100k Lives initiatives
    Henry Ford Health System, 186-87, 198, 200, 204, 205, 218
    progress report on campaign at HFHS, 207-13
    VA Boston, 88
access to healthcare
    awards for increasing, 27
    compared among countries, 12
    goal of Quebec's integrated health services networks, 116
    and open access scheduling, 86, 97, 123
    as problem (Sweden 1990s), 127
    and use of databases, 31
See also wait times
    accountability
    clinical integration management and, 169-70
    through fiscal responsibility, 39-40 (See also resource allocation)
    of NHS organizations, 52, 67
    and reporting systems, 217, 230-33
    use of electronic health records, 81, 95
    in VISN structure, 77-80, 101-3
See also performance indicators/measurements
Advanced Training Program (IHC), 161-63, 182
Annual Health Check (UK), 51
Ash Institute (Harvard University), 80, 88
assertive case management, 32-33
Audit Group for Medical Evaluation, 128
audit instruments, 128
See also performance indicators/measurements
awards in healthcare, 20, 27-28, 80, 96, 152, 158, 186, 208

See also Baldrige model; goals and incentives; Robert W. Carey Performance Excellence Program (VA)
Balanced Scorecard, 128, 132, 138, 230
Baldrige model, 163
award criteria, 20-21, 22, 111, 128, 132, 137, 194, 201
    Baldrige National Quality Program, 20, 90-91, 145-46
    Swedish version of, 122
    See also Qvalitet, Utveckling, Ledarskap (QUL)
Batalden, Paul, 89-91, 94, 96, 98, 102, 131, 157, 199, 201
Bergstrom, Michael, 130, 135
Berwick, Donald, 16, 85, 121, 162
Big Group Healthcare (Jönköping), 136-37, 138
Big Three automobile companies, 188, 190
Birmingham East and North Primary Care Trust (BEN PCT)
    background, 28-29
    and collaboration with HEFT, 29
    developing strategic goals and values, 34-35, 59
    improvement initiatives by, 30-33
    partnerships and national structure, 41
    recent achievements, 27-28
    strategic objective indicators, 59
    use of mentor organizations, 37-38, 40
See also National Health Service (UK)
Birmingham OwnHealth^®, 31-32
Body Shop, 37
Bojestig, Mats, 127-29, 131, 139-40
Boston University, 88
Breakthrough Series (IHI)
    and Calgary Health Region, 229
    and Jönköping County Council, 130-31, 134, 135, 147
    and Veterans Health Administration, 85, 86, 118
Burton, David, 155, 163-64, 166, 174

Calgary Health Region (CHR)
    accountability systems, 230-33
    achievements, 222-23, 239-40, 242
    Alberta Hip and Knee Replacement Pilot Project, 229, 243
    Alberta Quality Matrix for Health, 232, 239
    background, 221-22
    challenges to improvement, 229-30, 237-38
    Enterprise Master Person Index, 230
    patient safety, 233-35, 239
    physician engagement, 227-28
    Project GRIDLOCC, 237, 239
    Quality, Safety and Health Information (QSHI), 234-35, 238
    quality and safety framework, 231
    Quality Improvement and Health Information (QIHI), 224-25, 228-30, 232-34
    regional PCIS (e-health record), 227, 230-32, 237, 239
    and regional restructuring, 221, 223-24, 226
    restructuring of portfolios, 236, 242
    strategic planning, 225-27
    training collaborations, 228-29
    vision and mission statements, 234, 244
Canadian healthcare system
    awards for excellence in, 20
    challenges to, 216, 268-69
    compared to UK NHS, 66-69
    compared to VISN 1, 119
    and electronic health records, 117, 270
    and independent physicians, 117
    integrated health services networks, 115-16, 261, 270
    Jönköping's lessons for, 148-50
    need for national standards, 118
    object lessons for, 270-71
    performance and cost comparisons, 12
    selection of case studies from, 22
See also Calgary Health Region (CHR); Trillium Health Centre
Canadian Institute for Health Information (CIHI), 118
Canadian Patient Safety Institute, 216
capability building
    as component of quality improvement, 53-54
    components of, 17
    investments in (Jönköping), 136, 139
    in National Health Service (UK), 55
    system-level approach to (Jönköping), 131
    in Veterans Affairs strategic planning, 90
    in WRJ VAMC culture, 100
See also skills development for improvement
Carey self-assessment process, 90-91, 98, 101
change for improvement. See quality improvement
Chirico-Post, Jeannette, 74-75, 77-78, 80, 81-82, 91, 102-3
Christie, Sophia, 33, 34
clinical autonomy, 268-69
Clinical Governance Support Team (NHS), 53-54
clinical improvement projects, 30
clinical microsystems of care
    capabilities of, 15-16
    in Henry Ford Health System, 188
    in high-performing healthcare systems, 19-20
    in Intermountain Healthcare, 164
    in Jönköping, 135, 139, 141, 147, 149
clinical process management
    clinical practice guidelines (VHA), 80-81
    integration strategy (CHR), 237
    integration strategy (IHC), 163-69
    and patient outcomes and costs (IHC), 152-54, 171-72
Clinical Value Compass, 134
Cochrane, Patti, 249-50
collaboration and participation
    in assertive case management, 33
    education (Trillium), 254
    Jönköping and health professions, 135
    Latter-Day Saints Church and IHC, 156
    by non-physician professionals, 68
    in regional healthcare system, 224, 259
    with staff and stakeholders, 34-35, 92
    VA Boston and Institute for Healthcare Improvement, 82, 85-87, 118
    White River Junction Model, 97
    Working Together for Health (BEN PCT and HEFT), 29, 30-31, 37, 66

