Organizational coherence in health care organizations: conceptual guidance to facilitate quality improvement and organizational change.

Q Manage Health Care Vol. 23, No. 4, pp. 254–267 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Organizational Coherence in Health Care Organizations: Conceptual Guidance to Facilitate Quality Improvement and Organizational Change Ann Scheck McAlearney, ScD, MS; Darcey Terris, PhD; Jeanne Hardacre, PhD; Peter Spurgeon, PhD; Claire Brown, PhD; Andre Baumgart, PhD; Monica E. Nystrom, PhD ¨ Objective: We sought to improve our understanding of how health care quality improvement (QI) methods and innovations could be efficiently and effectively translated between settings to reduce persistent gaps in health care quality both within and across countries. We aimed to examine whether we could identify a core set of organizational cultural attributes, independent of context and setting, which might be associated with success in implementing and sustaining QI systems in health care organizations. Methods: We convened an international group of investigators to Authors Affiliations: Department of Family Medicine, College Medicine, The Ohio State University, Columbus (Dr McAlearney); Department of Corporate Strategy and ´ Innovation, Ecole Polytechnique Fed de Lausanne, ´ erale ´ Switzerland (Dr McAlearney); Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus (Dr McAlearney); Center for Family Research, University of Georgia, Athens (Dr Terris); Mannheim Institute of Public Health, Social and Preventive Medicine, Universitatsmedizin Mannheim, Medi¨ cal Faculty Mannheim, Heidelberg University, Mannheim, Germany (Drs Terris and Baumgart); Warwick University, Warwick, United Kingdom (Drs Hardacre and Spurgeon); Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden (Drs Spurgeon, Brown, and Nystrom); ¨ School of Public Health, Griffith University, Meadowbrook, Queensland, Australia (Dr Brown); Corporate Strategy and Development, Lucerne Canton Hospital, Lucerne, Switzerland (Dr Baumgart); and Department of Public Health and Clinical Medicine, Umea˚ University, Umea, ˚ Sweden (Dr Nystrom). ¨

explore the issues of organizational culture and QI in different health care contexts and settings. This group met in person 3 times and held a series of conference calls to discuss emerging ideas over 2 years. Investigators also conducted pilot studies in their home countries to examine the applicability of our conceptual model. Results and Conclusions: We suggest that organizational coherence may be a critical element of QI efforts in health care organizations and propose that there are 3 key components of organizational coherence: Correspondence: Ann Scheck McAlearney, ScD, MS, Department of Family Medicine, College of Medicine, The Ohio State University, 2231 N High St, 273 Northwood and High Bldg, Columbus, OH 43201 ([email protected]). The establishment of the collaborative research Network that developed this manuscript was supported by The Swedish Foundation for International Collaboration in Research and Higher Education (STINT). Pilot study results reported from McAlearney were based on research funded by the Agency for Healthcare Research & Quality (AHRQ). The content of this paper is solely the responsibility of the authors and does not represent the official views or recommendations of AHRQ or the Department of Health and Human Services. Pilot study results reported from Nystrom ¨ were supported by the Swedish Association of Local Authorities and Regions (SKL) and the Vinnv˚ard research program in Sweden (grant no A2007034). All authors declare that they have no conflicts of interest associated with this manuscript. Reprinted from QMHC Vol. 22, No. 2, pp. 86–99. The authors extend their thanks to all the study participants for their help and also to the STINT that supported the development of their international Network. DOI: 10.1097/QMH.0000000000000044

254 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Organizational Coherence in Health Care Organizations

(1) people, (2) processes, and (3) perspectives. Our work suggests that the concept of organizational coherence embraces both culture and context and can thus help guide both researchers and practitioners in efforts to enhance health care QI efforts, regardless of organizational type, location, or context.

