What Is Quality, Who Wants It, and Why? Pressure and Response

40
What Is Quality, Who Wants It,
and Why?
MANAGED CARE QUARTERLY/AUTUMN 1999
Leonard H. Friedman and David B. White
The health services literature is replete
with examples of the failure of total
quality management to produce
significant change in organizational
performance. Some authors suggest
that incremental quality improvement
be abandoned in favor of structural
reengineering. However, these
naysayers ignore the critical impact of
environmental change, managed care,
and customer service as primary
organizational drivers that demand an
enhanced focus on continuous quality
improvement. Coupled with these
factors is the movement towards the
creation of learning organizations. At
the core of any learning organization
is a commitment to quality and the
empowerment of employees to identify
and improve quality. Key words:
environmental change, learning
organization, managed care, quality
Managed Care Quarterly 1999; 7(4): 40–46
© 1999 Aspen Publishers, Inc.
40
Pressure and Response
There is no question that health service organizations (HSOs) of all types, including managed care
organizations (MCOs), are being confronted with pressures that are forcing executives to rethink the fundamental business theories that have governed their
operations for at least the past 40 years.1,2 Among the
pressures are constrained resources resulting from
prospective payment and capitation, the growth of
elderly populations, state and federal government
health care reform, and increased competition among
providers. Recent reports from the Health Care Financing Organization (HCFA) suggest that the Medicare Trust Fund will be broke by 2001. While the
growth in total health care spending is the slowest in
recent memory, over $1 trillion was spent in 1996 and
pressure continues to control spending.3
Concurrent with pressure to impose rigid cost controls has been the demand to maintain a high level of
service and improve clinical outcomes. However, the
difficulty has been to arrive at a satisfactory definition
of quality. Traditionally, those closest to the process
(typically physicians but sometimes nurses) were
charged with informing both consumers and payers as
to whether or not clinical success had been achieved.
Successful outcomes equated to high-quality care
regardless of cost or the perceptions of the ultimate
recipient of service. Generations of providers were
trained to see themselves as the final arbiter of quality.
According to this rationale, restraining autonomy and
demanding accountability would lead to diminished
quality and bad medical outcomes.
Leonard H. Friedman, PhD, MPH, is Associate Professor in
the Department of Public Health, Oregon State University,
Corvallis, Oregon. David B. White, PhD, MPH, ACSW,
RODP, is Associate Professor in the Department of Education and Health Services, Saint Joseph’s University, Philadelphia, Pennsylvania.
What Is Quality, Who Wants It, and Why?
Despite the insistence of providers that they continue
to be afforded sole control of the process of health care
delivery, a gradual change began to take place. Berwick
(1989)4 surfaced the idea that methods of continuous
improvement could be incorporated in health care
organizations. A physician with the Harvard Community Health Plan, he suggested that continuous improvement could improve clinical decisions, lower
costs, and enhance patient satisfaction. Earlier, Shortell
(1982)5 also challenged the conventional wisdom that
cost and quality were synonymous. He argued that
methods to control costs may actually improve quality
given a cooperative involvement of administration and
provider. These messages struck a resonant chord with
reformers, who rushed to try and implement these
wondrous new ideas. Many attempted to exploit the
concept that quality was predicated on the belief that
you needed to listen to the customer, create
multidisciplinary teams of quality, have complete
support from senior administration, and analyze outcome data. Hospitals, group practices, managed care
plans, public agencies, and other payers and providers jumped onto the quality bandwagon. This isomorphic behavior toward quality has been driven partly
by both the Joint Commission on Accreditation of
Healthcare Organizations (the Joint Commission) and
the National Committee for Quality Assurance (NCQA)
to make systemic quality part of virtually every health
care provider in the nation.