    WRJ VAMC and Dartmouth Medical School, 96
Columbia Hospital Corporation of America (HCA), 155
Commonwealth Fund rankings, 11-13
communication methods
    Big Group Healthcare (Jönköping), 136-37, 138
    cascading, 194, 205, 215
    through electronic records, 101
    in improving patient flow, 123
    Leadership Network (Jönköping), 131
    in quality management (VISN 1), 78
    between service lines in VISN 1, 76
    for successful improvement programs, 18
    telehealth monitoring programs, 114
    telephone-based care management, 31-32
    use of annual reports, 128
    use of e-mail, 85
    use of staff volunteers, 196
See also information technology
competition in healthcare systems, 100, 119, 132, 155, 271
    in care delivery and insurance, 183
    creating an internal market, 56
    and demands for quality improvement, 204
    and loss of market share, 190
    within programs, 81, 83, 171, 203
    service delivery and, 204
    when system is public, 67
See also market share
Connecting for Health (NHS), 52
continuous improvement
    challenges of, 89-90, 90-91
    as concept in quality improvement, 14-15
    education for (Jönköping), 135-36
    as necessary for success, 23
    as required in Sweden, 130
    and role of leadership, 148-49
See also quality improvement
cost of healthcare systems
    and activity-based costing, 157
    budget of BEN PCT, 28
    and clinical integration strategy, 171-72
    as compared to performance, 12-13
    and competitive health plan premiums, 155, 183
    decreased with improved efficiency, 31
    healthcare budget in Sweden, 125-26, 127-29
    and improvement in outcomes, 152-53
    Jönköping County Council, 127-29, 138-39
See also resource allocation
Crossing the Quality Chasm (Institute of Medicine), 14
cultural factors in patient populations, 28
See also populations served by case study systems
culture in healthcare systems
    and commitment to community, 156
    of financial discipline, 127-29, 139
    and leadership, 41, 98-99
    of patient safety, 234-35, 244
    in preparing for changes, 35-36
    strategies to shape, 248
    as supporting improvement, 17, 18, 83, 218, 260-61

Dartmouth Medical School, 89, 96, 131
data collection and integration, 15, 17, 18
    and audit instruments, 128
    in Canada, 118
    challenges of, 19
    in clinical process models (IHC), 167-68
    and cost of healthcare, 157
    e-record link with nurses, 31
    ICAST (identify, collect data, analyze, study, test), 195
    and interactive electronic presentation, 233
    local and external, 202-3
    in organizational change strategies, 36, 86, 128-29
    in orthopaedic triage service, 31
    standardized platform for (Trillium), 247
    to support improvement, 236, 252-53
    by third parties, 78-79
    use in engaging staff, 87
    Veterans Health Administration strategies, 111
See also information technology
De Gasta, Gary, 82, 89-90, 92, 94, 96, 98, 102-3
Delivering the NHS Plan - Next Steps on Investment, Next Steps on Reform (UK Department of Health, 2002), 56
Deming, W. Edward, 134, 139, 157-58, 161, 163, 201
Dr. Foster information system (UK), 41, 51

Eagle, Chris, 223-24, 227, 235-36, 239
Eddy, David, 162
education and training. See skills development for improvement
efficiency of healthcare
with booking system redesigns, 31
compared among countries, 12
See also resource allocation
electronic records. See information technology
equity of healthcare systems compared, 12
Esther initiative (Jönköping), 123, 132
European Foundation for Quality Management, 20
European Society for Quality in Healthcare, 21
Europe awards for healthcare excellence, 20
evidence-based medicine
    in clinical improvements (CHR), 237
    in clinical improvements (IHC), 153-54, 175
    and clinical process models (IHC), 165-66
    reviews of performance measures (VHA), 83, 84
    in strategic planning (IHC), 163-64
    and use of electronic records (IHC), 161

