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Health Serv Res. 2008 October; 43(5 Pt 2): 1787–1806.
PMCID: PMC2654162

Examining Quality Improvement Programs: The Case of Minnesota Hospitals



To determine if there is a hierarchy of improvement program adoption by hospitals and outline that hierarchy.

Data Sources

Primary data were collected in the spring of 2007 via e-survey from 210 individuals representing 109 Minnesota hospitals. Secondary data from 2006 were assembled from the Leapfrog database.

Study Design

As part of a larger survey, respondents were given a list of improvement programs and asked to identify those programs that are used in their hospital.

Data Collection/Data Extraction

Rasch Model Analysis was used to assess whether a unidimensional construct exists that defines a hospital's ability to implement performance improvement programs. Linear regression analysis was used to assess the relationship of the Rasch ability scores with Leapfrog Safe Practices Scores to validate the research findings.

Principal Findings

The results of the study show that hospitals have widely varying abilities in implementing improvement programs. In addition, improvement programs present differing levels of difficulty for hospitals trying to implement them. Our findings also indicate that the ability to adopt improvement programs is important to the overall performance of hospitals.


There is a hierarchy of improvement programs in the health care context. A hospital's ability to successfully adopt improvement programs is a function of its existing capabilities. As a hospital's capability increases, the ability to successfully implement higher level programs also increases.

Keywords: Quality improvement, program effectiveness, program implementation, Rasch model analysis

Over $2 trillion was spent on health care in the United States in 2006, the highest level of per capita spending in the world. With health insurance premiums doubling every 5 years, it is predicted that a family's annual costs for health insurance will be $22,000 by the year 2010 (DoBias and Evans 2006). Further, it is estimated that between 44,000 and 98,000 preventable deaths occur every year as a result of “errors” in the health care system and preventable health care-related injuries result in costs of between $17 and $29 billion annually (Corrigan, Kohn, and Donaldson 2000). Given the preceding scenario, many policy makers have begun to question the value that is being delivered by the U.S. health care system.

In an effort to strengthen their operating performance, leading health care organizations are instituting a variety of programs to reduce costs, increase safety, and improve clinical outcomes in an increasingly aggressive health care marketplace. Six Sigma, lean management, Studer programs, and the 100K Lives Campaign are some examples of programs currently being employed by health care organizations. However, it is not uncommon to see reports of both the successes and the failures for each of these programs. The difficult question confronting hospital administrators is, “Why do some programs fail and others succeed?”


Like health care institutions, traditional business organizations are also being confronted with a variety of choices for improving their performance. Because of intense global competition, manufacturing organizations are especially interested in understanding how operating relationships lead to improved performance. Ferdows and DeMeyer (1990) proposed that successful manufacturing operations utilized a sequence of management efforts and resources that could be visualized as a sand cone that consisted of mutually dependent layers. The operational progression was described as: (1) initially constructing a foundation that produces quality outcomes, (2) followed by increasing dependability within the operating system, (3) then enhancing the speed and flexibility of the system, and (4) finally emphasizing lasting cost improvements.

Based upon the sand cone framework proposed by Ferdows and DeMeyer, Roth (1996a) formulated a theory describing the development of manufacturing organizational capabilities as a cumulative process, the Competitive Progression Theory (CPT). The relationship among the stages was described as one where the lower level stages facilitated the accomplishment of upper level stages. Specifically, Roth (1996b) states, “higher level organizational knowledge-based competencies are required to move efficiently between successive stages” (p. 38.13). Rosenzweig and Roth (2004) tested the efficacy of the CPT model using a sample of high-technology companies. Their results found evidence of the hypothesized progression of companies through the four stages and that the progression was related to organizational performance.

Butler and Leong (2000) used their observation that the “Accreditation Manual for Hospitals is consistent with the principles of operations strategy being discussed in the general operations management literature” (p. 228) as an impetus to examine competitive operating priorities within the hospital setting. Their study found that hospital operating priorities included quality, cost, flexibility, and delivery. In particular, they found interrelationships among these four areas, which imply that the concept of a cumulative capability development process may be relevant to the health care setting.