However, there appears to be unease regarding the
original passion for quality improvement in some
quarters. There are a growing number of reported
failures of quality improvement and in many cases, it
has been abandoned in favor of an effort to reengineer
the organization. One article suggests that employerinstituted quality improvement programs may be a
violation of National Labor Relations Board (NLRB)
rules.6 Counte and colleagues postulate that the success of quality improvement in hospital settings is
uncertain given the unique organizational problems
that hospitals have in contrast to non–health care
related industries.7
This leads us to ask whether quality improvement
(QI) is dead (or at a minimum lies in a comatose state)
in health service organizations? The answer resides in
an examination of both the health services and business literature, combined with anecdotal reports from
health service executives. This article proposes to
41
achieve four purposes. First is to briefly trace the
literature on QI in HSOs. Second is to ask why QI
appears to fail and to examine the likelihood that
health care executives were not confusing QI with QA
or organization development. Third is to see if, as Will
Rogers stated, “The reports of my demise are greatly
exaggerated.” Is QI actually dead, or at least, on its way
out? Are there legitimate cases of successful implementation or is QI simply a means by which the Joint
Commission and NCQA can impose an added “hassle
factor” to an already overregulated industry? Finally,
we intend to examine some of the future challenges
with the realization that HSOs must be able to provide
high quality at a reasonable cost.
Overview of Organization Improvement
and Quality in HSOs
Historically, the prevailing wisdom suggested that
HSOs, although in dire need of intervention, had a
natural aversion to organizational change efforts. The
characteristics of this sector presented obstacles even
for seasoned professionals. The literature is replete
with examples of the difficulties of organization improvement. Weisbord8 pessimistically concluded that
organization improvement efforts were not effective
in medical settings because they have few of the
formal characteristics of industrial firms (where research was largely based). Weisbord asserted that
providers in such settings were socialized to be autonomous and to initiate professional judgment rather
than to be team players.
Early on, Kaufman9 specified a variety of obstacles
that impeded organizational improvement (most of
which, he concluded, characterize health care organizations) to include professional autonomy,
routinization of procedures and behavior (status quo),
opposition to change, specialization/division of la-
Historically, the prevailing wisdom
suggested that HSOs, although in
dire need of intervention, had a
natural aversion to organizational
change efforts.
42
MANAGED CARE QUARTERLY/AUTUMN 1999
bor, sunk costs and resource scarcity, and excessive
regulations. Goodstein10,11 advocated a systems approach for consulting to human service organizations,
but he urged caution and characterized HSOs as
bureaucratic, goal ambiguous, conflict avoiding, noncompetitive, and unresponsive to feedback concerning mission attainment.
Warner Burke,12 in reviewing the efforts at organization improvement in bureaucracies, declared that
“very little or no fundamental change is occurring in
bureaucratic organizations” (p. 429). Burke predicted
that bureaucracies and their organizational imperative would prevail for the foreseeable future. Tichy,13
in a strongly negative critique, concluded that organizational development (O.D.) (which is a process
complementary to Quality Improvement) still has
limited application in large health systems. The reasons are due to inadequacies in the field of O.D., and
to the special nature of managerial and organizational
problems in large health systems.
Although by no means exhaustive, this brief overview of the pessimistic literature concerning organizational improvement in health and human services
reflects that many analysts historically perceived the
obstacles to outweigh the possibilities. However, there
are notable exceptions to these negative assessments.
Berwick and colleagues in their groundbreaking work
took the findings of the National Demonstration Project
on Quality Improvement in Health Care and argued
that TQM methods could successfully be used in
health care organizations.14 Margulies and Adams15
cited many contributors who have succeeded regarding organizational improvement interventions in
health care institutions, usually in hospitals. Boss16
traced the challenges and barriers to interventions in
an operating room, nursing services’ division, and
city hospital-medical center and provided an optimistic analysis concerning the chances of success. His
review of the literature supports the positive results of
team building, management development, action research, role clarification, and structural changes in a
wide spectrum of health organizations.
Keys17 and Heyssel 18 reported on successful organizational improvements in an urban, human service
agency and a major teaching hospital respectively.
