John J. Nance, founding member of the National Patient Safety Foundation, reported on a rich set of systems reforms that has been achieved by the aviation industry. Nance highlighted strategies that go beyond well-honed aviation practices, such as checklists and methodologies in crew resource management (CRM), which could be of benefit to healthcare systems. He described how systems engineering has been applied in sophisticated feedback systems for reporting and learning from mechanical problems, the development of robust computerized processes for many aspects of daily operations, and standardization that has been applied widely across airline operations. He also described systems that have been built around the assumption that human beings can never be perfect, and thus they are designed to be capable of absorbing anticipated levels of human failure. The discussion also touched on the importance of applying systems thinking to training, on the value of improved communication among staff at all levels, on the usefulness of minimization of variables, and on how systems interact.

To demonstrate how systems thinking can help effect deep-set, meaningful, and lasting organizational change, Earnest J. Edwards, formerly of Alcoa, Inc., focused on improvements in a specific business practice, the financial close process. Detailing how a similar change effort was applied successfully in a leading corporation, a federal government agency, and a community hospital, Edwards demonstrated how systems thinking can help organizations lower costs, improve quality, and leverage systems to yield better information for use in decision making. Moreover, he suggested, undertaking the process of change can itself help staff learn how to become solution-oriented change agents with a focus on the future—and thus become more vital partners in the enterprise, with an expanded role in strategic decisions.

Kenneth W. Kizer, chair of Medsphere Systems Corporation, began by describing the condition of the veterans healthcare system in the early 1990s. Managed by the Veterans Health Administration (VHA) in the U.S. Department of Veterans Affairs (VA), it was considered inefficient and indifferent to patient needs. Kizer described how, through a concerted reengineering effort, the VA healthcare system was transformed into a model healthcare provider. Kizer described how the VA overhauled its accountable management structure and control system, integrated and coordinated patient services across the continuum of care, improved and standardized the quality of care, improved information management, and aligned the system’s finances with desired outcomes. Kizer suggested that similar interventions could help other healthcare enterprises achieve new levels of success.

In the final presentation described in this chapter, David B. Pryor, chief medical officer of Ascension Health, discussed the clinical transformation of Ascension, which is the largest not-for-profit delivery system in the United



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