High-performing health care organizations (HCOs) are characterized by a number of organizational functions, processes, and behaviors that contribute to their success. These include:

• A strong focus on patient safety and quality: HCOs that are consistently rated as high-performing have a culture of safety that permeates the organization. This culture is characterized by a commitment to preventing errors, a willingness to learn from mistakes, and a focus on continuous improvement.

• Effective leadership: Leaders in high-performing HCOs are able to set clear goals, motivate and engage their employees, and create a culture of accountability. They also have a strong understanding of the organization’s strategic direction and are able to communicate it effectively to all stakeholders.

• Empowered employees: Employees in high-performing HCOs feel valued and respected. They are given the authority and responsibility to make decisions, and they are encouraged to take risks and innovate.

• Effective communication and collaboration: HCOs that are consistently rated as high-performing have effective communication and collaboration channels in place. This allows for the sharing of information and best practices across the organization.

• A focus on data and measurement: HCOs that are consistently rated as high-performing use data and measurement to track their progress and identify areas for improvement. They also use data to inform their decision-making.

Impact of Organizational Functions, Processes, and Behaviors on Outcome Measures

The organizational functions, processes, and behaviors described above have a significant impact on outcome measures associated with the systemic problem identified in the gap analysis. For example, a strong focus on patient safety and quality can lead to a reduction in preventable errors and improved patient satisfaction. Effective leadership can create a culture of accountability and drive continuous improvement. Empowered employees can lead to increased innovation and improved patient care. Effective communication and collaboration can break down silos and improve the coordination of care. And a focus on data and measurement can help to identify and address performance gaps.

Quality and Safety Outcomes and Associated Measures

The following are some quality and safety outcomes and associated measures that are relevant to the performance gap identified in the gap analysis:

Performance Issues or Opportunities Associated with Particular Organizational Functions, Processes, and Behaviors

The following are some performance issues or opportunities associated with particular organizational functions, processes, and behaviors:

Strategy for Ensuring that All Aspects of Patient Care are Measured and that Knowledge is Shared with the Staff

The following is a strategy for ensuring that all aspects of patient care are measured and that knowledge is shared with the staff:

1. Develop a comprehensive performance measurement system: The performance measurement system should include measures of patient safety, patient satisfaction, clinical effectiveness, efficiency, and cost.

2. Collect and analyze data regularly: Data should be collected and analyzed on a regular basis to track progress and identify areas for improvement.

3. Share findings with staff: Findings from performance measurement should be shared with staff in a timely and transparent manner.

4. Use data to inform decision-making: Data should be used to inform decision-making at all levels of the organization.

5. Create a culture of continuous improvement: A culture of continuous improvement should be created in which staff are encouraged to identify and implement solutions to performance problems.

Change Model

The following is a change model that can be used to ensure that all aspects of patient care are measured and that knowledge is shared with the staff:

1. Establish a sense of urgency: The organization needs to create a sense of urgency around the need for change. This can be done by highlighting the performance gap and the potential benefits of change.

2. Form a guiding coalition: A guiding coalition of leaders and staff should be formed to lead the change effort.

3. Create a shared vision: A shared vision for change should be created that is clear, compelling, and achievable.

4. Communicate the change: The change should be communicated effectively to all staff.

5. Empower employees: Employees should be empowered to take ownership of the change.

6. Provide support: Support should be provided to staff throughout the change process.

7. Anchor the change: The change should be anchored in place by making it a permanent part of the