In response to a question about generalizability, Kupersmith noted that it is harder to translate efforts outside the VA than within the VA because it is a system with specific attributes. Translating efforts within the VA is not entirely possible because patients are all different.

The challenge is to learn how to be vigilant within one’s own institution and learn how to share lessons with others without fear of liability or embarrassment, Romano said. Groups must share what they have learned and publish that information so others can benefit. Using the pneumonia example, must people be needlessly scared about getting unnecessary antibiotics in order for others who need the antibiotics to get them on time? Health care should learn from other industries that also encounter the need to reduce errors, such as the airline industry, where the costs associated with having error-free systems are built into business models. These trade-offs are beginning to be identified, but must be made explicit. Kupersmith agreed, stating that transparency is critical for any quality improvement effort or research.


Alexander suggested two truisms of culture. First, changing culture in a small organization is different from in large, complex organizations. This is partly because large organizations do not have one culture, but multiple subcultures. Instead, a superordinate culture should be created that embraces the subcultures. This task is different from changing culture within a small hospital. Second, physician groups face less of a culture issue but more of an organizational climate issue. These groups often practice with a “siege mentality” and do not want to look outside of what is currently available, given the other pressures they are experiencing. A lot of work is involved to change behaviors in these organizations, Alexander concluded.

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