Specifically related to team building, Boss and Boss19
summarized a successful confrontational team building effort with nurse managers and concluded that the
intervention resulted in “statistically significant increases in organization climate and group effectiveness” (p. 252). Cope and Cox20 reported on a very
successful intervention in a psychiatric hospital, and
Shani and Eberhardt21 provided an exhaustive case
study of the successful development of a parallel
organization in a midwestern medical rehabilitation
hospital. Wieland22 noted that although there are
considerable problems regarding organizational interventions in health care (particularly physicians’
perceptions of intervention and interdependence as a
threat), there are notable successes, including teamwork development in health centers, improved culture in HMOs, and collaborative efforts in hospitals to
reduce patient length of stay. In a multi-institutional
study, Boerstler and colleagues23 reported that while
organization-wide change rarely occurred with the
implementation of total quality management (TQM),
specific departments can enjoy considerable benefit.
Freeman and Penrod24 reported on a successful
team-building initiative between physicians and
nurses in a midwestern hospital. They analyzed the
synergism of the TQM techniques and the O.D. processes noted above in their positive intervention and
concluded that change opportunities are numerous in
health care. Charns and Tewksbury25 likewise elaborated on the philosophical similarities between O.D.
and TQM and provided numerous examples of successful implementation in the field—in hospitals,
medical centers, and health service centers.
Brill and Pierskalla26 concluded that adhering to the
basic tenets of O.D. leads to a variety of benefits to the
organizations and their administrations. More recently,
Johnson and Boss,27 after studying cases where O.D.
interventions were effective, concluded that “health
care professionals are willing to consider options and
accept change when needed” (p. 717).
Griffith28 has noted that TQM requires an environment that has shared responsibility for care that is of
the utmost importance to all health care providers.
White also reviewed the literature on organization
improvement interventions in health and human service agencies, as well as educational institutions, and
found that success was established through consistency of purpose, committed leadership, empowerment strategies, and quality assessment.2 Although
only a brief summary of the optimistic conclusions,
these citations reflect a substantial body of knowledge
What Is Quality, Who Wants It, and Why?
sharing a positive consensus of contributions and
potential.
Impact of External/Contextual Factors
Complicating the mixed assessments of impact have
been the major economic changes that have profoundly altered our society. These “new realities”1 for
HSOs mean a paradigm shift from unlimited access to
care to more efficient and low-cost managed care,
from cost-based reimbursement to prospective payments based on diagnosis-related groups.29,30 We observe that the “provider driven” cost-be-damned era
is being replaced by a “consumer-oriented marketplace” atmosphere where fiscal solvency realities
predominate. As noted by Freeman and Penrod,24 “the
pressure on health care organizations to control costs
and improve quality has provided a strong incentive
to focus on improvement opportunities” (p. 61). Additional evidence for this cost-based transition is seen
in the rapid growth and development of integrated
delivery systems.31
It would appear that there are considerable challenges and opportunities for organizational improvement, that can have a positive effect on organization
and management efficiency, effectiveness, and responsiveness.1 Change will undoubtedly be the dominant theme well into the next century.30,32 Given the
events noted, adapting the organization to external
and internal stimuli may be the most difficult challenge facing managers who now truly have to manage,
lead, and strategize, and not just administer.33 Such a
crisis represents a challenge, as well as an opportunity, for continuous quality improvement. In their
totality, the incidences of success cited in the literature reflect opportunities. All are the impetus for
increased improvement, management efficiency, organizational adaptability, and strategic planning.34
In summary, external and internal realities for all
HSOs have changed dramatically. Many of the managerial problems, organizational influences, sector characteristics, and obstacles cited have been resolved or
partially resolved or tempered due to the events noted;
and perhaps more importantly, economic incentives
have changed precipitously. If one wants to change
behavior, one must change the economic incentives
that drive or at least support that behavior.35 Given the
massive changes that have beset HSOs, this has most
43
assuredly occurred and continues. Consequently, organizations previously unresponsive to improvement
interventions may be more receptive as a direct result
of a willingness to try something new, so as to adapt
and survive in a “challenging era.”2 In short, necessity
is often the mother of invention.
What Is Quality? Who Wants It! Why?
So if one is to assume that the utility, if not necessity, of continuous quality improvement in HSOs is
very much alive, where are we now? Recent evidence
would suggest that part of the difficulty of assessing
continuous quality improvement is in the multiple
definitions, varying perceptions, and even demands
for quality improvement. O’Conner and Bowers36 anticipate that consumers, third party payers, and government will all place increased emphasis on quality.
