Fueled by public incidents and growing evidence of deficiencies in care, concern over the quality and outcomes of care has increased in both the United Kingdom and the United States. Both countries have launched a number of initiatives to deal with these issues. These initiatives are unlikely to achieve their objectives without explicit consideration of the multilevel approach to change that includes the individual, group/team, organization, and larger environment/system level. Attention must be given to issues of leadership, culture, team development, and information technology at all levels. A number of contingent factors influence these efforts in both countries, which must each balance a number of tradeoffs between centralization and decentralization in efforts to sustain the impetus for quality improvement over time. The multilevel change framework and associated properties provide a framework for assessing progress along the journey.
JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. This study develops a theoretical framework that integrates institutional and network perspectives on the form and consequences of administrative innovations. Hypotheses are tested with survey and archival data on the implementation of total quality management (TQM) programs and the consequences for organizational efficiency and legitimacy in a sample of over 2,700 U.S. hospitals. The results show that early adopters customize TQM practices for efficiency gains, while later adopters gain legitimacy from adopting the normative form of TQM programs. The findings suggest that institutional factors moderate the role of network membership in affecting the form of administrative innovations adopted and provide strong evidence for the importance of institutional factors in determining how innovations are defined and implemented. We discuss implications for theory and research on institutional processes and network effects and for the literatures on innovation adoption and total quality management.* This paper also contributes to the growing empirical literature on TQM. In one of the few large-sample, academic studies investigating the performance consequences of TQM, Powell (1995a) concluded that most organizational features commonly associated with TQM do not yield significant performance benefits. We offer a theoretical explanation for such findings: when TQM adoption is driven by conformity pressures rather than technical exigencies, firms may realize legitimacy benefits rather than technical performance benefits from adoption. To test this explanation, we simultaneously investigate both the performance consequences of innovation and the legitimacy benefits of conformity by considering whether a transition occurred from one kind of benefit to another as the form of TQM became institutionalized. Researchers in a variety of disciplines have long been interested in identifying conditions TQM As an Administrative Innovation in the Hospital EnvironmentAn innovation is defined as "any idea, practice or material artifact perceived to be new by the relevant unit of adoption" (Zaltman, Duncan, and Holbek, 1973: 158). The tendency for researchers to conceive of innovation as a discrete phenomenon may derive from an emphasis in this literature on technological rather than administrative innovations (Damanpour, 1987 Overall, the hypotheses suggest that conformity to normative TQM adoption should effectively mediate the relationship between time of adoption and the organizational consequences of adoption, such that the time of adoption should predict the degree of conformity, and conformity, in turn, should predict whether hospitals derive primarily efficiency or legitimacy benefits from adoption...
We thank the participants in various seminars (Arizona State University, Copenhagen Business School, University of California at Berkeley, University of Illinois at Urbana-Champagne, University of Western Ontario), Dan Brass, and three anonymous reviewers who provided many useful comments and suggestions for the research. We also gratefully acknowledge the assistance of numerous former doctoral students who helped with data collection and coding, especially Tony Ammeter, Mason Carpenter, Suzanne Carter, Frances Hauge Fabian, and Jessica Simmons Jourdan. Special thanks go to Laurie Milton, who transcribed the focus group notes and helped develop the survey instrument. Finally, we thank the system administrators and physicians who graciously gave us their time and effort for this research.We use an established model of organizational identification to try to understand the voluntary cooperative behavior of professionals in organizations. We examined the relationships among physicians' assessments of the attractiveness of a health care system's perceived identity and construed external image, strength of system identification, and cooperative behaviors. We surveyed 1,504 physicians affiliated with three health care systems and collected follow-up data from 285 physicians a year later. Attractiveness of perceived identity and construed external image were positively related to physicians' identification with the system, which in turn was positively related to cooperative behavior. Extensions to the model of organizational identification are suggested.* Considerable attention has been given to the psychological attachment between organizations and their members and the consequences that such attachment has for each. Recently, a special issue of the Academy of Management Review was devoted to organizational identity and identification. The editors of that special issue (Albert, Ashforth, and Dutton, 2000: 14) noted that these concepts "provide a way of accounting for the agency of human action within an organizational framework." Although the concepts of identity and identification have generated a great deal of theoretical attention, relatively few empirical studies have been published that examine their effects. This is regrettable, because identity and identification may provide insights into some fundamental challenges of managerial life. For instance, the study of identity and identification may help us understand why some members of organizations regularly engage in cooperative behaviors that benefit the organization, whereas others do not. Theory on organizational identification (Ashforth and Mael, 1989;Dutton, Dukerich, and Harquail, 1994;Pratt, 1998;Elsbach, 1999) may provide a unique lens with which to view organizational members' decision to cooperate, particularly when there is no penalty for failure to engage in such behaviors, since decisions to engage in cooperative behaviors under these conditions are likely to be based on attitudes and cognitions about the organization (cf. Kramer, 1993), which are als...
The literature on continuous quality improvement (CQI) has produced some evidence, based on nonrandomized studies, that its clinical application can improve outcomes of care while reducing costs. Its effectiveness is enhanced by a nucleus of physician involvement, individual practitioner feedback, and a supportive organizational culture. The few randomized studies, however, suggest no impact of CQI on clinical outcomes and no evidence to date of organization-wide improvement in clinical performance. Further, most studies address misuse issues and avoid examining overuse or underuse of services. The clinical application of CQI is more likely to have a pervasive impact when it takes place within a supportive regulatory and competitive environment, when it is aligned with financial incentives, and when it is under the direction of an organizational leadership that is committed to integrating all aspects of the work.
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