The factors that are associated with successful CQI applications have been clearly identified, from its earliest applications in industry and throughout its evolution into health care.

FIGURE 2–1 Factors Influencing Successful CQI Implementation
The development of a vision and the commitment to that vision lead to what Deming called constancy of purpose for all in the organization, referring to a clear sense of where the organization is going or what a system is intended to accomplish (Deming, 1986). The type of culture that is needed to succeed in an organization whose goal is to continuously improve can be called a “culture of excellence.” This concept is similar to a “safety culture,” defined as a culture in which “a commitment to safety permeates all levels of the organization from frontline personnel to executive management” (AHRQ, 2011). Similarly, a culture of excellence is one that ensures excellence and high quality at every customer interface and in which a commitment to the highest quality—and CQI, in particular—is shared by all in the organization. Underlying the creation of a culture of excellence is a need for a systems view. A systems view of health care emphasizes the importance of adding value and the importance of leadership rather than management, influence rather than power, and the alignment of incentives focused on quality rather than quantity of services (Rouse, 2008). A culture of excellence embraces this view, is performance oriented, and at a minimum adopts a CQI philosophy (as defined in Chapter 1). It exemplifies the following elements outlined in Figure 2–1:

• Customer focus: Emphasizing the importance of both internal and external customers (see Chapter 1)
• Systems thinking: Maintaining a goal of optimizing the system as a whole and thereby creating synergy (Deming, 1986; Kelly, 2007)
• Statistical thinking: Understanding causes of variation and the importance of learning from measurement; having the ability to use data to make decisions (see Chapter 3 and Balestracci, 2009)
• Teamwork: Teams of peers working together to ensure empowerment, thereby creating the highest levels of motivation to ensure alignment of the organization, the team, and the individual around the CQI vision (see Chapter 4 and Grove, 1995)
• Communication and feedback: Maintaining open channels of communication and feedback to make adjustments as needed, including modifying the vision to achieve higher levels of quality in a manner consistent with a learning organization (see Chapters 6 and 10 and Senge, 1990), including feedback that is fact based and given with true concern for individuals’ organizational success (Balestracci, 2009)
Leadership and Diffusion

In discussing factors that support the implementation of CQI, the theory of diffusion of innovation clearly supports the important role of leadership in CQI. Innovativeness, as described in the literature of organizational psychology, is seen as critically dependent on good leadership; one of the key factors to the implementation and routinization of innovation once adopted is the consultation and active involvement of leaders. Furthermore, organizational leadership is critical to the development of a culture that fosters innovation (Greenhalgh et al., 2005). CQI is a form of change and innovation that also requires cultural change driven by leadership. As Greenhalgh et al. explain, “Leaders within organizations are critical firstly in creating a cultural context that fosters innovation and secondly, establishing organizational strategy, structure, and systems that facilitate innovation” (2005, p. 69). This perspective ties directly back to Deming’s point about leadership; leaders must know and understand the processes they are responsible for and lead by example, acting as part of the improvement effort and on the “corrections” required (Deming, 1986). This point was emphasized by Gawande in describing how the initial adoption of surgical checklists was accomplished:

Using the checklist involved a major cultural change, as well—a shift in authority, responsibility, and expectations about care—and the hospitals needed to recognize that. We gambled that their staff would be far more likely to adopt the checklist if they saw their leadership accepting it from the outset. (2009, p. 146)
Leaders at All Levels

Various types of leaders can contribute to (or detract from) the innovation process. Traditional organizational and team leaders are most often associated with CQI initiatives; however, in regard to innovations, the terminology of “leader” can be expanded to include opinion leaders, champions, and boundary spanners.

Opinion leaders represent a broad range of leaders “within the ranks” as well as those at the top level. In clinical settings, opinion leaders have influence on the beliefs and actions of their colleagues, either positive or negative in regard to embracing innovation. Opinion leaders may be experts who are respected for their formal academic authority in regard to a particular innovation; their support represents a form of evidence-based knowledge. Opinion leaders may also be peers who are respected for their know-how and understanding of the realities of clinical practice (Greenhalgh et al., 2005).

Unlike opinion leaders, who may support or oppose an innovation, champions persistently support new ideas. They may come from the top management of an organization, including technical or business experts. Champions include team and project leaders and others who have perseverance to fight both resistance and/or indifference to promote the acceptance of a new idea or to achieve project goals (Greenhalgh et al., 2005).

Boundary spanners represent a combination of these various types of leaders and are distinguished by the fact that they have influence across organizational and other boundaries (Greenhalgh et al., 2005; Kaluzny et al., 1974). Boundary spanners play an important role in multi-organizational innovations and quality improvement initiatives, such as quality improvement collaboratives. Each of these types of leaders is found in the adoption of quality improvement initiatives in health care, and often these various types of leaders are found in combination.