Hospitals, similar to organizations in other economic sectors, have begun to systematically employ a variety of improvement programs. Some of the programs have been developed in the health care environment while others have been adapted from different economic sectors (Shortell et al. 1995). Table 1 displays the correspondence of the improvement programs being examined in this study to the four stages proposed in the CPT. Evans (2008) provides an overview of how the varied improvement programs in Table 1 relate to each other. Essentially, he views the programs at the lower stages of the CPT model as consisting of total quality projects (improving services and work processes, etc.). In contrast, those programs at the higher stages of the model are viewed as integrating, larger scale initiatives, which provides a crosscutting framework that includes multiple functions or perhaps even the whole organization. Revere and Black (2003) provide the following commentary, “Using the Six Sigma metrics, internal project comparisons facilitate resource allocation while external project comparisons allow for benchmarking. Thus, the application of Six Sigma makes TQM efforts more successful” (p. 377). While specifically discussing Six Sigma in the hospital setting, Revere and Black's observations virtually mirror those presented by Evans in identifying the interrelationship of higher level activities to those occurring at a lower level. They point out that once a hospital achieves the ability to implement higher level programs such as Six Sigma, lower level TQM tools become more effective because the hospital is able to identify those parts of the organization that can benefit most from quality improvement (QI) projects.

Table 1
Correspondence of Improvement Programs to the Stages of the Competitive Progression Theory (CPT)

Research on competitive operating priorities from a cumulative development perspective provides a systematic approach for examining decisions in the hospital setting. The present study examines the experiences of Minnesota hospitals in implementing a variety of improvement programs. With this research, we provide a strategic perspective for the hospital decision making process. In addition, we seek to examine the impact of these operating decisions on performance. In order to address these issues, we consider two research questions.

Regarding the first research question, Butler and Leong (2000) note, “Researchers widely agree on four general operations competitive priorities: costs, quality, delivery, and flexibility” (p. 228). These operating priorities have been viewed from the perspective of cumulative manufacturing capabilities both at the theoretical level by Ferdows and DeMeyer (1991) and at the empirical level by Rosenzweig and Roth (2004) and Schroeder, Bates, and Junttila (2002). Hospitals, similar to manufacturing plants, are unit-level operating organizations. It is reasonable to suggest that hospitals also progress through a capability-building process. Thus, it useful to examine whether a hospital's capability-building process is similar to the experience of manufacturing organizations.

  1. Does a cumulative development process exist that influences the ability of hospitals trying to operationalize improvement programs?
    While a variety of research attempts to assess the efficacy of particular programs or practices, perhaps the most relevant finding relates to the number of programs used. Relative to implementation and usage, Corbett and Whybark (2001) report, “The larger the number and intensity of the practices used, the greater the performance of the firm” (p. 978). This study along with the cumulative capabilities research would imply that hospitals would be able to employ greater numbers of programs as they develop increased capabilities. Further, those hospitals having a greater ability to implement programs should demonstrate higher levels of performance as stated in the second research question.
  2. Is there a relationship between hospital performance and its ability to implement improvement programs?


This study investigates the usage pattern of improvement programs by member hospitals of the Minnesota Hospital Association (MHA). A two-stage analysis of the data was performed. The first stage identifies the capability of hospitals in carrying out improvement programs and defines the relative difficulty of the improvement programs themselves. The second stage of the analysis examines the relationship between the pattern of program usage and hospital performance outcomes.


An e-survey was sent by the MHA to 143 Minnesota hospitals during the period January to June 2007. The 674 selected survey recipients included Chief Executive Officers (CEO), Chief Medical Officers (CMO), Chief Financial Officers (CFO), Directors of Nursing (DON), and Quality Directors (QD). The MHA did not have contact information for all types of individuals at every hospital; at some hospitals one individual had several roles and some hospitals had several individuals with the same role. Three follow-up e-mails and a postcard reminder were sent to individuals who had not yet responded. Responses were received from 210 individuals within 109 hospitals, resulting in an effective hospital response rate of 76 percent. Multiple responses from an individual hospital were combined to create the hospital improvement program profile. Overall, 32 percent of the respondents were business administrators (CEO, CFO, or COO), 28 percent were medical administrators (CMO or DON), 30 percent were QD, and 10 percent were other managerial positions in the hospital. Characteristics of the responding hospitals are shown in Table 2.