Key words: health services management, organizational change, organizational improvement, organizational learning, performance improvement, quality improvement

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reating a culture of continuous quality improvement (QI) is a goal commonly found across a wide variety of organizations, regardless of industry sector. Yet, as has been shown in health care settings, an organization’s culture itself can either support or create barriers to effective QI.1–4 The ideal of a “quality improvement culture” is often lauded as a key factor contributing to organizational success in QI efforts, but this ideal has proved hard to achieve.5–7 As such, a clear incentive exists for researchers and managers to identify and proscribe specific elements of organizational culture as a necessary foundation to implement and sustain quality systems.5,8,9 Organizational culture, however, is influenced by the beliefs, values, and informal norms of the communities and greater society in which the organization is situated.10–12 An organization’s culture, in practice, may reflect the structural and strategic characteristics of that organization, as well as the demographic, social, and even geographic context of which it is a part. How, then, should we balance the need to foster a QI culture at the organizational level, while respecting differences in organizational culture that arise from fundamental values associated with the organization’s setting? Some of the most obvious difficulties in achieving this balance are found in the literature describing health care QI initiatives in developing countries. Too often in these projects, quality models are directly imported from developed countries into the developing country’s settings. The QI programs that are designed are then difficult to sustain in the long-term. This sustainability problem is partially attributed to resource limitations but also emerges because the adapted QI program models still maintain the fundamental values and structures of the country from which the models evolved—values and structures that are often incongruent with the current QI program implementation setting.13 Similar challenges involving translation of QI models into practice occur when these models are disseminated from one setting or context to another—between 2 developed countries, within regions in the same country,

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or even between 2 levels of the health system within the same country and region.14,15 Health care organizations can be described as presenting a challenging context for QI initiatives.16 In such settings, a host of factors interact and can impact efforts to improve health care processes and outcomes,16–18 many of which are not directly modifiable by the health services providers working within that given health care setting. For example, the ultimate outcomes of health care service provision can be influenced by the availability of new health technologies or interventions, but access to these interventions may be outside the control of service providers and health care delivery systems (eg, most physicians are not involved in product development, such as finding new formulations of pharmaceuticals to improve clinical outcomes, and not all patients have access to promising health interventions). Furthermore, although physicians may strive to influence patients’ health statuses and behaviors, in the end, physicians have little impact on the full range of factors affecting patients’ responses to medical care (eg, genetic, psychosocial, and socioeconomic factors and an individual patient’s adherence to treatment recommendations). Even the control of treatment recommendations and timing of those treatments is significantly affected by the policies and infrastructure of a health care provider’s practice environment and the local, regional, and national health system polices and regulations,19,20 thus illustrating the additional complexities associated with care delivery within the health care industry. The role of organizational culture in affecting the capacity of individuals and systems to change and embrace quality systems has been recognized, although perhaps not rigorously studied, in management science and industry for decades. Only recently have these same issues been raised within the context of health care QI research.21–23 However, organizational culture has proved notoriously difficult to change,24,25 despite research and practice evidence that have demonstrated culture change to be vital to facilitate improvements in quality and organizational performance.26–30 Questions remain about

how culture is affected by the context of organizations, and how culture may vary across organizational settings, and how this variation may affect QI efforts in health care. The purpose of this article is to introduce the concept of “organizational coherence” as a potentially valuable construct that may make a significant contribution to improve understanding of how health care improvement can be accomplished more successfully across settings. Our purpose in presenting this article is not to extensively review the literature, but to encourage discussion and consideration of this novel construct in health care organizations striving to improve quality of care and organizational performance across health care settings.

METHODOLOGY We convened an international group of investigators to explore the issues of organizational culture and QI in health care settings. These investigators represented a broad range of perspectives including the areas of work and organizational psychology, health services research, sociology, human resource development, health services management, health economics, and organizational development. Our network aimed to examine whether we could identify a core set of organizational cultural attributes, independent of context and setting, that might be associated with success in implementing and sustaining QI systems in health care organizations. Given our understanding of organizational culture, QI, and health care organizations, our hypothesis was that health care settings in 2 different countries would be more dissimilar than a given group of manufacturers in the same 2 countries. We were interested in improving our understanding of how health care QI methods and innovations could be more efficiently and effectively translated between settings in the face of significant and persistent gaps in health care quality internationally.31–33 Specific aims of the Network The primary aim of our Network in Organizational Culture and Quality Improvement (the “Network”)



