DISCUSSION AND IMPLICATIONS
The implications of the findings reported in this article must be considered within the context of the study's limitations. First, while the sample contains a reasonable degree of diversity of hospitals, the findings cannot be generalized to all hospitals throughout the United States or abroad. Second, the study design was cross-sectional capturing hospital quality improvement activities and outcomes at a single point in time. As a result, the findings must be considered as net associations and not cause-and-effect relationships. Third, while using charge data rather than cost data involves some measurement issues, these have been mitigated by using condition-specific charge data. Also, one would like to have condition-specific outcome data on severity-adjusted mortality and complications, patient functional health status measures {Ware and Sherboume 1992), and patient satisfaction {Nel son et al. 1989). Finally, there are limitations in using a single quantitative measure of culture at one point in time (Denison 1990; Siehl and Martin 1990). An advantage of the culture measure, however, is the collection of data from numerous individuals across different departments and levels of the organization, thereby permitting comparisons across organizations in the same industry {Sheridan et al. 1994).
These limitations not withstanding, the findings hold a number of important implications as well as suggesting avenues for further research.