Table 2
Respondent Demographics (N = 109 Hospitals)

Program Measures

For this study, data on program usage were collected as part of a larger survey. The survey respondents were given a list of programs and asked to select the programs implemented in their hospital. Table 1 presents the programs examined in this study, which include functional as well as larger scale organizational programs. The list of programs used in this study was generated through a literature search and consultation with practitioners and academics. The specific programs used were not intended to be an exhaustive list but, rather, a representative set of programs.

Outcome Measures

The second stage of the analysis examines the capability of the hospitals relative to the publicly available demographic and quality data from the Leapfrog Group. The Leapfrog Group is a consortium of major companies and other large private and public health care purchasers. In 2001, the Leapfrog Group created its initial survey to assess hospital performance based on practices that are proven to reduce medical mistakes. The Leapfrog Group rates a hospital's progress relative to the 27 safe practice areas that were identified by the National Quality Forum. Specifically, we compared the Leapfrog Safe Practices Score from the Leapfrog Hospital Quality and Safety Survey (Leapfrog Group 2007) with an ability score which was generated from our analysis.

Rasch Method

The data were first analyzed using Rasch Model Analysis (RMA), which is described more generally as a latent trait analysis. This type of analysis tries to define an underlying factor that cannot be observed or measured directly from other observable variables. Consequently, the independent variable in this analysis is latent rather than an observed variable. Borsboom, Mellenbergh, and Japp (2003) comment, “although the model cannot be tested directly for any given item because the independent variable is latent, it can be tested indirectly through its implications for the joint probability distribution of the item responses for a number of items” (p. 205).

RMA consists of a family of models. The original model developed by Georg Rasch (1960/1980) was proposed for analyzing dichotomous data. The principles of the original model have been extended to rating scales (Andrich 1978; Wright and Masters 1982) and graded items (Masters 1982; Linacre 1994). This analysis will utilize the original model for dichotomous data.

In this study, we will consider whether hospitals can be characterized by their use of improvement programs. The Rasch model will examine whether the data correspond to a specific, basic underlying structure. It will accomplish this task by employing two basic parameters, difficulty (δ) and ability (β). The most common form of the model is represented as

equation image

It is expected that the usage of individual improvement programs in hospitals provide varying degrees of challenge, which is referred to as the Rasch difficulty parameter (δ). In a similar fashion, it is expected that individual hospitals possess varying levels of capability in implementing improvement programs, which is referred to as the Rasch ability parameter (β). The δ parameters are a linear continuous measure of difficulty and the β parameters are a linear continuous measure of ability. RMA proposes that improvement program difficulty (δ) and a hospital's ability to achieve a particular performance improvement program (β) can be located on the same primary latent variable. Specifically, the Rasch difficulty parameter (δ) is used to locate these performance improvement programs along a continuum of program capability. Similarly, the Rasch ability parameter (β) conjointly locates an organization, based on its ability to achieve particular performance improvement programs, along the same underlying continuum.

In considering data, the overall approach that RMA employs is different than traditional assessment methods. Smith (1996) appropriately notes, “In descriptive statistical methodology, fit statistics are used to discover a model that fits the data well enough that the data could be considered to have been generated by the model. In Rasch analysis, the model is already chosen. The purpose of the fit statistics is to aid in measurement quality” (p. 516). Thus, RMA tries to fit the data to a predetermined model rather than uncovering a model that fits the data.

RMA was used in this study because of several distinctive characteristics. First, Rasch analysis can be used to assess whether a unidimensional construct exists that defines a hospital's ability to implement improvement programs, which is the program capability. RMA focuses on how well “individual differences can be mapped on a single real number line” (Andrich 1988, p. 9). Second, all data are transformed into an interval scale as part of the analysis (Bond and Fox 2007). As a consequence, the dichotomous choice items used in the survey are converted into equal interval units using a logarithmic transformation (i.e., logits) which allows the interpretation of the differences among hospitals in their ability to implement improvement programs, thus facilitating the second stage of the analysis. Finally, RMA allows the same set of data to be used for both estimating and testing solutions (Rasch 1960/1980; Wright and Stone 1979; Wright and Masters 1982). A more detailed technical discussion of the Rasch model used in this study can be found in Bond and Fox (2007) and Andrich (1988).