was to develop a conceptual model that could reflect core elements of organizational culture required to effectively implement and sustain quality systems in health care organizations. We hypothesized that the core elements would be independent of (1) the processes and structures implemented for QI (eg, a specific accreditation system), (2) the setting where the QI activity takes place (eg, Sweden vs Germany, developed vs developing country contexts), and (3) the level of the system where the QI activity occurs (eg, within a hospital or physician practice setting). By identifying the common, core elements of QI, we aimed to facilitate the translation of knowledge and methods between settings and contexts. We were also open to the possibility that QI, and all its related concepts, are by nature setting- and context-specific. We believed that this outcome would not negate the work of the Network, but instead, a finding that there are no common core elements of QI would be a valuable conclusion that could inform future efforts to disseminate QI knowledge and implementation strategies. Network activities Our initial in-person Network meeting was convened to introduce investigators and begin to explore the concepts of QI and organizational culture from the perspectives of the multiple participating individuals representing different countries involved in the Network. The first 2-day meeting involved brief presentations focused on organizational culture, QI, and organizational change in a variety of different health care settings, followed by intense discussions and debate about whether core elements of QI existed across these contexts. Our initial discussions centered around whether settings, individuals, and organizations had common understandings of quality and improvement and led us to develop a semistructured interview guide/open-ended questionnaire to use in pilot studies that could be carried out in the investigators’ home countries and settings. Pilot studies were conducted in Sweden (multiple case studies), Switzerland (interviews of hospital executives and managers), the United States (surveys of nurses), and the United Kingdom (interviews of

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clinicians and managers) after the conclusion of the first meeting. The pilot study results were then translated into English by the participating investigators and were synthesized. While the results of these pilot studies could not be formally combined due to both methodological (ie, case studies vs interviews vs surveys) and contextual differences (eg, community health workers in Sweden vs nurses in the United States vs hospital executives in Switzerland), a second in-person Network meeting provided the opportunity to discuss the synthesized results and consider the implications of our preliminary findings. After the second meeting, Network members pursued additional opportunities to extend our research (eg, among hospital executives and nurses in the United States), as well as linking our work to ongoing model development being pursued by Network investigators. Our further analyses also involved an ongoing review of the literature, and consideration of relevant conceptual frameworks in the areas of team mental modeling, strategic planning and management, leadership and change management, continuous QI, social psychology and organizational psychology, performance improvement, and organizational development. During our third Network meeting, our continuing review of pilot study results, related literature, and ongoing discussions enabled us to focus on the construct of organizational coherence in health care organizations that emerged as centrally important in efforts to improve quality and facilitate organizational change. We next describe this construct in greater detail and provide case examples from our pilot studies to illustrate the role of organizational coherence in facilitating QI in a variety of contexts and countries.

RESULTS Defining organizational coherence Coherence is defined by Merriam-Webster’s Dictionary as (1) the quality or state of cohering as (a) systematic or logical connection or consistency, (b) integration of diverse elements, relationships, or values and (2) the property of being coherent.34 Our


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cross-national study of health care organizations’ QI and organizational change initiatives led us to suggest that organizational coherence may be a key element of these improvement efforts. By embracing the notions of both context and culture, the construct of organizational coherence may facilitate organizational improvement and change. Within an organization, intraorganizational coherence prompts sense-making35 and permits development of a shared understanding across and between levels of staff and clinicians in health care organizations. For instance, if there is coherence within the organization, or a shared understanding of the logic and value of a particular QI effort, staff may be more likely to be engaged positively with the goals and strategies of the organization striving to achieve that improvement. This coherence can then facilitate consistent action on the part of staff members working to improve quality of care, regardless of whether the initiative is targeted to the unit, department, or organization as a whole. Furthermore, at the level of the organization, if the organization works in a coherent way, the processes in place in the organization are

more likely to further create coherence toward organizational goals, as these processes are consistent with the organization’s mission and values. We present Figure 1 to illustrate the notion of organizational coherence and the importance of coherent processes at all levels of an organization. As shown, at the level of groups or teams within an organization, social system coherence between and among individuals will help those individuals “do the right thing” as their understanding of their individual roles and responsibilities is consistent and coherent with the overall aims of the organization. Similarly, at the level of organizational units, intraorganizational coherence may be critically important by providing consistency of processes across these units and aligning efforts across clinical units, individual departments, and/or cross-functional teams working toward organizational improvement goals. Third, across organizational actors and levels, coherent processes are also vital, providing consistency around organizational efforts to achieve improvement goals, and ensuring alignment of efforts and processes with the organizational

