merican companies, including health care delivery organizations, were generally competing against other American companies; thus, the pressures to improve product quality were not perceived to be as significant as they were in the manufacturing sector. The advent of the longest duration economic recession in the United States since the 1930s, however, changed the appreciation of quality outside of the manufacturing sector of the economy (Armstrong and Symonds, 1991, p. 100). Companies in service, professional, and construction firms, including health care delivery organizations, in the United States became aware that quality must be emphasized in their operations, if they are to retain their customers bases.
Retention of a company's customer base is just one advantage associated with improved levels of quality. Operating profits may be expected to improve along with productivity, as quality levels rise (Hammonds and DeGeorge, 1991, p. 34). "Companies
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