BACKGROUND: For two decades health care workers have been struggling, with varying degrees of success, to use the principles of continuous quality improvement (CQI) to improve the quality of patient care. The Institute of Medicine report To Err Is Human prompted most hospitals to turn their attention to the pandemic of medical errors and to the realization that without changing the culture of blame, and thus releasing an avalanche of information, major improvement would not be possible. This article describes one community hospital's approach to changing its organizational culture and the critical role of leadership in that transformation. THE REALITIES: The places to look for trouble when diagnosing organizational problems are purpose, structure, rewards, helpful mechanisms, relationships, and leadership. Hospitals are professional bureaucracies in that the real power resides with clinical staff. Improvement requires that effective relationships be built within the executive suite. Relationship and team building must be part of the organizational culture. Quality improvement will not occur unless it is clearly aligned with the organization's core objectives. CONCLUSIONS: Managing the five realities is essential to creating a suitable environment for sustaining clinical or more general CQI efforts within health care organizations. This is particularly crucial if the basic culture of the organization is to be changed. All five realities must be addressed on a continual basis, which takes time, and positive outcomes can be expected only over a longer rather than shorter time frame.
BACKGROUND: For two decades health care workers have been struggling, with varying degrees of success, to use the principles of continuous quality improvement (CQI) to improve the quality of patient care. The Institute of Medicine report To Err Is Human prompted most hospitals to turn their attention to the pandemic of medical errors and to the realization that without changing the culture of blame, and thus releasing an avalanche of information, major improvement would not be possible. This article describes one community hospital's approach to changing its organizational culture and the critical role of leadership in that transformation. THE REALITIES: The places to look for trouble when diagnosing organizational problems are purpose, structure, rewards, helpful mechanisms, relationships, and leadership. Hospitals are professional bureaucracies in that the real power resides with clinical staff. Improvement requires that effective relationships be built within the executive suite. Relationship and team building must be part of the organizational culture. Quality improvement will not occur unless it is clearly aligned with the organization's core objectives. CONCLUSIONS: Managing the five realities is essential to creating a suitable environment for sustaining clinical or more general CQI efforts within health care organizations. This is particularly crucial if the basic culture of the organization is to be changed. All five realities must be addressed on a continual basis, which takes time, and positive outcomes can be expected only over a longer rather than shorter time frame.