Berman S (editor)
Chicago, Illinois: Joint Commission Resources and the Institute for Healthcare Improvement; 2005

Health care leaders are now finding quality and safety to be vital not only to the health of patients but also to the health of the enterprise. In this book, the experts widely considered top in their respective fields describe the most challenging issues facing health care leaders today and provide guidance and suggestions on how to address them. Topics include microsystem peak performance; organizational infrastructure for patient safety; using information technology for safety and quality; patient flow; staffing for organizational excellence; and strategies to spread improvement.

Bisognano M, McCannon J, Botwinick L. A campaign for 100,000 lives: The time is now for boards to lead quality and safety efforts. Trustee. 2005 Sep;58(8):12-14, 19, 1.

Increasingly, the role of the governing body in quality and patient safety oversight is being viewed as a fiduciary responsibility at least equal to its financial oversight role. This article discusses how hospital boards play a major role in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

Weick KE, Sutcliffe KM. Hospitals as cultures of entrapment: A reanalysis of the Bristol Royal Infirmary. California Management Review. 2003;45(2):73-84.

The dynamics of organizational cultural are explored in the case of the Bristol Royal Infirmary (UK), in which pediatric cardiac surgeries continued for over a fourteen-year period despite evidence of poor quality care and performance that was far below that of other comparable pediatric surgical centers. A single organizational process of behavioral commitment explains how the cultural mindset originated and why it persisted.

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Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: Processes of collective mindfulness. Research in Organizational Behavior. 1999;21:81-123.

High Reliability Organizations (HROs) have been considered outliers in terms of organizational theory due to their unique potentials for catastrophic consequences and interactively complex technology. The authors contend that HROs are more central to the mainstream because they provide a unique window into organizational effectiveness under trying circumstances.

Institute for Healthcare Improvement. IHI Innovation Series white paper. Going Lean in Health Care. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2005.

IHI Innovation Series white paper

Lean management principles have been used effectively in manufacturing companies for decades, particularly in Japan. IHI believes that lean principles can be — indeed, already are being — successfully applied to the delivery of health care.

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Great boards ask tough questions: What to expect from management on quality. The Governance Institute. 2005 Apr;16(2).

Effective boards are willing to deal with tough issues and place high expectations on management in order to get things done. Hospitals and health system boards have been increasingly focused on ways to improve quality in their organizations. One way to do this is to ask the right questions and expect results. This article features an interview with Donald M. Berwick, MD, MPP, President and CEO of the Institute for Healthcare Improvement, in which he states that boards should give quality of care the same attention they give to financial issues.

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Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006.

IHI Innovation Series white paper

Leadership is the critical element in a successful patient safety program and for building a culture of safety, and is non-delegable. This white paper presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organizations. Each step and its component parts are described in detail, and resources for more information are provided where available.

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Reinertsen JL, Pugh MD, Bisognano M. Institute for Healthcare Improvement. IHI Innovation Series. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2005.

IHI Innovation Series white paper

This white paper presents what IHI believes to be some important leverage points for leaders who want to achieve dramatic, system-level performance improvement. This set of leverage points is not offered as a tried-and-true method, but as a theory. The white paper has three sections: 1) A description of each leverage point; 2) Application of the leverage points framework to the leadership challenge for hospitals enlisted in IHI's 100,000 Lives Campaign; 3) A self-assessment tool.

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Mosser G, Scheitel S. Public Reporting of Health Care Performance in Minnesota. Bloomington, Minnesota: Institute for Clinical Systems Improvement; November 2004.

This position paper, published by the Board of the Institute for Clinical Systems Improvement (ICSI), focuses on a task force chartered to expand the use of public performance reporting in order to improve health care quality in Minnesota. The paper describes the aspects of public reporting addressed by the task force and the conclusions of their work.

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Find Our Way Home: A Blueprint to End Homelessness in Philadelphia. Greater Philadelphia Urban Affairs Coalition. June 1998.

Homelessness is a growing concern in many US cities and for some cities, like Philadelphia, the rising percentage of homelessness has become a major crisis that is a challenge to control.  In 1998, the Greater Philadelphia Urban Affairs Coalition brought forth this “blueprint” to help end homelessness — a phenomenal example of how many different organizations and systems can work collaboratively to accomplish one common goal.  By maximizing coordination between the housing authority, police, shelters, politicians and many other groups, the city started to transform their social system to eliminate gaps and prevent unneeded homelessness.  Whether it’s a health care system or a social system, identifying problems within any system is easy: but it takes strong leadership, common goals, system thinking, and real and permanent solutions to help accomplish the once unthinkable.