Section 3: Are You Ready To Improve?
3.A. Cultivating and Supporting QI Leaders
3.B. Organizing for Quality Improvement
3.C. Training Staff in QI Concepts and Techniques
3.D. Paying Attention to Customer Service
3.E. Recognizing and Rewarding Success
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Improving CAHPS scores, i.e., the patient's experience of care, is a quality improvement challenge that is somewhat different from improving a clinical or technical process of care. This kind of transformational work requires new tools and often challenges many existing practices in your organization.
Before embarking on this kind of improvement initiative, it is helpful to perform a self-assessment to evaluate whether your organization approaches improvement in a manner that is associated with the successful implementation of CAHPS-related quality improvement (QI) programs. This is a valuable exercise because it takes time and effort to work through the QI process, i.e., to identify weaknesses, develop and apply solutions, and refine your strategies until they have a measurable and sustainable impact.
Read this section to learn about several behaviors common among organizations that are committed to and successful at improving their performance:
- Cultivating and supporting QI leaders.
- Organizing teams responsible for improving patient experience.
- Training staff in QI concepts and techniques.
- Paying attention to customer service.
- Recognizing and rewarding success.
Once they become part of the organization's culture, these behaviors often play a large role in supporting and driving successful efforts to improve members' and patients' experiences with health care. If any are missing or inadequate in your organization, you may want to think about ways to introduce them. At the very least, recognize the impact of their absence on efforts to improve CAHPS performance and plan accordingly. You may, for example, need to devote resources to training team members in basic process improvement methods, or set aside time to educate and build support among physicians or board members.
3.A. Cultivating and Supporting QI Leaders
Many health care organizations are highly resistant to change. Employees are not encouraged to solve problems on their own, nor do they challenge the status quo. Most are accustomed to following standard operating procedures even when the policies and procedures may seem ineffective and outdated. Given the life and death issues confronted every day in most health care organizations, this risk-averse behavior is neither surprising nor hard to understand.
Because of this pervasive attitude, the search for better solutions and creative new approaches to long-standing problems requires strong and consistent encouragement and support. In order to achieve the goals of better performance on CAHPS measures, health plans and ambulatory care providers must cultivate strong leaders throughout their organizations. Leaders are those who can communicate a compelling vision, motivate clinicians and other staff to lower their resistance to change, and effectively and willingly participate in the redesign of new systems of care. Ideally, all levels of staff in the organization should become adept at leading change, making changes, and managing change.
3.A.1. Sources of Leadership
Leadership for quality improvement (QI) can emanate from multiple sources: the board, the CEO and senior leadership team, and mid-level managers. Leaders may obtain their power from the authority of a title, through mastery of knowledge, or through the strength of personality or persuasive abilities.
Senior Leadership: Studies suggest that leadership from the top is a key factor in determining whether clinicians and others support and participate in QI efforts.1 Senior leaders set the tone and establish the policies and organizational structure that can either strengthen or undermine QI efforts.
Mid-level Management: Because CAHPS surveys ask about multiple aspects of the care delivery process, the success of efforts to improve CAHPS scores often depends on the involvement—or at least cooperation—of clinicians, administrative managers, nurses, other clinicians, and practice staff. Medical group administrators and medical directors can also encourage cross-functional improvements in a group practice or ambulatory care site by selecting interdisciplinary team members and physicians with a special interest in QI.
The Board: Finally, strong board leadership can play a crucial role in QI. With the high turnover rates in plan and medical group senior executives, the board can help sustain a corporate culture focused on quality and provide "constancy of purpose."1
3.A.2. Attributes of Service-Oriented Leaders
Effective leaders maintain a focus on the needs of those they serve and their employees. Such leaders exhibit the characteristics listed in Table 3-1.