Figure 1. Conceptual model of organizational coherence considered in relation to organizational development and quality improvement.



mission, vision, and values. Combined, these 3 different aspects of organizational coherence help to increase engagement within the organization, and reduce the confusion and resistance that commonly hinder QI efforts. Examples of organizational coherence that emerged from pilot studies We used data from 5 pilot studies conducted across 4 countries (Sweden, United Kingdom, Switzerland, and the United States) to explore the applicability and appropriateness of the construct of organizational coherence in the context of QI in health care organizations. Brief summaries of these pilot studies and their findings related to the importance of organizational coherence in QI efforts are as follows. Pilot study in Sweden: case studies of 6 organizations successfully achieving continuous organizational improvement and learning36 Six Swedish organizations, ranging in size from 30 to 300 employees, were surveyed using semistructured interviews. The organizations were chosen on the basis of their successful efforts to achieve continuous organizational improvement, development, and learning. The 6 units covered a wide range of service delivery settings (ie, 3 primary care practices, 1 geriatric clinic, 1 emergency unit, and 1 audiology/hearing clinic) and were located in 3 different regions of Sweden. These pilot study findings emphasize 3 areas of organizational coherence (as outlined in this article). These areas are described further in more detail. Social system coherence. Swedish health care organizations reportedly successful at QI all appeared to have key change agents that emphasized the importance of a long-term commitment to improvement, providing support for improvement efforts, and enabling individuals within the organizations to enhance their abilities to make sense of the improvement goals from their own perspectives (ie, facilitating sense-making). Furthermore, in these organizations, the work environment and staff members’ needs were both seen as important, and their influ-

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ence on change projects was noted, especially with respect to organizational efforts to focus on patients. Intraorganizational coherence. Swedish organizations deemed successful at learning, development, and QI were found to have organizational systems consistent with the notion of intraorganizational coherence. For instance, these organizations were found to value and encourage employee commitment, participation, and involvement and had effective systems and structures in place to permit consistent communication and information sharing (eg, give all staff a clear overview of what is going on and enhance active interaction instead of top-down, passive communication). Furthermore, from an organization perspective, messages about the improvement effort were focused on the core task and the main customer (ie, the patient), and this focus was found to be consistent across the organization. Coherent processes. Successful Swedish organizations were found to have systematically employed change management processes to facilitate their efforts. For instance, a Plan-Do-Check-Act cycle37,38 or similar models emphasizing goals, measurement, feedback, and evaluation were typically used to guide improvement initiatives. In addition, these organizations also took care to devote adequate time and resources to the QI projects (eg, in relation to the context and scope of the project, the project leaders and members are satisfied with the time and resources allocated). These organizations also encouraged experimentation and quick pilot tests of ideas and were reportedly accepting of failures as part of the process. Challenges/Limitations. Challenges for achieving coherence were not specifically addressed, given the focus of the study. Nonetheless, those mentioned included the following: support from key actors, such as managers; staff being able to have influence; a sense of direction; and follow-up processes for QI that enhance longitudinal learning and relate to the holistic view of organizational activities. Each of these issues involves aspects of the proposed organizational coherence concept, thus indicating a need to address these challenges in future improvement work.