The first stage of analysis was the development of the Rasch model. When a Rasch model is able to be constructed, it indicates that there is an underlying dimension that is common to all of the variables. Several indicators are utilized in assessing the overall fit of the data to Rasch model: model reliability, item quality using point measure correlations, and measure quality using infit and outfit statistics. Winsteps version 3.63.2 was used to analyze the data.

Using RMA, we are able to independently assess the reliabilities for hospitals and improvement programs. The reliability analyses reveal the extent to which the program usage items yield an internally consistent measure. Hospital reliability is r=0.83 and program reliability is r=0.97. These values indicate a high degree of fit; thus providing an initial indication that a unidimensional representation of the data exists.

Next, the relationship of individual improvement program variables to the overall model is examined. The point measure correlation of each item with the total score indicates how well a program predicts the total number of programs supported. For this particular measure, the sign of the correlation should be positive and is the relevant aspect of the analysis, rather than the magnitude of the correlation. As shown in Table 3, all signs are positive with the exception of ISO/TS-certified programs. The negative correlation indicates that the ISO/TS-certified program variable does not fit the overall model for hospitals and this variable was removed from further analysis.

Table 3
Improvement Programs Scores

Finally, how well the individual items fit the model is considered. Mean square fit statistics are used to assess whether observations are in agreement with the Rasch model values. Two types of fit can be used in the Rasch model, outfit and infit statistics. The outfit measure is sensitive to unexpected observations of hospitals and programs that are relatively far from their position. The infit measure is sensitive to unexpected patterns of observations by hospitals and programs that are close to their position (Wright and Masters 1982). One way of examining individual item fit is by means of z-scores. The standardized z-scores for the fit statistics should fall within a −2 to +2 range for acceptable fit. As shown in Table 3, all of the remaining improvement programs are within the −2 to +2 standardized z-score range defining acceptable fit. Based on these results, we conclude that the data provide a good fit to the Rasch model, thus revealing the existence of a unidimensional latent trait that can be described as the program capability of hospitals.

Even though a Rasch model was able to be effectively constructed based on improvement program usage, its correspondence to the stage model presented in Table 1 also needs to be assessed. The measure scores in Table 3 report the difficulty of each program, the scores are ordered according to level of difficulty with the easier programs starting at the bottom. Assuming that all lower stage programs are implemented before the next higher level stage programs from Table 1, the Wilcoxon test, a nonparametric version of the t-test, was used to analyze whether a difference exists between the results of the Rasch model and the four-stage model presented in Table 1. No statistically significant differences were observed (W=−6, ns/r=8) between the improvement programs in the proposed four-stage model and the results presented by the Rasch model. Although some differences were present, the results provided by the Rasch model appeared to be consistent with the four-stage view of cumulative development.

The end result of the Rasch analysis is that all improvement programs receive a difficulty score and all hospitals receive an ability score. Both the difficulty score and the ability score are reported as logits. The results for both program location and hospital location are presented graphically in Figure 1, the variable map. The vertical axis in the center of the variable map serves as a ruler, with logits as a common unit of measurement, allowing the comparison of both hospitals and improvement programs.

Figure 1
Variable Map

On the right side of the map, the distribution of the improvement programs is shown. Those improvement programs that are located higher on the map are accomplished less frequently than those that are lower on the map. Rasch modeling literature refers to this aspect as a program's difficulty. Within the health care context, two significant sources of difficulty arise because: (1) an improvement program can be difficult to deploy throughout a hospital or (2) a hospital is unable to understand how a particular improvement program can be effectively employed. The hierarchy from the easiest to the most difficult programs to implement exhibits a range that spans more than 6 logits. This result implies that a well-defined hierarchical structure exists among the improvement programs. Based upon the Rasch difficulty scores, there is a statistically significant difference in difficulty (~z=3.85) between the bottom 25 percent of the programs and the top 25 percent of the programs, which approximates the first stage (quality conformance) and the highest level stage (low cost) presented in Table 1.