Table 3-1. Characteristics of effective service-oriented leaders
|Desired characteristics of service-oriented leaders||Non-desired characteristics|
|Energetic, creative||Not…Stately, conservative|
|Participatory, caring||Not…Removed and elitist|
|Listening, coaching, and teaching||Not…Supervising and managing by command and control methods|
|Motivating by mission||Not…Motivating by fear|
|Leading by means of personally demonstrated values||Not…Relying on institutional policies that are meaningless or outdated|
Source: Heskett JL, Jones TO, Loveman G, et al. Putting the service-profit chain to work. Harv Bus Rev 1994 March-April:64-74.
3.A.3. Key Tasks for Leaders at Every Level
Those who study effective leadership have identified ten practices that leaders at all levels can implement to produce and maintain an environment that emphasizes and encourages quality improvement.2
- Link QI goals to the organization's mission and strategic plan (in other words, integrate improvement planning with business planning).
- Establish and communicate the purpose of the organization.
- Adopt and encourage a view of the organization as a system.
- Use measurement and management's attention to keep the organization focused on the goals of QI efforts.
- Allocate financial and other resources (e.g., staff) to QI endeavors.
- Align incentives and performance appraisals to stimulate QI. (For example, create reward and recognition programs that reinforce the values and goals of the organization.)
- Design and manage a system for gathering improvement information.
- Remove barriers, which could be a function of finances, policies, system failures, internal politics, unsuitable attitudes, or legitimate concerns of personnel.
- Become directly involved in continuous improvement projects, perhaps by managing individual and team improvement activities.
- Market and advertise the QI work to the board, staff, and community through interpersonal communication, newsletters, and the media.
While some of these activities may be more appropriate for senior leaders, most can be applied throughout the health care organization.
- Berwick DM, Nolan TW. Physicians as leaders in improving health care. Ann Intern Med 1998;128:289-92.
- Leebov W. Essentials for great personal leadership: No nonsense solutions with gratifying results. American Hospital Association. Chicago: Health Forum; 2008.
- Lencioni P. The five dysfunctions of a team: A leadership fable. San Francisco: Jossey-Bass; 2002.
- Berwick DM. A primer on leading the improvement of systems. Br Med J 1996;312:619-22.
3.B. Organizing for Quality Improvement
Organizations that are successful with their QI work typically develop an improvement team and set up a structure and process for how that team will work together in managing the improvement activities. Some organizations create highly formalized structures; in others, a small, informal group leads the QI effort. Your choices about team membership, roles, and meeting schedule should reflect what will work best for your organization and the people who will be involved.
3.B.1. Building an Implementation Team
The "right" team can play a major role in determining the success of a QI initiative. The key is to carefully select people with the right skill set and mindset for quality improvement: people who are opinion leaders, are respected by their peers, and have appropriate expertise for the purposes of the intervention.
Identify a leader for the team who can serve as the "champion" for the improvement initiative.
This person will not only be the key to energizing the team and keeping the work moving forward, but also a visible spokesperson for the initiative within the organization. The champion should be someone who is well respected professionally, has influence in the organization (formal or informal) that can help garner support for the work and overcome challenges, and has a passion for improving the experience of care for patients.
Choose people for the team who are enthusiastic about the chance to improve care, even if they lack some of the formal skills or responsibilities.
Sometimes QI leaders select staff for a team because of their titles or their clinical or administrative expertise, even though they are clearly not convinced that quality improvement is effective or that patients' experiences matter. These teams are rarely successful because they spend most of their time debating whether they should even be involved or they simply do not show up or do the work.
Recognize that there is no one "correct answer" for how a team should be organized.
A team may consist of only one or two people, especially in a smaller medical practice where each staff person may have multiple responsibilities. This approach is fine, as long as it is a conscious decision rather than an oversight. In larger organizations, effective performance improvement teams typically include:
- A senior leader responsible for providing resources, removing barriers, and publicizing the work of the team through the organization.
- A physician or nurse leader if the intervention involves any aspect of clinical care.
- A team leader who is usually someone with administrative or clinical responsibility. This person could be a nurse, a practice manager, a pharmacist, or the supervisor of a call center, depending on the focus of the team.