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Pilot study in the United Kingdom: clinicians’ and managers’ perspectives on improvement Semistructured interviews were held with 6 managers and clinicians involved in leading improvement work in the UK National Health Service. The findings surrounding organizational coherence appeared particularly salient when considering the differences between factors that facilitated or hindered improvement. Specific areas of organizational coherence are described further in more detail. Social system coherence. Social system-level factors that supported improvement included a focus on teamwork and sharing a vision for improvement. Interviewees reported specific problems with a lack of coherence when they described a perceived clash between quality and cost goals, the difference between organizational views and professional values, and problems that emerged when improvements were motivated by achieving government targets or arbitrary cost-saving goals. Intraorganizational coherence. Across the organization, intraorganizational coherence was evident in factors supporting improvement such as consistent communication, everyone knowing their contribution, making improvement a priority, using clinical leads to champion projects, and having staff more engaged around safety than around finances or efficiency. In contrast, factors related to a lack of intraorganizational coherence that reportedly hindered improvement efforts included lack of engagement; not being allowed to try things out; hierarchical, topdown imposed changes; financial constraints; and improvement efforts that did not fit with staff philosophy. In addition, confusion about how efficiency and effectiveness could go hand-in-hand and conflict between the notions of pragmatism versus excellent service tended to reduce intraorganizational coherence around improvement goals. Coherent processes. A range of improvement methodologies and processes were evident in different parts of the UK National Health Service, including implementation of Lean principles, Plan-Do-Study-Act, “Breakthrough” collaborative methodology, Six Sigma, having a central improve-

ment team within the organization, and building capacity and capability in improvement skills into clinical teams. This range of processes was viewed as a potential enabler of coherence in the sense that organizations were able to select an approach deemed as relevant or appropriate to the local setting. However, such an array of QI processes appeared to be problematic when a single organization was deploying several or all these processes in different areas as separate initiatives; in these cases, there was no coherence among the processes or implementation efforts. Challenges/Limitations. The individuals surveyed in this pilot study were challenged greatly by the concept of improvement because they had different interpretations of what improvement meant. In this context, improvement was variously understood as using metrics, being driven from the frontline, taking individual responsibility for improving things, being financially driven, being integral to everything people do, and becoming part of the culture. Interviewees also listed changes they determined that should not be defined as improvement efforts: those that were not measurable, those involving jumping to solutions prematurely, those that lacked an impact assessment, and efforts primarily involving reductions of staff or cost-cutting. Inconsistent understanding about the concept of improvement was evidence of a potential problem with a lack of organizational coherence around improvement goals. Pilot study in Switzerland: senior physicians’ and senior managers’ perspectives on improvement from four central Swiss hospitals Semistructured interviews were conducted with senior physicians (senior clinical employees) and senior (nonclinical) managers of 4 central Swiss hospitals. The interviewees were associated with (quality) improvement initiatives in different areas and organizational levels in their hospitals, that is, certification of the entire hospital quality management system, improvement of patient pathways for ACS (acute coronary syndrome), or certification of a breast care center.



We found that the concepts of quality and (quality) improvement were understood differently among senior physicians and (administrative) senior managers. Senior physicians considered quality and improvement in terms of medical outcomes and concepts related to results-oriented measurement and initiatives. This outcome-oriented perspective did not consider any quality initiatives that were not related to patient outcomes or did not relate to (even hypothesized) outcome improvements. In contrast, senior managers focused on structural and process quality using ISO-based quality management concepts. Senior managers used quality systems, such as EFQM or ISO 9000 to establish a quality framework that could permit improvement measurement in their units using recommended measurement instruments. Their primary aim was not to improve patient outcomes or value but instead to improve patient or customer satisfaction as part of the quality management system. These definitional differences provided the foundation for exploration of the organizational coherence construct, as explained next. Social system coherence. A majority of interviewees claimed they needed additional support and more frequent exchange of information about improvement work among all hospital units. At the same time, the heterogeneity of definitions of improvement between management and clinical areas provided evidence of different cultures for QI work. Clinical directors reported that their primary forums for improvement work would occur during their regular patient visits or daily/weekly staff meetings. In contrast, administrative managers largely promoted improvement initiatives in the context of change/improvement projects associated with their QI systems (eg, fulfilling requirements of audit plans). Intraorganizational coherence. Clinical and nonclinical managers reported the urgent need to improve intraorganizational coherence through a central quality management unit that coordinates and manages the overarching QI initiatives or operationalizes strategies and goals in cooperation with the work of their units. However, aligning efforts across clinical units, individual departments, and/or