Fairlane Medical Center, 196, 197
See also Henry Ford Health System (HFHS)
fee-for-service
    and involving physicians, 116
    and pay-for-performance, 81, 83
    and physicians in change initiatives, 67
See also physicians
finances. See resource allocation
A First Class Service - Quality in the New NHS (Department of Health, UK, 1998), 51, 53, 56
Florida: A Healthy State (Pfizer initiative), 32
foundation trusts, 49, 50-51, 67
See also Heart of England Foundation Trust (HEFT)
frameworks to assess performance
    Baldrige, 20-21
    Henry Ford Health System, 191-94
    Jönköping, 128
    National Health Service (UK), 37, 41, 48-49, 50-51
    Trillium Health Centre, 259, 266
    Veterans Health Association, 90-91
funding. See resource allocation

Gantz Wiley, 196
General Electric (GE), 160-61, 174, 182
German healthcare system, 12
goals and incentives
    and accountability (HFHS), 217
    annual staff exhibitions (HFHS), 199
    and awards, 90, 204, 246, 247
    in Canadian healthcare, 269
    development of, 34-35
    for hospital CEOs, 137
    payment by results, 47, 81, 83
    for physicians, 48-49
    and scorecard indicators, 59
    set for all levels in organization, 78
    short-term and long-term, 36-37
    success stemming from, 17, 18, 65-66, 81-82
    in Sweden's healthcare system, 121-22, 133-34
See also performance indicators/measurements; resource allocation
Goldman, Mark, 33
Good Hope Hospital
    merger with HEFT, 39
    recent achievements of, 27-28
    vascular clinic in, 31
See also Heart of England Foundation Trust (HEFT)

Ham, Chris, 37
Harvard University, 80, 88
Healthcare Commission for Audit and Inspection (UK), 39, 41, 50-51, 58
healthcare failure mode and effects analysis (HFMEA), 229
Healthcare Improvement Leadership Development (Dartmouth Medical School), 89, 96
See also White River Junction VA Medical Center (WRJ VAMC)
healthcare insurance
    and competition in healthcare systems, 183
    in healthcare budget, 189-90
    private, 74
    and quality improvement, 172, 183
healthcare systems
    comparing national, 11-13, 20-21
    with interdependent elements, 14-15
    ranking regional, 21-23
See also individual case studies
Health Quality Council (Canada), 216
Health System Safety Analysis (HSSA), 229
See also Calgary Health Region (CHR)
Heartlands Medipark, 39
Heart of England Foundation Trust (HEFT), 28
    and collaboration with BEN PCT, 29
    designation of 'foundation trust,' 29, 34, 39
    and financial disincentives, 33-34
    fiscal responsibilities of, 39-40
    partnerships and national structure, 41
    strategy map of, 40
See also Good Hope Hospital; National Health Service (UK)
Henriks, Göran, 127-29, 131, 133-35, 139
Henry Ford Health System (HFHS)
    achievements, 185-87, 215
    Annual Quality Expo, 199
    background, 185, 189-90
    competing demands, 203-4
    data collection, 202-3
    depression care initiative, 187-88
    improvement models and methods, 200-1
    leadership team, 198-99, 216-17
    Office of Clinical Quality and Safety (OCQS), 196-99, 215
    performance measures, 193, 217-18
    physician engagement, 201-2
    and a quality culture, 218-19
    quality improvement as sustainable, 204-5
    Renewal, 194-95, 196
    service excellence initiatives, 195-96
    staff contract for patient service, 197
    Strategic Framework, 191-94
    total quality management (TQM), 199-200
Henry Ford Hospital (HFH), 186, 202
100k Lives initiatives, 187
Henry Ford Medical Group, 186
Henry Ford Wyandotte Hospital, 186, 195, 202
high-performing health systems
    as capable of continual improvement, 14-16, 23, 40, 89-90, 131, 156
    challenges in achieving, 19, 88
    compared among countries, 12-13
See also individual case studies