Teamwork

CQI in health care is a team game. These teams are composed of peers who are highly trained technical experts supporting each other and empowered to take a leadership role as required to meet the needs of customers. Teamwork is one of the most important components of all successful CQI initiatives; team building centers on the ability to create teams of empowered and motivated people who are leaders themselves and who will take the lead as needed to foster change, innovation, and improvement (Byham and Cox, 1998; Grove, 1995; Kotter, 1996). The glue that holds a culture of excellence together and that ensures there will be quality at every interface is the link between leadership and teamwork—with leadership exhibited as called for at all levels within a team. As Deming states, “There is no substitute for teamwork and good leaders of teams to bring consistency of effort along with knowledge” (1986, p. 19).

Inherent in teamwork is a high level of empowerment of team members, which in turn leads to high levels of motivation. Empowerment implies that levels of authority match levels of responsibility and training. For example, suggestions and interventions can be made to allow improvements and prevent problems or errors; this initiative goes beyond simply allowing team members to speak up, but means providing comfort in speaking up when something seems wrong (Byham and Cox, 1998; Deming, 1986; Grove, 1995). This is illustrated in the surgical checklist example, which emphasizes that all members of the surgical team are responsible for the outcome, not just the surgeon, and all members have a role in preventing errors, which implies the empowerment to question traditional authority and take actions (Gawande, 2009).

Improved motivation is the direct result of empowerment, and both will interact to lead to higher quality; but to work, these elements require another aspect of cultural change and associated leadership responsibility—building a culture of trust. This is emphasized in Deming’s 14 points, namely point number 8: Drive out fear. Create trust. Create a climate for innovation (see Chapter 1). Deming explains, “No one can put in his best performance unless he feels secure…. Secure means without fear, not afraid to express ideas, not afraid to ask questions” (1986, p. 59). This ties directly back to the surgical checklist example as well as the airline safety tradition, where use of a checklist implies responsibility to communicate and question each other as part of the checklist process, regardless of the team member’s rank. A leader’s goal must be to create a culture where people are empowered to do their jobs to the best of their abilities, with trust and a clear understanding of the vision that creates the constancy of purpose needed to achieve the highest quality.

Training is critical to the success of leaders and the ability to achieve constancy of purpose, not only training of employees in the skills required to do their jobs, but also training the future leaders of the organization. Training of future leaders is one of the most important responsibilities of a leader (Tichy, 1997). Several later chapters in this text discuss what is needed to train and educate health care professionals who are prepared to lead the improvement of health care. For example, in Chapter 17 the emphasis on quality improvement in the curriculum for the education of nurses is described; one critical goal described is to ensure that nurses, because of their close interaction with patients, can take a greater leadership role in ensuring the quality of care provided to patients and take more direct responsibility for identifying and leading, not merely participating in, quality improvement initiatives. Gawande (2009) addresses this issue in describing the process for testing and implementing the surgical safety checklist. Despite the obvious key role of the surgeon, it was decided that the “circulating nurse” on the surgery team would be the one to start the checklist process at the beginning of a surgery. This was done for several reasons, but one of the most important was “to spread responsibility and the power to question” (p. 137).

Examples of Leadership and Teamwork in CQI

The linkage between leadership and teamwork to ensure success in quality improvement in health care has been demonstrated in many instances, including the very successful implementation of quality improvement collaboratives (QICs), introduced in Chapter 1. QICs represent a form of virtual organizations (Byrne, 1993) whose effectiveness have been demonstrated in industry for many years. Part of the success of QICs can be tied to this effective team structure. For example, in describing the successful application of a QIC using the IHI Breakthrough series (Kilo, 1998) in 40 U.S. hospitals to reduce adverse drug events, Leape et al. (2000) identify strong leadership and teamwork among their most important success factors: “Success in making significant changes was associated with strong leadership, effective processes, and appropriate choice of intervention. Successful teams were able to define, clearly state, and relentlessly pursue their aims, and then chose practical interventions and moved early into changing a process” (Greenhalgh et al., 2005, p. 165).

In summary, leadership, effective teamwork, and the empowerment of teams have been critical factors in the evolution of CQI in health care and are directly related to the pace and broad adoption of CQI in health care in recent years. Chapter 4 provides a detailed description of how to build teams and ensure that they operate most effectively to improve quality in health care.