The distribution of hospitals is located on the left side of the map. The hospitals in this study had widely varying abilities in carrying out programs. Hospitals located higher on the left side of the map have been able to adopt more programs than hospitals that are located lower on the map. Rasch modeling literature refers to this aspect as the hospital's ability to carry out a program. Based upon the Rasch ability scores, there is a statistically significant difference (~z=2.13) between the bottom 10 percent of the hospitals and the top 10 percent of the hospitals in their ability to carry out programs. That is, the hospitals with the most ability were able to implement more programs than the hospitals with lesser levels of ability.

What does the preceding statistical analysis tells us? First, the ordering of improvement programs that we obtained in this study is consistent with the stages presented in the Competitive Progression Theory. As a result, we would expect that the improvement programs representing the highest stage activities would be accomplished less often than improvement programs representing the lowest stage activities in this model (because they are more difficult), which we found to be true. Finally, because of the range of difficulty presented by the improvement programs, we would then expect that hospitals would have varying levels of capability in carrying out improvement programs. Indeed, the most capable hospitals were able to implement more programs than the least capable hospitals. Aside from the theoretical framework that proposes general reasons for the success or failure in implementing improvement programs, the practical significance of this analysis lies in the interpretation of the variable map for individual hospitals.

The variable map is interpreted in terms of both hospitals and improvement programs. A program that is 1 logit higher than a hospital's position means that it is twice as difficult to accomplish as a program that is at its level. The converse is also true. A program that is 1 logit lower than a hospital's position means that it is twice as easy to accomplish as a program that is at its level. The difficulty of adopting the program can also be described in terms of its probability of success. Understanding these relationships can guide an organization in making more effective operating decisions and more efficient resource allocations.

For example, if Hospital A as denoted by the arrow in Figure 1 (at the level of the Balanced Scorecard) decided to pursue FOCUS PDSA, there is a 27 percent probability that it will be able to successfully implement the program. If Hospital A decides to pursue the Malcolm Baldrige Award, the chances of success are even lower, <5 percent. However, if the hospital did not have an employee suggestion system and decided to implement that type of program the probability of successfully implementing that program is quite high, nearly 75 percent.

The probabilities of success cited in the previous paragraph are related to the difficulty of achieving a particular program. Probability of success like difficulty is determined by distances on the vertical ruler (Bond and Fox 2007). If a program that a hospital wants to accomplish is 1 logit higher than where the hospital is currently situated in terms of its ability, there is only a 27 percent probability that the program will be accomplished. If a program that a hospital wants to accomplish is 2 logits higher, it is three times as difficult and there is only a 12 percent probability that the program will be accomplished. If a practice that a hospital wants to accomplish is 3 logits higher, it is four times as difficult and there is only a 5 percent probability that the program will be accomplished. One can see that the farther away a program is from the ability of the hospital the greater the chance for failure.

It is important to note that these are only probabilities. Any selection of a program will generally require devoting a substantial amount of financial, human, and time resources in order to ensure that the program is successful. It should be noted that low probabilities do not preclude a hospital from attempting to implement more difficult programs. It simply means that greater effort and more resources will need to be expended by a hospital to ensure the successful implementation of the program.

The second stage of analysis views the overall impact of a hospital's ability to implement programs within its organization relative to its operating performance. To measure the impact on performance, we used the results of the Rasch analysis in conjunction with the Leapfrog score. Because inclusion in the Leapfrog database is voluntary, it should be noted that only 48 of the hospitals taking part in this study also participated in the Leapfrog survey, which is 44 percent of the responding hospitals. A regression model was built using the Rasch hospital ability score (independent variable) and its respective Leapfrog score. Initially, we included case-mix index, number of beds, and urban or rural location in the model to control for differences among hospitals. However, none of these control variables were found to be significant and they were removed from the model. The results from the final model indicate the Rasch ability score is significantly correlated with the Leapfrog score, F(1.47)=16.846, p<.01. The r2=0.264 indicates that over 25 percent of the total variance in the Leapfrog score is explained by the Rasch model ability score. That is, the hospitals with greater numbers of implemented programs tended to have higher scores on the Leapfrog Hospital Quality and Safety Survey.