improvement. See quality improvement
incentives. See goals and incentives
information collection. See data collection and integration
information technology
    awards for use of, 27, 152
    in Canada, 270
    in case management, 33
    challenges to implementation, 261
    electronic health records, 81, 95-96, 101, 117, 159, 203, 230-32, 247
    for indicator measurement systems, 80-81
    Intermountain Healthcare use of, 152, 159-61
    in Jönköping County Council, 139-40
    in National Health Service, 52
    for patient care management, 80-81
    in quality improvement approaches, 17
    in redesigned systems of care, 14, 69
    use of shared e-records, 31
    in Veterans Health Administration improvements, 71
See also data collection and integration
infrastructure for improvement, 16-17
See also strategic planning
Institute for Healthcare Delivery Research, 153-54, 173-74, 179
See also Intermountain Healthcare (IHC)
Institute for Healthcare Improvement (IHI), 21, 82, 85-87, 118
    improvement education, 100, 199, 228-29
    and Jönköping initiative, 123, 129-31, 134, 145, 147, 148-49
    100k Lives initiatives, 88, 186, 218
Institute for Innovation and Improvement (NHS), 30, 41, 54-55, 68
Institute of Medicine, 14
integration of services
    achievements by CHR, 239-40, 242
    achievements by IHC, 152-54
    in Jönköping, 128-29
    and performance measurements, 117
    philosophy of (IHC), 151
    Quebec's integrated health services networks, 115-16
    role of information technology in (IHC), 159-60
    structural (IHC), 156
    in Veterans Health Administration, 71, 75-77
See also Veterans Affairs New England Healthcare System (VISN 1)
interdisciplinary and cross-functional teams
    communication channels in, 133
    in integrated health services networks, 115-16
    in integration of health and social care, 46-47
    medical emergency teams (METs), 250
    in performance measurement goals, 92
    in quality improvement, 15, 85, 86, 197-98, 237
    use of by BEN PCT and HEFT, 30-31
Intermountain Healthcare (IHC)
    background, 154-56
    clinical integration strategy, 163-69
    Electronic Data Warehouse, 159-60
    focus on improvement, 158
    incentives for clinical integration, 171-72
    and information technology (Help system), 159-61
    leadership structure, 169-70
    challenges for, 173-74, 182
    recent achievements, 151-54
    and study of physician clinical variation, 157-58, 159
    supports for clinical integration, 172-73
Isaksson, Lars, 127

James, Brent C., 153-54, 156-59, 161-69, 171-74
Joint Commission for the Accreditation of Healthcare Organizations International, 21
Jönköping County Council
    background, 121, 125-26
    business strategy of, 144
    collaborations with health professions programs, 135
    compared to other counties, 122
    culture of financial discipline, 127-29
    development stair (improvement journey), 138
    educating for change, 132, 133-34, 138
    Esther initiative, 123, 132
    harvesting ideas by, 134-35
    leadership in, 126-27, 131
    Passion for Life initiative, 135
    results of improvement initiatives, 146
    role of leadership, 148-50
    strategic improvement areas, 135-36
    successful quality improvement, 124
    sustainability of, 140-41
    system-level improvement, 129-31
    system transformation in, 138-39
    system view of, 139

Kaiser Permanente
    as mentor to BEN PCT, 37-38, 40, 68
    success of, 66, 118-19
    three-level model for population management, 32
Karlsson, Sven-Olof, 126-33, 136-37, 139, 148
    Kizer, Kenneth, 74-75, 77-78, 92, 119, 162
Kizer model, 103
Kizer Quality Achievement Recognition Grant (VHA), 91

Lawson, Michael, 83-85
LDS Hospital (Latter-Day Saints), 152, 155-56
See also Intermountain Healthcare (IHC)
leadership
    in an improvement culture, 98-99
    in approaches to improvement, 17, 18
    in clinical integration model, 169-70, 174-75
    collaboration by, 33-34, 66-67
    communication among, 131
    decision-making models, 230
    as distributed, 246-47, 248-49
    as engaged with staff, 84-85, 85-86, 87
    and flat organizational structure, 196
    within large networks, 102, 118-19
    through network of committees, 76-77
    and outcome-based analysis, 180
    as overwhelmed (Jönköping), 140, 149
    of physicians, 38, 118, 127, 227-28
    in quality improvement, 40, 83
    recognizing interdependencies, 138-39
    as role models, 194-95
    and service excellence process, 195
    as stable (Jönköping), 121, 127, 139, 148
    and staff contracts for service, 197
    supporting local leadership, 16
    System Quality Forum team (HFHS), 198-99
    taking ownership, 89
    and top-down strategy (HFHS), 205
    transformational (Jönköping), 148-50
    turnover, 49-50, 103-4, 140-41, 258-59
    use of performance measures by, 79-80
Leadership Network (Jönköping), 131
Lean improvement methods, 35, 68, 100, 162, 200, 258
Leape, Lucian, 13
Lewis, Steven, 23, 157
Local Health Integration Networks (LHINS, Ontario), 66