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cross-functional teams had not yet been accomplished. Coherence within a department/unit was based on individual skills or driven by the needs of the units/departments. Coherent processes. Across interviews, we found a lack of coherent processes that might align improvement strategies and goals with processes or work settings in departments and clinical units. More specifically, clinical department heads discussed the need for patient-centered quality management processes to continuously adapt to the growing information demands of regulatory bodies and the public with regard to patient safety. Challenges/Limitations. The key challenge for achieving coherence in clinical work settings was perceived to be the lack of information; this was often noted as a limitation. In addition, the growing informational needs associated with improvement initiatives were noted to impose additional workloads for personnel beyond routine data collection. As a result, improvement or change initiatives were perceived predominantly negatively, as additional required work. Pilot study in the United States: New York nurses’ perspectives on improvement A self-administered survey with open-ended questions was used to collect qualitative data about perceived facilitators and barriers to implementation of a pilot improvement program in New York hospitals. The goal of the program was to increase patient satisfaction at 2 affiliated New York City hospitals. Responses were collected from 21 nurses working in 2 units where the pilot program was implemented. A coherence framework was not initially used in our data analysis, but retrospectively, the identified themes could be linked to the concepts of coherence at the social system level, intraorganizational level, and process level. Social system coherence. The hospitals involved in the study were affiliated more than 30 years ago but still retain much of their individual identities, especially at the nursing unit level. Differences were observed, for example, in how the nurses in the 2 units studied viewed the improvement program. Nurses in


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one unit were more likely to describe the improvement program as being consistent with their roles as nurses and with the overall hospital policy, while nurses in the other unit were more likely to describe a disconnection between hospital policy, including the push behind the pilot, and routine care. The supervision sessions implemented as part of the improvement program provided another example where lack of coherence within the social system was viewed as a barrier. The supervision sessions involved the nurses participating in role-playing exercises in their patients’ rooms with the nurses’ patients also participating in the exercises. Some nurses reported feeling “uncomfortable” or “nervous” when alternatively serving as a care provider and trainee in front of their patients. As a result, the nurses perceived that the nurse-patient relationship was compromised in these situations and that, consequently, their role satisfaction was reduced. Intraorganizational coherence: The improvement program focused on helping the nurses better understand their patients’ needs and on more clearly informing patients about what to expect during their hospital stays. However, the input of unit-level nurses, and specifically of nurses from the participating units, was not included in the development and planning of the program. As a result, several nurses noted in their survey responses that being overlooked in program development and planning was a significant barrier to successful implementation of the program. Lack of coherence within a nursing unit (eg, inequity in assignment of tasks and variation in individual productivity due to lack of team commitment) was also mentioned as a barrier. Coherent processes. A final and often-expressed frustration with the program was that the training sessions included in the improvement program were scheduled during shift transitions. Shift changes are a critical time when focus is needed to facilitate effective patient hand-offs. Scheduling training during shift transitions was viewed as not being coherent with the overall goal of improving the quality of care provided in the units. The training schedule enabled the 2 groups of nurses to train simultaneously but created additional stress for nurses who de-

scribed the implications of working on understaffed units. Challenges/Limitations. A lack of coherence between the planning and implementation of the QI program was viewed by some respondents as reducing overall coherence with the program’s objectives and, as a result, limiting the sustainability of the QI program after the implementation phase. Pilot study 2 in the United States: organizational and unit-level perspectives about success with QI efforts Semistructured interviews of both organizationand unit-level key informants (n = 114) were conducted in 4 hospital settings. All participating facilities were involved in QI efforts focused on the use of high-performance work practices39,40 (also known as human resource practices, or people practices) and on reducing health care–associated infections (HAIs). Investigators found that organizational coherence was displayed among these organizations through consistency in organizational focus on HAI reduction. Coherence was seen with respect to social systems, intraorganizational processes, and coherent processes of communication related to HAI reduction goals. More specifically, 4 critical “success factors” emerged associated with organizations’ efforts to reduce and prevent HAIs and are explained further as follows. Social system coherence. The first critical success factor that emerged was the notion of a supportive organizational culture. This culture was seen to be important for organizations that were achieving success with HAI prevention efforts. In these “more successful” organizations (measured on the basis of reductions in blood stream infection rates), the focus was on system-level issues, not individual actions and blame. Moreover, a multidisciplinary team focus helped to emphasize cultural norms around joint accountability and shared goals, thus further highlighting the salience of organizational coherence around cultural norms and shared accountabilities. Intraorganizational coherence. The second critical success factor identified was the importance of strong leadership involvement and support, providing