- A data analyst to track the performance measures and share them with the team and senior leader
- Other team members who represent the different disciplines or types of staff who own a "piece of the problem."
- Edmondson A. Teaming: How organizations learn, innovate, and compete in the knowledge economy. San Francisco: Jossey-Bass, 2012.
- Leebov W. Working together for professionals in health care: Communication skills for collaboration and teamwork. Leebov Golde Group; 2012. Available at http://languageofcaring.com/book/working-together-for-professionals-in-health-care-communication-skills-for-collaboration-and-teamwork/.
- Katzenbach J, Smith D. The wisdom of teams: Creating the high performance Organization. Boston: Harvard Business School Press; 1993.
- Lawrence D. From chaos to care: The promise of team-based medicine. Cambridge, Massachusetts: Perseus Publishing; 2002.
- Scholtes P. The team handbook: How to use teams to improve quality. Madison, WI: Oriel, Inc.; 1996.
3.B.2. Establishing a Team Process and Structure
The team's job is to initiate the process of improving performance by assessing issues underlying performance problems, setting goals for improvements, developing a strategy and action plan for making changes, and then overseeing the implementation of those actions. During the early part of this work, the team members will be learning how to work together as a group. The leaders can reinforce the positive aspect of this (often messy) process by encouraging team members to express their views, by listening carefully, and by helping them reach consensus on how the team can best carry out the work.
The team will have to make several decisions about managing its QI work:
- What is the role of the improvement team?
- How often will the team meet?
- What method will the team use to make decisions and achieve consensus on improvement strategies and actions?
- Should it create other committees for specific parts of the improvement work?
- How will the team interact with others who will be involved or affected by the changes they introduce? See the box below about engaging stakeholders.
Improvement teams must make the effort to understand the perspectives and concerns of the variety of people who will be involved in or affected by the improvements being made. Many improvement efforts have failed or been slowed because changes were implemented that were not acceptable to one or more stakeholder groups essential to success. On the other hand, some of the strongest efforts have been those that thoroughly engaged stakeholders and empowered them to contribute to achieving sustainable changes.
Leaders of improvement teams need to answer two questions regarding stakeholder involvement:
Who are the important stakeholders for this QI initiative?
Think broadly to identify the groups who may have an interest in the particular improvements you are pursuing. For most initiatives, stakeholders typically include patients, physicians, nurses, and administrative clerks. Depending on the specific services involved, they may also include pharmacists, health educators, therapists of various types, attorneys, staff in other departments in the organization, and representatives from external organizations.
How should these stakeholders be involved in the improvement process?
Ideally, your improvement team will include representatives of the stakeholder groups that are important for your initiative. You can engage front-line staff and other stakeholders throughout the implementation process by establishing mechanisms for open communication and regular opportunities to provide feedback on the process and related tools and practices.
For example, as you begin to develop ideas for changes, ask the people who will be implementing those changes for their suggestions. Then seek their feedback on proposed actions before you begin implementing them.
3.C. Training Staff in QI Concepts and Techniques
One requirement for successful quality improvement initiatives is a staff that is familiar with the reasoning that underlies these efforts and comfortable using the required tools and techniques. Many resources and educational programs are available to help organizations accomplish this. Here is a quick review of the kind of investment in training that you might want to make as you lead your health care organization down the path described in this guide.
3.C.1. Teaching the Rationale
Since training programs should address the "why" of QI as well as the "what" and the "how," you may want to start by educating clinical and administrative staff on the central precepts of QI and how it can benefit the organization and its members/patients. It can be especially useful to share information on how others have used this approach to improve patients' experiences with care and what their responses have been. Strategies to improve patient experience and engagement can also have an important effect on clinical outcomes and physician and staff satisfaction. (See box below.)
In the 1980s, Greenfield and Kaplan* designed a randomized controlled trial to assess the impact of increased patient involvement in care. The patients were visiting a clinic that specialized in ulcer disease.