Magnet Hospital status, 152
Making the Shift project, 30
Malcolm Baldrige National Quality Program (US). See Baldrige model
market share
    applied to Canadian system, 182
    competition for, 39, 67, 151
    and regulation, 182
    See also competition in healthcare systems
    Mayo Clinic, 189
    McKay Dee Hospital Center, 152
See also Intermountain Healthcare (IHC)
measurements. See performance indicators/measurements
medical emergency teams (METs), 249-50, 252
microsystems. See clinical microsystems of care
Model for Improvement, 130, 132, 162
models and methods for improvement
    at Henry Ford Health System, 199, 200-201
    at Intermountain Healthcare, 162
    as various, 15, 229-30
See also Breakthrough Series (IHI); LEAN improvement methods; Model for Improvement; Plan-Do-Study-Act (PDSA)/Plan-Do-Check-Act (PDCA); Six Sigma method for improvement
Modernisation Agency (UK), 35-36, 53, 54, 55
Monitor (regulatory agency) (UK), 34, 41, 49, 51
Montreal Health and Social Service Agency, 115
See also Quebec
mortality and morbidity rates
    in BEN PCT's Southeast Asian population, 28
    compared among countries, 12
    as reform driver in NHS, 43
Moving Forward Together (HEFT), 35
multicultural communities, 28, 36, 65
multidisciplinary teams. See interdisciplinary and cross-functional teams

National Board of Health and Welfare (Sweden), 126, 130, 140
National Center for Patient Safety, Veterans Affairs (US), 88, 96, 112
National Center for Post-Traumatic Stress Disorder, Veterans Affairs (US), 96
national healthcare systems compared, 11-13, 20-21
National Health Service (UK), 28
    awards, 27
    background, 43-44
    flexibility of, 69
    focus on financial discipline, 41
    high-level structure of, 44
    information systems, 41
    information technology, 52
    Making the Shift project, 30
    national guidance, standards and targets, 49-52
    pressure for change from, 33
    quality improvement in, 53-55
    reforms to demand side, 47-49
    reforms to supply side, 44-47
    regional accountability, 52, 67
    rules about collusion, 40
See also Birmingham East and North Primary Care Trust (BEN PCT); Heart of England Foundation Trust (HEFT)
National Institute for Health and Clinical Excellence (NICE) (UK), 51-52
National Institutes of Health (NIH) (US), 96
National Primary Care Development Trust (UK), 134
National Quality Institute's Canada Awards for Excellence, 20
National Service Frameworks (NSFs) (UK), 51-52
Nelson, Bill, 151, 163, 171, 174
The New NHS - Modern, Dependable (UK Department of Health, 1997), 56
New Zealand healthcare system, 12
NHS Direct, 32
The NHS Improvement Plan: Putting People at the Heart of Public Services (UK Department of Health, 2004), 57
The NHS Plan - A Plan for Investment, A Plan for Reform (UK Department of Health, 2000), 56
Nolan, Tom, 138
nurses/nursing
    enhanced roles for, 124
    excellence in, 152
    and Magnet status, 152
    negotiating with unions for, 84
    and non-nursing tasks, 255-58
    and nurse practitioners, 269
    in performance measures, 84, 113, 172
    in quality management, 78, 254-55
    in relationship with physician leaders, 38

occupational therapists, 124
Office for Learning and Innovation (Jönköping), 133
Office for Strategic Health Authorities (UK), 54
Office of Quality and Performance (VHA), 80-81
Ontario, Local Health Integration Networks (LHINs), 66
Ontario Ministry of Health and Long-Term Care, 10, 29, 72, 125, 154, 191, 259, 277
Organisation for Economic Co-operation and Development (OECD), 12
organizational development, 15, 34-36, 40
See also skills development for improvement; strategic planning
Our Community Working Together for Excellence in Health (Calgary Health Region), 225-27
Our Health, Our Care, Our Say: A New direction for Community Services (UK Department of Health, 2006a), 57