As hospital administrators sort through the various improvement programs at their disposal, the obvious question is: “Where do we start?” There are several key points arising from this research that can assist in the decision making process. First, the highest level programs are statistically more difficult to accomplish than the lower level programs. While there were some differences in ordering of improvement programs among the stages proposed in Table 1 and the actual results, overall the two were not found to be statistically different. That is, the research found the hierarchy of adoption of improvement programs among Minnesota hospitals to be consistent with the four-stage development model. Second, the most capable hospitals were able to implement more programs than the least capable hospitals. More importantly, the hospital capability, as identified by the Rasch model, resulted in a statistically significant correlation with the Leapfrog Hospital Quality and Safety Survey indicators.

The current study can provide some clarification relative to existing research. For example, a recent study by Weiner et al. (2005) reports that some of their findings were contrary to their initial expectations. In particular, greater involvement in QI efforts by multiple hospital units resulted in lower values on quality indicators. They offer several interpretations of their findings. One of these interpretations was, “extensive involvement by multiple units could yield little to no improvement in hospital-level quality indicators if QI projects work at cross purposes because of poor coordination or inappropriate sequencing” (p. 326). Our findings tend to support the preceding interpretation of Weiner et al.'s apparently contradictory results. If a hospital implements elements of improvement programs in the wrong sequence, it would most likely face an increase in costs or in the worst-case experience outright failure. For instance, trying to achieve success in a Six Sigma program would be substantially more difficult if many of the lower level initiatives were not already implemented.

Limitations and Future Research

Several limitations exist in this study. First, the sample used to develop the variable map was based exclusively on hospitals located in Minnesota. Generally, Minnesota hospitals operate as not-for-profit organizations; therefore, the findings may not be applicable to all types of hospitals. Second, we assumed that the type of respondents that we selected, higher managerial levels, would have knowledge of the various programs implemented within their organizations. Even though the respondents occupied higher level positions, they may not have been familiar with activities in all areas of the hospital. Third, not all of the hospitals taking part in this study were contained in the Leapfrog database. As a result, the statistical relationship found between hospital ability and Leapfrog Hospital Quality and Safety Survey could be overstated. Finally, the improvement programs examined in this study consisted of a representative list, thus some noteworthy programs may have been excluded.

As hospitals emphasize a more systematic approach to improving the quality of care, patient safety, and business processes, future research should examine whether organizational efforts focusing on only one type of improvement program is sufficient. For example, Benitez et al. (2007) indicate that Six Sigma and Quality Function Deployment have been successfully utilized together to create and maintain effective hospital processes. Caldwell, Brexler, and Gillem (2005) advocate the adoption of a combination of lean management and Six Sigma practices to overcome existing deficiencies. It would be useful to understand whether the complexities of combinations of programs are more difficult to implement.


A hospital's ability to successfully adopt improvement programs is hierarchical in nature, some programs are easier to implement than others. Implementing higher level programs becomes easier when lower level programs have already been implemented within the organization. By understanding its own level of capability, a hospital can effectively identify its stage of development thus allowing scarce resources to be deployed more efficiently. This research can provide a roadmap for the selection of improvement programs so that the probability of successful implementation is maximized.


Joint Acknowledgement/Disclosure Statement: We would like to thank the Minnesota Hospital Association for providing us access to collect data from their participating membership.

In addition, we would like this manuscript to be dedicated to our colleague Julie M. Hays who passed away suddenly while we were working on this project. Her dedication and leadership made this research possible. We lost a great colleague and friend who will be truly missed!

Finally this research was generously supported through grants from the Opus College of Business, University of St. Thomas and the College of Commerce at DePaul University.

Disclosures: The authors have no financial or other conflicts to disclose.


Additional Supporting Information may be found in the online version of this article:

Appendix SA1. Author Matrix.

Please note: Wiley-Blackwell is not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.


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