During a 20-minute session before their regularly scheduled visit, patients in the experimental group received help in reading their medical record and were coached to ask questions and negotiate medical decisions with their physicians. The intervention relied on a treatment algorithm as a guide. Patients in the control group received a standard educational session of equal length.
Six to eight weeks after the trial, patients in the experimental group reported fewer limitations in physical and role-related activities, preferred a more active role in medical decision-making, and were as satisfied with their care as the control group. Analysis of audiotapes of physician-patient interactions showed that patients in the experimental group were twice as effective as control patients in obtaining information from physicians.
Results of the intervention included the following:
- Increased involvement in the interaction with the physician
- Fewer limitations imposed by the disease on patients' functional ability
- Increased preference for active involvement in medical decision-making
- Improved patient and physician satisfaction with the encounter
*Source: Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med 1985;102(4):520-8.
3.C.2. Teaching Concepts and Methods
—Berwick DM, Nolan TW. Physicians as leaders in improving health care: A new series in Annals of Internal Medicine. Ann Intern Med 1998;128(4):289-92.
Once assigned to CAHPS-related improvement teams, staff members will need basic training in specific QI concepts (such as microsystems, change concepts, small tests of change, and the diffusion of innovation) and methods. To learn about these concepts and methods, refer to "Section 4: Ways to Approach the Process of Quality Improvement." Teams that have had basic training in QI techniques, group work, and team building are usually able to achieve success much faster than teams that have had no previous training or experience. However, sometimes teams focus on the training as the "end goal," making it important to set clear aims for the success of any QI project at the outset.
Depending on their role in the team, many staff will also benefit from more advanced training in the effective use of statistical methods, graphic analysis, and multidisciplinary teams.
It is important to note that physicians are unlikely to be familiar with QI methods. While many professionals and managers receive some kind of QI training in their basic education, most physicians do not. Doctors are trained to succeed as individuals but not as members of a team, despite the reality that almost everything they aspire to accomplish is dependent on successful relationships with other staff and their patients.
- America's Health Insurance Plans (AHIP)
- American Medical Group Association (AMGA)
- American Society for Quality
- Baldrige National Quality Program
- Institute for Clinical Systems Improvement (ICSI)
- The Institute for Healthcare Improvement (IHI)
- Medical Group Management Association (MGMA)
- National Committee for Quality Assurance (NCQA)
- Virginia Mason Institute
3.D. Paying Attention to Customer Service
The ability of health plans and primary and specialty care practices to deliver high-quality clinical and administrative service to their members and patients depends in part on their understanding of basic customer service principles and their ability to integrate these principles into clinical settings. This section briefly reviews why excellent service is so critical and suggests some steps for achieving better service at the physician, group, and plan level.
3.D.1. Why Worry About Customer Service?
There are several reasons for health care organizations to pay attention to customer service:
- First, better service translates into higher satisfaction for the patient—and subsequently, for the employer who pays most of the bills.
- Second, as in any other service industry, a satisfied (and loyal) member or patient creates value over the course of a lifetime. In the context of health care, this value may manifest itself in the form of repeat visits, trusting relationships, and positive word-of-mouth. A dissatisfied member or patient, on the other hand, generates potential new costs. Patients who are not happy with their plan or clinician may not follow clinical advice, can develop worse outcomes, and are likely to share their negative stories with friends and family members.
- Third, existing patients and members are an invaluable source of information that can help health care organizations understand how to improve what they do and reduce waste by eliminating services that are unnecessary or not valued.
- Finally, poor customer service raises the risk of a negative "grapevine effect." More than 50 percent of people who have a bad experience will not complain openly to the plan or the medical group. But research shows that nearly all (96%) are likely to tell at least 10 other people about their bad experiences.3 Word-of-mouth reputation is important because studies continue to find that the most trusted sources of information for people choosing a health plan, medical group, doctor, or hospital are close family, friends, and work colleagues.