Palmberg, Margareta, 130
Parker, Scott, 155-58, 163
participation. See collaboration and participation
Partners in Health Centre (HEFT), 30-31
Passion for Life initiative (Jönköping), 135
patient care management
    chronic care initiative (HFHS), 188-89, 200, 204-5
    depression care initiative (HFHS), 187-88, 201
    improving patient flow, 86-87, 123
    use of information technology, 80-81
patient education
    by BEN PCT and HEFT, 30-31, 32
    self-management, 123, 134-35
patient needs, 15, 17
See also patient care management
patient safety, 13-14, 87-88, 97, 102, 134
    in a just and trusting culture, 235
    100k Lives initiatives, 88, 186-87
    and non-nursing tasks, 256, 257
    risk monitoring matrix (Trillium), 248
    Robson Report for CHR, 233-34
    Safer Healthcare Now!, 246, 249-55, 259, 261
Patient Safety Officer program (IHI), 134
patient satisfaction
    and assertive case management, 33
    awards for increasing, 27
    improved by BEN PCT and HEFT, 31, 32
    increased choice of providers, 31, 48
    and service excellence initiative (HFHS), 194, 195-96, 218
    and staff service contract (HFHS), 197
    of Veterans Affairs Boston, 89
    of Veterans Affairs New England Healthcare System, 74
    and Veterans Health Administration, 78, 111
performance indicators/measurements
    Baldrige criteria for, 90
    challenges to (WRJ VAMC), 94-95
    Christmas tree/stoplight reports (VISN 1), 78-80, 92, 93, 94
    and competing demands, 38-40
    education leadership for (Jönköping), 132
    in HFHS integration strategy, 193, 217-18
    identifying priorities with (CHR), 230-31
    local versus national (WRJ VAMC), 91-92
    in NHS organizations, 50-51
    nursing report card (VA Boston), 113
    quality, utilization and efficiency (QUE) studies, 157, 158, 180
    tools for, 128
    of UK Health Commission, 58
    at VA Boston, 83-84
    in Veterans Health Administration, 71, 111-12
    for VISN 1, 107, 108-9, 110, 117
    in VISN structure, 77-80, 82
See also goals and incentives
Pfizer Health Solutions, 32, 40-41
physicians
    challenges in Canada, 116, 117, 217, 269
    and defining excellence in healthcare, 13
    engagement in improvement programs, 19, 67-68, 201-2, 227-29, 237-38, 240
    and financial incentives, 48-49, 56, 81, 83, 84, 171
    funding models for, 147
    as independent contractors, 45, 56, 195, 202
    input into restructuring (CHR), 225
    in leadership roles, 38
    in patient safety, 88
    and pay-for-performance, 81
    performance assessments of (NHS), 51
    and strategic planning, 33, 36
    in structure of improvement, 17, 18
    system attitude toward, 224
    training for improvement, 135
    and use of information technology, 81, 95, 161, 168
    and variation in clinical practice, 157-58
Plan-Do-Study-Act (PDSA)/Plan-Do-Check-Act (PDCA), 72, 92, 130, 132, 135, 162, 199, 200-201
politics
    improvement concepts and ideology, 68
    operating within environment of, 101-2, 125, 127-28, 140, 146-47
population management three-level model, 32
populations served by case study systems
    BEN PCT, 28
    for Jönköping, 126
    Veterans Affairs New England Healthcare System, 74, 101, 103
Portland protocol, 88
practice-based commissioning, 45-46
Press Ganey, 196
primary care trusts (PCTs), 28
See also Birmingham East and North Primary Care Trust (BEN PCT)
process management
    analysis in quality improvement, 15
    in Baldrige criteria, 20, 101
    and components of capability, 17
    in Jönköping, 127-28, 136-37, 139
    methodology of Institute for Innovation and Improvement, 55
    as participatory, 34-35
    in Veterans Health Administration, 111-12
Pursuing Perfection initiative, 123-24, 138, 140, 146-47, 199-200

quality, utilization and efficiency (QUE) studies, 157, 158, 180
Quality and Outcomes Framework (QOF) (UK), 37, 41, 48-49
Quality by Design study
    crafting of case studies for, 22
    goals of project, 19-20, 29, 72, 124-25, 154, 190, 223
    limitations to, 23
    selection process of, 21-22, 29-30, 72, 125, 154, 191
    strengths of, 23-24
Quality Conference (Sweden), 130
quality improvement
    integrated networks for, 115, 156
    organizational processes necessary for, 16-19
    to system transformation, 138-39
    tensions in, 82
    theories of, 133-34, 161-62
    use of data for, 140
    use of term, 14-15
See also continuous improvement; skills development for improvement; individual case studies
Quality Management for Healthcare Delivery (James), 158
Quebec
    electronic health records, 117
    integrated health services networks, 115-16, 117
QUL. See Qvalitet, Utveckling, Ledarskap (QUL)
Qulturum learning centre, 133-36, 140, 148
    Futurum, 135
See also Jönköping County Council
Qvalitet, Utveckling, Ledarskap (QUL), 122, 128, 129, 130, 132, 138
See also Baldrige model

