Intended for healthcare professionals


Time for organisational development in healthcare organisations

BMJ 1998; 317 doi: (Published 07 November 1998) Cite this as: BMJ 1998;317:1267

Improving quality for patients means changing the organisation

  1. Christian Koeck (, Professor of health policy and management, University of Witten-Herdecke
  1. Koeck, Ebner and Partner Inc, Alserstrasse 4, A 1090 Vienna, Austria

    The discussion on quality of care has come a long way: from the efforts and research of visionaries such as Ernest Codman and Avedis Donabedian in the 1970s to the introduction of quality management and continuous quality improvement; from assessing quality from the perspective of a single profession to a more integrated and process oriented view; from control to improvement. Most of this development has been driven by pioneers with an outstanding vision, such as Don Berwick, who felt that we could do better for our patients and must improve. However, numerous publications, countless conferences, and broad discussions have not yet produced sufficient improvements of actual quality. This week the journal Quality in Health Care adds to this debate with a supplement on Organisational Change: The Key to Quality Improvement that reviews current thinking (and achievements) in the NHS in particular and health care in general (see or It provides yet another sign that what has been achieved cannot yet satisfy patients, payers, and professionals. So why is it so hard to get real improvement and change?

    Over the past century health care has also come a long way—from the doctor in a solo practice, a generalist able to master all the relevant medical knowledge and apply it to the treatment of his patients, to the network of highly specialised consultants, who depend on each other for complementary expertise; from the asylum, where the interaction of nurses and doctors could guarantee optimal treatment, to today's hospital, where personnel clustered in over a thousand job categories have to run a highly complex and interactive system.1 As …

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