support for the importance of intraorganizational coherence that could be fostered by leadership. Leadership support was seen in organizations’ overall commitments to QI and infection reduction at the executive/hospital board level, the presence of leaders willing to “back up” QI efforts with changes in policies and protocols, and the support of individual staff members for “doing the right thing” and were all consistent with the notion of increasing organizational coherence around the QI goals. Coherent processes. Third, an emphasis on accountability for QI results helped to reemphasize the importance of QI in the organization. In organizations where this accountability was measurable, infection rates were tracked on organizational scorecards, HAI rates for individual units were reported and widely disseminated, and any infection occurrences were immediately identified and explored so that the individuals, involved units, and the organization could learn from failures. Furthermore, rewards and recognition at all levels (eg, individual staff member, unit, and organization) were linked to improvements, providing a means for successes to be celebrated, and mistakes to provide opportunities for growth. Finally, an operational QI infrastructure was demonstrated by financial and human resource commitments to develop and sustain a QI infrastructure supported by both dedicated staff and ongoing resource availability. This provided an additional example of coherent processes. Challenges/Limitations. These case study organizations experienced similar challenges hindering their HAI prevention efforts. Barriers included resource constraints, competing priorities (ie, too many “important” priorities all at once), changes in personnel, and lack of control over physicians (ie, in hospitals where physicians were not employed, there was less “control” over the voluntary physician staff). Not surprisingly, these barriers might be interpreted as threats to organizational coherence and need to be taken into account in organizational QI efforts. Across sites, however, the shared objective of “getting to zero infections” created a salient goal for individuals, units, and the organization as a whole, further demonstrating the important opportunity for

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organizational coherence around QI efforts to improve the likelihood of QI success. Key components of organizational coherence in health care organizations Synthesizing findings across our 5 pilot studies, we suggest that there are 3 key components of organizational coherence in health care organizations striving to improve quality of care: (1) people, (2) processes, and (3) perspectives (Figure 2). We next provide detail about how we characterize these key components on the basis of the results of our pilot studies and conceptual discussions. First, coherent health care organizations working toward improvement will be appropriately focused on people. Within such organizations, we would expect to find a positive view of people, or the shared perspective that employees and affiliated providers should be respected, can be trusted, and that they can change and learn. In addition, these organizations will have made strides toward identifying champions and change agents able to drive improvement efforts and maintain coherence in the face of organizational confusion. Furthermore, the focus on people will be reiterated in an organizational culture that values negotiated agreements rather than imposition of external or others’ values and beliefs upon organizational actors in a pursuit of win-win situations. The second key component of organizational coherence is processes. We suggest that coherence will be evident with respect to organizational processes that are coherent with organizational goals, not detached from the organization, nor imposed from outside without organizational acceptance. Similarly, these organizations will likely reflect a balance within the organization between top-down and bottom-up processes to encourage engagement within the organization, as well as flexibility to manage and organize as needed to achieve organizational goals and objectives. Within coherent organizations, there will also be consistency among project efforts rather than evidence of a list of unconnected projects with fragmented goals and unspecified connections to the organization’s overall objectives.


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Figure 2. Organizational coherence in health care organizations—embracing people, processes, and perspectives.

Finally, the third component of perspectives is also a key. For health care organizations exhibiting coherence, we would expect to see institutionalization of organizational values that are consistent with the QI goals and objectives of the organization. Another important perspective would be expected with respect to time—coherent organizations would be more likely to have a long-term commitment to improvement, including a favorable orientation toward forming long-term relationships and enabling sensemaking to permit a long-term commitment. An additional important element of an organization’s perspective will be found in the notion of integration. Organizations that value integration as part of organizational coherence will be different from organizations that suffer from silo-based thinking, political power-plays, or loosely assimilated collections of short-term objectives, where QI efforts are described as a “flavor of the month.” Finally, an overarching perspective inherent with organizational coherence is that of alignment of the organization’s agenda with the QI goals and objectives of individuals, groups, and other units within the organization. This align-

ment and consistency will be critical in helping the organization to move forward to achieve success with QI efforts.