rapid cycle methodology, 85, 134, 139, 170, 200, 201, 229, 252
Reason, James, 13
Reinertsen, James, 138, 162
resource allocation
    in Canadian system, 68, 261
    conflicting demands, 237-38
    and disincentives for change, 33-34, 137
    financial discipline of Jönköping, 127-29, 134
    financial discipline of NHS, 41
    and funding improvement work, 36-37
    HFHS funding, 185, 189-90
    in improvement programs, 17, 18
    increased funding and capacity to NHS, 44-45
    and physician responsibility, 38
    and practice-based commissioning, 45-46
    for project management (Trillium), 251, 258
    for quality improvement initiatives (HFHS), 196
See also accountability; competition in healthcare systems; cost of healthcare systems
return on investment (ROI), 157, 162
See also resource allocation
Robert W. Carey Performance Excellence Program (VA), 90-91, 98, 101
Robert Wood Johnson Foundation, 123
Robson Report (Calgary Health Region), 233-34
role redesign, 124
root cause analysis, 88, 97, 133, 229, 264
Royal Pharmaceutical Society, 27
Ryhov Hospital, 133
See also Jönköping County Council

Safe Practices for Better Healthcare (National Quality Forum, US), 198
safety in healthcare. See patient safety
Sahney, Vinod, 199-200
Schlichting, Nancy, 185, 191
self-management by patients, 123, 134-35
See also patient education
Six Sigma method for improvement, 100, 162, 200, 258
skills development for improvement
    Advanced Training Program (ATP) (IHC), 161-63, 174-75
    attribute of successful improvement, 17-18
    for case management (HEFT), 33
    in clinical integration, 168-69
    through collaborations (VA), 99-101
    collaborations with professional programs, 135
    to foster collaboration (Trillium), 254
    for front-line staff (BEN PCT, HEFT), 68
    for internal expertise (Jönköping), 134
    investing in (Jönköping), 129-30, 149
    in leadership, 246-47
    during organizational change (BEN PCT, HEFT), 35-36, 40
    during organizational change (CHR), 228
    during organizational change (HFHS), 199-200
    as part of culture, 100
    in patient safety, 239
    Quality 101 training, 201
    restructuring to align with (Jönköping), 130-32
    and role redesign (NHS), 45
    for succession planning (VA), 96-97
See also Qulturum learning centre
    Solihull PCT, 39
staff satisfaction, 89, 195-96, 197, 203-4, 237-38, 239
standardization and systematization
    of information technology, 80
    limitations of, 102-3
    as national strategy, 118
    tensions inherent in, 82
    use of clinical practice guidelines, 80-81
    in VISN 1, 75, 77-80, 101, 117
statistical process control, 229
Strategic Health Authorities (SHAs) (UK), 43, 52, 55
strategic planning
    articulating goals, 16-17, 18
    articulating goals (Jönköping), 133
    as criteria of Baldrige Award, 20
    and data collection, 36, 86
    data collection in (Jönköping), 128-29
    developing goals and values (BEN PCT), 34-35
    as evidence-based (IHC), 163-66
    frameworks for (WRJ VAMC), 91-92, 101
    for integration of services (IHC), 151
    monitoring of (Jönköping), 127
    as part of culture (WRJ VAMC), 100
    quality planning at centre of (Jönköping), 136, 146-47
    and regional accountability (NHS), 52
    and restructuring for improvement, 224-27
    scorecard (BEN PCT), 59
    stoplight report for (WRJ VAMC), 92-93
    Strategic Framework and diagram (HFHS), 191-94
    and total quality management (HFHS), 199-200
Studer Group, 195
sustainable change, 36, 204-5, 260-61
Sweden
    goals for quality in, 121-22
    healthcare system in, 125-29, 141
    politics and healthcare, 127, 130
    Wait Times Guarantee, 128
See also Jönköping County Council
Swedish Association for Local Authorities and Regions (SALAR), 126, 130, 135, 140, 141
priorities of, 143
Swedish OG (audit instrument), 128
Swedish Pharmacy Association, 133

teams and teamwork. See interdisciplinary and cross-functional teams
total quality management (TQM), 128-29, 138, 158, 199
See also continuous improvement
training. See skills development for improvement
Trillium Health Centre
    achievements, 245-46
    enterprise risk-management/risk-monitoring matrix, 246, 248, 263
    Foundations of Leadership/distributed leadership, 246-47, 248-49, 260, 264
    information technology, 260-61
    medical emergency teams (METs), 249-51, 252, 254-55, 260
    Non-Nursing Task Force (NNTF), 246, 249, 255-58, 260
    quality reporting framework, 259, 266
    reduction of ventilator-associated pneumonia (VAP), 250-51, 253-54
    Safer Healthcare Now! (SHN!), 246, 249-55, 259, 261, 265
    staff education, 246-47, 254, 260
    strategic priorities for improvement, 248-49
    THINK (Transforming Healthcare into Integrated Networks of Knowledge), 247, 253, 261