As competition (driven by market reforms) continues
to grow, there will be increased pressure and expectations for quality and services. As noted by O’Conner
and Bowers, the link between an organization’s internal marketing, satisfied employees, and service quality becomes manifest. Noteworthy is that this is the
essence of TQM/CQI noted by none other than Edward Deming.37,38
Helping to answer the question of who wants quality, one need look no further than their appropriate
regulatory or accrediting agency. The two leaders in
this drive are without question the Joint Commission
and the NCQA. In the early 1990s the Joint Commission revised its accreditation rules to recognize and
promote a quality improvement approach for every
organization it visits.39 The Joint Commission specifically speaks both to doing the right thing and to doing
the right thing well. In order to achieve this goal, the
Joint Commission includes the elements of process
design, performance measurement through data collection, analyzing current performance, and improving and sustaining improved performance.40 More
recently, the NCQA has worked to develop a set of
quality standards that, since 1991, would apply to the
accreditation of managed care organizations. While a
significant number of variables are measured, over 40
percent of an MCO’s total score is a function of quality
management and improvement. There is a great deal
of pressure exerted by large payers for managed care
plans, HMOs, and managed behavioral health care
44
MANAGED CARE QUARTERLY/AUTUMN 1999
organizations to submit themselves for NCQA accreditation. Their work on the Health Plan Employer
Data and Information Set (HEDIS) represents an attempt to develop a uniform set of standards by which
health plan quality will be measured and judged.
The relationship between employee satisfaction
and patient satisfaction is also key in implementing
TQM/CQI programs. Lawrence and Packwood41 and
Morrison, Mobley and Farley42 clearly demonstrate
that the effort is a holistic, humanistic oriented program. They evaluated interrelationships not only
among coworkers, but also between employees and
patients. They concluded that the focus is on process
and product. O’Conner, Shewchuk and Carney43 astutely point out that patient satisfaction with service
quality is correlated with retention in treatment: larger
market share. Aharony and Strasser44 likewise note
that patient satisfaction is crucial, but link that outcome to compliance with treatment, better communication between patients and providers, and improved
outcomes.
The idea that patients need to be satisfied with
quality care should not seem all that revolutionary,
but surprisingly the literature points to evidence that
there is a wide gap between provider perceptions and
patient expectations. O’Conner, Shewchuk and
Carney43 observe that patients place value on empathy
and responsiveness in their providers when assessing
service quality, but that physicians in particular are
unaware of and need sensitizing concerning this fact.
By closing this gap, positive outcomes such as profitability and market share will accrue to the institution.
As pointed out by O’Conner and Bowers,36 providers
have traditionally defined service quality, but in the
current environment patients/consumers and payers
are the ultimate arbiters of quality. This is not to say
that technical/clinical quality is not important, but
rather that there is a socioemotional dimension to
quality care as well. Are not most other products/
commodities/services so judged? Why not health care?
Consumers who experience more positive, interactive quality have higher levels of satisfaction and rate
quality higher.
Currently the weakness lies in our inability to
measure patient satisfaction and quality with any
validity and reliability.44 As we begin to view continuous quality improvement as an organizational commitment to humanitarian patient care and service
quality, the need for reliable indicators of outcome are
critical. It is not that CQI is dead, but quite the
contrary: the demands of the paradigm shift in HSOs
have outpaced the ability of administrators and providers to adapt. We have much to learn from other
service industries.
Managed Care/Quality Improvement
Due largely to market forces, competition, and the
pressure from business and third party payers, managed care and capitated payment systems are becoming the norm. In spite of resistance and criticism by
many, integrated delivery systems, managed care networks, and the pressure for efficiency and effectiveness will continue.2 Quality improvement efforts will
be of particular importance as integrated health networks (IHNs) continue to grow in response to heightened environmental and competitive pressure among
both payers and providers. Quality is not merely a
function of charting the number of complaints and
suggestions posed by “customers.” IHNs will need to
define quality in terms of outcomes-based measures
that need to be applied to the entire organization. One
of the inherent difficulties attached to this process has
less to do with the information system and more to do
with the culture and values of the member organizations connected to the IHN. There is evidence that the
success of IHNs will be primarily determined by
aligning mission, vision, and values (including quality) and less on economic incentives and compensation packages.45
The demands on HSOs and MCOs will thus persist.
