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In Reply: Dr Levin-Scherz and Dr Yaes both point to the important role of financial incentives in determining the rate of spread of an innovation. In the framework of Everett Rogers, such incentives alter the "perceived advantage" of an innovation compared with the status quo.¹ However, financial consequences are only part of the story. If they were adequate, why would hospitals, for example, not be rushing to use queuing theory to reduce delays in their own operating rooms, or streamlining documentation to avoid wasting the time of their nurses in useless recordkeeping, or standardizing treatment protocols to the best-known models—all of which save money and improve quality at the same time? The answer is that these require changes in behavior, attitudes, and systems that attenuate responses to incentives, alone.

As Drs Epping-Jordan and Ludman point out, systems for accelerating the spread of change can be constructed and managed quite self-consciously. . . . [Full Text of this Article]

Donald M. Berwick, MD
Institute for Healthcare Improvement
Boston, Mass

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