THE article by Solberg, Taylor, Conway, and Hiatt on quality improvement and transformation in large multi-specialty group practices (LMGPs) offers readers a window into the perceived "success characteristics" that are most responsible for highly successful improvement projects in LMGPs. All the authors have deep and extensive experience in attempting to promote better quality and better value care in large, progressive health systems. Their insights are worth understanding and paying attention to. I appreciated having the opportunity to read this article and to have been given an invitation to discuss the results and their implications.
In this commentary I will address 3 issues:
1. A summary of findings
2. A second interpretation of the findings
3. Successful projects in contrast to durable transformation
SUMMARY OF FINDINGS
In brief, the authors collected "stories" of successful improvement projects in 24 LMSGs and performed a qualitative analysis of the characteristics that were associated with the success of 8 of the most successful projects-that is, substantial measurable improvements benefiting large numbers of patients. The authors identified 18 project success "driver" characteristics that were embedded in the success "stories" and asked leading physicians who were close to each "story" to rate the importance of these characteristics. Although almost all of the 18 characteristics were rated high on importance, 5 moved to the top of the rankings-communication, use of evidence-based medicine, leadership, measurement, and reporting. The authors note that their results are generally consistent with both the healthcare and general literature on quality improvement and are associated with the 6 challenges that were noted in the Institute of Medicine's Chasm Report.
SECOND INTERPRETATION OF THE FINDINGS
When one looks at these findings from a certain vantage point, it can be concluded that what the authors found was a short list of factors that were perceived to be important determinants of successful projects by the clinical leaders of these projects. When these 5 factors are placed in an arrow diagram, it can be argued that the "stories" tell their own, simple story. The story within the "stories" starts with leadership and ends with communication:
* Leadership [horizontal ellipsis] described as "stakeholder involvement in initiating, implementing, and sustaining the change"
* Communication [horizontal ellipsis] described as "communication of expectations and goals"
The other 3 factors are all ways that the leaders can actively and intelligently engage frontline staff and other stakeholders in communicating goals and expectations and achievements made at realizing the goals and expectations based on promoting evidence-based medicine, performance measurement and feedback linked to "clear consequences/ rewards," and reporting the "data to drive change." A picture of the story inside the "stories" can be illustrated with an arrow diagram (Fig 1).
This modest reinterpretation of the findings is offered to underscore for leaders of improvement projects (a) the starting conditions (ie, leadership and engagement of all the players, (b) the means (ie, evidence-based medicine, measurement and reporting), and (c) the ends (ie, clear unambiguous communication of goals and expectations).
SUCCESSFUL PROJECTS IN CONTRAST TO DURABLE TRANSFORMATION
The terms transformation and transformative change have become common in today's healthcare lexicon. Many recognize that the nation's healthcare system cannot deliver what is needed and that small, incremental changes are unlikely to yield the massive and systemic changes that are being demanded by many policy makers, purchasers, employers, and the ultimate beneficiaries-individuals burdened with illness and their families, friends, and communities.
My own view is that if we wish to have a transformed system then we will need to take a systems-based approach to achieve the quantum leap forward that is suggested by the term transformation. Transformation suggests becoming "something else," not something a little bit different. Transformation suggests that healthcare professionals will adopt new patterns of sentiments, thoughts, beliefs, actions, and interactions that replace their older established ones (that have been successful heretofore) and this requires unlearning as well as new learning.
Making improvements on the basis of projects is necessary and important. It is essential to have successful projects and to uncover the special blend of ingredients that tend to produce successful improvement projects in healthcare. Individual projects can make things better in the short/long run and can build the new knowledge, attitudes, practices, and beliefs of those engaged in the project that contribute to the organization's own "culture" and that must be transformed if the "system" is to be transformed. But understanding what factors contribute to successful projects is not equivalent to understanding the factors that will combine to create the conditions for transformative change in healthcare.
The scholarship of Donald Schoen, John Kotter, James Brian Quinn, Stephen Shortell, Donald Berwick, Paul Bate, and many other students of organizational change all suggest that transformative change requires intraorganization cultural change (eg, the persistent patterns of actions, interactions, processes, attitudes, and beliefs that have been found to be successful by an organization over time) at all levels of each organization that is a candidate for major change. A fundamental challenge for healthcare leaders at all levels of the health system is to create the conditions to promote large and durable changes in the way things work-and the cultural and technical infrastructure that supports how things work-that have the potential to generate sustained high performance as measured by both short-term results and long-term outcomes in the domains of quality, safety, and costs.
Successful projects can play a part in creating better whole organizations and supportive local cultures that may begin to open the big, heavy door that leads into a new space called "transformed care." It is through research done by Dr Solberg and his colleagues that we may get a better view of what it will take for our healthcare system, and the organizations of which it is made, to go through that door called "transformed care" and to have a better understanding about what it looks like on the other side.