DISCUSSION In this article, we have introduced the concept of organizational coherence in health care organizations and suggest that this construct may be invaluable in helping to improve our understanding of how health care QI efforts can be accomplished more successfully across organizations and settings. We aimed to examine whether a core set of organizational cultural attributes, independent of context and setting, might be associated with success in implementing and sustaining QI systems in health care organizations, and our analyses and reviews of literature and theoretical frameworks suggest that the construct of organizational coherence may have these attributes. More specifically, our work suggests that the concept of organizational coherence embraces both culture and context and can be appropriately applied



across health care organizational settings. We had hypothesized that such a construct might be found to be independent of the processes and structures implemented for QI, the particular setting where the QI activity took place, and the level of the system where the QI activity occurred. We note that the construct of organizational coherence around QI does indeed meet these criteria and can thus help guide both researchers and practitioners in their efforts to enhance health care QI efforts, regardless of organizational type, location, or context. We suggest that focusing on 3 key components of organizational coherence—people, processes, and perspectives—can help in efforts to plan, adapt and enhance initiatives and interventions to improve quality of care in health care organizations. While these key components may appear to encompass a long list of “ideals” to facilitate organizational improvement, we note that these characteristics are more likely to be present when there is organizational congruence around improvement. Furthermore, we suggest that professionals and practitioners involved in health care QI efforts consider the potential influence of organizational coherence on their improvement activities. By enhancing our understanding of this construct, our findings may thus help inform organizational decision-making about improvement activities and improve efforts to increase organizational coherence in relation to QI so that organizational success can be more likely and elements of successful efforts can be spread. Practice implications Our preliminary findings may have numerous implications for health care practice. For instance, there may be important linkages between the construct of organizational coherence and innovation implementation efforts (eg, the degree of organizational coherence might affect implementation of an electronic health record system or facilitate sustainability/ maintenance of desired organizational improvements). In contrast, for organizations facing daunting patient safety problems, lack of success with such initiatives may be attributed to a lack of organi-

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zational coherence around particular patient safety goals. Such experience might suggest that improving the patient safety program itself could result in greater organizational coherence, thus leading to better results with respect to patient safety for the program and the organization overall. At the same time, it is certainly possible that despite important QI goals, it may not be possible for organizational change agents to directly address and/or intervene to improve organizational coherence (eg, due to organizational complexity). Under these circumstances, we would hope that better understanding of the construct of organizational coherence can help these organizations indirectly address such challenges by highlighting the role of coherence in organizations, and its influence on improvement activities.

LIMITATIONS Predictably, our preliminary work has a number of limitations. First, given the scope of this exploratory work, we were unable to definitely evaluate the relevance and fit of all related theories and constructs, thus leaving room to further refine this construct in the context of additional literature, and taking into account research that has been conducted in non– health care settings. In addition, we recognize that our use of multiple disparate research studies, while illuminating as pilot studies providing preliminary evidence, in no way represents an integrated, multivariable data set; as a result, our ability to draw insights across these various studies is limited. Finally, while we suggest that there is likely an important link between organizational coherence and demonstrated success with QI efforts in health care organizations, our study was not designed to validate this association. Next steps Looking ahead, we hope to strengthen our preliminary work by further developing the construct of organizational coherence, and operationalizing how


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this construct may appear in different practice settings. In particular, we would like to confirm our preliminary findings by validating the association we suggest between organizational coherence and QI success. Furthermore, there are both qualitative and quantitative methodologies that can be used in future studies designed to measure organizational coherence in health care organizations, and to assess variation in coherence. For instance, our findings suggest that there may be an association between organizational readiness for change and organizational coherence (ie, greater readiness for change would be found in organizations with greater organizational coherence), but this type of study would require the development of a tool with which to measure organizational coherence.

6.

7. 8. 9.

10. 11. 12. 13.

CONCLUSIONS

14.

We suggest that for a health care organization to be more successful with improvement efforts, it will be important for that organization to ensure coherence around QI goals and objectives for improvement. In practice, a focus on people, consistency of processes, and alignment of organizational perspectives can help in health care organizations’ efforts to achieve QI success and sustainability of successful solutions by maximizing the likelihood that there will be organizational coherence around improvement efforts.

15.

17.

REFERENCES

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