—Goodman J, Malech A, Marra T. Setting Priorities for Satisfaction Improvement. Quality Review 1987 Winter.
Health care organizations also need to pay attention to customer service because service quality and employee satisfaction go hand-in-hand. It is almost impossible to find high employee satisfaction in organizations that have low patient satisfaction. And organizations that place a premium on customer service tend to have high employee satisfaction as well.
Employees often are frustrated and angry about the same things that bother patients and members: chaotic work environments, poor systems, and ineffective training. No amount of money, signing bonuses, or other tools currently used to recruit hard-to-find staff will offset the negative impact of these problems on staff. The real cost of high turnover may not be the replacement costs of finding new staff but the expenses associated with lost organizational knowledge, lower productivity, and poor experiences for patients and members.
3.D.2. Advice on Achieving Better Customer Service
The most successful service organizations pay attention to the factors that ensure their success: investing in people with an aptitude for service, technology that supports front-line staff, training practices that incorporate well-designed experiences for the patient or member, and compensation linked to performance. In particular, they recognize that their staff value being able to achieve good results, and they equip the staff to meet the needs of members and patients. For health plans, this could mean developing information systems that allow staff to answer members' questions and settle claims quickly and easily; for provider organizations, it could mean providing the resources and materials that clinicians need to provide high-quality care in a compassionate, safe environment.
Experts on delivering superior customer service suggest that health care organizations adopt the following set of principles.4
- Hire service-savvy people.
- Establish high standards of customer service.
- Help staff hear the voice of the customer.
- Remove barriers so staff can serve customers.
- Reduce anxiety to increase satisfaction.
- Help staff cope better in a stressful atmosphere.
- Maintain your focus on service
Many customer-service programs have been developed for companies outside of health care. Although the strategies are similar, Leebov and Scott have adapted this work for health care settings in ways that increase its credibility and buy-in, especially from clinical staff. Their books offer practical, step-by-step instructions about how to identify and solve customer service problems through the health care delivery system.
- Leebov W, Afriat S, Presha J. Service savvy health care: One goal at a time. Lincoln: Authors Choice Press; 2007.
- Leebov W, Scott G, Olson L. Achieving impressive customer service: 7 strategies for healthcare managers. San Francisco: Jossey-Bass; 1998.
- Leebov W, Scott G. Service and quality improvement: The customer satisfaction strategy for health care. Chicago: American Hospital Publishing, Inc.; 1994.
3.E. Recognizing and Rewarding Success
The pursuit of better performance benefits greatly from positive incentives, whether at the organizational level or the individual level. Rewards can be financial or non-financial, but what matters is that they are directly linked to either the effort to improve or, ideally, the actual improvement.
3.E.1 External Rewards
Over the past decade or so, the idea of rewarding health care organizations that exhibit good quality or a commitment to improving their performance has taken off, accelerated by various provisions under the Affordable Care Act. Initially, these rewards came in the form of public recognition. Some purchaser organizations point out high-performing health plans to consumers, while some health plans do the same with medical groups, practices, and even individual physicians to steer members to better performers.
Superior performance also receives public recognition through the growing use of health plan and provider organization "report cards." Many large employers, regional and state-based collaboratives, and government purchasers (such as Medicare and state Medicaid agencies) are producing Web-based reports with comparative information on the quality of health care organizations such as health plans, hospitals, and medical groups. Their goal is to provide consumers with better information for making health care decisions.
These public reports often highlight organizations that achieve better results than others on standardized measures such as CAHPS and HEDIS. While the impact of public reporting has not been extensively evaluated, there is some evidence that making performance information public stimulates quality improvement activities in areas where performance is reported to be low.5,6
More recently, purchasers and payers have explored ways of offering either increased market share or higher financial payments for good quality. Prominent examples include programs implemented by the California-based Integrated Healthcare Association and the Centers for Medicare & Medicaid Services:
- The Integrated Healthcare Association (IHA), a multi-stakeholder leadership group in California, administers a statewide "pay for performance" program. Through this program, health plans use common measures to evaluate the performance of their contracted physician groups serving commercial HMO enrollees, and develop individual bonus programs that pay significant financial incentives based on that performance.