Kotter’S change Model

A traditional model that is used to define a culture of change and in particular the role of vision and leadership is the eight-stage change model developed by John Kotter (1996), which is outlined in Table 2–1. The discussion of leadership, organizational culture, and teamwork presented previously described “what is” the type of culture that is needed to implement successful CQI initiatives; Kotter’s model describes “how to” implement major change and also provides guidance on traditional errors to avoid. These two approaches are closely related. There is clear overlap between Kotter’s model and the factors defined in Figure 2–1, which describe the culture of excellence. These common elements include empowerment, communication, feedback loops to produce more change, and, most important, the central role of vision and anchoring change in the culture.

TABLE 2–1 Kotter’s Eight-Stage Process of Creating Major Change

1. Establishing a sense of urgency
2. Creating the guiding coalition
3. Developing a vision and strategy
4. Communicating the change vision
5. Empowering broad-based action
6. Generating short-term wins
7. Consolidating gains and producing more change
8. Anchoring new approaches in the culture
Source: Adapted from Kotter, 1996.

One key point of Kotter’s model that is worthy of a bit more discussion here is his first point: “Establishing a sense of urgency.” This effort relates to an earlier point about how long it takes, or should take, to implement CQI concepts. The emphasis is not that decisions should be rushed, but that complacency is to be avoided. Complacency may be due to many reasons that can be associated with the need for CQI in health care. These include, according to Kotter, “too much past success, lack of visible crises, low performance standards, [and] insufficient feedback from external constituencies…. Without a sense of urgency, people won’t give that extra effort that is essential. They won’t make needed sacrifices. Instead they cling to the status quo and resist initiatives from above” (1996, p. 5). This point directly relates to CQI in health care; the importance of ensuring safety and quality in health care requires a sense of urgency.

See Kotter’s text for a comprehensive description of the elements in Table 2–1 and the broader subject of how to implement organizational change.

CONCLUSIONS

The factors that are associated with successful CQI applications have been clearly identified, from its earliest applications in industry and throughout its evolution into health care. Most notable among these factors are leadership and teamwork and their synergistic role in developing a vision that leads to a culture of excellence, embracing CQI. This has led to widespread use of CQI in health care and the emergence of a new set of leaders who lead by example, teach others, and continue to develop and expand both the philosophy and processes of CQI.

Despite the widespread use of CQI methods and a good understanding of the leadership and teamwork processes that make it work, its effectiveness and its further adoption in health care remain subjects of ongoing research and continue to meet challenges; most notably, there has been lack of documentation of substantial progress in improving quality of health care and, most importantly, reducing harm to patients (Landrigan et al., 2010; Wachter, 2010). The literature on diffusion of innovation suggests some guidelines to understand factors that influence the adoption of CQI. Most notable is the fact that complexity inhibits further adoption, just as it does for other forms of innovation. Understanding the factors that enable or influence adoption of CQI, as well as the factors that present barriers, is particularly important as more countries around the world are utilizing CQI to solve health challenges, including resource-poor countries (see Chapter 19), and as national health plans are being modified or introduced around the world, including in the United States.

While CQI implementation is slowing down in some health care sectors after the impact of early adopters may have worn off, other sectors of health care, such as public health (see Chapter 16) and nursing (see Chapter 17), are embracing and expanding CQI concepts and methods. Likewise, the increasingly successful use of CQI in QIOs (see Chapter 15) is having a significant impact on quality of care for large populations of Medicare and Medicaid patients in the United States. The impact of accreditation across multiple sectors continues to be noteworthy (see Chapter 18) as a broad global force for the greater adoption of quality improvement methods. These experiences and those that led to them provide a rich source of knowledge for how to diffuse CQI more widely in health care; the challenge is to understand how to accomplish this in the face of declining health quality in many places.

With challenges come opportunities. One example is the use of novel approaches such as social marketing to further the adoption of new CQI tools and processes. Social marketing is an example of a planned, central approach that has been shown to be effective in promoting the spread of innovations in health services and for analyzing the impact or lack of impact of innovations (Greenhalgh et al., 2005). As described in Chapter 8, it may be useful for understanding and promoting compliance with CQI initiatives, such as the surgical safety checklist. This is one of several areas of needed research to better understand how to encourage wider adoption of proven CQI ideas.

Overall, despite the need for wider diffusion of CQI in health care, current trends indicate a continuation of cross-disciplinary learning and significant interprofessional spread of CQI. So while it is important to understand the factors that inhibit the broader use of CQI and the problems affecting the improvement in health care overall, it is more important to review what works so that others may learn. These factors and approaches illustrate how the new sectors within health care that are enthusiastically adopting the CQI philosophy and processes may improve their performance within the health care system.

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