United Kingdom
    healthcare system, 12
    policy and financial mechanisms in, 34
    policy papers, 56-57
See also National Health Service (UK)
United States healthcare system
    performance and cost comparisons, 12
    top ranking integrated health systems, 152
University of Toronto Department of Health Policy, Management and Evaluation, 29, 71-72
University of Vermont, 89

Vaggeryd Primary Care Centre, 132
See also Jönköping County Council
value stream analysis, 31
Västerbotten County Council (Sweden), 141
Veterans Affairs Interprofessional Fellowship Program in Patient Safety, 97
    Veterans Affairs Medical Center, Boston
    background, 82
    collaboration with IHI, 85-86
    General Internal Medicine program, 88
    implementing changes, 84-85, 118
    improving patient flow, 86-87
    100k Lives initiatives, 88
    nursing report card measures, 113
    patient safety, 87-88
    performance measurement, 83-84
    staff and patient satisfaction, 89
See also Veterans Health Administration (VHA)
Veterans Affairs National Center for Patient Safety, 97
Veterans Affairs National Quality Scholars Program, 96-97, 112
Veterans Affairs New England Healthcare System (VISN 1)
    aging and decreasing patient population of, 103
    background, 72-74
    change to a healthcare system, 74-75, 118-19
    Clinical Leadership Committee structure, 76-77
    External Peer Review Program, 78
    government rules and relationships, 101-2
    information technology, 80-81
    leadership and staff turnover in, 103-4
    organization of service lines by (care delivery), 75-77, 116
    performance measurement system (Christmas tree reports), 78-80, 92, 94
    use of Baldrige framework by, 91
See also Veterans Health Administration (VHA)
Veterans Affairs Nursing Outcomes database, 84
Veterans Affairs Outcomes Group Research Enhancement Award Program, 96
Veterans Equitable Reimbursement Allocation (VERA), 74
Veterans Health Administration (VHA)
    education of staff, 99-101
    electronic record system, 80-81
    External Peer Review Program, 78, 94
    Kizer Quality Achievement Recognition Grant, 91
    national standards, 118
    Office of Quality and Performance, 80, 111-12
    radical transformation of, 71
    Robert W. Carey Performance Excellence Program, 90-91, 98, 101
    staff turnover, 99
    VHA clinical patient record system (VistA), 80
See also Veterans Affairs Medical Center, Boston; Veterans Affairs New England Healthcare System (VISN 1); White River Junction VA Medical Center (WRJ VAMC)

wait times
    awards for reducing, 27
    and booking system redesign, 31
    collaborations to reduce, 85-86
    improvement in (Jönköping), 123
    monitoring of (VISN 1), 78, 107
    in NHS, 43, 45, 49-50
    and patient satisfaction (HFHS), 196
    and process improvements (VA Boston), 84
    reducing of by BEN PCT and HEFT, 30, 31
    reducing of by CHR, 229
    Wait Times Guarantee in Sweden, 128
    at WRJ VAMC, 97
Warden, Gail, 199-200
Warner, Homer, 159
West Midlands Strategic Health Authority, 28, 41
West Roxbury units (VHA), 87
See also Veterans Affairs Medical Center, Boston
White, Ken, 245-47, 258
White River Junction VA Medical Center (WRJ VAMC)
    background to improvement initiatives, 89-90
    Care Coordination Home Telehealth program, 114
    collaboration with Dartmouth Medical School, 96-97
    and culture of improvement, 98, 100
    electronic health record system, 95-96
    External Peer Review Program, 94
    field site for VA National Center for Patient Safety, 97
    leadership and improvement, 98-99
    leadership and staff turnover, 103-4
    overcoming challenges, 91
    as part of VISN 1 network, 102
    performance measurements, 91-95
    stoplight report, 92, 93
    Stop Workforce Accidents Team, 114
    use of Baldrige/Carey initiatives, 90-91
    VA Interprofessional Fellowship Program in Patient Safety, 97
See also Veterans Health Administration (VHA)
Working for Patients (UK NHS, 1989), 56
Working Together for Health initiative (BEN PCT and HEFT), 29, 30-31, 33, 36-37

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