and medical education must change to support widespread reforms in how medicine is practiced. The patients will benefit from these changes.


Dougherty commented on potential opportunities to blend the basic science (theoretical side) and applied science (practical side) of quality improvement research. The testing of theories about context and the nature of implementation in real-world settings can help build the basic science, Dougherty said.

Shortell proposed a framework for considering context. The framework focuses on the alignment of four areas: an organization’s strategy, its culture, its technical components, and its structure. First, an intervention must fit in an organization’s overall strategy and be considered a strategic priority to be sustained. Second, support for the intervention must be supported by the organizational culture; otherwise, people will not be able to successfully spread the change throughout the organization. Third, technical components to support the intervention must be in place so that information can be gleaned to assess the change. Fourth, the organization’s structure must be able to support both formal and informal ways of learning to share information. Otherwise, improvements will be suboptimized, with improvements in one division or team, but not throughout the organization. The challenge for systemwide quality improvement is to align all four areas to achieve sustained change.


Responding to a comment about the risk of attempting quality improvement at the system level when the basic science of quality improvement is not well understood, O’Neill said there are some truths to all organizations, one of which is binary communication. Binary communication allows for only yes or no answers, not maybe, and helps judge a system’s level of organization. Health and medical care has not done a good job of encouraging binary communication, O’Neill said. Better binary communication could decrease chaos in the system and would thus be able to identify leverage points for change.

Characteristics of great organizations hold three virtues, O’Neill proposed. First, every person in the organization should be able to say that he is treated with dignity and respect. If a person is not as valuable or is less valuable than others, he should not be there.

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