- The Centers for Medicare & Medicaid Services has implemented several programs, some in the form of demonstrations, to reward health plans, accountable care organizations, hospitals, and physicians for both providing high quality care—including patient experience—and improving that care over time.
Learn more in "Health Policy Brief: Pay-for-Performance," Health Affairs, October 11, 2012.
3.E.2. Internal Rewards
External reward systems motivate the leadership and the staff of an organization to focus on quality. Internal reward systems pay close attention to the front-line staff and middle managers who do what is necessary to achieve the external rewards. Reward and recognition programs usually include formal programs, day-to-day feedback, and informal recognition programs.
—Gelinas L, Bohlen C. Tomorrow's Workforce: A Strategic Approach. VHA Research Series; 2002.
3.E.2.a. Formal Programs
Examples of internal formal programs include:
- Staff recognition awards that focus on different behaviors, i.e., service excellence, clinical competence, teaching, and mentoring.
- Years of service awards: 5, 10, and 25 years.
3.E.2.b. Day-to-Day Feedback
Managers provide consistent and timely feedback to employees about their performance. Experts confirm that providing praise in a timely manner does have a positive effect on employee motivation and sense of belonging. Some organizations develop formal coaching programs to assist managers in coaching and providing feedback to their employees and peers.
3.E.2.c. Informal Recognition Programs
Many employees go above and beyond their assigned duties to assist patients, other staff, clinicians, and the community. It is important to encourage the recognition of these individuals for their customer service, teamwork, integrity, or overall positive attitude. Research indicates that informal recognition by managers is a key motivating factor for effective job performance.7
One example of an informal program is called R.E.W.A.R.D., which stands for Recognition of Employees When Achievement & Responsibility is Displayed.
How to Recognize: Some organizations create a J.A.C.K. In-The-Box, where J.A.C.K. stands for Job Acknowledgement Care Kit. The JACK In-The-Box provides a number of rewards that can be used for instant recognition when situations "pop" up. These can include gift certificates, time off, extra vacation days, or other small tokens of appreciation scaled to fit the accomplishment.
Draw on your understanding of the person you want to recognize when selecting the recognition item. Some people like public recognition of their efforts; if you are not sure, ask the person what he or she would be comfortable with.
When to Recognize: There are no rules about how often recognition should take place. Ideally, recognition should take place as soon as possible, whenever you want to say "Thanks" or "Congratulations."
What to Recognize: People can be recognized for many things. Here are just a few:
- Exceptional job performance
- Excellent team work
- Outstanding customer service
- Extraordinary performance of regular duties in a particularly difficult circumstance
- Extremely good performance of regular duties over a long period of time
- A "Good Catch" (i.e., the person took the initiative to nip a problem in the bud or avoid a disaster)
- Active participation in projects
- Applying new skills and knowledge
- Meeting goals and targets
- Displaying commitment and loyalty to the organization
- Demonstrating innovation through new ideas and initiatives
Orientation of new employees is the best place to begin the education about the culture of your organization. It is also an excellent way to highlight how the internal reward and recognition system is linked to the philosophy of care and organizational standards.
The objective of orientation should be to do the following:
- Instill a feeling of self-worth.
- Create a sense of belonging.
- Develop an attitude of pride and confidence in oneself and the organization.
- Spark a desire to succeed.
- Enhance the relationship between the employee and the organization.
—Rosenbluth H. The Customer Comes Second. New York, NY: Harper Business; 2002.
3.E.4. Compensation and Benefits
Compensation and benefits can be designed to reinforce the desired behaviors and performance standards of the organization. Compensation levels can be linked to meeting service-oriented performance standards, coaching and mentoring goals for managers, and other indirect reward activities such as completing performance reviews on time.
