in sustaining change. Individual champions often seek funding for their change ideas in order to provide validation to their organizations. On the other hand, team leaders tend to ask for funding when a new structure is taking place, such as during times of reorganization or new leadership. At the organizational level, adverse events and bad publicity are often the motivators to improve quality. At the system level, change can often be leveraged through legislation, regulation, accreditation, or financing. Using these examples, Bau observed that sustainable changes in quality improvement are generally much more reactive to opportunity or crisis than proactive.

Stakeholders often neglected in planning change are consumers and purchasers. In talks with unions and businesses, Bau said their focuses are often on access to care and cost, without regard for quality. Creating a demand for quality through purchasers, including smaller businesses, could be a promising way to advance quality improvement. Patients should be more involved in this, especially in moving beyond measures of patient satisfaction (e.g., being treated with respect and having long wait times) to really being able to judge whether care was of high quality. Patients should be empowered with enough information to create expectations for their care without having to know the technical details of medicine.

If health care delivery and research were more patient centered, the system could begin to break down the barriers to providing coordinated care. Quality improvement should not be based on condition, disease, or procedure, but on people interacting with the health care system.

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