Cooperation between providers and managers will be
the key to providing safe and efficient care of the
highest quality within the constraints of cost containment and managed care.2 The need to manage quality
is central to organizational success. Lathrop46 asserts
that service quality (not clinical quality) will become
the most common competitive dimension pursued
and marketed by integrated delivery systems. As clinical protocols evolve and third party pressures demand
a high standard level of clinical quality in the managed
care environment, consumers/patients will make purchasing decisions based on other factors such as service
and customer satisfaction. HSOs will have to determine
what consumers want and meet their expectations:
quality service at a reasonable price.
What Is Quality, Who Wants It, and Why?
Cooperation between providers and
managers will be the key to providing
safe and efficient care of the highest
quality within the constraints of cost
containment and managed care.
There is considerable evidence to support this contention and to demonstrate what consumers mean by
service quality. A recent study of patient satisfaction
in hospitals conducted by Press, Ganey and Associates found that “interpersonal issues such as attitude,
interactive skills, caring behavior . . . [and] staff
response to patient’s needs to be informed, treated
with respect and shown concern for personal stress
were most associated with overall satisfaction and
likelihood of recommending a facility.”47
O’Connor and Bowers36 believe that the future portends an increased concern for quality and patient
satisfaction with the need for management to overcome their inaccurate perception of expected service,
and internalize service systems that emphasize a
culture of service quality. They contend that very
little is known about service orientation in health care
and they explain the definition as “disposition to be
helpful, thoughtful, considerate and cooperative.” It
is a set of attitudes and behaviors that affect the quality
of the interaction between health care employees and
patients.
The accumulating evidence indicates that “service
quality” as defined by customers is the future in
MCOs—if not in all industries. In effect, perception is
reality and customers who are not satisfied will in a
short time no longer be customers.48 As expressed by
Press, Ganey and Associates, the one million plus
patients surveyed in their study have vividly declared
that they “care more about what’s done to them and
what’s told to them than other aspects of their stay . .
. we ignore them at our peril.”47 This needs to be
repeatedly emphasized to administrators and providers alike.
The challenge is to learn as much about service
quality as possible and apply it to HSOs.49 A change in
process and culture is what is sorely needed. It will be
an evolutionary, not a revolutionary, phenomenon,
45
but it has to happen for organizational survival. Interest by the Joint Commission, NCQA, industry reform
groups, insurers, and consumers makes the service
quality commitment imperative.36,43,49
Support for this need for continual change is evidenced in the growing interest in learning organizations.50 MCOs that do not adopt measures to monitor
and continually improve quality will lose a significant competitive advantage to those who make quality an integral part of their mission and daily operations. In an environment of high levels of flux and
uncertainty, the organizations that survive will do so
by allowing employees at all levels the freedom to
achieve their maximum professional potential and to
try new and innovative approaches to providing the
highest quality customer service possible. Anything
less than a total commitment to quality and quality
processes will prove to be a fatal error in tomorrow’s
competitive and cost-conscious environment.
REFERENCES
1. D. White, “New Realities in the Health and Human Service
Sector in the 1990s Translate into New Opportunities and
Challenges for O.D.,” Organization Development Journal 10,
no. 3 (1992): 1–10.
2. D. White, “National Health Care Reform: Implications for
Organization Development,” Organization Development Journal 13, no. 1 (1995): 1–8.
3. K.R. Levitt et al., “National Health Spending Trends in 1996,”
Health Affairs 17, no. 1 (1998): 35–51.
4. D. Berwick, “Continuous Improvement as an Ideal in Health
Care,” New England Journal of Medicine 320, no. 1 (January 5,
1989): 53–56.
5. S.M. Shortell, “Improving Organizational Effectiveness. A Comment on Effectiveness in Professional Organizations,” Health
Services Research 17, no. 3 (1982): 367–372.