Cafeteria-style benefit packages help meet the needs of a diverse work force without creating a sense of inequity in your workforce. Some organizations offer unusual benefits such as pet insurance, health club memberships, flexible spending accounts for medical and childcare expenses, and even home financing assistance and education.
3.E.5. Rewards That Go Beyond the Individual
Rewards can also be actions and changes that support the entire organization and help transform the culture. Examples include the following:
- Improve your systems to "make it easy to do the right thing" and improve quality of life for front-line staff.
- Make sure people have the aptitude, training, and the resources they need to do a job well done.
- Give star performers the opportunity to attend conferences of their choice and/or receive tuition reimbursement for courses that advance their expertise.
- Tell stories, create legends and celebrate "heroes."
- Help people get recognition internally and externally through presentations at meetings and conferences, newsletters, and local media.
- Recognize people personally for behavior consistent with the organization's stated philosophy and rules.
- Use thank you notes, voice mailboxes that allow patients to compliment staff, and public postings of thank-you letters from grateful patients and families.
- Be aggressive about the management of poor performers (i.e., staff who do not uphold the values and culture of excellence).
- Show respect for people. Start everything on time.
- Invite front-line staff to meet with senior management and the board routinely to improve communication and trust in management.
Learn more: Gelinas L, Bohlen C. Tomorrow's Workforce: A Strategic Approach, VHA Research Series; 2002.
- Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med 1989 Jan 5;320:53-6.
- Camp R, Tweet AG. Benchmarking applied to health care. J Qual Improv 1994;(20):5.
- Collins J. Good to Great: Why Some Companies Make the Leap... and Others Don't. New York: HarperCollins; 2001.
- Heskett JL, Jones TO, Loverman GW, et al. Putting the service-profit chain to work. Harv Bus Rev 1994 Mar-Apr;164-174.
- Institute of Medicine. Crossing the Quality Chasm. Washington, DC: National Academy Press; 2001.
- Kotter JP. Leading change: Why transformation efforts fail. Harv Bus Rev 1995;73(2):59-67.
- Langley G, Nolan K, et al. The Improvement Guide. San Francisco: Jossey Bass; 1996.
- Powell AE, Rushmer RK, Davies HTO. A systematic narrative review of quality improvement models in health care. Social Dimensions of Health Institute at The Universities of Dundee and St Andrews, February 2009. Available at: http://www.healthcareimprovementscotland.org/previous_resources/hta_report/health_care_improvement_models.aspx. Accessed July 2015.
- Tucker F, Gaither S, Zivan M, et al. How to measure yourself against the best. Harv Bus Rev January/February 1987:8-10.
- Weiner BJ, Shortell SM, Alexander J. Promoting clinical involvement in hospital quality improvement efforts: The effects of top management, board, and physician leadership. Health Serv Res 1997;32(4):491-510.
- Langley GJ, Nolan KM, Norman C, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass; 1996.
- American Society for Quality. Basic Facts on Customer Complaint Behavior and the Impact of Service on the Bottom Line. Competitive Advantage: ASQ Newsletter; 1999.
- Leebov W, Scott G, Olson L. Achieving Impressive Customer Service: 7 Strategies for Healthcare Managers. San Francisco: Jossey-Bass; 1998.
- Hibbard JH, Stockard J, Tusler M. Does publicizing hospital performance stimulate quality improvement efforts? Health Aff (Millwood) 2003;22(2): 84-94.
- Totten AM, Wagner J, Tiwari A, et al. Closing the Quality Gap: Revisiting the State of the Science (Vol. 5: Public Reporting as a Quality Improvement Strategy). Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul. (Evidence Reports/Technology Assessments, No. 208.5.) Available from: http://www.ncbi.nlm.nih.gov/books/NBK99879/.
- McElroy J. Managing workplace commitment by putting people first. Human Resource Management Review 2001;11(3): 327-335.