Who participates in the change process and how?
An important early choice confronting an organization is whether in responding to increased environmental pressure for better performance—such as that arising from the Institute of Medicine’s report 1 —it should initiate change in a few or many of its components. Depending on the degree to which the response reshapes and reconfigures the different components, change can take a variety of forms. A simple response may be “to do better than or do more of what already exists.” Typically, such “incremental change” or “tuning” can be implemented without altering any of the organizational components. A more complex response may require a radical redefinition of an organization’s mission, competencies, and culture. Invariably, such “transformational change” or “reorientation” calls for changes in multiple organizational components and their congruence. Systemwide improvements in patient safety are possible only if there are coordinated changes in multiple components—clinical procedures, attitu