6. R.K. Robinson et al., “Employee Participation Programs in the
Health Care Industry: Are They Unlawful under Recent Labor
Rulings?” Hospital and Health Services Administration 40, no.
1 (1995): 124–137.
7. M. Counte et al., “Improving Hospital Performance: Issues in
Assessing the Impact of TQM Activities,” Journal of Hospital
and Health Services Administration 40, no. 1 (1995): 80–94.
8. M. Weisbord, “Why Organization Development Hasn’t Worked
(So Far) in Medical Centers,” Health Care Management Review
(Spring 1976): 17–28.
9. H. Kaufman, The Limits of Organizational Change (Birmingham, AL: University of Alabama Press, 1971).
10. L.D. Goodstein, Consulting with Human Service Systems (Reading, MA: Addison-Wesley, 1978).
11. L. D. Goodstein, “Consulting to Human-Service Organizations,” in Annual Handbook for Group Facilitators, ed. J.W.
Pfeiffer and J.E. Jones (San Diego, CA: University Associates,
Inc., 1980), 213–223.
46
MANAGED CARE QUARTERLY/AUTUMN 1999
12. Burke, W.W., “Organization Development and Bureaucracy in
the 1980s,” Journal of Applied Behavioral Science 16, no. 3
(1980): 423–437.
13. N.M. Tichy, “Organization Development in Health Care,” in
Organization Development and Change, 3rd ed., ed. E.F. Huse
and T. Cummings (New York: West Publishing Co., 1985),
432–437.
14. D. Berwick, A.B. Godfrey, and J. Roessner, Curing Health Care:
New Strategies for Quality Improvement (San Francisco, CA:
Jossey-Bass Publishers, 1990).
15. N. Margulies and J.D. Adams, eds. Organization Development
in Health Care (Reading, MA: Addison-Wesley, 1982).
16. R.W. Boss, ed. Organization Development in Healthcare (Reading, MA: Addison-Wesley, 1989).
17. P.R. Keys, “New Management in Action: A Case Study,” in New
Management in Human Services, ed. P.R. Keys and L.H.
Ginsberg (Silver Spring, MD: National Association of Social
Workers, 1988), 133–166.
18. R. M. Heyssel et al., “Decentralized Management in a Teaching
Hospital,” in Health Services Management: Readings and
Commentary, 3rd ed., ed. A.R. Kovner and Duncan Neuhauser
(Ann Arbor, MI: Health Administration Press, 1990), 236–245.
19. R.W. Boss and L.A. Boss, “Team Building with Nurse Managers,” Consultation 6, no. 4 (Winter 1987): 252–264.
20. D. Cope and S. Cox, “Organization Development in a Psychiatric Hospital: Creating Desirable Change,” Journal of Advanced Nursing 5 (1980): 371–380.
21. A.B. Shani and B.J. Eberhardt, “Parallel Organization in a Health
Care Institution: An Exploratory Action Research Study,” Journal
of Groups and Organizations 12, no. 2 (1987): 147–173.
22. G.F. Wieland, ed., Improving Health Care Management: Organization Development and Organization Change (Ann Arbor,
MI: Health Administration Press, 1981).
23. H. Boerstler et al., “Implementation of Total Quality Management: Conventional Wisdom Versus Reality,” Hospital and
Health Services Administration 41, no. 2 (1996): 143–159.
24. C. Freeman and P. Penrod, “Applying OD and TQM Strategies
to Organization Change in Hospitals,” Organization Development Journal 11, no. 4 (1993): 61–69.
25. M.P. Charns and L.J.S. Tewksbury, Collaborative Management
in Health Care: Implementing the Integrative Organization (San
Francisco: Jossey Bass, 1992).
26. P. Brill and C. Pierskalla, “Issues in the Applications of Organization Development in Health Care Organizations,” in Organization Development in Health Care Organizations, ed. N.
Margulies and J.D. Adams (Reading, MA: Addison-Wesley,
1982), 377–391.
27. J.D. Johnson and R.W. Boss, “Organization Development
Interventions in Health Services: Looking Back and Moving
Forward,” Organization Development Journal 10, no. 1 (1990):
73–78.
