mouth drawn
down,
shook her head once or twice in a little strutting way. Some
husks
blew down and whirled in streamers about her skirts.

Then she went on, parting her way from side to side with the
cane, through the whispering field. At last she came to the end,
to
a wagon track where the silver grass blew between the red ruts.
The quail were walking around like pullets, seeming all dainty
and
unseen.
“Walk pretty,” she said. “This the easy place. This the easy
going.”
She followed the track, swaying through the quiet bare fields,
through the little strings of trees silver in their dead leaves, past
cabins silver from weather, with the doors and windows boarded
shut, all like old women under a spell sitting there. “I walking
in
their sleep,” she said, nodding her head vigorously.
In a ravine she went where a spring was silently flowing
through
a hollow log. Old Phoenix bent and drank. “Sweet-gum makes
the water sweet,” she said, and drank more. “Nobody know who
made this well, for it was here when I was born.”
The track crossed a swampy part where the moss hung as white
as lace from every limb. “Sleep on, alligators, and blow your
bubbles.” Then the track went into the road. Deep, deep the
road
went down between the high green-colored banks. Overhead the
live oaks met, and it was as dark as a cave.
A black dog with a lolling tongue came up out of the weeds by
the ditch. She was meditating, and not ready, and when he came
at her she only hit him a little with her cane. Over she went in
the

ditch, like a little puff of milkweed.
Down there, her senses drifted away. A dream visited her, and
she
reached her hand up, but nothing reached down and gave her a
pull. So she lay there and presently went to talking. “Old
woman,”
she said to herself, “that black dog come up out of the weeds
to stall you off, and now there he sitting on his fine tail, smiling
at you.”
A white man finally came along and found her—a hunter, a
young
man, with his dog on a chain. “Well, Granny!” he laughed.
“What
are you doing there?”
“Lying on my back like a June-bug waiting to be turned over,
mis-
ter,” she said, reaching up her hand.
The field of dead corn and
the ghostly atmosphere are
more images of death.
25
Dancing with the scare-
crow (whose purpose, of
course, is to scare scaven-
ger birds) symbolizes the
woman’s intent to drive
away thoughts of death, to
continue her journey with

determination.
Details of the setting—
here, a description of the
wagon track—are used to
tell us that the old woman
is following a familiar path:
She is alert and able to
pace herself in the “easy
going” part of her journey.
30
The well, which “was here
when I was born,” reminds
her of her long life; the
drink of water helps renew
her spirits.
35
The dog and the white
hunter represent new
external conflicts that the
woman must face.

Character Chapter 5
He lifted her up, gave her a swing in the air, and set her down.
“Anything broken, Granny?”
“No sir, them old dead weeds is springy enough,” said Phoenix,
when she had got her breath. “I thank you for your trouble.”
“Where do you live, Granny?” he asked, while the two dogs
were
growling at each other.
“Away back yonder, sir, behind the ridge. You can’t even see it
from here.”
“On your way home?”
“No sir, I going to town.”
“Why, that’s too far! That’s as far as I walk when I come out
myself, and I get something for my trouble.” He patted the
stuffed
bag he carried, and there hung down a little closed claw. It was
one of the bobwhites, with its beak hooked bitterly to show it
was
dead. “Now you go on home, Granny!”
“I bound to go to town, mister,” said Phoenix. “The time come
around.”
He gave another laugh, filling the whole landscape. “I know
you old colored people! Wouldn’t miss going to town to see
Santa Claus!”
But something held old Phoenix very still. The deep lines in her
face went into a fierce and different radiation. Without warning,

she had seen with her own eyes a flashing nickel fall out of the
man’s pocket onto the ground.
“How old are you, Granny?” he was saying.
“There is no telling, mister,” she said, “no telling.”
Then she gave a little cry and clapped her hands and said, “Git
on
away from here, dog! Look! Look at that dog!” She laughed as
if
in admiration. “He ain’t scared of nobody. He a big black dog.”
She whispered, “Sic him!”
“Watch me get rid of that cur,” said the man. “Sic him, Pete!
Sic him!”
Phoenix heard the dogs fighting, and heard the man running and
throwing sticks. She even heard a gunshot. But she was slowly
bending forward by that time, further and further forward, the
lids stretched down over her eyes, as if she were doing this in
her
sleep. Her chin was lowered almost to her knees. The yellow
palm
of her hand came out from the fold of her apron. Her fingers
slid
down and along the ground under the piece of money with the
grace and care they would have in lifting an egg from under a
set-
ting hen. Then she slowly straightened up, she stood erect, and
the nickel was in her apron pocket. A bird flew by. Her lips
moved.
40
The hunter rescues the old

woman from her encounter
with the dog, but there is
discernible conflict between
these two characters: The
hunter is on a mission of
death and the old woman
is on a life-saving mission. 45
Money is used to heighten
the contrast between these
two characters and to
emphasize their contrasting
racial circumstances: The
hunter has money; the old
woman has none.
50
Character Chapter 5
“God watching me the whole time. I come to stealing.”
The man came back, and his own dog panted about them. “Well,
I
scared him off that time,” he said, and then he laughed and
lifted
his gun and pointed it at Phoenix.

She stood straight and faced him.
“Doesn’t the gun scare you?” he said, still pointing it.
“No, sir, I seen plenty go off closer by, in my day, and for less
than
what I done,” she said, holding utterly still.
He smiled, and shouldered the gun. “Well, Granny,” he said,
“you
must be a hundred years old, and scared of nothing. I’d give you
a
dime if I had any money with me. But you take my advice and
stay
home, and nothing will happen to you.”
“I bound to go on my way, mister,” said Phoenix. She inclined
her
head in the red rag. Then they went in different directions, but
she could hear the gun shooting again and again over the hill.
She walked on. The shadows hung from the oak trees to the road
like curtains. Then she smelled wood-smoke, and smelled the
river,
and she saw a steeple and the cabins on their steep steps.
Dozens
of little black children whirled around her. There ahead was
Natchez shining. Bells were ringing. She walked on.
In the paved city it was Christmas time. There were red and
green
electric lights strung and crisscrossed everywhere, and all
turned
on in the daytime. Old Phoenix would have been lost if she had
not distrusted her eyesight and depended on her feet to know

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