28. J.R. Griffith, “Reengineering Health Care: Management Systems for Survival.” Hospital and Health Services Administration
39, no. 4 (1994): 451–470.
29. E. M. Melhado, W. Feinberg, and H.M. Swartz, eds., Money,
Power and Health Care (Ann Arbor, MI: Health Administration
Press, 1988) .
30. S.M. Shortell and A.D. Kaluzny, eds., Health Care Management: Organization Design and Behavior, 3rd ed. (Albany, NY:
Delmar Publishers, 1995).
31. L.H. Friedman and L.A. Mullins, “Development of a Local
Integrated Health Network,” Hospital Topics 73, no. 2 (1995):
22–27.
32. P.R. Keys and L.H. Ginsberg, eds., New Management in Human Services (Silver Spring, MD: National Association of Social
Workers, 1988).
33. A.R. Kovner and D. Neuhauser, eds., Health Services Management: Readings and Commentary, 4th ed. (Ann Arbor, MI:
Health Administration Press, 1990).
34. R. Kropf and S.B. Goldsmith, “Innovation in Hospital Plans,”
Health Care Management Review (Spring 1983): 7–16.
35. R.E. Berry, Jr. and R.D. Feldman, “Economics and Health
Services Research,” in Social Science Approaches to Health
Services Research, ed. T. Choi and J.N. Greenberg (Ann Arbor,
MI: Health Administration Press, 1983), 155–182.
36. S.J. O’Conner and M.J. Bowers, “An Integrative Overview of the
Quality Dimension. Marketing Implications for the ConsumerOriented Health Care Organization,” Medical Care Review 47,
no. 2 (1990): 193–219.
37. W.E. Deming, Quality, Productivity and Competitive Position
(Cambridge, MA: MIT Press, 1982).
38. W.E. Deming, Out of the Crisis (Cambridge, MA: MIT Press,
1986).
39. A. Flood, S. Shortell, and W.R. Scott, “Organizational Performance: Managing for Efficiency and Effectiveness,” in Essentials of Health Care Management, ed. S. Shortell and A. Kaluzny
(Albany, NY: Delmar Publishers, 1997), 405.
40. The Joint Commission on Accreditation of Healthcare Organizations, Comprehensive Accreditation Manual for Pathology
and Clinical Laboratory Services (Chicago, IL: The Joint Commission, 1998).
41. M. Lawrence and T. Packwood, “Adapting Total Quality Management for General Practice: Evaluation of a Programme,”
Quality in Health Care 5, no. 3 (1996): 151–158.
42. E. Morrison, D. Mobley, and B. Farley, “Research and Continuous Improvement. The Merging of Two Entities,” Hospital and
Health Services Administration 41, no. 3 (1996): 359–372.
43. S. J. O’Conner, R.M. Shewchuk, and L.W. Carney, “The Great
Gap: Physicians’ Perceptions of Patient Service Quality Expectations Fall Short of Reality,” Journal of Health Care Marketing
14, no. 2 (1994): 32–39.
44. L. Aharony and S. Strasser, “Patient Satisfaction: What We
Know About and What We Still Need to Explore,” Medical Care
Review 50, no. 1 (1993): 49–79.
45. L.H. Friedman, “The Unfocused Strategic Vision,” Managed
Care Quarterly 5, no. 4 (1997): 1–7.
46. J.P. Lathrop, “Competitive Strategies for the Next Generation of
Managed Care,” Healthcare Forum Journal 39, no. 2 (1996):
36–38, 52–55.
47. “Patient Satisfaction with Hospitals: One Million Surveyed,
Surprising Results,” Philadelphia Business Journal, March 1997,
p. 15.
48. D. Pedersen, “Dissing Customers: Why the Service is Missing
from America’s Service Economy,” Newsweek, 23 June, 1997,
56–57.
49. D. White, “The Key to O.D. in Health and Human Service
Organizations: Service Quality,” Organizational Development
Journal 17, no. 1 (1999): 95–103.
50. P. Senge, The Fifth Discipline (New York, NY: Doubleday
Currency, 1990).